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Wilkommen to my blog - if you're looking for ramblings on life as a junior doctor, my attempts to dual-moonlight as a scientist and balancing all that madness with a life, you've come to the right place. Comments and thoughts welcomed!

Saturday, 20 September 2014

Fulbrighting

So the time is nearly upon me to pack up my stethoscope and the NHS and leave the UK for American shores.  After over a year of emails, phone calls, panic and excitement, I can't believe in two weeks time I will be calling the USA home for nine months.

This blog so far has charted the ups and downs of my final months at medical school and the whirlwind first two years as a qualified doctor.  I have decided, as many do at this stage in their training, to tag out of training.  I am trading my stethoscope for a lab coat.

I am not alone: A third of UK doctors take a 'gap year' between their foundation years and specialty training.  I have to say, from personal experience I'd say that statistic is even higher.  Why?  A number of reasons really.  The last time I made a radical decision about my life was when I was applying to medical school as a teenager.  OK, so I took a year out to live in London and do a science degree, and had to apply for my first doctor job, but these were very much with the tide of my peers.  Finishing foundation (the UK name for these first two years) is the first time you actually have to decide a) what sort of a doctor are you going to be and b) where am I going to live for the next 5-10 years?!  It's quite odd hitting that sort of milestone in your mid twenties having made few major decisions in the interim aside from 'how am I going to make sure I actually have food in the house throughout my 12-day work stretch'?  Plus job applications come just after you've finished your first year of work and I certainly felt it was too soon for the big commitment of geography in particular.  And for some people they are still unsure about which specialty to commit to; if paeds is your hunch, it's a minimum 8 years of training - yikes if you're not 100% sure!  I love my job, but I'm also exhausted.  Sure, being a doctor is tiring, but so are all jobs - I think when you are a junior doctor, there is the added emotional, inexperienced stress factor which is all the more draining.
A few from recent countryside runs.

Plus, frankly, why not?  There's a big old world out there and in an age where so many people seem obsessed with nationalism and national pride, I am quite content to have my own pride about being a citizen of Planet Earth.  Life is short and I am keen to explore...

Little English town...
So I am meandering Stateside to Yale University for the year, and was lucky enough to get a Fulbright scholarship to help fund a brain tumour research project.  Being a Fulbrighter has already been an incredible experience and I haven't even gone yet - my fellow scholarship people and I had an induction session a few months ago and I just couldn't believe what an awesome bunch of people they were.  I think we shared disbelief that we had somehow got through the application process and felt unbelievably lucky.  As a medic, it was also hugely exciting and refreshing to meet these inspiring people from such a range of disciplines, given that my world is so often just about medicine.  I am excited about all these new friends and colleagues I am yet to meet, and all that I will learn about in a new area of science.

I'm saying my goodbyes, packing up my things and preparing for one hell of an adventure.  Recent events have reminded me once more that you just never know what wonderful things are around the corner, and that's a hell of a blessing.  America, be nice to me!

I shall miss you!


Wednesday, 3 September 2014

'Is there a doctor in the house?'

The tube juddered to a halt - I, along with a carriage full of other tourists and commuters, struggled to stay on our feet.  A siren gave its intermittent noises indicating that the emergency stop button had been pressed.  I did a little harumphing and sighing, as did most of us in my carriage.  Anyone who has lived in London knows that barring an emergency requiring you to immediately jump out of the tube carriage, it is way faster to hang tight 'til you get to the next station.

But then I heard the words that chill you to your very bones the second they give you your medical degree.  

'Someone's unwell, we need some help'.

I was on my way to sort something out for my American travels - a strict appointment that I had been told in no uncertain terms I couldn't miss.  I was in jeans and a jumper with a casual canvas bag, earphones plugged in listening to my generic music device.  I could not have looked less like a doctor if I tried.  I waited a few seconds to see if anyone else was making any moves, peering to see if anyone else appeared to know what was going on.  Realising that no-one was doing so, I pottered over (I should add - there was no screaming or hysteria suggesting anything truly awful had happened.  I wouldn't want you to think I saunter in this fashion to all medical emergencies).

