Picture by Tyler
Picture by Tyler
Among the commonest tests ordered by doctors is a full blood count. The test presents signs of iron deficiency anaemia. The prevalence of that condition is reported as follows:
In Australia in 2011–12, around 760,000 people aged 18 years and over (4.5%) were at risk of anaemia, with women more likely to be at risk than men (6.4% compared with 2.5%). The risk of anaemia was highest among older Australians, with rates rapidly increasing after the age of 65 years. People aged 75 years and older were more likely to be at risk of anaemia than all other Australians, with 16.0% in the at risk range compared with 3.6% of Australians aged less than 75 years. Australian Health Survey
With regard to this blood test (AACC):
Therefore among the pathognomonic features of established iron deficiency anaemia (IDA) is a low Mean Corpuscular Volume (MCV). The sensitivity and specificity of a low MCV for a diagnosis of iron deficiency anaemia are quoted as 42% and 93%. Assuming a prevalence of 3.6% in the under 75 year old age group this means that if 100 adults in Australia had a full blood count then 3-4 will have iron deficiency anaemia. Screening these people for IDA with this test 8.3% of people will be told they have an abnormal test i.e. 8 people. Of these only 1-2 will be a true positive for IDA. On the other hand 6-7 may be misled into thinking they might have iron deficiency. 91 will be told they have a normal test in this case 2 may be incorrectly reassured. Of course there are other significant conditions which present with a microcytosis ( low MCV) although ‘treatment’ is not necessary in many such cases and also screening for IDA involves other and more sensitive tests.
If the prevalence of the condition was 20%, then even the modest sensitivity and specificity of this test would identify more people at risk of IDA even though it will also miss people with the condition.
In practice the sensitivity and specificity of tests may be assumed closer to 90% in each case. Given these figures the numbers of people from 100 people test and correctly identified, incorrectly reassured or told they are ill depends on the prevalence. The prevalence of most pathology in the community is low often well below 1%. The figures are presented in the infographic below.
Prevalence 0.005% ( 5 per 1000 people, e.g. hypothyroidism ) 2% ( e.g. diabetes) 20% (e.g. common and plantar warts).
From these figures it can be seen that testing is more fruitful in circumstances in which the prevalence is high. The prevalence is higher in those who have signs and symptoms of a condition. One could argue therefore that the ‘prevalence’ is much higher in those who choose to consult a doctor as opposed to the ‘prevalence’ in the community. For iron deficiency anaemia these circumstances are well known. Which means an effective consultation in which the patient is heard and examined is crucial to interpreting test results. As can be seen from the calculations there is a substantial risk of labelling people as ill, or requiring yet more tests given the modest prevalence of most conditions in the community and where there might be an indiscriminate use of tests.
It is hard to disagree with Campbell and colleagues who considered this issue and noted that:
1) Diagnosis is based on a combination of tests and clinical examination and there is little research based on the sensitivity and specificity of the combination of different examinations as opposed to a one-off test, which is why GPs are unlikely to know the values.
2) It is unclear what is meant by the prevalence of asthma or diabetes for these GPs. It is not the proportion of people in the population with the disease, but rather the proportion of people who come to consult who have the disease (perhaps with similar age and clinical history). This proportion is likely to be quite high and so the issue of overestimating the positive predictive value is less important.
3) The prevalence of the disease will also depend on the severity of the disease being tested for and so this also muddles the calculations.
We might however equally reasonably expect doctors to have an understanding of the issue if only because the practice of medicine involves the most crucial of ‘tests’ the history and the examination and this issue highlights the importance of that activity. Tests that are not appropriately interpreted can be harmful if only because they become a source of anxiety.
