Are you one of "The Trophy Generation"??

Bella mamma

I am, and I'm not impressed. And I'm not lazy thank you very much Dr. Luke.

http://www.rte.ie/radio1/podcast/podcast_patkenny.xml

PART 1, from 19 minutes
Dr. Chris Luke, ED Consultant Cork University Hospital
The discussion, from the start, is about the ED and how to have an efficient health service generally

That guy is seriously out of touch. A plane crashes in Cork and one of the A & E counsultants has time to swan around on national radio calling NCHDs lazy... and he wonders why they're having such trouble filling posts.

Ihaveanopinion

Oh Chris - Worked in this department, a doctor sees 3 or 4 patients in a shift in his A&E! I don't think so

He sees 30-40 patients per shift - I don't think so.

He is going to raise a lot of annoyed eyebrows.

Bella mamma

I couldn't see eyebrows being raised thru my radio, but I did hear hands clapping

SleepDoc

Listen.
A great number of overworked and undertrained
Nchd's are
Getting out of this country and going where they can get
Equtable treatment, training and oh maybe a bit of
Respect from consultant collgeagues who as a general rule don't get cheap laughs on national radio at our expense.

RobFowl

as a GP I felt quite insulted at his comments about GP's
To say they charge "60euro to write a bit
Of a note"
Saying Dear Dr Please
See ? abdomen
Essentially that sort of thing is nonsense. In the
Real world the vast majority of NCHD's and GP's work bloodly hard and deserve more respect and support form supposed colleagues

chanste

I am stunned that a man in his position could talk about "baby" doctors like that. I'd bet he surrounds himself with bitter old gits spending their time reminiscing of how things were better in their day!

Vorsprung

Ever since Chris Luke was reported as saying that NCHDs had "an obsession with their own work-life balance rather than serving the citizens of this country", I've taken anything he has said with a rather large pinch of salt.

Comment here - http://www.imt.ie/news/latest-news/2011/02/nchds-working-in-fools-paradise-—-imo.html

drfrank

I'm unsure as to whether this chap is simply deluded or an attention junky ?

How can any NCHD work in the ED at CUH when he is stating that you are all lazy, overpaid spoiled brats ? ? !!!!!

It is truly unbelievable. I take it he will be in the dept tomorrow apologising ? and was no doubt 'quoted out of context'

imported_guy

drfrank wrote: »

I'm unsure as to whether this chap is simply deluded or whether he is simply an attention junky ?

lol was in the gym and he was on the telly talking about the guys who died on the plane (RIP) and the ones who got injured he was the 6 o clock news (i thinkk?) those were exactly my thoughts. hes running the only level 1 trauma centre in ireland during relatively major crisis and he found the time to adress the media

opinion guy

imported_guy wrote: »

lol was in the gym and he was on the telly talking about the guys who died on the plane (RIP) and the ones who got injured he was the 6 o clock news (i thinkk?) those were exactly my thoughts. hes running the only 1 trauma centre in ireland during relatively major crisis and he found the time to adress the media

Found the time ??
He spent most of the day on the air it seems

resus

Sorry but ANYONE who works in the emergency department will attest to the absolutely inappropriate ABUSE of Emergency Medicine from SOME GPs.

YES, our OPDs are TOTALLY understaffed and that patients with chronic problems are waiting inappropriately long times for such clinics, but FFS Emergency Medicine is NOT and SHOULD NOT be a dumping ground for "acuteish" on chronic disease. We DON'T have any faster access than GPs to USS or Clinics ! Chris Luke has a very valid point there, perhaps polarised, but VERY valid.

{says me summing up all the will power to not inappropriately vent!}

RobFowl

resus wrote: »

Sorry but ANYONE who works in the emergency department will attest to the absolutely inappropriate ABUSE of Emergency Medicine from SOME GPs.

YES, our OPDs are TOTALLY understaffed and that patients with chronic problems are waiting inappropriately long times for such clinics, but FFS Emergency Medicine is NOT and SHOULD NOT be a dumping ground for "acuteish" on chronic disease. We DON'T have any faster access than GPs to USS or Clinics ! Chris Luke has a very valid point there, perhaps polarised, but VERY valid.

{says me summing up all the will power to not inappropriately vent!}

8 years working in AE and 12 as a GP and we'll agree to differ here.
Some times you have to try to understand what these "absolutely inappropriate" referrals are there for. Emergency access to USS/doagnostics is available only via AE and acute flare ups of chronic disease are absolutely appropriate referrals.
Sometimes you have to sit back and look at the best way of dealing with problems ask ask what are the reasons they have been referred. Is there an alternative pathway? Often the answer is no..

crazy dude

I have a friend who is a registrar and she took a year off work. When she returned to work she did feel that the interns tended to want you to do everything hard and wanted to observe a lot more than in her day as an intern.

