The "Little People"

A gaggle of medical students representing all major
demographics. Long hair, short hair. Tall and small. Thin
and... ah wait, we're missing one...

As some of you may have realised, Dr Jr has been away from the "blogosphere" (seriously, who thought of that as a name?) for a month now. Why is this?

Well, Dr Jr has had a few things keeping him busy in his personal life. Nothing to worry about, but it had stolen what little time I had post work. Hopefully now I'll have a bit of time to get back to the way of the online words.

Anyway, the biggest development in Dr Jr's professional life in the last month is the sudden and rather dramatic appearance of medical students almost bursting onto the wards, eager to learn, eager to practice, eager to do!!!11! It made me think somewhat of how I was this time last year. Alas, Dr Jr was not the most eager of students, but I always made sure I arrived on time, did lots on the wards, then buggered off home to do diddly squat (I was and still am very much a "home time is home time" kinda guy).

However, what was most surprising is that these medical students were asking Dr Jr to help them out and teach them. What most medical students don't seem to realise is that FY1s know less than you do. OK, we can probably cannulate better than you and might have less bother putting a catheter in (I say probably and might because some FY1s can't even do those things), but when it comes to actual knowledge about rare conditions or the pharmacokinetics of amlodipine, you are much more likely to know than us.

Some might ask why? The answer is simple. As an F1, you don't actually need to know any of that stuff. Picture a bath full of water. That's the knowledge you have for finals. Now pull the plug. Picture the watery residue with what suds are left from the bubble bath, clinging to the bath through surface tension. That's how much knowledge you have as a F1. It's that bad. It's only a few years down the line when you're applying for your specialist training posts do you realise that you've forgotten everything you ever needed to know about your speciality.

So to all medical students out there, do us F1s a big favour. Could you come in and teach us about Wilson's disease and exactly how SSRIs affect uptake in the synaptic cleft , as I think we've all forgotten...

Dr Jr will be back!

Dr Jr's one week off seemed to turn into a slight sabbatical. What with the rest of my life and all that, Dr Jr hasn't really had much to blog about recently. But do not worry, I will be back!

A week off!

Dr Jr needs to learn not to tempt fate. After that post last week, the week got horrible. Lots of deaths, lots of people who spent a couple of hours going off with me at their side doing everything but achieving nothing. For another time maybe.

So, on the plus side, Dr Jr has a week off, courtesy of my good friend, the European Working Time Directive. Not only shall I use this time to visit the folks and be looked after (imagine that!), but also detach completely from medicine. Glory be eh?

So in the meantime, I suggest you listen to this monster of a tune. Musical brilliance with a video to match!

Why nights are much better than days.

Dr Jr really likes night shifts. Yes, they're 12 and a half hour long (they'd be longer if they were allowed to make them longer). Yes you end up having to deal with ill patients by yourself. Yes you get woken up from moments of snatched sleep by your bleep for the most trivial of reasons ("I have a bag of fluid that'll run out in a few hours time, could you write the patient up for some more?"). It's stressy, disjointed and full of very sick or very mad patients.

Sounds like the perfect horror story, so why do I like it so much? Absolutely no paperwork! By paperwork I don't mean writing in the notes, because that's part and parcel of looking after patients. By paperwork I mean reams of blood cards, piles of radiology requests and meticulous list-keeping. The whole night is entirely about patient care or interacting with patients.

I had a lovely moment with a young-ish gentleman with learning difficulties. He was getting very upset as he had been noisy and the clinical support worker had threatened to call security. I think what she failed to realise is that just because he has learning difficulties, it does not mean he wouldn't get upset at being threatened by security. I sat down with him (on his bed I'll add, with him sitting beside me - sorry infection control, but I will never listen to your complaints about sitting on patients' beds. There's not a jot of evidence and patients much prefer it in my experience. Allegedly there's a paper that says that patients overestimate how long doctors spend with them when they sit on the bed, but that's a whole different story...). We had a very slow conversation; it took him about 15 seconds to formulate a response. He said, in his own way, that he was upset that he had been threatened by security, he was knackered and just wanted to go to sleep now. So I helped him into bed, tucked him in and wished him good night. He was asleep five minutes later.

I'd never get to do this during the day - there's just too much going on, but on nights, you can occasionally snatch a few golden moments like this. And although being thrown into clinical situations can scare you, the whole experience is exhilarating when you get it right, and there is always a reg to offer advice down the phone when you need it, for the times when you're not sure what to do.

