Just a note to say that I’m retiring this blog and moving onto a new one, to be hosted at http://hughstephens.me . The new blog (Rants & Raves) is a lot more general, and a place where I feel more at home writing about anything that crosses my mind or path. This blog’s previous posts are now hosted there.

For a bit more about why I decided to open a new one, read the first (new) post, ‘New Beginnings‘.

Thanks everyone for the adventures and fun. Here’s to hopefully more frequent blogging and many updates to come.

Hugh

I’ve made up a bit of a summary (that isn’t that short! 1 and a half hours of tweets is more than you’d expect) and have included it below.

I’ve posted the article on the One Step Further site, so head over to read it.

I really wanted to push that we need to work toward public health education in our medical schools. Future doctors need to know and understand how to make meaningful change not only on the individual level but be able to contribute to larger-scale public health initiatives. This should include electives in media skills, planning campaigns and how to mobilize communities.

Along similar lines, we also need to work together to get rid of the social stigma that still surrounds mental health issues, HIV/AIDS, sexuality and socioeconomic status (to name a few). Cultural change is difficult (just ask @ckraine from Hello Sunday Morning), and it requires everyone to have a zero-tolerance attitude.

Just a few thoughts.

I’m currently writing a long post on p values, so rest assured that there will soon be a return to some form of educational content.

I’m also working on a very exciting mental-health-related campaign which I’ll provide more details of soon.

It’s about time I share a bit of my personal story with those who follow me and my bizarre world. Many of my friends aren’t aware of it all, and I’ll explain my reasons at the end for telling it.

A disclaimer/warning shot: this post will be long and vastly irrelevant to medicine in the scientific sense.

The timing of this post couldn’t be better with Alison Fairleigh’s post about her past experiences and discusses why she now advocates for rural mental health (side note: check out the @RuralMH tweetchat :p ). Additionally, the Australian Medical Students’ Association recently published their “Keeping Your Grass Greener” wellbeing guide.

It’s fairly well documented that medical students have pretty poor mental health. A simple OVIDMedline search for the intersection between Medical Students (MeSH) and depression, anxiety OR stress (MeSH) gives you some 413 results, from Sugimoto K’s “Lifestyle and psychological distress in medical school students” just recently to more specific articles like Bakir B’s “Relating depressive symptoms to Machiavellianism in a Turkish sample”. We get it knocked into our heads all through first year that we are all more likely than the public to experience any number of psychological issues (not to mention alcohol and other drugs dependency, which is far higher in the medical population!).

Of course, there is a lot of ‘well that won’t be me – it’s only the people with some pretty significant problems in their lives that get that bad’.

Last year, I started clinical medicine (and this blog, which started in late March!). That’s hospitals, day in, day out. Tutorials and lectures – hospitals. Ward rounds and ‘chasing people’ became much of my daily life.

The problem that I have is that I don’t like that to define me. And last year I probably took on too much. Well, I did take on too much.

Between managing medicine, I was working on so many projects. I won’t list them because it seems pointless but it included some pretty high-intensity projects like organizing the $200k+ sponsorship for our student society and our 850-person annual ball into a warehouse that had nothing in it (necessitating hiring everything from cutlery to toilets).

At some point along the line, things started to overtake me being able to manage them. I was working continually to try to keep up with deadlines, projects, life.

The first thing to go was many of my relationships. Friends fell far behind the pile of emails and work to be done.

The second thing was uni. I slowly started to skip classes (which I know sounds like normal behaviour for a uni student but it’s not for me!) and just lost interest.

I became so angry. Angry at every person who told me that I needed to relax, angry at anyone who I thought could be wasting my time (of which a few were legitimate).

Eventually, I just stopped. I desperately wanted to just reset, start again and not have to keep chasing my tail. I pretty much withdrew from everything.

