"It feels like I have Bruised Lungs Doctor" - Managing Clinical Uncertainty

SPEAKER_00 0:12

Hello and welcome to the Home of Medicine Podcast with me, Dr. Amy Burbridge, and my ever faithful host.

SPEAKER_01 0:20

Hi, it's Ben here. My name's Ben Lovell, and uh happy to be back for episode number whatever it is, X.

SPEAKER_00 0:28

X. And this is a podcast in association with the Royal College of Physicians, Edinburgh. And also, Ben, I have some really exciting news and that I started a new job this week.

SPEAKER_01 0:41

Uh-huh. Librarian, no bartender, holiday rep.

SPEAKER_00 0:47

Oh, I think I'd be a good holiday rep. I think I quite like that. I'd wear a bedcoat. Um, so um this is my this is my second day. Um, and I'm working at Lincoln Medical School, and I'm going to be doing involved in professionalism and also developing the clinical reasoning curriculum, which is just couldn't be more perfect for me, um to be honest. So I'm incredibly happy to be starting this new chapter of my career.

SPEAKER_01 1:18

And what is your new job title?

SPEAKER_00 1:21

So, my new job title to start with is Associate Clinical Professor and Director of Professional Development.

SPEAKER_01 1:29

Oh, wow. Well, clapping hands. Absolutely fantastic. Well done. And writing an undergraduate curriculum in clinical reasoning for medical students. That's trailblazing stuff.

SPEAKER_00 1:40

It is, but also it's, I mean, it's just like my dream job. So I'm incredibly happy. But I will still be doing clinical work, um, which means the podcast will continue, and I have a case for you today.

SPEAKER_01 1:54

Thank you. I thought you were gonna say, and you're resigning from the podcast, then I was distraught. Good, we keep going.

SPEAKER_00 2:00

Okay, are you ready?

SPEAKER_01 2:02

Yes, please.

SPEAKER_00 2:04

I have a 33-year-old female. Now, I was called in to see her as almost like a second opinion. Now, this was the third time that this individual had presented to the same day emergency care unit. And actually, on this time, it was for a follow-up. So I'd already been seen twice, and the doctor previously had said, come back in on this day. We just want to follow you up, make sure things are going in the right direction, or to figure out what's going on. So, this was the third time that she'd come to STEC and she'd been seen by a resident doctor, and the resident doctor knocked on my door and said, I don't know what to do. Can you come and see this patient? And I gave a little bit of advice, and I was like, actually, yes, I think it's best if I come and start from the beginning, take your history, examine and try and figure out what was going on. So I went in to see this patient who was there with her partner, and I said, Okay, we're gonna go back to the beginning, let's forget everything that's happened so far. Tell me what's been going on. So she recounted a story of a two and a half week history of feeling generally unwell. She said that she'd been intermittently short of breath, there was no particular trigger or relieving factors. But she described bruised lungs. She kept saying to me, It feels like my lungs are bruised. And when I asked to expand on that, she couldn't really give me any more information. But she said that all of her body at the top felt like it was in pain, like it was dullache, but she described it as bruised. She also said that she was coughing up phlegm, and within this phlegm, she described possibly some blood. On further questioning, she said that this blood was bright red in nature. It wasn't really mixed in with the phlegm and it wasn't happening all the time, just on occasions. But when she was bringing the phlegm up, she said that it wasn't really a cough, but it was just more like it was being produced in her throat, in her mouth. Okay. She felt this consistent need to clear her throat. Of interest as well, she also said that she'd lost some weight in a couple of weeks, thought to be about two kilos. She said she'd had some night sweats in the last two weeks. She said she'd been tired, and her words were, I've been completely flawed by this illness. She said that she had one episode of diarrhoea, but no vomiting. And that was what she told me. Any thoughts?

