On not striking

Today I went to work. I do this most days, but my arrival today was unexpected because this day I had planned to participate in a strike that the vast majority of junior doctors in England had voted for.

It was made clear by the BMA that this industrial action was a last resort. Doctors have never wanted to strike but we have been backed into a corner by a destructive health secretary unilaterally imposing a cruel and damaging contract on the medical workforce. The BMA balloted its members for industrial action and obtained phenomenal support from doctors collectively appalled at the decisions of central government. 

98% of those who voted (76% of those eligible, so 74.5% overall) said they would support strike action, a massive mandate for change and a clear sign, from those who know, that the government should re-examine their actions. The accusation that the BMA is merely a small band of "militant doctors" has been soundly disproved - essentially all doctors are willing to strike to prevent further erosion to doctor's conditions, ultimately to defend the NHS as we know it.

Compare this mandate with that of our government who received 36.9% of the vote, of 66.1% of the electorate: only 24.4% of the electorate gave their consent for the conservatives to vandalise our health service.

At the last moment the day before the strike Jeremy Hunt agreed to the BMA's conditions; lifting (temporarily) the threat of imposing a new contract and returning to meaningful negotiations via Acas. This was needlessly late in the day as there have been many, many occasions for the government to listen to the legitimate concerns of nearly all doctors.

I disagree with some of my colleagues who feel let down by the BMA. Some are angrily cancelling their memberships and have accused the BMA of weakness. Striking after receiving a reasonable truce would have been counter-productive in the extreme, leaving doctors open to accusations of greed and callousness. Striking is not our goal, it is our last resort tool in the struggle for a fair contract - its misuse would be very damaging to the public's perception of the profession and to our cause overall.  Right now I think we retain both the upper hand and the moral high ground. We're winning, and Jeremy Hunt knows it - so he continues to cast doctors as villains, openly lies and attempts to divide us to weaken our resolve. Not going on strike is a good outcome at this point. Not least because we save our innocent colleagues and patients from some inevitable and regrettable hardship and inconvenience.

Of course I would have enjoyed the novelty of standing at a picket line rather than enduring the often tedious and menial tasks I perform on the ward. I wanted to express the righteous indignation and fully demonstrate my depth of feeling for the profession and for the NHS.

And of course I still think Jeremy Hunt is a dishonest, smug, odious tosser and I don't trust his treacherous grinning weasel face with any aspect of managing the nation's health. 

But there's a much bigger picture: Doctors (and the health service and public sector as a whole) must remain united, dedicated and utterly professional in the struggle for fair treatment and the continued existence of the NHS. We have been gracious enough to give Hunt's first offer of conciliation the benefit of the doubt but if his arrogance continues we have the legal and moral mandate to strike in January.

Doctors feel attacked and denigrated, they have united to express this view and the secretary of state has been made to listen. The threat of imposing the new contract has been lifted for now, yet we maintain our mandate for industrial action should talks break downs. The most effective strike is one we don't have to do (yet).

youtubes

Four excellent videos

View on Flipagram

A letter

I'm still angry at the government.

But at least one MP understands what I mean: Famous Green Caroline Lucas has sponsored a sympathetic early day motion http://www.parliament.uk/edm/2015-16/539, so I wrote a letter to my MP at www.theyworkforyou.com to bring it to his attention.

                              


                                        Tuesday 20 October 2015

Dear My Local MP,

I have recently moved to constituency to begin work as a junior doctor
at hospital, and so have become one of your constituents. I am writing to
ask for your support in opposing recent changes to doctors' working
conditions and further to express my disappointment in the current
government's handling of the NHS.

I am sure you are well aware of the collective anger felt by doctors at
prospective contract changes. Much opinion and analysis has been
published in the national press, as well as on social media. I expect
many doctors will have written to you before now and you will have no
doubt seen coverage of the large demonstration in London last weekend.

I speak for many of my colleagues in stating that I believe the imposed
changes are damaging for a great number of reasons. The proposed
contract devalues doctors, patients and the NHS. 

The contract fundamentally changes the way doctors get paid, such that
they would expect no increased pay for working evenings or Saturdays.
This  allow rota managers to significantly worsen the working
conditions of all doctors, and will result in a significant pay cut for
doctors already working difficult rotas.

The contract would remove safeguards against doctors working long
hours. Doctors could be coerced into routinely working longer than
their contracted hours, further demoralising and fatiguing those in the
profession.

The reason for this change appears to be to work towards a 7 day health
service. The benefits of a full 7 day (elective, as emergency cover is
already 7 day) NHS has been grossly overstated by the government. Many
people would welcome the huge increase in staff (and funding) required
to achieve a full 7 day service, but unfortunately there has been no
suggestion of this.

Without extra funding and extra staff the alternative solutions would
be either pulling doctors out of their weekday jobs to cover the
weekends - and the NHS is already straining to operate Monday to Friday
- or increasing the working week of doctors by approximately 40% more
hours. Both are directly harmful to doctors and patients. The contract
would also pave the way for other healthcare professionals to be
expected to work at the weekend and/or face (further) pay cuts
themselves so these concerns will be soon also directly felt by nurses,
consultants, porters, radiographers, ward clerks, physiotherapists and
so on, and on, and on.