Picture by Aplonid
The ideal innovation is inexpensive, readily incorporated into practice and has substantial patient benefits. In this context the humble physical examination is a strong candidate. However it is reported that in practice laboratory and or radiological tests are requested more often than not. Here is a quote from an editorial in the British Medical Journal (2009):
In the first camp are those who pine for the old days, bemoan the loss of clinical bedside diagnostic skills, and complain that no one knows Traube’s space or Kronig’s isthmus. In the second camp are those who say good riddance and point out that evidence based studies show that many physical signs are useless; some might even argue that examining the patient is just a waste of time. Verghese and Horwitz
Research suggests that most diagnoses are based on the history and examination:
In this prospective study of 80 medical outpatients ….in 61 patients (76%), the history led to the final diagnosis. The physical examination led to the diagnosis in 10 patients (12%), and the laboratory investigation led to the diagnosis in 9 patients (11%). The internists’ confidence in the correct diagnosis increased from 7.1 on a scale of 1 to 10 after the history to 8.2 after the physical examination and 9.3 after the laboratory investigation. These data support the concept that most diagnoses are made from the medical history. The results of physical examination and the laboratory investigation led to fewer diagnoses, but they were instrumental in excluding certain diagnostic possibilities and in increasing the physicians’ confidence in their diagnoses. Peterson et al
In only one of six patients in whom the physician was unable to make any diagnosis after taking the history and examining the patient did laboratory investigations lead to a positive diagnosis. BMJ 1975
Also the value of tests is contested in some cases:
Information from the history, physical examination, and routine procedures should be used in assessing the yield of a new test. As an example, the method is applied to the use of the treadmill exercise test in evaluating the prognosis of patients with suspected coronary artery disease. The treadmill test is shown to provide surprisingly little prognostic information beyond that obtained from basic clinical measurements. The JAMA network
A considerable number of plain abdominal films taken for patients with acute abdominal pain could be avoided by focusing on clinical variables relevant to the diagnosis of bowel obstruction. European Journal of Surgery
However the predictive value of the physical examination appears to depend on the clinical scenario. If the patient appears ill it is far more likely that they will have clinical signs:
In order to study the occurrence and positive predictive value of history and physical examination findings suggestive of serious illness in ill-appearing and well-appearing febrile children, 103 consecutive children aged ≤24 months with fever ≥38.3°C were evaluated from July 1, 1982 to Nov 24, 1982….The positive predictive values of abnormal physical examination findings for serious illness in ill-appearing (11 of 14, 79%) and well-appearing children (3 of 12, 25%) were significantly different (P = .02 by Fisher’s exact test). The trends for abnormal history findings in ill-appearing and well-appearing children were similar to those for abnormal physical examination findings but did not achieve statistical significance. The results, indicating an important interaction between a febrile child’s appearance and physical examination findings, are discussed in terms of probability reasoning in clinical decision making. McCarthy et al
In some common clinical scenarios it is difficult to find objective evidence in support of a diagnosis and tests are necessary. There are many examples including:
Irritable bowel syndrome
Individual symptoms have limited accuracy for diagnosing IBS in patients referred with lower gastrointestinal tract symptoms. The accuracy of the Manning criteria and Kruis scoring system were only modest. Despite strong advocacy for use of the Rome criteria, only the Rome I classification has been validated. Future research should concentrate on validating existing diagnostic criteria or developing more accurate ways of predicting a diagnosis of IBS without the need for investigation of the lower gastrointestinal tract. Ford et al
Differences in clinical parameters in heart failure patients with decreased versus normal systolic function cannot predict systolic function in these patients, supporting recommendations that heart failure patients should undergo specialized testing to measure ventricular function. Thomas et al
Thirty one consecutive patients with a first flare of shoulder pain were prospectively included in the study. All had a physical examination performed by two blinded rheumatologists. Ultrasonographic examination was carried out within one week of the physical examination by a third rheumatologist experienced in this technique who had no knowledge of the clinical findings. Ultrasonography was considered the optimal diagnostic technique. Naredo et al
Also relevant are the physician’s skill in eliciting and interpreting signs:
Agreement between 24 physicians on the presence or absence of respiratory signs was investigated. The physicians were divided into six sets of 4; each set examined 4 patients with well-defined chest signs. There was generally poor agreement about particular signs. Overall, the 4 physicians in a set were in complete agreement only 55% of the time. Some signs such as wheezing seemed to be more reliably elicited than others such as whispering pectoriloquy. Comparison of diagnoses based on the clinical findings with the correct diagnoses supported by investigations showed that 28% of physicians’ diagnoses were incorrect. The more often the examiners differed from the majority on the presence or absence of a sign, the more likely they were to make an incorrect diagnosis. The Lancet