SPEAKER_01 4:50

Okay. Alrighty. So the first things I wrote down were intermittent short of breath, bruised lungs, coughing up phlegm with some hemoptosis, weight loss. Okay, so so far, the first three things you could square away with a chest infection, which may be pneumonia or not. Um intermittently short of breath. It's only a two-week history. Bruised lungs, I'm interpreting that as, well, thoracic pain of some description. I don't know, I don't know if she means pleuritic pain or if she means sort of costochondritic pain. So maybe something will come up on examination. Um, should you be coughing up blood with a chest infection? You shouldn't really. I have seen patients who are coughing like crazy sometimes bring up some rusty sort of sputum because uh their throat and their trachea is so inflamed with all the coughing and the infection, they actually do bring up a little bit of blood. But if she's describing bright red blood, hmm, no, that's not a pneumonia, that's not a community-quiet pneumonia that we that we see. So that sits slightly apart. Then we get on to weight loss nights where it's tired. Again, acute infective illness could explain some of that. She could be febrile overnight. She definitely needs a chest X, right? Um, but then you just wonder weight loss nights where it's entired that does whisper malignancy. Could it be a malignancy? So in young, in a young woman, I'm thinking about a new diagnosis of if I had to pick one, maybe a hematological malignancy. Is this young lady got lymphoma or leukemia? Could that explain some of her symptoms? If she has quite bad lymphadenopathy around the corina or the trachea, for example, that can activate your cough reflex and you can cough like mad. And eventually you might bring up a bit of blood if you've got a bit of your bleeding as well. Um, it's quite a sudden onset for new malignancy, but anything's possible. Um, and that does tie things together neatly. So, what I'm thinking about is infection versus new malignancy here. Oh, and you let me be more specific. Uh, lung infection versus um hematological diagnosis, which might show up in the FBC on examination or a chest x-ray. Now, people might be going, well, hang on a minute, why hasn't she got a PE Ben? Hemoptosis, chest pain, shortness of breath. And you're right, but just in my experience, hemoptosis isn't usually actually a feature P unless it's a super duper one. That's not the medical term, a massive or a submassive one. Don't say super duper one in your exams, um, which has caused um significant um alterations to the bronch uh pulmonary uh circulation. So you don't normally see, and these people tend to be really sick if you see hemoptosis due to pulmonary embolism. So it's there, but it's not our number one, and that's where I am right now.

SPEAKER_00 7:50

Okay, so infection, PE, malignancy.

SPEAKER_01 7:54

Yeah, I think that's a fair enough punt based on that.

SPEAKER_00 7:57

Okay, so this was the third time this patient had been to the SDEC. And today she'd come in for a follow-up, and on the first and the second occasions, she'd been given antibiotics. She's had a course of emoxicillin, and on the second occasion, she'd had a course of doxycycline, and nothing had improved. She also had a she'd also had a chest x-ray, which you suggested on the second admission, which was completely normal. So she had a chest x-ray.

SPEAKER_01 8:24

According to whom? According to whom?

SPEAKER_00 8:26

So me. So again, I don't want to. Okay, that's fine. That's fine. But I'm really funny about x-rays in that if somebody says to me the x-ray is normal, I'm like, can I have a look at it? And they'll try to.

SPEAKER_01 8:39

That's what I was pushing at, yeah.

SPEAKER_00 8:40

Yeah, the report comes up, and I'm like, no, no, no, I want to see the x-ray itself. Um I'm missing. Yeah, on this occasion, I didn't get my ultrasound probo out, which I know I've talked about probably every episode in the last few months. Um, so um I carried on talking to her and asking her more questions. She had no past medical history of notes, um, didn't take any medication. She just took the antibiotics, the moxicillin and adoxycycline. She wasn't allergic to anything. Um, so I was like, okay, I'm gonna examine you. So what would you is there anything in particular on examination that you would be looking for in this individual?

SPEAKER_01 9:23

Um gosh, in particular. Well, I want to get my stethoscope on her chest. Um but I'd be looking at the hands, I'd be seeing if she was tachycardic, seeing any splinter hemorrhages in the hands, you know, thinking about endocarditis. That sometimes shows up as sort of almost mimicking a malignancy sometimes, endocarditis, but their weight loss, the night sweats, and all that. Um, so I'll be looking at her nails, um, thinning her pulse, I would be uh listening to her chest very carefully, and I want to have a look inside her mouth. Now, I confess I don't do many throat exams as an acute physician. Um, but in this case, if she's telling me that blood is sort of coming out of her very easily, I want to make sure she hasn't got any point of bleeding that I can see either in the mouth, something dental, or in the pharynx, as far as I could visualize. So I'd be having a look in there as well. Um, I'd be having a look at her skin for any easy bruising, just because I did mention lymphoma and leukemas, didn't I? Um you're going to tell me the full blood count soon, but uh yes, so so any any signs of easy bruising, um uh, you know, any telangectasia, because she's got a rare condition like hemorrhagic telangectasia, which is causing some lung bleeding. I'm getting a bit weird now. Um, what else I'll be looking at? So feeling for lymph nodes, so feeling um uh uh cervical lymph nodes, any in the neck, feeling in the armpits and in the groins for any lymphatinopathy, and then doing abdominal exam, feeling for splenomegaly. Again, that's my sort of general nook, the hematological um disease, uh, and any pitting edema, what's her fluid status? That sort of thing would be, I think, the final thing I would look at.