Again, reassess.  Man on floor.  Definitely awake, talking.  Also, it definitely appeared there there were no nurses or doctors or medical types around. Here we go...

'Um... can I help... I'm a doctor...'

Cue mass relief - 'make room, there's a doctor here'.  Weirdly, it was like a tension in the group of passengers who had crowded to help the gentleman was suddenly released, as if I had some kind of magic wand.  A quick ABC told me there was little I needed to do immediately.  I asked a few questions to rule out some of the worse things running through my mind and felt reassured.  I did by pure chance have my stethoscope in my bag but we were literally perched in the middle of a a London tube carriage with everyone staring, so I decided to leave that.  Confidentiality and privacy had gone out of the window as it was.  We just needed to get moving to the tube station.  

Once we had made it to the tube station, I waited with the gentleman until relevant people came to get him to hospital.  Of course by this point I didn't care that I might be late for my appointment, but for what it's worth, I was perfectly on time.

There were a few interesting reflections from this.  One is how Londoners totally get an unfairly harsh reputation - everyone around this gentleman was trying to help.  When I asked if anyone had any water for him, about five people reached into their bags and someone even found a cup from somewhere. A few other people waited with me and were hugely apologetic when they had to head off.  

Another is, I guess, a more personal one about how crazily calm I felt despite having an entire crowd of strangers staring at me, hanging on my professional opinion.  It was like the ultimate OSCE.  I obviously don't know what happened to this gentleman, but I felt really comfortable with what I was doing and thinking.  That was... unexpected.  Does this mean in my two years as a qualified doctor, I actually have some experience to offer, and confidence in myself?

It is very strange to think that when I head to the USA in a few weeks, 'doctor' is a role I will be hanging up, along with my stethoscope, for nine months.  It's moments like this episode in a London tube carriage that make me realise that being a doctor is as much who I am as what I am.  And that is a very strange thing to accept.

Wednesday, 27 August 2014

Singing songs and other human things

On popping home recently, I bumped into a very old friend - someone I hadn't seen for years. I always find myself embarrassed by myself in these situations - there's something about saying 'Um... so I'm a doctor' that has the potential to feel like you've dropped a bomb.  Out of the resulting crater can spill out a whole bunch of emotions, as it did in this instance.  My friend had close family who were going through the complex map that is NHS-and-social-care and they were deeply frustrated.  Doctors crooking their heads and telling them what they thought was best, despite being a quarter of the age of the patient.  An a-amotional stream of medical types who had fifteen minutes maximum per day devoted to each of their patients (ward of 20 patients, 8 hour day - you do the maths).

There is always a question in clinical medicine (and I have previously written about the pros and cons of the so-called game face in medicine) - how much of 'you' do you reveal?  Particularly when you're a junior doctor, and, dare I say it, particularly when you're a female junior doctor?  When does 'being yourself' just become unprofessional?

I find myself increasingly leaning more on the human side of things than others might.  My friends roared with laughter when they heard that I sang an entire song from my childhood to a patient (and their family) because I thought it might make her smile at an otherwise rather difficult time.  I regularly tell tales and memories of my grandparents, and my (still living and going on mightily aged 93) grandmother is frankly famous from the number of patients I have told about her as an example of age just being a number and focusing more on what people can do rather than the date on their birth certificate.  If patients or relatives sigh at me and say 'you doctors just don't know what it's like' with complex discharge planning regarding their elderly relative who lives 300 miles away from them, I am willing to share their frustration with my own family's experience of exactly the same thing.  I talk German to my patients who are German.  I only introduce myself as 'Dr Purshouse' when the situation requires it (e.g. official-dom) - the rest of the time I'm 'Karin, one of the doctors'.

You're probably reading thinking I'm marking myself out for sainthood, but these are not beliefs and practices held by everyone.  Some people (and my colleagues) want doctors to maintain a more professional manner.  One of my colleague always introduces himself as 'Dr So-and-so' so there is no confusion later on about who he is, and to a degree also set the tone - he is a professional, giving his professional view.  Frankly it can be just confusing to patients, and a more formal approach can make it easier to understand who everyone is.  Some doctors prefer to keep their private lives to themselves, absolutely all of it, and part of that is also self-preservation and not getting too emotionally involved with their patients.


