Monday, 27 August 2012

Work and play

Red and yellow stripy lilies
Norfolk, July 2011
I seriously cannot wait until I retire, when I will have time and energy by the bucketload and everything will be delightful and sunny and the house will be in perfect condition because we will have sorted it out beautifully. This will obviously not happen, because life is not like that. But I would like to have more time, and I would like to attend to the shortcomings of our 'home-making', and the two are clearly connected, along with our disinclination to spend our limited leisure hours on structural improvements.

In the work arena, the grown-ups in our office (senior Dietitians) were both away on Friday, which meant that when the call came to see a patient in the private hospital, one of the kids had to stand in. So off I went to the fancy shmancy 'ward', which comprised carpeted corridors and bedrooms rather than hard floors and beds separated by curtains. Obviously I will say nothing whatsoever about the patient and the treatment, but I feel slightly embarrassed that for such a large amount of money, the patient received dietetic treatment from a Dietitian with nearly seven whole months' experience.

This has been my first brush with the interesting relationship between private healthcare and the NHS. You certainly get better accommodation by paying for it, but is that all? I suspect that nursing care is also more attentive, but clearly therapy is absolutely no better than NHS, and you get the same doctors with the same time pressures and no better treatments to offer for the money. Investigations may be done without waiting quite so long for your turn on the CT scanner, and you might get your treatment more quickly. But it will be the same treatment, and if there's an emergency you'll be shipped into the NHS Emergency Department quicker than you can say "Find me a trolley and call me a porter".

Outside work, Lola II and Mr M have been visiting, and we had a very successful day on Saturday. Lola II has been converted to the One True Way of the Charity Shop, and found another skirt and pair of trousers, this time in an even smaller size than before. I now have a car charger for my phone, so no more telephone boxes for me on long journeys. Lola II has lost so much weight that even her feet have shrunk, so we ended up buying her shoes from the childrens' department of Clarks, where she had her feet measured in the old-fashioned way where you can choose shoes according to both length and width. The advantage is that shoes are not quite as expensive as in the adult department; the disadvantage is children's shoes tend to be flat rather than with heels.

Then we all went off to the Red Lion in Hunningham to watch a film on the huge inflatable screen followed by camping in the adjacent field, which was all lovely, despite the usual early wake-up call from a nearby small child who doesn't understand that it isn't necessary to shout at 6 a.m. in a campsite. I discovered several things about breakfast in Leamington - the cafe I'd been told about is definitely there, but closed for two weeks in August, and Sainsbury's doesn't have a cafe, just a Starbucks. But we have a 'Frankie and Benny' outlet, and it turns out that they do breakfasts, so that's where we went.

Mr A was away at a wedding (I don't do weddings) so after Lola II and Mr M had departed I had some wonderful free time, which I used in cooking for next weekend's family gathering, going to the cinema, reading books, listening to podcasts, and working in the garden. Each time I tidy up about a quarter of the area, but the other three quarters seem to gain on me quicker than I can deal with them. Sadly no badminton tonight because of the bank holiday, and it's back to normal and to work tomorrow.

Tuesday, 21 August 2012

Camping holiday in the Southwest

Boats in the marina and sky reflected in the still water
Brixham marina
Mr A and I have been on holiday. My main recollections from this holiday included a great deal of long distance driving, interspersed with reading for delightfully long periods, with talking to interesting people coming third and a significant amount of mist and rain in fourth place. At one point, I discovered I had reached one of my personal goals without knowing it - I had forgotten it was lunchtime until Mr A pointed out that I was being unaccountably ratty and it might be a good idea to have something to eat. This signifies that I have, albeit briefly, begun to think like a thin person. I am hoping that it continues - not the 'missing meals' or 'being unaccountably ratty' part, but the 'thinking like a thin person', because it should make it easier to remain the size I currently am.

I digress. Long distance driving - this also included reading for long periods, except I didn't like my main audio book but needed to carry on with it in case it got better. Luckily I had a few podcasts too, and the first series of 'Fags, Bags and Mags', a delightfully surreal sitcom about a Scottish shop which is both amazing and great. Reading was also indicated for long periods in the tent, while waiting for the mist/rain to pass, and enjoying the peace and quiet of the evening until it got dark.