SPEAKER_00 10:55

Okay, so um on examination, the respiratory rate was 14.

SPEAKER_01 11:00

Normal.

SPEAKER_00 11:01

Saturations for 99% on room air.

SPEAKER_01 11:04

Normal.

SPEAKER_00 11:05

Heart rate 76. Normal. Temperature 36.

SPEAKER_01 11:11

Good, yeah.

SPEAKER_00 11:12

Cardiovascular examination was normal. On respiratory examination, I thought there was possibly some noisy breathing in expiration on the left side, but I don't even know what that means or what it could have meant, so I didn't really pay much heed to it, to be honest. Abdomen was soft and non-tender, calves were soft and non-tender, no pilledema, no palpable lymph nodes in the cervical region, the auxiliary region, and the groin region. And I palpated those because of the weight loss and the night sweats, thinking about is this a lymphoma, potentially. And I looked in the back of the throat, and I'm I always look in the mouth because I'm often caught out with oral thrush. And it's amazing how many people do have oral thrush in hospital, whether they're either on antibiotics, steroids, or on inhale steroids as well. And it's always something to think about. Um, and actually, what I did notice at the back of the throat was some red, very red, very sore, and looked like some possible superficial ulceration, potentially on the back of the throat. Does that sway you at all? Are you thinking anything with that history, that examination?

SPEAKER_01 12:26

What was her blood pressure? Sorry, I missed that.

SPEAKER_00 12:29

114 over 75.

SPEAKER_01 12:33

Okay, so that's normal as well. Good. Right assignments are normal. So the only positive finding you've got is did you say posterior throat ulceration? Gosh, mouth ulceration. What have you got there, Ben? Okay, we've got um one question to ask.

SPEAKER_00 12:48

You've got one question to ask this patient. What is it?

SPEAKER_01 12:52

Oh yes, just one. Honestly, my question would be how long have you had these ulcers for? Uh have you noticed them? Is this over the same time frame as before? I don't have another magic question.

SPEAKER_00 13:06

So is it a couple of weeks? So I was just thinking more along the lines of um, is she sexually active? Um is there any trouble? So I'm sorry, I've given second question now, any travel. Um, and as a woman, I always think about menstruation. And you know, is there a link at all with any of these things? So her peeries were normal, she wasn't menstruating, um, she was sexually active, she'd been married, um, no, you know, no issues there. Um, and there was no sort of vaginal discharge or anything that would suggest a sexually transmitted disease.

SPEAKER_01 13:44

Okay. Um what about blood results? She's been here twice before, right? So she must have had a full blood count in the dance.

SPEAKER_00 13:51

Okay, so hemoglobin 141.

SPEAKER_01 13:56

Oh good, very healthy.

SPEAKER_00 13:58

White cell count is six, neutrophils four, lymphocytes 1.2, CRP less than four. What else would you like to know?

SPEAKER_01 14:10

Uh platelets.

SPEAKER_00 14:12

424.

SPEAKER_01 14:14

Normal. Normal coagulation.

SPEAKER_00 14:16

Yep.

SPEAKER_01 14:18

All her cell counts were normal then, actually. Okay, all right. And her U's and E's were okay as well? Normal. Us and E's normal. Okay, so mouth ulceration. So now the only other thing I'm thinking about is something rheumatological, which I didn't have in my differential before, like an autoimmune disease um or inflammatory condition, mouth ulcers, bosh, I've got Beshet's disease in my mind. What was her ethnicity? Uh, just thinking about the likelihood of Beshet's disease.

SPEAKER_00 14:52

Caucasian.

SPEAKER_01 14:54

Okay, so very unlikely then. Um that causes um recurrent or ulcers, lupus, um, some kind of vasculitis. Um, is she having sort of posterior nosebleeds which she's bringing up forward thinking it's hemoptosis or it's triggering the cough and the chest infection because she's got something like what we used to call Vaganer's disease, and we now we call polyangitis, uh granulomatosis. Um she has no history of asthma, does she?

