Mangling Medical Careers

When I started this blog, I deliberately tried to avoid writing about Modernising Medical Careers (MMC) because the whole debacle pissed me off so much and I’d just get really angry whenever I thought about it.

It’s now two years since specialty training and recruitment came under the MMC umbrella, so I thought I’d revisit the subject to see if the powers that be have managed to iron out the problems the new system had at its inception.

One of the key concepts of MMC, the new post-graduate training system for doctors, was to end the “lost generation” of Senior House Officer (SHO) junior doctors who spend far too long in SHO posts and face far too may barriers to career progression.

A quick look at the MMC website shows how beneficial the changes have been to junior doctors. They’ve got rid of the name “SHO” and given us names like CT1, ST2, FTSTA2, ACCS1 etc… etc… but the jobs that we are doing are essentially the same, so I’ll refer to all these posts as “SHO” in this post to try and avoid confusion. All SHOs would like to progress to being a Specialist Registrar (SpR) with the long term aim to complete our training and become a consultant.

MMC has renamed the SpR posts as “ST3”

Now, lets say that you’re a junior doctor and are coming to the end of your two or three years as an SHO and want to move on to an ST3 (SpR) job next year to progress your training. Oh, and lets say that you want to stay roughly where you live at the moment because that’s where your friends and family are.
For the specialty of anaesthetics, let’s see exactly how many jobs there are to apply for in England & Wales in 2009.

East Anglia and the East of England – 1
East Midlands – 2
Kent, Surrey & Sussex – ZERO
Manchester, Lancashire and the North West – ZERO
Newcastle & the north – ZERO
Oxfordshire – ZERO
Cornwall, Devon & Dorset – ZERO
Bristol and the Severn area - 1
Wessex – 1
West Midlands – ZERO
Yorkshire – ZERO

All of Wales - ZERO

In fact, the only places where are any vaguely sensible numbers of jobs are Liverpool and London. If you happen to live anywhere else, you’re going to have to move. In the whole of the country, there is a sum total of 55 jobs available in 2009. My back-of-an-envelope calculations tell me that there’ll be in the region of 350-450 doctors wanting one of these 55 jobs. What happens to the people who don’t get one of these jobs? Nobody knows, and the impression that I get is that nobody really cares. The situation is even worse for doctors who want to be surgeons, paediatricians or physicians.

Remember that the stated aim was to PREVENT barriers to career progression. How can a system that’s been six years in the making fuck things up so badly?

Happy Christmas

I wish you all a very Happy Christmas indeed.

Pink or Blue?

It was a few months after I’d started my anaesthetic training and I was slowly becoming more confident (and competent) about giving general anaesthetics safely. I was going a general surgical list and Dr James was the consultant anaesthetist in charge. Dr James said that she was going to “loosen the reins a little” and told me that I was going to look after this list by myself and that her role that morning was to “drink coffee and administer the occasional bollocking.”

So I got cracking and things were going well. True to her word, Dr James made various cameo appearances throughout the morning and “questioned” my choice of drugs and anaesthetic technique. The last man on the list was a 77yr-old with a few medical problems. Of all the people I had to put under that morning, he was the one I was most concerned about.

Anyway, I get him in the anaesthetic room, do all the per-op checks with the ODP (anaesthetic assistant) and get the monitors on. I put in a drip and set about getting him anaesthetised. I figured that he wouldn’t need much of my induction drug, so I slowly trickled in the propofol.
Despite my caution, things started to go wrong. After he became unconscious, I was able to bag-mask ventilate him OK and I after I put in the LMA, his chest was rising and falling, a sign that I was getting oxygen into his lungs. Despite this, the monitor was showing

O2 sats: 77%

And this is bad.

The ODP was a man called Edward, who was very experienced – in fact I believe he was set to retire in a couple of years’ time. Edward looks at me and says “Sats are low”

“I know,” I reply as I turn to oxygen up to 100%
“Is the LMA in properly?” he asks.
“I reckon so”
“Are you sure, I mean sats are only 75%! Do you want to take it out?”

I really didn’t think that this was an airway/ventilation problem and the fact that the blood pressure cuff was taking an awful long time to give me a reading made me think that the problem was that the patient didn’t have a blood pressure.

“No, leave it in,” I say.
Edward looks at me incredulously. “Well, what do you want to do?” he asks. “Shall I call for Dr James?”
“Yes, please do.”
Edwards kicks open the door to the operating theatre and yells at the theatre nurse to go and get Dr James NOW.