SleepDoc

crazy dude wrote: »

I have a friend who is a registrar and she took a year off work. When she returned to work she did feel that the interns tended to want you to do everything hard and wanted to observe a lot more than in her day as an intern.

http://www.youtube.com/watch?v=-eDaSvRO9xA

opinion guy

crazy dude wrote: »

I have a friend who is a registrar and she took a year off work. When she returned to work she did feel that the interns tended to want you to do everything hard and wanted to observe a lot more than in her day as an intern.

Supposing this were true - is it a bad thing ?
Historically and currently interns are pushed into doing things they should not be doing without proper training. The old medical catchphrase is still very applicable - 'see one, do one, teach one'

MrCreosote

Maybe when the good Dr Luke comes up with an examination finding that rules out any serious pathology in someone with an acute abdomen, then I'll be very happy to no longer send my "?abdomen" referrals to him...

And Emergency depts don't have quicker access to imaging and bloods than GPs??? Yeah right.

ergo

what an arsehole :mad:

how dare he put this slur on the reputation of NCHD's everywhere?

I think nowadays recently graduating doctors, rather than riding on the reputations earned by doctors from back in the day, have to work harder to earn the respect from patients that was lost due to the arsehole-poor-communicator-doctor-knows-best type consultants

I could possibly speculate that the above type of doctor has likely added to ireland being one of the most litiginoos countries in the world medically speaking

at least nowadays we are training doctors that are taught basic manners and respect for patients and colleagues, more than I can say for our friend Dr. Luke (with regard to respect for colleagues anyway)

With Emergency Medicine being such an unappealing career choice for anyone who wants to stay in ireland (estimated one new ED consultant needed per year in Ireland for the forseeable future) is it any wonder sensible people are leaving for countries with actual prospects nad no glass ceiling in place?

regarding his indenture idea...well, the way I look at it is this..and for the record in my career I have worked approx 18 months in Irish ED's and 6 months in an Australian ED..
anyway, the way I see it is as follows: In Ireland I think there should be a guarantee that the NCHD's you encounter in ED should be top quality or at least competent and that the rota will be filled in whatever ED you attend. currently there are ED's that I would tell my parents/friends to avoid as the chances that you will encounter poorer quality medical staff (unsupervised) are increased

for my parents and for when I get (much) older hopefully and need to use ED's I would hope that these ED's can be staffed with the brightest (or at least competent) Irish-tax-payer funded graduates..With no career prospects in ED in Ireland there will have to be some way of putting those doctors in ED...maybe through GP and medical and surgical schemes that will be enough but possibly not with all the potential medical types leaving for foreign shores

in Australia they fill the undesirable rural positions by rotating them from the big teaching hospitals, that kind of thing may need to be increased in Ireland to help staff the ED's

but with medical SHO schemes, for example, having difficulty filling their vacancies maybe we will have to look at the options for putting interns in or something

back to original thing, once in my career did I see 30 patients in one shift, it was paeds ED though so quicker turnover, it was the shift from hell, and I was effectively unsupervised for 8 of that 12 hours.

in adult ED that kind of turnover I'm sure would bring Dr Luke lots of litiginous type headaches, does he want them seen or seen properly? Writing two words like "refer medics" might be the kind of review he wants done but that wasn't the standard practice in the Irish ED's I've worked in

resus

The interesting paradox, speaking to anyone that has worked there in the last 2 years, is that MUH (Luke's department) is probably the only ED in the country where NCHDs are guaranteed their contractual rights, have a family friendly rota, have ALL their study leave, ALL their Annual leave and are paid correctly.

ps Todays crap GP referral, on a Saturday, when we are heaving and paramedics are waiting an hour to find a trolley for their patients:
"{Usual demographics} Abdo pain since Christmas, please assess." That was ALL that was written on an A5 piece of scrap, I kid you not. Please don't try to pretend it does not happen.

tallaght01

resus wrote: »

The interesting paradox, speaking to anyone that has worked there in the last 2 years, is that MUH (Luke's department) is probably the only ED in the country where NCHDs are guaranteed their contractual rights, have a family friendly rota, have ALL their study leave, ALL their Annual leave and are paid correctly.

ps Todays crap GP referral, on a Saturday, when we are heaving and paramedics are waiting an hour to find a trolley for their patients:
"{Usual demographics} Abdo pain since Christmas, please assess." That was ALL that was written on an A5 piece of scrap, I kid you not. Please don't try to pretend it does not happen.

there's crap docs in any specialty though.

Try doing paeds, and look at the **** referrals u get from ED. Literally "presenting complaint: is a child. Plan: refer paeds".

GPs are far better than ED at making sensible referrals in paeds (in my experience).

MrCreosote

Maybe someone should start a "Hospital drs giving out about GPs" thread.

There's no point griping about bullsh*t referrals until GPs have proper access to diagnostic tests. Clinical examination is overrated anyway, and an ED doc is going to have to take a history from scratch themselves. So a letter with too much information is only going to cloud your judgement. The only things that are really important is presenting complaint, past history and medications/allergies. A big storybook history of presenting complaint?-who cares!