SPEAKER_02 15:21

No.

SPEAKER_01 15:22

No. I guess we have to exclude acute HIV, serial conversion, um, as well. So when she needs an HIV test. Um nutritional things? She has gonna really have any kind of nutritional deficiencies. Is she causing her mouth ulcers? If she keeps a balanced diet. Um, and finally, uh Crohn's, I guess, or oral adverse ulcers is a very unusual manifestation of inf of Crohn's disease, just causing um predominantly upper. Um I've been right around the houses there. So infection, we've taken infection history, hematological. I guess we could do some more tests, but I'd be honestly, the normal FBC really points away from that. Um, and the next tests would be something like LDH, beta 2 microglobulin, and and even considering a PET scan if you thought there was sufficient evidence to proceed. And I don't think there is. I think we need to rule out infectious, uh, we need to rule out HIV. I think for rheumatological conditions, maybe um go back and ask a more focused history. I didn't ask about skin rashes, um, previous miscarriages, um, previous DVTs, um, and um anything else that might indicate lupus uh liver function tests. We could do an auto antibody screen, double-stranded DNA, um uh complement levels, anchor. Um and do I need to do a thyroids? I can't think of a thyroid manifestation. This would be a thyroid disease, so I'm not sure. So here's me throwing a lot of stuff at the wall and seeing what fits. I don't have a diagnosis yet.

SPEAKER_00 17:05

Okay. So she hadn't lost any hair. Um, and because I was thinking, could this be rheumatological? And um on further questioning, she'd said that she'd had a non-itchy, non-painful rash on the upper part of her back, which had self-resolved. And on examination, I wasn't able to find any rash at all. So I didn't, I wasn't really too concerned about that. Now she had had a autoimmune screen done. So her ANA was negative, anchor negative, um, ESR was less than it was net, you know, it was negligible. It was, it didn't really um give us any further information. Every single investigation that this patient had had was normal. What are you going to do?

SPEAKER_01 17:57

Well, in the I think we've we've ruled out quite a lot of stuff. If everything I've mentioned so far today, all the tests I've mentioned have been reassuring, then the only thing that you could maybe do next, if you thought she had if you had truly objective evidence that she was losing weight, um with these mu you could do a CT scan, which would be get some cross-central imaging and look for any hidden malignancy. If you thought you had the uh enough evidence to proceed, but otherwise, it's a very acute onset of a systemic illness with a cough and some mouth ulcers. It could all be a self-limiting thing, a self-limiting viral infection. And to be honest with you, at this point, I think I would observe, but I don't think I'd progress to any cross-sectional imaging at the moment. I don't think I've got enough inf enough compelling evidence to write on the report request to get it through a radiology assessment. And uh uh at the moment I'm I'm I'm a bit mystified.

SPEAKER_00 18:57

Okay, so I'm glad you said that because that was what I was thinking too. So after spending quite a long time with a patient, her partner, and the resident doctor, and looking at everything, I said, I don't think there's anything seriously wrong. I think you've probably had a viral infection that has completely flawed you, it's knocked you off your feet. It might have been COVID, for example, and you've been coughing, you've had some irritation at the back of your throat that may have caused a bit of the blood within the phlegm. I was like, I really don't think we need to do anything. I was like, you've had ammoxicillin and doxycycline, it hasn't helped. Your bloods are normal, your observations are completely normal. I'm really, I'm happy to watch and wait. And I said, I think the best course of action is to stop the antibiotics. Well, the antibiotics had finished by now. I said, I'm not going to do any more tests. Um, I don't think we need to do any more tests. I think this is probably viral. It will all settle down. If it hasn't settled down in seven days, C or GP will come back and see us.

SPEAKER_02 20:01

Yeah.

SPEAKER_00 20:01

End of consultation.

SPEAKER_02 20:03

Yeah.

SPEAKER_00 20:03

It wasn't though. So I walked out the room and uh the resident doctor who'd asked me to see the patient said, Um, I disagree with you. Um, I think this patient's got cancer, and I think they need an urgency, T thorax, abdomen, and pelvis. And I was like, okay, I don't believe that they have. I said, I've had no convincing evidence that this is the case. And we went back and forth, back and forth, back and forth about to do a CT or not. It's really interesting conversation. It was a it was a it was a really good conversation. It wasn't a bad conversation at all, but it really challenged my clinical decision making, challenged my ability to manage uncertainty, challenged my thought process about, I don't like to do many tests. Um you know, me, I like the history, I like the examination. And it really got me thinking, why do we have to make a diagnosis then? Sometimes after this patient had been seen and all the tests were normal, why isn't that good enough? Why do we have to keep looking and looking and looking?