That and the fact it's only a four day week. Man, I love nights. And I think it's time to go to bed. Night folks!

(On a side note, Dr Jr was just scared out of his mind when he heard some banging on his first floor windows, only to see a giant brush cleaning them...)

A weekend, hurrah!

Dr Jr has finished his 12 day monster stretch. With last week being horrible owing to the huge amounts of doctors and nurses off on sick leave, I think I'm just a bit relieved to have time to space out in front of my television for a change! Dr Jr also celebrated the end of his monster stretch by inviting a couple of friends round for his one-of-a-kind homemade lamb and mint burgers, with home made chips, homemade potato skins with bacon and cheese for starters and a bramley apple pie with custard for dessert. I would give you my recipies, but alas, I don't have one, I just throw stuff in as a I go along.

Who said British food had to be boring?

When being in hospital is dangerous

Roland Holbrow will not be the last.

Maintaining anonymity on a blog such as this allows someone like myself, working on the front-line, to tell the readers of my blog how things are on the shop-floor. The Daily Mail is a paper that annoys me, simply because it's sensationalist anti-NHS stance means that real concerns are drowned out but the drivel that comes. You'll find a real concern here.

Dr Jr was covering the wards this weekend. Never the nicest of jobs at the best of times, but for some reason, the hospital was heaving this weekend. The bed manager spent most of the weekend trying to close the hospital to new admissions due to bed pressure. On top of that, half the nursing staff phone in ill. What resulted was utter bedlam, for both staff, and the patients in the hospital.

In a hospital, I respect the nurses more than the doctors. A hospital could survive a week without doctors, most of the senior nursing staff are much more skilled and knowledgeable than many of the junior medics, such as myself; juniors (F1s and SHOs) also outnumber registrars and consultants. Even if patients went off completely, the critical care nurses would easily be able to bring them round. Short of internal surgical problems such as a massive bleed, most patients would survive. The reason I mention all this is when half the nursing staff are off ill, 2/3rds of the total patient care goes off too.

Now why are they all ill? Chronic understaffing. Understaffing to the level it's verging on dangerous, but not quite making it. Managers don't want to be in charge of a "dangerous" hospital, it means more work for them, maybe they'll even have to stay 15 minutes late once in a while. So just enough nurses so that all the essential stuff gets done and the actual bits of care that make such a huge difference to quality of stay (such as feeding, cleaning), just don't get done. When even one nurse goes ill, the whole tower of cards crumble, which stresses the working staff out to the point where they need time off. It's a cycle that continues onwards.

With some wards of upwards of 30 patients with just two qualified nurses covering them, Juniorville Hospital was sheer bedlam. The bed manager was trying to clear as many patients as she could, she directly told me "it's safer out on the street than it is in here this weekend". Oh dear.

Meanwhile, in my side, I had already worked all week and was covering 13 hour shifts over the weekend. It got worse when a registrar and SHO called in sick on AAU and I had to end up covering them both. Yes, a lone F1 covering the job of a SHO and a registrar.

Is this normal show across the land? To be so short staffed on the nursing front and requiring medical staff to frequently change firms because they can't employ enough to cover a team over their rotations? It definitely wasn't where I trained. What worries me more is posts like this from PC Bloggs, who presents a similar picture from our on the beat friends over at the local nick. When you see what cuts have done over there, you just fear for the NHS. I don't believe a single word the government says about ringfencing. The axe will come, and when it comes, as always, it's the front-line staff who take first blood. If my hospital is anything to go by, we are in big, big trouble.

Empassioned bleating that restricting junior doctor hours to 48 a week completely miss the point. The problem is the shortage of nursing staff. The 48 hour week doesn't help situations mind, but if you want more work from doctors, where's the money going to come from to pay them for the extra 12 hours a week they'll probably end up working? If hospitals instead bothered to bolster their nursing staff, they would spend less money due to the lack of need to bring in much more expensive bank staff, especially when nursing stress went down and they didn't have to go off ill as a result.

This is when being in hospital is more dangerous. I fear we're heading that direction if we don't stop this cart now and what's worse, I think the brakes on this thing are shot.

The Free Lunch

There's no such thing as a free lunch, is there?

Well for most of the population, that is indeed true. Lunch costs money, figuratively and literally. However, doctors seem to avoid the trend and get an actual free lunch once in a while.