To go back on topic, I was interested in one thing Dr Luke mentioned which was roughly that if Drs want to get the prestige in society, they have to be ready to martyr themselves to get it. Maybe younger docs don't want to be held up as some sort of societal hero- I certainly don't. Medicine is just a job, and any doctor who feels they should have a special position for doing it is a fool.

opinion guy

MrCreosote wrote: »

To go back on topic, I was interested in one thing Dr Luke mentioned which was roughly that if Drs want to get the prestige in society, they have to be ready to martyr themselves to get it. Maybe younger docs don't want to be held up as some sort of societal hero- I certainly don't. Medicine is just a job, and any doctor who feels they should have a special position for doing it is a fool.

Indeed. And I think Dr Luke's words betray how he views himself as a doctor and a 'prestigous' member of society. He really is a gobsh1te.

Ihaveanopinion

MrCreosote wrote: »

Maybe someone should start a "Hospital drs giving out about GPs" thread.

There's no point griping about bullsh*t referrals until GPs have proper access to diagnostic tests. Clinical examination is overrated anyway, and an ED doc is going to have to take a history from scratch themselves. So a letter with too much information is only going to cloud your judgement. The only things that are really important is presenting complaint, past history and medications/allergies. A big storybook history of presenting complaint?-who cares!

I have a huge problem with this comment. Clinical exam is a hugely important part of every patient encounter. You only have to look at the US where 'clinical exam isnt that important' and you'll find that every patients gets every investigation under the sun before a doctor lays a hand on the patient. If you think that clinical exam is over-rated, you need to have a think about your approach to patients!

To go back on topic, I was interested in one thing Dr Luke mentioned which was roughly that if Drs want to get the prestige in society, they have to be ready to martyr themselves to get it. Maybe younger docs don't want to be held up as some sort of societal hero- I certainly don't. Medicine is just a job, and any doctor who feels they should have a special position for doing it is a fool.

Also not true - Medicine is a privilege - its a privilege to be able to help people and a privilege to be able to delve into peoples private lives. To compare it to 'just a job' like working in Smyths toys, or at a factory line, is a fallacy. There is prestige attached to the job whether you like it or not, so this false humility is very misplaced.

MrCreosote

Ihaveanopinion wrote: »

I have a huge problem with this comment. Clinical exam is a hugely important part of every patient encounter. You only have to look at the US where 'clinical exam isnt that important' and you'll find that every patients gets every investigation under the sun before a doctor lays a hand on the patient. If you think that clinical exam is over-rated, you need to have a think about your approach to patients!

Also not true - Medicine is a privilege - its a privilege to be able to help people and a privilege to be able to delve into peoples private lives. To compare it to 'just a job' like working in Smyths toys, or at a factory line, is a fallacy. There is prestige attached to the job whether you like it or not, so this false humility is very misplaced.

I just said it was overrated, not unnecessary! Definitely a focused clinical exam has its place but in reality it's just a performance because people expect it most of the time. It's all in the history. JAMA did a series about "rational clinical exam" a few years back which showed how bad clinical examination is in terms of sensitivity/specificity of individual examination techniques.

And I'll stand by what I said- medicine is a job. A good job generally, but a job none the less. Medicine is changing anyway- people are getting more and more of their information from the internet, and the doctor will become more of purely a technician or coordinator role. The whole doctor-patient relationship concept that has been rammed down our throats since we started university will become less important. A good thing- if you ask me, this is just a way of making the doctor feel guilty when a patient doesn't e.g. make lifestyle changes- "oh, there must be something wrong with the doctor-patient relationship."

We need to get over ourselves- I'd suggest a good start would be by banning the use of "Doctor" as a title outside the hospital. How many other professions use their job description as a title??

opinion guy

Ihaveanopinion wrote: »

I have a huge problem with this comment. Clinical exam is a hugely important part of every patient encounter. You only have to look at the US where 'clinical exam isnt that important' and you'll find that every patients gets every investigation under the sun before a doctor lays a hand on the patient. If you think that clinical exam is over-rated, you need to have a think about your approach to patients!

So whats more important then - number of tests ordered or number of diagnoses missed ? The sensitivity and specificity of almost any many clinical exam findings is broadly somewhere around 0.5 - i.e. same as chance. Your critique of the US system is only justified if the Americans were missing more diagnoses than in europe. I SERIOUSLY doubt that's true. In any case the reason people have every exam under the sun in the US (and I'd argue increasingly so in the Irish private sector) is because of the insurance companies and money.

Let me put it to you this way - if someone was giving you a history of increasing dyspnea on exertion and you were trying to determine if their heart and lungs were the issue, which would you put your faith in more - lungs clear to auscultation and normal heart sounds......or a chest x ray and an echo ????

Biologic

opinion guy wrote: »

The sensitivity and specificity of almost any clinical exam finding is broadly somewhere around 0.5 - i.e. same as chance.

