A beginner's guide to being a junior doctor

Trial run - Google+ blog post

2011-11-07T22:25:00.001Z

So this is an experiment. After my last post about NHS reforms I didn't check blogger for some time, and so missed a comment by a friend which warranted more attention than I gave it. As I am now able to link Google+ and blogger, here goes - I'm reposting his comment here and we'll see how the G+ conversation thing works...

Firstly I'd agree that the concerns of Goldsmith regarding the needs of an ageing population is a smokescreen to cover a bill which merely accelerates the entry of private consortia into the Health service.
The late Auberon Waugh of the Daily Telegraph was swift to say that anything Shirley Williams was in favour of was automatically a bad idea, based on her disastrous educational reforms of the 1960's, she's not someone I would want to utilise in support of or opposition to any argument. Nevertheless, I think we do need to look at reforming the NHS. A number of points arise, which opponents of NHS reform fail to address:
Not sure Shirley Williams' education reforms half a century ago are particularly relevant to her opposition to NHS reform now, but as you go on to address some of the points she raises I'll half-let you off!
1/ The US healthcare system is used as a kind of all-purpose 'bogeyman' for opponents of reform. However, the blithe assertion of Williams:
'The NHS is recognised by the OECD, the US Commonwealth Fund, most of our own medical organisations and many of those who use it as one of the most efficient, least costly and most effective in the world'
is surely wrong.
Williams' comment about the NHS being recognised as one of the most efficient etc. isn't really a "blithe assertion" - she names two continental groups who've acknowledged it and alludes to dozens of others! What's more, she linked to the actual reports in her original article, which is paragon journalism: I'd respectfully suggest that the blithe assertion here is your "is surely wrong".
If that were the case, disregard the US, and examine why any of: France, Germany, Japan, Australia, Canada , New Zealand or South Korea have not chosen to emulate.
The obvious response to why the other healthcare systems you mention haven't switched to our model is that it'd be too bloody difficult to get to work. It's founded, without wishing to get all high-falutin', in a spirit of post-war austerity and commonality in the face of adversity, and the NHS works so well because the people who make it work are those on crap salaries who do it out of a love for what they're doing. I'm not talking doctors - our salaries are pretty fucking terrible on an hourly rate basis, certainly, but the ones who make the NHS run as well as it does are the secretaries, back-office staff, and receptionists on eff-all an hour who do it because they want their local hospital to be good and because it makes them justifiably proud to say they work for the NHS.The corollary to that - and I accept I can't prove it - is that once you lose that goodwill, you can't get it back. Welcome to the modern NHS.
I can recall the US polemicist Mark Steyn recounting the tale that in response to his comment that:
'Whilst the NHS may be the envy of the odd Bhutanese Yak farmer, I have never met anyone in Canada, Australia or New Zealand with the slightest envy of the British health system'
he received a letter from a Bhutanese man, who whilst not a Yak farmer himself, came from a long line of Yak farming stock , and agreed that when his parents had been taken ill in London, they found our system considerably inferior to the British Health care system.

I can't tell if this is a joke (and assume you mean "...the Bhutan Health care system"). If not, then the plural of anecdote isn't data (if this is the same Mark Steyn, he acknowledges he's just peddling anecdotes here). Either way, I rather suspect that a Bhutanese man whose parents can afford to fly to London probably aren't on the Bhutanese equivalent of the NHS anyway...

2/ Williams extols the NHS's £80 billion budget as evidence of an axiomatic good. The NHS, I believe remains the third largest employer in the world, against the Red Army and Indian railways. Surely it is right to examine the baisc principles behind it. Life expectancy in Wales has sunk below Tianjian province in West Wales, and in Northern Scotland to below Slovenia and Croatia. Surely we need to be looking to move provision to where it is most needed.