There is already a large retention and recruitment crisis in the NHS.
Training positions in many specialities remain unfilled and demands of
patient care are only barely met with expensive and less efficient
locum staff. As doctors decide that the working conditions are no
longer tolerable then the working conditions for those remaining get
worse still as they must shoulder the annually increasing burden.
Obviously this situation is already bad for patient care, and the
problem will only be exacerbated as this contract will force many
doctors out of the NHS to better jobs in the UK or abroad.  I am very
concerned that an understaffed NHS will not survive much longer.

It is painful to watch as my profession and the NHS continue to be
undervalued, misunderstood and mismanaged. I do not have confidence in
the Secretary of State for Health's ability to protect the nations
health. I urge the Secretary of State to listen to his workforce and to
engage in meaningful talks. Unfortunately this has not occurred as yet
and many doctors feel forced to take the uneasy decision to vote for
industrial action in the coming ballot. I sincerely hope there can be a
strike-free resolution that allows doctors to feel valued, patients to
receive excellent care and shows investment in the future of the
National Health Service.

I strongly believe that the NHS is worth fighting for and so I would
like to ask your support for Early Day Motion 539: Junior Doctors (tabled
19/10/15), and also to ask what you and the Labour Party will do to protect
doctors, patients and the NHS.
Many thanks for listening to my concerns. I look forward to your reply.

Yours sincerely,

Dr O
MA MBChB 





On the 5th of November I got a fairly supportive copy paste reply, albeit vague and without reference to the Early Day Motion I asked support for.
 (re-copied and pasted here with names removed) 

Dear Dr 

Thank you for your recent email regarding junior doctor contracts.

The Labour Party is currently leading on this issue in the House of Commons. Last week, we secured an opposition day debate on the matter where we called for the Government to drop their plans for a new junior doctor contract. We also put forward new proposals which are fair for staff and safe for patients.

Ultimately, the Labour Party believes that it is wrong for the Government to want to pay some junior doctors less to do the work they do now. Labour is concerned that the removal of safeguards which prevent junior doctors having to work excessively hours may leave them too exhausted to provide safe patient care. Jeremy Hunt should recognise the increasing public concern on this issue, stop his high-handed demands and demonstrate a willingness to compromise and prioritise patient safety.

I can assure you that this issue is a priority of the Labour Party’s. In opposition, we will continue to follow this matter closely to hold the Government to account.

I have also offered to meet with a group of constituents and junior doctors who are concerned about this matter.

Please do not hesitate to contact me again if you feel that I can be of any further assistance with this or any other matter.

Yours sincerely

Doctors strike: what's all the fuss about?

From the point of view of an internet-generation junior doctor the level of awareness, anger and coverage of the DDRB contract proposals is overwhelming (DDRB is the Review Body on Doctors' and Dentists' Renumeration, advises the government on rates of pay). Years of frustration are finally being vented across social media sites and articulate and human arguments for fair working conditions and for the survival of the NHS are commonplace.

Until recently the discussion has been largely restricted to junior doctors themselves, various websites and forums becoming an echo chamber for doctors to agree with one another, preaching a familiar message to a choir who are already well aware of the issues and who are more than ready to reply with similar stories and personal perspectives, and occasionally this can breed an element of oversimplification, hysteria, or hyperbole, particularly as the issues are a little too complicated to be adequately summarised in a tweet or hashtag. However this hotpot of energy and anger is spilling over and is now beginning to be reported by the national mainstream media. There have been issues in expressing this anger in an understandable and constructive way but we are beginning to find a common voice. 

Manchester Picadilly Gardens last night- pic by Manchester junior Dr Jeremy Lyen

Last night I attended a march in central Manchester, forming part of a slightly smaller but no less passionate crowd than the 5,000 in London the previous evening. It was moving to see so many doctors and medical students united in the campaign, and it was excellent to see the support from the public. It marks the beginning of a campaign to make doctor’s issues well known, and to highlight the direct threat to patients and the NHS. Some form of industrial action in the next few weeks seems inevitable and it is absolutely essential that the public are aware of why doctors feel this is the only path forward. Without the backing of patients and the public any strike will further alienate and vilify doctors and pave the way for the profession and the NHS to be dismantled.

To that end I feel obligated to highlight some key points that may not be obvious to people outside of medicine. The grievances of doctors are multiple and complex so what follows is merely a heavily simplified personal take on the main issue – the BMA website is a good place to start for more details, or the facebook page of any junior doctor. I want to clarify 1) what a junior doctor is 2) why the contract is unfair for doctors and 3) why it is poisonous for patients and the NHS.

The BMA is the union that represents doctors in the UK, and took the uneasy decision (backed by members) to walk away from junior doctor contract negotiations after several discussions, realising that the proposals were neither safe nor fair, and were not a position from which an acceptable contract could be negotiated from. The government plan to impose this new contract on junior doctors in England (not Scotland or Wales) from August 2016. The current vocabulary is misleading, and poorly understood even by other medical staff including consultants. A “junior” doctor is a qualified graduate from medical school undertaking postgraduate training in hospitals or the community. The term includes the very bottom (yours truly) foundation doctors, but also any doctor in training that is not a consultant or GP. Virtually every doctor under 35-40 will be a junior doctor. The label “junior” sticks even if you are in your ST8 year of surgery training or have taken time out of the training programme for example to do research, change specialty or do voluntary work. It is very likely to be a “junior” doctor that performs your elective surgery or resuscitates you in A+E or sees you in clinic. These doctors, from new “juniors” (F1) to experienced “juniors” (senior registrars), make up about 40% of all doctors working in the country and all stand to suffer at the hand of new contract changes.

