Friday, May 6, 2016

Personal Strike FAQ

Since the new junior doctor contract hit the headlines about 6 months ago, I've been asked my opinion by medical and non medical friends alike. Most  have been supportive, some confused, a few not supportive. I thought I'd direct them to a FAQ so I didn't have to keep repeating myself.

Why do you want to strike?

Like a good politician I will not actually answer the question, I will answer the opposite of the question to appease people who think I'm greedy.                  


OK, now I've cleared that up, I'll answer the actual question.

 I can see why the BMA wants to keep the narrative about patient safety, inability to cover rotas (seeing as we can't already) and discrimination to women and part timers. However for me when it comes down to it, I do not want a pay cut. As a trainee who has changed career I have benefited from pay progression in my years as a surgeon. With pay progression scrapped for career changes and academic trainees will doubly affect me. My argument for keeping  pay progression is that my experience in surgery has positively affected my work in this post pretty much everyday. The pregnant lady who I knew had appendicitis from her walk across the waiting room probably agrees.

 Seeing as my rota is not changing my previous post explained how I might get a pay cut. As a single income household with 2 kids and a mortgage I really don't fancy losing nearly £5k a year. I actually think a pay cut should be enough of a justification for industrial action but there we go. Entitled doctor opinion or not. Vocation is a wonderful thing which I have in spades, but unfortunately it isn't legal tender.

As I need to break even to pay my mortgage, my solution to the pay cut would be to work more locum shifts. This sort of shoots any "I'm really worried about the amount of hours I work" argument out of the water. However caps to locum pay would  mean almost a 50% cut in take home locum pay. The free market should be allowed to be free, except for public sector workers.

The other thing is that would sort of go against having another agenda for wanting to strike is a hypothetical situation where we were given the current contract and complete loss of hours safeguards but we'd all be paid 80 grand a year. Do you think we would all be out on the streets? I wouldn't be.

As it happens I agree with the wider argument from the BMA that the junior doctor contract is one facet of a wider campaign to undermine the staff in the NHS in an attempt to open it up to private investment. Others including getting rid of bursaries for student nurses and the health & social care act. This happens to be a convenient vehicle to voice concerns in general.

So you agree with the strike action, Why are you scabbing then?

Almost exactly the same answer. MONEY

I'd love to say my intense desire to keep my patients safe compelled me to cross the picket line. That was not really the case as at no point were any inpatients in any danger during any of the strikes.

It is the fact that I would lose £200 a day for each strike day that is what compelled me. When you are borrowing money from your Dad to pay your MOT and spending every other "rest day" in A&E locumming, losing £400 a month is quite a hit.

I was quite happy to work and let my colleagues strike, ones with no kids or money worries. You could say it is short sighted to not strike when you stand to lose out in the long run. That is what the government wants unfortunately, and my bank manager won't accept late payments because of my staunch principles. I can't afford jam today, so I'll worry about today now and worry about later, later.

What would it take to get me to be happy with the contract?

Well, I'm not really sure, which is why I've put my faith in JDC to negotiate for me. Probably a complete reversal and no change would satisfy me, but that isn't going to happen.

The problem with the old contract is that banding payments only have a few levels (50% 40% 20% 5% and nil) and this meant that people working wildly different hours could be paid the same. For example as a surgical registrar I worked a partial shift pattern with overnight on calls. The urology registrar worked every other Saturday and no nights. We were on the same salary. The new contract won't address this issue as the pay cuts will mostly affect those that work the most unsociable hours, making people like myself in Obstetrics worse off and people in day time "office" specialities better off.

So essentially, I'll be happy if the BMA are.

What would a 7 day NHS look like?

I don't know, and that is the problem. There have been no sample rotas, no plans to open clinics or theatres at weekend, no plans from our trust about how we will provide this "Truly 7 day NHS". What is the point of introducing a new contract if we don't change our working patterns. When I'm operating an elective list on Saturdays have the trust got plans to pay for ODPs, porters, scrub nurses, support workers who also need to be there? I don't think so.

Salford has managed to provide excellent 7 day emergency access to MRI etc. and have a Standardised Mortality ratio of 88 (This is good). They have done this with current staffing and contracts.

Didn't we pay for your training?

Yes, you did, and bloody good value for money as well. I'm old and lucky enough to only have £25k of student debt and the taxpayer put up about £175k over 5 years. That's quite an investment. One solution would be a golden handcuff to keep us in an NHS post for 5-10 years post qualification. That will only reduce numbers coming in the door or poor students attending. The thing is where would such a policy end? Teachers? Nurses? Police? Anyone who works in the public sector should pay back all their education fees? What about those working in private sector, they are using taxpayer education to profit someone else, is that right? Does this mean that nobody should get state funded education? Having a well trained workforce is good for the country but there needs to be good enough jobs to keep people there.

Here I will put paid to the myth that your taxes pay for all my post graduate training is not good value for money. Whilst HEE pay some of my salary I can guarantee you that the time I spend in post graduate "training" is actually spent providing a service at a cut price. All the discharge paperwork, cannulas, radiology forms, coding paperwork actually contributes to the running of the service, not just my "training". So beware people who quote £500k as a training figure as that includes my salary for all my years in training. Of course, my post graduate "training" isn't passively looking over a consultants shoulder and absorbing knowledge. A lot of service work goes into it as well. If I do an appendicectomy at 2am on my own, am gobbling up your money being trained? Or am I actually providing a service within the remit of my current skills?

What is your solution?

Unless enforced ill health, misadventure or a better long term alternative comes along, I won't give up my National Training Number. This puts me in somewhat weak position with regards to the new contract. Now I have a family and a mortgage and am not yet a consultant so I can't just up sticks and leave for Oz like last time. So whatever happens I'll be at work in August. I can't say the same for my colleagues. In my department alone we have 1 going to Scotland, 1 moving abroad and 1 leaving medicine all together. I know the plural of anecdote isn't evidence but I did a teaching session for our 14 FY2 doctors last week. More of them were moving away, locumming or taking time out than staying for a specialty post. Maybe a zero hour, poorly trained cohort of juniors is what the government want?

Next BMA action could be to not sign any one up to a new post in August and instead form a locum agency to outsource trusts own doctors back to them at locum rates. Then nobody has to strike and it will show you how much a medical workforce could cost. Indefinite emergency only care is an option but suffers the same problems that caused me to scab this time. We could work with the deaneries to give all trainees 3 months "out of program experience" so nobody had to lose their training numbers and nobody starts work on August 5th. This is difficult to achieve seeing as HEE is a government agency.

The NHS is a monopoly employer so I can't just go and work and train at the hospital down the road.

Do you want to bring down the government?

Well, Yes. I'm a member of a political party which isn't the conservative party, so seeing the government brought down would be great. Just not over the JD contract dispute. There are lots of reasons not to like what is going on in the current government, but it's not out of character is it? People knew what they were voting for and they're getting it.

Friday, April 22, 2016

New junior doctor contract is a pay cut: A proof

Many people have eloquently expounded the problems with the contract from a patient safety point of view.  The government have said I won't get a pay cut, and some of my non medical friends have asked me what my problem is as I'm getting a 13.5% pay rise. So I thought I would compare my current pay with the proposed pay from the new contract. Hopefully I can prove I am getting a pay cut despite the government assertion that I'm getting  a 13.5% pay rise. #algebra

I have a 1:8 rota where I work 7 nights (8pm-8.30am) every 8 weeks and 1 Saturday and 1 Sunday day shift every 8 weeks (8am-8.30pm). I also work 5 long weekdays every 8 weeks(8am-8.30pm). Every other day is a normal working day or rest day. As far as I know our department is not planning to change the rota despite the need for 7 day services. I therefore will be working the same hours in August as I am on now. Our rota is EWTD compliant, i.e. we work no more than 48 hours per week on average. Just for the record, I've worked a very similar 1:7, 1:8 or 1:9 rota in every hospital job I have had in the UK, so I don't work a particularly unusual or busy rota, I'm not in the small minority.

Prove by contradiction that new contract will result in a pay.

I will use the assumption that I will not get a pay cut.

Current pay = Proposed pay

Current pay is a 50% banded job  = 1.5x (x = basic salary for 40h/wk normal working days)

Proposed pay: (source NHSE)
 Nights attract 50% uplift
 Sundays attract 30% uplift

 87.5 of my 384 (48hrs per week x 8weeks) hours over an 8 week period are nights. ~23% which attract 50% uplift

and 12.5 of my 384 hours over an 8 week period are long day Sundays. ~3% which attract 30% uplift

No uplift is attracted for weekday long days or Saturday long days. This means 74% of my hours attract normal rate.