I look at the monitor again, it still says that the sats are 75% and, rather ominously, this mans heart rate had dropped from 70bpm to 45bpm.
“Edward. Squeeze this bag for me” I say and I open the cupboard to get out some emergency drugs. I pause for a second to consider which inotrope to use and at that moment, Dr James bursts into the anaesthetic room.

She looks at the patient then looks at me, then looks at the patient again then looks at me. “What’s going on?!” she exclaims.

“Hypotension… and bradycardia.” I mumble
She bags the patient and asks, “what have you got in your hand?”
“Atropine.”
“Ok, give 300mics”
I do so, and seconds later, the patient is better. Sats read 95% and the blood pressure is back to 133/58.
“How much propofol did you give?” Dr James asks me
I look at the syringe that is sitting on the anaesthetic machine. “105mg altogether”
“That’s not a great amount is it?”
“No, not really. I was actually really surprised that such a small dose had such a massive effect on this man”
Dr James shrugs and says “sometimes it happens like that.”

We get the patient through into the operating theatre and onto the theatre table. Dr James laments, “whenever I get called into the anaesthetic room, my first question is: ‘Pink or blue?’”

“Pink or blue? I’m confused”
“As in; ‘Is the patient pink or blue?’ This man…” she gesticulates at the patient on the operating table “was pink. So I knew things weren’t too bad.”

I mentally raise an eyebrow at this. I’m not sure how bad things have to be before Dr James gets worried.

“You did a good job,” she says and literally pats me on the back. “Carry on…” and with that she saunters back out of the operating room, presumably back to her coffee.

Edward and I look at each other and shrug as the surgeon starts the operation.

Christmas Bonus

My girlfriend got her Christmas Bonus the other week. Because of her hard work and dedication though these difficult economic times, her company has given her £1000 to say thank-you for all that she’s done for them in 2008. What’s more she’s now out dancing the night away at her company’s Christmas party, with free drinks at a venue all paid for by her company as a thank-you to the staff.

I got my Christmas Bonus yesterday. As a reward for all my hard work and dedication over the last year, my company gave me a £1.50 discount voucher for the Christmas Dinner. It meant that only had to pay £3.00! I feel so happy that all the extra (unpaid) hours I put in have been recognised. That I get some recompense for all the occasions that I’ve done extra shifts to cover the gaps in the rota. That my hospital wishes to thank-you for all the unsupervised lists that I did – not because it helps my training, but to cover for absences and make sure that operations don’t get cancelled.

Such is life as a public sector worker.

It’s not all bad though. After I paid my £3.00 for the Christmas Lunch, I got a “free” Christmas cracker – so I can’t complain too much, can I?

Hi! My name is... My name is... My name is...

DrJDR posed me this question in a comment to a post that I made earlier in the week

I wonder what you think about the whole 'first names' question? That is, should
you (the doctor) introduce yourself by your first name - such as 'My name is
James, I'm a forensic psychiatrist'? I remember being told off in an exam for
doing this kind of thing, and since then I've always been very careful not to
use my first name and stick to surname - ie 'my name is Dr Blunt' (well it isn't
really, of course). I think that this does set the professional boundaries very
clearly which I think is important for patients. I used to constantly cringe
when hearing young nursing staff / assistants breezily addressing sick old men
and women on their first meeting by using their first names. I always thought
this inappropriate, and personally I would not like to be called by my first
name by someone I had never met. Professionalism in medicine as a whole is
something which has really suffered, and which I think we need to keep going.
Patients expect us to act in a professional manner, and when we do this gives
them confidence in us.

To be honest, I have no hard and fast rules about which title I use to introduce myself. I’ve used “Michael,” “Dr Anderson” and even “Dr Michael Anderson” depending on what seems most appropriate at the time. I have to say that my “default” when introducing myself to an adult or late adolescent is “Dr Anderson,” but I do vary it – yesterday's post for an example.

When addressing patients, I tend to use their full names to start with and then I’ll use their surnames for the rest of the conversation, unless they tell me otherwise. So, generally, it goes something this:

“Good afternoon, is it Amy King?”
“Yes, it is.”
“Pleased to meet you, my name is Dr Anderson, I’ll be the anaesthetic doctor for your operation later on today. Is it Miss or Mrs King?”
“Mrs, but please call me Amy”

Patients are frequently extremely anxious when I see them pre-operatively and you’re right, that professionalism and good communication are incredibly important.

