Career choices

The problem with being a junior doctor is a bit like choosing a university or course after not very much time.

As a foundation year 1 doctor you usually have 3 jobs in a year (some deaneries* do more and shorter attachments). This could be a mix of anything. A loose rule of thumb is that you do at least 1 medical or at least 1 surgical. The rest could be anything.

You can never do emergency work in first year (to my knowledge).

Just before the end of the first rotation in foundation year 2 (end of November/early December) you have to decide which area you want to specialise in.

And now there is the problem.

I have done 4 different jobs since qualifying and none of them are my chosen career (if I actually know what I want to do...). It is possible to do a taster week earlier in training, although I never got the chance to do it.

So here is my dilemma. I have applied for two different speciality training pathways (there is no limit to how many different specialities you can apply for) but a) what happens if I don't get a training post and b) how do I know I've made the right choices??

Is it too earlier to choose the pathway for the rest of your career?

I think so


*group of hospitals that work together to provide training to foundation doctors that is accredited by the GMC etc in order that all juniors get signed off for the same experience level.

Read this

http://bit.ly/VpAHqI

At what point do we say no?

My patients are, and will always be my first priority.

As a junior based solely on the shop floor (i.e. the wards) I'm often better suited to tell the consultant or registrar how the management plans have been panning out.

The problem comes when the seniors expect you to go above and beyond the line of duty.

I work hard - very hard. I often don't take proper breaks and almost never leave on time. However this is being taken for granted. At 1700 I'm officially 'not here / a figment of your imagination / don't ask me unless it's life threatening' however it seems to be expected that I will stay practically forever to ensure things are to my consultants liking.

I get that medicine used to be like that, however with greater workload, paperwork and responsibility comes a higher likelihood of burnout. In my current job I feel I'm heading that way.

I'm finally learning so say 'no' but it doesn't seem to be going down well.

Ive tried explaining that I'm happy to hand things on to the on-call team but it seems this isn't good enough.

What would you do?

Attachment

Sometimes knowing when to stop is one of the hardest things in medicine.

I find looking after a patient list so hard because I have lots of sick patients who sometimes die. It's difficult to know how far to go before you hold your hands up and admit defeat.

The debate at the moment with the Liverpool Care Pathway makes me very frustrated. The LCP is not a morphine pump to kill people (as a patient told me this week), but a (hopefully) more comfortable and less agitated way for dying people to pass away.

As part of a multi disciplinary team I have completed the paperwork for the LCP several times and it's never been something I've regretted. In fact on one occasion I felt horrific as I'd missed the opportunity to start the LCP and a patient died very distressed.

Making a decision about when to stop medical treatment for a patient is one of the hardest to make and is even harder given the appalling press coverage recently.

So much for supporting the NHS

Oh dear

As I mentioned in my last post I'm having teething problems.

After today I'm not so sure they're just going to be a short term issue. The problem comes down to the usual shortage of resources and division of labour, i.e. there are only so many things I can do within a finite time period.

I manage my time well, barely get breaks and have a strong work ethic appropriate to my grade. If I can't get everything done when you ask me to then you either need more staff or a more senior/experienced doctor.

I'm not superhuman. I can't wave a magic wand and get everything done instantly, some things have to take clinical priority. Doing discharge paperwork when I have a patient with a very low blood pressure is not sensible. The bed manager might prefer it that way as they could end up getting 2 empty beds for the price of one, but I don't think the GMC would view it favourably.

Give me the opportunity to do my job and leave me to prioritise my tasks according to need. If you can't do that then feel free to muck in and help me.

Rant over

Teething problems

The reason things have been so quiet lately is mainly due to work problems.

The job switch went fairly smoothly initially but is now not working out so well with regards to logistical issues and job role.

It's all a work-in-progress and will hopefully sort itself out shortly, but if not, well, it's only 2 months until job change again.

The joy of nights

As an F1 some hospitals won't let you do nights. I wasn't that unlucky.

Nights help you feel like a real doctor - the kind that actually has to make decisions off their own backs.

As you can probably gather, I love nights. There are less relatives, less hospital management and generally less people to annoy everyone.

