Cognitive Dissonance

What's wrong with this situation? Sometimes it's the bleeding obvious. Other times, it's the smaller details. What makes us notice and register the oddness, jolting us, momentarily, from our exisiting line of thought or preoccupation...

Why do we notice the grubby child's handprint halfway up an escalator on the metal skirting?

Why notice the elderly lady in perfectly matching skirt, blouse and fabric trolley but no shoes?

Perhaps the junior doctor wearing two stethoscopes?

The teenager strolling around the supermarket with a recently chlorhexidine-ed foot?

Or the hundreds of medical students smiling, joking as they walk into an exam?

Top Docs (viz TV)

Medicine is taught to most people through television shows; having watched (and been inspired by) a fair-few television medics, I thought I'd make a wee list of my top five;

5. For long stretches of the West Wing, it's easy to forget that Abigail Bartlett (played by Stockard Channing) is a medic. She balances her medical career, family and her role as the First Lady with apparent ease. Dr Bartlett shows us that being a medic is part of your life, not your entire life.

4. George O'Malley put his finger in a cop's heart in a broken lift. TR Knight's character in Grey's Anatomy undergoes a mental transition from the "holy crap this is hard and terrifying and I'm tired" to the "hey, this is important and rewarding and I'm good when I focus" in the space of an episode. Realistic self-belief is something that often flourishes when we're put outside our comfort zone; George's elevator operation is less about being a gun whilst saving the officer's life than depicting personal growth under pressure.

3. B.J. Hunnicutt, the foil to M*A*S*H's Hawkeye, always struck a tone with me. His kindness and level-headedness in stressful, ghoulish settings was unbeatable if sometimes unconventional. Additionally, Hunnicutt (Mike Farrell) could rock a moustache like nobody's business. But it's is compassion, caring and inability to say Goodbye that rockets him up this list.
2. Omar Epps as ER's Dennis Grant. It was only in doing some research for this post that I discovered that prior to becoming the superb Dr Foreman on House MD, Epps played a role that affected my early awareness of the stresses of being a junior doctor. I remember watching the character's suicide by train as an early-teenager, and the long discussions it provoked with my parents. It's always been a reminder that medicine is not glory and heroism.

1. John Dorian vs Perry Cox have been battling it out as long as I've been at University; timing that, for me, is not withough significance. Zach Braff and John C McGinley (and Turk/Donald Faison) have managed to broach many of the contorversial and thought provoking aspects of medical ethics, death and whole-person practice that come with in-hospital experience. Evidently, I'm a massive Scrubs fan; each of the doctors on the show have strengths and weaknesses. I'll watch entire seasons on the trot, as much for the issues above as the fantasy sequences, plot, character development or scorching one-liners. The pilot episode "My first day" remains powerful and poingiant enough that I'll drop whatever I'm doing to watch it through. Where JD is overwhelmed by exhaustion, I feel inspiration and joy; It's two months until I face the music.

Hospital Pharmacy

In my final year of pharm school, I promised myself I'd never work as a hospital pharmacist. It's not because I think it's unimportant, nor that Hospital pharmacists play an ineffective role in the health care team. It's because, for all thier skills at detecting errors and spotting interactions, there is just are three vibes that I find frustrating and counter to good patient care.

Firstly, Hospital pharmacists have been known to suffer a loss of perspective. Like the pharmacist who said that an antibiotic needed to be changed because it interacted (significantly) with the patient's statin. The patient is a late-septugenarian, and was unwell. They were to be on antibiotics for five days. The organism was only sensitive to this antibiotic. So, instead of holding the statin for the duration of anti-infective therapy and treating the infection, the pharmacist recommended a change to a less effective antibiotic. I've seen similar situations several times whilst on the wards, including in Intensive Care. Which leads me to my second beef;

Secondly, although this doesn't apply to all Hospital pharmacists, the sense of medicines-related arrogance and condescenion that I've been treated by a number of times is staggering. Notably, the same pharmacists have spoken to ICU consultants with similar disdain, so I don't feel as bad. But seriously, ICU consultants are freaking gurus. In this case, the doc concerned handed the pharmacist their ass on a plate, and deservedly. Good, well-read clinical Pharmacists know a cart-load of information about medications. what they're not so good on is the pathology, physiology and more complex situations. Hospital pharmacists play an essential part of the health team, but they're not the leading role and they're rarely on the same level of knowledge (medication or otherwise) as the specialists in their field. A little respect and understanding of the 'graded assertiveness' pathway would go a long way to improving the hospital pharmacist's face-to-face communication.

Thirdly, rigid thinking is generally unhelpful, particularly in the case of healthcare. Millions of reams have been printed on the importance of 'patient-oriented' care. If a doc writes 'tablets' and the medication only comes as capules, I've heard of hospital pharmacies not dispensing the prescription, or where the alternative is avaiable but not funded, charging a patient ten times what they'd pay for the intended formulation. Moreover, these pharmacists patronisingly note that prescriptions cannot be amended to fix these obvious errors. In community, these slips of the hand, especially for regular medications (think meloxicam caps instead of tabs), are regularly amended an the patient maintained on their exisiting formulation. But not in hospital.

But what was the final step to triggering this wee rant? Recently, a Hospital Pharmacist talked to the graduating crop of med students. She was patronising, absurdly impractical and took great pains to denigrate community pharmacy, along the lines of 'not caring' and 'have no idea'.

Pharmacy is a profession mired in tension - between healthcare and business, between evidence and outcome-based prescribing and bureaucratic penny-pinching. This pharmacist did nothing to assist this situation; Pharmacists need to see eachother for their flaws and strengths.

Sure, Community pharmacists might not have the impractically high knowledege of clinically irrellevant interactions of their hospital colleagues. But they see patients regularly, they know the finer points of how their patients live. Heck, the shop assistants might even visit the patient on a weekly basis. This is community caring; it's how life rolls outside the hospital.

I'm sure this reads as though I've a chip on my shoulder, so let me be clear - Hospital pharmacists save lives. Healthcare is built on knowledge, respect and effective communication between a myriad of health professionals and their patients. Community pharmacy, hospital pharmacy and doctors are on the same team. We need to work together, realistically , practically and with patient care as our focus for good individual outcomes.