New basic salary = y = 1.135x (13.5% payrise)

Proposed Pay breakdown: 0.74y + [0.23 (1.5y)] + [0.03(1.3y)]

multiplying out gives us:

0.74y + 0.34y + 0.039y = 1.119y

substituting y = 1.135x

New pay = 1.27x

1.27x =/= 1.5x


I'm OK for 3 years as my  pay protection is worth the ~4.8k a year I will lose. This is an appreciable amount of money. This is stated very clearly on my NHSE pay calculator. This won't help the new doctors starting  this year or doctors coming from abroad who will be worse off than I am, despite doing the same job.

Not fair is it?

Tuesday, July 28, 2015

Hunt's Long Game

Last weekend there was a twitter tag #iminworkjeremy which got big enough to be picked up by the mainstream media. My Twitter feed being a small left wing microcosm (after the general election Labour twitterers were so confused "but all my followers voted  Labour and we still lost!"), I didn't think it would go very far but the independent and the BBC picked up on it. My tweet was included in the buzzfeed article but not the independent one. Probably because it was such a terrible selfie! My vanity aside, the whole thing was a response to criticism of hospital doctors by the Health Secretary Jeremy Hunt.  Now his plans for 7 day working have been rebutted in depth by much cleverer people than me here and here. Funny that, doctors might be smart and well researched and be able to analyse a flimsy paper on which you hang the weight the entirety of the 7 day NHS reforms.

Now the first question is "Do we need 7 day a week care?". The answer is clearly yes, you can't have parts of the service close at weekends as it is inconvenient and potentially risky, as some of the government analysis shows. Most of the doctors on the #iminworkJeremy were engaged in emergency work which continues 24/7 as my 3am laparotomy patient can attest. However the solution to provide more services isn't to make doctors work harder.

I worked as on call registrar for general surgery last Saturday and for some of the day the senior decision maker for patients potentially needing surgery. One of my patients I decided  needed an ultrasound scan. This couldn't happen until Monday. The next patient needed an endoscopy. This couldn't happen until Monday. The next patient needed to see a stoma specialist. This couldn't happen until Monday.

This is in no way a dig at my colleagues in radiology, endoscopy or stoma care. Quite the opposite. They work as hard as the rest of us. Medicine is a team sport and it can't work if only one cog in the wheel is made to spin harder. I'm useless as the surgeon if there isn't a whole array of specialists and technicians to support patient care.  All the other services including scans, scopes, bloods, portering, wound care, community which are not funded to work at weekends, need to be, with enough recruitment and funding to cover this. You can't expect a 40% increase in productivity with and 8% increase in funds. But that won't happen, as it would be expensive.

The next, more interesting question is "Do we need 7 day a week Elective care?" A more difficult answer. In my opinion, No, we don't. Firstly, is there any evidence that performing routine care at evenings and weekends improves patient safety? I can't find any. Does it improve access and patient satisfaction. To an extent yes. But would spreading services to weekend without extra money force us to lose service provision in the weekdays thus making patient safety worse off? In my experience the only clinics I used to do which were underbooked were evening and Saturday clinics. This is because people want to use  their leisure time not in the doctors surgery. I don't think it would be a good use of resources risk patients in the week by making us work more at weekends. What is proposed is a massive increase in provision of service without the same level of investment.

Which leads me onto what I think would happen.

Many people have commented on how naive or inept Hunt is. I do not believe this for a second. I think he is a very clever man with a very clear aim. He wants to privatise the NHS and open it up to becoming a more US style system. Not only due to his donors and previous publications on the subject see Direct Democracy 2005, but the tactics being employed stink of a plan to privatise a service.

Firstly, defund. Check. There is potentially a £20bn shortfall in NHS funding despite the challenge to find the same in efficiency savings. An £8bn pre election promise and £500m winter pressure payments are sticking plasters. To say we spend a lot on our health service is interesting when we spend as a proportion of GDP less than most other developed nations.

Secondly, demoralise. Check. First the GPs by trying to get them to make more sausage with less meat, by getting them to open 8-8 7//7 with no proportional funding increase. Criticising them through CQC, print media and press releases. Making promises of extra GPs which anyone who could see GP  application numbers falling could see was nonsense. Funny how this was shelved immediately and quietly after the election. Next by telling consultants and hospital staff that they are not working hard enough or long enough. This is patently untrue. Myself and my consultant bosses are as dedicated and present as ever as shown with the huge outpouring for #iminworkJeremy. My 12 years of training, numerous hours in the NHS goodwill fund after my shift finished as well significant personal and financial sacrifice has enabled me to provide decent care for my patients, to be told I don't have a sense of "vocation" would be laughable if it didn't anger me so much.

Lastly, and this is the best part of the plan. Get the doctors to destroy the NHS. Privatising the NHS openly in the UK is political suicide. It will be for the forseeable future. It is one of the few things this country has to be proud of. Therefore in order to execute the plan, the only group powerful enough to resist changes need to be the ones to destroy it.

Here is how it might go. Try to enforce an inferior contract on doctors. Either the BMA roll over like they did for the pension reforms or Industrial action ensues as the only option for an oppressed workforce; despite the weakness of the BMA there must be a line somewhere. (If the RMT were in charge of us, we'd have downed tools already!). Media blame money hungry doctors as the cause of strikes and worsening conditions in NHS hospital. Mass resignations  by doctors and serious patient safety incidents in understaffed hospitals would leave the government no choice but to introduce a pay it yourself service and blame the doctors for not willing to work for free or have more sense of "vocation". And there he has it. A nice juicy service ripe for the picking so he can go and advise the  board at private healthcare plc and make a tidy pension.

What am I doing about it other than moaning on social media. I've joined the BMA for what it's worth as well as a non government political party, to at least get my views out there. I don't want money to play a part in whether patients get care, no-one should profit from ill health directly and I think the ideals of NHS is what keeps me in the UK at all. Of all the country's family silver it should be the shiniest, well looked after piece and not for sale, covert or otherwise.

The Long Road Home

6 month between posts, you could be forgiven for thinking this blog had gone on permanent hiatus. Just been bust moving house, starting yet another new job and trying to look after our newly minted  2nd child.

I started this blog in 2009 to chart the time of being an  FY1 doctor straight out of medical school. Initially I chronicled my worries and flip flopping about what specialty I wanted to do for the 40 odd years. It regularly changed but by the time my foundation training had finished in 2011 I had narrowed it down to either Surgery or Obstetrics & Gynaecology. Usually, you enter specialty training straight after completion of foundation training.

Next week, 4 years later, I finally start Obstetrics & Gynaecology training.

Firstly, I am very happy to be finally on course in a training program which ends in CCT and my next interview is potentially for a consultant post. Especially in a specialty I have long wanted to join.

So why did I take so long?

2 reasons really.

Firstly, I wanted to gain experience in both before embarking on one or the other. Other than a 1 week taster course I did not do any O&G as an FY doctor so went abroad to work in O&G in Australia for a year. This firmed up my decision to proceed with O&G as I loved  both the medical and surgical aspects of a job as well as the intense emotions on the labour ward. This accounts for a 1 year delay and leads onto the next reason for it taking so long.

I'm terrible at interviews. Absolutely so. I have had many and had lots of practice and courses to improve the problem. My CV wasn't bad and neither were my clinical skills yet my communication skills, which when measured in work based assessments as good crumbled to terrible in a job interview. I don't know why, perhaps I've always had a problem with getting nervous around people in authority.

I had 3 interviews in 2012, 1 for O&G, 2 for Surgery which was more a second choice to ensure I moved back to the UK.

*aside* I know one should never embark on a career like surgery as an alternate choice, but at the time moving back to UK was more important. *end aside*

I failed 2 of them on communication skills and passed a surgery interview but not well enough to get a post outright and was placed on the reserve list. 10,000 miles away I anxiously waited for other candidates to reject the job I wanted. I got it and moved back to the UK.

I still wanted to pursue O&G so in 2013 applied again. Failed again, worst than the first time. Made many of the same mistakes and despite knowing them seemed unable to resolve them. As I had the job in surgery I resolved to go wholeheartedly into general surgery. I could be and proceeded be the best core trainee I could. I did all the courses and log books and exams and assessments and publications and teaching and management degrees and interview prep and in 2014 applied for a higher surgical training job. The same thing happened. Completely froze in the interview and despite getting the clinical skills and portfolio right failed on the communication skills. I get into knots as I try and 2nd guess the interviewer and then hesitate to find the correct words.  This led to me having to get a staff grade middle grade surgery job somewhere at short notice. Which is why I spent 2014-15 in the furthest reaches of Yorkshire.