In some cases physical signs are unreliable:
A review of published studies of patients suspected of having pneumonia reveals that there are no individual clinical findings, or combinations of findings, that can rule in the diagnosis of pneumonia for a patient suspected of having this illness. However, some studies have shown that the absence of any vital sign abnormalities or any abnormalities on chest auscultation substantially reduces the likelihood of pneumonia to a point where further diagnostic evaluation may be unnecessary. JAMA
Therefore always relying on physical signs without conducting tests is unsafe. However the value of the clinical examination as an integral part of the patient experience was eloquently articulated in the BMJ editorial:
A third view of the bedside examination, and one that we advocate, is that it is not just a means of data gathering and hypothesis generation and testing, but is a vital ritual, perhaps the ritual that defines the internist. Rituals are all about transformation. The elaborate rituals of weddings, funerals, or inaugurations of presidents are associated with visible transformation. When viewed in that fashion, the ritual of the bedside examination involves two people meeting in a special place (the hospital or clinic), wearing ritualised garments (patient gowns and white coats for the doctors) and with ritualised instruments, and most importantly, the patient undresses and allows the doctor to touch them. Disrobing and touching in any other context would be assault, but not as part of this ritual, which dates back to antiquity. Verghese and Horwitz
Common sense dictates that where the patient appears unwell the physical examination will have a higher yield. In those circumstances clinical examination is crucial:
Misdiagnosis of acute appendicitis is more likely to occur with patients who present atypically, are not thoroughly examined (as indexed by documentation of a rectal examination), are given IM narcotic pain medication and then discharged from the ED, are diagnosed as having gastroenteritis (despite the absence of the typical diagnostic criteria), and with patients who do not receive appropriate discharge or follow-up instructions. Rusnak et al
Therefore the physical examination has an incalculable value not necessarily obviating the need for tests but increasing patient satisfaction and reducing the risk of litigation. Click the link for an excellent video on examination.
Those who talk about the future of healthcare often describe the world as if the patient were a robot. They speak of devices and computers that will tell us what nature has already equipped us to know:
I haven’t slept well, I didn’t do much exercise today, I ate too much and I drank too much.
Many futurists appear to believe that providing information on a small screen will be enough to make all the difference to our behaviour. Doctors know this is a fantasy driven by commercial interests because they also know by virtue of their experience that so much of what we choose is contingent on more than just information. Some of these ‘innovations’ are losing market share faster than the receding snow cap of Kilimanjaro.
The overwhelming evidence is that if I decide to stop smoking it isn’t just because of the information that tobacco causes cancer. If I commit to jogging four days a week it isn’t only because of information on how little I’ve moved today. These decisions are driven by much deeper psychological factors. We are ready to act on this ‘information’ only when the compulsion to make new commitments is greater than the urge to maintain the status quo. This happens in teachable moments. These are unique to each of us. When there is motivation and ability but we are also triggered to act then as BJ Fogg proposes we will do something different. Noting that we will sustain the effort only as long as it is a new habit. Therefore the task in the consultation is to gauge the motivation, enhance the ability, trigger the action and help to generate the habit.
The future of healthcare isn’t simply about access to information, whether on a wrist band or on a video screen. It isn’t only about access to the doctor or some pale imitation of the real thing. The world of healthcare cannot exclude the physical presence of the practitioner as the one who can address all four aspects noted above by engaging people at the deepest human level. However as a starting point to designing the future we note that doctors are often at odds with the patient in the consultation:
There is evidence of a discrepancy between the numbers of problems noted by the patients and their doctors. It is possible that this is because doctors give priorities to certain diagnoses while ignoring others. Doctors may also focus on a known pre-existing condition of a particular patient rather than attending to the actual reason for the encounter. Thorsen et al
The authors further conclude:
The vast body of literature covering consultation patterns focuses on patients’ reasons for deciding to consult. Little research has focused on what patients have on their minds while in the waiting room regarding the forthcoming consultation.
Policy change that aims to turn back the clock so that people are forced to visit the same doctor who will do the same old thing….sound uninspired. If we consider the consultation as theatre then there are aspects that cannot be changed. Neither the actors nor the the plot (healthcare) can be changed. Patients will attend doctors who are trained to take a history, examine the patient and prescribe treatment. However the props and the script can be used to greater effect. These components impact on what the patient can see, smell, taste, hear and feel. The impact of these on the outcome of the consultation is the same as the impact on the person’s decision to buy anything.
