Frequent Flyers

As it's winter, we are once again inundated with headlines about the impending NHS "disaster". There are no beds, more and more people are turning up at A&E and services simply can't cope. There is, of course, some truth in this. A particularly cold winter or an unusually aggressive strain of influenza can result on unexpected pressure on health-care services. That said, services are almost always under more pressure in winter so I'm not sure why the press jump on this like it's a new phenomenon.

As the pressure on health-care services mounts, people naturally start looking for "quick fixes" in order to relieve this. Recently, there has been a lot of talk about "frequent flyers" - an unpleasant term used to refer to patients who access health-care services more than others. There is a suggestion going around that if these greedy so-and-sos learned to self-manage better, the NHS would be in much better shape.

Although I've only been a qualified doctor for 2 and a half years, I've met a number of so-called frequent flyers. I recall a young girl with cystic fibrosis who I looked after during my respiratory rotation who had multiple admissions during the 4 months I worked there. I'm pretty sure that if she had an option, she wouldn't have been in hospital, but multiple spontaneous pneumothoraces are pretty hard to manage at home. There was a middle-aged gentleman who I met during my gastroenterology job. Despite everyone's best efforts, flares of his inflammatory bowel disease repeatedly landed him in hospital. Now I'm working in paediatrics, I can think of several patients who bounce in and out of hospital. A viral upper respiratory tract infection is generally something that can be managed at home, but if you have a rare metabolic disorder, chronic lung disease or a complex cardiac condition then it can be deadly. I can't think of a single "frequent flyer" who had multiple admissions for any reason other than that they were unlucky enough to have an unpleasant chronic disease.

Yes, keeping frequent flyers out of hospital would definitely relieve pressure on hospitals. Now, if the people who come up with these soundbites could come up with the medical advances required to cure these patients so that they don't need to keep coming in to hospital, then that would be wonderful. I'm pretty sure the patients would appreciate it too. In the meantime, let's stop blaming patients for pressure on our services and look at ways to better deal with increased demand.

The Black Dog Bites

A few years ago, whilst I was still at medical school, I wrote a post about various mental health issues I'd had over the years. There are ups and downs and these issues become more or less prominent a part of my life at different times. Today, the internet tells me that it's World Suicide Prevention Day, and for this reason I find myself thinking a little more about the black dog.

I wish I were as eloquent as the chap who made this lovely video, but I'm afraid I'm not, so I just find myself rambling and hoping that perhaps something I write makes a little sense.

As many people reading this will be aware, I'm now on a specialty training programme in paediatrics. I'd be lying if I said it was always easy, but on the whole I love it. However, it does mean I frequently meet teenagers who have similar problems to those I had at their age (and, to an extent, continue to have). This is something which I will always find difficult.

Back when I was on my adolescent psychiatry placement, I found myself wondering whether I would ever be completely recovered. I've now concluded that I won't. That may sound negative, and I suppose at times it feels negative, but there's also a bit of relief in admitting that I may never be 100% "better", and that it's ok not to be ok.

As I get older, I get better at recognising what triggers off my lowest moments. Although I can't always do much about them, it's helpful to know that they are there. Currently, I spend some of my time in a job where I do little more than observe. This is really difficult for me, as my mind isn't kept as busy as it likes to be, and I therefore find myself overthinking and drifting into negativity. Whilst this is frustrating, it's also good that I know it's partly the lack of intellectual stimulation which is problematic as it means I can at least attempt to find solutions (in true Learnaholic style, these solutions are at present an MSc dissertation, a systematic review and helping to organise a conference). I've also never been very good at adapting to changes - from crying in playschool when my milk was in the wrong colour cup to feeling nauseated when our high school French teacher said we could sit in different seats as a "treat" - I've always liked routine, so a 350 mile move and a new job was always going to be tough. There's a certain amount of help in just realising that actually, most people would find that hard and that it's ok for me to feel a bit out of sorts for a while.