(1) The NHS being a large employer is only de facto a bad thing if it's inefficient. Compared to other countries, as outlined above, quite the reverse is true. (2) I'd love to examine the basic principles behind it - but you're not doing that here. What you're doing is cherry-picking data. I'll raise your "West Wales vs. Tianjian province" and "Northern Scotland vs. Slovenia and Croatia" by one "North American child mortality vs. British child mortality". Let's look at the big picture here, not keep sifting through the data until we find a couple of tiny pieces which make a nice headline titbit. A child in North American is more likely to die than they are in the UK. Life expectancy is shorter. Healthcare spending is vastly greater. Why? Those are the basics we need to examine right there.

3/ I won't even address the issue of Health 'tourism' -suffice to say from exposure to the NHS at very long remove in the London Borough of Brent, where my ward drew its population from primarily four countries, India, Sri Lanka , Pakistan and Bangladesh, the concerns over racism and endemic abuse of the system for family members reident in those countries, meant that in effect we were attempting to provide support for a population approaching 2 billion combined people. With abuse on this scale, surely the reforms proposed by the coaliton are a sideshow?

Perhaps true, but a separate point - and both here and with the cherry-picking above of the unhealthiest populations in the UK to use as comparisons, you touch on the fact that there's overlap between healthcare and social issues. Put simply, the fact the NHS can't make people in Northern Scotland live healthier lives, or "solve" immigration, is not a reason to ignore destructive, greed-driven reforms to it.

2011-11-07T22:02:00.000Z

Just read this gloss of the downright-dishonestly named "Better Services, Better Value" review of NHS reform in SW London. It was so hideous I decided to rewrite it in the style of Crazy People.

No change is not an option for health services in south west London, and we must therefore proceed with reforms without any hesitation or pause for thought. The report Better Services Better Value is a frank picture of where standards of care are falling short and where the safety of patients may be at risk, with the aim of 'telling it like it is' so that patients, carers and stakeholders have their expectations set as low as humanly possible before things start to get worse after our reforms.

Better Services Better Value is a review of health services across South West London being led by GPs, hospital doctors, nurses and other healthcare professionals who are geared up to make obscene sums of money by selling their patients down the river. Dr Howard Freeman, local GP and Joint Medical Director for NHS South West London, said “We have to be honest with local people about the challenges we face. The local NHS must change if we are to give patients the services they need in future. This is why local doctors and nurses are looking at how they might obtain as much of the £2.3 billion we spend on health services every year."

"We face a range of challenges – an ageing population, financial pressures, more people living with long term conditions and we aim to address this by providing such a poor service while lining our own pockets that people just die quicker. Ergo, we reverse the trend towards an ageing population, and leave fewer people living with long term conditions. What's not to like? In case the doctors who have a conscience try to object, we're going to put in place an arbitrary shift system to make them work until their eyeballs bleed and they don't have time to complain."

"Changing the way we deliver health services will save lives. A recent study showed over 500 deaths could be avoided in London if more senior doctors were available in hospitals at the weekend, and by study I mean editorial piece with some entirely fictional statistics in based on an excel document in which my formulas pointed to the wrong cells."

“The case for change lays bare the problems – and local doctors are nurses are determined that the patients we see every day should be involved as we try to solve them. We’re grateful to the hundreds of people who have already been involved and would urge others to have their say.”

I should say I have no idea whether Dr. Freeman is actually planning to award a whole load of services to himself under the new model, but even if he's not then he's drinking the kool-aid despite the opera-chorus of opposition to this idiotic bill.

The NHS reform bill: writing to your MP

2011-09-04T18:30:00.000+01:00

It will not surprise you, I hope, to learn that I'm against the current government's proposed reforms of the NHS. The reasons are legion, but have been adeptly summed up by Baroness Shirley Williams in today's Observer. The actual report she refers to was commissioned by the public action group 38 degrees, which I first came across when they (successfully) campaigned against the sell-off of public woodlands. They subsequently polled their members about what to do next; the NHS came up top, so they paid for a firm of solicitors and two barristers to report, independently, into the legal ramifications of the bill. It's important to note that the document Shirley Williams has commented on is written by lawyers - it is the professional, paid-for opinion of lawyers specialising in the area.

