Anaesthesia final exam candidates have completed their written and medical vivas – proving that it is a survivable experience.
Waiting to be invited to the next round of anaesthesia vivas can be trying. Don’t wait until the results to resume your preparations with enthusiasm. Knowledge and training are never wasted! Welcome the experience.
Evidence shows that rest and exercise are important elements to effective and improved learning…. There are also a couple of new videos to help you refresh your efforts for the next phase of preparation – watch the trainee space!
Best wishes to you all!
Canberra Medical viva candidates (with visitors!) – what would you rather be doing March 2018
Boot Camp 2018 was the biggest and (I would say) best yet.
With administrative support from ASA’s Jade Melville, Jo and Rod Katz – the program and the all-important breaks flowed very smoothly1 78 delegates and 6 faculty represent a lot of looking after – thank you all.
The John James Foundation kindly supported Boot Camp with their outstanding facility for the weekend.
Drs Steve Davies, Nicola Meares, Carmel McInerney, Linda Weber and Sally Wharton were a very hard-working part of the program: myth-busting isn’t easy!
Thank you to all of the delegates – there was an infectious buzz in the room. Best wishes to you all for effective preparation and outstanding performances for March-May!
Mercy Ships is a global charity that has operated hospital ships in developing nations since 1978, bringing hope and healing to the forgotten poor by mobilising people and resources worldwide, serving all people without regard for race, gender or religion.
Anaesthetist Dr Kara Allen of Monash Simulation reviewed “Anaesthesia: the gift of oblivion and the mystery of consciousness” – a new work by Kate Cole-Adams. Dr Allen’s review was written for theconversation.com.
The French refer to the emergence from general anaesthesia as “réanimation” – literally to restore consciousness. This is a crucial attribute – that consciousness will return following the desired period of oblivion. This is skilfully explored in Kate Cole-Adams’ book Anaesthesia.
Cole-Adams delves into questions about consciousness and self. Are we restored fully to self or does the experience of anaesthesia change us in a way that may not be measurable? The result is a nuanced, powerful book, grounded in Cole-Adams’ decision to undergo scoliosis surgery, and developed around the analogy of submerging in a bottomless sea and breaking into wakefulness like a swimmer surfacing from the depths.
Anaesthetists have a short time to establish rapport with a patient who is quite literally putting their life in our hands. We know our purpose is to provide unconsciousness and analgesia, so short-term harm can take place for long-term gain. Cole-Adams writes eloquently:
It is a form of denial that enables them to act upon us in ways that would otherwise be unthinkable. To ignore the ghostly griefs and joys and hopes that trail each of us into the operating rooms, and to get on with the vital business of slicing, splicing and excision.
Occasionally the book strays into the sensational, particularly with reference to studies investigating situations where people have become aware while under anaesthesia, but don’t have a memory of this happening. But predominantly, Cole-Adams writes compassionately and competently about the art and science of anaesthesia, and of practitioner and patient.
As a practitioner, it’s fascinating and beautifully written. Some 50% of the population of Australia and New Zealand are not sure that anaesthetists are doctors, so a book that outlines the contribution of a specialist anaesthetist is very welcome.
Much of Cole-Adams’ focus is on two of the biggest aims of anaethesia: rendering the person unaware of what is happening, and ensuring they don’t remember it later. She also explores the complex question of consciousness – if we don’t form memories of an experience, and have no detectable conscious perception at the time, does the experience cause us harm?
Awareness and recall under the knife
Cole-Adams explores the phenomenon where people become aware during surgery, and can remember it. This is known as “awareness with recall”. There’s no doubt awareness with recall is an important problem with profound implications for the patient.
A large study found the number of patients aware during surgery was extremely low (measured by validated questionnaires administered after the operation), although some procedures (such as those with very large volumes of blood lost) and patients (such as those with severe heart or lung disease) were at higher risk than others.
Most cases were brief and not associated with distress or pain. Compassionate, timely disclosure of the events leading to the awareness and psychological support decreased long-term implications such as post-traumatic stress disorder, which could otherwise be severe.
She examines several “spooky little studies” that found people were aware under anaesthetic, but spends less time on the studies that failed to find evidence these things occur. The popular press like to focus on graphic and shocking stories, but it’s important to remember these are rare and extreme cases.
She also explores “perception under anaesthesia” – where a person may show a preference for certain words or images they heard or saw under anaesthesia. Studies have shown the overwhelming majority of patients have no detectable memories or evidence of consciousness under general anaesthesia.
And does it matter if someone perceives they’re in surgery while under anaesthetic if they don’t remember it afterwards? We don’t have enough information to say perception while undergoing surgery won’t affect someone psychologically if they don’t remember it. The process of surgery and post-operative recovery can all take a psychological and physical toll. It’s an interesting question, but almost impossible to answer.
Awareness is a rare but real problem that should be examined, whereas we’re not really sure perception under anaesthesia exists. And if it does, we don’t know if it would affect the patient at all since they have no memory of it.
Consciousness is a continuum – from drowsy through to completely inert. In situations where sedation is required, anaesthetists will administer drugs to cause amnesia, reduce pain and occasionally cause brief periods of unconsciousness. There are no hard and fast barriers between sedation and general anaesthesia – “deep sedation” often looks very much like general anaesthetic.