The contract fundamentally changes the way doctors are paid. People may need medical attention at any time of the day and on any day of the week. The NHS is straining but it is providing a 7 day service 24 hours a day. The current government has allowed misinformation to be spread such that patients now fear hospitals at the weekend. At present junior doctors receive a basic salary that rises with experience, and receive a supplement on top of this if their rota involves a lot of night shifts or weekend work. The new contract redefines “social” hours” as 7am-10pm six days a week, so rotas involving working evenings and/or all day Saturday would attract no increase in pay compared to a  9-5. The new contract would increase the basic pay but slash the unsocial work supplement such that doctors working in more acute specialties (already unenvied and overworked doctors such as in A+E, hospital medicine or ITU) may end up with a 15-40% pay cut whilst doctors with more normal hours may have a modest increase - but are at risk of seeing their rotas suddenly becoming much more antisocial without increase in pay. Almost every recommendation of the DDRB contract proposal is worse for junior doctors, and is therefore directly toxic to the NHS as a whole.

It would be dishonest to suggest that a strike is “not about the pay”, because no sane person would be willing to accept such a pay cut – particularly not if they had already been silently suffering a pay freeze/de-facto pay cut for several years (15% less than 2007 in real terms). The current system also does not seem to recognise the increased amount of unpaid overtime (>5hrs/week on average), self funded training, BMA/GMC/royal college membership costs, compulsory medical insurance, spiraling university debt (36K for 4 years tuition alone), or essential, expensive and difficult postgraduate exams. The public perception remains that doctors are well paid, and the well-heeled, golf-playing, Mercedes-driving doctor is a persistent one. This cliche is probably true for a small minority, especially a small number of hard working and very experienced consultants that may supplement their NHS income with private practice. But it is not true of the current generations of doctors in training.  In truth junior doctors at the moment are paid more than the average UK worker, and pay does increase with experience.  There have been several unhelpful comparisons of doctors with the perceived circumstances of other workers. In my opinion it does not help to compare with tube drivers, retail workers, McDonald's managers or physicians associates, as these workers have their own grievances and are of course also entitled to fair pay. Such comparisons serve only to perpetuate the idea that doctors are self-important and entitled: we stand to alienate ourselves from other professionals and the public, many of whom will (unfortunately for us) remain unconvinced that a junior doctor in their 20s or 30s is deserving of a salary that approximates their age in £K, no matter how many bleeding heart "open letter" accounts of their jobs they might read.

The wider issue however is the future of the NHS. In the short term patient safety is likely to be compromised as doctors working longer hours for less pay will be tired and demoralised. There will be more burn out and more mistakes. In the longer term these doctors will continue to leave the NHS in England. There is already a recruitment crisis in several specialties including GP and A+E. 20-50% of training positions in GP and A+E remain unfilled, yet somehow the government expects to attract even more doctors to these careers by making the job less satisfying and reducing the pay. About 60% of FY2s (second year post medical school) last year took a year or more out of training for various reasons and that number is sure to grow as more and more juniors are either forced out of the profession as they can no longer afford childcare or mortgage repayments, or realise that enough is enough; their skills and training are appreciated to a far greater extent outside of the NHS, outside of England or outside of the profession itself. NHS workers have been leaned on already. If the doctors don't stand up to the changes and fold then I am sure the bosses will go for other professionals. The NHS is suffering an insidious end by a  thousand cuts. If the contract is implemented as it is currently I foresee a slow and sad cycle of positive feedback as for each doctor that leaves the NHS leaves a slightly less tolerable atmosphere and workload for those remaining. Morale gets lower and patients are harmed, expensive locum and agency staff are required to fill the gaps and eventually the public will be led to conclude that the NHS has run its course and must be rescued by the private sector. 

I am deeply saddened that this is the situation I have found myself in after years of medical school and only two months in the job. It is a treasured privilege to work as a junior doctor and I am immensely proud to work for the NHS. And because I value both of these things I will be voting alongside thousands of my colleagues in favour of industrial action to protest these contract changes.

One more junior's voice

So many people have taken to the internet to express a lot of what I am about to reiterate too. Much of it is written with greater thought, clarity and passion than I can hope to here. But there is no defense in omitting such an important topic from my so-called blog. A few plagiarised images will have to suffice in trying to express these concerns.

I really have no idea what the general public know or think about what is happening to the NHS as I type this. All of my professional contacts and a large proportion of my personal ones work for the NHS in one way or another, and each of them feel similarly numb and impotent and downhearted by the situation we find ourselves in. The current handling of the NHS via its funding, organisation and staffing very directly affects me and the people I know. But it also directly affects every single NHS user as chronic underfunding of services and maltreatment staff will inevitably lead to cracks that will continue to erode the service and endanger patients.

