Jamie Barclay

There is a model of skills acquisition and performance that nicely sums up how you get good at doing something. I forget the name, and I used to teach it to outdoor education students, but I was never good at remembering names (or numbers). The curve starts at “unconscious incompetence” - the inability to do something well and the lack of insight to know that there is a better way of doing it.  In medicine I suppose a good example might be learning to take a history from a patient. Not knowing there is a useful structure and framework to getting all the salient information from a patient, a medical student or lay person would be forgiven for asking a few simple questions and not getting the key relevant details.   The next level is “conscious incompetence”. You now understand that you are not yet competent at the task you are performing, you have insight. At medical school we are necessarily moved rapidly from “unconscious” to “conscious” performance; there’s not...

Mr Healthy was referred by his local community clinic. He is lean, well kept, with an old, but clean and neat, bright red two-piece suit, and leather shoes.  His hair is close cut, grey at the temples, and he has a toothpick protruding from the corner of his mouth, which he occasionally wiggles in a casual sort of way.  He is the epitome of "dapper". I first notice him as he is walked into resus to have an ECG taken.  He is in his late 60s but strolls in with a casual ease, no signs of creaking joints or the fatigue of chronic disease. The clinic letter states he was referred for an incidental finding of bradycardia (slow heart rate), his pulse was about 35 beats per minute. I examine the ECG. It is sinus bradycardia - a normal but slow heart rate, and I cannot see any other serious signs of a heart problem.  In the meantime he has been attached to a monitor, and blood pressure, oxygen saturations, heart and breathing rate are all up on the screen.  They ...

The little boy was sat cuddled on the lap of a young woman. I presumed she was his mother. She wasn’t. He was about 2 and a half, a toddler. He looked about the right size for a toddler, not undernourished and small like so many of his peers.   He seemed comfortable enough, sat sideways across her lap, she was cuddling him but didn’t make a fuss, he was equally calm, eyes half closed as I approached. The triage sheet simply stated: “PVA” - this is “pedestrian vehicle accident”, i.e. pedestrian hit by vehicle. He had been carried on his mother’s back when she was struck by a vehicle, I presume a car. There was no witness from the scene, and the mother was apparently elsewhere in the emergency department being treated for her injuries – though when I searched later I could not find any sign of her.   The child had apparently been flung some distance from the mother and landed on tarmac, this was all I could glean from the lady caring for him, she shrugged whe...

A middle aged lady had been admitted feeling generally unwell, with a cough, systemic symptoms, and she had HIV. This was all elicited from the history and none of it was remarkeable, but as the story unfolded tears ran down her cheeks. I tried to comfort her, less with words than a hand on the shoulder, and she explained that she had not been on antiretroviral treatment (for HIV) for over 5 months. This was largely due to circumstances outside her control, but she was sincerely upset at the potential state of her health after missing such crucial treatment for so long. I took bloods for CD4 count and viral load, both of which were subsequently very poor. The CD4 was 17, and the viral load very high. One year previously, her viral load was undetectable. Tests for TB and cryptococcal antigen (routinely tested for if CD4 counts are below a certain threshold) were both negative. She was commenced on empirical treatment for a chest infection and referred to the medi...

I had an online conversation with a medical friend about the purpose of blogging / tweeting / sharing medical experiences.  She directed me to a "Intention to Tweet" tool here (https://www.researchgate.net/figure/Baron-Townsend-Intention-to-Tweet-Decision-Matrix_tbl1_318438041) Developed to assist decision making about whether a story or comment is appropriate and within professional standards of practice. Major issues include patient confidentiality, which clearly goes well beyond simply removing specific names and addresses from cases. Posting very specific details regarding age and clinical details of a case, particularly within a few days or weeks of the event, clearly comes with a risk of making that individual too easily identifiable and impinging on their right to privacy. It also raises the risk of breaching patient confidentiality. In the age of the tweet, we no longer have to wait 30 years for a clinician to post educational, amusing, moving stories of their expe...

I have started keeping a diary of some of my experiences working as a junior doctor in Cape Town for 2 months.  Here is the start, I intend to try keeping it updated but this may not be that often.  It is for my own benefit as a clinical reminder of interesting things I have seen and learned, and hopefully of interest to a wider audience of friends both medics and non medics. The first few days are summarised here - a piece written for the Bangor Emergency Medicine page (my home hospital). https://www.mountainmedicineyg.co.uk/post/khayelitsha-diary-two-months-working-in-a-cape-town-hospital