I'm also very lucky that I can switch from days to nights (and back) very easily. I know some of my colleagues struggle with nights, but I love them.

But then I guess nights are like Marmite - you either love them or hate them!

Locum

AKA being a mercenary. Is it wrong to pick up extra shifts for 2.5x your normal working rate? (or should I be requesting more!)



Sent from my iPhone

The fallout from the killing season

It's suggested (hopefully mythically) that August in the NHS has the highest death rate for the whole year. Strangely this correlates with the period where new junior doctors start their career.

It's very strange to think that 12 months ago that was me, and I was a terrified FY1.

I'm sure that everyone says this, but I'm pretty sure I didn't have an attitude like a couple of people I work with have. Humility is a great tool when you start a new job, especially one where you don't have a lot of experience.

It is also very weird to be called an SHO (senior house officer) as this suggests greater responsibility. It also covers doctors from FY2 right the way to CT/ST2 or 3 (the doctors that are just about to become registrars) and as such the experience gap is massive.

So while I'm not aware of massive mess ups yet within my job I'm sure there are plenty of learning opportunities to be had by everyone.

Back to school

It's especially strange to think that tomorrow is my last day in my current job and as of Wednesday I'm an FY2 doctor who is fully registered on the GMC website.

Since I'm changing hospital trusts again it has an odd feeling of starting a new school year.

I've bought my new pens, selected and ironed my clothes, scheduled my bed time, polished my shoes and filled the car up with fuel.

This extra preparation won't make a difference though as I will still be bricking it tomorrow evening for a new job. I'll also be back to my usual self next week and forgetting to make myself some lunch and prepare clothes the night before.

As much as I've really hated my current job, I really love the people I've worked with. I think we shared a mutual dislike of the particular speciality and made the best of it. Possibly one of the best bunch of people I've ever worked with and the patient care has been genuinely excellent.

I'm going to miss having the time to chat to patients, make sure they get a drink while we're there (yes we really do do this as we know the nurses are manically busy) and explaining things to family without massive time pressures. I won't have this luxury in my next job.

So all in all I've learnt a hell of a lot in the last year - probably more than I ever realised. I think I've kept most of my personality and humanity despite working in a couple of tough specialities and as much as I've had some really stressful times, I wouldn't change it for the world.

So here's to medicine and making hopefully the correct decision for me when I was choosing between being a doctor and a paramedic.

Don't get ill in August...

365 days in the blink of an eye

From August 1st I will have a full GMC registration (F1 doctors in the UK hold provisional registration until they have been signed off as competent after 12 months). This means I'm technically an SHO (senior house office), albeit at the bottom of the pile.

The plus side of being hellishly terrified is that I get a payrise for having been through hell for the last year.

I think the reason I'm so scared is that now there are people more junior than me that aren't medical students! This means I have to pretend to actually know some stuff and not just stand quietly behind the SHO.

The good news is that I rotate jobs and I'm hoping it will be more interesting than my current one. If I find something I don't particularly enjoy then I don't learn a great deal - my current job falls into this category.

So for everyone new as an F1 on Wednesday welcome to the working world of the NHS and prepare to have your eyes opened.

How quickly a year passes

A year ago I hadn't quite graduated, was rather unwell and didn't have a provisional GMC number.

Since then I've worked for 50 weeks and just been informed that the GMC is happy to fully register me from 1st August (black Wednesday).

It's all gone incredibly quickly and with only intermittent amounts of stress and exhaustion.

Best of luck to the new F1s doing their preparation for professional practice soon!

And tomorrow is another day

Tomorrow is the BMA day of action. As previously stated here I will be taking part in the industrial action as it is something I feel passionately about.

In the last year I have regularly worked on rotas that are in excess of 60 hours per week, and my personal best was in the region of 94 hours. For this I get a salary much lower than you would actually expect a doctor to be on. My basic pay is similar to that of a newly qualified nurse although I get 'banding' for jobs that have antisocial elements to them. I can guarantee it really isn't worth it.

By the time I am 68 I don't want to be busting a gut to carry on working my backside off just so I can claim my pension. My pension, which by the way, is being reduced by the government to an average salary pension and I am now paying greater pension contributions from my wages.