With children, especially young children, I do tend to use first names more, but again, this is no hard and fast rule, and I'll often use surnames with children as well. It depends on the child.

At the end of the day, part of my aim is to try and make the person I'm talking to feel as comfortable as I can using whichever names I feel fits the situation best. It seems to work pretty well for me, but no doubt there's occasions where I've got it wrong and no doubt, I'll get it wrong in the future, after all, every person is different.

I do call patients “dear” or “my dear” occasionally, (yes, I know we’re not supposed to) but again, I’ll do this only when I feel it’s appropriate and certainly not until I’d built up a relationship with the person that I’m speaking to.

A Sliver of Hope

It's 9pm and I'm on nights once more. There are no emergency operations to do, so I'm in the intensive care unit, helping out as best I can. Bindhu is the registrar on call tonight and is my direct senior for the shift. We’re walking round the unit and she’s giving me a brief handover of all the patients as we do so.

We pause at the end of one of the beds and I recognise the lady in it. It’s Mrs Campbell. Last week, I’d pre-assessed her for her emergency operation and then handed over her care to the anaesthetist on call during the day time. I smile at her and receive a tight grin in return.

"You won't get much out of her," says Bindhu. I give her my best "quizzical" look, so she elaborates. "It's a bit strange. Every time I try to speak to her she won't answer me, or even acknowledge me, but when I watch her with the nurses, she seems to be completely different. Mind you, she's apparently been a bit better today. In the daytime, they made the surgeons come down and explain to her what went on - or should I say, what went wrong - with her operation and explain what they're planning to do about it. I mean, it's only fair isn't it? I don't see why we (anaesthetists) should have to take the flak, when really the cause of her problems is nothing to do with us."

"Indeed." I reply. "I'll bet you that I can make her smile though."

Bindhu throws her head back and gives one of her lilting little laughs. “Good luck with that,” she says and we move on to talk about the next patient.

It’s now 11pm and Bindhu and I have done all the pressing things for all our patients on the intensive care unit. The nurses have just turned down the main lights, so the room is illuminated by soft glows coming from the lamps at each patient's bedside.

I walk up to Mrs Campbell’s bedside.

“Hello. Mrs Campbell,” I say softly. Her eyelids flicker open and she fixes me with a cool stare. “Do you remember me?” I continue.

She rolls her eyes away from me. “No. I don’t remember you,” comes her flat reply. “I don’t remember… anything. For the last few days, I don’t remember anything.”

This doesn’t come as a surprise to me as she’s been in a coma on a ventilator until a couple of days ago, but I suppose I was hoping that she’d at least recognise me from before her operation. I was wrong.

“My name is Michael, I’m one of the anaesthetic doctors and I saw you before you had your third operation. I just wanted to see how you are feeling.”

“How I am feeling? How am I feeling?” she seems to ponder the question for a while, like she’s rolling the thought around her consciousness. “I feel lousy.”

And then there’s The Silence.

I like to think of myself as a pretty chatty, outgoing person who can talk to just about anyone, but every now and then, I find myself at a loss for anything to say at all.

Here I am, late at night standing next to a woman with several tubes coming out of various parts of her body. A woman who’s just come out of a coma and is too weak to even feed herself. I feel that there’s just no way that I can relate her and what she’s had to go through. There’s no way that I can understand how she must be feeling. There’s no way that I can put myself in her position or even begin to imagine what it must feel like. I fear that any words of comfort that I might attempt will sound trite in the face of this lady’s experiences, so I’m left with no words at all – just The Silence.

As The Silence stretches on, it begins to feel more and more uncomfortable. I’m just standing next to her bed saying nothing, feeling stupid, so I’m compelled to try and just say something, anything at all.

“Yeah, I understand that you must feel pretty lousy right now. Am I right in thinking that you’ve been able to have a chat with the surgeons about the operation?”

She sneers at me. “Oh, I know what they’re planning to do tomorrow. And I know what they’ve done.” She looks away from me again and stares in the direction of the far wall, which has silver tinsel draped along it. “They’ve given me a stoma.” She spits out the last word, like it’s a piece of rotten fruit she’d accidentally bitten into.