Arguably the headline finding:"Effectively, the duty to provide a national health service would be lost if the bill becomes law.", and with it we would "effectively [fragment] a service that currently has the advantage of national oversight and control, and which is politically accountable via the ballot box to the electorate".

They have been encouraging people to write to their MP, which I did via the BMA's stock contact form, and also have an excellent page on myths surrounding NHS reform. The text of our exchange so far follows; 38 degrees are monitoring individual MPs' responses and they make interesting viewing - you can check what your own MP's been saying if you wish. It looks very much as if instructions have been sent out to Conservative MPs to respond to concerns about provision of a national health service by subtly changing the wording to promote, thereby dodging the issue (to his credit, Zac Goldsmith has not done this, although his opinion as a layperson contradicts that of the legal experts here).

My initial e-mail was the stock BMA e-mail, so I won't reproduce it here; you can read it on their website if you wish.

Mr. Goldsmith responded:

Thanks for getting in touch, and I appreciate your concerns.However, I’m afraid I just do not agree with you. The Government is increasing investment in the health service by £11.5 billion over the next four years – investment opposed by Labour. The Government’s modernisation plans will release £5 billion of NHS bureaucracy savings that will be reinvested into patient care.

The NHS Future Forum confirmed that there is broad support for the principles underpinning the reforms. It also confirmed that the NHS is in need of reform, if we are to keep pace with the rising costs of treatments and technologies and in anticipation of an ageing population. I would go further and say that without change, the future of the NHS is under genuine threat. We need to find a way to get a great deal more from less.

With regards to your concerns about competition, the Health Department have said: 'We will ensure that there are new safeguards against price competition, cherry picking and privatisation. Monitor’s core duty will be to protect and promote the interests of patients – not to promote competition as if it were an end in itself'. The Prime Minister also gave his assurances saying, 'We will not sell-off the NHS and create some American-style private system - we will ensure competition benefits patients'.

I hope this is helpful, but if you'd like me to direct specific questions to the Health Department, I will gladly do so. Please let me know.

I replied:

Thank you for getting back to me. While I agree with two pillars of your reply, namely that the ageing population poses challenges, and that change is needed to address these, I cannot agree that the bill as proposed will address these in any meaningful fashion.

I am not alone in this concern. I would point out that pretty much every notable charitable organisation in the country that represents the interests of those with chronic illness has come out publically against the bill, including the Alzheimer's Society, Asthma UK, Breakthrough Breast Cancer, and the Stroke Association. Dementia affects about 1 in 6 of those over 80, and along with stroke represent perhaps the two largest causes of chronic illness in the elderly after perhaps heart attacks. If those two organisations, who would benefit enormously from any improvements to NHS care for the elderly and infirm, publically oppose the bill, I would respectfully suggest they do so firstly from a position of knowledge about the existing state of affairs for the elderly in this country, and secondly from a careful examination of the bill's likely impact on the populations they represent.

I should point out, too, that every notable organisation representing those who, like me, work for the health service, is opposed to the plans, including the British Medical Assocation (which I mentioned in my original e-mail to you), the Royal College of General Practitioners, the Royal College of Nursing, the British Psychological Society, and the Royal College of Midwives. (I didn't include this in my reply, but there is an excellent pictorial representation of those for and against the bill here, courtesy of the Jobbing Doctor's blog).

You will no doubt be aware of the concerns raised by Baroness Williams in the press today based on the work of the firm of solicitors Harrison Grant and the barristers Stephen Cragg and Rebecca Haynes assessing the proposed bill. Their professional opinion is that, notwithstanding the assurances given by the Prime Minister and others, that the bill removes the government's accountability for the health service, that it opens up the NHS to competition, that it removes or dilutes the government's ability to hold providers to account for their work, that it runs the risk of falling foul of EU competition law, that commissioning groups will be subject to costly EU procurement laws, and that it amounts to - and I quote "privatisation by stealth". It is perhaps unreasonable to expect you to ask theDepartment of Health how they would respond to these points, notwithstanding your kind offer to, but I would be grateful if you would encourage them firstly to take proper legal advice about the points the report raises, and secondly to respond to it in detail.