Which is where I had to make another decision. 3 years in surgery and I had learnt to do a lot but still had the confidence issues and still not able to secure higher training jobs. Do I continue a 3rd time at surgery or cut losses and do something else entirely. I had failed O&G twice, did I want to go through it again now I was 3 years from my last experience in it? I wasn't enjoying the lifestyle away from family and friends and with 2 kids to look after we needed some roots. I love operating and working with families on the labour ward so tried again to get an O&G post back home, which is what I had wanted all along. Was it difficult to give up 3 years after starting surgery. Yes it was. A part of me will always run the "what if" scenarios in my head. Perhaps I would have got the training job with more experience, but I doubt it as I was away from an academic centre as a non training doctor. Maybe I would have had a rewarding career as a surgeon. I get the feeling I made the right choice. Many colleagues told me "You're far too nice  to be a surgeon." Which may well be the case, but it also meant I wasn't ruthless  or hardheaded enough to get on,so perhaps it was for the best.

  Now I write this from my  house in the East Midlands about to start run through training with my lovely larger family! I think the year as a registrar gave me the confidence to finally pass a communication skills exam. 4 years late via Queensland, West Yorkshire and about 100 appendicectomies, but I'm where I want to be finally! Are there still worries? Sure thing. I have got used to some of the benefits of being a registrar and will have to go back to being a novice and probably a lot of admin and mundane work. I'm worried I'll blur the line between my old role and new role. I'm worried people may expect too much from me, having been a surgical trainee in the past.

Is there a lesson to be learnt from this?

Perhaps, stop dithering and make your mind up earlier? I don't know, I think it is possible to love 2 specialities and researching will only get you so far. I think if you are equally happy in either, then persuing either is fine.

Prepare more intensely for interviews and work on flaws harder? Perhaps, but how much can you iron out an inherent flaw in your technique, stumbling over  words. Sheer bloodymindedness worked eventually as I passed the interview on the 3rd attempt.

Be flexible and open minded about your options? Medicine is an incredible career and its variability is what makes it so interesting.

So I think finally if there is anyone struggling to figure out what they want to do in medicine, it is OK to go a circuitous route if you can justify your decisions and it makes you interesting. You don't have to flow smoothly from one MTAS designed program to another. I honestly feel my 3 years in general surgery are going to come in mighty useful in the next few years. You'll get there in the end. Or not, and you can do something else equally interesting and fulfilling.

Monday, March 9, 2015

Phrases that annoy me: Part 3

"It's only a silly game."

With my 2 favourite sports being football and cricket, today was a big deal for me, with England getting knocked out of the Cricket world cup by Bangladesh and United hosting Arsenal in the FA Cup quarter final. I did have a brief Australian based foray into rugby league but that is for another time. Also the United game hasn't started at the time of writing so I thought I better write whilst I was at least half optimistic the day won't turn out terrible.

Anyway, I expressed my disappointment at being knocked out of the world cup on social media along with many other folk who follow England, as well as mentioning it at work. I was quickly confronted by the phrase:

"Why do you care, it's only a silly game?"

Now the issue with this isn't that I'm annoyed people don't like cricket. They are allowed not to like it. I belong to a fairly small group of people in my social group who does enjoy the game, In fact, if you can understand the game you probably find it boring; it's impenetrability & "oldman-ishness" is part of it's charm.

What I don't like is people taking something I like and reducing it to being "silly". It's only silly  because you don't like it. There are 90,000 people at the MCG on Boxing Day who don't think it is silly. What people mean when they say it's "silly" is actually "I don't understand or like this activity, but it appears to provoke some sort of emotion in you, how odd".

Everyone has different interests and pastimes that make them happy, frustrated or out of pocket. That is what makes being a human so good. There really are thousands of things to wile away your precious time.

The thing is, every activity that is not related to acquiring food, sex or shelter is inherently pointless, it's up to us as humans to find stuff we enjoy. Yes cricket is essentially pointless but then so is everything else.

 Therefore, I enquired into what the particular interests were of the person who uttered the phrase.

Formula 1, wine drinking and Amateur Dramatics. Now, I don't go in for any of these activities and I could write an essay on what I don't like about Formula 1, but I don't think any of those activities are "silly" even though all of them are pointless.

So, let me enjoy my pointless activity and I'll let you enjoy yours.

Thursday, February 12, 2015

Phrases that annoy me: Part 2

"You're not doing nothing, Doctor."

From time to time, I have to deal with unhappy patients or staff members. This is part and parcel of the job, and it is why we undertake many hours of communication skills training to deal with these situations effectively. Shouting, swearing and name calling I can deal but the title phrase irks me every time I hear it, and whenever I do, I always try to confront it.

Obvious double negative notwithstanding, this is the only phrase I hear at work that really makes me cringe because it is so obviously fallacious. I understand long waits and being in pain do not mix well and I can understand people's frustration but the initial consultation is not usually where I hear this phrase and if I do I tend to apologise for their wait and implement some resolution to this.

I usually hear this phrase from people with whom have had repeated interactions with healthcare professionals with repeated investigations, treatments and consultations. Now I understand people remaining in pain which hasn't been diagnosed and treated can be frustrating but telling me I haven't done anything to help hurts, as that's what I am there for.

This may not have been the best way to handle such a complaint but I challenged the assertion of the last person who told me "You're not doing nothing, Doctor."

In an effort to show the person that we were taking them seriously I presented all of their pathology, radiology, endoscopy, microbiology and histology results as well as every consultation in the notes with a HCP and every dose of pain relief, anti emetic and vital sign observation. I normally take a much more conciliatory tone but it is something in the phrase that is accusatory about our teams perceived collective laziness which is just untrue. Fortunately, this approach worked as we came to a better understanding of the others position and managed to work out where we could go next.

I sense most of these type of complaints aren't malicious and usually can be dealt with at the bedside as they stem from frustration and fear rather than a true attempt to declare our service inadequate. Most offers to speak to our complaint department are rebuffed. However sometimes, and this is only my observation, but many of the people who use the phrase are younger and have an expectation that whatever is causing their pain can be diagnosed  and sorted out immediately. The reality of the situation is sometimes at odds with a patients expectation of instant relief.

Sometimes an adequate explanation of what is going to happen at the start of the consultation can help prevent this sort of problem. For example when a patient presents with abdominal pain and the diagnosis of appendicitis is equivocal it is accepted practice to enact a period of "watchful waiting" where we measure vital signs and blood tests over 24 hours to see if there is any resolution/deterioration. This is because some things that mimic appendicitis can disappear on their own and appendicitis usually deteriorates. It helps identify patients who would not benefit from an invasive procedure (appendicectomy).

However if patients do not know that this is our plan, then they can understandably become upset when in 24 hours they only have 4 or 5 BP readings to show for their stay. This is our responsibility to ensure patients are fully involved in our decision making process.

So there are two ways I see that I can hear a reduction in the use of these phrases. Firstly, adequate communication and expectation setting by the HCP treating the patients and secondly some patient education on what they can expect from their health care system.

Phrases that annoy me

"You need to broaden your horizons."

It's nice to be able to expand on something in more detail than 140 characters, having recently finished my complete transplant onto twitter.

Somehow, over the last few years I have gained a reputation for being a bit of a home bird and not being very adventurous with travel, food or pastimes.

Over discussion today about a fish restaurant that was the venue for a work night out, I was asked what I thought. I stated I don't like fish so probably wouldn't want to eat there unless there were other things on the menu. I was quite happy to go along and eat chips and bread-sticks so I didn't derail anyone else's night. Then one of my colleagues uttered the title phrase.

"You need to broaden your horizons."

Now, I may have narrow interests and horizons but that it because I have had broad horizons and chose to narrow them, because the broad ones were rubbish and gave me dysentery. When it comes down to it, I like simple things like football, fast food and pubs.

It is one thing to be resistant to change, it is entirely another to have experienced different cultures and decide that you don't actually like it. This is something many of my friends don't understand. How can you have visited the 4 corners of the globe but want to go for dinner in the same pub in Northampton? It is very simple, I compare gastronomic experience to my yard stick (Bacon cheeseburger) and if it is not as nice I don't go for it again. I don't see why you can just do the things you enjoy, many people I know seem to do odd things just because they can. I understand, I was like that a few years ago.