The talking to interesting people included the friends I've previously given the blog handle 'The Bikers' (or 'Biker Couple') who have now produced an attractive child and no longer have any bikes. We stopped with them on Friday night, and made our way onwards to the campsite on Saturday. We dismantled Mr A's two-man tent which had been there since Thursday and pitched the enormous family tent, then did very little except sit and read for much of the rest of the day, with small excursions to see the nearby beach and to a local town to eat fish and chips. The road to the beach was narrow and we kept having to stand in the hedge to let cars past, the beach had quite good surf but was otherwise unattractive (and it kept getting misty and raining), but the fish and chips were both amazing and great.

On Sunday we'd arranged to see a lady who used to teach English to Mr A at secondary school, and we did very little except drive all the way to her house in Cornwall, have a nice lunch including an authentic and delicious Cornish pasty, and then drive all the way back again. Then there was more sitting and reading. On Monday we did some proper tourism, spending most of the day in Brixham, which is famous for its seafood. So we had some oysters and a crab sandwich each, and it was very sunny and didn't rain for a change, and we walked about a bit and would have gone to the museum except that it was closed.

After that we drove a long way to Mr A's cousin and her husband (who has now given up the beef farming). They have bought a motor home and spend two months in France every year, from where she continues to work full time with the assistance of a satellite Internet connection. Finding them was an achievement - I was hoping to rely on the excellent directions I had been getting from my phone via its built in navigation system, except it ran out of battery and I don't have a car charger. So I found a red telephone box (haven't been in one of them for ages) but it only took BT Charge Cards and not coins, so I went back to the previous town and found a different phone box that accepted coins. I discovered, along with the directions and the fact that it costs 60p to phone from a telephone box nowadays, that the first phone box I had been in was less than a mile away from the farm - but I would never have found it by guessing.

Back home now, and I have an extra day's holiday which arose because I lost the first day of my holiday because of having an interview on Friday, which also explains why Mr A started his holiday on Thursday. The interview went as well as could be expected, but also had the anticipated negative result, given that I only have six months' dietetic experience. They were very nice about the rest of my interview though, including the presentation. I really must buckle down to the admin that's still waiting. A pity to spend a day's holiday on income tax and pension arrangements, but if I don't do it now I'm not sure I ever will.

Stern stone statue of a man with a gull on his head
William of Orange landed 'near this spot' in Brixham

Thursday, 16 August 2012

Henry vs. Schofield

Large white daisies
Sissinghurst, June 2012
You will be pleased to learn that this week has been sooooo much better than last week. Two colleagues have returned and only one has gone on holiday, my wards are unusually quiet, and the other dietitians seem to be picking up the extra work at the moment. I don't know if it's deliberate so that I can have a bit of a break, or just that they don't realise I don't have that many referrals at the moment. Instead of seeing loads of patients, I have been constructing presentations.

Some months ago I volunteered to do a presentation about a new set of equations that are supposed to be slightly more accurate for estimating daily energy requirements. We use this type of estimation all the time for patients on the wards, where we calculate how many kilocalories (kcal) and grammes of protein they are likely to need in order to meet their nutritional needs and promote recovery. If they need a tube feed, then we estimate energy and protein requirements in order to judge how much feed to give; if they are eating and drinking then we estimate from their own descriptions and from written records how much energy and protein they've taken in of their own accord, and suggest options to make up the difference.

In an ideal world we would then weigh the patients regularly to find out whether they are gaining or losing weight, and try to adjust our recommendations accordingly. The reality is that either they get better and are discharged, or turn their noses up at our supplements and continue to lose weight, or hang around for ages without being weighed so we don't really know whether our estimations are close to real requirements or not. Up to now we've always used equations for calculating Basal Metabolic Rate (BMR) that were published in 1985 by a chap called Schofield.

Basal Metabolic Rate is not the minimum amount of energy that the body needs to operate, but it is the rate of energy consumption of an unstressed body at rest, lying down but fully awake, at least 10 hours after food and in a thermo-neutral environment (22-27 Celsius). It can be measured directly by monitoring the heat emitted by the body in a sealed environment (calorimetry), which is obviously impractical on the wards, so we have to use equations which differ according to sex, age and body weight.

To estimate the total energy required by a person, we start with BMR and then add on the energy needed due to the stress caused by illness, an estimate of activity, and 'diet-induced thermogenesis' (DIT), which is simply the energy we use to digest our food. In a person who is not metabolically stressed we can also adjust our estimate of energy required by either adding some extra kcal if the individual is underweight, or subtracting some if they are overweight. Beyond a BMI of 30 kg/m2 (i.e. if the person is obese) there are a number of other ways of adjusting our estimates.

