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.