I don't have an opinion on the value of clinical exams yet but your statistical comparison is disturbingly far off the mark. Chance only has a specificity of .5 if there are only 2 possibilities. Definitely not the case in medicine.

opinion guy

Biologic wrote: »

I don't have an opinion on the value of clinical exams yet but your statistical comparison is disturbingly far off the mark. Chance only has a specificity of .5 if there are only 2 possibilities. Definitely not the case in medicine.

Sigh. I don't mean to be rude but you don't know what you are talking about. Any test result can be split into one of four possiblities: true positive, false positive, true negative, false negative.

Specificity measures the percentages of true negatives correctly identified
Specificity = true negs/ (true negs + false pos)

in other words - there are one of 2 possiblities behind specificity - true neg of false pos. THerefore 0.5 is roughly equivalent of chance.

Read more here:
http://en.wikipedia.org/wiki/Sensitivity_and_specificity#Specificity


Here's an example relating to third and fourth heart sounds (actually the specifities aren't as bad as I expected, but the sensitivities are beyond crap)
http://jama.ama-assn.org/content/293/18/2238.abstract

Edit: oh and to point out - in that study the heart sound analysis was done by computer. In other words the biggest source of variation i.e. the doctor's hearing and interpretation has been eliminated. So in practical terms you might just as well be making it up

Biologic

opinion guy wrote: »

Sigh. I don't mean to be rude but you don't know what you are talking about. Any test result can be split into one of four possiblities: true positive, false positive, true negative, false negative.

Specificity measures the percentages of true negatives correctly identified
Specificity = true negs/ (true negs + false pos)

in other words - there are one of 2 possiblities behind specificity - true neg of false pos. THerefore 0.5 is roughly equivalent of chance.

Read more here:
http://en.wikipedia.org/wiki/Sensitivity_and_specificity#Specificity


Here's an example relating to third and fourth heart sounds (actually the specifities aren't as bad as I expected, but the sensitivities are beyond crap)
http://jama.ama-assn.org/content/293/18/2238.abstract

Edit: oh and to point out - in that study the heart sound analysis was done by computer. In other words the biggest source of variation i.e. the doctor's hearing and interpretation has been eliminated. So in practical terms you might just as well be making it up

No need to apologise for rudeness, I've thicker skin than that. I understand what the terms indicate. Presenting them as though there is absolutely no value in clinical examination made me think you didn't. It's a blatant false dichotomy to say that the only outcome relevant to clinical exam is the true neg/false pos rate. Examination gives essential input into forming a differential backed up with investigations. "Making it up" doesn't do this so the raw true + or - rates between chance and examination aren't comparable in isolation.
More importantly, without clinical examination you wouldn't be able to arrive at your hypothetical situation whereby you have a diagnosis to get right or wrong. It's a null point to imply that you can just make up the specificity outcome (even if it is .5) because without examination you would have nowhere to go after that even if chance brought you the right answer. I'll admit I don't know enough to get into the intricacies of clinical examination, but to compare it to chance obviously isn't applicable. That's the point I want to make.

Ihaveanopinion

Got to disagree with you again - opinion guy. There are numerous studies showing the high sensitivity and specificity of clinical examination. In fact, the common theme at the end of most of them is that expensive tests are often unnecessary. Clinical exam is more than waving a stethoscope at a chest.

A simple questionnaire to identify TIA (history taking I know - but a similar vein) Sens 82% Spec 62%

Neuroepidemiology. 2011 Feb 10;36(2):100-104. [Epub ahead of print]
Sensitivity and Specificity of Stroke Symptom Questions to Detect Stroke or Transient Ischemic Attack. Sung VW, Johnson N, Granstaff US, Jones WJ, Meschia JF, Williams LS, Safford MM.

Testing a bunch of Subscap tests - Sens 80+%

Knee Surg Sports Traumatol Arthrosc. 2010 Dec;18(12):1712-7. Epub 2010 Apr 8. Diagnostic values of clinical tests for subscapularis lesions. Bartsch M, Greiner S, Haas NP, Scheibel M.

Sens 100% Spec 80 %

Physiotherapy. 2011 Mar;97(1):59-64. Epub 2010 Aug 1.
Reliability and diagnostic validity of the slump knee bend neurodynamic test for upper/mid lumbar nerve root compression: a pilot study.
Trainor K, Pinnington MA.

Sens 86% Spec 100%

Foot Ankle Int. 2011 Feb;32(2):189-92.
Validity of the posterior tibial edema sign in posterior tibial tendon dysfunction.
Deorio JK, Shapiro SA, McNeil RB, Stansel J.

you get the idea. Anyway, my point is - to state that clinical exam is essentially a coin toss is incorrect. A proper clinical exam can obviate the need for specialised testing.