The economic reality is that people will be reticent to pay for something that is cheaper or readily available free elsewhere. However they are willing to pay for services that offer an experience. What is becoming a driver for innovation in primary care is the need to offer patients not only what they need but also what they want in terms of engagement with the practitioner. It is about changing how people feel in that space that we call an ‘office’ but could be redesigned as a ‘health pod’ in which the choreography aims to make it easier to identify teachable moments and trigger better outcomes. An office is for bureaucrats, accountants and lawyers. We need to create a new environment that is conducive to selling health and healthy living.
If you are a doctor try this you might be surprised by the result:
How else can you make the patient feel more valued in the encounter?
Picture by Jeff Warren
It was a Friday evening. It’s almost always a Friday when this sort of case presents. She was in most ways unremarkable. She smiled readily, wasn’t evidently confused and worked in a senior administrative role. She came after work. This was the story:
I have a pain in my shoulder that becomes intense in my left arm pit. I can hardly bear to touch my arm pit. My hand becomes numb and cold. Today it’s so bad I’m finding it hard to turn the steering wheel.
I had 15 mins to sort this out, no scans, no blood tests, no discussion with a ‘team’ of young doctors working to pass their exams. She was describing symptoms that may have indicated a neurological emergency. And yet none of it made sense. She hadn’t fallen or been involved in any other trauma. There was no rash, no swelling. She swung her left arm over her head without any difficulty. I could not detect neurological signs, reflexes were normal. No Horner’s syndrome. No breast lesion. No obvious sensory loss. Twenty minutes later I could find nothing in her records or in her presentation that gave me any clue to the cause of these symptoms. And yet she was clearly worried. Regardless of the outcome I had to achieve one thing- this person like every other person who seeks help from a general practitioner needed to know that she had been taken seriously. Not for us the option of sending her back to whence she came with a note:
No organic pathology. Refer elsewhere.
A number of possibilities came to mind. Top of the list was ‘brachial plexus neuropathy‘ or Thoracic Outlet Syndrome. There were no objective signs at the time of presentation and I had never seen this before albeit that I had read about it sometime while at medical school. But then that’s primary care. We are the first port of call for anyone entering the healthcare system and often they present too early for anything to have manifested objectively. Not for us the text book presentation. About this diagnosis we know that:
Damage to the brachial plexus usually results from direct injury. Other common causes of damage to the brachial plexus include:
Brachial plexus neuropathy may also be associated with:
There are also numerous cases in which no direct cause can be identified.
We also know that:
Signs and symptoms of thoracic outlet syndrome vary from patient to patient due to the location of nerve and/or vessel involvement. Symptoms range from mild pain and sensory changes to limb threatening complications in severe cases. Physiopedia
Diagnosis is difficult, tests and examination can be normal, prognosis is variable. By the time a diagnosis was made weeks later and she presented to a specialist everything was obvious. But on that Friday evening with a surgery full of patients I was on my own. My patient trusted that I would not let her walk out of there only to lose a limb. Assuming a benign cause she would be back and need more. This was the start of a longterm relationship and how I managed this episode would set the tone for the duration.
While improvement may begin in one to two months, complete functional recovery may not be achieved for up to three years or longer in some cases. Tsairis et al
Picture by Mahree Modesto
There’s a wonderful video that illustrates the point I’m making this week. You can see it here.
It is assumed that continuity of care is a good thing. That if you consult the same doctor every time then you will benefit with better health. We all have relatives who insist on seeing the same doctor every time. No one but Dr. X will do. Yet doctor X has all sorts of interesting approaches to their problems and despite knowing Aunt Mildred for years hasn’t twigged that her latest symptoms may be a manifestations of some family drama. She might suddenly be more bothered about her aching hip because Uncle John is making her miserable or making her carry the shopping on their visits to the supermarket.
So, is there strong evidence that people who consult the same doctor at every visit are:
The evidence is equivocal at best. Even the most ardent supporters of continuity conclude that there is ‘lots more research needed’.
So what does that tell us?
Perhaps it suggests that simply because people choose to see different doctors does not necessarily mean they are opting for, or receiving, inferior care.
When it comes to test ordering ‘walk-in’ patients are not necessarily after tests and there is some evidence that those doctors who order tests in the hope of ‘satisfying’ the patient are misguided.
There is lots of evidence that ‘continuity of care’ increases trust in a doctor. As per the example of Aunt Mildred. But there is no evidence that Aunt Mildred will be better off trusting her doctor because ‘trust’ ( which isn’t consistently defined) does not guarantee better outcomes. If Aunt Mildred attends here GP presenting with symptoms of bony metastases and is referred for urgent investigation because her GP recognises the clinical signs then she will have been well served regardless of whether she attends Dr. X, Dr. Y or someone at another practice. The point is one of them should spot the moonwalking bear.