Now, I will admit, it's not necessarily "free" - you're giving your time in return, but as to what you do with that time is really up to you, you can wangle it into the most free of calorific delights. Today, there was a Grand Round. Grand rounds are effectively teaching sessions for everyone from medical student to professor, where a doctor from your hospital presents a topic, usually specialist in nature, with the aim of imparting that knowledge onto doctors from other fields who may never see this condition in their normal practice.

Naturally, as with most educational things, no-one senior would go to them. The eager juniors might. The registrar who is interested in progressing his career in that field might, but a lot of doctors wouldn't. It's not necessarily that they think they're holier-than-thou, but generally because they're too busy to rip themselves away from the ward/clinic/golf course.

However, if you add a nice chicken korma, with rice, naan bread and some mango chutney, then even the radiologists will turn up! But is the lunch really free? If you enjoy the topic that's being talked about, then yes, or if you're like me and the topic is waaaay over your head, you can simply sit at the back and fill out all your blood cards and request forms safe from the nurses and their never-ending stream of requests. So you're fed whilst doing your normal job. Sounds free to me!

Sometimes the job gets your down, but for a busy jobbing junior, especially one who's led by his ever increasing belly, there are times when you've just got to smile.

Big momma

Does this make me look fat?

Dr Jr had a patient today who needed an MRI scan. Alas, he was too big to fit in the MRI machine. The question is, what now?


In other news, Dr Jr bought a new TV. Apparently it's the traditional thing to do with your first paypacket. I'm not complaining!

When medicine fails

Dr Jr had to certify his first death on the wards yesterday.

You could see it as lucky that it's taken a month and a half to have my first death on my shift. You always know it's going to come some day, but the small, optimistic part of your head thinks that it won't come for a while.

Mr Salisbury (name changed of course) had been admitted with neutropenic sepsis secondary to myelodysplastic sydrome. Basically his bone marrow had given up and stopped producing the wide variety of cells needed to fight of infection. He had been discharged from hospital only a few weeks ago, but had managed to pick up what seemed like a hospital acquired pneumonia. On top of that, he was having severe epistaxis (nose bleeds) due to his horrendously low platelet count (which was only 2, when the minimum normal value is around 150). Although we topped him up with platelets and fed him enough antibiotics to kill a small rhino (well, not literally, but you get the idea), the only path for this poor chap was down.

His family and the medical team thought it would be a good idea to discharge him to a hospice to live out his final few days. However, on the day he was due to go, he suffered a haemorrhagic stroke. From being a patient who was, although unwell, perfectly compus mentus, telling jokes and having chats with the staff and his family to a panicked, hemiparalysed man incapable of coherent speech is a horrible enough experience for me, but for the family, I can't even begin to imagine the thoughts and feelings they were going through.

At that point, we put them on the The Liverpool Care Pathway (see my previous post), and within 6 hours, he had passed away. After leaving the family for an hour with the patient, I had to go in and certify death.

It's a completely different experience to check for pacemakers in the morgue. Mr Salisbury was lying in his bed, exactly where he had been for the past couple of days, except he wasn't chatting, laughing or sleeping peacefully. He was dead.

Confirming someone dead is an odd experience. Although you know they're dead, you still have to ask them if they're all right. Although you know there isn't going to be a pulse, you have to feel and listen for one. Eve n though the chest is resolutely still, you listen for breathing. Their eyes may be blank and staring, but you shine a light at them anyway. They remain fixed and dilated. You pinch them and get no response. You save yourself some bother later by checking for a pacemaker now. You look at your watch. What time your watch says defines at what time that person is declared dead.

After writing it in the notes, you carry on your day. While you're busy filling in blood cards, the family are sobbing beside their father/brother/uncle/grandfather. And it never feels quite right to just carry on, but it's what you've got to do.

This is when the job sucks.

Back to business

Dr Jr has been away of late. After having had most of last week off, followed by an awesome weekend karting at the British 24 Hour Kart Race, Dr Jr is back to work again this week.

This week, Dr Jr has been on an endocrine team. Although I'm getting the slightest bit peeved at never having any continuity of care, endocrine has been a good learning experience for me. Endocrine has always been one of my weak points and getting to grips with all the different forms of insulin, SIADH and pancreatic insufficiency has been a useful learning experience. What is nice is being able to get on time every day. Although my colleague who is usually on endocrine seems to never leave before 6.30, I've managed to get all the jobs done, even though we've had more patients on endocrine than at any point since I started. Maybe this is a good sign about how I'm settling in after a month of working.