I spent 4 years at medical school, and 7 years at university in total. Clearly it wasn’t a particularly efficient way of gaining employability, but even the most decisive school leaver must spend a minimum of 5 years as a student before they qualify as a doctor – and current students now pay £9,000 per year for the tuition fees alone. As a recent graduate I might spend ten or more years as a junior doctor, but even if I were to choose the fastest possible path, and succeed at every hurdle along the way, they would need to spend at least five years before becoming a GP or consultant.

Not even two months into this journey the government brutalise the system by pushing through a contract universally opposed, representing a long list of kicks not least of which is an expected 10-40% pay cut for trainee doctors. This takes junior doctor pay to pre-2000 levels and is a near-fatal blow to the morales of staff throughout the country. Furthermore the contract redefines "social working hours" to include 7am-10pm, 6 days a week. The BMA, with backing from doctors, made it clear that this was unacceptable and were unable to negotiate from here but the contract will be rolled out from Aug 2016 regardless.

 This is not the way I expected to start the career I had waited so long to begin; feeling betrayed, undervalued and impotent. We feel we deserve to be treated better, and it is this that is ominous for the future of the NHS. Even before this recent revelation I was well aware that there are far far more attractive employment opportunities for doctors outside of the UK, most foundation doctors I’ve spoken to had entertained the idea of leaving the NHS, either for a few years or permanently .There is a current retention crisis; doctors are choosing to retire earlier or change careers, and there are unfilled training posts in several key specialties including GP and A+E. As things stand these problems can only be significantly worsened in years to come. Understaffing is already a huge problem, with gaps only superficially filled with expensive locum and agency staff. The cycle is bleak:  inadequate staffing causes increased stress and mistakes, the service is less satisfying for staff and patients and so more doctors drop out of the game.

I do a small amount of e-mentoring for prospective medicine applicants, and I am quite often a source of information and advice for applying friends and family or work experience students at hospital. I now feel that it would be dishonest to recommend this path for the nations bright, optimistic and dedicated students. There are certainly other careers that pay far better, careers where you might feel respected or valued, and possibly even where you might have a better chance at a work-life balance.

This is a very good account about the situation, from the point of view of an ITU trainee doctor, and another excellent one here from an A+E trainee.

According to the BMA it costs about £260,000 to train an FY1 doctor, and a further £300,000 to train them to consultant level. New doctors will now find it difficult to even pay off their loans. It simply does not make sense in my head to invest so deeply in training medical staff only to be apparently unconcerned when many of them feel they have no option but leave the NHS. To me it sends a message that there is no concern for the future of the NHS, it seems that consciously or not the NHS is being set up to fail so that in the not-too distant future we are led to believe that the NHS is an unworkable idea  and privatisation is the only solution.

The level of outrage amongst staff, both junior and senior, medical and non, has been visceral and overwhelming. We share a keen sense of injustice but are struggling to find a constructive voice. Today my facebook wall is alive with righteous anger, though the audience reached may often be mostly other junior doctors. We cannot sleepwalk towards deeply unfair, short sighted and dangerous reforms and I will begin by joining many others in writing to my MP. It seems clear to me that a well funded and well functioning health service (available to all) is of vital importance to a nation, and a workforce that is present without resentment is essential for this. It is a message that I have no confidence that Jeremy Hunt has heard, and we are becoming exasperated at his continued inability to understand the issues surrounding healthcare delivery, and his continued refusal to hear the concerns of the public or the professions.  Clearly the recent petition re a vote of no confidence achieved very little despite overwhelming support (220,000 signatures and Mr Hunt did not attend the debate). I am concerned that the collective voice of doctors in the UK will continue to be ignored and some sort of strike action becomes unavoidable. I doubt this can be achieved without alienating the public or putting patients in harm’s way but there is far too much at stake to do nothing.

Some background and media coverage
http://www.bma.org.uk/working-for-change/in-depth-junior-and-consultant-contract/junior-doctor-contract-negotiations-home

http://www.independent.co.uk/voices/comment/i-dont-blame-doctors-for-walking-out-of-pay-negotiations-with-the-government-10506483.html

http://www.theguardian.com/society/2015/sep/18/junior-doctors-new-contract-cut-pay-40-per-cent

http://www.telegraph.co.uk/news/health/news/11875628/Junior-doctors-threaten-strike-over-new-contracts.html

http://metro.co.uk/2015/09/20/doctors-are-being-pushed-to-strike-over-new-contracts-which-will-risk-patients-lives-5399640/

From the Facebook page of Dr Philip Lee MBBS MRCP(UK)(Geriatric Medicine)
Consultant Physician in Acute Medicine and Care of the Elderly

Nobody likes a complainer

Nobody likes a complainer, so I feel real sympathy for my friends and family who have listened to me moan about my job with astonishing regularity and passion over the past couple of months.

There are dozens of things that irk me about my job, and since it feels like I am at my job most of the time I feel irked most of the time, in dozens of ways.

What is difficult is that despite all of my complaining, most of my friends and family don’t really understand why I am so angry all of the time. So I can only conclude that 1) I am not at all good at articulating my gripes and 2) I am an unusually grumpy and furious sort of person.