She looks back at me now and meets my gaze. I realise for the first time just how piercingly blue this lady’s eyes are. She sighs. “My sister had a stoma,” she says, her voice is a mere whisper.

“And you really didn’t want one…”

“I cared for her for years… For years. That’s her picture over there.” She gestures to the photo frame at the side of the observation chart. I go and pick it up and look at the picture.

“What happened to your sister?” I ask.

“She had MS. And cancer. I spent years looking after her, and looking after my mother. We were inseparable, you know? And do you know what’s funny? During all the time I was looking after her, I knew that there was something wrong with me. But I had to be strong, you know? For her. I’m a very determined woman. But I knew there was something wrong. But I never thought I’d end up just like her.”

“I know this is easy for me to say,” I respond, “but you must try and stay positive. You are getting better. I know you must feel awful now, and there’s a long, long way to go, but, hopefully each day you’ll feel stronger and, as you do so, you may be able to look forward to the future. You’ve just got to try and think…”

“That God knows what he’s doing?” she interjects.

“I guess so.”

“Last Christmas was hard…. very hard. My mother died. She kept saying ‘I want to be with my daughter. I want to be with my daughter’ She kept saying it again and again…” Her voice trails off and tears well in her eyes. “And now she is,” she whispers.

“I saw her last night, you know,” continues Mrs Campbell. “My sister. She was stood over there near the door…”

I wait for her to continue, but there are no words coming. Once more The Silence envelops the two of us.

“Yesterday, I didn’t want to live,” she says. “I’ve got nothing left to live for. Yesterday, I really didn’t want to go on. But today… Today I feel better. I’ve got a dog, you see. I have a little dog that loves me, and I love her. So I’ve got to get better haven’t I? For my dog.” She gives a little laugh. “That dog saved my life.”

“That’s something,” I say. “And as you get better, and are able to do more things, then I’m sure things will start to look brighter. I’ll leave you to get some rest now, Mrs Campbell. Sleep well.”

She closes her eyes and I walk away.

My name is...

One of the things that was drummed into me again and again at medical school was the importance of introducing myself to my patients. In every single undergraduate clinical exam and every single postgraduate exam I have every sat, there have been marks allocated for introducing myself to the patient at the start of the interaction.

Personally, I used to think that being told this again and again and again was really tedious. After all, it’s just good manners isn’t it? I always introduce myself when I meet a new person and patients are no exception.

“Mr Smith? Good morning, my name is Michael. I’m one of the anaesthetists, do you mind if I ask you a few questions?”

or

“Mr Smith? Good morning, my name is Dr Anderson. I’m one of the anaesthetists, do you mind if I ask you a few questions?”

When I first started my anaesthetic training just over a year ago, that was how I’d introduce myself to my patients.

When I first started my anaesthetic training just over a year ago, I’d frequently get blank, uncomprehending looks from the person that I was talking to. Sometimes, people would try to be polite, but it soon became obvious that they had no idea who I was or what I was planning to do to them. You see, it became very obvious, very quickly that, generally, people have very little idea what anaesthetists do, so introducing myself as an anaesthetist didn’t shed much light.

Since starting my anaesthetic training, I’ve had some cracking comments about my job – often from people who (I thought) really should know better.

“Oh, I didn’t know you had to be a doctor to be an anaesthetist!” – from one of FashionGirl’s friends

“If you’re an anaesthetist, all you do is give an injection – and that’s it. Well, that’s what happened when I had my operation. Why do you have to train for seven years to learn how to do that?” – from my own mother

“Once the patient is asleep, you guys don’t do anything do you?” – from a surgical FY1 doctor

“But what do you DO?! I don’t understand what you do. NOBODY understands what you do.” – from my former housemate who is a cardiology registrar (he was v drunk at the time).

“So, are you a doctor then?” – from a patient just after a ten-minute discussion about epidurals, invasive lines and HDU after care.

…and it goes on and on and on.

Over the year or so I’ve been doing the job, I’ve noticed that my simple introduction to the patient is starting to sound more like a job description. These days, I’ll say something like:

“Mr Smith? Good morning, my name is Dr Anderson. I’ll be the anaesthetic doctor for your operation later on today. It’s my job to give you your anaesthetic and to look after you while the surgeon is operating. Do you mind if I ask you a few questions?”

It’s a bit wordy, but it seems to set the tone a bit better and I seem to get a few fewer blank looks.