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Is being a doctor just a job?

May 11, 2017

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You hear this phrase a lot; being a doctor is “just a job”, but funnily enough in widely different contexts.On the one hand, the “higher calling” of medicine is derided by some, who insist it’s “just a job” like any other. On the other, doctors under extreme pressure need to know sometimes that their work is “a job”, it should stay compartmentalised and allow them a life outside the hospital or surgery, to balance their own mental health against their working lives.

Which is it?
I don’t think anyone who has working in any emergency setting with human beings would accept the derogatory label of “just a job”, whether that job is doctor, nurse, physiotherapist, pharmacist, fireman, policeman, or paramedic. The normal course of a human life is long periods of normality and stability, punctuated by “Life” with a capital L; births, deaths, marriages, divorces, comedy and tragedy. There’s only…

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Diary of a CT1 – Moving On and Acting Up

December 19, 2016

It’s that time of year when I usually write about changing over jobs, switching up my flavours of medicine. Recalling all the useful lessons and insights I’ve gained from my outgoing job and cursing that I’ve traded places just as I’ve found my place. But not this year. This year, still working in Respiratory Medicine at Ysbyty Rhywle.

Instead, I keep calm and carry on (for two more months in this rotation) and watch as the Foundation doctors change it up. And I doubly sad, because I’ve lost not one but two FY1s. There was the ward F1, who I with glee discovered was a secret Pokémon nerd, and the on-call F1, who I spent every on-call in the Rhywle with. I’ve watched them put four months of being actual, real doctors under their belt. I’ve watched them go from quailing at venepuncture and cannulation to inserting catheters into genitals groaning with prostatism with ease and aplomb. I taught them what I could along the way, about prostatic genitalia and other things. I’ve watched them grow from meek, unsure medical students to my doctorly colleagues. They even sass me now. (They grow up so fast, he sighed, wiping away a tear).

They’ve gone off to Surgery and now I have two new F1s to play with. They’re a little more sure of themselves but they’re still diamonds in the rough. For God’s sake, my on-call F1 can’t even do a high-five! How am I supposed to work with this?!

The anger is a defence. Really. I’m sad. I’m relinquishing two colleagues – and dare I say, friends? But there’s more to it. What of all the SHOs and SpRs I’ve worked with before who I’ve left behind in the previous chapter of my künstlerroman journey? Is this how they felt (or were they glad to see the back of me)? Time makes a fool of me. I’ve gone from Luke Skywalker to old Ben Kenobi.

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Me and my old SpR. Tales from a different age.

The other thing that is curdling my seasonal spirits is a paucity of registrars. On the wards, a number of our registrars are evolving into consultants and there is currently a lacunar on our ward rounds where they should be. The other SHO and I divvy up the work the best we can but it’s an odd situation. In a double reflection of the F1s; firstly, we’re taking unsure baby-Bambi steps on patient management and care that they would have skipped through with ease; secondly, plainly, I miss them.

This is where I have grow into Obi Wan Kenobi, from Ewan McGregor into Alec Guinness. It’s the art and science of Medicine. I have my good days – The consultant gave me a solid thumbs up for my deft management of a severely wheezy patient. Hell yeah!

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Artist’s impression of the Med Reg

Then there was a recent batch of night shifts, where our Med reg had been felled by something nasty and viral. Increasingly frantic emails by Medical Staffing found a locum SHO willing to “act up” as the medical registrar. But as he was new to the hospital and its various demons and gremlins, we agreed that I would hold one of the registrar bleeps, the one concerned with the sick and very sick new admissions since I would be clerking in A&E anyway.

So a third bleep, in addition to the two bleeps I normally carry overnight. People jokingly remarked on my new fashion and I forced myself to laugh to.

That’s when the call come in; “Are you the Med SpR?

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“Well,” I replied diplomatically, “I’m holding the Med SpR bleep…”

At first, it was nervewracking but we mostly survived until dawn. There were a couple of transfers from other hospitals, which were much like any other referral I’d normally get. (With the addition of “Why do they need to come here?” to “Why do they need to come in?”). I also took a few calls from the F1 (the new one, who can’t high five) and the ANPs on the wards. That’s the main learning point from play-acting as Med SpR – So many interruptions! Maintaining momentum was like getting water to flow uphill.

There’s more to learn. There’s always more to learn. But now there’s a little less to learn. And the new F1s still need me, just not for all the same things as before.

I mean, if not for me, who is going to teach these fledgling doctors how to high-five?