There is good evidence for both 1) and 2), but I don’t think we can exclude the third possibility being true at the same time: 3) there are several problems with the job at present that are only acutely apparent to an fy1 in my position. So with that in mind I’ll power on ahead with some more complaining about a particular aspect of my job, mercifully in a highly ignorable way.

A broad category of irritation is prescribing; managing patient’s drug therapy is an important part of the role of junior doctors.

On my most recent night shift I got talking to a pleasant patient who refused to relinquish his usual tablets to the nurses for safekeeping. I was unable to convince him because I privately agreed that this was a pointless thing to do.

A patient in hospital is expected to hand over all of their regular medications to the nursing staff so they can lock them in a safe. A junior doctor is then asked to copy all of the drugs and doses onto a hospital drug card which instructs the nurses when, if and how to give each drug.

A pharmacist then checks that this has been done correctly, and alerts the junior doctor to any mistakes so he or she then can return to correct them. This is common because very junior doctors have only a small fraction of the drug expertise as the pharmacists, but only doctors can prescribe.

Even if a patient previously had complete control over when to take each drug, in hospital it is the nurses that administer the medication. The gentleman I was talking to protested that quite often on his previous admission he was left for long periods of time before being allowed his pain medication as the nurses were unable to attend to him immediately, because they have millions of other things to do.

When the space on the drug card runs out the junior doctor is then asked to copy out the drugs once again onto a fresh drug card. These re-writes would not be necessary if we adopted electronic prescribing.

http://www.polyp.org.uk/index.html

When a patient is well enough to be discharged from hospital the junior doctor must take the dug card to a computer and type them into a specific and ancient piece of user-hostile software in order to produce a printout of the patient’s list of drugs (the same drugs as on the drug card) to give to a pharmacist, who will check the list and dispense the drugs.

A pharmacist then checks that this has been done correctly, and alerts the junior doctor to any mistakes so he or she then can return to correct them. This is common because very junior doctors have only a small fraction of the drug expertise as the pharmacists, but only doctors can prescribe.

This prescribing process is required for every patient in hospital, even when their drugs are exactly the same before, during and after their hospital stay. It creates delays for patients receiving their drugs, requires the input of and communication between at least three different professionals and delays discharge from hospital, further contributing to the already pressing hospital-wide bed shortage.

A patient cannot be discharged until a doctor writes their discharge summary, and their medications are “prescribed” by a doctor. It falls to the junior doctor to write this summary even if they have never before met the patient. The doctor must also prescribe their drugs without expert knowledge of their condition, or management plan, or why they are even on the drugs, so often they are prescribing drugs simply because they were on them before admission. Such time-consuming paperwork never takes priority over more urgent jobs for unwell patients and so very often discharges are delayed, at great cost to the NHS. Some trusts employ “discharge locums”, doctors who are paid simply to ensure all of this paperwork is done and all these boxes are ticked to allow beds to be freed up. This isn’t an entirely satisfying solution but may be a pragmatic solution to the issue in the short term: on the same nightshift I was bleeped repeatedly to do some of these TTOs  (“to take out” medicines) left over from the day before, and I ended up doing the discharges when I had a spare minute away from more urgent tasks- at 8am the next morning.

Let me quickly insert dozens of caveats; I am not questioning any of the following:

I can see that there is value in having a clear record of a patient’s drug therapy before and during a hospital stay.

I can see that there is value in allowing nurses to control medications, especially when there are issues with a patient’s capacity to safely administer them himself. I can see that it might be important to store controlled drugs away securely to prevent them getting into the wrong hands.

I can see that experience in prescribing is an essential part of the training of doctors.

I can see that having a clear summary of what happened in hospital is important, and I can see why having an up-to-date list of medications and any changes is important for record keeping and to inform future management decisions.

But I am questioning all of the following:

I am questioning whether it is appropriate for a junior doctor (on-call or otherwise) to complete discharge paperwork for patients they’ve never met.

I am questioning whether it is a good use of resources to mandate that nurses dispense routine medications to competent patients.

I am questioning why it is necessary for the doctor to perform tasks that are then repeated and improved by a pharmacist.

I am questioning whether it is safe for junior doctors to write discharge summaries without clear instructions from senior doctors regarding future management or follow up.

I am questioning whether it is reasonable to expect discharge summaries to be completed between 2pm (end of ward round) and 5pm (closure of pharmacies) when there are a multitude of more important things to be done.

I am questioning the sense of using a paper based prescription system that is simply translated to an electronic one (via hideous software) upon discharge.

Of course, none of these problems would be quite so irksome had we either sufficient time or staff to perform the tasks to a satisfactory level without feeling rushed.

On Outliers.

Due to bed shortages, about half of the vascular patients are not on the vascular surgery ward but are "outlier patients" distributed across 5-10 different wards all over the hospital. This makes the simplest of tasks infuriatingly slow, the (true) worked example below is illustrative of common occurrences.

Consultant:

“Do you mind re-doing this patient’s bloods ready for the ward round tomorrow?”

“ I’d absolutely love to!”