And I slept. Sleeping through lectures, tutorials, anything. I was so tired, all the time. This was a problem that I’d talked to my GP about a while before (thought I had hypothyroidism among other things) and was slowly getting worse without looking like it was going to get better.

I was moody and unapproachable. Like one of those mythical black storm clouds.

I didn’t feel like there was anything I could do. Didn’t have the effort or ability. My sense of self-confidence, which usually is all that keeps me going, was pretty much at zero. Starting anything would just lead to me realizing how much I had to do, and the anxiety of thinking about that killed any form of productivity.

And nothing really interested me anymore. I didn’t feel like doing anything. Eating was a chore, and one that I did about as rarely as I managed to get any work done. I lost a lot of weight, and have never had much to lose!

Perhaps the part that most disturbed me was that I did have suicidal thoughts. While it mightn’t make sense, I was in the mindset that nothing could solve my problems and all I wanted to do was to get rid of them. Luckily I never made any plans or followed through with such ideas. But it’s honestly the scariest thing in your life, to suddenly catch yourself thinking about committing suicide.

And all along, I managed to hide it really well under the guise of being intensely busy. And acting like everything else was fine when I was asked.

I was so lucky that eventually, one day my girlfriend (who probably only knew only half the story – that I was sleeping and losing a lot of weight!) told me that I had to sort myself out. And it was probably the best advice I could have gotten. I saw my GP, particularly after I K10′d myself and got a medium-high risk result, and started to go along the path of getting everything back in order. I’m so privileged to have a great GP who makes time for my hypochondriatic tendencies and was lucky to find him. Even now I drive half an hour each way (a long way in Melbourne) to see him!

I can say that I’ve had depression, and have now got my life back under control. I still run around like I’m on fire (don’t think that’ll ever stop) but I have learned my limits, and know my signs to look out for. And I realize now the importance of friends and family and everyone else around me.

Telling this story isn’t easy. It’s not easy to tell to close friends, let alone to the internet. But the reason it’s so hard is just another reason to tell it. A lot of people (possibly including myself) might tell me that I shouldn’t post this kind of thing on the internet in the event that it impacted future employment, or caused others to judge me, or whatever. But honestly, that’s part of the problem.

Depression and mental illness causes the most Disability Adjusted Life Years (takes into account early deaths, years lost of effective life etc) to young Australians. So why is there such an intense stigma? 1 in 4 young Australians will experience mental illness before 25. That’s a lot. And if 1 in 4 of my friends/colleagues (also young) have experienced that, why don’t we hear about it more often?

There’s currently strong stigma about mental health. I know because I thought it myself, and that was a lot of why I was refusing to seek treatment. Mental illness (or ill-health as it is sometimes known) doesn’t need to be scary. Sure, it will never be some kind of ‘Hi, I’m Hugh. I’ve been depressed’, much the same that you’ll never have people walking around saying ‘Hi, I’m Steve, and I have chlamydia’.

But we need more people to tell their stories to let others know that they can talk. Talking is the first step. Whether it’s to your friend, your GP or to a counselling service (Lifeline/headspace/take your pick), talking is so important.

My past experiences are part of why I chose to raise awareness for youth mental health through my One Step Further expedition. We need more people in the media saying ‘hey, this s**t is common. Many people are affected and doing nothing about it is only going to make the problem worse for yourself and those around you’. Sadly, mental health doesn’t “sell” as well as the Royal Wedding. The media need a stimulus to bring these issues up. Whether it’s an expedition across Antarctica or a catchy title.

There is so much more work to be done. I’m happy to share my story if it will encourage others to speak up. Talk to your friends, family and workmates. Ask them if everything is okay. And keep asking them.

Finally, a video. I think that one of the best things for anyone to have is a passion. No matter what it is. This guy is passionate about Helvetica (the font).

I’ve posted before about my research project and the very beginnings. So here’s an update.

I (finally) got my ethics submission through. These things certainly don’t work particularly quickly! I still have to get expedited approval through 2 other ethics committees but these are just to tick the uni’s boxes rather than be required from an ethical standpoint.