Diary of a CT1 – The Hardest

November 13, 2016

 

I stand atop Ysbyty Rhywle’s roof, stare grimly into the setting sun, gripping an IV stand tightly, and utter “Brace yourselves. Winter is coming.”

Winter is a terrible time to be sick. The cold bites in arthritic joints. Freezing blood struggles through atherosclerotic coronaries, until finally waylaid by thrombus and plaque.  The spectre of influenza stalks the streets and the old man’s friend, pneumonia creeps in with every cough and sneeze.

Winter is a terrible time to work in the NHS. While “bed pressure” and capacity (and lack thereof) have become perennial problems, the cold and dark months seem especially bad. Heaven help you if your lot is the emphysematous and bronchitic, the asthmatic and bronchiectatic, who Jack Frost singles out for extra punishment.

Heaven help me.

Personally, Winter started a few weeks back at the end of October. It was Friday. It had been a busy day but we were nearly done. One of the nurses asked me to review a patient. They had been very unwell, but stable, earlier. Now everything had changed. Blood pressure down,  heart rate up, all the numbers in the wrong order. I asked my SpR for help but I knew that this patient was dying, and there was nothing left that we could do but keep them comfortable. The SpR made their assessment and said as much. I called the family and prescribed comfort medicines.

It’s a narrow, selfish thought but  – what a way to finish the week! But the beast that is Medicine wasn’t done with us yet. The nurse came back and asked us to review the patient next to the patient we had just seen. My SpR and I shared a glance – “Really?” Again, this patient had been sick but stable earlier in the day – and now was actively deteriorating in front of us. We made our assessment and came to the same conclusion as before. We could do nothing but witness – and comfort where possible.

Death is something that comes with the job, grimly. I’ve seen plenty of it by now and have grown somewhat inured to it – but seeing it in stereo felt particularly brutal that Friday.

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I felt a lot like this. No defibrillators were harmed.

I was doubly fortunate in that first, there was Twitter, with a few words of support and gifs of wine, and then second, I got to spend the weekend with a close friend and find my way back to humanity.

I wanted to write this blog a few weeks back, closer to the raw rage and despair I was feeling. It’s probably better that I didn’t. In the interim, my thoughts have had time to cool and ferment.

When I started out as a doctor, it was hard because of all the running around, taking bloods, siting cannulas, et cetera. Then the next year was hard because I had to do actual medicine-y stuff, while still doing the runaround stuff. This year is hard because I’m expected to know the medicine-y stuff (knowing it last year was a bonus) while leading ward rounds with the F1 and medical student. Medicine doesn’t get any less hard but the particular way in which it is hard changes, with the physical gradually replaced by the mental, runaround gives way to responsibility.

But it is and always will be emotionally hard. Every time I’m at risk of forgetting this, that beast called Medicine finds a way to remind me of this.

Winter is coming. And this year, it’s going to be cold and dark and brutal. It’s going to be hard physically, harder mentally and hardest emotionally.

I wanted to write this blog when I was sad and angry. I didn’t and I’m glad because here’s a postscript. A very important postscript and in a year like 2016, perhaps the most important postscript there is.

It gets better. Medicine, like all things, ebbs and flows. It gives and takes away. It gets better. The drugs do work. Patients heal and improve and they leave hospital through the front door.

It. Always. Gets. Better.

Winter is coming and it’s not going to pull its punches on me or my patients, but I’m going to keep on working until Spring.

Diary of a CT1 – Where and Elsewhere

October 1, 2016

Eight years ago this weekend, we packed up my life into the back of my dad’s Ford Focus and headed to London and the start of medical school. For someone with a geographically stable childhood, univsersity was a big upheaval in more ways than one. I’m sure I’m not alone in this. I imagine most people who go to university end up away from their family, away from home, away from their comfort zone. When you’re 18, everyone has got good advice for getting used to a new surrounding, making new friends and not feeling so lonely.

But what gets neglected is what comes next.

From London, I moved to the south coast, and from there I’ve moved now to south Wales. Why? Because medicine, that’s why. My first training programme as a doctor covered a region from the south bank of the Thames to the English Channel. Living and working in London one year then relocating to a different hospital, perhaps 100 miles away overnight. That’s right. I finished at St Elsewhere’s, London, on a Tuesday and started at Worthwhile General on the south coast on Wednesday.

This August, I played the same game again. Finished at Worthwhile General on Tuesday, then a 150 mile journey through the night (it was a dark and stormy night) so I could start at Ysbyty Sant Rhywle the very next day. That I was starting on a night shift meant I had to readjust my body clock as well as my compass.

