Saturday, 21 February 2015

Wet walls and Not Very Well

Signs of damp on the wall
Hall wall, February 2015
It's been busy, but when is it ever not busy? There was the 3rd Annual Gulloebl Film Festival (Random Chairs in a Darkened Room) - 1 screen, in 1 venue, across Europe. There has been badminton club, a badminton match, three different health-related issues, car stuff, a trip to the National Exhibition Centre in Birmingham to look at tents, and an evening out with work people. And work, of course, except I had the day off on Thursday for the NEC tent thing and to sit on the sofa feeling poorly watching Seven Psychopaths on DVD (confusing, odd, violent, but ultimately a film worth watching).

Health issue no. 1 is tennis elbow, which is new to me but many badminton players and the Interwebs gave me advice and suggestions which seem to have worked - ibuprofen, strapping, a bigger grip on my racquet, changing my computer mouse to the other hand, and resting the arm (guess which one I didn't do?) I'm about to have a week off badminton, so that may give it a chance to improve some more.

Health issue no. 2 is a small cold or flu which seems to be going around - it was quite bad for about 24 hours but is now just niggling in the background. I thought I was going to be proper ill for my skiing holiday, but with luck it will be gone in a couple of days.

Health issue no. 3 happened at the restaurant where we celebrated a work colleague's 65th birthday. The chair I sat on was broken, and when I pulled it towards the table I found the seat wasn't attached to the frame. I trapped my little finger which is now going purple and giving me problems typing the letter a (and q and z but I don't use them as much. I haven't been to any quizzes. Ouch).

On the bright side, Lola II and Mr M's film festival was a hit - I attended four screenings this time, and the previews, trailers and adverts before each film were of the usual high standard. I even helped to create several of the Chinema classics featured on the two 'Now That's What I Call Chinema' albums. My few moments of stardom are showcased here and here.

Most of the rest of the week was a bit less delightful, what with the elbow, and we lost the badminton match quite convincingly, and the cold/flu, and the finger, and I had to have the car windscreen replaced because of a long and growing crack, and the car is making a new rattling noise, and the burglar alarm has gone wrong so we can't turn it on, and the NEC show wasn't as good as I'd hoped. The show occupied 5 halls of the massive venue, but only one was showing tents and it was geared at the large family and glamping market so there was hardly anything in the smaller scale I was looking for. Sprayway Hood River 3 and Vango Aura 300 are the most likely contenders from the companies that were represented, but I'm going to have to do much more research because there's a lot more out there that wasn't at the show.

And my biggest achievement of the week - I've had the hall roof fixed! The blessed Alf is busy elsewhere, so I have found a substitute whom I shall call Elf. He came and had a look and diagnosed rotten felt, which he has replaced with a rubber membrane. He even provided pictures:

I think that Elf has done a good job, and there is plenty more for him to get stuck into. One of the ideas I have is for him to spend a day as my personal slave, fixing all the indoor things that are wrong, like re-hanging a door, fitting a pane of glass, that sort of thing.

Now it's time for me to get packing - I'll be back in about a week!

Friday, 13 February 2015

What I've been reading

Image of the book cover

The Mysterious Stranger
by Mark Twain

narrated by Don Randall
"The stranger comes to a medieval village in the persona of a beautiful, lovable, yet exasperatingly amoral young man claiming to be the blameless nephew of the devil. Befriending a small group of boys, he expounds on the Moral Sense which distinguishes men from brutes, and changes the lives of many of the villagers."
This seems to be a fairly obscure work - Twain's last, published posthumously. My limited research suggests he'd had quite a bad time in his last few years, and perhaps this book reflects his disillusionment with his fellow man. The Stranger's philosophy is that humans are worse than animals, who do not deliberately inflict pain or death on each other in the name of religion or moral goodness, and that there is no god and all reality is an illusion. The narration is astonishingly bad for a commercial publication - there is an alternative version available so I don't know why I chose this one.

Image of the book cover

A Brief History of Time
by Stephen Hawking
"Was there a beginning of time? Could time run backwards? Is the universe infinite or does it have boundaries? These are just some of the questions considered in an internationally acclaimed masterpiece by one of the world's greatest thinkers."
I went to see the film "The Theory of Everything" in between reading the previous science book "In Search of the Edge of Time" and starting this. The film is based on the book written by Hawking's wife and the science content is brief and tangential to the life story, but it made a nice trio. I first read this book not that long after it was published in 1986, and it's difficult to remember whether I found new information in it, but I can't deny the fine writing making the subject extremely accessible. It would be interesting to know how much of the content still holds true, and where our current knowledge of the subject differs.