I’m getting started on my literature review and am really looking forward to getting down to writing it – hopefully well and truly before it is due.

My project is in organ donation. Specifically Donation after Cardiac Death or Non-Heart Beating Donation.

Essentially, there is a push in the transplant field to now use DCD as an additional criteria for donation. DCD was the protocol used ‘back in the day’ before brain death could be meaningfully diagnosed. Since then, there have been multiple scenarios where patients have been unable to donate due to not meeting the brain death criteria, yet their condition will not allow for any recovery. Many of these patients’ families have asked why donation couldn’t proceed since they were to lose their loved one regardless.

Since then, DonateLife (who coordinate donation issues and are the advocates for organ donation in Australia) have developed the National Protocol for Donation after Cardiac Death, available online. As you can see from a brief read, there are some very specific criteria used. Many of the patients who are considered for DCD do not end up donating because they do not meet these stringent criteria. A brief overview (after treatment has been deemed futile and the necessary consent procedures have been completed)

1. Withdrawal of cardiorespiratory support
2. Death determined no less than 2 minutes but no more than 5 minutes after support withdrawn
3. Family given time to farewell patient.
4. Retrieval surgery begins as soon as possible. The following guidelines show the maximum ‘warm ischaemic time’ (time since SBP < 50mmHg). For liver and pancreas, 30 minutes. For lungs, 90 minutes.

From then, transplant proceeds as usual.

My project is in determining the potential for DCD in Australia, using deidentified data that is collected about all potential donors (DCD or otherwise) in Australia.

A study came out recently in the US that found  that DCD could increase donors by up to 25% – this is the kind of data we’re hoping for!

I’ll keep everyone updated with the progress as things continue.

(photo credit)

In Australia there are three ‘scores’ that are used to determine entry: your high school marks, the UMAT (Undergraduate Medical Admissions Test) and your interview score.

The UMAT is a glorified IQ test. Effectively useless excepting to weed out people who can’t afford the registration fees and/or a preparation course (but their role is controversial), it seems to exist only to give universities another score with which to differentiate students. I think it is vastly overused and don’t really see the benefit of its use. But enough about that and onto interviews.

Medical school interviews vary significantly between different universities. In one interview, I was asked the questions I was expecting; about my leadership experience, why I wanted to do medicine, what I did at school and so on. In another, I was asked extensively about how many and what type of friends I had, and my most memorable primary school teachers and experiences (bizarre!). In a third, we were asked a mixture of the first two and had some activities to do: detechnicalize a concept (mine was protein denaturation, which I had no idea what it was so undoubtedly didn’t do well there) and respond to an emotive scenario (mine was about someone being unable to work due to injury).

When discussing my experiences with this young school graduate, I had the opportunity to reflect on the answers that I gave. I can certainly say that I would now give significantly different answers to many questions. It is almost a waste of time asking people why they want to do medicine; from what I’ve seen we all seem to change our minds year by year regardless. Honestly I’m still not 100% sure why I wanted to do medicine: it always interested me, but I won’t profess to be someone who decided at age 6 to become a doctor and that was that. The reason has changed over time and continues to do so.

Different people have their different reasons, and I think that one isn’t really better than another. While I personally don’t agree that medicine is the only way to ‘help people’ compared to other professions (allied health, or even things like Engineers Beyond Borders!), that is a key factor in some colleagues’ decision making. The important thing is to have a reason why you want to do medicine. This shouldn’t be ‘helping people’, as you could do a multitude of professions and get the same outcome. Helping people is part of practicing medicine but there are so many other reasons to go into health: working in a field which is always developing and improving, a particular personal story or experience of your own or that of a loved one, or a particular interest in applied science and biology.