In every one of the hospitals in your constituency - and I've worked in most of them - acute care (accident & emergency and acute medicine) run at a loss, and they are effectively subsidised by the income generated from elective procedures. It is right and proper that this should happen, and that the NHS should pay for the emergency care of those most in need by making a small profit from elective care. Under the proposed NHS bill, every private firm that wins a contract to perform elective procedures is increasing the cost to the country (or decreasing the quality) of providing emergency care. This is particularly the case in light of the potential for expensive litigation which is outlined in the report Baroness Williams has spoken about publically today.

These reforms will mean the £11.5bn investment you talk about will end up not being spent where it should on those most in need, but rather ending up in the coffers of private firms who cannot legally be prevented from cherry-picking profitable procedures and who cannot practically be held to account for the long-term effects of their failures in care.While as I said I appreciate your response, I would again urge you to oppose these reforms until they can be passed in a form which meets with the approval of those working in the health service and those representing the elderly and those with chronic illness who it should aim to benefit.

The detail perhaps isn't interesting - but if you haven't e-mailed your MP, consider doing so, and unless you're absolutely sure you fall into the tiny percentage of the population fortunate enough to reach old age completely well, you should also consider voting against any government which tries to put in place plans suh as these. If not, sadly, you will pay for it later.

On looting and incentives

2011-08-09T23:02:00.003+01:00

The rioting / looting in London over the last few days has been marked by a reassuringly widespread sense of horror at how things are playing out, and by a much less reassuring polarisation of opinion relating to events. People seem incapable of believing both that Tory cuts and the innate shittiness of people can play a part - either the looters are misunderstood, or they need shooting, and ne'er the twain shall meet.

I have no particular insight into this, and I'm not the first to draw unwelcome comparisons between the police response to the current disorder and the police response to the recent tuition fees protests - the police themselves have been reflecting on that. However, reading Tim Harford made me think about it in terms of incentives...

We know that people's actions are governed to some extent by incentives - hence bonuses - and to some extent by punishments, hence prison. The obvious questions this raises aren't about whether what has happened has been right or wrong. It's apparent that the status quo didn't work. Either the incentives weren't enough - witness the left-wing view that it's all because of the withdrawal of social support to underpriveleged communities, or that it's because of the lack of opportunity open to the underprivileged. Or, the punishments weren't enough - witness the right-wing view that it's all because we've gone soft on crime.http://www.blogger.com/img/blank.gif

It's all a bit tired, isn't it? These arguments in essentially unchanged form are trotted out regularly. They're not just tired - the regularity with which they're trotted out demonstrates that they're sterile.

The obvious solution is a randomised controlled trial - and again I'm not the first person to call for those. In practical terms they're difficult. No one likes them. They seem unfair. So we'll disregard those.

So - what's the difference between the behaviour on the tuition fees marches and the Mark Duggan marches? Are the looters different in makeup from the students? Are they subject to different incentives and punishments?

Far though this is from scientific, possibly not.

The problem really is knowing what to change - incentives or punishments - and which is more expensive. Perhaps more on this to follow.

Blogging in the runup to the election: an invitation

2010-04-19T21:39:00.004+01:00

It appears that the eminent Dr. Grumble has been told from on high that he cannot blog in the runup to the election or he will be sacked.

Happily, no one has told your correspondent this from his Trust, which means either that he is totally unimportant, or that all those billions wasted on NHS management have not got them to the point that they can keep track of email addresses.

Actually, both are true, and I have a great deal less to lose than some of the veterans. Anyway, I had no intention of blogging about the election (isn't that what Twitter is for?), but this proclamation is a red rag to a bull. So, having consulted a very good friend who's an employment lawyer, I wish to announce the following:

(1) I work in the NHS.
(2) I will be voting Liberal Democrat at the upcoming election for several reasons, the most important of which to healthcare is that they have been honest about the possibility of cuts in the NHS rather than engaging in the unseemly scrabble of the other two main parties to see who can tell the most outrageous lies about the subject.