This is all a bit off point anyway. Someone who is in heart failure, of course, needs to be investigated appropriately. While I agree that Chris Luke is a gob****e, the excuse for sending people to the emergency room to beat the OPD queue is not valid.

tallaght01

Just depends on what you're looking for from the examination, and how good the "operator" is.

Some disease have very specific findings, and others don't. You can't package them up into one homogenous "clinical" examination group.

In my early neonatal days especially, I missed findings that my reg/consultant could elicit.

As far as I know Opinion guy studies/works in WIT and isn't a doctor, so don't get too stressed by what he says biologic. Those of us who've been doing it, have seen consultants diagnose some crazy **** by just clinical examination, especially the old school consultants. We've also seen people who just scan/xray everyone who walks in the door.

take everything

tallaght01 wrote: »

As far as I know Opinion guy studies/works in WIT and isn't a doctor, so don't get too stressed by what he says biologic. Those of us who've been doing it, have seen consultants diagnose some crazy **** by just clinical examination, especially the old school consultants. We've also seen people who just scan/xray everyone who walks in the door.

I wonder how many here would be confident with the different parts of the JVP. :pac:
It's unfortunate that signs aren't taught better.

opinion guy

tallaght01 wrote: »

Just depends on what you're looking for from the examination, and how good the "operator" is.

Thats a variable.

Some disease have very specific findings, and others don't. You can't package them up into one homogenous "clinical" examination group.

Oh I agree with that. Some exams are better than others.

As far as I know Opinion guy studies/works in WIT and isn't a doctor, so don't get too stressed by what he says biologic.

Eh no idea where you are getting this stuff from. Never set foot in WIT in my life. And as before I'm not telling ye what I do. Frankly I enjoy watching you all jump to conclusions - its amuses me. Its fascinating to me how some doctors deal with opinions that are different to their own. But leaving that aside - take note dear readers, that I'm the one arguing the issues above. And tallaght01 if memory serves you are studying public health are you not? Then you are more than able of arguing on the merits of the argument and are very familiar with the techie terms I'm using above, are you not ??? Then why don't you ? Could it be you know I'm right and attacking the poster is all that you are left with ? i

Those of us who've been doing it, have seen consultants diagnose some crazy **** by just clinical examination, especially the old school consultants. We've also seen people who just scan/xray everyone who walks in the door.

Yeah. I've no doubt they do diagnose random ass stuff - but its not about that - its about whats missed. Do they diagnose the random ass stuff all the time ?

Biologic wrote:

No need to apologise for rudeness, I've thicker skin than that. I understand what the terms indicate. Presenting them as though there is absolutely no value in clinical examination made me think you didn't. It's a blatant false dichotomy to say that the only outcome relevant to clinical exam is the true neg/false pos rate. Examination gives essential input into forming a differential backed up with investigations. "Making it up" doesn't do this so the raw true + or - rates between chance and examination aren't comparable in isolation.

No I understand your point of view. Diagnosis is 90% history, 10% exam right. The point I am making however is that if you are basing the decision to do an investigation and your 90% history is inconclusive and you make your decision on the 10% clinical exam part you are highly likely to miss stuff. Especially if you are suffering under a delusionally high confidence in clinical examination.

More importantly, without clinical examination you wouldn't be able to arrive at your hypothetical situation whereby you have a diagnosis to get right or wrong. It's a null point to imply that you can just make up the specificity outcome (even if it is .5) because without examination you would have nowhere to go after that even if chance brought you the right answer. I'll admit I don't know enough to get into the intricacies of clinical examination, but to compare it to chance obviously isn't applicable. That's the point I want to make.

I'm sorry but you are just wrong here. Clinical history can often point the way to a diagnosis, but very often in disease states clinical examination findings may be absent. (And obviously I am not talking about ALL clinical examination but say taking the paper I linked above - placing any faith in 3rd and 4th heart sounds for example would be very foolhardy would it not ??).

Ihaveanopinion wrote:

Got to disagree with you again - opinion guy.

Err....we disagreed before, I must have missed that ????

There are numerous studies showing the high sensitivity and specificity of clinical examination. In fact, the common theme at the end of most of them is that expensive tests are often unnecessary. Clinical exam is more than waving a stethoscope at a chest.

A simple questionnaire to identify TIA (history taking I know - but a similar vein) Sens 82% Spec 62%

Not a clinical exam. History is very different to clinical exam. The old maxim - diagnosis is 90% history and 10% exam holds true. This finding does not surprise me.

Neuroepidemiology. 2011 Feb 10;36(2):100-104. [Epub ahead of print]
Sensitivity and Specificity of Stroke Symptom Questions to Detect Stroke or Transient Ischemic Attack. Sung VW, Johnson N, Granstaff US, Jones WJ, Meschia JF, Williams LS, Safford MM.

Again history

Testing a bunch of Subscap tests - Sens 80+%

Knee Surg Sports Traumatol Arthrosc. 2010 Dec;18(12):1712-7. Epub 2010 Apr 8. Diagnostic values of clinical tests for subscapularis lesions. Bartsch M, Greiner S, Haas NP, Scheibel M.