Interactions with (especially teenage) patients who are having mental health difficulties are always going to be tough for me. One of the things I struggle most with is that I can't hand on heart promise that it gets better - and for that I feel inexplicably guilty. Guilt is, oddly, a very prevalent part of depression for many people. The ironic "you have nothing to be depressed about" comments are unhelpful for many reasons, not least that I *know* I have a good life and already feel guilty that I'm not full of the joys of spring without someone else mentioning it.

Once again I find myself having typed a stream of consciousness which may or may not make any sense, but having retweeted the link to my initial mental health-related post, I felt like a follow-up was overdue. This post wasn't meant to be all doom and gloom, although it seems to have turned out that way. I need to emphasise some of the positive things going on too. I graduated from medical school, completed my foundation training and got a place to train in the specialty of my choice. I'm 2/3rds of the way through a master's degree. I live independently. I am, on the whole, not doing too badly. 10 years ago, I didn't think I would ever get here. I guess, all things considered, I'm doing ok. 

The End of An Era

After 9 years in the city where I studied for my BSc, went to medical school and then did my foundation training, I will be moving on next week. Just a weekend of night shifts and 350 miles stand between me and the next chapter in the Learnaholic Chronicles.

In particular, I'd like to take this opportunity to reflect on the crazy, stressful, interesting, exciting years that are foundation training. A year ago, I wrote this post as a sort of FY1 survival guide for all the new doctors starting their training. This year, #tipsfornewdocs (started by people much wiser than me, I must point out) seems to have gone viral and everyone from the highly entertaining Medical Registrar on facebook to the British Medical Journal keen to impart their words of wisdom onto the fresh faced new graduates about to be let loose on the wards. With that in mind, this isn't going to be a list of tips - there are loads of them out there. It's just my thoughts on what the last 2 years have meant and what I've learnt.

Setting foot on the wards 2 years ago was the start of a huge learning curve. As I've mentioned before, I had a bit of a difficult time outside of work in the first month of the job, so in particular the first few weeks were pretty tough. Slowly, though, I think I've managed to find my feet.


There are some things that I think I will always remember. There are a lot of firsts for junior doctors, and those tend to be pretty memorable. From the first death I confirmed or the first time I told a relative their loved one had passed away to the first time I did a lumbar puncture or correctly interpreted a CT scan, those "first" encounters tend to be pretty memorable. Some of the memories make me cringe, others I think I dealt with pretty well.

Then there are the people you just won't forget. I'm not sure why certain stories stick with me more, certain patients are more memorable than others. Often it's about timing; a particularly memorable patient is often one who I've spent more time with and got to know properly. Other times, it's been a particularly intense encounter, or a patient who has reminded me of someone I've known personally. From the lady who hugged me and thanked me after I told her her brother was dying to the patient with terrible venous access who I'd have a daily giggle with whilst attempting to get his morning bloods, some people are just etched on my brain.

I've attempted before to try to express how I feel about the encounters we have in medicine. I still haven't worked out exactly the way to say it. I suppose the key thing I've learnt over these past two years is just how much of medicine is about people. I love the detective work involved in working out a new diagnosis. I love the science which helps me to understand why condition x produces symptom y and is treated by drug z. But a doctor who gets every diagnosis right and knows the molecular mechanism behind everything he does will only get so far. I'll admit to having rolled my eyes at the "fluffy" bits at medical school, but if these couple of years have taught me anything, it's that without the fluffy stuff, we're not much use at all.

(Not) Just A Minion

There is a temptation as a junior doctor to refer to oneself as "just a minion". This is particularly true of FY1s/residents, but it persists a fair way up the food chain. After all, we just go around obeying orders and doing as we're told, right? WRONG.

A junior doctor tends to be the first person to be called to a sick patient, whether a new admission or a current inpatient who has deteriorated. Every day we make decisions about whether to start or stop fluids, analgesia, antibiotics etc. We are the ones who decide whether a new admission can wait to be clerked in by us or whether we need to intervene immediately. When we review patients, we are not robots, simply asking a series of questions. We are interpreting (sometimes vast amounts of) information and making complex decisions based on that information. We have spent many years training to become critical thinkers, analysts, problem solvers. It would be utterly ridiculous to then unleash us into a job where we are simply yes-men. Yes, we have limited experience compared to our seniors, but we are still expected to think relatively independently.