Trying to be a 'serious doctor'.
My take on this?  I am a doctor, and I ask for the same professional respect as I afford every human being (patients, colleagues, anyone), but if I wanted to be an emotionless robot, I would have picked a different job.  Obviously I judge every situation on its merits, and being super-casual is not what showing your human character is about.  Sometimes I think I should be a bit more formal at highlighting my role though: one of the questions on a confusion questionnaire screen is 'what is my job' - and if I had a nickel for every time someone said 'secretary'....

Hmm.  Perhaps I should try it for a while.  Keep the singing, but instead do a trial of 'Hello, I'm Dr Purshouse but please call me Karin' as a compromise?

Oh, it's tricky being a doctor and being human!

Tuesday, 19 August 2014

Open Access, Closed Door

Earlier this week, I got some exciting news - an article I wrote is going to be published! It's a small online journal with a teeny impact factor, but for baby doctors like me, it is great to just get some experience of the whole process.  It's an article on novel therapies for small cell lung cancer that I wrote for my Masters, if you're interested...

But here's the big hurdle: how to make it Open Access?


Now anyone who reads journals will be familiar with the difficulty of reaching journal articles stuck behind massive pay walls.  It's very frustrating - you find the article on Pubmed (other search engines are available) that promises to tell you everything you want to know about a topic, or explain the method for a certain experiment you want to do, or could outline a study you thought was novel but has actually already been done.  They problem?  You either have to hope your institution has access (that is, if you have an institutional affiliation) and if not, it's tough cheese unless you want to fork out some big bucks to read the article.  Which might turn out to be useless, but of course you don't know that until you've read it.

And this is all despite the fact that research is largely publicly funded and undertaken by scientists who get paid relatively diddly squat to do ground breaking research.  Journals are supplied with articles from said scientists, and then the refining and peer review process happens by other scientists in the same field who do not get paid to do so.  Most journals these days are predominantly read online.  So the main overheads for journals are for editing, formatting etc... Um... so why do journal subscriptions cost so much...?

Especially in the UK, there has been a real drive towards Open Access, and encouraging journals to make their publications freely available.  One method to cover the overhead costs is to charge a publication fee - and herein lies my challenge.  For a little journal like the one I'm publishing in, it still costs a few hundred dollars to meet that fee.

Who pays for that?  Me.  I pay for that.  Because institutions can often only support those who are funded through specific funding bodies who usually ring fence some of their monies for that purpose (e.g. Wellcome, RCUK).  This reflects well on these organisations, but you're a bit stuck if they're not your funders.

Doesn't this just become a thing where people who can afford to pay get stuff published (in this scientific world that is already ruled by a 'he who survives must publish' mantra?), thus devaluing the whole process into one driven by money?  And what about those in the developing world - how do their research groups publish in even the smaller journals with these kinds of fees?  And what hope is there of reaching some of the bigger, more expensive journals, who have much higher publication fees? And what about journals that are a mix of open access and pay-for articles - if you have to pay a subscription fee for the whole lot anyway, don't you just end up paying twice - once to publish and another to read?

I'm totally team Open Access, but it feels a bit like some journals are winning a game where old boundaries remain and new ones have been created.  Hmm.  I don't like those sorts of professional games.

As a complete aside and nothing to do with the above, my new-found employment freedom has given me a bit of brain breathing space which I didn't even realise I needed.  The kind of breathing space that actually winds you quite majorly when all those squashed parts of the soul get some air time.  Without wishing to get too heavy with you, dear blog reader, I will instead say that I can most heartily recommend such pauses, and share with you the view from the lake I went swimming in yesterday.  Pretty sweet, huh?

Sunday, 10 August 2014

Black Wednesday

It's official - I am one of the unemployed masses.  Well, sort of - available and willing to locum at a hospital near you!  And that's what I've been doing this week, weathering the perceived storm that is 'Black Wednesday'.