Back to Schofield - he looked at all the available data from about 1914 to 1980, and came up with his set of (linear) equations in the form '(A x Weight) + B'. It has been recognised for some time that the Schofield equations are flawed, and not only because they don't work for obese people, as metabolic requirements don't increase linearly - fat tissue is less metabolically active than muscle and organs, so BMR tends to plateau as weight increases. The dataset he used included a disproportionate number of fit Italian males, many from the military, whose BMR results were very high relative to the 'ordinary' population, skewing the results. There were also very few subjects from tropical regions.

New research was commissioned to come up with better equations, which were published by a chap called Henry in 2005. It's taken a while for them to permeate through to the coalface, but I volunteered to investigate how the Henry equations compare with Schofield's, with the underlying aim of changing our practice in estimating BMR. Henry did his analysis with more data, excluded all the Italian subjects, and included more from tropical regions, to make the equations 'more relevant to the global population'. His equations are also in the form '(A x Weight) + B', with different coefficients A and B, and are similarly inappropriate for people who are obese. The Henry equations generally come up with a lower BMR than Schofield, except for subjects over about 100 kg (about 15 stone 10 lb, or 220 lb).

Of course, having volunteered ages ago, I did nothing whatsoever about the presentation for as long as possible, especially as the last two weeks have been a bit busy. Not knowing that this week would be a little easier, I actually spent Sunday afternoon on it, and then Monday afternoon as well. On Sunday afternoon my biggest challenge was trying to think of a way to compare the two methods graphically. On Monday I just tried to make sure the content wouldn't be too boring. In the end the presentation was short, but seemed to be well-received, and we collectively made the decision that we would start using Henry instead of Schofield on the wards.

The results were not entirely cut and dried, though. Subsequent to the publication of the equations, a comparison was done between Schofield, Henry and actual BMRs measured by calorimetry. This research found that Schofield was within 10% of the measured BMR in 69% of subjects, and Henry scored 79%. Not a particularly accurate estimate, then.

Henry produced equations that included height as well as sex, age and weight, and I was hoping that this would successfully deal with the issue of high BMIs. Henry himself concluded, however, that there was little benefit in using height as well, and including height makes the calculation quite difficult (although not impossible) with a non-scientific calculator, which is what we generally take onto the wards.

I did manage to produce some graphical comparisons between Schofield and Henry, one for each of four adult age ranges. Three of these made sense, but the one for the oldest age group (>70) showed that up to a weight of about 70 kg (11 stone/154 lb) Henry's estimated BMR was lower than Schofield's, but above this weight Henry's estimated BMR increased dramatically and unrealistically. On reflection, however, it is highly unlikely that we would encounter anyone on the wards who is both over 70 and heavier than 70 kg.

Our Dietetic Manager is also in favour of a completely different calculation which deals much more successfully with obese subjects, and which she has set up in an Excel spreadsheet for our benefit. We had a short discussion about this after the presentation, and decided to stick with Henry, for two reasons: firstly, we very rarely deal with obese patients on the wards, and secondly, we don't have access to Excel on the wards, and her preferred equation absolutely requires a scientific calculator. In clinics, where we can use Excel, we very rarely calculate energy requirements, because we work on the basis of eating more if you are underweight and less if you are overweight, in comparison with your current intake. It isn't usually helpful to estimate what the absolute calorific value of that intake is.

The other presentation is for my interview tomorrow. I have had to lose almost two days of my holiday and almost every evening this week for these presentations. I hope it's worth it.

Saturday, 11 August 2012

Jobs and birthdays

View of garden through brick gateway
Sissinghurst, June 2012
Another long, difficult week, with two colleagues still away and the added bonus of having a student with me for much of the time on the wards. A good student, which is so much better than a bad one, but still, it's a little bit of added pressure. Last week we made the considered decision that I would not be able to do a clinic while two of my colleagues were on leave, and there was only one patient left in that clinic by Tuesday who was seen by the Dietetic Manager. I have no idea why we did not make a similar decision this week given that the same constraints applied, and instead of one there were five patients that I had to see. But I am not complaining, oh no, I have a good job and some lovely colleagues and I cannot afford to get cross with it because I must continue to turn up for work every day for the foreseeable future. The unforeseeable future - now, that's a different story.