I will of course keep you all posted should the Thought Police come after me for the above. I would remind them at this juncture that all persons and places mentioned on the blog are fictionalised, and that they should not waste my time by trying to dress this up as a confidentiality issue.

(3) Vote Lib Dem!

Was that overtly political enough, do you suppose?

Addendum: it seems we haven't all been gagged - perhaps the merciful lack of 'managers' of senior doctors in primary care...?

Rules of accident and emergency (1)

2010-04-08T13:06:00.006+01:00

Working in A&E is a rum business. My experience has been that it's unlike anything else I've done apart from GP, which - despite the whining and bitching we A&E doctors do about some of the referrals we get from General Practitioners - is similar but with a slightly different focus. At its simplest level, in a perfect world GPs would manage all the worried well, and A&E would manage the acutely unwell.

Because it doesn't quite work like that, however, you can spend one day in A&E seeing people with colds and no common sense, and the next seeing people who've been stabbed or in car crashes (and very occasionally both). It also does make you want to lay down certain ground rules to anyone who walks in the door, and as I only occasionally get vexed enough to do this to people in the department, I thought I'd lay some Rules of A&E out here.

(1) Don't complain about the wait. Ever. We know there's a wait. We are sorry there is a wait. We do not need to apologise to you for it, and your complaining about it MAKES IT LONGER.
(1a) Don't ever complain about the wait by saying "I came in a (fucking) ambulance". Coming in to hospital in an ambulance does not mean you should be seen quicker. All that it means is that you either thought you were a lot more unwell than you are, in which case you're thick/misguided, or that you were too lazy to get the bus or to find someone to drive you in. Reminding me that you've just wasted several hundred pounds' worth of taxpayers' money and an ambulance crew's time is not a good way of encouraging me to see you faster.
(2) We do not accept referrals from private doctors with a dubious grasp of ethics for investigations they tried to get you to pay for there but you couldn't afford. This is particularly the case if they haven't bothered to examine you properly. If I think you'll need it, I'll try to get it organised; if I don't, you don't need it.
(3) No, you can't "just stay until the morning". You have hospitals confused with bed and breakfasts.
(4) No, we can't get an ambulance to take you home. You have hospitals confused with minicab companies. If you decide to come into hospital, you take responsibility for getting yourself home.
(4a) Further to the above, don't remind me that you arrived in an ambulance. If you're well enough to go home inside four hours, you didn't need that ambulance in the first place (and see 1a above).
(5) If I tell you to man up, man up. This is particularly the case if we've let you sleep off some of your hangover in a hospital bed you don't need and you're resisting my clearing you to go home because you want to sleep longer.
(6) Yes, you do have to pay for outpatient prescriptions in hospital. If I'm sending you to the hospital pharmacy for drugs, it's because we don't keep those drugs in A&E. Because they aren't needed in emergencies.
(6a) If you have come in with some trivial complaint I've written you a prescription for, and you don't need to pay for your drugs normally, you will need to prove this to the hospital pharmacy just as you do outside hospital. If you can't do this, then please don't come back and complain to me about it: I cannot prove you're exempt. That's the DSS. In particular, don't do this because if you thought your problem was serious enough to come in to an emergency department for, it should be serious enough for you to pay your seven quid for the tablets I think will make it better. Especially if, as happened in one case I saw recently, you are flying to Bermuda in three days time for a holiday.
(7) Before coming in, please ask yourself one simple question. "This is an accident and emergency department. Which am I?".

More to follow. Maybe.

Medical Education England survey: it isn't just me!