Picture by torbakhopper
You’ve heard it before
I’m at that age doctor when I should have a full body scan. Like it’s being offered here.
or at the very least
Can I have a scan doctor?
When offered radiological tests immediately the public is led to believe that such investigations are necessary. In Australia between 1996 and 2010, total CT scan numbers have increased almost 3 fold. (Medicare Australia, Group Statistics Reports 2010, Report No. 2. Available from here). The number of CT scans is reportedly growing at about 9% each year in Australia. In the USA there are estimated to be 62 million scans per year as compared with about 3 million in 1980 with growing concern about the wisdom of exposing people to increasing levels of radiation.
At the same time the value of most tests carried out is also in doubt. In a study of an academic medical department it was concluded that:
…almost 68% of the laboratory tests commonly ordered…. could have been avoided, without any adverse effect on patient management; this figure corresponds to 2.01 unnecessary tests ordered/patient during each day of their hospitalisation. Miyakis et al
In the context of hospital medicine inappropriate test ordering adds to the cost of healthcare. In primary care there is the additional concern that tests fail to achieve any useful outcome. The patient may experience considerable dissatisfaction with the failure of diagnostic tests to explain their pain and may feel they they are being labelled a malingerer.
Therefore one might pause to reflect before requesting yet another investigation. Physical examination, which arguably obviates the need for many tests has an enormous value to the patient even in the context of advanced cancer.
Most patients (83%) indicated that the overall experience of being examined was highly positive (median score, 4; interquartile range [IQR], 2-5; P ≤ .0001). Patients valued both the pragmatic aspects (median score, 5; IQR, 4-5) and symbolic aspects (median score, 4; IQR, 4-5) of the physical examination. Increasing age was independently associated with a more positive perception of the physical examination (odds ratio, 1.07 per year; 95% confidence interval, 1.02-1.12 per year; P = .01). Kadakia et al
According to Paul Little and colleagues reporting in the BMJ perceived pressure from patients is a strong independent predictor of whether doctors examine, prescribe, refer, or investigate in primary care. It seems, at least in part that we may be responding to such pressures to order necessary tests. On the other hand our perception of the value of examination may be blunted. As Professor Little wrote:
The doctors thought, however, there was no or only slight medical need among a significant proportion of those examined (89/580, 15%), given a prescription (74/394, 19%), or referred (27/125, 22%) and among almost half of those investigated (99/216, 46%).
One could argue with the doctors’ impressions of the ‘need’ for medical examination. To some extent it is necessary in every case. We may be losing the sight of the therapeutic effect of the examination as part of effective communication in primary care. There is a need to revitalise our ability to heal. At a time of increasing costs in healthcare examining patients is a relatively low cost intervention with significant potential to improve outcomes.
Picture by COM SALUD
A timeless and effective innovation:
The best one yet is the humble tongue depressor. How does your gadget, gizmo or app compare?
I recall our then 14 year old returning from a visit to his GP.
Dad, he didn’t even examine me!
It seems the doctor did not look into his sore throat and somehow the patient felt ‘cheated’.
But son, it wouldn’t have made any difference if he did look in your throat, doctors can’t tell if a sore throat is cause by a virus or something else just by looking at it.
I know that dad but the ‘magic’ is in the examination.
That from a 14 year old! A few months later an older woman consulted me with the ‘worst sore throat ever!’ I took a history of what sounded like a upper respiratory tract infection and the examined her very unimpressive throat with said wooden spatula. As I turned away to put it in the bin she said:
There’s one more thing doctor. For the first time in ten years I haven’t been able to afford books for my kids going to school. So I’ve been working as a prostitute.
It is possible or even probable that she would have told me this anyway. However I posit that the an examination with a wooden spatula is a profoundly intimate act. It changes the dynamic in the consultation when your doctor is able to see your sore red throat, is able to notice what you had for your lunch, whether you clean and floss your teeth and smell your bad breath. These intimate details are not shared with everyone or even with our most trusted confidantes. Indeed breath odour has been associated with a very significant impact on self image:
…smell from mouth breath odour can connect or disconnect a person from their social environment and intimate relationships. How one experiences one’s own body is very personal and private but also very public. Breath odour is public as it occurs within a social and cultural context and personal as it affects one’s body image and self-confidence. McKeown
In that context further disclosures can follow an examination of the mouth in a way that can change the diagnosis and management.