At the moment the long term prospects in medicine seem less than rosy, and this needs to change.

If you want impassioned doctors who care about patients and who aren't exhausted, jaded and financially much worse off in our older years, then support doctors tomorrow who are taking action.

I became a doctor because I always knew that this is what I wanted to do. I adore working with talented and well educated staff to make patient care our first priority, but something has to change. If it doesn't, we're all screwed.

Longevity

I have just realised, in my usual observant way, that I have been blogging now for over 7 years. Beer anyone?

The list

It's that time of year where my current group of F1 doctors are all desperately trying to get our paperwork signed to get us into F2. It's irritatingly tedious but for me it's mostly done.

So for those of you about to start F1 in August there is something you will need to know - you need to know the rules of the list.

1. DO NOT LOSE IT
2. DO NOT TAKE IT OUT OF THE HOSPITAL (see point 1)
3. Your boss will want a copy of it so keep it reasonably up to date
4. Have most recent blood results and investigations on it
5. Go through it regularly with colleagues and divvy up the work.
6. As an F1 you will often be doing mini ward-rounds on your own. Initially this is terrifying but sometimes the list is all you have without reading the notes.
7. Most importantly see points 1 and 2.

Your list is your life as an F1

Support from colleagues

The topic of industrial action came up again today at work. It was discussed amongst my team to ascertain who would and who wouldn't be taking action.

It turns out that despite a large vote in favour of action, no one else in my team is taking action. Sadly they also do not seem to support the action.

Given the representation of members from the BMA ballot it would seem possible that my team colleagues may not have voted. In fact I know of several people who not only didn't vote, but who cancelled their BMA membership out of principle.

While I respect that everyone has a right to their own opinion I think it's incredibly rude to slag other people off due to their decisions. While I haven't been at the receiving end of verbal abuse yet, some colleagues have made scathing remarks about shirking work and putting patients at risk.

When we're all screwed over our pensions and working lives then we'll all be in it together, whether we agree with each other or not.

It's nice to feel supported by your colleagues

48 hours

The European Working Time Directive says that we should work no more than 48 hours per week. Doctors can opt out of this if they want to, but my rota isn't written beating this in mind.

The hospital gets around this by saying that the 48 hours is worked as an average over a month. As much as I would think this was normally amazing I reckon I'm due a week off soon.

Last week I worked my rota of 70 hours in 7 days but never managed to leave on time. I ended up working closer to 80-85 hours in that time.

While you might think this is a rare occurrence I have the hell period coming up again where I work 12 days in a row. That's 107 hours if I manage to leave on time every day for 12 days. It won't happen. It has nothing to do with time management or prioritising, it's just that patients seem to get sick at the most inopportune moments.

I can't speak for other hospitals and departments but this is how my rota runs.

And as a result of this doctors have no social life and make mistakes due to exhaustion.

This is why there is burnout and compassion fatigue amongst NHS doctors.

Roll on 21st June

It's really come to this

Who knows best?

I know that the days have passed where doctors know the best for their patients, but I am so bloody fed up of relatives shouting at me. I have had over a month now of relatives yelling at me because I'm on the ward and know the patient in question. Sometimes you just can't win- I've been yelled at because we were still investigating the cause of an illness, and then also yelled at (sometimes by the same person) for solving the problem (or at least identifying it) and trying to discharge the patient. The problem is that although the relatives know the patient infinitely better than I do, they don't understand the disease (usually). On the plus side, my communication skills have got better, as have my instincts about when to get out of the way or call security!

Bleep etiquette

I'm not going to claim to own this, but I saw a copy pinned to a doctors office wall this week and it reminded me to post it here.

Most of these have happened to me....

1. Bleeping is not a spinal reflex. Please take a few seconds to breathe, think and organise your thoughts, and stop flapping about. Half the time you may realise you didn't even need to pick up the phone.

2. Mention what ward you are on. I don't have the whole hospital directory of numbers memorised. This is called the 'bingo-bleep'.

3. If you bleep someone, please wait by the phone. How can there be no-one picking up the phone at your end when I ring back?! This is called the 'bleep-and-run' and is exceptionally irritating.