Step one: Find a spare few minutes in the afternoon(?!)
Walk to the opposite side of the hospital (approx 10 miles)
Try and find a free computer to request blood tests
Attempt one:  software doesn’t work for some reason
Attempt two:  this one isn’t connected to a printer
Attempt three: Great! This one works. Press print.
No paper.
                “excuse me , sorry, where do you keep your pathology paper on this ward?”
Fill printer, press print.

Answer bleep: “unwell patient at opposite side of hospital, please attend immediately”

.....

Return to ward.
                “excuse me, sorry,  where do you keep your venepuncture equipment on this ward?”
                “excuse me, sorry,  do you know the code for the treatment room?”
                “excuse me, sorry, there doesn’t seem to be any tourniquets/syringes/needles in the
                treatment room, do you know where I can find some?”
Eventually collect correct kit. Locate correct patient. Wash hands.

Answer bleep: “unwell patient at opposite side of hospital, please attend immediately”

Go directly to ward. Do not pass go.

..... 

 Return to ward.
                “Hello Mrs Patient I’m one of the vascular doctors, is it okay if I take a quick blood sample?”
                “Sure if you can! The last person tried six times!”

(Sigh loudly.)

Attempt three failed.
I’ll just take an arterial sample instead.
Need to get more kit.

                “excuse me, sorry, could you tell me the code for the treatment room again?”
 Obtain blood sample, blood everywhere. Make token effort to clean up. Need to send sample to the lab.
                “excuse me, sorry, do you know where the pathology bags are kept on this ward?”
Answer bleep: “please return to other side of hospital to do several outstanding jobs”

.....

Return to ward. Better  find a free computer to check the blood results and write them in the notes for the ward round tomorrow.
Attempt one: the software doesn’t work for some reason. Try again.

                “excuse me, sorry, do you know where Mrs Patient’s medical notes are? No? Ok thanks anyway I’ll keep looking then” 

.....

The following day:
                “Good morning Dr Consultant, I did the blood tests you asked for and...”
                “Yeah, er thanks, whatever.  Plan: Discharge today”

Do you want this done quickly or do you want it done well?

Neither. You can have neither.

I have now completed 11 full days as a junior doctor and it is tiring. In common with the thousands of other new doctors I have experienced a whole spectrum of new feelings in my first few weeks. I’d quite like to document every single thought and feeling I’ve had because I’ve had a lot of them, but I won't because more than ever before I am seriously lacking in spare time to do so, and I am making a small effort to be less tedious.

A quick summary:

A normal day on the vascular ward involves arriving at the doctor’s office at about 7.30 and updating the list of patients ready for the day. There’re about 15 on the ward and 10 or so scattered around the rest of the hospital and it’s important to have an up-to date list of their names, locations and problems. Then we try and find all of the illegible clinical notes to put into a trolley ready to take around on the ward round. This sounds like quite a simple task but it’s nearly impossible to find all of the information as the patients randomly move beds several times a day, I seem to spend most of my day looking for notes because there is a chaotic and inconsistent system of organising and storing the notes that in no way keeps up with the Brownian motion of the patients through the hospital. 

Within seconds of printing out the handover list I usually find out that it is mostly inaccurate because I failed to predict all of the new admissions or changes or discharges that occurred overnight. This happens every morning and it is most annoying.

From 8 o’clock (when my working day begins) we go round the ward and hospital checking up on the patients, usually under the supervision of a senior doctor/surgeon. This takes the form of an intense memory challenge to remember what has been happening to each of the patients (most of which has not been recorded in the clinical notes that I couldn’t find), and/or an intense balancing challenge involving several folders and scraps of paper to scribble on frantically whilst the consultant speed-raps a completely new management plan. My general coordination impairment means I drop a folder and explode its contents onto the floor at least once a day. The ward round is usually led by a different doctor each day so the management plan is different each day too.

We usually finish the rounds in the early afternoon and then set about doing the jobs that have been generated, concurrently with the infinity of day to day paperwork and the routine or symptomatic management of any problems with the patients. So far I’d say that >50% of the job has been infuriatingly inefficient and often pointless administrative work. A large portion of the rest of the time is spent phoning a bunch of different people to ask how to do literally every little thing that it is assumed we already know, and then trying to correct all of the things that we did wrong the previous day. Due to the nature of the problems managed by the vascular team there are frequently huge burdens of disease, complicated patients with poor outcomes and occasional medical emergencies that often end in true tragedy. Here especially the feelings of not being up to the challenge can reappear.

A common game among doctors, and especially new doctors, is the “my job is harder than your job” contest: everyone wants to be a martyr, or a moaner at least. The truth is the job of any junior doctor is quite a lot harder than being a medical student, and it’s not quite the dream job many of us had been hoping for. The funding and staffing shortages in the NHS are very real and unfortunately there isn’t nearly as much senior support as we thought we’d have. The hours are universally longer than in our “contracts”, the breaks non-existent, the computer systems and protocols maddening, and the decision making is more difficult and much more significant than answering MCQs – which you can simply guess blindly, get half wrong, and still call yourself Dr.