One thing that hasn’t changed is the ‘rumors’ about what you should or shouldn’t say. Whether you should or shouldn’t mention that your parent or relative is a doctor (I hazard a yes – it means you know what you’re getting in for!) or whether you went to a state or private school. Really, I don’t think that it matters very much.

Medical school interviews were very much just another challenge that seemed to be ‘the ultimate challenge’ at the time. We finish school, then we have our ultimate interviews. Then we get in (if we’re lucky), and eventually have the ‘ultimate exams’ in year one. Then in year two. Then year three. Then year four. And so on until your physician or surgical exams. Every time we overdramatize and turn these moments into far more than they really are; just another step in learning to become a doctor.

What were your experiences of interviews? What were the key tips that you got or would now give? How have things changed?

For those of you overseas, was your process similar or different?

(photo credit)

I hope to get a decent handful of responses to the study in order to better inform and explain to organizations such as the Australian Medical Association and the Australian Medical Students’ Association about where medical students are on the internet and what they are doing.

Why do we need to know this?

Firstly, it is this kind of data that helps us educate and write policy about students’ use of social media. Universities will very soon start writing policy about students’ use of social media both in med school and outside it on a social level. I was unimpressed with the conclusion of this study, which is about Facebook use in University of Melbourne students:

These cases indicate that using Facebook as part of learning and teaching is as much of a challenge for many students as it may be for most educators.

Facebook is not a learning platform. Moodle is. Sakai is. Blackboard is.

Students might occasionally use Facebook for study related activities. But often this is because there isn’t something handy available from their university that allows them to create their own collaboration groups, let alone the education in how to use such a system. Sakai is a wonderfully powerful tool that allows versioned editing of files, wiki-style pages etc – which could be great for collaborating on an assignment!

The biggest barrier is usually the students’ desire to collaborate – many students prefer to allocate sections and complete assignments in this way, then meet up and put it together. And there isn’t anything wrong with this method!

Anyway.

Alexandra Bornkessel (@SocialBttrfly) asked recently a question I’ve thought about for some time:

I thought: what else can we crowdsource?

The answer came to me while developing the questions for this study. Why not ask the networks that I’m trying to survey (with the huge bias of only those who know me – so it’s not anywhere near a representative sample) their thoughts on questions? Is there anything I’m missing out? Do the questions make sense?

So I invite you to also have a look at the questionnaire. I hope to blog some preliminary results and aim to get the study published so that there is finally some more data out there on what is happening.

I chose to use Google Docs rather than another platform for review (such as one of my favourites, ReviewBoard) because of its simplicity and that a lot of people are already familiar with it.

Check out the preliminary study questionnaire here and have your say and contribution to the study!

(photo credit)

I presented initially on the relationship between social media use in mental health care and the law in Australia. We covered Duty of Care, Confidentiality and Privacy, which all relate to social media use and how to engage within a legal framework. I have a brief one-page summary that is part of the drafted policy below. I’ll talk about an interesting issue – that of ‘proximity’ when it comes to duty of care and the effect that the internet has on this area of duty of care at another time.

Secondly, I ran a workshop where we drafted a social media policy for an organization. This was based on that of Headspace Australia so thanks to them for sharing their policy.

A few salient points when drafting such a policy:

• Work out what your objectives are first. Don’t just decide ‘there are people on Facebook, so we should be too’ – have a purpose behind your social media engagement before deciding what networks to use.
• Define the sites and/or areas (e.g. blogging) you want to engage with for each purpose. For example, engaging with other professionals via LinkedIn is different from engaging with patients over Facebook. Twitter is interesting since it can be used for both purposes, and this might necessitate two separate accounts; one for patients and another for professional networking and engagement!
• Define what your boundaries are. Social networking allows you to share information via many sources – not just your own website. Are you okay to retweet content from other users or from other sources (e.g. newspapers)? What if this content has some parts you agree with and some you don’t (as will often be the case)? This is part of how strong you want your ‘brand’ to come across and how much content that you are willing and able to create.
• Let your users know when you will be around. Whether it is 24/7 or only within business hours, it’s nice to know when to expect a response if they contact you.
• Social media is a dialogue not a platform to communicate one-way. Encourage users to comment, ask questions etc –> and respond to them!
• What are you going to do about staff with personal accounts? There is no point telling them NOT to have accounts, but you should define whether they should disclose their relationship to you and things like what to do if a patient ‘friends’ them on the social network. This often helps the person by being able to point the ‘friending’ patient to the policy and advising them that this is why they have not ‘friended’ them – stops the awkwardness and only improves the relationship!