But why can’t you just stay put in one hospital or one NHS trust? I hear you ask. Because I need to finish my training and because of the centralised oversight of these training programmes, my choice in these matters is somewhat limited. I could work in a staff grade (i.e. not a training post) in one place for years – I’ve met people who’ve done just this – but that means I don’t get any closer to the golden McGuffin of post-graduate training, a Certificate of Completion of Training, needed for becoming a consultant.

So my Hobson’s choice is between geographical instability and training inertia. BUT WAIT THERE’S MORE!!

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She will cut you up good.

Let me introduce Eve, my wife and light of my life. We met in medical school and I’ve grown quite fond of her. She makes me smile and pop songs make sense when I’m with her. A doctor, like me. So take all the hurdles I mentioned above – and double them. 

We were lucky starting out. We linked out FPAS applications and the South Thames deanery honoured by placing in reasonably neighbouring hospitals, both in London and on the south coast. Things have grown more difficult since then as every career move one of us makes is made with one eye on what the other is doing. Our compromise this year means she is working 50 miles away – for someone who doesn’t drive and with major railway engineering in the area – that is one hell of a compromise.

When she is on-call, she stays overnight in hospital accomodation because it is not worth the time, money or effort in coming home before heading back for another day. She is on-call this weekened. When she’s home next weekend, I’m on-call. She’s lonely, I’m lonely. This is the happy-ever-after of a medical marriage.

But it could be worse. My SpR works, obviously, in Ysbyty Sant Rhywle while her husband works in Scotland. Yes, that Scotland. Compounding this, she is looking after their young child by herself, effectively a single medical mum. Whenever she explains this domestic situation, she is met with unanimous incredulity.

Yet no-one ever tells you about this. All through medical school, it was renin-angiotensin-system-this and vascular-supply-of-the-colon-that. No-one ever says to get used to living out of suitcases and avoid putting down deep roots in any one place. In fact, if they had told us that in medical school, it would have been too late. This is caveat emptor-type stuff. Kids, if you want to do medicine – Buy a caravan.

It’s not strictly true that no-one ever told us this. I remember as a fifth-year student, still with plenty of time before stressing about applying for jobs, our consultant on an Oncology placement stressed the importance of planning ahead and planning your career around your home life. I wish I’d paid more attention back then…

I don’t want this to sound like I’m whining. I am whining, but I don’t want it to sound that way. Work is stressful but I enjoy it, I’m in the training programme I want to be in, I have a beautiful, smart and compassionate wife who I love (and whom I would dearly love to see). My point is, much has been made of low morale and burnout in the NHS at present, and every year final year medical students stress about where to start their careers as doctors. I just want to get it out there that the where (and the with whom) is just as important as the what.

P.S. My SpR has completed her training and secured a job as a consultant in Scotland, where she can re-unite her family. This is the silver lining; this is the golden ticket I’ve got my sights on. As film critic Mark Kermode often says, it’ll all be alright in the end.

Diary of a CT1 – A Majestic Salmon

August 22, 2016

It’s been an odd kind of year so far. Got an interview for Core Medical Training. Didn’t get a job. Reapplied. Got married! Came home early from honeymoon to attend a second interview. Got a job! Closed the loop on an audit and received a commendation for a different audit. All this on a background of strikes and protests and negotiations and referendums. Needless to say, my self-esteem has slingshotting this year like the tides on a restless beach.
ChS0OuFWMAQNl5NAnd now we arrive at yet another August, yet another new beginning. I am now a Core Medical Trainee, with the goal of being an even better jack-of-all-trades and perhaps master of some. The winds of fate have blown me westwards to Ysbyty Sant Rhywle – After a long journey in the wilderness in Imperial College, St Elsewhere’s and Worthwhile General, I have (nearly) returned home like a majestic salmon.

The first thing I’ve noticed is that the FY1s are getting younger. When my current house officer colleague was born, I was playing with Thunderbirds Tracey Island. Admittedly, not much of an age-gap but it can only lengthen. Get behind me, vulturous Time! Aside from being a baby-faced memento mori in a stethoscope, they’re keen to work and keen to learn.

The FY1 on the next ward asked me to supervise her inserting a urinary catheter, her first as a doctor. I could see she knew the theory but still lacked the confidence to put it into practice properly. There was Instillagel and penis flying every which way – but I let her fumble her way through it, providing a guiding hand just at the end so the catheter would go into the bladder and not turn the patient’s prostate into Emmenthal.

