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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!

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.  

Saturday, 3 May 2014

(Not) Breaking Bad News

There are a few magic words in hospital that are likely to get a doctor to your side in reasonable haste, but not all of them require any intervention.  A few examples of these include 'I've just had a fall', 'I've got chest pain' and 'I've got a weak arm'.

Now, not every fall is really a fall, not every bit of chest pain is a heart attack and not every clumsy arm is a stroke.  All warrant medical review.  But having assessed the patient, I'm still learning the nuance of when to intervene, and when to have the confidence in your clinical acumen to leave it alone. Half the trick of being a doctor is as much deciding when not to do something as when to do something.

But there are some things that you cannot leave alone, and must be investigated.  Often we're investigating because of the small chance it's something serious, like a cancer.  And it occurred to me and a few of my doctor chums at lunchtime that sometimes we are absolutely lousy at verbalising this.

All of us could recall the first big bit of 'bad news' we had broken.  I think it is quite a defining moment for a junior doctor.  I still remember mine.  I had the whole family sat around me, keen to know some scan results.  I did everything they had taught me at medical school; found out what they already knew, what they were expecting, what their concerns were.  Often, by this point, people have a notion of what might be going on.  Not this time.  Gulp.  There was no getting around it.  I just had to say it.

'I'm sorry but I've got some bad news'.

Of course they were upset.  But I explained what we knew, what we were doing next, when we could next discuss things.  They thanked me.  They smiled.  Relief.

Because breaking bad news is something you can only do once, so you'd better do it well.  And yet, my little lunch group and I felt uncomfortable about the fact that we've started to skirt around the issue when we're still at the 'query' stage.  They teach you that you should check how much people want to know - but if patients don't even know that a serious diagnosis is on the list, how can you really check?  There are certain clinical presentations that now ring alarm-bells in my mind, and as a result I will request certain tests to rule serious things out.  I worry that sometimes I anticipate some kind of telepathy on the part of the patient about this.  The other day I got so worried that I was simply expecting the patient to be on the same page as me that I actively put down what I was doing, sat down again and went through their ideas, concerns and expectations.  Cheesy, but true.  It was a huge reality check - had I simply used medical mumbo-jumbo?  Had I managed to strike the right balance between being clear about what we were checking for and not instilling unnecessary panic?

Somehow there is something incredibly scary for you, the doctor, about saying out loud that you're doing a test because it could be something serious.  I know that sounds incredibly selfish.  But really it's all about communication.  And not hiding behind cryptic words or alternative phrases is part of that, as well as not sending someone into an unnecessary panic.

I actually do love my job though.  There are few things more satisfying than getting a few smiles out of a patient or three despite the misery of being stuck in hospital.  It literally makes my world every time.  But this is a package deal.  (Not) breaking bad news is not an option.  

Tuesday, 15 April 2014

Being a doctor being a patient.

 A mix of emotions from top left clockwise - how I feel now,
how I felt a lot of my night shifts, how I felt when occasionally
panicking, what I spent the first half an hour after
my shift feeling like i.e. ahhhhh!
Apart from slightly losing my marbles circa 6am, and perhaps again at 9.15am, I have survived the first two weeks of my new job as the medical SHO which have thus far consisted of night shifts and nothing else.  Finishing yesterday morning was another great wave of half-relief-half-nausea, relieved somewhat by having a cuppa with some of my old lab chums.  Remember how I said clinical medicine seemed the comfortable norm?  Hmmm... rose tinted glasses, much!  Although I must say I kind of enjoyed it (Kind of, in the sense that it is tough to say your enjoyment is complete when you are at work over an entire sunny weekend, sleeping during the day and up all night). 
The last fortnight has been completely insane.  Apart from a bunch of night shifts, I've also done a day-and-a-half of exams, written an assessed essay, work on a conference agenda, done prescribing-related teaching for all the house officers and then an afternoon of simulation teaching.  I managed to catch up with some of my favourite university people in between these various studious things, before you think I'm a total social loser.  

But actually the weirdest thing of the last fortnight is that I had a flavour of being a patient.  

I've had a couple of health worries on my mind and the first of these I found out about via a poorly timed (by me) phone call to my GP surgery.  It was really quite unfortunate and perhaps my fault that I ended up finding out over the phone that I needed to have some more tests done.  I wondered whether it was more worrying because being a doctor means knowing a bit too much about the worst case scenario.  I guess I was also a bit distressed because I'd like to think I am quite particular about the when/where/who/why of any news I am dishing out to patients, and realised that because the news breaker probably didn't realise they were 'breaking news' I wasn't given that sort of consideration.  I then found out I had a second medical issue that needed investigation, and within a fortnight I found myself with two hospital referrals and a whole bunch of worry.  

Any social recluse-ing I've been guilty of recently has been a genuine apathy symptom of compartmentalising stress.  I'm quite an open person, and it's strange having things that you don't feel able to share with friends and family.  I felt quite irrational as I knew that it was all cautionary really, but also perhaps felt that by vocalising my worries, it made it all more real.  Even sitting in the waiting room is a bizarre and lonely experience.  It's a bit like being in a massive herd of cattle, waiting to be picked out and painted.  Once you're in the room, it turns out the 'so what do you do for a job' question is pretty much numero uno, so there was no hiding my professional identity.  It's pretty weird going to see a doctor in the place that you also work.  I accepted that I might know them - in the event I was quite glad I didn't as it made it easier to slot into the patient role, although I must say everyone I encountered was excellent without exception.  