On  Wednesday I did another job application and didn't go to badminton, which always makes me slightly less cheerful. The interview for the first job I've applied for is looming, and I have to get my interview presentation ready for Thursday when it has to be emailed to the recruitment panel. I have very foolishly volunteered to do a CPD presentation to my colleagues all about how a new lot of equations are now favoured over the old lot of equations for estimating energy requirements, and it's on Wednesday and I haven't even started looking at the equations, let alone the evidence behind their use. I have no idea when I'll have time for this, let alone my tax return and various other important items of home-based administration.

On the other hand, Mr A and I celebrated our birthdays on Thursday with dinner at Queans, the local restaurant that gained such a great review from a celebrated newspaper restaurant critic. But directly before dinner I went to donate blood again, and after pricking one finger and finding my iron level was borderline they had to draw some blood to evaluate it a different way, and then said I was OK to donate. So I turned up at the restaurant with plasters everywhere, and then halfway through dinner I had a funny turn and had to put my head between my knees. Despite all this I thought it was a delightful dinner, and my duck breast was cooked to perfection. I'd definitely love to go there again, but Mr A was less impressed, perhaps because his expectations were higher and partly because he had to choose a vegetarian starter (I always underestimate his desire for animal flesh). I'm wondering whether it's worth carrying on donating blood, but perhaps will do so in future only when no other activities are planned for the hours to follow.

It seems incredibly dense, but I have only just realised why it has been difficult to maintain the frequency of my blog posting. When I started the first, student blog, I had already left work to do the degree. It is only since starting this blog that I have been working full time. Naturally there are fewer hours for leisure now that I am occupied all through the day. I don't know why it's taken me this long to cotton on.

Monday, 6 August 2012


Red rose just starting to open
Sissinghurst, June 2012
Last week was a difficult week at work, for a number of reasons. Firstly, both of my peers were on holiday, leaving me and the two seniors covering their wards as well as our own. Luckily, things were quiet, otherwise I'd have had a worse week than I did. I had to give up my outpatient clinic, though, and I missed it.

As well as the greater workload, I had some challenging patients. Not that they were challenging people, but their situations were complex, difficult and depressing. And a patient that I'd spent a lot of time with, and really tried to help in many different ways, died. I'm not usually affected by this, but on this occasion I spent a minute in silent contemplation when I found out.

I'm also annoyed at having so little time for thinking, and when I did stop to think this week, I was assailed with doubts. Was that the right treatment? Should I have considered other alternatives? Did I really do my best for that individual, or am I just going through the motions? Am I doing a good job?

I have to admit that this job has not improved with time, and my original thought when I started the whole process of retraining for this new career still holds true: the hospital setting is not where I want to end up. I look forward to my outpatient clinic with eager anticipation that I don't feel for another day on the wards. I am frustrated by my role in nutrition support, which doesn't seem to utilise much of the enormous body of knowledge that I acquired during the degree, and gives me little opportunity to promote behaviour change, which it turns out is what I am really interested in. Working on the wards does not inspire me.

I was discussing this preference with a colleague, who described a similar level of frustration with outpatient work. She finds it frustrating that outpatients come to the Dietitian for advice, but then often don't follow that advice and either don't return, or come back without improvement. She is much happier to work in the ward environment, where we might have a little more influence over whether our advice is put into practice or not.

I feel the opposite: an outpatient has the choice whether or not to follow my advice, and my job is to help them find the right path, tailoring and tweaking my advice to take account of their lifestyle and supporting them in reaching goals that I may have helped them to choose. I find the ward environment frustrating because there are so many institutional variables that prevent patients from achieving nutritional objectives, which are mostly imposed upon them. I acknowledge that I have no control over how a free-living individual chooses to eat and drink, but we ought to be able to do better on the wards, and often we don't.

I have applied for another job in a different NHS Trust, and have told the Dietetic Manager (because I had to list her name as a referee). The good news is that I have been offered an interview; the bad news is that it is scheduled in the middle of our planned holiday in the South West. We are adjusting our plans so it shouldn't disrupt the holiday too much.

I think that it is appreciated that when one has a temporary post covering maternity leave (or in my case, two days permanent and three days temporary per week), one has to take up opportunities when they present themselves. But I don't think that the Dietetic Manager is aware of the main reason for me applying for the job: it is in Primary Care rather than the hospital setting. Finding myself in the position of anticipating an interview, only seven months after the end of the last round of interviews, makes me rather apprehensive and a little sad. Interviews really are painful, and not just because of the Lady-shoes. And this time I have to do a presentation.