Sens 100% Spec 80 %

Physiotherapy. 2011 Mar;97(1):59-64. Epub 2010 Aug 1.
Reliability and diagnostic validity of the slump knee bend neurodynamic test for upper/mid lumbar nerve root compression: a pilot study.
Trainor K, Pinnington MA.

Sens 86% Spec 100%

Foot Ankle Int. 2011 Feb;32(2):189-92.
Validity of the posterior tibial edema sign in posterior tibial tendon dysfunction.
Deorio JK, Shapiro SA, McNeil RB, Stansel J.

you get the idea. Anyway, my point is - to state that clinical exam is essentially a coin toss is incorrect. A proper clinical exam can obviate the need for specialised testing.

Yeah I do get the idea (ok leaving aside the question of whether or not we are going to trust orthopods to do the stats that is :P). in fact I was waiting for someone to point out a good clinical test. For obviously above I was arguing the extremely negative point. Some clinical tests ARE useful in making a diagnosis. Few are useful in ruling out a diagnosis. But the point is we need to chuck out the **** ones don't we. Stop wasting students and teachers filling peoples head with the nonsense of 3rd and 4th heart sounds for example.

This is all a bit off point anyway. Someone who is in heart failure, of course, needs to be investigated appropriately.

Exactly. And listening for 3rd and 4th heart sounds is currently part of deciding whether or not they have heart failure for many docs. Should it be ? No. They should just get an echo.

Vorsprung

I think tallaght is mixing up imported guy and opinion guy

tallaght01

Vorsprung wrote: »

I think tallaght is mixing up imported guy and opinion guy

I dunno. someone on here told me he's a WIT person when we were talking about how much madness he writes.

It's obvious, however, that he's not medically trained, yet still goes on like he is. I know we don't all reveal our identities on here, but in fairness to virtually everyone else who posts here regularly, they will at least say what their specialty is, and usually their rank. You wouldn't trust it enough to give someone medical advice, but you get the feeling that it's the truth with most people. And it is relevant, IMO. I've met a few people from here, and they've always been what they said.

You can ban me for this, but opinion guy talks ****, and gently implies that he's qualified, and masks his reluctance to expand on his actual role as having something to do with liking people jumping to conclusions, which is of course crap. he's been doing it for a long time, and no end of people have commented on it. I don't care all that much, as I don't use this place that often. But it's worth pointing out.

A lot of people won't agree with that, and think that the option of total anonymity is essential. That's fair enough. It is in come cases. I doubt it is in this case.

I'll be gutted if he was mixed up with imported_guy, as I completely admire imported-guy's strategy of posting on the GAMSAT threads trying to put people off doing it, so there's less competition for him. It's an entrepreneurial spirit that we need in medicine :P

Vorsprung

People are entitled to anonymity if that's what they want. I got into a little bit of trouble when I said stated the speciality of a regular poster here - not bad trouble, he PMed me asking that I remove the reference but unfortunately I didn't see it for a few days, and a mod was asked to change it. My bad for assuming that people wanted their details made public.

You are of course entitled to your opinion, but so is everyone else, whether they work in a healthcare environment or not. As with disagreeing, that's fine, disagree but no need to air it repeatedly on the forum.

tallaght01

Vorsprung wrote: »

People are entitled to anonymity if that's what they want. I got into a little bit of trouble when I said stated the speciality of a regular poster here - not bad trouble, he PMed me asking that I remove the reference but unfortunately I didn't see it for a few days, and a mod was asked to change it. My bad for assuming that people wanted their details made public.

You are of course entitled to your opinion, but so is everyone else, whether they work in a healthcare environment or not. As with disagreeing, that's fine, disagree but no need to air it repeatedly on the forum.

People are absolutely entitled.

I just wonder about the reluctance. How much of a risk is it to say "I'm a cardiology SHO" or "I'm a biology student".

It's more the reluctance when asked that makes me suspect. But I see your point, and i'm not hugely bothered generally.

The poster who contacted you would be readily identifiable because of the other stuff he talks about, when combined with the info that you posted. Almost all of the medics here know him, and the fact that we know his background means we take what he says on certain non-clinical issues as being almost gospel.

Biologic

opinion guy wrote: »

Frankly I enjoy watching you all jump to conclusions - its amuses me. Its fascinating to me how some doctors deal with opinions that are different to their own.

opinion guy wrote: »

I'm sorry but you are just wrong here.

Fascinatingly hypocritical.

opinion guy wrote: »

Clinical history can often point the way to a diagnosis, but very often in disease states clinical examination findings may be absent. (And obviously I am not talking about ALL clinical examination but say taking the paper I linked above - placing any faith in 3rd and 4th heart sounds for example would be very foolhardy would it not ??).