A lot of juniors are also under the (false) impression that senior = infallible. This is clearly not true. Sometimes, as juniors, we are the ones who alert the consultants to something important. Prescribing diclofenac as instructed is not a smart move if you recall the past history of gastric ulceration - something a senior may not be aware of (because you took the history, remember?). Your boss may not have seen the latest blood results and it may be up to you to point out the deteriorating renal function or rising inflammatory markers. There are also occasions where your seniors will make errors. Pointing them out doesn't mean being arrogant or argumentative, but a simple "I'm interested, why did you decide X?" or "I was under the impression that you do(not) do that in situation Y" could prevent a patient coming to harm.

One of the main reasons I (and, I suspect, some of my colleagues) dislike the "just a minion" attitudes is that it seems to remove an element of responsibility from the junior, as if their actions and decisions are meaningless. You worked hard at university for a long time. You are paid an enviable salary. You are a member of one of the most trusted professions there is. So stop with the "just a minion" talk. You're a doctor, and what you do matters.

(Thanks to @drbobphillips for suggesting I write this post) 

"I Did It!"

Despite filling most of my time with work, academia and general geekery, I do have time for the odd hobby or two. People who know me will be well aware that working with children is something I love, and as well now working in paediatrics, I try to fit in some volunteering with Over The Wall and also help to run a Cub Scout group.

Last weekend, we took the Cubs away for a night camping. We filled the day before and after the actual camping with a variety of activities including archery, crate climbing and of course ending with the legendary soap slide (which may explain some of the bruises on my legs...). Any camp purists will be delighted to know we also had an excellent camp fire, complete with lots of singing and toasting marshmallows.

People often question my sanity when I tell them that I spend my rather limited free time in this way (I was actually quite proud when a colleague called me "completely insane" recently...) and sometimes I struggle to explain exactly why I choose to do these things. At camp this weekend, as the kids excitedly told me how high they climbed on the crates or how many bulls eyes they got, I was hit again by the sense of why I do these things. To hear a child say "I did it!" There is something immeasurably special about helping someone to achieve something they didn't think they could do. As a person who has gone through life convinced (for no good reason, although impostor syndrome comes into it) that they are rubbish and can't achieve anything, helping other people discover what they can do is something I feel I need to do.

I still get tears in my eyes when I remember a child at Over The Wall last year, partially sighted and scared of heights, manage half of the climbing wall she initially didn't even want to try because she "couldn't do it", or the incredibly self conscious teenager finally dare to perform at talent night (and give us all goosebumps with her rendition of Someone Like You).

There is a more selfish element to all of this, of course. There's an episode of Friends where Phoebe is determined to show that you can perform a truly selfless deed - even going to the somewhat bizarre lengths of "letting a bee sting (me) so that he could look cool in front of all his little bee friends" - and finally conceding that every "good" act is tinged with selfishness. I enjoy what I do. I enjoy seeing young people achieve and I enjoy knowing that I've played a part, however small, in helping them to do that.. Facilitating this achievement gives me my own "I did it!" feeling. And it's amazing.

(If you fancy joining in the fun, and sharing the "I did it!" feeling, go and browse the OTW and scouting pages.)

Empathy

empathy, n.
Pronunciation:  /ˈɛmpəθɪ/
The power of projecting one's personality into (and so fully comprehending) the object of contemplation.

Definition from the Oxford English Dictionary

Following on from my recent quality improvement blog, I've been thinking a lot about patient centredness and what patient centred care really means. I stated (probably more than was strictly necessary) that I believed that so long as we aimed to provide high quality patient care, quality improvement would naturally occur. I also used a definition of quality which included the term patient centred. I think, therefore, that it is pretty important to reflect on what patient centredness actually is.

I don't actually think patient centred care is a difficult concept. It's all about providing care which focuses on the patient and what they both want and need. What is trickier is working out how to go about actually doing this.

