Wednesday, November 15, 2017

The modern Physcian's Pledge to replace Hippocratic Oath?

One of the oldest professional oaths is the Hippocratic Oath, which is now as old as 2400 years old.
The practice pledging this oath begans at the University of Wittenberg in Germany in 1508.
The contents of the oath are still relevant, although pledging in the name of long forgotten medieval Greek gods is probably what makes it out-dated.

A new modern version of the oath, known as ‘The Physician’s Pledge’, encapsulates the essence of the Oath while removing the peripheries has been published in JAMA (click here).

The full text of the 2017 pledge now reads as:
AS A MEMBER OF THE MEDICAL PROFESSION:

I SOLEMNLY PLEDGE to dedicate my life to the service of humanity;

THE HEALTH AND WELL-BEING OF MY PATIENT will be my first consideration;

I WILL RESPECT the autonomy and dignity of my patient;

I WILL MAINTAIN the utmost respect for human life;

I WILL NOT PERMIT considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing, or any other factor to intervene between my duty and my patient;

I WILL RESPECT the secrets that are confided in me, even after the patient has died;

I WILL PRACTISE my profession with conscience and dignity and in accordance with good medical practice;

I WILL FOSTER the honour and noble traditions of the medical profession;

I WILL GIVE to my teachers, colleagues, and students the respect and gratitude that is their due;

I WILL SHARE my medical knowledge for the benefit of the patient and the advancement of healthcare;

I WILL ATTEND TO my own health, well-being, and abilities in order to provide care of the highest standard;

I WILL NOT USE my medical knowledge to violate human rights and civil liberties, even under threat;

I MAKE THESE PROMISES solemnly, freely, and upon my honour.

A very interesting addition to the oath compared to Hippocratic Oath is this:
I WILL ATTEND TO my own health, well-being, and abilities in order to provide care of the highest standard”
This addition has been lobbied by Dr. Sam Hazledine.

To quote MIMS.com,
Dr Sam Hazledine from Queenstown, New Zealand made history by petitioning for the amendment last year, where he obtained 4,500 signatures to include a clause for doctors to focus on their own health as well as of their patients.

I guess it is a solemn reminder that physicians should do what they preach.



Monday, October 09, 2017

Doctor-Patient Communication

The slide deck of a short sharing I gave to a group of first year medical students of Universiti Malaysia Sarawak (UNIMAS). It is indeed a good move to talk about doctor-patient communication early in their medical studies, to expose them to the intricacies, the skill and the art of communicating with patients, including how to break bad news.


Doctor-Patient Communication Skill from Chew Keng Sheng


The best resource on doctor-patient communication that I have found is Skills for Communicating with Patients by Jonathan Silverman, Suzanne Kurtz and Juliet Draper (Amazon link). This text is the first entirely evidence-based textbook on medical interviewing, describing the core skills which represent the foundation for doctor-patient communication

I have found a number of sample chapters that can (still) be downloaded free (these 2 chapters, Chapter 2 and 3, are already informative enough to give us a good grasp on this subject matter):
Chapter 2
Chapter 3

A chapter from its companion volume, Teaching and Learning Communication Skills in Medicine, can be downloaded here:
Chapter 1

Google book also provides a good sampling of the book and the full e-book version can be purchased at the cost of about RM150. Click here for the google book preview version.

And download an article by one of the co-authors of the book (Suzanne Kurtz) here.

Watch a lecture on the art of communication in medicine by Dr. Jonathan Silverman here:

Monday, August 29, 2016

Life Threatening Electrolytes




Slide deck (in pdf) for the above presentation:


Life threatening electrolyte abnormalities from Chew Keng Sheng


Perhaps one thing which I did not make clear in the video and the slide is the use of 3% hypertonic saline:
As 1g of Na = 17 mmol
therefore, 
3% NaCl means
3 g in 100 ml
or 
30 g in 1000 ml (1 L)
= (30 * 17) mmol in 1 L     [since 1 g NaCL = 17 mmol)
= 510 mmol/l 
~ 500 mmol per 1000 ml (1 L)
therefore, 
1 ml of 3% NaCL = 500/1000 = 0.5 mmol ------- Equation 1

Sodium deficit is
[Desired sodium - measured sodium] * Total Body water
= [Desired sodium - measured sodium] * 50% * Body weight (BW)

Now,
let say we wish to raise the serum sodium by 1 mmol/l  a.k.a. [Desired sodium - measured sodium ] = 1 mmol/l]

therefore,
[1*50%*BW] mmol/ = the amount of sodium deficit required

But we know from Equation 1, that 1 ml contains 0.5 mmol
therefore,
    0.5 mmol ------- 1 ml
    (0.5 * BW) mmol -------- (BW) ml

    Therefore, 1 ml per kg BW of 3% hypertonic saline raises serum sodium by 1 mmol/l

    However, as mentioned in the slide, the degree of serum sodium elevation may be more than expected. This is because as sodium is replaced, water re-absorption occurs initially. This removes the hypovolemic stimulus for the release of ADH. As a result, there will be greater degree of diuresis than expected.



    References:
    Parham WA, Mehdirad AA, Biermann KM, Fredman CS. Hyperkalemia revisited. Tex Heart Inst J. 2006;33(1):40-7. Can be accessed FREE here.


    Verbalis JG, Goldsmith SR, Greenberg A, Korzelius C, Schrier RW, Sterns RH, et al. Diagnosis, evaluation, and treatment of hyponatremia: expert panel recommendations. Am J Med. 2013;126(10 Suppl 1):S1-42. Can be accessed FREE here.







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