I vote for Jexit

Please see below extremely lazy buzzfeed-like sumamry post, a few choice images recycled from my facebook and twitter feeds.


 


Jeremy Hunt has to go.
The last two days have seen further junior doctor industrial action: full walkout of junior doctor support including emergency cover including A+E, the crash team, ITU, obstetrics and so on.

Contrary to the scaremongering from the hateful daily mail there have been absolutely no patient safety issues, obviously, as the care was expertly provided by experienced and dedicated consultants and allied healthcare professionals. And we are extremely grateful for their support.

And despite hostile sections of the media it is clear that patients and the public are largely supportive of the doctors. Whilst on-call last weekend an 85 year old gentleman I was seeing in resus with a fast irregular heart rate stopped my examination to ask whether I also supported the " young doctors sticking it to that nasty Mr Hunt".

On the picket line I attended this morning we received numerous heartening beeps from passing cars, buses and ambulances. Several of people came to talk to us and express their support, and it was also nice to see some very british members of the public awkwardly display nods and thumbs ups whilst walking past. An old man with a frame stopped across the road and applauded. Several consultants and members of the public also came by with donations of gratefully received food and hot drinks.

http://www.independent.co.uk/news/uk/politics/the-public-increasingly-blame-the-government-for-the-junior-doctors-strike-a7003056.html

The NHS is already straining under the current contract. There are not enough doctors to fill rotas, making each shift more stressful for the few doctors that work them. Having recently moved onto a medical job I can report that 0/4 of my 12 hour on call days had a full complement of medical staff; the remaining team were rushed off their feet to try and see all the ward medical problems and new admissions. 

This is a genuine junior doctor rota (names erased) from a different hospital. The boxes in yellow are represent shifts where there is currently no doctor allocated. These extra shifts are frequently advertised as locum jobs but without much success - it is unpleasant to work under such short staffed conditions and there is increased risks of making mistakes. Junior doctors are already tired from working 50+ hours a week and value their free time. New government policy to cap the hourly rate of such locum shifts removes any small remaining incentive to work further hours.

Jeremy Hunt frequently claims (lies) about increasing funding for the NHS, when actually it is facing real terms cuts. He expects to make doctors work harder and longer in the context of £20billion worth of "efficiency savings".  source

It is clear that a treacherous and callous government is taking a heavy heavy toll on junior doctor's morale.

GP satisfaction in the UK is plummeting. More and more (junior and senior) doctors are leaving - no sign of those 5000 promised new GPs.

The new contract is also explicit in its discrimination of women and those with disabilities

 - and may indeed be illegal according to Britain's equality watchdog.

The tactic seems to be to grossly underfund and destabilise the NHS to set the scene for private companies to rescue the profitable parts - this sneak privatisation is already happening and has been hastened by the conservative's 2012 health and social care act (then health secretary lansley responsible for this act now advises private companies how to profit from the NHS). 

Remember Jeremy Hunt himself co-wrote a book about how to privatise the health service. The NHS is paid for by generations of UK taxpayers and is valued most by the poorest and most vulnerable - the people who could not afford private health care (and the people who are unlikely to vote conservative.) It does not belong to the political elite and it is not theirs to sell.

Despite, and perhaps partly because of, the ongoing pressures facing the health service Junior doctors remain positive. Jeremy Hunt has inadvertently strengthened the profession as we unite against his government's abuses of the public sector. There is rekindled camaraderie amongst colleagues of different specialties, junior and senior, doctors and other healthcare workers standing together passionate in their defence of a world class free health service that is adequately funded, and fair for patients and staff. 

Picket line in Manchester April 26th 2016

Appendix

A good, simple explanation of the main concern:

I'minworkjeremy

I was at work last weekend. On Friday, Saturday and Sunday night I was the surgical FY1 on call, covering all the surgical patients in the hospital (with support from a team of dedicated more senior docs on call). Fortunately for me there were no real emergencies to deal with and the number of tasks was fairly manageable compared to other shifts I've done. Over the course of thirty six hours over three nights I prepared patients for surgery the following day, I assessed patients in pain or nausea and prescribed medications and fluids. I assessed unwell patients and alerted the seniors where appropriate. I sat and talked with anxious patients and I quietly examined and verified those few who had passed away. I prescribed anticoagulation for patients to prevent strokes and DVTs and started patients on treatment for infections. I organised blood transfusions, inserted intravenous cannulas and clerked and admitted emergency patients when the surgical admissions team were busy in theatre. This is all routine FY1 fare,  and this particular shift was far more tolerable than the average night; there wasn't all that much to do and I was never expected to do anything beyond my training or experience- I even managed to get through a decent chunk of a novel during the unprecedented bleep-free periods.