I've been to every continent except Antarctica and sampled many a dish and activity. Some, like bungee jumping and guinea pig I never want to repeat again. Others, like test match cricket and tacitos I have taken to my heart and carried them on. When on my elective in South America, the group of travellers I was staying with also noticed how I was less than thrilled with some of the "experiences" on offer. One jokingly said I should write a travel guide titled "The world through the eyes of a grumpy bastard."

The example they were referring to was the description of my trip to Machu Pichu:

"A World Heritage site? It took 5 days to walk there and all I was greeted with was pepsi stands and panting tourists. Magical ruins? More like boring rocks, the church in my village is older and prettier. At least climbing up Wayna Picchu meant I could look at the site and leave the panting tourists to their angina."

I think it has some legs, but Karl Pilkington appears to have cornered the market in the genre since I went so it'll probably not make me my fortune. I have diaries of all the major holidays I have been on and some of them make me chuckle but I'm not grumpy, honestly, I just like very simple things!

So, the phrase annoys me because it assumes that I haven't experienced life enough. I have, I just choose to be boring.

Friday, October 31, 2014

Obelisk of Light

One of the few things I do which doesn't involve work and makes me happy is playing football. Now I'm no professional but I played for a Sunday league team for 5 years in various positions . I was more upset about leaving the team behind when I moved than most other things about leaving Northampton. The thing I liked most about it, was the fact that it was a Sunday league football team that wasn't completely populated with angry, hungover meatheads. We were probably the politest team I've ever seen. This was both good and bad for results!

So the first chance to go back and see how they are doing I took last week. In the time I have played for them they went from 2nd division also-rans to being in the top Sunday league. They mostly achieved this without my help as we recruited young talented students to replace the old timers like me. So it was sad to see them bottom of the league and in trouble of going under.

A number of reasons behind their fall from grace. Firstly the students who carried us to glory have  all graduated and left the team. Secondly, it is very difficult to run a Sunday league team with any sort of sustainability. You need to recruit, organise games, pay officials, buy & wash kit, organise training, liaise with league officials. You also need to chase up players for money to fund all of this.

Now once this was done by one group of people and over time it was taken over by another group of people. I think the amount of work involved became too much and they have fallen by the wayside.

It is very sad and I wish I had enough time to take over and sort it all out.

I'll add it to the  list of things I can't do due to work!

Monday, October 27, 2014

4 hours in A&E

Much is made of the 4 hour waiting target for A&E departments in the UK and various hospitals' adherence to the target as well as methods hospitals use to fudge the  numbers to make it look like they adhere to the target.

The Mary Seacole Program which I have just completed exists as a direct  result of the Francis Report trying to improve education and leadership in the NHS workforce. Something mentioned in the Francis Report was the fact that Mid Staffs were placing adherence to targets  above the need for safe patient care.

I understand that fast care should result in improved patient safety and satisfaction and targeting time spent in the A&E department should bring about improvements. Unfortunately imposing arbitrary and artificial restraints on a system will mean that the system will adapt to nullify the effect of the restraint. This took the form in mid Staffs of holding wards, inappropriate discharges, boarding patients in inappropriate places and generally harassing staff who were there to see the patients. In my experience I've seen all of these in one form or another in the various places I have worked. I would like to share an example of the unwavering adherence to the 4 hour rule and how ludicrous it can make us look.

It was a Saturday night and I was on call for Urology. I was called to a very busy and rowdy A&E department to see a patient with a painful urological problem which whilst distressing was quite easy to fix and would result in complete resolution and discharge from hospital immediately after the procedure. It was uncharacteristically quiet in theatre so I proceeded to A&E without delay to be met at the entrance with a clip board wielding band 8 nurse who was "site manager" for this shift. This is hospital speak for "enforcer of 4 hour wait rule"and the extent of her first interaction with me that evening boiled down to:

"Majors 12 has been here 3 hours 55, Send him home now or he is going upstairs [to the admissions unit]"

Firstly, I was referred the patient at 3 hours 50 minutes and expected to sort them out in 10 minutes. Secondly, having reviewed the patient quickly I was confident the short procedure would send him on his way home. This would probably take about 5-10 minutes to perform, but would take him over 4 hours in the department. This obviously couldn't do.

After confirming the problem, I left the room to get a pair of gloves and the piece of equipment needed to help the patient out, having applied some local anaesthetic to the area in question and leaving the patient in a compromising position in the private room. In the 10 seconds I took to get the gloves, a porter and "site manager" had gone into the room and wheeled him out (still in a compromising position) in order to transfer him to the admissions ward.

My protests fell on deaf ears:

Me: "I'm only going to take 5 minutes, he doesn't need to go upstairs"
Manager: "He is about to breach, whatever you are doing it can wait until the admissions ward."

So it takes half an hour for patient to be transferred and admission paperwork to be completed before the patient is in a room able to do the procedure. I have a very irate, embarrassed patient who has been paraded in front a department with his pants down. It takes less than 5 minutes to do the  original procedure yet he has been admitted, had an admission nurse fill out a booklet full of paperwork and been subjected to a humiliating trip. All so he didn't breach the 4 hour target.

What should have happened is that he would have remained in the department for 4 hours and 5 minutes and he would have gone home happy. This chain of events hindered the nurse on admissions, myself, the porter and most importantly the patient. It didn't help anybody and wasted a lot of time, effort and money. Thankfully other than a complaint, it didn't actually harm the patient. I'm sure there are many other examples that have.

So that's why I don't like the 4 hour target; it makes people do silly things in order to get the numbers correct.

Trauma Services in Westeros

A perpetual state of war is the perfect environment for innovation in healthcare to flourish and nowhere is this more in need than Westeros. Currently trauma services are in disarray with pauper and king alike at risk from mismanagement in the dangerous world of the 7 kingdoms.

Alarm bells began with the peacetime death of Robert Baratheon in a hunting accident. Adequate access to quality surgical and anaesthetic care may have prevented the realm being plunged into chaos in the first place. Given his stability at presentation he had time for a full history and examination including co-morbid conditions of obesity and alcohol dependence. Expedient wound debridement and surgical control of intra-abdominal sepsis with post operative ICU care and prevention of alcohol withdrawal would have probably prevented the War of 5 Kings.

With war on 3 fronts, expert medical care was largely an afterthought with  only the Northern Army having any noticeable care for wounded soldiers. Not that this could save their king in the North from succumbing to a cross bow bolt trauma which could have been decompressed with an intercostal drain and appropriate blood products. Things got worse at the Battle of Blackwater with no recognised Burns unit in the capital leading to thousands of unnecessary deaths barely hundreds of feet from the gates to the city.

The next king to suffer from poor investment in his own healthcare system was Joffrey, appearing to die from poison setting off severe laryngeal oedema. Being in the biggest population centre in the realm would mean prompt management of a threatened airway with access to intubation and in extremis a surgical airway. None of which was forthcoming, which leads to cries of regicide.

Things are little better across the Narrow Sea in Essos where leader of the Dothraki, Khal Drogo has succumbed to wounds inflicted in a minor scuffle. Here, appropriate access to antibiotics and sepsis source control will have negated the need to use poorly defined and non evidenced based therapies used by the Blood Magi. Being Barbarians, they could be forgiven for not having a well developed trauma service, but this must become a priority given how much blood is spilt in their name. They need only look towards slavers bay for an effective surgical practice. Becoming unsullied requires an invasive procedure and the fact there are 8000 survivors is testament to go post operative care and cleanliness.

There are reasons to be optimistic, not least in the survival of the  Kingslayer after a grossly contaminated forearm amputation was promptly managed with haemorrhage and infection control from Masester Qyburn, who whilst spurned by the Maesters in their Ivory towers is producing some promising results in acute care situations, results of his treatment of the Mountain are awaited with some excitement.

So what is the answer? The Maesters and the Master of Coin need to sit down and plan an effective and wide ranging trauma network throughout the 7 kingdoms. This should start with a dedicated level 1 major trauma centre in the capital to serve the population of in excess of half a million people. This should be equipped with access to immediate radiology, general, orthopaedic, vascular and cardiothoracic surgery as well as the opening of the Oberyn Martell Memorial neurosurgery unit. This should be complemented by a hub and spoke system of trauma centres located in the major population centres of the largely rurally populated Westeros. Transportation to the MTC should be provided when patients are stable in view of the  large distances involved. Furthermore, field care should be provided by mobile trauma units following the great hosts of Westeros to war and at Tournament, with a banner befitting their neutral and altruistic nature. Lastly the Maesters need to be up to date with evidence and all must attend an ATLS course as a matter of urgency to learn how to care immediately for the injured in battle or intrigue.