I remember so clearly when that was me, so timid and nervous with every move. But practice becomes routine becomes confidence. And now I’m teaching the next generation. Just how and when did that happen?

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But as I’ve learned so much over the last two years, there’s still much more for me to learn. I spent this last weekend on-call and it was an on-call to rival the best of them. When did 12 hours get so long? And so draining? The upside is that I have a real good team of doctors to work with, and we’re rota-ed to the same shifts so we can really work as a team. One of the more senior players, a wise and kind CT2, offered to supervise and assist me perform a much-needed lumbar puncture on one of his patients.

(A lumbar puncture – LP – is a procedure where we insert a long, fine needle into someone’s spinal cord from the back, to sample their cerebrospinal fluid, the goop that the brain and central nervous system floats in. Very important if you suspect meningitis or subarachnoid haemorrhage)

I thought back to the FY1 and the catheter. Two years on and I’m back on the other side of the examination couch. I knew the theory, even practiced once or twice on silicone prosections, but finally here was my chance to step up. I was nervous but the CT2 guided me through it sagely. We got that crystal clear fluid and the patient got their diagnosis. I did that. Me.

I clambered to the top of medical school to land at the foot of the Foundation Programme. Then I scaled the Foundation Programme and I find myself here at the start of another journey. Leading ward rounds, clinics, sticking larger needles in deeper places…

Let’s get started!

Diary of an FY2 – A Compartmentalised Life

June 29, 2016

It was Socrates who said that the unexamined life is not worth living. I have nothing to fear. Life in GP-Land is filled with examinations, between the history and the green prescription forms and usually a self-referral leaflet for physiotherapy. But between the middle ear infections and arthritic knees and suspicious lumps and tired-all-the-times and coughs and cold and all sorts of pain, there is still room left to examine myself.

I find my clinics are getting more emotionally and intellectually draining as the weeks creep by. This is due in part to the frequent mental gear-changes I have to make, with shark-like turning precision. As different actors shuffle in and out, playing the role of Patient, I remain the Doctor. But that role changes so frequently:

  • Avuncular, explaining that it is just a sore throat and will get better with fluids and paracetamol. And antibiotics won’t help.
  • Concerned that those vague symptoms – feeling a bit more tired, losing a little bit of weight, a niggling tummy pain – might be the stars in a sinister constellation. Please don’t be alarmed but I’m faxing a referral letter now and thinking of a word beginning with C.
  • Reassuring. The ultrasound, the chest X-ray, the blood tests are back. It’s good news, everything is clear! Or, well, you’re kidney and liver function is good but I’m a bit worried about your cholesterol and HbA1C so here are the things we can do about that…
  • Consoling the woman who has escaped an abusive relationship but gently weeps in my clinic room. Offering a tissue and the silence she needs to speak. Offering what help I can, signposting where she can go next.
  • And then back to someone who has burning, stinging sensation when they pee.

At least, I hope that what patients get when they come to me, not just the the prescriptions and information leaflets and X-ray forms and blood tests. I hope that I am more than just a vending machine for co-codamol and amoxicillin, a Chinese Room in chinos. Cogito ergo sum – I think, therefore I am more than just that?

The Doctor exhibited 1891 by Sir Luke Fildes 1843-1927

The Doctor by Sir Luke Fildes. Dispassionate exam? Compassionate witness?

Often patients will apologise for bothering me, or wasting my time, with their complaints. I am hasty to correct them. Appointments that have given rise to blood tests, X-Rays, specialist referrals are the exact opposite of a waste of time. And even those who illnesses are self-limiting often have quite valid reasons for seeing someone with a stethoscope.

But that is only half of it. As Socrates said, the unexamined life ain’t worth living. I can see hundreds of ears and throat, listen to lungs and hearts abundent, and feel knees unending, but there is still one system left to examine. Doctor, know thyself! Life in GP-Land is not just a mental rollercoaster, but an emotional one too.

I enjoy treating the minor, self-limiting illnesses, comfortable in the knowledge that 99.9% will improve no matter what I do, but my “laying on of hands” has validated its benign course. (But all-the-while paying heed to the small voice at the back of my head that this could be epiglottitis, could be a tumour, could be Crohn’s or an ulcer).

Musculoskeletal problems frustate me because I can’t guarantee if and when they will improve – But be it bone, muscle or tendon, I know most things are helped by ibuprofen and physiotherapy.

Investigating the squishy bits (Internal medicine, if you will – horribly vague US phrase) is so very different to the Medicine practiced in St Elsewhere and Worthwhile General. My most powerful tool and treatment is Time, as I’ve mentioned before. Time to titrate, experiment and investigate. I get a real pleasure out of this kind of Medicine.