SPEAKER_01 21:23

Fear. Fear of missing something.

SPEAKER_00 21:27

Yeah, to know.

SPEAKER_01 21:28

Fear of missing something and harming a patient.

SPEAKER_00 21:30

I've wrote that on the top of my paper, fear of missing something. Yeah.

SPEAKER_01 21:34

Yeah. Fear of missing something, discomfort at sitting with uncertainty. Yeah. Fear fear of missing something and harming a patient, and also fear of being the victim of a of I don't know, a complaint if you have missed something as well. I think we should acknowledge that. That that's an unreasonable concern to have. If I miss something, I'm not only missing something, but I I could be causing harm in both directions. Directions. And I think patient expectations, it's not easy to end a consultation with I don't know. I have done it. And I have said I have said things along the lines of, do you know what? I think next month you're going to look back. We're all going to look back at this and go, What was that? But it'll be gone. And I think that's okay. But if it doesn't, here's our number. But not every patient is okay with that. And some some of them may challenge. And I think those are the main, the main driving things because we that's when risk we sit with risk. And that's where the risk sits. So when you say, I don't know, you're putting yourself and your patient in a position where you've said, look, I'm accepting risk today. Do you accept it with me? And the patient may say no, or they may say, I trust you, doctor, yes, okay. If you think that's best. And that's not an easy conversation to navigate. It's not as easy as saying, hello, you've got a chest infection, take this for five days and have a nice life, which is no much easier to do, isn't it?

SPEAKER_00 22:57

How about if you're in a consultation and you've had a conversation and said, I believe this is a viral infection. I believe that you're getting better. All of your investigations have been completely normal. I'm happy for you to go home. But the patient had already been told by the doctor before me that this could be cancer.

SPEAKER_01 23:17

Um okay, there's a couple of ways you can play this because what you don't want to do is undermine a colleague. So you don't want to say, oh, they don't know what they're talking about. Exactly. Um, you know, that load of nonsense. Uh I mean, I'm probably have a conversation with that colleague and say, look, just be careful what you say. Because you can't throw the C-word around like that in front of patients. You've terrified that poor girl out of her wits. But I think what I would do is um say, oh, I can appreciate it's very strange for me to come in now and say nothing. Just to recognize um I am the consultant, I'm the senior doctor on court today, and I was brought in to consult on your case because it's not an easy, it's not an easy one, it's not a straightforward one. And they wanted someone with a bit more experience to give an view on this, and this is my view. And hopefully, you trust me, and if I had any thought that you could have a cancer, I would not take that risk at all, and I would do some few more things. So hopefully the fact that I've assessed you thoroughly for a really long conversation and I'm relaxed, hopefully that can convince you as well that this isn't cancer. Um I don't take this conversation, uh sorry, these these sort of decisions lightly. And I've really, really thought about this, and that's probably how I would play it. So, you know, recognizing that I've come to the table as a senior um senior opinion on this case, almost a second opinion, really.

SPEAKER_00 24:33

Yeah, and I'm not saying that that's what happened, but that's what can happen, isn't it? Often when a patient comes with expectations of a particular investigation or a particular diagnosis, and then we go in and say that's not going to happen. Now in this case, um, I really didn't feel that a CT scan was warranted. Somebody else felt that a CT scan was very warranted, and we ended up at the stalemate. What do you do in that position where I truly believe that a CT scan was over investigation? I felt that there was everything had been done which was normal. The patient herself that day said actually she felt much better but was concerned because she's never ill. Um so did have some concerns. I did not want to do that CT. Somebody else wanted to do that CT, another clinician. We were at stalemate.

SPEAKER_01 25:38

Okay, so what I would do is I'd I would listen. I'd say, come on, then make your case. I've got an open mind to yes, make your case for for for the CT. And I promise I will listen without prejudice.

SPEAKER_02 25:48

Yeah.