So we've from "clinical exam is as good as chance" to "some clinical exam has reduced use". That's fine with me, point made.
Regarding my point that I'm apparently just wrong on. I'll be more succinct because it obviously didn't get through. Something is worth doing if it can change patient management. Clinical exam can, your idea of just making up the outcome can't. Therefore, they're not equal.

Vorsprung

Clinical exam is absolutely important!!

I saw a lady the other night who had some UTI symptoms. On exam she had a sore renal angle which she didn't realise she had, making her a pyelo. It was only mild, but it upgraded the diagnosis, purely on exam.

opinion guy

Biologic wrote: »

Fascinatingly hypocritical.


So we've from "clinical exam is as good as chance" to "some clinical exam has reduced use". That's fine with me, point made.
Regarding my point that I'm apparently just wrong on. I'll be more succinct because it obviously didn't get through. Something is worth doing if it can change patient management. Clinical exam can, your idea of just making up the outcome can't. Therefore, they're not equal.

Yup it sure can. Never said it couldn't. But NOT ALL THE TIME. The problem is people don't realise the limiitations. A positive exam is very useful. A negative exam is useless. If the history points to something then you will almost always have to do an investigation anyhow.

Vorsprung wrote: »

Clinical exam is absolutely important!!

I saw a lady the other night who had some UTI symptoms. On exam she had a sore renal angle which she didn't realise she had, making her a pyelo. It was only mild, but it upgraded the diagnosis, purely on exam.

Case in point. Positive exam being useful. But then I've also heard of relatively asymptomatic early pyelo being picked up on CT when it wasn't even in the differentials. As I keep saying - its not about what you catch with physical exam - its about what you miss!!!

opinion guy

tallaght01 wrote: »

I dunno. someone on here told me he's a WIT person when we were talking about how much madness he writes.

It's obvious, however, that he's not medically trained, yet still goes on like he is. I know we don't all reveal our identities on here, but in fairness to virtually everyone else who posts here regularly, they will at least say what their specialty is, and usually their rank. You wouldn't trust it enough to give someone medical advice, but you get the feeling that it's the truth with most people. And it is relevant, IMO. I've met a few people from here, and they've always been what they said.

You can ban me for this, but opinion guy talks ****, and gently implies that he's qualified, and masks his reluctance to expand on his actual role as having something to do with liking people jumping to conclusions, which is of course crap. he's been doing it for a long time, and no end of people have commented on it. I don't care all that much, as I don't use this place that often. But it's worth pointing out.

A lot of people won't agree with that, and think that the option of total anonymity is essential. That's fair enough. It is in come cases. I doubt it is in this case.

I'll be gutted if he was mixed up with imported_guy, as I completely admire imported-guy's strategy of posting on the GAMSAT threads trying to put people off doing it, so there's less competition for him. It's an entrepreneurial spirit that we need in medicine :P

Lol. Curious who you were discussing how much 'madness' I apparently write. Hmmm you see have your little rant here (no need to ban anyone mods). Tallaght01 I stick with the logical argument. You can't seem to help turning to ad hominems. If you disagree with my point of view then argue the point and give some data to back it up - I gave you data. And it doens't matter what my background is as long as my data and logic is valid - which it is.
Simply tallaght01 - do you believe that 3rd and 4th heart sounds are useful aspects of clinical examination ? And if you do please explain your veiwpoint in light of the study I linked to above.

ZYX

opinion guy wrote: »

Yup it sure can. Never said it couldn't. But NOT ALL THE TIME. The problem is people don't realise the limiitations. A positive exam is very useful. A negative exam is useless. If the history points to something then you will almost always have to do an investigation anyhow.

I don't see what you are trying to get at here. As a GP the vast majority of people I see and diagnose do not get an investigation to determine diagnosis. So in most cases you do not need an investigation.

Just some very common situations: Abdominal pain, history and examination (especially if exam is normal) are sufficient in most cases. Investigation of headaches- history and negative examination is enough. Skin rashes, viral infections/bacterial infections, mood disorders, the list goes on. In fact most things I see in general practice are best diagnosed with history and a negative examination.

opinion guy

ZYX wrote: »

I don't see what you are trying to get at here. As a GP the vast majority of people I see and diagnose do not get an investigation to determine diagnosis. So in most cases you do not need an investigation.

Just some very common situations: Abdominal pain, history and examination (especially if exam is normal) are sufficient in most cases. Investigation of headaches- history and negative examination is enough. Skin rashes, viral infections/bacterial infections, mood disorders, the list goes on. In fact most things I see in general practice are best diagnosed with history and a negative examination.

What I'm getting at is that depending on the examination the negative examination can be entirely misleading

ZYX

opinion guy wrote: »

What I'm getting at is that depending on the examination the negative examination can be entirely misleading

So when you said:
A positive exam is very useful. A negative exam is useless.
You didn't actually mean it:rolleyes:

The reality is, a negative examination is massively important in so many conditions and I would hazard that in GP it is more valuable in making a diagnosis than a positive exam.

opinion guy

opinion guy wrote: »

What I'm getting at is that depending on the examination the negative examination can be entirely misleading

ZYX wrote: »

So when you said:
A positive exam is very useful. A negative exam is useless.
You didn't actually mean it:rolleyes:

Eh what ? You just completely reversed the meaning of what I said.