Now is the perfect oppurtunity to improve trauma care in Westeros and only short sighted temporary leaders will prevent this.

Sunday, October 5, 2014

Head above the Parapet

Where I work in RuralTown a vast majority of births are in the hospital. We don't have any home birth midwives as far as I know, and we don't have a birth centre. Our private obstetrician also delivers at the hospital, so women who want a home birth don't have much choice out here. 

From canvassing the opinions of my colleagues I don't think home birth is a big thing in Australia. I don't have much in the way of stats, but something like 1% of births are home births, and this is confined to large cities, indigenous communities and accidents in remote areas where there isn't time to get to hospital. 

So, in ante-natal clinic, a pregnant woman asked me where I'd like my wife to have babies when it comes to her.

Now, I'm not quoting studies or being a vagina-controlling doctor, I just answered her question honestly.

I would like my wife to give birth in quiet, clean, safe environment surrounded by people who care about her, and give her the choice to do whatever she wants.

I would also like to be within a 
cord prolapse distance from a fully staffed obstetric operating theatre, with full obstetric, midwifery, anaesthetic and haematology support. Preferably with a neonatal ICU available, ready to deal with any catastrophe that could arise.

I don't think that the two places I have mentioned have to be mutually exclusive.

I have seen enough women and young babies who are alive because of prompt intervention to make that decision for me. And they weren't all "high risk" women either. All any of us want are healthy mothers and babies and I think with births in hospital the trade off between losing some privacy, choice or seeing the likes of me is outweighed by being in an environment that can deal with an emergency. Some things in obstetrics are too fast to allow a transfer. Fortunately, it doesn't happen often, but when it does it's fairly harrowing stuff.

I also think that there is a reason it is so difficult to get indemnity insurance to be a home birth midwife and there is a reason RANZCOG do not advocate it. For balance, have a look at this 
site to see why doctors are all self-serving control freaks who rely on scaring women into having Caesareans. Now, putting my obstetrician hat on, I would love nothing more than every woman birthing their babies at home in complete safety and ease. But they don't. Which is why I get called at 3am.

So that is why I wouldn't want my wife to have a home birth. She happens to agree with me, and if she didn't I would support any decision she made. 

I'm not cleaning the sheets after a 
PPH though.

Tuesday, September 2, 2014

7 months on.....I sound like a broken record!

So 7 months have passed since my last post, I bet you all thought I had disappeared for ever. No? Don't care? Thought not.

Well a lot has happened I say that much. I now have a very happy healthy one year old son, who is better than anything else so I'll mention him first. He still doesn't have a presence on Facebook which I am happy about and is still doing all the right things for his age.

I have also moved house. Again. Fortunately for my family it isn't quite as far as Queensland this time, but still a good 3 hours up the M1 to West Yorkshire. Once more this was necessitated by my damned need for paid employment.

You see, I didn't get a training number. Again. I am starting to see a pattern emerging here of poor communication skills and a lack of direction in the portfolio. I am going to have to focus more clearly on what I want to do as opposed to hedging my bets as I did this year. I have completed my core surgical training and attempted applications for ST3 in general and paediatric surgery. Having to plan for 2 interviews meant not planning for either enough. Suffice to say I hate interviews at the best of times and probably buried my head in the sand about actual preparedness as I hate practising interview questions and handing over built in answers. It is all so fake and makes my skin crawl, Yuk. It is something I need to get over as that is now 4 interviews I have messed up and it is starting  to affect me.

Anybody who wants a career in surgery should think very carefully. There is not enough spaces for everyone who wants to do it, even those who get into core training at CT1 as per the ASIT website. I feel the whole concept of core training is flawed as more than 2/3 of those in a post will not progress to the next level, as most people who go into it don't go in wanting to do radiology or A&E (or they could do that straight away). I feel it is just a way to save money and fill SHO rotas under the guise of training. What's worse is that ST3 applications now downgrade candidates who have been out of medical school longer (presumably to level the playing field and smooth the flow for candidates straight from core training).Therefore next year my portfolio score will be marked down as I have more experience. Again I wonder about the fairness of this as not everyone choose to go into surgery straight away or is full time all of the time. Anecdotally from the 18 core trainees that entered my core surgical training deanery in 2012, 5 got training positions. More than 5 are doing some stop gap or research and more than 5 left surgery altogether. I'm doing a stop gap. ST3 posts were released on May 24th and I needed a job by August 5th. Panic stations set in and I knew I didn't want to be someone else's research monkey for 3 years.

I am currently working as a Specialty Doctor in General Surgery at Airedale in Yorkshire. It is essentially a non training registrar staff grade post and is in a wonderful part of the country. We live in a cheap, spacious house with rolling hills and farmland all around, charming towns a short drive and within an hour I can be in Manchester or Leeds. The job itself is pleasant and I'm not working with any egos or idiots. I get more responsibility and the chance to work as a registrar and do my own clinics, ward rounds and teaching (but not theatres yet butterfingers). This has its upside as in it is more rewarding and I'm acting like a doctor and not just a ward administrator and retractor holder but means I get my fair share of problems which I used to send up the chain as an SHO, most notably dealing with difficult patients or having difficult conversations.

I am nearing completion of my Post graduate certificate in Leadership (Mary Seacole Program). Whilst the contact days have been enjoyable, I have found the whole process a bit overwhelming with having a full time job. Some of the other candidates on the course get 8-12 protected time at work to work on it! No such luck for me. I'm sure that would get laughed at if I mentioned that applying to me. My department in Leicester were not exactly helpful in doing the practical project side of things going and I'm glad it is soon to come to an end. I really wish I had enough time to engage more fully with it and not move house 3/4 of the way through it as the programme I feel is worthwhile.

So time goes on and the same things are happening  to me. I've had to nail my colours to the mast and go all out to be a general surgeon. I really like my current job and actually want to go in this direction as opposed to just being all "meh" and going with the flow. That is not to say I won't change my mind when I'm unsuccessful next year. My difficult to placate ego means I don't think I'll want to be a staff grade for ever, however it is very possible that my talent for surgery doesn't match my ego and I will have to try and climb the medical ladder in other areas. I have looked into the new alternative route of entry into emergency medicine training, which I am eligible for as a surgical trainee. It would suit my desire for action and immediacy but I might not like handing my patients off after 4 hours. I have put a lot of time, effort and money into being a general surgeon.

  • MRCS Parts A (£450) & B (£900)
  • ATLS (£600)
  • CCrISP (£700)
  • BSS (£400) 
  • Basic Laparoscopic Skills (£250)
  • Logbook (£200 per year) 
  • RCS fees (£300 per year)
  • Interview  course (£200)
  • Teaching Course (£180)
  • 6 audits
  • 5 book chapters
  • 3 posters
  • 2 regional presentations
  • 2 service improvements
  • 1 publication
  • 1 weekly teaching commitment
  • 1 mentoring programme
  • 1 post graduate qualification (£5000 - luckily bursary paid for) 
  • Not to mention all the annual leave and rest days I didn't take so I could do more operations.

And because I get nervous when interviewers ask me awkward questions, none of that was enough to get even within 200 places of a job. And my list isn't spectacular, in fact some might consider my CV slightly bare. So, again(!) we will wait and see. Hopefully I get a surgical training job, possibly accept a long term staff grade position, potentially change career entirely.

Or sack it all off and go back to Australia.

Oh, and I'm still really fat. More fat than ever. I seem to coincide starting diets with doing blog posts. I must give my fingers something to do when they aren't stuffing pies down my chops.

Monday, February 3, 2014

A tale of 2 rants.

Rant 1:

Circumcising babies for no medical reason.

I have worked in paediatric surgery for 6 months, so I am aware I see skewed picture. On average we see about one admission a month for complications of the aforementioned procedure. Now I understand it is an important religious rite for some people, but that doesn't have to mean I like it. People who say it is a low risk procedure, have you ever seen a 3 day old baby exsanguinating from the tip of their penis? Or a young boy which a suprapubic catheter because he lost the end of his urethra? It's not low risk, which is why it should be performed by urologists, in hopsitals, with consent forms and machines that go beep, for reasons that are physical not metaphysical.

The WHO suggested that male circumcision should be included in a comprehensive HIV prevention strategy. This is aimed at populations with high rates of HIV, and not at the expense of education and actual prevention. It does not stop transmission of HIV, only a modest reduction in transmission. There is no firm evidence to support its use to prevent UTIs, STIs or HPV penile cancer (which is rare as it is). Safe sex is the only way to actually reduce any of these. A recent paper in JAMA has suggested it is cost effective if used in the USA by reducing these. This is because their government funds the procedure. I'm upset about private procedures having complications that cost the NHS. People compare circumcision with vaccinations in terms of perceived health benefits. There is a large discrepency between the benefits of vaccinations and that of routine circumcision.