Image of the book cover

by Kurt Vonnegut

narrated by Ethan Hawke
"Billy Pilgrim is a man who becomes 'unstuck in time' after he is abducted by aliens from the planet Tralfamadore. We follow Pilgrim simultaneously through all phases of his life, concentrating on his shattering experience as an American prisoner of war who witnesses the firebombing of Dresden."
Although this was obviously written very much earlier and is set in a very different landscape, there are clear similarities with 'The Time Traveller's Wife', which is one of my favourite books. I wonder if the author of the latter has ever acknowledged the connection? Many of the reviews I've read compare this book to 'Catch 22', another of my favourite books, but that similarity is less clear to me - they say both books are funny, but I don't think they are. I'm sure this is fine literature, and it's certainly well written, but I was looking for meaning in the alien abduction, or some connection with the Dresden fire-bombing, but could find none. I find many 'classics' similarly unsatisfying. But then, 35 years ago I got an 'E' in my English Literature O level, so what do I know?

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On the Way to the Wedding
by Julia Quinn
"Unlike most men of his acquaintance, Gregory Bridgerton is a firm believer in true love - he is just biding his time until the right woman comes along. But when she appears in the rather lovely form of Lucinda Abernathy, Gregory is dismayed to discover that she is set to marry another man."
Another trashy Regency romance - I mooched three of them at once, so another two are on the shelf for easy reading when days are short and nights are long. Not in the least taxing, nicely written and so straightforward that I don't end up feeling that I've missed something. What I don't understand is how I can bear this type of book but can't stomach modern chick lit?

Image of the book cover

The Pursuit of Love
by Nancy Mitford

narrated by Emilia Fox
"Longing for love, obsessed with weddings and sex, Linda and her sisters and cousin Fanny are on the look out for the perfect lover. But finding Mr Right is much harder than any of the young ladies thought."
This book is the first of the trilogy - I read the second one first (Love in a Cold Climate), which was a bit of a shame, but still enjoyed this immensely. The characters are so real! I didn't expect to like Nancy Mitford so much, but she does seem to have a habit of bringing the book to an end very abruptly. The story shows no sign of stopping even though the ipod says there's only 20 minutes to go, and then wallop! it ends. We'll see if the third book does the same thing.

Image of the book cover

Londoners: The Days and Nights of London Now—As Told by Those Who Love It, Hate It, Live It, Left It, and Long for It
by Craig Taylor
"From the woman whose voice announces the stations on the London Underground to the man who plants the trees along Oxford Street; from a Pakistani currency trader to a Guardsman at Buckingham Palace - together, these voices and many more, paint a vivid, epic and wholly fresh portrait of Twenty-First Century London."
Lola II loaned me this book and it's very readable and rather good. Lots of different people talked to the author and he has simply transcribed their words into short chapters. He could have talked to a million more people and their stories would all have been as interesting as the ones he has chosen.

Monday, 9 February 2015

Continuing professional development

Close up of yellow stamens in a red flower
Peckover House, August 2014
It's blimmin' cold. This is, of course, not unusual in the winter, but it's always at February time that I start to get impatient for better weather. It may be that the house - Victorian, no cavity walls - gently cools so that the heating becomes less effective as winter progresses, but I tend to wear thermals or a duvet if I'm going to be indoors and stationary for any length of time - like when I'm constructing these blog posts, for example.

I have been keeping myself busy with a lot of curricular and extra-curricular activities. I went to a very interesting meeting one evening about the new guidelines on treatment of Type 1 Diabetes that are due to be published this year by NICE. It is fairly esoteric and a bit technical; I thought about summarising the changes for the blog but it really would be of interest to only a very few, so I summarised the changes for my colleagues who weren't at the meeting instead.

This sort of thing is very useful for my professional registration. Every two years, 5% of registrants (i.e. practising Dietitians) are selected for audit of their competence to practice. This is based on evidence of activity during the previous two years that demonstrates that they have kept up to date with best practice through continuing professional development (CPD). Attending meetings is one of the activities that count, but it helps if you can demonstrate that you have reflected on the things you learned and applied them to your practice. Just attending isn't enough.

I am a bit obsessive about my CPD portfolio. I cut out articles from professional magazines, print blog posts, include copies of diet sheets that I have worked on - I assume that pretty much everything that I do could be deemed as evidence of CPD. They are very keen on reflection, so every so often I will consider something that has happened within consultations, and write a short reflective piece: "What happened? So what? What next?" Some of those Dietitians selected for audit have to piece together two years of CPD from looking at their diary and working it out from scratch, which is time consuming and hard work. If I am selected, I'm hoping it won't be too much effort to construct my account of the evidence that's needed.

I digress. One lovely bit of CPD is my DESMOND educator accreditation. As mentioned in the last blog post, I have now had my first Mentor visit, which involved being observed in two sessions, one about activity and the other about food and cardiovascular risk (fats and calories). The observer provided some really good constructive advice that I couldn't have worked out on my own - for example, I was aiming for open questions but kept starting with "Do you know...?" or "Does anyone know...?" which are actually closed questions masquerading as open questions. Very interesting, and I hadn't spotted that I was doing it until it was pointed out. The next phase ends with a final assessment at the end of March, if I can get things together that quickly.