We also had our first medical student to tend to this week. It's hard to think that only a few months ago I was in her position. It's very odd being the one suggesting which patients would be good to see for a change. It's got me looking forward to them arriving en masse in a few weeks time where not only can I educate them on the finer points of what you really need to know for final year, they can get excellent practice at doing TTOs. It has nothing to do with lightening my workload. Honestly. I'm being serious...

CPR and why I love my job.

Dr Jr has been feeling that his past few posts have been a bit gripey, so maybe it's time to put the shoe on the other foot and explain why he loves his job so much.

I've finished my weekend of nights and I'll tell ya, I haven't run around so much since I started training for a marathon (which I never actually entered, pffft). On the most, it was mainly prescribing fluids and warfarin where the day doctors had forgotten (or been too lazy...) to do. Patients also didn't seem to like having cannulas in either - another chunk of my time was replacing "lost" cannulas or trying to thread in cannulas where site practitioners had failed miserably and left me with a vein more equivalent to a loose thread of string than a large drainpipe.

But weekends have their upsides. For one, although being the only junior doc in the entire hospital, it gives you a lot more responsibility and forces you to make a lot more decisions by yourself. Of course, if there's anything you're unsure of, you can call your reg, but initial management is entirely down to you. A man decided that sleeping peacefully at night wasn't for him and decided to get severely short of breath. The poor guy was absolutely terrified and was begging for help between his gasps for breath. After listening to his chest and it sounding more like an off-key, underwater orchestra than a finely tuned organ for efficient gas transfer, I popped him on salbutamol nebs, stopped his fluids and gave a stat dose of frusemide (sounds much better than furosemide doesn't it?) to pull the fluid out of his chest. 15-20 minutes later, he was calming down and the difference in his breathing was staggering. Within the hour, he was peacefully asleep. Having a little touch of extra responsibility and seeing your decisions make a proper difference really fills you with "feel-good". But that pales in comparison to what happened later.

If only the person who made this really knew...

I had my first crash call this weekend. While keeping some poor lady up at 3am in the morning trying to take some blood to get gentamycin levels that the day docs had forgotten to do, the siren call of my attached "blue baby" (what I've started calling my bleep. Small, noisy, demanding and never satisfied, just like babies, and in a "cute" (bleurgh) shade of what can only be described as baby blue) shouts out "Crash call, X Ward!". Apologising profusely, I take the needle out of the patient (who's had three different people poking her with needles for the last 2 hours to try and get some blood) and sprint across the hospital and up two flights of stairs, passing the AAU SHO who is ambling at a rather leisurely pace.

When I get there, I see I'm the first doc. The nurses have just started CPR and are looking expectantly at the sweating and smelly Dr Jr. It's at these points that you realise you have several metres of detrius in your brain covering the bit of knowledge you need to save this woman's life. After spending a few milliseconds waving away the hazy recollections of that party the night after Dr Jr learnt his advanced life support, your brain engages. I took over CPR, asked the nurses to get the defibrillator and attach the leads so we could get a heart tracing. I asked another nurse to get the adrenaline and amiodarone ready incase we needed it down the line.

Now what Joe Public don't understand is that CPR is rarely successful. On Casualty, ER and the like, you get the impression that someone slides your hands across your chest rather pathetically and a minute later, you're up and chatting, throwing roses and thank you cards at your new-found-hero. The reality is a bit more gruesome. For a start, the success rate is tiny and of those people who go into arrest, only 5% ever leave hospital again. On top of that, you generally end up breaking every rib in someone's body, at least if you're doing it right. The feeling is horrible.

Then there's the "shock". For a start, only a very small number of cases are "shockable". Cardiac arrest can be any one of four heart rhythms, of which only two are shockable. Can't remember which TV program I saw recently that someone in asystole was shocked and came around. No wonder public expectations are high.

In any case, by the time we got a rhythm readout, my reg and the SHO had made their way up and took command. I just carried on chest compressions. Lo and behold, a minute later, the patient's eyes open with a start and she starts moaning. She's alive.

The feeling of satisfaction for doing something like that is simply indescribable. It's at points like these you forget the horrendous hours, the frothing-at-the-mouth consultant biochemists, the smell of various bodily fluids everywhere you go, the patients who try to punch you, the constant wandering around like a zombie trying to find somewhere to sleep and every trial and tribulation you go through on a daily basis and remember:

"I'm a doctor and I can make a difference."

And at that point, you realise that you love this job and couldn't do anything else.

It's all dark and quiet...

Dr Jr is working his first night shifts this weekend. Already I'm having difficulty with it as I don't know exactly how to shift my sleeping patterns yet and reckon I'm going to start this evening dead before it's even begun.