4. Have the notes, obs chart and drug chart in front of you. Chances are I need to know what the obs were without waiting for you to run over to the bed and look, then run back over to the trolley to get the notes when I ask the next question. This is called the 'relay-bleep' and is probably not fun for you.

5. Please mention the name, age, and working diagnosis of the patient. The following is not acceptable: "Hello doctor, please see patient in 4, 6, she has chest pain". That is 'bleep-spam'

6. All patients with chest pain need an ECG. Don't bleep me until one is being done or there in front of you.

7. If I'm in theatre (surgery), leave a clear message. The following is not acceptable: "Can you come to the ward afterwards, there are a few things to do". This also counts as 'bleep-spam'

8. Once in a while I will not respond to my bleep. This is because I am jumping on top of someone's chest trying to save their life. I am NOT 'on break'. Doctors don't have these.

9. Please check with the other nurses that you aren't asking the same question as them. I really hate being bleeped from the same ward from two phones and two nurses for same patient. This is called the 'déjà-bleep' and is distinctly un-fun

10. You spend twenty times as much time with each patient than we do. We appreciate your opinion and pertinent information. The following is not acceptable: "Well you're the doctor, you should know". Well actually I'm on call and have never met this patient who has spent 5 weeks with you.

11. Please be cheery on the phone and perhaps even flirt a little. I've just spent 12 hours running around the hospital doing mundane tasks, talking to angry relatives, putting my finger up bums, taking blood and ordering xrays. You will get your way far easier by making me smile.

12. When I answer the bleep please don't say 'Oops, sorry I had a question but not any more". This is called the 'fart-bleep' and gets on my nerves (See also point 1).

13. Please don't ask me to see virtually every patient on your ward. That's called a ward round.

14. If you do cannulae on the ward regularly you will be my favourite nurse and I will do anything you say.

15. If I answer my bleep and the line is engaged because you are bleeping me from that phone again, I may well explode. This is called the 'torpedo-bleep' because of its incessant battle with my morale. Three hits and the boat may sink.

16. If a patient has died, he/she no longer cares how long it takes me to get to the ward. That's a medical fact. Chances are I can do a few other jobs on my way there. If you bleep me again for this patient it better be because they have miraculously come back to life. This is called the 'Lazarus-bleep'

17. The 'MEWS / EWS / EWSS / PARS' score is a trigger for you to call me and is useless after that. I don't give a crap what the score is. Tell me WHY the patient has scored it (e.g. respiratory rate? BP? heart rate?).

18. Please don't start a sentence "Just to let you know..." or "Just so you know..." I hear this 50 times per shift. This is called the 'zombie-bleep' and you have just inadvertently disengaged my brain.

19. Please don't make the person who picks up the phone have find to you from the other end of the ward. This is called the 'bleep-and-hide' (See also point 3).

20. Don't have someone else (e.g. a student) bleep for you. It's cruel to them, and they are not your secretary. This is called the 'kamikaze-bleep' (see also points 4, 5 and 19)

21. Dosing a patient's warfarin (whom you have never met and don't know their history) at 4am is horrible, tedious, legally dubious and just plain bad for the patient. Please slap the day team round their faces when they arrive the next morning and don't let it happen again.

22. Sit down! You may be surprised with how much this helps points 1, 2, 3, 4, 5, 9, 11, and 19

23a. If you happen to have a spare moment, eavesdrop when a doctor bleeps another doctor. The majority of the time you will see how it should be done.

23b. Sometimes point 23a doesn't work because the doctor is a week old and still learning the 'etiquette'. He/she will learn very quickly as their senior on the other end shouts them down!

24. When a patient is in an ACUTE confusional state, please do not repeatedly ask me for, or demand sedation. This is not the year 1912. I might give sedation AFTER ruling out an infection, over-medication, drug withdrawal, metabolic cause, trauma, neurological, hypoxic, endocrine, and vascular causes, and AFTER using every other method of calming down the patient.

25. Read the latest entry/entries in the medical notes. Your question may be answered already (see also points 1, 4, 12, 13)"

Dissection of a working day

Well, since brown wednesday has been and gone I thought I'd let you in on what my normal-ish daily life is like.