But occasionally there are glimmers of job satisfaction. A lot of the time the only doctors on the ward are FY1s, and often there is only one. Through trial and error my feelings of inadequacy are slowly reducing and the occasions when I know the correct thing to do are becoming more frequent. It is quite ridiculous that when patients wish to speak to a doctor they often prefer to trust the very most junior doctor over some of the vastly more knowledgeable other members of the team to explain their situation. This is a privileged position of trust that I aim to live up to.

This weekend will be my first weekend of night shifts and I’m actually quite looking forward to it, despite the inevitable feelings of being new, exhausted, overwhelmed and inadequate all over again.

day zero, nearly

Tomorrow is the first day of the rest of my life

Well, at least as much as every new day is anyway. Today I drove up the M6 to move into hospital accommodation outside of a hospital near Manchester. I have a small and uninspiring room with a shared kitchen and bathroom, all of which are decorated mostly with police warnings about the high incidence of crime in the area. It’s not quite luxurious, but it is cheap, clean, comfortable and convenient for now.

Tomorrow I turn up to my hospital for a final few days of lectures and hanging around on the ward to prepare me for Wednesday 5^th August, my first proper day as a junior doctor. I’m glad of this apparently gradual introduction to actual work. It seems quite manageable, but despite this I can’t quite shake a fairly powerful sense of dread. Part of this is the feeling I get daily when reading about Jeremy Hunt’s nefarious schemes and the government’s absolute refusal to address the concerns of many, but I’m sure I’ll rant about all of that it here at some point. 

I’m suspicious of change at the best of times so a large part of my dread is from a bit of underlying stress in starting a new job in a new city. Most immediately unsettling however is the fact that the annual new doctor changeover day “Black Wednesday” is associated with a 6% increase in patient mortality. We are fairly closely supervised by seniors to begin with so things aren't supposed to go far wrong, but even so when new doctors joke about trying not to get ill in August, we're actually deadly serious.

But despite all of this I really am looking forward to the challenge, dread and all. I chose medicine for a reason and it’s taken an inefficient length of education to get here so I am very eager to finally do some (hopefully meaningful and useful) work contribute a little to something important.

Helping people, doing good, saving lives, changing the world, etc etc etc. It’s not easy being a hero you know. (Really I’m just looking forward to my first proper pay packet.)

Cape day

Yesterday, Wednesday July 15^th, was an important day because I wore a hat and costume and shook hands with another man wearing a costume in a hall of other people wearing costumes, and I also got a piece of paper with my name on it. Turns out wearing a baggy gown over my suit was a good idea as it hid (to some extent) my extreme sweatiness in the beautiful sunshine. Despite this many people seemed to want to take my photograph a lot, and there was an awful lot of clapping, smiling, handshakes and sweaty hugs. I was pleasantly surprised how enjoyable such a strange series of events turned out to be.

Gryffindor

In the hall those of us receiving our MBChB stood up and recited the GMC’s “duties of a doctor”, a modern-day Hippocratic Oath of sorts. I was reminded that there’s a fair bit of responsibility in my chosen job. I think that it’s quite a good creed, so worth reinforcing by typing it out here:

I promise to:
- Make the care of my patient my first concern, providing a good standard of practice and care
- Keep my professional knowledge and skills up to date and recognise and work within the limits of my competence

I promise to:
- Take prompt action if I think that patient safety, dignity or comfort is compromised, and protect and promote the health of patients and the public

I promise to:
- Treat patients as individuals and respect their dignity, treat them politely and considerately and respect their right to confidentiality

I promise to:
- Work in partnership with patients, listening and responding to their concerns and preferences

- Give patients the information they want or need in a way they can understand
- Respect patients’ right to reach decisions with me about their treatment and care

- Support patients in caring for themselves, to improve and maintain their health

I promise to:

- Work with colleagues in ways that best serve patients’ interests
- Be honest and open and act with integrity
- Never discriminate unfairly against patients or colleagues
- Never abuse my patients’ trust in me or the public’s trust in the profession

I know that I am personally accountable for my professional practice
I must always be prepared to justify my decisions and actions

ex-med-student

Since passing my finals I've received four or five emails addressing me as Dr.

All of them are junk e-mails but I still get a small warm zap of egoism each time. And although I haven't yet seen any patients or participated in the hat ceremony my identity as medical student is steadily and undeniably drifting away from me.

The most significant manifestation is the expiration of my student card which runs out at the end of the month. I am deeply saddened at the prospect of paying actual money to acquire that daily shameful extra cheeseburger from the McDonalds down the road from the hospital.

This all means that my rubbish unoriginal blog title and url need updating too. "medstudentwords" was boring but descriptive but now its not even accurate. So, until I outgrow it or change it, the new title for my home on the digital will be "juniorblogtor".   I am aware that this is an extremely poor title, but my alternatives were even worse:

cyberjonny
technolojonny
drblog
procrastimedicine
bowelsoftheweb
juniordoctorwords
crashcall
blogtoroctopus
drblogtopus
droctoblog
weak-foundations
diarrhoeaideas
jonnyology
blogacetamolqds

sheesh.

Kindle RIP

I broke my Kindle. Well actually it belongs/belonged to my brother but I’ve been using it for over a year. It is/was a third generation kindle with a keyboard and wifi and it was very good. I was 61% through Jonathan Safran Foer’s “Everything is Illuminated” but now the top half of the screen became un-illuminated so I can only read the bottom half of each page. Incidentally the first 61% of EIL is pretty good. I’ve not seen the film.