And then when I'm in, the non-stop pitiful bleeps are no doubt going to drive me up the wall. No doubt I'll get bleeped for surgical patients when I'm a medical on-call. No doubt someone will have forgotten to rewrite a drug chart or prescribe fluids.

And who knows, maybe I may even get a nap! Or maybe I'll just never get a chance to sit down. Am I the kind of doctor who uses Zopiclone to get my patients to sleep or will I try and calm them down first? In any case, let's just hope that for the patients I tend to tonight, it's a night shift rather than a graveyard shift...

The Liverpool Care Pathway

Today was one of the saddest days I've had, not only as a F1 doctor, but from starting out a fresh-faced medical student. Today, my team signed someone on to the Liverpool Care Pathway.

For those of you who don't know what it is, the Liverpool Care Pathway for the dying patient is an end of life protocol. For patient's whose death is expected an imminent, we withdraw all treatment other than medication to make the final few hours or days as pain free and comfortable as possible.

Now I've never been sure of the ethics of death. It's not something I've ever had to face in my professional career. Many people are heavily against the idea, some feel it "sanctions euthanasia", but seeing it in action as a doctor who is directly responsible for a patient's care really made me think twice about criticisms which I used to think may have an element of justification about them.

The hardest part is the deterioration.

Mrs Thompson (name changed of course) was one of those people who never let life's niggles bother her. About 6 months ago, she noticed some pain in her breast, but of course, didn't complain. It wasn't like her to do so. About a month later, she mentioned it to her son, who, naturally, was very concerned, and badgered her to see the doctor. She didn't. After another a month, her son made an appointment for her and dragged her to see her doctor.

Unfortunately, she had developed breast cancer. And unfortunately, this cancer had spread. There was little that could be done. She went home to spend time with her family.

A few weeks ago, she came in having lost six stone in only six weeks. She had completely stopped eating and drinking. One of the most important things in times like this are calories. The body needs sustenance to stay strong enough to go against the physiological effects that cancer has on the body. After treating her initial problems, she started eating again and things improved.

However, early last week, her appetite disappeared again. No matter what we did, how much her family encouraged her and no matter how often she was told how important it was to eat, she refused. She barely managed half a banana a day. Due to an underlying diagnosis of dementia and her advanced age, it was decided that PEG feeding (putting a tube through her abdomen directly into her stomach) was unfeasible. Immediately moves were made to try and get her home with a complete care package to look after her as best we could.

Unfortunately, these things take time. Over the last 48 hours, she deteriorated massively. On the ward round this morning, my consultant decided that if there was any further deterioration, she would be placed on the Liverpool Care Pathway. By late afternoon, she had become barely responsive and was bringing up secretions.

I phoned my registrar, who spoke to my consultant, who decided that there was nothing more medicine could do. I crossed out all her drugs and wrote her up for medication to take away the pain an nausea, whilst he spoke to the son about what was happening from here.

When you join medicine, you always have ideals of saving patient's lives and making a difference. The feeling you get when you have to simply admit failure is horrible. But it doesn't make a decision like this any easier. Death is an unfortunate consequence of being alive.

Withdrawing all other treatment may seem cruel, however, on reflection, it seems there is a time when everyone, including the junior doctor who's been at the bedside talking to the family and the patient for weeks, just has to let go.

When I go in tomorrow, I don't expect to see her name on the board.

It's the weekend, spend the ash cash?

It's the weekend and Dr Jr will be taking a well earned break from hospital. That said, I have a very good day today on the whole. Much more relaxed. I was still an hour late getting away, but that's more down to me arriving 15 minutes late and having a 1 hour "lunch" break (late in because of having my car towed to the garage and an hour at lunchtime to collect the car).

I signed my first cremation form today. For those of you who don't know, anyone who wants to get cremated needs a doctor to sign them off for it, after death. As this falls outside the NHS, there is a fee which ends up in my pocket down the line somewhere. It's commonly referred to as "ash cash".

Now I'm never sure about the ethics of this. Should I accept money for signing someone off to burnt? Is it ethically wrong? There's several schools of thought. One is that, no, profiting from someone's death is wrong, but then what would we do without undertakers? The other is that it is my duty to provide a death certificate. Anything beyond that is beyond what I am duty bound to do and therefore am doing it as a service to those who are deceased.

It's anything but free...