At this point, I'd like to share a favourite video of mine. It's from the Cleveland Clinic in Ohio and, like many things I am likely to blog about, I was first shown it during my MSc teaching. It is slightly "American" in tone, so for those of you who feel you'd prefer a "British" alternative, there is a very similar version produced by Wrightington, Wigan and Leigh NHS Foundation Trust. Both videos end with a quote: "If you knew how they felt, would you treat them differently?".

I don't know who first said "Everyone you meet is fighting a battle you know nothing about. Be kind, always" - it's been attributed to so many people, from Plato to the Dalai Lama. Regardless, I think it sums up the essence of those videos nicely. It is all too easy see a patient's illness in isolation, without considering what else may be happening in someones life. If you don't at least attempt to understand an illness in the context of a patient's wider life, how can you even attempt to work out what they want and need from their healthcare interaction?

I think that really, empathy is what patient-centred care is all about. The most important person in any healthcare setting is the patient. Empathy is a crucial quality for any healthcare professional to possess. Without it, ascertaining what a patient wants and needs (and therefore providing patient centred care) becomes almost impossible.

I'll end this post with a challenge: next time you're about to get frustrated with a patient who has turned up late to an appointment or not taken their medications as directed, just stop and think about what else could be going on in their lives.

QI

The two letter acronym QI may refer to several things. One is a television quiz show hosted by a personal hero of mine, Stephen Fry. In this context, QI stands for "quite interesting". In a context closer to my heart, it also stands for "quality improvement".

 I was first introduced formally to the concept of quality improvement during my MSc module on "Organising and Delivering High Quality Care", where the motivational and enigmatic Prof Mitch Blair and Dr Bob Klaber (and several of their colleagues) gave us an overview of the concept. Quality Improvement very much does what it says on the tin. It's all about facilitating anything which improves quality. In a healthcare setting (my main focus as that is where I work), this is about ensuring high quality care for all patients. "High quality" may sound a bit fluffy and I was challenged when I suggested at the recent Faculty of Medical Leadership and Management conference that all that we do as healthcare professionals should be underpinned by a desire to provide high quality patient care; it was suggested that we ought to actually focus on delivery of safe care. For clarification, when I refer to the concept of quality in healthcare, I refer to the definition proposed by Don Berwick from the Institute for Healthcare Improvement in the States. He describes high quality care as that which is "safe, effective, patient-centred, timely, efficient, and equitable". As a doctor working in the NHS, that seems like as good a definition as any, and given that it was proposed by one of the world experts in patient safety, I feel relatively justified in saying that providing high quality patient care is not at odds with providing safe patient care!

A worry of mine at the moment is that QI in some establishments is not driven by the desire to improve care. This may sound odd - surely if someone is carrying out a QI project then by definition they wish to improve quality of care? Unfortunately, I fear there is a very real danger that, much like audit (and, to a lesser extent, research), doctors in training see it solely as a tick box exercise which is carried out purely for CV-boosting purposes. I am not alone in holding this concern. I have asked several of my senior colleagues why they feel there is so little drive towards QI amongst my contemporaries, and they have all given me similar replies - we aren't in a competitive deanery, so people don't feel they need to undertake these CV-boosting tasks. To me, this completely misses the point. As healthcare professionals, our motivation should not be solely to get our next job or to pass our ARCP as painlessly as possible. We should be motivated by a desire to provide high quality patient care.

Let's not forget why we went into medicine in the first place - we (mostly) went into this field for the patients. They must still be our focus. Ward rounds, clinics, GPs, ED... They're all there with the aim of providing patient care.

We should *want* to continually improve care, not only to boost our own CVs, but because if providing the best possible care to our patients no longer drives us, we probably need to start thinking about a change of career!

 **addendum** It has been pointed out to me that the definition of quality I quoted comes from the Institute of Medicine; this was modified by the IHI when creating their own goals. Apologies for any confusion caused.

FY1 in blog form!

How time flies - I have just got home from my last shift as an FY1! As I mentioned earlier, I was one of the poor sods who started on nights. This seems to be a pattern for me - as I started my second job on nights too, and tomorrow I start my first FY2 job on nights... Despite this run of frankly appalling luck in the rota department (I also did long day Christmas day and nights over New Year), I have had a pretty good year. I have no doubt that newly qualified doctors up and down the country are now anxiously preparing for starting work tomorrow, so I thought I'd write down a few survival tips which I've found useful.