I was told that on this weekend over 20% of the hospital beds were occupied by patients who were "medically fit for discharge". These are patients who are awaiting social care input and so cannot be discharged until there is somewhere safe for them to go.  It makes the job of the ward cover on call doctor (moi) a bit easier when a large proportion of the patients are not officially unwell (though far too many of them will get a hospital-acquired infection whilst awaiting discharge and so become unwell again, further delaying discharge but also risking preventable death). If "spare" hospital beds are occupied with such patients then new patients can't be admitted. On Saturday night there were 87 "breaches" in A+E; on this single day 87 patients were are not admitted within the 4 hour target time, at considerable financial cost as each breach results in a hefty fine to the trust. Clearly the problem of insufficient beds is not solved by forcing more doctors to work at the weekend.

Although my latest weekend was relatively, and frankly astonishingly, quiet, it was still fairly unpleasant because of course it is unpleasant forcing yourself to be awake when you're too tired to think or speak, and of course it is unpleasant working straight through a weekend.  Believe it or not I'm not really complaining about this - it is important to have medical cover 24/7 and so some people will have to work evenings, nights or weekends. All sane people know this and all applicants to medical school knowingly sign up for this. It would be churlish to complain about my current rota in the current system as it really isn't bad as far as junior doctor rotas go; I probably work one weekend in three or four, and for every Saturday or Sunday I work I get a midweek day off -allocated at random. It's worse for FY1s at a lot of hospitals (a close friend has double the number of nights that I do), and almost certainly worse beyond FY1 as  in many specialties fewer and fewer doctors are available to fill on-call rotas. Under the current system anti-social hours are recognised and doctors receive a "banding" supplement to their basic salary to compensate.

One of the most infuriating things about the government's steamrollered "7-day" new doctor's contract is their refusal to acknowledge that a) the NHS already provides 24/7 emergency cover, obviously, and b) weekends are more valuable than weekdays, obviously. On Saturday I missed a gathering of close non-doctor friends I've not seen in months because I, and only I, was at work. Having Tuesday off, alone and fairly disoriented to time, was not much of a substitute. This year I also worked through the new year bank holiday weekend, as one of the lucky ones have escaped working Christmas. So, like almost all doctors in training, some weekends #iminworkjeremy, and happy to be. But to suggest/force/blackmail doctors into working more hours, more nights and more weekends for less pay is insulting, as is recognised by 98% of junior doctors who voted for, carried out, and will continue to take part in industrial action over this issue and others.

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.)

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.

Judging the SJT

It has come to my attention that I am coming to the end of my last proper Christmas vacation. Friends and relatives are keen to remind me that next year, all being well, I probably won’t have two straight weeks off to binge on crisps and mince pies because I might have a job and responsibilities and other such nonsense. I take this realisation with great sadness as the student sloth has been my annual routine and identity for the last 24 years. But in order for this seismic transition from scrounger to “professional” to occur later this year (Happy New Year by the way), I need to first sit and pass the notorious SJT. This is the Situational Judgement Test, a confusing but essential hurdle to clear to be allocated a job.I wrote a bit about it here a few months ago when I summarised the application process and complained about having to apply for a job.

My exam is next Friday and so I figured it's about time to find out what the fuss is about. I soon realised that I was unable to adequately explain the SJT to various people that asked me, and this was a bit alarming since it is the main measure that decides whether I get to be a doctor in the NHS in August or not, and if so where.

What are SJTs and Why are they used? – according to the medical schools council. 

"Situational judgement tests are increasingly popular recruitment tools, a measurement method to assess judgement in work-relevant situations. They present challenging situations likely to be encountered at work, focusing on non-academic/professional attributes (e.g. integrity, empathy, resilience, teamwork)"

Questions go through a long process of piloting and amendment and are reviewed by psychologists and clinicians. Predictive validity for junior doctors has not been shown yet – the study will track the progress of the 2013 cohort.

SJTs are cost-effective methods to administer and score applicants compared to interviews, and are arguably fairer than essay-based application forms that can be filled out by candidate’s relatives, for example.An SJT has been used to select candidates for GP specialist training since 2007, and here they have been shown to be superior to both knowledge tests and high fidelity selection centres.

I don't really know what the arrows are for either

SJTs are also used in the FBI selection process.

The SJT also allows the system to find candidates that have severely deficient personal or professional attitudes; I will be embarrassed if I get revealed as a psychopath or a moron through taking this test. It is important to recognise the importance of practical intelligence in addition to academic intelligence in being a useful doctor. Book smarts are in books, and even morons and psychopaths can buy books and pass exams.