It actually carries a hefty legal responsibility. I have to be absolutely certain and beyond any doubt that the patient has died of medically natural causes. If there is absolutely any suggestion of foul play, negligence or the patient died of a communicable disease, then I cannot do the form as cremating someone instantly destroys the evidence.

On top of that, if the patient has a pacemaker or IED (implantable electrical defibrillator), it needs to be removed. If I miss it, and they go into the crematorium, there will be an explosion that will do thousands of pounds worth of damage to the cremation chamber and cause unimaginable distress to the family of the deceased. I then, of course, would need to pay for a new crematorium.

So, all that in mind, I think I'll take the money, thank you very much!

Have a good weekend folks!

One of those days

When it rains, it pours.

Today, Dr Jr was leaving for work. After reversing about 1 metre out of my parking bay, my front suspension decided to snap, rendering the car undriveable. I would suspect that Juniortown's numerous potholes are to blame. It seems like most of my money from my first paypacket will go to repairs and I'm not due my first paycheck until the end of the month!

Once I arrived in hospital (late, of course), the day didn't improve much. I was bleeped almost immediately to come down and write a death certificate for one of my patients on CCU who sadly died last night. It was the first death certificate I have written in a professional capacity - the patient I had gotten to know a bit over the last few days or so. A lovely elderly lady with lung cancer had come in short of breath, with pulmonary and pericardial effusions. They were drained and she was on the mend, but unfortunately, last night, she passed away.

Luckily, I have enough hair to be able to pull some out.

Death is never something easy to deal with and my first patient death came on a day I was already up to the eyeballs in stress. What is most saddening is the fact she has lived a life and now it ends with me signing a piece of paper. To my professional life, that is all she became - some ink on a piece of paper. However, to her family, she was a mother and a member of a very close family. On a personal level, a bit of her will always remain in my mind. Rest in piece Mrs Patient.

Shortly afterwards, I got a very angry call from a consultant biochemist (I'm not entirely sure, are they actual doctors?). One of the patients who we'd just received from AAU had a blood test, which had come back with a potassium of 2.2 - potassium is a very essential salt in the blood, and values too high, or too low can cause cardiac arrythmias and eventually cardiac arrest if untreated. However, I had a loud, angry bollocking on the phone telling me how terrible I was and how terrible my care of the elderly team was for letting this potassium get this low. My pleas of "we've only just received this patient" were rudely shot down with "I've not finished, you will listen to me or I will blame the death squarely on you if she dies."

She was immediately treated and remains completely stable and well. It reminds me of my post from a few days ago about how important a good consultant is - I'm thankful to not be working for this dragon!

To finish the day, I had to walk home. One of my patients pointed out "someone is watering the plants tonight outside." I headed home shortly afterwards. Alas, in my haste to try and get to work in time, I didn't bring a coat or umbrella.

And when it rains, it pours.

A weight off my workload

My consultant took pity on little Dr Jr today.

For the last few days, Dr Jr has been the only F1 for 30 patients spread over two wards, one of which is a CCU. The consultant decided this was somewhat taking the proverbial and decided to foist CCU on another F1 (who only had 6 patients).

Not so much anymore!

What's quite amusing is that at lunch, the surgical F1s were moaning about their workload. They have 14 patients between 2 F1s.

I still didn't leave until an hour after finishing, but at least I did a much more thorough job and was much happier with the work that I did do. I'm sure jobbing GPs across Juniorville will be very happy at the new and improved "Dr Jr's discharge letters Mk 2.0"!

Consultants: Why a good one is essential for new FY1s

I must say I am a blessed man. I have a roof over my head and a career that will provide for myself and a future family ahead of me (unless of course I do something plain stupid and get struck off).

However, most of my colleagues are in a similar position. Everything is looking good for now. So what about actually being in work?

I am lucky to have a rather superb consultant in charge of our Care of the Elderly team. Not only does he have an undying need to make sure each and every one of his patients gets the best care they could possibly get, but he goes about it in the most amiable, upbeat and pleasant way you possibly could. This being on top of the fact he is responsible for no less than 40 inpatients (in a small DGH) with clinics and suchlike and a very small team to back him up.

It's a pleasure to work with him. He helps out as much as he can, he makes himself available to chat at all hours (one of the first things he did was give me his mobile number and told me to call him "any time"). Most importantly, he treats all his team as equals, himself included. I feel invigorated and eager to work with him. Yes he'll point out what you've done wrong, but in a way you will do nothing but learn from the situation and become a better doctor.

"And ye shall be cast into the firey pits of FAILURE!"