2010-03-04T17:43:00.004Z

The Royal College of Physicians of Edinburgh has responded to the NHS MEE survey on the European Working Time Directive. Although this isn't the survey I discussed in my last post (which was on Foundation Training), it's unavoidably related, as the explanatory rubric for the Foundation survey acknowledges: "We recognise that the European Working Time Directive (EWTD) and its impact on the medical workforce is of major concern to many stakeholders. As you will know, EWTD is the subject of a current review by MEE. Please focus submissions on the Foundation Programme itself with references to EWTD to the extent to which it impacts the Foundation Programme."

The RCPE response is pretty comprehensive, and it's well worth a read. They point out:
(1) Prior to its introduction, 84% of physicians expected it to impact negatively on training
(2) After introduction, fewer than half of rotas were in reality compliant
(3) Most continued to feel it was negatively affecting training after its introduction
These three points - with which they open their response - neatly encapsulate the problem with the DoH's interference with medical work:
(1) Doctors' views on the proposed change are ignored, despite being overwhelmingly in one direction.
(2) The promised benefits to doctors and patients don't materialise in practice, despite their continuing to be trumpeted around the press whenever possible.
(3) The doctors' predictions on the change turn out to be correct, by which time of course their work and their patients are suffering the consequences.

This was exactly the pattern followed with MTAS, PFI, and the introduction of private contractors into the NHS, to pick arguably the most catastrophic of recent examples.

Pleasingly, the RCPE go on to reaffirm pretty much what I said in that last post, and indeed in rather more concise fashion. Most pertient to what I was saying are:
7. Rota patterns to achieve 48 hours were causing trainees to miss outpatient clinics, teaching lists and ward rounds. This is of particular concern for specialty training with missed teaching sessions (elective lists, clinics, procedure sessions etc) due to trainees covering more general duties in wards, on call duties or rostered off duty.
9. There is even less opportunity for consultants to work with their allocated trainees and this limits teaching, assessment and mentoring opportunities. Many expressed concern about inadequately assessed/trained consultants in the future and worries about erosion of professionalism and work ethic.

Perhaps most damning of all, however, was this:
12. Trainees accept that service provision provides a rich training environment but they feel the balance has shifted completely towards service with consequent disruption of their training and erosion of their quality of life through difficult rota patterns. Some felt that employers’ threats of imposing shifts may be stifling complaints.

This is pretty much exactly the situation that MMC promised to get rid of. Instead of abolishing the "Lost Tribe", they've turned an entire generation of trainees into them - service automatons with no training, no quality of life, and no control over the working patterns. When you read their response, doesn't it even sound worse?

Medical Education England, evaluation of Foundation Training Programme

2010-02-27T00:46:00.003Z

Medical Education England are conducting a consultation on Foundation Training of junior doctors. This is in itself a laudable thing to do, as one might expect from something recommended in the rather marvellous Tooke Report. However, the thankfully-now-departed-Lord Darzi, whose job title I've already paraphrased in my head as "hopelessly out of his depth", decided to remove from the body the budget for medical education.

As president of the Royal College of Surgeons, John Black, has pointed out, this makes it doubtful they'll have the ability to get things changed.

Anyway, their questions are nicely targeted at the key failings of the system as is, so here is my response to it. It is largely rant, but parts of it may be entertaining, and it may make interesting reading for a few of you. Questions from the consultation document are in bold, thus.

1. What were the original objectives of the Foundation Programme?
Respondents may wish to consider both educational objectives and other objectives (e.g. service provision, workforce planning etc.)

In practical terms, the programme was intended to ensure all graduates delivered good clinical care, could work safely and appropriately within teams, and developed from where they were as medical students – or showed potential, if you like. They needed to show that they understood the framework within which we operate as doctors both locally at a community level, nationally, and internationally. It also required that we produce large numbers of workplace assessments with no demonstrated educational value, thereby producing a neat piece of hypocrisy in relation to another of its purported aims, that of encouraging us all to demonstrate evidence-based practice (reminder: per p.39 of the 2008-2009 survey, none of the assessments in use "received a rating higher than 41% from consultants, even from those trained in their use".

