I’m feeling focused

At the start of the year, I made a promise to myself. I promised that I would spare myself the trauma of applying for jobs this year, and I would focus on passing the Fellow of the Royal College of Anaesthetists (FRCA) Primary Examination instead.

That was the talk, now it’s time for action. The first (MCQ) exam is next Tuesday, meaning I have only a few days left of study to go. I’ve not been blogging much recently because I’ve been working really hard over this past month or so – sometimes putting in nine or ten hours study per day. To be honest with you, this exam is rock hard and very soon, I’ll find out if I’ve done enough work.

Though my study period so far, I’ve been through self-delusion, pontification and despair, but in the last fortnight I’ve developed a sort of gritty focus that will hopefully see me through.

The exam is negatively marked and the FRCA website says that to pass you need to score about 53%. In the last week or so, I’ve been scoring 48-58% so, as things stand, my chances of passing are about 50-50. I’ve had lots of advice from the other SHOs and SpRs who have been through it and medical staffing have been very understanding. Now it’s all down to me and I’m determined to pass if only because I’ve invested far too much of my time and mental energy on this exam. Failure is not an option.

Right, now I’m off to learn which of the neuromuscular blocking drugs have active metabolites.

Wish me luck.

Stupid Me: Story #4514

I’m a fourth year medical student and it’s the summer. I wake up in my bed in the hospital accommodation and realise to my horror that I’ve slept through my alarm. I’m supposed to be in the paediatrics clinic at the other side of the hospital in exactly 18 minutes.

As a cohort, we’d already had the lecture from the lead consultant about “showing courtesy and respect” in the way we dress and the way we act around the children and parents, so I was sure she wouldn’t be impressed if I rucked up late to my very first clinic with her.

I leap out of bed, brush my teeth and get myself washed and dressed in about 10 minutes. I grab my stethoscope and white coat and run towards the Outpatients Department. When I need to, I can move at quite a rate of knots and I hurtle past the hospital canteen and charge into one of the swing doors that leads to my destination.

Only problem is, the swing door doesn’t swing. There’s something behind it; or, more accurately, there’s someone behind it. I look up to see the face of the consultant physician from my previous block squashed and framed perfectly in the window of the swing door.

“Ah, I’m so sorry!” I shout over my shoulder as I keep running and don’t look back…

How the NHS works

It’s there if you want it…

It's well known that a minority of health professionals abuse drugs and alcohol. I'm happy to say that abuse of hard, medical narcotic drugs happens very rarely (as far as I know). One of the things that really surprised me when I started working in the operating theatres as an anaesthetist was the easy access to, and ready availability of narcotics to me.

In anaesthesia, we give just about all the street drugs (heroin, cocaine, barbituates, tranquilisers, ketamine) plus many others (morphine, fentanyl, midazolam etc… etc…) in their pure medical form to our patients to help them through surgery.

Strict restrictions exist over these “controlled drugs” but the restrictions only go as far as to the point when the drug leaves the drug cupboard. What happens to it after that is purely in the hands of the nurse or doctor who signed it out.

In my job, I’ve wandered round with syringes full of heroin, ketamine etc… in my hands and I’m telling you, it would be the simplest thing in the world to slip the odd syringe into my bag to “enjoy” later.

I suppose that if you are that way inclined, then you’d find a way of getting your hit, no matter what, but I think this shows the amount of trust and responsibility our employers, our patients and the public as a whole put on us health professionals to behave ourselves.

The occasional bad apple will abuse this trust but the majority of us would never dream of abusing medical substances. This is partly because it goes against everything we’re training for and also because, as doctors, we’ve seen too often where that road ends.

Can you answer this riddle?

If one doctor doctors another doctor does the doctor who doctors the doctor doctor the doctor the way the doctor he is doctoring doctors? Or does the doctor doctor the way the doctor who doctors doctors?

You're Fired (or maybe not...)