Now, contrast that with a consultant who I was under at medical school. A polar opposite more obvious there could not be. Like most doctors, he cared for his patients, however, his treatment of his colleagues (read "underlings" in his mind) was nothing short of appalling. Regularly reducing the students to tears with his overly brutal approach to junior education, making a mockery of staff and student alike in front of each other and even patients was the order of the day. He wasn't even part of the "old guard" of consultants who were simply "God". He simply was inserting his head slowly into an anatomical region with enough of a chip on his shoulder that the entire product line of Heinz tomato ketchup could not satisfactorily cover it.

Now, for someone like me, it made me work harder. When he told me in an assessment, "I hold no hope for you and I wouldn't count yourself amongst next semester's cohort," (which was apparently quite light going by some of the things he told my colleagues) it drove me to work much harder to go "I'll show you". I promptly merited my OSCEs.

However, it drove some of my colleagues to tipping point. One student who was otherwise high-flying crashed in their OSCEs. It, as expected, turned out to be the one blotch on their otherwise sterling medical school career.

At the end of the day, the work needs to be done, the lessons need to be learnt. As an F1, it is the role of Dr Jr and his colleagues to learn and take point from many of the consultants we will work with in years to come. I'm lucky to have such a good one. If any consultants are reading this, remember, the F1s will be tomorrow's consultants - we don't want to be gods, please don't teach us it's the only way to do things.

EWTD - A new doctor's perspective.

I'm sure we've all heard a lot about EWTD and impressions from many important people across the media and blogosphere. For those of you who don't know what EWTD is, I'll give a brief synopsis.

The European Working Time Directive was introduced in June 2000, with the aim of reducing working hours across Europe to less than 48 hours a week on average. The reasoning is that work related stress is a major problem, accounting for vast amounts of sick leave, and that excessive hours are one of the main contributing factors to this. Penalties are levied for any organisation that makes its workers work more than an average 48 hours per week. This is of course, an average. If you work 96 hours one week, and then none the next, it all balances out. Other rules include having at least 24 hours off in any 7 days, or 48 in any 14.

Excessive hours have driven this doctor
to telepathic communication with the walls...

The NHS, being the slow, cumbersome monolith that it is, were very slow to introduce the changes. Eventually, the NHS fell into line in 2009, taking a very slow route to get there.

There have, of course, been supporters and detractors in the NHS. One of the big worries is the loss of training that this provides. One of the most vocal critics is the Royal College of Surgeons, who claim that it leaves hospitals "less safe". They have consistently said that it means that Consultants cannot be there throughout the stay of their patients and that training for juniors will be much impacted, leading to a new wave of consultants who will supposedly know very little.

As a jobbing junior doctor, my view on this is slightly different. I am working mainly in medicine at the moment. My career aspiration is not fully set yet, but I'm thinking of anaesthetics. But for now, I'm just a lowly FY1.

In my opinion, 48 hours is a decent amount of hours to work, infact, I have no complaints at all. One of the biggest things that seem to worry my seniors is that I won't get enough "experience". Now in a perfect world, Dr Jr would fully agree with that, however, this is simply not how it works.

For a start, I don't work 48 hours a week. I work much more. I don't leave until at least an hour after I'm supposed to finish, sometimes more. Yes maybe that is partially down to inexperience, however, leaving earlier just leaves me more work for the next day.

To address concerns about experience, in the one week I have worked, I can count how many times I've used my "clinical noggin" on both hands. Most of my work involves filling reams of paperwork. Doing the ward round is the most valuable experience of my day (although running around at light speed trying to translate the volumes of gobbledegook coming out of my Consultant's mouth into a succinct output of events on paper is never fun), everything after that is simple paperwork. Blood forms, drug chart rewriting, examination requests, discharges and the like form the bulk of my working day, which requires little medical knowledge or skill.

Most importantly, I wouldn't deem it as "experience". After the first few forms, you learn very little about medicine. You do as your consultant tells you. "Order this CTPA for this suspected PE", "I need FBCs, U+Es and a CRP for this patient", "Doctor, can you write up this patient for some paracetamol please?"

Working more than 48 hours a week simply means I do more paperwork and the trust employs less doctors. I'm stretched enough as it is (I cover two wards of different specialities by myself. No SHO or reg on the wards).

Managers hate it too. It means they need to employ more staff, which of course costs more money. And everyone knows that if it costs money, managers will find a way around it, even if it means overworked, grumpy staff.