Let me be clear:
A positive exam is very useful. A negative exam is useless = What I'm getting at is that depending on the examination the negative examination can be entirely misleading

These two statements are expressing the same sentiment.
Unless you have some alternate understanding of English that is.

Biologic

opinion guy wrote: »

Lol. Curious who you were discussing how much 'madness' I apparently write. Hmmm you see have your little rant here (no need to ban anyone mods). Tallaght01 I stick with the logical argument. You can't seem to help turning to ad hominems. If you disagree with my point of view then argue the point and give some data to back it up - I gave you data. And it doens't matter what my background is as long as my data and logic is valid - which it is.
Simply tallaght01 - do you believe that 3rd and 4th heart sounds are useful aspects of clinical examination ? And if you do please explain your veiwpoint in light of the study I linked to above.

For someone so versed on logical fallacies (accusing of ad Hominem attacks), you should know that what you're saying is a non-sequitur logical fallacy. Your data may be fine but your logic isn't. Maybe that study regarding heart sounds is right, it doesn't follow that clinical examination is bogus. That's what you implied initially and what riled people (me, anyway) up wrong. If you want to argue that some types of clinical examination have dubious benefits then go nuts, but your initial deductions were way off.

ZYX

You said:

opinion guy wrote: »

Yup it sure can. Never said it couldn't. But NOT ALL THE TIME. The problem is people don't realise the limiitations. A positive exam is very useful. A negative exam is useless. If the history points to something then you will almost always have to do an investigation anyhow.

That quite clearly says a negative exam is useless.
Now you are changing what you are saying to "a negative exam can be misleading". Well of course it can. But then a positive result can be even more misleading and a positive investigation can be even mote misleading again.

The reality is, a negative exam is a vital part if many diagnoses and results in no further investigations being needed

opinion guy

Biologic wrote: »

For someone so versed on logical fallacies (accusing of ad Hominem attacks), you should know that what you're saying is a non-sequitur logical fallacy. Your data may be fine but your logic isn't. Maybe that study regarding heart sounds is right, it doesn't follow that clinical examination is bogus. That's what you implied initially and what riled people (me, anyway) up wrong. If you want to argue that some types of clinical examination have dubious benefits then go nuts, but your initial deductions were way off.

I've said several times I don't mean all clinical exams. But many. I did word it that way initially but that was an error - I'll fixed that now. I am not saying that clinical exam is bogus and should not be done. I am saying that most people put way too much faith in it and that the more objective investigation based US approach is not such a bad thing.

ZYX wrote: »

You said:


That quite clearly says a negative exam is useless.
Now you are changing what you are saying to "a negative exam can be misleading". Well of course it can. But then a positive result can be even more misleading and a positive investigation can be even mote misleading again.

The reality is, a negative exam is a vital part if many diagnoses and results in no further investigations being needed

I'm sorry but this is just absolutely double speak. Misleading is WORSE than useless. Don't you get what I'm saying - making a decision based on a false negative physical examination finding is DANGEROUS AND YOU CAN MISS STUFF.

ZYX

opinion guy wrote: »

I
I'm sorry but this is just absolutely double speak. Misleading is WORSE than useless. Don't you get what I'm saying - making a decision based on a false negative physical examination finding is DANGEROUS AND YOU CAN MISS STUFF.

Congratulations. That must be the stupidest and illinformed comment ever on this forum. If you even lack the basics of how a diagnosis is made I cannot help you. Why do you assume a negative result is a false negative?

opinion guy

ZYX wrote: »

Congratulations. That must be the stupidest and illinformed comment ever on this forum. If you even lack the basics of how a diagnosis is made I cannot help you. Why do you assume a negative result is a false negative?

Why do you assume it isn't ?
My point is you don't know either way.

oh reported for personal abuse by the way.

ZYX

opinion guy wrote: »

Why do you assume it isn't ?
My point is you don't know either way.

oh reported for personal abuse by the way.

I abused the comment not the person.

Many diagnoses are dependent on a normal examination. Tension headaches & irritable bowel are just 2 common examples but there are many more. Now do you get it? Unless the exam is normal you cannot make the diagnosis. If the exam is abnormal then you may have to investigate. In that case the positive exam finding would have been misleading

PhysiologyRocks

History taking can be very productive. Examination can reveal a lot. Investigations can too. Emphasis on "can".

However, disease can be asymptomatic. Even if examination reveals lots of positive signs, the disease may or may not be present (same goes for negative signs). Tests can come back falsely positive or negative too.

No one system is infallible. All anyone can do is combine the above as sensibly as possible. All three aren't always necessary.

Asking how useful examination is is a bit like asking someone how fast their car is.