Eugene Lloyd
School of Physiology and Pharmacology, University of Bristol, UK

https://doi.org/10.36866/pn.89.18

I would like to use this opportunity to share with you my reflections upon the privileges and challenges of teaching medical students and junior doctors. I studied medicine in the early 1990s and was given the impression that anatomy was the most important preclinical subject. I intercalated in pharmacology and, after qualifying, worked in general medicine. I now work as Senior Teaching Fellow in Physiology at the University of Bristol, and as a Speciality Doctor in Emergency Medicine. I therefore teach medical students throughout their undergraduate years, help to train junior doctors and run a refresher course in applied clinical physiology for trainee surgeons.

One of the great challenges for emergency medicine (and society) is Britain’s ageing population. In 2005 16% of the population was over 65 years old and the International Longevity Centre estimates that this will rise to 21% by 2025. I suspect that health and social reforms have extended the quantity of life but not necessarily the quality. Many of our elderly citizens are living a very vulnerable existence in their homes. Even a minor illness such as a urinary tract infection can make it impossible for them to cope at home and result in admission to hospital. It is not unusual for such a patient to arrive in the emergency department with a carrier bag of their ten or more regular medications.

The introduction of the European Working Directive has resulted in significant changes to the delivery of care for inpatients. The ‘firm’ structure, of a team of junior doctors led by a consultant caring for a patient from admission to discharge, has been partly replaced by a shift system. This requires handover of complex patient information between medical staff. There is no universal approach to handovers – sometimes it’s just a few notes scribbled on a piece of paper and there is huge potential for errors to be made. The NHS Institute for Innovation and Improvement recommends the situation–background–assessment–recommendation (SBAR) tool. I’m pleased that this includes explicit mention of key physiological variables such as body temperature, pulse rate, blood pressure, respiratory rate and oxygen saturation. I discourage students and colleagues from using imprecise terms. I recall being told by a trainee over the phone that a patient had a blood pressure that was ‘slightly low’, and I was horrified to find the patient had an actual blood pressure of 62/40 mmHg due to septic shock!

Medical students are bright, enthusiastic high-achievers and they thrive in a world of social media. Their talents, both academic and extracurricular, never cease to impress me. However, my personal opinion is that some of them don’t cope well with failure or uncertainty and lack resilience. There is a tendency in the early years to ‘learn and forget’ rather than taking a deeper approach to medicine. I’m concerned that the pressures upon them for ranking for the foundation year jobs encourages dysfunctional behaviour rather than the teamwork skills that are so important for the practice of medicine. They also struggle to adapt to learning in the clinical environment. In some cases I think curricular reforms have exacerbated the situation by replacing time spent with patients with more lectures and tutorials, whereas I believe medicine is best learned through contact with patients.

In the emergency department I’m often asked if a medical student can shadow me, which implies a passive type of learning with the student watching what is happening. In contrast, I believe that the learning should be active with the student hearing the patient’s story, examining them, formulating a list of potential diagnoses and interpreting results of special investigations. This can be achieved through discussion between teacher and student with an ethos of shared care and is an excellent opportunity to illustrate key physiological principles. I’ll illustrate this with a very memorable case.

An elderly gentleman was brought to the emergency department by paramedics. They said that the patient had dementia and had fallen. They suspected a diagnosis of a fractured hip. The student helped me to perform the primary survey, a structured approach to seek any potentially life- (or limb-) threatening physiological disturbances. None were found. The secondary survey (a detailed head-to-toe examination) revealed nicotine-stained fingers and that the patient’s right leg was shorter than his left. The patient experienced pain on attempting to lift the leg up off the bed and when his hip was touched. He was too disorientated to tell the story of what had happened. The medical student suggested a diagnosis of a fractured neck of femur and that an X-ray would be the appropriate investigation.

The X-ray showed an unusual fracture of the acetabulum resulting in the head of the femur entering the pelvis. This was the type of fracture described in the Bolam court case of 1957. The jury returned a verdict of negligence as the patient had been given electroconvulsive therapy without being warned of the risks and without neuromuscular blocking drugs. The treatment had resulted in bilateral acetabular fractures. We began to wonder if the patient had fitted rather than fallen. I discussed with the student which investigations should be performed next, including a CT scan of the head and blood tests to include plasma concentrations of sodium, calcium, magnesium and glucose.

While the patient was having the CT scan, his wife and daughter arrived. Although distressed and upset, they were able to tell us that he didn’t have epilepsy but had been standing in the kitchen when he suddenly went rigid, fell to the ground and began to convulse. It had lasted approximately five minutes. They mentioned that his confusion had started about three months ago, prior to which he had enjoyed hobbies such as gardening and golf.

The CT scan showed compressed ventricles and the loss of sulci typical of cerebral oedema without any evidence of a tumour or stroke. Subsequently the biochemistry laboratory telephoned to say the patient was profoundly hyponatraemic with a plasma sodium concentration of 111 mmol/L and a plasma osmolality of 250 mosmol kg–1. I discussed with the student the control of plasma osmolarity and negative feedback. Under guidance, the student suggested a diagnosis of the syndrome of inappropriate antidiuretic hormone (ADH) secretion (SIADH) and suggested that a chest X-ray and measurement of urine osmolarity should be performed.

The urine osmolarity was elevated at 960 mosmol l–1 and the chest X-ray demonstrated a mass that was later confirmed to be a bronchogenic carcinoma. With the student present, I broke the news to the family that the patient had a lung cancer that was secreting abnormal amounts of a hormone that had disturbed his water balance causing his brain to swell and resulting in a fit that caused the fracture. The patient was admitted under the joint care of a respiratory physician and orthopaedic surgeon. The student reflected upon how much basic science across several systems of the body had been involved in this patient’s illness.

One of my favourite sayings is, “To assume makes an ‘ass’ out of ‘u’ and ‘me’”. In the practice of medicine, making assumptions can be dangerous. In my lectures I emphasize to the students that the electrocardiogram records the electrical activity and not the mechanical activity of the heart. Initially they don’t understand the importance of this, so I recount a story of when a junior doctor telephoned me for help because they couldn’t work out what was wrong with one of their patients. Upon entering the room I found the doctor looking at the cardiac monitor that displayed sinus bradycardia with the patient in bed apnoeic and pulseless. This condition, known as pulseless electrical activity (PEA) or electromechanical dissociation (EMD), had puzzled the doctor who had assumed that if there was electrical activity as shown on the monitor, there must be mechanical activity.

When I’m teaching physiology I encourage the students to think about how the human body works. When I’m teaching clinical students I encourage them to think about why these mechanisms have been disturbed, in order to integrate pathology, pathophysiology and to provide safe clinical care.

I would like to thank The Society for awarding me with the Otto Hutter prize and express my thanks to all those who have taught me.