That is a truly valuable innovation.
Picture by USMC archives
I recall the awkward silence when I couldn’t decipher the carotid angiogram thrust at me on Monday morning. As a newly qualified doctor who’d spent the weekend on-call, I would not have been able to describe my route home much less recognise the stenosis in the relevant cerebral artery. Never mind ‘doctor’ spat my boss. Tell us is the patient I’m about to operate on a nice man? He said winking at the gathered retinue.
Actually professor he is. Trouble is he asked me the same question about you and as you can see I’m not a very good liar.
That cheeky reply probably spelled the end of my surgical career. This style of ‘education’ was known as pimping and that day I had just refused to accept it. Among the legions of would-be doctors, there are a few who will go on to be brilliant in the course of their careers. There are those who will one day discover the cure for Alzheimer’s or cancer. There are those who will perform surgery to save life against impossible odds. There are those whose pills or devices will earn fortunes. But brilliant are also those who will reassure and revive. They will be the unsung heroes whose name won’t appear on any honour’s list. They will offer that undefinable quality that helps us to prime our regenerative capacity and immune systems, more often than not in spite of the limitations of technical fix-its. Those who will be the healers of tomorrow already have the qualities within them even before their first anatomy or physiology lecture. They are intelligent and resourceful but also have an innate sense of what to do when faced with a human being in distress. Our job is to hone those qualities and help them to recognise the precious gift that lies dormant until it is needed on the wards, in the clinics and at the bedside. It is truly a privilege to be part of their journey to nurture their talent despite the many disappointments and frustrations that are part of the landscape of any medical career.
We conclude that compassion is everyone’s business and that learners require early and sustained patient and client contact with time for reflection to enable the delivery of compassionate care. Davin and Thistlethwaite
What the world needs is healers, not technicians because doctors care for people and not machines. So in answer to my boss’s question the man he was about to operate on was an incredibly nice person. He would hail us over in the middle of our shift and insist that we took the fruit that his family had brought knowing that we were unlikely to have made it to the canteen before closing time. My boss really was an excellent technician. What helped the patient through this episode wasn’t just this technical skill, it was the compassion and concern that was lavished on him by the dedicated team of nurses and doctors who would ensure that he was pain free, that his questions were answered, his wounds were dressed and that his family were informed of his progress through intensive care and on the wards as was his wish. I’m sure he remembers his surgeon fondly as the brusque, brilliant and efficient man who helped keep him from a stroke but I’m sure he also remembers the junior doctors who would come to him in the middle of the night when his temperature spiked and the staff nurse was worried that his wound was infected. Without this care what was a difficult time for the family would have been a nightmare and the outcome may not have been as good. There were many times during that illness that we came close to losing that patient except that he had the resilience to hold firm to life and we were in his corner.
Picture by Spirit-Fire
For months, my wife had been worried about the mole. I couldn’t see anything wrong with it but then it was on my back and I was peering at it through a mirror. In the end, she put the job of getting it examined by a doctor into my diary and it became ‘urgent and important’.
I decided I’d ask my colleague in the office next door if he could recommend a dermatologist.
Do you want me to take a look?
I hated to impose, it seemed hardly worth wasting a surgeon’s time looking at something I was convinced was benign.
Without a second thought, he bounced out of his chair and headed to his car appearing a moment later with a head-mounted magnifier.
It looks benign. However I have three rules with these things. We remove it if your wife is worried about it, if you are worried about it or if I’m worried about it. It’s a five-minute job. We can’t be sure until it’s sent to the lab. But you know that.
He smiled kindly. It was a small courtesy to a colleague, but a telling example of how a man you had been a surgeon all his life could still be spontaneously kind. His rule made excellent sense. This behaviour is not in any medical textbook. It’s not recognised as an ‘innovation’ that can improve outcomes. It’s just plain old-fashioned, good-natured thoughtfulness. It doesn’t require a grant or a special piece of equipment or anyone’s approval. It makes all the difference to all of us every day. It’s the sort of thing that speaks of vocation. I’m grateful that my colleague works with me, he is a wonderful communicator and that matters when you are training future doctors.
Picture by British Red Cross