In no particular order, my #tipsfornewdocs

- Ask where things are early on. In a difficult/stressful situation with a sick patient, you don't want to be running around like a headless chicken trying to locate the ECG machine/resus trolley/cannulating equipment etc. Hopefully all of the new FY1s will have done some shadowing on the wards they will be working on so should know this, but for future jobs, find out where all useful things are as soon as you possibly can.

- When a consultant/registrar asks you to request an investigation, clarify exactly what they are looking for. You are unlikely to convince radiology to perform a CT scan unless you have a very good reason - and "my consultant asked for it" is not a good reason!

- If inserting a new cannula or taking a gentamicin level at 5am, check whether the patient is due any other bloods in the morning - they'll thank you for taking them off at the same time and avoiding them being stabbed a second time!

- Find time to eat/drink. You may think you're being efficient by working through lunch but if you then end up fainting and having to go home or being admitted to hospital with urosepsis (and yes, those things have happened to F1s I know) things will be a whole lot more behind than if you'd just taken 20 minutes to have a sandwich and a coffee.

- Keep up with your friends and maintain a social life. Sometimes rotas will mean you don't see friends for months at a time, and working nights and weekends means you'll have to turn down invitations to nights out. Make an effort to socialise when you can. Whilst I wouldn't advocate getting horrifically drunk the night before a shift, popping out for an hour or two rather than missing out entirely may just keep you sane.

- Invest in some decent curtains. There is nothing worse than being exhausted between night shifts but not being able to sleep because it's too bright.

- Be nice to the nurses. Sometimes you won't see eye to eye on things, but be polite and friendly anyway. They're the ones who can make your life a misery if they so choose! Also, they're often very experienced and will have a good idea of what particular consultants like doing in certain situations, so befriend them and listen to their suggestions.

- Feed people. Specifically, your senior colleagues. If you become known for bringing in cupcakes or sweets on a regular basis, people tend to look more favourably upon you.

- If you are asking for an urgent review from another specialty, saying you're phoning on behalf of Prof/Dr/Mr Consultant gets you taken a whole lot more seriously than just saying you're the FY1 (once resulted in the grumpy neuro reg sending his consultant to review someone in 20 minutes). 

I'm sure I'll think of many more - feel free to leave other suggestions as comments and I'll edit this and add them in (with credit to the author).

Best of luck to everyone in their new jobs tomorrow, but especially the new FY1s - you'll be great!

The Impact Factor

As a budding academic, I hear all too often about the importance of the 'impact factor'; that is, how likely articles from a journal are to be referenced in a later article. It's a somewhat controversial measure of how "good" a journal is, but the journals with the biggest reputations (eg Science, Nature) do seem to have the highest impact factors anyway. Frankly, at my stage, I'm still happy enough if anyone seems interested in publishing something I've been involved in writing so it doesn't particularly bother me if the impact factor is 0.01, but no doubt if things progress then at some point I'll probably have to start choosing to submit to higher impact journals.

Despite just writing a paragraph about it, this blog entry wasn't meant to be about the impact of journals and articles. It was about the impact we have on patients. Sometimes, I think it's easy to get wrapped up in the numbers and figures. A busy day of surgical receiving becomes 4 query appendicitis, 6 diverticulitis, a renal colic, the stab wound in A&E and 3 from GP still to be seen. Another 5 blood results awaited, 3 abdominal films to chase and would radiology please hurry up and report that CT scan. Yes, we care about our patients deeply, but sometimes what we do becomes so routine that we may forget that although this is our 24th acute abdomen, for the patient it's the first time in hospital or the most terrifying thing they've ever experienced. Even for those patients who we see regularly - the chronic pancreatitis after another alcohol binge, the poorly controlled Crohn's disease desperate to avoid a stoma - their interaction with the health service is likely to have a significantly greater impact on them than it does on us. 