The reason it is done privately by GPs in their own rooms is because no right thinking doctor would do it otherwise in the UK. It is done without anaesthesia or pain relief. What really gets me is that these private, unnecessary procedures may only go wrong in a small proportion but the cost is born by the NHS not the privateers. Each baby that has been brought in this year has had to spend a night in observation for it. This indirect cost is not measured in pro circumcision papers.

Also, the boys have no say in whether or not they lose their foreskin. I would quite like to be informed if I was going to lose some of my genitals. Female genital mutilation is rightly seen as a ghastly act in most of the world, but if a study advocated its reduction in STIs or HIV would we still want to be using it? I'm aware the risk profile increases with age with the procedure, but waiting a few years or not getting it done at all would be more in keeping with my notion of primum non nocere.

So, if you are thinking of getting your infant son circumcised, firstly the NHS do not recommend it, secondly perhaps you should ensure that the guy who makes a mint out of you to do it, gets invoiced for the bill when it goes wrong.  Whilst you're at it, teach your son that condoms are better than lacking a foreskin at reducing STIs. Not that any of that would happen, because questioning 15,000 year old rituals would appear to be the height of bigotry.

Rant 2

People hating stay at home mothers.

When I tell people that we have a new son, one of the first questions I get is. "When is your wife going back to work?" When I tell them "Not for the foreseeable future." I am met with at best surprise and at worse criticism.

Things seemed to have changed in the world. It seems that it is no longer acceptable for just one partner to do money work and one partner to do child work. Many people including writers for "the newspaper that shan't be linked to" seem to think it's lazy and that people revel in being lazy whilst extolling the virtues of living such blatantly idle lives. It is as if child rearing has suddenly become an easy service that can be outsourced.

Luckily, I have a wage that can support a family of 3 which doesn't necessitate the need for my partner to go back to work to keep a roof over our head. Actually, Luckily is the wrong word, because there is nothing lucky about studying for 12 years passing medical school, post graduate exams and post graduate qualifications and accruing 30K worth of debt in the process. I've worked very hard to be in a position where I can allow my partner to raise our child.

The government seems to want everyone to make as much money as possible and outsource care to make even more money. This is not how I see living my life. I don't want some minimum wage dolt raising my children for over a third of it's life, surrounded by dirty toys and even dirtier children. Surely I trust my wife more than anyone else to raise our children, and she has a vested interest in raising him well as he is her child too!

From a simple economic view the gains do not outweigh the costs. A simple Google search of nurseries in my area puts the cost of a months day care at between 750-1000 pounds per month which does not include unsociable hours or extra curricular activities. If my partner was also a doctor we would have to find time out of hours, overnight, weekends, evenings at a premium rate or rely on parents/family to see us through. My wife's last job before maternity leave paid slightly more than the above quoted figure. Is it worth her working full time to come out with about 25% of her wages at the end of the month.

But wait! What if the government want to pay all of your childcare costs (in whatever fantasy land that will happen in). My wife still misses out on all the positive life affirming aspects of seeing your child grow themselves and not learn 2nd hand from an (NVQ certified!) child care assistant that her son strung a sentence together. Possibly along the lines of "Is it my fag break yet?".

Sure, we made a decision to spawn a being and are paying for it, we are 1000s pounds a year worse off for doing so. But this is our decision based on how we wanted to live our lives. Making a small proportion of it back by sending my wife out to work doesn't make up for the chance to raise the child yourself in an environment you have control over.

But it's sexist! I'm enforcing 1950s gender stereotypes on my wife by forcing her to stay at home! Not really. She has a choice to work or stay at home and she made it. I happened to agree with it. Working 160 hours a month for £300 sounds more exploitative to me. If I was the minority earner in the relationship, you might have found me at home in the day doing the housework and baby changing.

Lastly, being a stay at home mum is fun! Why shouldn't I encourage that. There is a fair share of one on one care work for our son, and then there is time for cake making and such! A lot of the negative criticism comes from simple jealousy that my wife leads a nicer life than slaving at an office to earn a bit of cash for somebody else, missing their child develop. Agitator in chief, you know the woman who quit The Apprentice and was on This Morning, her, the one who doesn't like the name Tyler, decries the coffee sipping, lunch goers. That is because these women are very happy, with partners who don't have to put up with the likes of her!

In conclusion, we pay for ourselves and have a happy, productive home, so you can take your opinions about our childcare arrangements and stick em.

Friday, December 13, 2013

Desert Island Drugs

When I was a medical student we had an interesting PBL topic where we were given the scenario of being stuck on a desert island with a population of people similar to what you encounter in general practice. On the island you were allowed to take with you 8 drugs and no others. These are the only ones you can use to treat any illness that may befall your population. You had to present your reasons for picking each drug. It was to teach us some pharmacology and also to think about the populations that we were treating.

Some people took it seriously, picking well thought out medications to help the most amounts of patients, doing what the task was designed to do. Others not so seriously, picking out all the drugs of abuse to go and get nice and high on the desert island.

I thought it would be a good idea to present mine again. Unfortunately I have forgotten completely the ones I picked 5 years ago. So I picked new ones based on my current hospital and primary care experience.

1) Morphine: Sorts your pain out innit. If life on the island sucks you can just get off your tits. Seriously one of the commonest and distressing things for a patient to have is pain. It makes sense to have one of the most powerful pain relievers to hand. I haven't packed a laxative, so my islanders may end up constipated addicts.

2) Co-Amoxiclav: Treats pretty much any infection. I'm struggling to think of a wider spectrum oral agent. Can be given orally. I'm sure I could distill the clavulanic acid out to give it to pregnant women. Not much fun for people with penicillin allergies though.

3) Prednisolone: Rheumatological problem? Dermatological problem? Haematological Problem? Respiratory problem? Sorts 'em all out! Unknown problem? Combine with 2) for best effect. I like my patients Cushingoid and Diabetic.

4) Aspirin: For pain not bad enough to need morphine. Also used in secondary prevention of strokes, MIs, cardiovascular disease in general and recurrent miscarriage. Plus if everyone takes it, it is a good way of avoiding or delaying elective surgery!

5) Haloperidol: Some very common problems - Nausea, vomiting, psychosis, bat-shit crazy, delirium, insomnia, reduced lactation, being a Soviet Dissident. All of which can be cured by vitamin H! I feel we need something to quieten people down and make people feel less sick when they have other problems. Extra-pyramidal side-effects notwithstanding.

6) Amitriptyline: Combine with the above for a quiet night. Although not a great anti-depressant this "dirty" drug (dirty in the sense it blocks a lot of receptors) has found a new lease of life as a second line treatment for chronic and neuropathic pain. Also used to treat urge incontinence, migraines, tension headaches, IBS, peripheral neuropathy and a range of psychiatric disorders. Overdoses are "interesting" to treat and nobody likes a dry mouth.

7) Hartmanns: Ill, Starving, or run out of water on a desert island. Better than Saline, I know this because my boss told me so. Contains a little bit of everything you might need. This can be used to replace fluid lost whilst your Augmentin is working. A good way to deplete somebody's potassium. You could assume I could knock up some IV fluid from local seawater etc. but that's stretching the metaphor a bit.

8) Lignocaine: I'd say this is my most controversial one. Now I'm assuming we have enough equipment and stuff to perform minor surgery on a desert island. Surgery, is a common reason to see your GP. You know, getting moles, lumps and bumps removed etc. Also good during and after child birth for tears. Can be used in joint injections and as a class 1 anti-arrhythmic. There's actually a surprising amount of surgery you can get done with it. It wouldn't contain adrenaline, so I could use it on fingers and penises.

So, there's my 8. Some surprising admissions (5-8) and some less surprising ones (1-4). However I feel I have a balanced bunch based on what I would prescribe in the community and in hospital to treat as much disease as possible. I've made some compromise with efficacy to ensure as many symptoms as possible could be covered. You may notice most of my drugs treat non-life threatening problems. Which exactly what most medical problems are.

Also, some equally surprising omissions from the list, which by the way can only stretch to 8. No insulin? With the 7% of our population with diabetes is a pretty big one to leave off the list. However it's of no use to the other 93% of the population. I'm assuming also desert island lifestyle involves a lot of exercise and fruit so type 2 diabetes rates should plummet.