The SJT Practice Paper*

So I found the official practice paper online and spent a morning reading about it and then doing the test. Sitting the practice test kindled some strong emotions in me (frustration only) and I considered writing a tedious blow by blow account of my mood and thoughts. Mercifully I decided against this. So I’ll just make some sweeping statements about the questions in general to make excuses as to why I do so badly in it next week. I realise that my time will certainly have been better spent practising questions or reading GMC guidelines but I’ve started writing this now so oh well.

The test consists of 70 questions to be completed in 140mins. If my calculations are correct that’s about 2 minutes per question. My first thought was how unpleasantly the SJT scenarios portray working life. It seems that every other day I can expect to be undermined by various colleagues, or be bullied or shouted at. I also need to deal with the dangerous F1s, the infection spreading nurse, the fraudulent doctor, the shouting consultants, the drunk F1, the rude nurse, the various weeping junior doctors and the angry locum. Seven separate questions involve dealing with other F1s who refuses to do their job properly and dump extra work on me.

 The first 47 questions (about two thirds, about 94 minutes, using maths) consist of a paragraph describing a one ranks five statements in order of how appropriate they are for a given scenario. Each question is marked out of 20. Full marks are awarded if you get the order exactly “correct”, and marks are gained for getting it nearly right. For example you only lose two points if two adjacent options are switched. I think these questions are more subjective than the remaining 23 questions (choose three best options). 

The scoring system for the rank 5 in order questions

It seems to me that because the exam format is already quite artificial, the questions can never be completely unambiguous or completely fair. For some questions the order matters a great deal more than for others i.e. you could lose six marks when you risk patients dying on one question and lose six marks for finishing late on the next.

On the front of exam you can find the words “you may sometimes feel you would like more information before answering, but please answer each question based on the information provided”. Indeed in almost every single question I want more information. Without more information a candidate need to fill in the gaps sometimes, and so will be penalised if they do not make the same assumptions as the examiner. I need to correctly guess that a patients “breathing difficulty” is not an emergency and is best seen by a nurse, guess that the “Urdu speaking doctor” exists and is nearby and is free to help out when I could use his services, guess that my fictional F1 colleague would value the support of another when talking to a senior about his work-life balance, rather than find this embarrassing, patronising or an invasion of privacy. Usually guessing wrong will not have a large effect on the mark but it is still unfair that for some questions this will arbitrarily reduce the mark for some candidates.

For example one of the question calls for a candidate to choose to attend theatre for personal learning and experience ahead of checking a colleague’s prescriptions when a nurse has raised concerns about them because “Ensuring that the nurse’s concerns about errors are addressed is very important, but not immediate". I think this would be inappropriate if there were concerns that these errors endangered patients (100mg potassium cyanide PO STAT), but this important information is absent from both the question and mark scheme so one is supposed to err on the other side to caution and must assume that patient safety is not compromised to score 20/20.

Other questions do not clearly discern by what measure an option is deemed best: is it the gold standard time-consuming or expensive option that is most likely to result in a satisfactory outcome or the option that is easiest and quickest to do first? Is it the option that will definitively solve a problem long term or the option that will contribute most to patient care in the short term? For example there is a question asking what a junior doctor should do in the unlikely event that there is not enough work or training opportunities in his or her post. I think prompt discussion with the consultant and programme director is important to allow time to rectify this before the next rotation. The mark scheme suggests that one should first assist on other wards (and so this option comes before talking to the programme director), to me this is clearly what should occur to fill free time after the problem has been raised with seniors.

Some of the questions use the stem: “Rank in order the extent to which you agree with the following statements in this situation”. Honesty is apparently a desirable quality in junior doctors and I feel aggrieved that this question may require me to lie about how much I agree to get the best mark.

In over half of the practice paper questions I think it is possible to make a sensible and defendable case for an order other than that given in the mark-scheme. I therefore think it is false to have a definite single best order. In the practice paper there is usually a good option and a terrible option but sometimes options are equally good or bad. One shouldn’t lose marks if they rank the two terrible options (is it more wrong to stab the kitten or the puppy?) in the bottom slots but in an apparently incorrect order. In these cases it doesn’t make sense to order them if either order is arguably consistent with the ambiguities of the question and known best practice guidance (stab both simultaneously).

So finally to my conclusion: It is perhaps impossible to create a completely clear, cost-effective, perfect system for assessing 7000 candidates and suitably assigning them positions. It is important to show the importance of professional “soft” skills – in having an SJT test at all forces medical students to think about difficult situations and read the best practice guidance online. However, there is not enough precision in the SJT to use it to fairly stratify candidates with sufficient resolution to allocate jobs nationally.

*By all accounts the practice paper bears little to no resemblance to the actual SJT test so please continue to ignore everything I have said