I was recently in a bar with a colleague when a lady approached us. "I know you" she said to him. He looked momentarily embarrassed and I assumed he had no idea who she was. Her next sentence took me (although I suspect not him) by surprise. "You're the doctor who saved my husband's life". I didn't go into details with him about what had happened, but it was clear that in the course of going about his daily work he had made a huge difference to this family (and, I suspect, many others). She was very pleasant, updated him with how things were, wished us a good night (and said it was great to see that doctors were humans who you saw drinking in pubs in town like normal people - but that's definitely a different topic...) and went on her way. I was surprised by how very uncomfortable my colleague seemed with this. He muttered something about "just doing my job" to me and returned to his pint. 

The "just a job" attitude is an incredibly difficult one to get right. After more and more guidelines about what we can say on Twitter or the photos we shouldn't put on Facebook, many doctors have become fed up with the constant attempts to control our out of work lives. This has resulted in many of us (myself included) taking the staunch position of "it's only a job". I don't think that this is wrong. I go to work, do my job and hopefully do it well, and then I go home to the kind of social life I choose. I don't believe that drinking more than my recommended alcohol intake or (god forbid) having a cheeky cigarette makes me less competent at what I do. Where this attitude falls down, though, is that it makes us more likely to forget how important what we do is. We're privileged enough to be involved in some of the most important times of families' lives. Let's not forget the impact each of our interactions will have on a patient and their loved ones.

2 Out Of 3 Ain't Bad...

Or so Meatloaf would have us believe.

Despite what my blog would have you believe, I have actually really enjoyed my first 8 months of working.

My first job, which was in medicine, was tough as there wasn't a lot of senior support and out of hours there was sometimes noone to call other than the consultant if I had concerns - something quite intimidating for a newly qualified junior. However, I worked with mostly lovely people, learned absolutely loads and felt like I really developed as a doctor.

My second job (the one I finished last week) was also medical, and was fantastic. There were a few issues, mostly with other juniors not pulling their weight, but that aside I loved it. I got on especially well with one of the registrars and 2 of the SHOs, but all of my seniors were fantastic. Again, I learned lots and am definitely much more confident in my abilities than I was before I started. I also had chance to get involved with some research, which is great given my academic ambitions.

And now, I have most to general surgery. Eugh. Despite not wanting to be a surgeon, I had thought I would enjoy this rotation. Numerous friends who are medics through and through had told me how much they'd loved their FY1 surgical post. I don't think I will be jumping on that bandwagon though.

A few months ago, I was chatting on Twitter about how I felt I needed to revise some surgery, as after 8 months working in medicine I was a bit rusty. A surgeon on there, who I get on with pretty well, had said I didn't need to know any surgery. I totally unintentionally upset him but saying that I wanted to be able to suggest differentials for emergency admissions so I could order appropriate investigations. I was genuinely confused when he was so angered by my comment that surely I ought to be ordering targetted investigations to confirm or refute a diagnosis and not just going on a fishing trip for information. After all, that's what we were repeatedly taught throughout medical school and it was definitely the case in my medical jobs. It appears that things are slightly different in the surgical world. At induction for this job, we were told that everyone gets the same set of tests ordered and we shouldn't try to work out which were indicated and which weren't - and then I realised that my comment on Twitter had unwittingly criticised the way huge numbers of surgeons expect their juniors to behave (and by implication, criticised them I suppose). It's a big change in the way I think.

I am struggling with the mindlessness involved in this job. A few days in, and I have already discovered that "chase the bloods" literally means "write the results down in a folder". In my previous jobs, I would have been criticised for not acting on results. Now, I'm not expected to act on anything. Yesterday I was chastised for prescribing further NaCl for a patient who had already received several bags. No-one cared that my reason for doing so was that the patient was (still) borderline hyponatraemic and I had checked the blood results before deciding which fluids to write up. It seems I shouldn't try to use my brain, I should just write everyone up for Hartmans, Hartmans, Hartmans.

Of course, there is the distinct possibility that my seniors are just being super-cautious because I have only just started working there. Maybe I will discover that, actually, I am quite happy doing this repetitive kind of work once I adjust to the change. I could settle in and find that actually I love my new job. If not, I've enjoyed 2 of my 3 FY1 jobs. And 2 out of 3 ain't bad.