It is said that psychiatry accounts for 40% of general practice appointments. I don’t know where that number came from, or even if it is accurate, but it has a strong feel of “truthiness.” There was a time when I thought, yes, this is what I want to do! Nowadays I feel, not hopeless, but helpless. Patients come to me with their anxieties and their depressions, feelings that they’re no good, that everyone would be better off without them, occasionally the feelings that they should kill themselves. I see women coming out of abusive relationships carrying their mental scars with them. I see so much struggle and strife and suffering and, armed with a prescription pad and a leaflet about talking therapies, I feel wholly inadequate.

Who doesn’t feel like this? But I do what I can, and I try to do it with compassion. And I’ve seen people get better and I might have played a small part in that. A friend of mind has a tattoo that reads, This too shall pass. It’s a reminder worth writing in indelible ink.

There are times when I feel out of my depth, when I feel like “just a medical student” pretending to do Medicine. Then there are times when the diagnostic cogs click, I make the diagnosis and start the treatment and, damn, I feel like a doctor. Not just any doctor, maybe even a good doctor.

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The space between these times is usually around ten minutes.

 

Diary of an FY2 – The Doctor is In

May 26, 2016

The weather is slowly but surely improving. The Earth’s tilt and orbit around the sun are dragging the country, kicking and screaming into British Summertime. The change in climate brings with a change in scenery. I’ve traded in the slicing and dicing (by proxy) of General Surgery for the myriad cups of tea of General Practice.

I like the change of pace. Regular, reliable hours with sensible waking hours. Even as morning person, General Surgery too damn early for me. Waking up earlier than most everyone else (including the Sun) but not so early that you could enjoy the solitude with the morning chorus. Now that the Sun is up and about during all my working hours, I get to work on topping up my Vitamin D.

But it’s than just calcium homeostasis. Instead of running about all over the hospital, clerking and treating patients just before or just after surgery, I have been installed in my room with a computer and a blood pressure cuff (one of the old-fashioned ones with mercury in it) – and the patients come to me! My knees are grateful for this stationary approach but I do miss running down long corridors, with a mind to do medicine and kick butt. Is that shallow?

And instead of surgery, it’s…well, everything. I’ve loved the breadth of General Practice – I’ve always had trouble narrowing my focus and raising the flag for a single organ system. I can see a 96-year-old with a rash, followed by a 4-year-old with a sore throat. I enjoy exercising that “Jack-of-all-trades” mindset, the mental fluidity to go from back pain to palpitations to asthma before back to back pain again.

I’ve been given 30 minute appointments, in recognition that I am a doctor in training, and this does take the pressure off. Even so, I often feel thoroughly “thinked-out” at the end of the day. I can’t imagine working with 10 minute appointments, with three times as many patients, on top of the full complement of paperwork required to run a surgery.

However, time is something I struggle with. In Worthwhile General, I had the full suite of investigations and treatments at my fingertips. We might have to wait until the next day for a non-urgent CT scan, and a bit longer for an MRI scan. Specialist advice was always at the end of a phoneline and if you were particularly silver-tongued, you could even get a SpR (or, Holiest of Holies, consultant) review. We could start treatment and could say within hours if it was working.

All those things are still available but they seem removed from my reach, like Tantalus reaching for the fruit. I can still request blood tests and X-rays, but they take a day to come back (from the time the patient gets the investigation). Specialist advice is obviously still available, but my referrals must first run the gauntlet of fax machines, secretaries and internal mail. And I only know if my treatments are working if the patients come back and tell me so. But this is the art of General Practice – being able to help patients without the largesse of hospital medicine.

But the one investigation and treatment that I underused in Worthwhile General was Time. When patients first present to their GP, the symptoms can be mild and vague; the differential is long. To narrow the differential (like any other investigation), wait diagnostically. Let the illness evolve and resolve. “But what if the patient gets sick! They’re still in pain!” My clinical mind screams. “If they are so sick, they need to be in hospital, send them to hospital. If not, tell them which symptoms mean they are getting seriously sick.” Chides my as-yet-underdeveloped General Practice gland.

And sometimes, I don’t need to pour Tazocin on a sore throat, or Oramorph PRN on musculoskeletal pain. They say time heals all wounds – so let it! The noble art of medicine, as Sam Shem put it in The House of God, is:

LAW 13: The delivery of good medical care is to do as much nothing as possible.

But I’m still getting used to it.