SPEAKER_01 25:49

If I listen to their case and I still don't find it compelling, then I would say that um thank you for raising, you know, thank you for raising your concerns. It it takes takes a bit of guts to do that. Um I appreciate that's how you feel. I'm a consultant for this patient, so I will not be progressing for a CT scan. And hopefully I've explained to you why. Uh and that's that is ultimately what's what the direction of travel is going to be, because I'm the I I am ultimately responsible for this patient's care in the direction of care. So that's why we're not doing that CT scan today. But um, but thank you for stating your case. And I think I would do it like do it like that. If it was the patient who was insisting on the scan, um, that could be harder. This happened to me actually a couple of weeks ago, and it didn't come to a very satisfactory conclusion for either of us. Uh and sometimes the easiest thing to do is the is the scan, and the right thing to do.

SPEAKER_00 26:45

Really difficult, isn't it?

SPEAKER_01 26:46

Yeah. Yeah.

SPEAKER_00 26:49

I don't know whether there's a right or a wrong answer, but in the end, um, I did what you said, I listened and I um I think it's really important that we give doctors in training and our resident doctors autonomy to make decisions as well. So ultimately, I said something along the lines of, I really, you know, I I completely get where you're coming from. These are my thoughts, but ultimately I'm gonna be guided by you because that's how you learn. So if you believe that a scan is the right thing for this patient, absolutely do the scan. Um, and again, we umdenard about it and decided to do the scan. CT thought.

SPEAKER_01 27:29

Go on then. Yeah, yeah.

SPEAKER_00 27:31

Which was completely normal.

SPEAKER_01 27:34

Oh, okay. I thought we were gonna go a different direction then.

SPEAKER_00 27:37

No, no, and I don't, I don't I guess that the point of this case is not to say that, oh wow, I'm great. I you know, I wouldn't have done this test, but it's not about that because yes, sometimes this has happened and the scam that I haven't wanted to do is pick something up, and I'm like, oh gosh, that was a little surprise. Um I think there's a few things there is when we see patients in hospital, we what is our focus? Is that focus to give a diagnosis when sometimes there isn't one to give? And how do we balance that? You know, a patient has a viral infection, or sometimes they may not have anything at all, but because we are trained as doctors to give diagnoses out, how does it feel when there isn't one to give?

SPEAKER_01 28:26

Yeah, it feels unsatisfactory, it feels like I think I think we we are it's almost quite transactional, isn't it? But but I think that's the model we're used to. Um this is why I don't envy GPs and the work that they do, because this is such a big part of their caseload, and I couldn't do it. I don't think I've got the guts to do it because um people come to them with all sorts of issues, and not only have you got to take unbelievable amounts of risk in that GP surgery without access to same-day blood test scans, you name it, you've got to make judgments based on history and examination, and you have to deal a lot uh with patients who uh trying to convince and explain and reassure why you're not making a referral to this specialty or why you're not sending them up to the big hospital for the scan. Um, and that that cannot be easy to do from a time management perspective and from like your own emotional resilience perspective. Um, but it does happen, it does happen as part of my job as well. And I think I just really take the time to make sure the patient doesn't feel rushed to show that I have taken the time to examine and listen to them. So when I come to my judgment, even though it doesn't quite make sense to them, they know it's because it's not because I didn't bother to listen or didn't bother to look at them. Um so if they go home and say that doctor was useless at the hospital today, he didn't do any of the scans I wanted, fair enough. But they can't say he didn't even listen, he didn't even examine me, I was in and out in five minutes. They can't say that. That wouldn't be fair. So I I try and make that investment with them to hopefully reassure them that I'm thinking about this, you know. I I'm engaging my my little grey cells about this, I'm not being flippant with my decision making. And hopefully that comes across.

SPEAKER_00 30:07

Yeah. Whenever you say little grey cells, that reminds me of Poirot.

SPEAKER_01 30:12

That's where I get it from.

SPEAKER_00 30:12

Yeah, ah, yeah, yeah. Does that mean I'm Hastings or Miss Marple?

SPEAKER_01 30:19

Oh, I'd rather be Miss Marple, actually. I think she had the better storylines, yeah.

SPEAKER_00 30:23

She did have good storylines, that's true. Um so I get it's a really unsatisfactory case. I'm sorry about that, Ben.

SPEAKER_01 30:31

No, I think it's a really interesting case, actually. And it's a bit different to what we do normally.