A few recommended resources for those interested are at the bottom of the document that includes the developed policy skeleton, which is available here.

Additionally, for those looking at information about social media use in healthcare, the Mayo Clinic Center for Social Media (of which I am an External Advisory Board Member) have a Social Media Health Network that you can join. It has a great collection of blog posts and tutorials about areas such as using web video to promote your organization, plus tutorials on the usual culprits of Twitter, Facebook and Blogging. While it is quite a new network, once all the resources are completed and available it will be a fantastic way of getting yourself acquainted with Social Media specifically from a health perspective!

For those of you in Australia (or even overseas!), I’m happy to review any policy you write or come and speak about the use of Social Media in your organization. Get in contact with me via my Contact page and I’ll see what I can do.

(photo credit)

I’ve recently been invited to sit on the External Advisory Board for the Mayo Clinic’s Center for Social Media and have been doing a hardcore course in statistics by distance education. Finally I’ve been working on my Antarctic expedition that I’m planning for the end of the year. If you’re interested check out the One Step Further website.

But my research has moved slowly along. Very slowly.

Ethics submissions have to be the bane of any researcher’s life. Endless revisions, chasing others’ signatures and so many copies of one form floating around.

I have to do three. One for a national body, one for the hospital I’m working at and one for the University. So much paperwork to be done!

Hopefully I’ll be able to post on the start of the ‘actual’ work soon. At the moment I’m just searching the literature and trying to get up to speed with everything that has happened in the last 10 years!

Today I thought I’d post a few thoughts about statistics that haven’t really been taught to me through uni. Hopefully they make sense and are of some use!

Calculating Confidence Intervals

We all see confidence intervals on all the papers we read. This is a measure of what the possible outcomes of the research could be, and is a roundabout measure of the spread of the results.

How is a confidence interval calculated? It all starts with the Margin of Error.

The Margin of Error is a statistic that includes 3 parameters. Firstly is the ‘z-score’ which is a number from a t-table (magical tables for normally distributed data). You just look it up based on the confidence you desire (e.g. 95%, 90% etc). For example, the z score for calculating ANY 95% CI will be 1.645.

The second parameter is the standard deviation (StDev) for the data. StDev is a difficult statistic to calculate manually but luckily even the most basic of calculators with statistical function can do it for you (so can excel etc). It is measure of the variability / spread of the data. In a normally distributed dataset, about 69% of the results will occur within one standard deviation of the mean.

The final parameter of interest is ‘n’, the number of people in the study / group being analyzed.

To calculate the Margin of error, we use the following equation:

where ME is Margin of Error, z is the z-score, s is the standard deviation and n is the number of people being analyzed.

The confidence interval is simply calculated by taking the mean and adding the ME (top of the CI) and then subtracting it from the mean (bottom of the CI).

So keep this in mind! It helps make sense of situations where your confidence interval is wide or narrow – wide when there is a lot of variance in the collected data or the number of patients is low and vice versa.

I’ve been compiling for some time a collection of quotes and images to use as an introduction and give a few lessons to those about to start the sometimes daunting, yet exciting, task of beginning full-time in the hospital.

You miss 100 percent of the shots you never take.

– Wayne Gretzky

The first lesson is to always turn up. Without turning up every day, you’ll quickly miss opportunities for learning, inspiration, the clinical examination you needed signed off in your logbook (!) or doing that super-fun practical skill.