I was watching The Apprentice the other week and the candidate’s task was to put on a themed dinner in a pub. As per normal, general chaos ensued. One of the teams was in the market, trying to buy tomatoes but they really didn’t know how many they needed and so had to try and wing it. Sir Alan Sugar was not impressed and he said something like:

“It seems to me that you had no bleeding idea how many tomatoes you were buying. You had no idea how much soup you were expecting to sell so you had no idea how much soup you needed to make and how many tomatoes you needed to buy. What did you do? Did you just pluck a figure out of the air did you? That doesn’t seem to be a very smart way to go about business if you ask me…”

The reason I bring this up is that it strikes a chord with the ongoing MMC fuck up. One of the biggest errors of MMC 2007 was around workforce planning. The Department of Health seem to have no idea how many consultants they will need, how many they want to employ and thus, how many junior doctors they want to train. How on earth can you plan medical school numbers and training positions for junior doctors without this most basic of information? I know that people aren’t tomatoes but the principle of basic planning surely applies. No wonder it’s all going tits up.

The House of Commons Health Care Committee has released its third MMC report and it seems that they agree with me that the people who ran MMC had “no bleeding idea” how many doctors they need in the NHS (see paragraph 19 on this link).

I’m sure Sir Alan Sugar would have had no truck with this level of staggering incompetence, but unlike The Apprentice, Liam Donaldson hasn’t been fired. He’s still sitting pretty in his job after screwing with the lives of literally thousands of junior doctors.

Finals Countdown

There are a lot of very worried looking final year medical students hanging round the hospital at the moment. They’re pretty easy to spot. It’s the bags under their eyes, it’s the gaunt expressions it’s their whole demeanour that just screams out “I am stressed.”

I don’t like thinking back to the time that I sat my finals because it was really horrible. I’d actually go as far as saying that the run-up to my final medical exams was the worst three month period of my life so far.

Five years of study gets compressed down and assessed in a two-week period. There’s nowhere to hide, you really have to stand up and be counted. The sheer volume of stuff that you have to know is immense. You know that the examiners could pick just about anything in the field of medical science to test you on, so you really have to be able to talk and write sensibly about everything.

You pray that you get something “easy” to get examined on - something like angina, multiple pregnancy or osteoporosis. But you know that they could just as easily pick rare conditions like facioscapulohumeral dystrophy that you may never ever have heard of.

Your whole academic year is trying to achieve the same goals at the same time and EVERYBODY is stressed out. A good proportion of my year were on some sort of anti-anxiety medication in those weeks before the exam. It ends up being like a pressure-cooker of stress because everyone you speak to about the exam is stressed out, and the fact that they’re stressed makes you more stressed, which then stresses them out more and it goes on and on like this.

People who have been through finals try to comfort you by saying stuff like “Just do the study and you’ll be fine. You have to remember that the vast majority of people sitting Finals pass them. The University WANT to pass you, so you have to fuck up pretty badly to fail.” I’m not really convinced that hearing stuff like that was particularly helpful though.

The worst thing about it though is that there seems to be no end to it. There’s nothing to look forward to, there’s nothing to enjoy. You wake up, you study, you go the hospital to try and see some patients. There’s loads of you all doing it so the doctors, nurses and patients in the hospital get pissed off because there are loads of students hanging around. So you come home and study some more. This pattern is repeated day after day, weak after week, month after month and it gets really, really depressing.

Anyway, my finals came and went. They were just as horrible as I imagined them to be. I was unlucky. I didn’t get the easy topics like heart disease or hernias, I got the random stuff and it was horrible. I got through it though. I’d done enough work to say something sensible in each viva so I passed. I got my medical degree and earned the letters after my name and the right to call myself “doctor.”

It took me several weeks to de-stress afterwards, to get my personality back and feel like my normal self. Medical finals are horrible and my heart goes out to all the medical students studying for them up and down the land.

I wish you all the best of luck.