The ubiquitous Paracetamol? I figured I'd cover it with other things that has 2 uses such as morphine or aspirin.

What if there is a cardiac arrest. No adrenaline? No amiodarone? I'd like to think the boat the washes me ashore would have a defib.

Propanolol almost made the list for its use in treating blood pressure (poorly) but also tachycardia, anxiety and stress.

What about propofol? Have that and we could have some real fun with surgery and sedation procedures. Pulling a shoulder might be easier, but we'd need an anaesthetist around to wield it as A&E folk are unworthy.

We could please the government and their venous thromboembolism gods by giving everyone clexane.

What about PPIs, hopefully coconut milk and lack of coke, cigarettes and beer would reduce acid related problems.

How would we control the population or womens periods without the OCP. Perhaps fashion prophylactics from coconut sap and bamboo leaves? Birth rates and bleeding would increase on the island.

As I alluded to before, what about all the constipated people from all the morphine and amitriptyline? Again hopefully the islands high fibre diet would take care of that.

If you are allergic to penicillin on the island as 5% of people would be? Tough, no room for an alternative. Erythromycin or Ciprofloxacin being possibilities.

Lastly, nothing to treat seizures. Carbamazepine also works for chronic pain. You could argue terminating seizures is more important than depression. Maybe not if the islands suicide rate started to climb.

So a lot to consider, and for a nerd like me very fun to hypothesize. Let me know if you have any suggestions for your list?

Monday, October 7, 2013

Desert Island Discs

An interesting conversation from the pub was about our favourite albums and which I would take should I only have 5 CDs and a player on my desert island. No iPods allowed I'm afraid. No compilations or multidisc sets either! This list is going to make me sound like a 90s NME fanboy, which is exactly what I was when it mattered to me what music I should listen to. So in no particular order.

1) The Queen is Dead - The Smiths: Not heard it being played during the jubilee but it's my favourite album by my favourite band. It's controversial, eloquent with excellent guitar accompaniment. It contains repressed rage and sneering arrogance to make me laugh and think every time I listen to it. Any song that can rhyme spanner with piano and not sung by Chaz and Dave is all right by me. Unfortunately it is only 36 minutes long and recycles by the time by 45 minute drive home has finished.

2) Definitely Maybe - Oasis: 2nd best début album ever, after the next one. So what if it sounds like a Beatles cover band? The Beatles were excellent. The production on this album is so good, it always sounds louder than any other song if you play "Live Forever" on a duke box. If you can get away with blatant cocaine references being played on radio 1, I like. Pity they are both Citeh fans.

3) The Stone Roses - The Stone Roses: Best début album ever. Mesmerising. I love Ian Brown's singing in it. It's really melodic when it has no right to be. I am the Resurrection is probably the best finish to an album I know of.

4) Magical Mystery Tour - The Beatles: There had to be one Beatles album on here. It might not be the one everybody else would pick. It manages not to be everyone's favourite despite having Strawberry Fields Forever on it. The drug addled psychedelia on I am the Walrus and ominous sounding Fool on the Hill give the album a really good mix.

5) Rage Against the Machine - Rage Against the Machine: One of this list is not like the others. 4 fairly standard indie classics to start with, this one is a bit left field. I first listened to this album when I was 15 in drama class, and it was immense. It was loud and angry and I could learn the bass lines and sound awesome. It was helped by Wake up being the tubthumping ending to "The Matrix" which is one of my favourite films. It lead me to buying the rest of their albums which are equally as good, especially if you fancy yourself an activist.

Some notable absences: Blood Sugar Sex Magic - Red Hot Chilli Peppers, Metallica - Ride the Lightening, Radiohead - The Bends. You get the idea!

Feel free to list your own, and tell me why my selections suck.

Saturday, September 21, 2013

A tale of 3 CDs

Before my set of nights this week I went out and did something I haven't done in about 5 years. I went and purchased new music. Not new music to me, but new album releases. Even more out of character all 3 albums were in the top 20 of the current UK album chart. It was about time I embraced being an old man consumer of music instead of a young swotty hipster, which I don't think I ever was anyway, hopefully. It had been so long since I went to a music shop I had trouble finding one on the high street as the ones I knew have all shut.

Seeing as I don't post about medical stuff any more, because I don't want to get the sack and my interests outside of doctoring include childcare, music and football, I should post about that sort of stuff!

So 3 different albums and 3 different reviews.

Example - #Hits: 5/10

I have never really been into UK hip-hop or dance music so this cross over seems a bit different to me. However he was massive in Australia when I was over there and was fond of some of his popular club songs as it was quite nostalgic. Being a complilation it felt like a good place to start with a genre I have very little knowledge of.

Things started well enough, with the 2 tracks I knew best "Changed the way you kissed me" and "kickstart". Both of which familiar and toe tappingly engaging. After that is where it sort of goes awry for me. Possibly because they had less air time, but the next 10 or so songs sort of blend into once big electro meh. Beats were good enough on the ear to keep me awake on the M1 after a night shift, but nothing really stood out. Also, I never thought it would be the case, but a lot of his lyrics are kind of depressing. I figured dance/hip hop would be upbeat and confident, but there is alot of introspection on there. Not that I'm against deperessing, I thought it was a bit at odds with the background.

Thankfully he saved best for last with a Stone Roses "Fools Gold" sample and wretch 32 on "Unorthodox". Probably my favourite song on the album, because it was new, but familiar and lyrically brilliant from both of them.

The 1975 - The 1975: 3/10

Right, I purchased this going against every fibre of my being. They were on Soccer AM last week and I thought they were arrogant disengaged pubescent hipsters. I walked into the shop and the bloke behind the counter sighed loudly when I placed their CD on the counter. Both warning signs. However I liked their single "girls" and they were number 1 in the album chart and they'd come out of nowhere so they must be pretty good for all those British people to buy that album. All those British people are wrong.

It sounds as if some teenagers have listened to an All American Rejects album from 2002 and thought " You know what? Combine this with a bit of Cockney talking in the bridge and this will be great!" It started with a disjointed intro track, then came one pointless cliche after another. "She already has a boyfriend", not exactly inspiring. It sounds like some GCSE students English Literature essay, but graded at C at best. The lyrics are boring or inaudible. Backing singing is poor. Some of the melodies were Westlifeesque. Track 11 "girls" is genuinely quite good and they were right to release it first. The guitar has a bit of a calpyso quality about it, and he can carry a tune in it.

The rest of the album I could leave. So much so that when the CD finished, went on loop and played from track 1 again, I didn't even notice as it was so bland. So the lesson from this experience for me is: Don't buy an album on the strength of a good single or the behest of the public. The last time I did that was Alien Ant Farm's - "Anthology" and I'm still shuddering.

Arctic Monkeys - AM: 8/10

I was very much a Monkeys fanboy in 2005. I was living with friends at uni, we thought we were cool and we'd seen this band do a secret gig at our union in front of no more than 300 people. 3 weeks later they were number 1 in the singles chart and winning Grammy's. I loved their first album, I thought Alex Turner's voice was fantastic and his lyrics were gruff but poetic at the same time. He sung about stuff that I knew about which it should as we are the same age. The music was simple and fast and funny. "Fake Tales of San Francisco" could have been about some of the girls in my first year at medical school.

However I sort of lost touch with their music after that. Their next 3 albums passed me by as I became an uncool recluse who studied a lot and listened to too much Morrissey. I didn't even realise that this was their 5th studio album already and have still not listened to "Humbug" or "Suck it and see".

So I thought I'd give this one a whirl after my cousin was waxing lyrical about it to me. I'm glad to say I wasn't disappointed.

Firstly, they have come a long way as a band. Their sound is a lot cooler and edgier now. The lyrics are still fun and sometimes about the mundane but that speaks to me all the more. The guitar on "Arabella" reminded me of Black Sabbath's "war pigs" which is one of the best there is.

The sound could be straight out of some trendy New York underground bar. He has toned down his accent slightly and sings a bit more, both for the better. Some of the beats are so hip-hop and heavy they could have come straight out of Compton. The production is so good you can tell he has cool friends and is not just thrashing out a song on an old BBC telecaster. "R U Mine" is a great single and "Why do you only call me when you're high" was strangly melodic and hyponotising.

It only drops 2 points because I have a short attention span and some of the middle tracks follow a similar theme and probably fall victim to the other tracks being so entertaining. Other than that, I suggest you go out and buy it. I can't wait to put it on again when I get in the car later.