0815AM - wake up. Not impressed, alarm clock not working well. Decide to snooze again for another 14 minutes. Fiancé somewhat confused that I should be at work at 0900 and am still in bed.

0845 - leave house. Damned traffic and ambulances slow me down further. Arrive on to site at 0900 exactly and get on to ward 3 minutes later. I still haven't got used to working for a medical team and start at 0900 rather than 0800. Despite having more of a lie in, the school run traffic is a nightmare.

0903 - handover with team. I was on late last night and need to tell them about the patient we have inherited from surgery who has a surgical problem. We are a medical firm and everyone is generally confused.

0910 - take some bloods from a difficult patient. Patient is a little unusual and I'm glad that the nurse stays in the room.

0930 - start ward round. No consultant to come with us so our core trainee divides the patients up for us to see. I have an amazing medical student with me who is final year and keen to learn. She does most of the work while I scribe.

1030 - have seen 2 patients from the list. They are both complicated with lots of medical and social issues to deal with. Liaise with nurses a lot regarding their care.

1100 - have to do an investigation on a patient myself. It feels a bit like House. This ties me up for 70 minutes and in between doing things I fill in a lot of my ePortfolio and do some e-learning for healthcare. It's surprisingly productive but means that I don't have a clue what is going on with patients on our list.

1250 - quick stop via the canteen for a can of something diet and fizzy in a can before heading off to a departmental meeting. Lunch goes with me. Thankfully this is generally acknowledged as acceptable and munching away on an apple while someone is talking is fine.

1400 - regroup as a team (juniors) to work out what the strategy for the afternoon is. We have a barrage of investigations to order for a patient so we split up and sort them out. Half of medicine is talking to various people (microbiology, haematology, radiology, the lab, physios, nurses, psych liaison, pharmacists etc) to explain why we want certain things done, and that we aren't just trying to waste everyone's time for the sheer hell of it. This takes up most of the afternoon.

1630 - after running around the hospital all day chasing things that other people have already done (we aren't massively great at communicating with each other yet...) it's time to do a final handover with each other to work out what jobs the 'on call' person needs to do. I am the on call person.

1645 - I take the on call bleep and prepare to head to the medical assessment unit (MAU) to do a ward round for all the new patients. Thankfully my team only has 2 jobs for me to do.

1700 - MAU have no patients for me, which is marvellous. Manage to speak to the consultant before she runs up to the ward and relate the good news. She is happy, this makes my life easier. Told to liaise with specialist registrar (SpR) regarding outstanding jobs.

1730 - manage to find the SpR and realise that she has done all except one job - prescribing a complicated medication regime. She dictates what she wants me to do and I head off to do it. No further jobs are given to me.

1740 - find the complicated patient. Prescribe the appropriate complex regime and hand over to the nurses, who, as always, are more clued up than I am.

1745 - grab my bag and head to the canteen and the doctor's mess. Eat a nice healthy salad and find a comfy sofa to deposit myself on. I check that my bleep is actually working (it is) and settle down to watch something trashy on Sky.

2020 - still sat in the mess. Have checked bleep a further 4 times - it is working well and I'm being paranoid.

2025 - go to night handover and report that I have nothing to hand over. Time to go home.

Whistleblowing: V2.0

S: (n) whistle blower, whistle-blower, whistleblower (an informant who exposes wrongdoing within an organization in the hope of stopping it) "the law gives little protection to whistleblowers who feel the public has a right to know what is going on"; "the whistleblower was fired for exposing the conditions in mental hospitals"*

 

I'm going to start by asking a fundamental question: is whistleblowing ever unacceptable?

You would think that the answer should be 'no', and in the interests of the bigger picture it should be the case. By raising concerns the theory is that someone more senior than yourself investigates the issue and how it is affecting the services offered, especially if the outcome is detrimental to the public.

 

But allow me to ask another prudent question: would you ever report your concerns about patient care in a training hospital where you were receiving training?

 

This question is purely hypothetical in its current context, but I have had my fingers burnt in the past, as have several of my colleagues.

I've heard tales from close colleagues where they found themselves excommunicated by not only nursing and other allied health professionals, but also by other doctors and senior managers because they dared to ask the question: 'hang on, I'm not sure that I'm happy with this situation, something here isn't right.'