In all likelihood, this year will be the first year you encounter ‘real’ death and suffering on a professional level. And it hits some hard. It’s very tempting to just take the next day off, just to ponder and lurk around at home. But don’t. Turn up. Always.

There are no strangers here; Only friends you haven’t yet met.

– William Butler Yeats

Hospitals can be scary places. People rushing everywhere, rarely having time for you – a lowly first-clinical-year student. But get involved, and say hi. Ask someone what they’re doing. Ask if you can watch the ultrasound that someone is pushing through the ward; offer to push it for them, or grab the patient’s chart!

Through doing these things, you can not only meet a lot of fantastic clinicians, nurses and other staff, but learn new things, meet a future research supervisor, and perform that elusive task known as ‘networking’.

My catchphrase for much of this year is chase, chase, chase. Every time you see a patient head toward theater, chase. Every time you see a path nurse going on venepuncture rounds, chase. Every time you see a ward round, chase.

A patient a day keeps the [supplementary exams] away.

– My 2010 Clinical Dean

Never forget that the point of being in the hospital is to see patients and see them often. Try to see a patient a day.

What is ‘seeing’ a patient? Find someone in the hospital, take a thorough history, do an examination, and then go to their chart and see what you missed. If you can, present the patient to another student in your year, an older student or a doctor nearby. Practice these things often and it will help you significantly come time for your practical examinations throughout the year.

It’s far harder than it sounds and I certainly did a pretty poor effort (one of my regrets about the past year!). So try to keep up. Some students make groups who present patients to each other daily or weekly, others spend a lot of time with their ‘clinical partner’ and some rough it on their own. But build a system into your life that ensures that you see patients.

Read often. And read widely.

– Aforementioned Clinical Dean

This is a great tip that both allows you to keep up with conversations you hear around the wards and learn a few things. Read whatever you can. Read books about medicine (fictional and non-fictional!), read journal articles if you dare, read blogs, read anything.

I have followed about 20 blogs for the last year, reading every post using Google Reader (which I would recommend highly). I’ll post up a little review about some of the best ones if you’re interested in finding some, but the best place to look is aggregate posts like Grand Rounds or SurgeXperiences, where the ‘best’ of that week is collated and presented to you.

Journal Clubs are also a great thing to read. Whether it’s the ACP Journal Club or a great weekly resource like that at …., reading what is currently happening in the literature helps you sound very up-to-date with senior students and clinicians, and often helps you make sense of confusing conversations you hear during ward rounds.

Get inspired.

Find out what motivates you, and do it. Inspiration is something I found I had little of during my pre-clinical years at campus, and a resource that is almost endless during clinical years.

Even if you know that your heart is set on one specialty, try to find something inspiring in every rotation you do. Whether it’s one of the patients you see or the incredible bedside manner an oncologist has, find something to inspire you and to keep you coming back every day.

Never forget that it’s your first clinical year. This means you are allowed to make mistakes, say the wrong thing or totally miss the point. Take every opportunity as a chance to learn medicine or more about yourself.

Don’t worry about the doctors or nurses that make your life hard. Perhaps they have regrets about what they did as a young medical student. Maybe they just don’t like you. But don’t let it faze you, and remember that you have a chance to learn from them what not to do in the future.

Enjoy the time that you have while you’re a student. Responsibility (and the associated stress!) is only going to increase as you go along. Now is your chance to say the answers that come into your head that are blatantly wrong. Remember these times fondly, as many doctors and nurses I’ve met have done.

Just remember to always turn up, and keep yourself inspired and motivated. It’s a long ride, but totally worth it in the end.

May your coming year be filled with magic and dreams and good madness. I hope you read some fine books and kiss someone who thinks you’re wonderful, and don’t forget to make some art — write or draw or build or sing or live as only you can. And I hope, somewhere in the next year, you surprise yourself.

– Neil Gaiman