Aside from work, I spent a weekend watching badminton in Crawley - the English National competition. Nowhere near as mind-blowingly good as the international competition that takes place annually in Birmingham, but I left it too late to buy tickets for the internationals and there weren't any good seats left. I booked a cheap last minute room in a very posh hotel and was very unimpressed when the TV didn't work, so they switched me to a room where the TV was fine but the heating didn't work, and when I complained again they supplied a convection heater. On the positive side, they had a little fitness room and I did my first ever run on a treadmill, which was much easier than running outside, so I ran further and for longer than ever before.

I spent Sunday at the falconry centre, helping them to get ready to open to the public again - I applied teak oil to wooden benches and moved large rocks for a few hours. And as I still have a few minutes in my life that aren't full of work, badminton or running, a friend tried to persuade me to join a clarinet choir ("It's only once a month...") I dithered, but remembering that I'd thoroughly enjoyed the workshop that Lola II persuaded me to join, I gave in and signed up. It was good fun; I was by no means the worst despite having played so little over the past 30 years, and... it's only once a month...

Tuesday, 3 February 2015

Outcome measures and service development

Plants and a lantern on a sunny windowsill
July 2013
We have been encouraged for some time to try to establish a measure of the value of the work done by Dietitians. It is part of the ongoing 'modernisation' of the NHS, because we are all aware that if what we do does not appear to be of benefit (and when I write 'of benefit' what I mean is 'cost-effective') then our services will not be commissioned and we'll all be out of a job. For example, the Medicines Management people have latched on to the very low carb lifestyle as something that may help the Trust to save money because some patients with diabetes can reduce their medication, but against that must be balanced the cost of the Dietitian and Nurse time in helping them to succeed with the lifestyle.

With a surgeon or a physician it is sometimes possible to compile statistics on mortality and recovery from acute conditions; with a chronic condition like diabetes then improvement is unlikely - preventing progression is worthwhile, but difficult to measure. How can we tell whether the Dietitian made a contribution that made a patient better or saved the NHS money? Would the patient have got worse without the dietetic input? We have no way of knowing.

The Dietetics department has finally succumbed to the pressure to measure 'Outcomes', and my Dietitian colleagues and I have been trying out a set of four parameters specific to diabetes that have been proposed and are being used elsewhere. They are fairly easy to apply (although a bit of thought is needed), and we could conceivably start to record these Outcome Measures, but the next step is to find out how they will be used, and that subject will be discussed in a forthcoming meeting. It is a meeting that I will not have to attend, thankfully, but there are a number of questions that I hope will be answered - do we do this for every patient? What about those in groups? What will happen to the data that we generate - how will it be used?

There is also a change coming to the way that our services are organised, following the 'consultation' earlier in the year. It was a fairly token consultation given that the patients were not given anything like the information they would have needed to make informed choices, but if they had, most of them would have been unable to understand and process it (I am still not entirely sure what's going on - it's inordinately complicated). But the Clinical Commissioning Group (CCG) can state that it has consulted patients, and proposals for change towards an 'Integrated Diabetes Service' in the community have been made.

I have been to more than one meeting about this (I definitely don't intend to go to any more) and I still barely understand any of it. What does seem straightforward is that many people with well-managed Type 2 Diabetes should be discharged back to the care of their GPs instead of being seen by specialists such as those in the team where I work. Despite the fact that this message was delivered by the consultant who is working with the CCG on managing the change, he himself has failed to discharge any of such patients from his own clinics. So I am about 60% confident that little will change in my particular working area, but that leaves 40% of a chance that I am wrong. It's due to start in the new financial year, so we'll have to wait and see what happens then.

Not much more to say about work, although my full time hours have unofficially been extended to September. I don't yet have the paperwork to support the extension, so nothing is for certain. If it goes ahead, though, it should give me enough time to be fully certified as a DESMOND educator - an external assessor is attending my next course to provide some feedback towards my accreditation. I've also been standing in as an educator on a different course for people with Type 2 diabetes. DESMOND is for people who are newly diagnosed, but the other course is to promote the lower carb approach to people who've had diabetes for some time. It's much shorter in duration, and neither I nor the Diabetes Specialist Nurse who delivered it with me had done one of these before, so we launched ourselves at it and charged through at a gallop to make sure we squeezed everything in. Part 2 is this week, and perhaps we'll be able to moderate our speed. It was quite a ride.

If only I could tell you the details of some of my consultations! They have been particularly interesting in this post-holiday period, as people find different ways to explain how they really let things go over Christmas, but they are definitely going to get going again now. I had one afternoon when my input was more in the way of marriage guidance than dietetics; another appointment with a patient who had a lot to say and hardly gave me a chance to introduce myself. Occasionally I feel I can really make a difference with just one nugget of information.

But there are still a few patients who are baffling - their understanding of diabetes and their ways of managing it have been deeply embedded over many years, and trying to get to the bottom of what is going on can be frustrating, and sometimes futile. For these people it is a question of working within the parameters they set, and trying to find a way to ensure the best outcomes possible. Most of the time I would encourage the patient to plan just one or two small changes, although there is so much that could be done. But it is impossible to know what would have happened if I'd acted otherwise, and I do think that succeeding with one thing is better than being faced with too many challenges and not overcoming any of them.

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