Yes, I can understand that further down the line, experience will come more readily, but for the F1, more hours brings nothing but more paper. For people like myself, EWTD allows a work life balance and at least I can be recovered going into work the day after. Does anyone care what the F1 thinks? I hesitate to comment.

And so it has begun

Dr Jr has started his job as Foundation Year 1 doctor.

After a weeks worth of induction (being told how to lift things and escape burning buildings), we were unceremoniously dumped on the wards, expected to know how to do everything.

So, other than forgetting to order bloods for most of the patients on my ward on the first day, it went quite well! I may have worked an extra hour... or two... every day, but I'm enjoying what I'm doing in any case. Luckily, the nursing staff and senior doctors are pretty darn amazing. Happy, easy to talk to and work with and helpful in my early days where I know nothing, I don't think I could have wished for a better group of people to work with.

Admin is already proving hassle-some - however maybe I'm just thinking this because everything has been so hectic that I've not had time to fill in all these forms. Seriously, how many forests were felled to provide me with all these documents to sign? I don't even know what I'm signing half the time!

But all in all, it's been a good, yet hard, first week. I'm not having to do any on-calls or weekends for a few weeks yet, so hopefully I'll be able to settle in and bed down before the fun really begins. Another plus, none of my patients died! Sadly, it seems like an inevitability that some will, considering the specialty I find myself in, but for now, they remain ticking. Hopefully that won't have changed over the weekend.

Now, I think I must go to bed, my sleeping patters are still skewy since my student days!

Not long to go...

The 4th August. It's really not that far away now and not long until I start many a long and grueling year pulling along the rickety rickshaw of the responsibility of being a doctor.

They say moving house is the most stressful time in life - I'm thinking that maybe the first day is going to be my most stressful day. I've managed to start reading "Trust Me, I'm a Junior Doctor" again and it's really beginning to freak me out a bit! Although EWTD will probably be useful in controlling what used to be a horrendous work/life balance, I have a sneaking feeling that mistakes and deaths are less than two weeks away for the poor citizens of Juniorville.

As yet, I don't even have any idea how many fellow jobbing juniors I'll be working with! Baptism of fire, I guess you await me with open arms!

Tiredness

Wow.

Dr Jr has had a hectic past week and I'm absolutely shattered. However, this probably pales in comparison to the hours I'll be working come August 3rd. Not only am I petrified I may hurt/maim/kill/paralyze/render corpse-like (delete as appropriate) a patient and their family and their dog, now I'm also petrified I may, quite literally, fall asleep on the job.

I have a bad feeling I'm going to miss my morning lie-ins...

Dr Jr versus Admin. Round 1

Dr Jr has his first run-in with admin staff today. After getting a rather "threatening" e-mail claiming they didn't have any of his paperwork, he started to panic a bit.

However, on checking, Dr Jr knows he sent everything, as he has a recorded delivery report to rely on and he even traveled several hundred miles and delivered his contract by hand.

Shortly afterward, apology email arrives.

Score!

Dr Jr:   1 - 0   :Admin

The first day on the wards... sort of.

Today Dr Jr was a very busy person.

Not only did he sort out his accommodation for the next two years (with the inevitable last minute hitches and dramas...), but he had his first visit to Juniorville Hospital as well. Being a sociable young chappy, I decided to pop my head into the ward to say hi to various folks of the ward. What I saw both excited and petrified in equal measure.

It seems that Juniorville Hospital is a nice, friendly place at first glance. As I'm moving a fair distance from where I graduated, I was a bit wary of what to expect; the hospitals where I did all my undergraduate training were exceptionally well staffed and very pleasant places to be. However, I'm not so sure about Juniorville. The nurse lovingly told me "Junior doctors? We don't see those so often around here! Everytime we see one we tie them down to the chair so they can do all the paperwork that needs done."

Oh dear...

Good afternoon. And so it begins.

Good day people.


My name is Dr Jr (Doctor Junior) and I'm a recent graduate in the field of medicine. I decided to start this blog as for years, I've been a fan of many medical blogs from much more senior colleagues all around the world. Their observations, musings and comments have kept me on the go through the inevitable thick and thin of a medical degree, but now it's time to start my own journey, which I hope to chronicle.

Hopefully my trip from sane student to crazed, disheartened, cynical doctor will be slow and hopefully venting my spleen at the inevitable problems I encounter within myself and the system at large will help. This blog will display to all the trials and tribulations of my journey as a Dr Jr. Thanks for popping by. It will be a thrilling ride. I think. Maybe.