SPEAKER_00 30:36

Exactly. But I think it's the bread and butter of an acute physician, actually. So, you know, we see a lot of patients, particularly on a busy clinical day, maybe an STEC, when there isn't a diagnosis to give, or we don't have one at the moment, and it's how do we communicate that to the patients in a way that they're happy and we're happy that we've done it in that in a right way. Um, and I came away from this consultation feeling unsettled. Unsettled because I didn't feel like I'd done the a great job, I guess. Um but what I really loved was being challenged by the resident doctor, and I would really encourage resident doctors to challenge people more, you know, whether it's their colleagues or whether it's you know their seniors in a in a very professional way, but having my decision-making challenge really made me stop and think, and I really valued it. I mean, this doctor is incredible, you know, so knowledgeable, brilliant. And I was like, yeah, thank you for raising that. That's a really good point. Um things to think about, I think. Stop and think.

SPEAKER_01 31:49

I I I've got some thoughts about that because I cannot count how many times a resident doctor who more junior to me has saved me from really making a muck-up of a case by showing me something I hadn't seen or considering something I hadn't appreciated. And I've gone blimminette, that is a good idea. Oh, Doctor, would you mind if I do this? Why would you do that? Oh, because I've noticed this. Oh gosh, then definitely do it. Thank you. Um, I couldn't even tell you. But um, I also have to confess that it it may depend on my mood on the day. And a day when I am absolutely overstretched, I'm in that danger zone where I am just firefighting and I'm running from emergency to emergency. I might become a bit irritable if I feel like I've said, Do you know what? You've seen me examine the patient on balance, let's just discharge, not an email test. And then they said, no, I disagree, I want to do the city. I might actually get a bit irritable on a certain day and say, I've actually told you what's going to happen here. Um, and and I've listened to you and we've made our case, we've had a conversation, and you need to stop pushing now. I would phrase it very, very carefully. But I uh I've got to be honest, I can't pretend that I'm this paragon of a consultant every single segment, every single day, who's like, thank you for challenging me. Thank you for arguing me. Because sometimes I might say, look, this conversation, we need to move on. We need to see the next patient. That's it. And I have said that before if I felt like we're just going round in circles here and I'm getting a bit a little bit annoyed. But um, that's for me being brutally honest. Um, and you say you encourage residents to challenge consultants, easily said than done. Absolutely, yeah.

SPEAKER_00 33:26

Yeah. I agree.

SPEAKER_01 33:27

Have you heard of the graded assertions? Um different sort of mnemonics you can use.

SPEAKER_00 33:33

Uh, remind me, Ben. Remind me.

SPEAKER_01 33:35

There's a couple of mnemonics we use when we're teaching about human factors, about how you can raise concerns, what we say, raising concerns against the gradient, against a hierarchical gradient, which isn't always easy because it might not feel psychologically safe to do so. You might be cut down, humiliated, ignored, um, called stupid or something. So people are worried about doing it. And there's a couple of models, they're acronyms. One's called PACE, um, but the one that I'm more familiar with is CUS, C-U-S-S. And it's called graded research in. And it's about um about how you can, in a stepwise approach, C U S S, four steps towards raising what you think is a valid patient safety concern against a hierarchy. Um, and the C stands for concerned. So that usually comes out as I'm a bit worried we might have missed something here. That's usually a resident doctor in our framework raising a consultant and a psychological, raising to a consultant in a psychologically safe way their concern without the loss of dignity or feeling undermined if they were to go, no, no, no, I've considered that. I'm concerned we might, or I'm worried that I'm worried there's something going on here. I'm worried this patient might actually need a CT. If you get no response to that initial C, the next letter is U, and that means unsure. Um, I'm unsure or I'm uncertain that we should be sending this patient home because I'm really worried. And sometimes that gets you a consultant who's not quite picked up what you're concerned before, and they might go, okay, tell me again why you're unsure. The third is the S in cus, and that stands for safety. I I just wonder if this is safe. Or I'm not sure this is the safest thing to do for this patient, or I wonder this could be a patient's safety issue. Sometimes that can actually get the consultant's attention for the first time and go, Oh, okay, I hadn't thought of that. Sorry, explain what you mean. The last S in cusp is the nuclear optimum, which means stop, which is, I think we need to stop and think about this again. Um, and that takes a lot of bravery to do. Um, I went to uh I think I might have said this story before on the podcast, but I went to a clinical reasoning um seminar once, and uh a pilot, an airline pilot, was there and he was saying we have something similar to that um in in the cockpit. And it was it was three steps. Uh, and it was um uncertain, safety, listen. And it was um uncertain. Captain, I'm uncertain that, or I'm unsure this is the right thing we should be do here. And the next thing was, Captain, I don't know if this is safe. And if you don't get any response, that the third thing is Captain, you must listen. And that was the magic sort of phrase that made you things of down tools, turn around, look you in the eye, and say, explain what your concern is. So Casa's a little bit like that. Yeah. The other one, the other one is pace, um, which says P-A-C-E, and that sounds for probe alert challenge emergency. And I do see, I do see residents do that sometimes. Probe is basically ask a question of a consultant why they're taking an action. And do you know how you must have heard this? How this always tends to come out as um, just for my own learning. Yes, why are we not doing the CT scan? Don't they do that? And that's because they're trying, they're they they don't feel totally safe to probe. They want to probe in a safe way. So they phrase it as just for my learning. Why why are we doing this? Because you can't shout at someone who's trying to do something with her own learning.