Anyway, as expected everything was absolutely fine and dandy with nothing further needed, and I could worry about my night shifts in peace.  But there's nothing like experiencing what it's like on the other side before being on call for a whole weekend to remind you that every patient is a human being with worries, fears and a life.  

Excepting the odd panic moments, it was these thoughts that kept a smile broadly stuck to my face the whole weekend, hopefully staying cheerful and providing a chuckle or two as I dashed across seven floors of a hospital.  

Friday, 4 April 2014

'Hi, it's the medical SHO on nights...?'

I feel a strange combination of hungover, awake-and-wired and fretful panic.

It is this joyous phenomenon I love to hate - the 'I've just finished nights' effect.

I've now been awake since 7pm yesterday evening (it's now 4pm), having done a twelve-hour night shift in between.  I've tried to nap, but every time I close my eyes I have a nauseating wave of 'oh... wait... did I do that right'?  Here's a night in the life of a medical SHO.

9.30-10.30pm-ish - Arrive at work and enjoy a splatter of bleeps, phone-calls and face-to-face meetings with people I've never met wanting to hand stuff over.  I cover a myriad of random medical specialties on nights - geriatrics, gastroenterology, cardiology and a smattering of new admissions (they're in many ways the most fun - because they have a tendency to be moved in the middle of the night, leading to another fun game - 'hunt the patient').  Some people give me things to check (blood tests, x-rays etc), others tell me about patients they want me to review during the night, and some do the triple whammy of giving me a bleep too.  By the time handover is done, I've got three bleeps to receive calls on, and a couple of pages of things to do.  I try to remember who has given me what and which patient belongs to which teams - after all, in twelve hours, I have to hand them all back.
I am not a person... I am a bleeping machine...

10.30-00.30 - the worst time, I find.  This is usually when any immediately sick patients tend to be discovered, as well as drips ceasing to function (thus needing to be replaced) and it's usually when you'd be keen to cast an eye over the sick patients you were asked to review.  If only you could be in three places at once!

00.30 - 04.00 - this is when the night shows itself i.e. if it's going to be a complete disaster or not.  By 2am, usually all the immediately unwell people are dealt with, and you have made a plan that will last for the next few hours.  Hopefully.  You return to the list and it might be the first chance you've had to check those blood tests or scans you've been asked to chase.  Every finger is crossed that they are normal, or abnormal in a way that is manageable overnight e.g. prescribe some fluids or a medication that will stabilise things.  What is less ideal is when they are abnormal in a way that requires intervention overnight - that is ultimately what I am there for, but sticking needles into people to do repeat blood tests at 3am is not a speedy way to make friends.  Another surprise entity is when you are hunting down tests results that never seem to appear - cue some detective work to sniff them out!

04.00-06.00 - if you're in luck, this is your chance to grab a quick sandwich and drink of water.  I've found that carrying a bottle of water around with you is absolutely essential, and certainly an error I made in my earlier night shifts - it helps to keep your head clear, and a loo-break is also reassuring from the point of view of knowing your kidneys are still working.  One of my night shifts I even had time to go and help the take (i.e. new patients coming into hospital) and clerk someone in.  The key for this time is to get everything done by 06.00 i.e. any bloods you need to do for the day teams, any patients you wanted to review.  Because what happens at 06.00?  Nursing rounds.  And that's when the next round of unwell patients/failing drips etc tend to be discovered, ready to keep you busy until handover.

06.00 - 09.00 - it's hard to keep perspective about the fact that your shift is nearly over.  In fact, that's not as frustrating as being so UNBELIEVABLY close to normal working hours that if you actually want to speak to a specialty or get something done urgently, it doesn't require an inordinate amount of persuasion.  Everything is starting to get a bit hazy as fatigue starts to set in.  I sit down quietly for a rest for a cumulative time of about 5-10 minutes in the average night shift.  Keeping your list attached to your person and up-dated is the only way you're going to make sure nothing gets missed and all the jobs get done.

09.00-10.00 - hurrah!  Handover time! Or... time to play 'hunt the doctor team'.  Everything you received (bleeps, patients, etc) must be handed back; the question is, who is who?  You walk up to a team of doctors, looking quizzically around their little circle - 'which team is this?' you enquire timidly.  Everyone looks slightly aghast, as if it is both obvious and scandalous that you didn't know that this was Dr so-and-so's team.  You are relieved when you recognise a few faces and can at least get some direction.  Sometimes it is easier just to bleep the people directly or just go to the ward to hand people over.  It's actually quite scary handing patients back - ultimately, in the cold dark of night you have to make the best decision you can with the information you have at the time. You didn't hear that Mrs Smith always has that funny turn at 2am and that it's perfectly normal.  You weren't aware of exactly what number of crackles on the lungs are normal for Mr Bloggs, because until that night shift, you've never listened to his chest before.  You weren't there for that discussion about Mrs Jones about just how aggressive to be with the intravenous fluids.  Obviously you look for trends in patient notes, but you have to have a bit of confidence in your thought processes, obviously with a healthy dollop of humility.

Starting a new job on night shifts was never going to be easy, but it is definitely one of those times where I think - 'next time I'm NOT on nights and go to greet the night doctor, I'm going to make an extra effort to be nice, sympathetic and helpful'.  I do have a propensity to be a worry wart about these things, but all doctors, myself included, have made mistakes.  It's really not a 'what if', and rather a 'when'.  I hope I did a good job, and I forgave myself for calling the registrar for advice on the basis that doing your first night shifts in a year after four months away from clinical medicine was probably not the time to attempt heroics.  Equally, I hope I start to build a little confidence, as I really think that's half the battle.

Exams next week, and then more nights next weekend.  Bring. It. On.