A quick tip

People of Britain, if you are going to start a fight whilst drunk tonight, try not to pick on anyone who is:

a) harder than you

b) more sober than you

c) both

If you fail to follow these simple rules, then there's a good chance I'll be seeing you tomorrow...

Physician's Assistants

I’ve heard about Physician's Assistants (previously known as "Anaesthetic Practitioners"), but didn’t really know much about them. These are people who aren’t doctors, but have been on a 2-year diploma course to learn how to give general anaesthetics, and thus work as anaesthetists. There aren’t any such people in my hospital, but one of my friends from uni has worked with them before. I asked him how the Physician's Assistants fitted into the grand scheme of things and the conversation we had was illuminating to say the least.

It seems that someone had a bright idea…

“Gather round people, I have a brainwave. I’ve been spending some time in the operating theatres recently and I’ve seen what happens down there. It seems to me that these anaesthetists don’t do very much. They give a couple of injections, put a tube into the mouth and that’s about it. We have to pay them all this money and I reckon it’s money for old rope. I don’t think you need to be a doctor to give a general anaesthetic. I reckon that you could send people on a diploma course for a couple of years and after they finish, they’ll be qualified enough to give a general anaesthetic. As long as the patients are reasonably healthy, then these people could provide the anaesthetic and do away with a couple of expensive doctors.

“Of course, patient safety is paramount, so there must be a fully trained consultant anaesthetist immediately available should anything start to go wrong and we’ve worked out that one anaesthetic doctor can safely supervise two of these Physician's Assistants at the same time.

“So, here’s the proposition. We could set up the theatre lists so that these Physician's Assistants could have only healthy people on their lists. This means that we run two theatre lists simultaneously with two PAs and one expensive doctor! We get twice the work from a single doctor! It’s genius!”

So far, so good.

The trouble is, giving an anaesthetic isn’t really that simple. In order to give a safe anaesthetic, you need to know a lot of stuff. You can’t train just anyone to do it, especially in only two years. You need clever people.

The problem is, clever people are expensive. The powers that be quickly found out that, in order to attract people to the course who would be bright enough and motivated enough to actually finish it, they had to offer salaries of £35000+. (In fact, The Ferret pointed out this advert offering £42 - £49K for an Physician's Assistant job based on a 37.5hr week.)

Now, in my friend’s hospital, unlike the junior doctor anaesthetists, the Physician's Assistants don’t work evenings, nights or weekends, they only anaesthetise healthy (ASA I and II) patients, they do not anaesthetise anyone with moderate medical problems, they do not anaesthetise children, they do not do epidural, spinal or any other regional anaesthesia, they do not cover emergency surgery, they do not cover trauma theatres, they do not cover A&E, ITU, maternity or the delivery suite and they are not part of the crash team.

In short, they are not employed as “replacement junior doctors” (who would otherwise be working on the healthy patient lists), but they are being employed as “Consultant-Lites”

Let’s look at the simple maths of the comparative salaries for two surgical lists run by the two systems

Consultant Doctor + Consultant Doctor

£90 000 + £ 90 000 = £180 000

Physician's Assistant + Physician's Assistant + Consultant Doctor

£40 000 + £40 000 + £90 000 = £170 000

When you factor in the additional pension contributions involved in employing an extra person, the cost to the NHS is pretty much the same.

So, the big question is, what was the point of training these people if it’s going to work out to be just as expensive as before and when a consultant Anaesthetist can do so much MORE than a Physician's Assistant?

Maybe, the powers that be failed their O-level mathematics papers or maybe, just maybe, it’s not about the money.

My friend spoke about it to one of the Physician's Assistant Trainees and it was telling that the PA said something like, “from a personal point of view, the (diploma) course is fantastic for me. I really like it, it’ll look great on my CV and if I get a job at the end of it, then I’ll get paid well. Looking at the wider picture though, I’m not sure I see the point of it. Don’t get me wrong, I’m not complaining but it seems to me that things would run just as well without us.”

I think it’s not about the money.