As consciousness recedes, harm to heart and lung function are more likely. This is particularly concerning when sedation is administered by health professionals without specialty training or indeed medical training. Only the term “specialist anaesthestist” is protected, so a less qualified person may administer anaesthesia or sedation, for example by the proceduralist in cosmetic surgery or dentistry. It’s one thing to put a patient to sleep; it may be a more difficult task to wake them up again.
This is fundamentally a story, not a scientific text, and has the potential to be slightly alarming for the uninitiated. We are fortunate in Australia that anaesthesia is extremely safe and highly reliable, but often there is emphasis on complications in the media. Cole-Adams has thought deeply about these topics, resulting in a book that is an exploration of the psychological, physiological and at times philosophical roles of anaesthesia and the implications for modern surgery.
For the interested reader, it’s an outline of the science, with an emphasis on the unknown. For the practitioner, it’s a patient experience, eloquently expressed. There’s much more to anaesthesia than meets the eye, and this book provides a glimpse into the depths.
Ockham’s Razor – the ABC Radio National program for all things scientific – presented a thoughtful piece on pseudoscience this morning.People are free to choose whatever they like, but governments should spend public money on research, universities and healthcare in a rational manner.
Consistent and coherent courses should be offered in universities. Homeopathy is based on the premise of “like cures like”, a claim that a substance that causes the symptoms of a disease in healthy people would cure similar symptoms in sick people. This is a theory that is inconsistent with all modern pharmacology and medicine.
In 2013, the National Health and Medical Research Council (NHMRC) concluded that “There is a paucity of good-quality studies of sufficient size that examine the effectiveness of homeopathy as a treatment for any clinical condition in humans. The available evidence is not compelling and fails to demonstrate that homeopathy is an effective treatment for any of the reported clinical conditions in humans.”
Do pharmaceutical reps really influence doctors’ prescribing?
I believe, with the wide availability of independent medication information, I do not require promotional material from visiting sales representatives from pharmaceutical companies (‘Drug Reps’). The primary role of the Drug Rep is marketing: encouraging doctors to prescribe their company’s medications. This conflicts with my role to provide the best evidence-based treatment and independent advice to my patients. I therefore take this ‘No Advertising Please’ pledge and choose not to see Drug Reps at my practice for one year.
It seems highly unlikely that pharmaceutical companies would spend so much money on promoting their products to doctors via pharmaceutical reps – more than US$6 billion annually in the USA – if reps were ineffective. It would also be irresponsible to their shareholders to spend money in this way. Unfortunately for those of us outside the pharmaceutical industry, we don’t get to see much of the industry’s data on the effectiveness of promotion.
We don’t see the data, but the companies do. We know that the profit from each rep must outweigh their total annual cost: salary, vehicle, training, gifts and other add-on costs. And we know the rep’s only method of making a profit is to influence what flows out of the doctor’s prescription printer.
Specifically, the profit comes from the extra volume of company products the doctor prescribes after seeing the rep, compared to the volume they would have prescribed anyway if they had not seen the rep. If this difference was nil or minimal (as many doctors claim would be their own case), all drug rep jobs would have vanished long ago. In fact, the after-costs profit from these extra scripts presumably totals more than $6 billion annually in the US, or the pharmaceutical industry needs some new accountants!
Many researchers have tried to study direct examples of whether promotion is linked to prescribing changes, and whether these prescribing differences are good or bad. In 2010, Geoff Spurling and colleagues did a systematic review of all such available studies looking at the provision of information from pharmaceutical companies and doctors’ prescribing. This included pharmaceutical reps, print advertising, meeting sponsorship and so on. They found that promotional information was not always linked to changes in prescribing, but when it was, it was almost always associated with more prescribing, lower quality prescribing, and more expensive prescribing. (Spurling)
Better information is readily available!
In Australia, NPS Medicinewise is a well-resourced, independent body which offers practical tools and evidence-based resources on various therapeutic topics to support quality use of medicines and medical tests. It provides extensive, free online resources and decision-making tools for health professionals. NPS also provides free facilitator visits to medical practices, which we recommend as an excellent alternative to visiting pharmaceutical reps.
Rather than focusing on just one drug—let alone just one brand of one drug—the NPS facilitators and resources compare the various available treatments for a particular disease or symptom. This ‘evidence-based comparison’ approach offers a far better basis for balanced clinical decisions than does a series of marketing visits and leaflets advocating the benefits of each individual medicine brand.
For the same reason, the Australian Medicines Handbook – is a practical, reliable, comparative medicines information resource. Again, the availability of this time-saving, independent resource provides a counter argument to doctors who claim they must obtain a ‘balanced’ view by seeing all the drug reps from rival companies.
The Australian Therapeutic Guidelines prides itself on publishing independent, unbiased and objective information about medications. They have no sponsors, advertisers or shareholders, and maintain strict and transparent conflict of interest guidelines. The Therapeutic Guidelines series covers fifteen topics, with advice about the use of nearly every therapeutic medication most doctors would ever use.
The product information (PI) for every drug approved by the TGA is readily available online, just a couple of mouse-clicks away. The PI has been written by the pharmaceutical company, and provides the scientific basis for all the clinical claims allowed to be discussed by their pharmaceutical representatives.
There are many other good sources of medication information online published by government bodies and hospitals (e.g. Melbourne’s Royal Children’s Hospital handbook and pharmacopoeia), and it is important to look for those that are more independent, and transparent about potential conflicts of interest. Independence is not all-or-nothing, and some judgement is called for when comparing sources. However, to put this into perspective, remember that visiting pharmaceutical representatives, by definition, have substantive conflicts of interest and are never independent.