Black Wednesday instils fear in Joe Public and junior doctors alike - the first day of work for thousands of newly qualified doctors, and simultaneously changeover day for most doctors in training (i.e. everyone from a senior house officer to senior registrars).  It's hard to imagine any other job where on a Tuesday you could be working a 13 hour shift in Exeter, and expected to rock up to your new job in Inverness the next day.  The finger is often pointed at the newly qualified ones as to why the death rate is allegedly higher on Black Wednesday; I think you could make a strong case for the mass move of all junior doctors as a bigger factor.

Although you get an induction, every hospital has different computer systems, different parameters for certain blood tests, different ways of requesting tests, different ways of managing some acute medical problems, different departments available on site...  And hospitals are big places!  Running to a crash call in a hospital you don't know is rather tricky when you don't know where you're going and you don't know who anyone is (sometimes it's useful to know that the guy running next to you is the anaesthetist).  The whole week is an upheaval - the above scenario of moving across the UK is not uncommon, and is seemingly rarely considered in rota planning.  I know a number of my colleagues who only got their rotas the week before starting their new job in a new place.  This means sometimes working a 19-day stretch if you're unlucky enough to finish one job having worked the weekend, and start the next scheduled to work the next.  And that's before you throw night shifts into the equation.  In one case my friend has been rota'd onto nights the weekend she is supposed to be getting married!  Given that changeover day is exactly the same every year and the rota itself can only likely change very slightly, this all seems a little ridiculous.  The flexibility in the system is created by junior doctors themselves - swapping last-minute on calls and cross-covering to allow someone an afternoon to at least move house.

I offered to do extra night shifts on Wednesday and Thursday nights, thinking I must be the craziest person in the NHS.  Given how many night shifts I have already done in the last four months and how completely frenzied they often are, the thought of doing them on a week where no-one knows what's going on seemed foolhardy at best.  But actually it was great - certainly at my hospital they threw a lot of doctors at the situation of handover week, and gave a bit of purpose and use to doctors already working in the hospital such as myself who are doing 'F3' (i.e. finished their first two years of clinical practice and now taking a year out).  We offered the continuity of those logistical uncertainties that come from simply working in a new environment, as well as being an extra person to call upon for the newly qualified doctors.  Well, at least I hope I did...  For me it was a useful combination of learning to advise junior docs and continuing to gain more clinical experience as a junior doctor myself.  In my job, every day is a school day.  Pretty great, huh?


People get very worried about the medical knowledge of new junior doctors.  But this week's experience tells me that while new junior doctors may lack experience, crucially they know how to ask for it.  Perhaps people should focus a little more on easing the transition between jobs of the thousands of doctors in training at the rungs higher up the ladder.  After all, they're the ones that all these newly qualified doctors will turn to on their first days when things get tough.

In the mean time, I'm off to get my life back before Fulbrighting begins.  Can you believe it?  A year ago it was just a pipe-dream, and now I'm about to move to Connecticut for 9 months.  But more on that later.  

Wednesday, 25 June 2014

To resuscitate, or do not resuscitate?

I recently had my first full discussion with a family about resuscitation.  I had watched many such discussions happen previously.  Like an actor, I practiced my lines; a few variants of them, in fact, depending on how the conversation might go.  The family had thought about it already.  They did not think resuscitation would be appropriate, and I agreed.  We discussed and agreed a ceiling of care.  Everything was documented, and a DNACPR form completed.  My consultant countersigned the form later that day. 

Not all discussions are like that.  Resuscitation is stressful, whether you do it or not. 

Resuscitation has become a major political issue, with a recent legal ruling putting it into the spotlight once more. This ruling confirmed that it is now a legal duty for doctors to discuss with patients and/or their families before putting a DNACPR form in place.  To confirm, prior to this it was considered best practice, and in all honesty I can't remember any occasions where the family was not consulted.  

Resuscitation is such a thorny issue.  Casualty, ER, Holby City... they are all a little guilty of giving an overly optimistic presentation of resuscitation.  There is a scene in the second Hunger Games film where Peeta Melarck miraculously recovers after a few rounds of breaths and chest compressions.  The hard medical facts are: chest compressions and breaths alone will never revive someone with genuine cardiac arrest (that is to say, if they are, they didn't actually have a cardiac arrest) - they are an important holding measure.  Full CPR means chest compressions, drugs and sometimes electrical shocks.  And it is hard work.  Ribs are often cracked.  Blood needs to be taken.  Shocks can be delivered.  And success rate in terms of survival to discharge is an optimistic 15-20%, and this paper highlights that there are a range of factors that predict the likelihood of success - renal failure, sepsis and previous lifestyle being among those most cited as predicting failure.  Ultimately, with the best will in the world, some patients have multi organ failure that no amount of CPR is going to fix, and certainly not in a way that will result in a positive long term outcome.