It is also for a job that is a higher grade than the one I have at present, and this seems very precocious given than I have only completed six months in a Dietetics role. The same Trust is recruiting for posts at my current level as well, but because the students in the year below mine have now graduated and are looking for their first jobs, the vacancies at that grade closed almost immediately, well before I could put together my application. If I am given the role I have applied for, it is possible that I will be senior to Dietitians who have more dietetic experience than I do. That is a sobering thought.

Looking on the bright side, there are many positives to offset the negatives in my current job. My colleagues really are the nicest people I have ever worked with, without exception - if I get the new job, I shall be truly sorry to leave them behind. And aside from work, when we happened to mention to Smurf that it was my birthday on Monday, he offered us a free meal in the pub, which we had on Tuesday. I've played badminton twice this week, watched two films, we had dinner in Wofon, and while writing this I'm sitting on the sofa with Mr A opposite, in my pyjamas, with a nice cup of tea and some birthday chocolate. Things could be a lot worse.

Wednesday, 1 August 2012

What I've been reading

Image of the book cover
Just My Type: a book about fonts
by Simon Garfield

"Just My Type is not just a font book, but a book of stories. About how Helvetica and Comic Sans took over the world. About the great originators of type, from Baskerville to Zapf, or people like Neville Brody who threw out the rulebook, or Margaret Calvert, who invented the motorway signs that are used from Watford Gap to Abu Dhabi."
An interesting and well-written book, so why did I end up feeling it could have been better? There is clearly a great deal of fascinating information and history that surrounds the use of typefaces and fonts and the transition from letters chipped in stone to pixels within an electronic matrix. Some of this fascinating information can be found in this book, but it's missing the vital spark that would have made it a gripping read. It was OK though. Damned with faint praise.

Image of the book cover
About Love and Other Stories
by Anton Chekhov

"Elusive and subtle, spare and unadorned, the stories in this selection are among Chekhov's most poignant and lyrical. While his popularity as a playwright has sometimes overshadowed his achievements in prose, the importance of Chekhov's stories is now recognised by readers as well as by fellow authors."
So now I've tried Tolstoy, Dostoevski and Chekhov, and concluded that either I don't much like Russian books, or that they lose something essential in translation. This one was by no means as awful as Crime and Punishment, but not as easy reading as Anna Karenina, unless it was the audio format that made Tolstoy more accessible. Or that the concept of the 'short story' is interpreted differently by Chekhov. I was taught that stories have a beginning, a middle and an end, but he sometimes doesn't bother with one or more of those segments, most often omitting any form of ending - the story just stops.

Image of the book cover
by Ben Elton

"Stark has more money than God and the social conscience of a dog on a croquet lawn. What's more, they know the Earth is dying. If you're facing the richest and most disgusting conspiracy in history, you have to do more than stick up two fingers and say 'peace'."
In 1989 I clearly thought this book was worth keeping, because it was selected for a place on the shelves, and that only happens for special books that I think I would like to read again. I picked it off the shelf during a sequence of pretty dry reading when I thought I'd like something a bit lighter and easier to read. But it is immensely annoying, written in the style that Ben Elton uses in his comedy, which might be OK for a 30-minute TV show but doesn't hold up for a whole book. Needless to say, it won't be going back on that shelf, but it did have some insight to give - I hadn't remembered that the whole global warming thing went back this far. It wasn't called global warming back then, and we had acid rain and the hole in the ozone layer to contend with, but the issues were being identified, and the root causes too. I don't think I'll still be around when an answer is eventually found to the question of how we achieve a sustainable planetary population.

Image of the book cover
Gods Behaving Badly
by Marie Phillips

"Life's hard for a Greek god in the 21st century: nobody believes in you, your own family doesn't respect you, and you're stuck in a dilapidated hovel in north London with too many siblings and not enough hot water. Being immortal isn't all it's cracked up to be."
This was a lovely little book, and just the sort of light refreshment that I've been looking for - so thank you to Lola II for an early birthday present. It was nicely set up, an unpredictable story, and the gods came over as just the sort of arrogant yet blinkered individuals that you could imagine them to become if their powers had faded away.
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