SPEAKER_02 36:56

Yeah.

SPEAKER_01 36:56

And then alert, alert is sort of like, I need to alert you that the patient has been losing a lot of weight having night smokes, and there could be a hidden malignancy here in your case. If no response to that, C is challenge. Do you mind if I gently challenge you on that, please, Dr. Breverbridge? Because I personally think that the CT scan is really important here. And then E is emergency, which is uh again the nuclear option, which is I think this is an emergency situation. So there's a couple of sort of graded assertion mnemonics out there, and I do see residents sometimes doing it, not because they've been taught it, just because maybe it's it's sort of human nature to capture things in a certain way. But some medical cultures are different to others, and raising a concern. I gotta think, if I would when I was in FY1, I was terrified by some of my consultants, and I never would have said anything except, yes, boss, leave it with me. That's not right. Sometimes I'd notice things they hadn't noticed, but I kept my mouth shut because I didn't want I didn't want to get uh rollout on the ward round, which happened more than once. So that's something for us to think about, I guess, as consultants. What's the culture we want to set?

SPEAKER_00 38:02

Yeah, and I think that's I think going forward into my new role where I'll be working with medical students, you know, at what point within medical student education do we bring this in uncertainty challenge? I think probably from day one, you know, obviously not day one, um, but you know, very early on in the medical curriculum to just try and introduce that concept of if you uncertainty is normal and normalized uncertainty, and feel confident and comfortable to raise concerns and that you won't be shouted at or dismissed, but you'll be acknowledged and listened to.

SPEAKER_01 38:42

We hope. We hope.

SPEAKER_00 38:43

Absolutely.

SPEAKER_01 38:44

Yeah.

SPEAKER_00 38:46

Any last thoughts, Ben? What's your one takeaway point from that episode?

SPEAKER_01 38:52

Um, my takeaway, I I guess if people are listening to the listening to this, I'd want them to think that it is okay to gently challenge, even hidden under the little veil of just my own learning, that's fine. And it's okay to stick up for your patient. Um, but the reason the reason why we structure teams the way we do, consultant, registrar, uh, SHO, what have you, is because we ultimately do need someone who is going to sit at the top of that hierarchy and hold the risk.

SPEAKER_02 39:22

Yeah.

SPEAKER_01 39:23

And that does sit with me, you know. And if I had missed it, it'd be me answering the complaint letter and me answering going to the caller's court or whatever. And that's fine. That's why I do my job. No problem with that. But I guess that's ultimately defending why I have the ultimate say. Um, and I think as long as you've raised your concerns in a really um uh articulate way, yeah in a sensible way, and they still disagreed with you, then you've done your job if you are a resident doctor who's still in training.

SPEAKER_00 39:51

Yeah, absolutely. So I guess what you're saying there is being the patient advocate is really important. So advocating is best for the patient, but also advocating for yourself and your learning and your thought processes as well is really important. Yeah. I hope that the listeners resonate with that episode. I know it's a little bit different, but I think it's something to think about, you know, a little bit more challenging. Um, I promise you, the next episode we will have a you know, a case with a really interesting diagnosis. But you know, sometimes not making a diagnosis is just as important as making a diagnosis. Thank you to all of our listeners. Please rate review and subscribe to the podcast. Huge thank you again to the Royal College of Physicians of Edinburgh. And watch this space. We will have our very own website soon, homeofmedicine.com. Thank you, Ben.

SPEAKER_01 40:42

Thank you, Amy.

SPEAKER_00 40:43

Thanks for listening. Goodbye.