Most patients and their families understand this, and I have a lot of respect for the families who engage in this discussion at what is usually a highly emotional and difficult time.  And of course I agree with the recent ruling in terms of what it is trying to achieve - families should be involved.

But the problem is that not all families agree, and some have unrealistic expectations of what CPR can achieve.  Perhaps that is our fault for not fully explaining what is happening medically - but truly I have witnessed this challenge in the face of the most thorough explanations.  What then?  The risk is inappropriate attempts to resuscitate someone in a quite traumatic and aggressive way with no discernible hope of success - and I think that's also something worth fighting against.  Sometimes situations arise quickly, in the middle of the night or family cannot be contacted.  What's the right thing to do legally as well as for the patient?

DNACPR does not mean 'do not treat'.  DNACPR means not doing CPR if the heart stops or they stop breathing.  It does not mean that infections won't be treated, fluids won't be administered and nutrition won't be given.  It is not equivalent to saying you think someone is actively dying.  Equally it is not a one-way street, and can be reviewed if the clinical situation changes.  

If being a doctor has taught me anything, it is that I would want clear information sharing about resuscitation wishes ahead of time between my family and I.  In terms of the here and now, I will try not to shy away from these discussions, and hope that if this recent debate has had one benefit, it is that people think ahead of time what they and their relatives would want.  

Saturday, 24 May 2014

Battered and bruised versus confused

I've narrowly avoided being hit over the head with a walking stick.

I've also (literally) had my wrists slapped, been called a 'stupid cow', and had to wrestle for control for a telephone handset.  I've had to persuade patients that self-discharging themselves at 2am is not a wise move, and had to disappoint patients claiming to await their (long deceased) parents that they probably won't be visiting today.  I remember well one particular incident where a nurse nearly got punched in the face by an elderly patient.  My friend and colleague who was the doctor looking after them was distraught about eventually having to give the patient some mild sedation so that neither the patient or anyone else came to further harm.

This is a side of the ageing population people don't see, or perhaps even hide away.  Delirium. Dementia.  Call it what you will.  Sometimes patients are confused, and as a result can become agitated, distressed or even violent.

Having just finished another week of night shifts, I am all too familiar with this scenario, and yet I am still scared by it.  It can be a daunting prospect to be called to resolve these issues, and it's usually once the nursing staff have done everything in their powers to calm things down.  I always teach my medical students to remember that the person brandishing a water jug as a weapon is still a human being.  They have a life, family, friends, a career and hobbies.  And they would probably be horrified to see how they were behaving if only they could know.

When it comes to my patients, I always try to understand or see reason in what they are saying (or shouting).  Their rage almost always comes from a logical place - even if it does not seem logical to us.  I'd be pretty darn confused if I woke up in a strange place with strange people.  I try everything from explaining where we are and what's going on, to encouraging patients to talk about their wife/dinner/previous job.  Usually this diffuses any tensions, but not always.  I have only twice had to resort to using medication, and it is always with a heavy heart and a feeling of failure.

My German grandmother is 93 this year, and although my other grandparents are no longer alive I have been lucky to know most of them as an adult.  Granny Deutschland has had a life every bit as exciting as I could imagine, growing up in what is now Poland, living through the second world war, emigrating for a short time to South Africa and travelling the world with my grandad in their retirement years.  I see her in every older patient I see, and remember her life and adventures.  I imagine every one of my patients would tell me their stories if they could.

I'm off to Germany next week after yet another set of nights to replenish my stock of Granny Deutschland tales with my sister and niece.  Hopefully I will successfully dodge any further walking sticks or similar in the mean time.

In fact I am baking banana bread (with some creative ingredient substitution) and reading entries for a writing competition today, tucked up in my little cottage. Rock. And. Roll.