It puts me in a difficult position because I hate kindles. I hate them because they threaten to extinguish the printed press. Ebooks are cheaper than books, but unless people keep buying books then there will be no bookshops, and without bookshops there is no browsing. I hate that Kindles are made by the sinisterly convenient Amazon.co.uk, and so contribute to the mega tax-avoiding corporation undercutting the traditional retailers and dehumanising shopping in general. Physical items have pleasing weight, texture, colour; ebooks are merely ghosts of books. The distinctive smell of books, of old dusty relics or new shiny stories, is far far better than the smell of plastic and silicon, of ones and zeroes. I hate kindles because they look rubbish on bookshelves, and because you can’t judge them by their covers. How will people know all of the impressive-sounding books I’ve bought but not read if they’re not pretentiously displayed in my house?

Kindle's are not welcome in Hay-On-Wye

At the same time, I love kindles. I love that I can carry around 100 virtual books more easily than 100 real ones, and so have on one’s person a book for all moods and occasions, the ability to abandon a title and replace it at a moment’s whim. I love that I can obtain almost any book almost instantly, or can download UK newspapers to read in non-UK countries.  I love that I can read the very hungry caterpillar on the train without the judgement of others. I love that there are zillions of free ebooks including legally downloaded copies of books from 70 years after the author’s death. I love that I can read all of the books that my brother downloaded to the kindle before I seized control.

Since I will be graduating and leaving Birmingham in a couple of weeks I attended my final book club meeting recently. It was sad to say farewell to a great group of people who’ve shared a good number of varied books. I hope to continue the discussions with virtual meetings using goodreads (also owned by blasted amazon), so I’ve another reason to continue with the kindle.

So in order to read the rest of the books I’ve started, and to not lose the books already downloaded onto the device, and in the interests of fairness and good manners I’ve ordered a replacement kindle for my brother, and I will continue to borrow it from him indefinitely. 

I don't know what to think about Scotland

This time last year I had finished my exams and was quickly realising that I didn’t really know the first thing about Africa (or medicine), and I was feeling excited about starting my elective in Tanzania.

This time this year I have finished my exams and am quickly realising that I don’t really know the first thing about medicine (or Africa), and I am feeling intensely glum about the future.

My life of late has been dull in the extreme: I’ve done a bit of revision and sat a few exams and I have been slowly abusing my body with junk food and terrible sleep hygiene for a long time.  So I’ve looked forward to finishing the final set of my extended student career. I anticipated spending the time afterwards reading things for interest not exams, maybe bloviating some more on the internet, reacquainting myself with ignored friends and family, and re-engaging in general. I was looking forward to beginning life and work in Manchester as an FY1 doctor for the long suffering NHS.

Alas, any joy gained from finishing my medical finals on Thursday was violently annihilated by the election results a few hours later. The exit poll was worse than all the previous polls, and the result worse even than that. We have voted for another 5 years of conservative government, except now it will be unmitigated by Liberal Democrat presence.  I am concerned that this country is becoming unkind and insular and selfish and unpleasant, that the people in it are seemingly unconcerned about the healthcare system, about the poor, about immigrants, about welfare, about human rights, about food banks, inequality, about relations with Europe, about big corporations holding governments to ransom.

But smallest of victories: Nigel Farage, and Paul Nuttall and 619 other UKIP failed to win seats, despite some 3.88million UKIP votes. Nearly 4 million adult human beings decided voting UKIP was a good idea.

I stole this picture from the bbc website

It’s cruel that the Tory’s unexpected success has benefited so much from the surge of their ideological opponents in the SNP. It seems that fear of an SNP-Lab coalition dissuaded enough labour voters, whereas hatred for the ruling Tories England caused an SNP whitewash in Scotland.

It’s tempting to blame our electoral system; under proportional representation the parliament would look significantly different:

Party	Actual result	P.R.	Difference
Conservatives	331	242	-89
Labour	232	199	-33
Lib Dem	8	51	43
SNP	56	31	-25
Ukip	1	82	81
Green	1	24	23

In my simplification to consider coalition governments:

“LEFT” = LAB(232) + LD(8) + SNP(56) + GREEN(1) = 297 (vs 305 PR)
“RIGHT” = TORY (331) + UKIP(1) = 332 (vs 324 PR)

(Apologies for ignoring all of the smaller and welsh/NI parties)

But I suppose the reality is much more complicated than this – a lot people I know would have voted differently under proportional representation. Plus I see no chance of voting reform as it would never benefit the ruling parties, and of course 2011’s AV referendum was a shambles.

There’s lots and lots and lots to say about the state of British politics this week, and lots has been said and re-said and said again, and I’m aware that I’m neither qualified nor able to clearly articulate the issues.

So I’ll just quote a line from Richard Herring’s blog:

“This is democracy though. It’s all about what most people vote for. And people are fucking idiots, so you can’t be surprised when they do something stupid”

Or perhaps a better and more optimistic one from Aneurin Bevan 1948:

"The NHS will last as long as there are folk left with the faith to fight for it"