The GMC recently published a policy called Raising and Acting on Concerns in Patient Safety. The theory should solve all of my concerns, but I bet it won't make one iota of difference.

F1 doctors (foundation year 1, first 12 months post qualification) like myself have to be signed off by a supervisor to be granted full GMC registration (as opposed to the provisional registration that we have for the first year). Is the signing off process likely to be affected by any previous concerns that have been highlighted by that F1?

Medicine shouldn't be a network of archaic attitudes and closed doors and closed ears, but my experience so far has shown me that it has been. Please don't misunderstand me, I love my work and I'm still very happy to be ploughing my way through my F1 year. This hasn't actually happened to me while I've been qualified, but I do know that it's happened to some of my close friends.

I can't help but thinking 'what would I do?'

 

 

 

* http://wordnet.princeton.edu/

 

What should a doctor look like?

How a doctor acts plays an important part in how patients perceive the care they receive. It's commonly expected that a doctor should be compassionate, polite and have excellent communication and interpersonal skills. We (and I) expect doctors to explain things in a way that patients understand. We expect them to take the time to explain diagnoses, prognosis and management plans in a way that a patient in a vulnerable position will be able to take in and make informed decisions.

But if a doctor fulfils all of these requirements, then should it matter if they dress appropriately but happen to have bright blue hair and a nose stud?

Do sick patients have less faith in doctors who don't look the same as their colleagues?

In my time as a doctor and a health care assistant I've seen many nurses and ancillary staff with unnatural hair colours, piercings and tattoos, but it's rare to see a doctor who makes a similar statement.

Have we all become so stereotyped that we have to become clones of each other?

Should a job or career affect who we are in our personal lives?

While I have no problem in stepping outside of the stereotype 'doctor' box, I can't help but feel that I will never truly be able to express myself until I reach a much more senior position and my external appearance is less likely to affect my career progression.

Should it be like this? Isn't this a more subtle type of discrimination?

So for now, unless someone else is bold enough to make a statement in my deanery, I guess I'll just have to stick to hidden tattoos, discrete piercings and 'natural(ish)' hair colour.

*sad face*

But what do you think?

Is a change as good as a rest?

It is just over 3 weeks until job change again and I'm back to feeling anxious about starting yet another new post.

It seems that as soon as you feel you're getting the hang of something you get moved on. This time at least I don't have to move hospital, which is a massive benefit.

The problem is that I don't especially enjoy my current post, yet I suspect I'm going to detest the next one, and the banding is lower (40% vs 50% at present).

I'm just going to have to see where it takes me...

Best of luck to any current final years due to sit exams soon.

Merys

Sent from my iPhone

Just a bit of good news

As all at work is going slightly bonkers at the moment, I thought I would share some good news with you.

I am now engaged!

Complete surprise and wonderfully happy.

Help!!!

Does anyone know how to fix a sewing machine?
I seem to have lost a lump off mine when I moved back from the last hospital (and yes, I did take my sewing machine with me....) and can't find it and don't quite know what I'm looking for to replace it.

It's a Janome if that's of any use to anyone knowledgeable!

The Maplin Game - a deviation from medicine

This game can also be played in any hardware, model or otherwise 'manly*' shop.
1. Enter shop alone, or ditch any boys at the entrance and let them follow you in.
2. Go and look at something. It doesn't have to be anything in particular, but generally the more obscure, the better the result.
3. Wait
4. Wait a bit more, it usually won't take long before someone (almost always male) approaches you and asks if you're OK.
5. Observe that as you move around the shop this will happen more than once.
6. Laugh that it never seems to happen to male counterparts in the shop.
7. See if you can beat my personal best of 3 in 5 minutes!



*I'm not saying that these shops are just for men, I often frequent them to look for arts and crafts tools.

Changing times

Christmas this year brought the usual strife with my family, but thankfully my in laws are wonderful and seem to have adopted me.

The new job is going well, although much less stressful than my previous post - it's proving hard to get used to leaving at 5 and on time rather than 3 hours late!

I promise to try blogging more this year and wish all final years the best of luck with impending exams!