So there we go, a proper album review. I won't wait up for my call from NME. Also, I can see my wife reading this and thinking I'm a pretentious oaf. We'll see.

Saturday, September 7, 2013

New Horizons

Please excuse any errors due to writing in a largely sleep deprived state due to the newest addition to the Mabbutt household, baby Connor, born on the last day of July. The whole labour experience wasn't very pleasant for anyone involved but that rant is stored for another day. Some friends have questioned why I haven't posted any pictures of him online as they are all very keen to see him. Well my friends in Australia notwithstanding, you can see him any time you like. He's in our house 24 hours a day. Also, with social media pictures, he doesn't have a say in whether or not he wants his pictures to go on facebook and therefore I don't want to put pictures up unless he wants me to. I know I wouldn't want unapproved pictures of me going on facebook. If you don't feel close enough to us to visit but would like to see what offspring I have produced then I don't mind sending you a picture, just not for the public domain.

Parenthood in general is pretty much what everyone painted it as. "You'll have no idea what it's like! Life changing!" I heard those two phrases ad nauseum whilst Abi was pregnant and now I know why. I'm bloody knackered. He is a very nice looking baby and I have fun interacting with him but he doesn't do much further than produce stuff from various orifices. He has also learnt we come running if he cries, so now does so just for attention even if he is full, burped and changed.   However since going back to work I do look forward to coming home to see him. He did start smiling recently but I'm pretty sure that's gas. Surprisingly, he is pretty cost neutral. The money I spend on nappies and formula *gasp from the breastapo* is mitigated by the lack of money I spend on socialising. Also, we get 20 quid a week from the goverment just for procreating, which I find astounding as I think the government has better things to spend their money on than. The money could probably far more benefit somebody else as opposed to a family who are relatively comfortable. I won't say no to free money though so I'm not that saintly.

I have also started a new job in a new hospital in a city an hour away. I have decided not to move there as we currently have a good social support network in Northampton and I'm not exactly a fan of Leicester having lived there for 4 years and being burgled and robbed plenty of times. I've never worked in a large teaching hospital before and it is definitely a step up. In complexity and number of patients. I'm working in Paediatric surgery which is immensely interesting and rewarding, and being a parent myself definitely helps me know what parents of sick children go through. However as it's a new place I need to gain the trust of my bosses before I'm allowed to do anything, and still getting to grips with drug dosing and differences with children as patients. The nurses are very experienced and are quick to provide feedback on how best to position patients and cannulate them etc. Also, all juniors from FY1-2, CT1-2, ST1-3(paeds) GPVTS1-2 are all on the same rota, so I get a feeling not much is expected of us if a house officer can do the job, and sometimes feel like I'm treated accordingly. No offence meant to house officers but you gain some insight into how a hospital works if you've done it for 5 years already. I did an elective module in Paediatric surgery as a student and wanted to be a paediatric surgeon, but the lack of jobs and wide geographic area over which they work both put me off.

As for the hospital itself. The computers are standard hospital slow, the parking is terrible, the lifts are haphazard, the ceilings are too low, the neonatal unit is a 10 minute walk from the paediatric ward, the canteen is extortionate and all the catering staff wear silly looking flat caps. Other than that I like the new hospital I work in. I've also been assigned to do an audit, one that isn't related to my specialty which is odd as I'm normally pretty proactive in starting my own. I guess it's to make sure everyone gets one done so the department looks good.

Another gripe I had from the last week came in the form of an email I received. I was sent am email with a poster for a local conference and there were 100 spaces. The price was £40 for nurses and other health care professionals and £70 for doctors. Now why the bloody hell do I have to pay almost double the amount of money that a nurse has to for what is exactly the same list of lectures and seminars. I don't get anything extra and before people say "but doctors get paid more, so should pay more" I say a band 8 nurse consultant or matron is on a damn sight more money than I am, so should they pay more as well?

I've also had my supervisor meeting where my masterplan for ST3 applications was formulated. All in all the last few weeks have been all new and exciting.

Sunday, August 18, 2013

Abdominal pain = Surgeons

There is an interesting rule at our hospital that anybody with abdominal pain is seen be a surgeon before anybody else. The reason for this is that most causes of abdominal pain are dealt with by surgeons. This is thought to stop patients coming in under another team and then having a serious surgical diagnosis missed. It is also about sharing out the inpatient work load as the physicians are very busy and is unfair them looking after all the non operative chronic abdominal pain. It might also have something to do with grumpy surgeons refusing to see patient's that they deem "not surgical".

 This is very noble and a good idea in theory but the problem comes when the abdominal pain is due to something surgeons aren't good at managing. Once a patient has your name on them, it is very hard to get another person's name next to them, even if they'd be better off with them.

Also not every patient with abdominal pain necessarily has a surgical problem. Below is a list of diagnoses that I have actually seen in patients referred to myself as the surgical on call.

- Inferior MI - Epigastric pain and sweating
- Right lower lobe pneumonia - Right upper quadrant pain
- DKA - central abdominal pain and sweating
- Pre-eclampsia - Right upper quadrant pain 3 days post partum. This was made even worse by her having a BP of 160/100 and no platelets which no-body put 2 + 2 together.
- Septic Hip - Right iliac fossa pain (and a limp!!!)
- Ectopic - Right iliac fossa pain + vaginal bleeding + pregnancy test
- Labour - Yes, I've actually had a patient referred to me with "Abdominal mass, amenorrheoa and intermittent abdominal pain. ?tumour". 4 hours later they gave birth.

I haven't managed to get the Porphyria patient yet. But all the others are true.

Furthermore, the converse is true. Many patient's pigeonholed into being "medical" later turn out to have a surgical problem. The below patients are all patient's I have been referred by the medical on call and needed surgery.

AAA - collapse ?cause
Pancreatitis - confusion ?cause
Boerhaave Syndrome - Chest pain ?ACS
Necrotising Fasciitis - Leg swelling
Small bowel obstruction - Vomiting

Here is an interesting idea. Why can't we diagnose our patients and send them to whoever the patient needs. Medicine is not all about fitting people along a pathway or fitting in a box. Not every abdominal pain needs a surgeon and many patients without abdominal pain do.

This isn't a moan about A&E doctors. I've done a couple of locums in there and I don't envy their job at all. It's the politics behind the making up of arbitrary rules of who sees whom that annoys me. Perhaps if we were all a little more trusting and a little more keen to take over cases that come our way, this set up wouldn't occur.

Saturday, August 17, 2013

Locum Agencies

I got very annoyed last week whilst on call. I think it was justified.

I got paged by an outside line during a particularly busy on call shift. This normally means a GP has a sick patient who needs to be seen or another hospital has a VERY sick patient with a vascular problem. Also, as the outside lines are on hold, the bleep tends to keep on going until you answer it. So I tend to answer these bleeps fairly promptly, sometimes even interrupting seeing patients to do so.

So I run to the nearest phone and dial the extension to be greeted by an enthusiastic male voice with the following:

Idiot: "Hello, Are you the surgical SHO on call? We here at Idiot Locums have multiple locum opportunities just for you!"

Dobber: "You know this is the on call page FOR EMERGENCIES?! Please do not call this number again"

I think I then got a bit uppity and self important with him, saying stuff about how I'm a very busy and important doctor and his call has potentially wasted time I could be spending with a patient. And then I was going to call switchboard to block calls from his number again. So all in all I spent another 5 minutes of my shift just trying to stop this idiot doing it again. I really annoyed me, because when I spoke to switchboard they said they put an emergency call through to us. So not only was he a time waster, he was a liar. I'm actually quite keen on locum work, if he had just asked our medical staffing department, he could have had my email address!

Pagers in general are a great annoyance. Not only is our hospital so lame that they can't pay for my bleep to get replaced as its 20 years old. It is also very obnoxious and inefficient. You can't receive messages so you don't know what you are ignoring whilst you are doing a procedure. They also give no guarantee that the other person will pick up the phone at the other end. Carrying mobiles is even more annoying as you can't ignore them and will keep ringing until you pick them up. I always feel sorry for patients if I have to interrupt their history for a bleep. Even an urgent one. Especially as to the patient, the story they are telling is the most important thing to them at that moment.

Another thing! When I say I'm "on call" people always assume that means I'm asleep all night and that I only get a couple of calls a night. This is wrong and on call does not mean that any more! On call means that I cover the entire surgical side of the hospital and I don't sleep (my contract even says it is not allowed) at night. I work very hard and then go to bed in the morning. So I should just say "working night shift". But that makes me sound like I pack shipping containers. Which with the size of some of my jobs wouldn't be far off.