Theoretically, it was founded on the Unfinished Business, Modernising Medical Careers, and from the NHS Plan (2000) document (sections 8.27 & 8.28) and its commitment to increasing consultant numbers and modernising the SHO grade. Perhaps most notable are the problems listed in Unfinished Business (p.4) with the old system: (1) poor job structure, (2) poorly planned training, (3) weak selection and appointment procedures, (4) increasing workload, (5) inadequate supervision, assessment, appraisal and career advice, (6) insufficient opportunities for flexible training, (7) unsatisfactory arrangement for meeting the training needs of non-UK graduates, (8) the variability in the relationship between Royal College examinations and their relevance to training programmes.

1.
What were the original objectives of the Foundation Programme?
Respondents may wish to consider both educational objectives and other objectives (e.g. service provision, workforce planning etc.)

In practical terms, the programme was intended to ensure all graduates delivered good clinical care, could work safely and appropriately within teams, and developed from where they were as medical students – or showed potential, if you like. They needed to show that they understood the framework within which we operate as doctors both locally at a community level, nationally, and internationally. It also required that we produce large numbers of workplace assessments with no demonstrated educational value, thereby producing a neat piece of hypocrisy in relation to another of its purported aims, that of encouraging us all to demonstrate evidence-based practice.

Theoretically, it was founded on the Unfinished Business, Modernising Medical Careers, and from the NHS Plan (2000) document (sections 8.27 & 8.28) and its commitment to increasing consultant numbers and modernising the SHO grade. Perhaps most notable are the problems listed in Unfinished Business (p.4) with the old system: (1) poor job structure, (2) poorly planned training, (3) weak selection and appointment procedures, (4) increasing workload, (5) inadequate supervision, assessment, appraisal and career advice, (6) insufficient opportunities for flexible training, (7) unsatisfactory arrangement for meeting the training needs of non-UK graduates, (8) the variability in the relationship between Royal College examinations and their relevance to training programmes.

2. How successfully is the Foundation Programme delivering against those objectives?
Well, to deal with those points in turn:
(1) The new system is more structured than the old. You now know you will be doing 6-8 placements of 3-4 months each at 1-3 hospitals over two years. With that structure, however, you lose flexibility. Whereas in the past trainees in their second year were able to choose jobs which allowed them to try out their possible careers, they’re now not able to do this, and even straightforward requests to swap medical rotations between trainees at the same hospital require an insufferable number of people to sign off that this is okay, when the rotations themselves are nominally all identical anyway. The increase in structure is not a bad thing per se, but it has reduced our ability to investigate our interests and to choose to do a year’s worth of service provision if we have other things (marriage, childbirth, ill relatives) going on.

(2) Poorly planned training. I take this to encompass both training as a whole and the subset within that of education. Training is now a mess. It is virtually impossible, thanks to the shift patterns worked by all doctors, to find time to spend with patients in the company of a senior doctor who can teach you. The workplace assessments hinder this because they are badly thought out, have no appreciable evidence base, and cast spending time with trainees as a box-ticking exercise for senior doctors who find that process as loathsome as most trainees do. You cannot make up for that deficiency in clinical time with your seniors with any amount of well-intentioned “modern adult education”; helpful though things like ALS and simulation training are, they must be adjuncts to and not substitutes for training on the job. Education is haphazard at best, with trusts given the impossible job of delivering the entire Foundation curriculum to a group of shift-workers in disparate geographical locations. Foundation education sessions are therefore variable in quality to say the least, particularly at F2 level where nights and A&E rotas are commoner. Outside education courses, although they are the single most useful things you can do to further your career, are almost never funded and rarely allowed as study leave during the Foundation Programme.

(3) Weak selection and appointment procedures
The application form I went through for the Foundation Programme read like something written by management consultants who hadn’t done very well at university but had read books with titles like “who ate your pineapple” or “the forty-two secrets of successful despots”. It was an awkward, fumbling attempt to embrace tools used carefully, on small groups of people, by experts, as a small part of the selection processes in business, and to clutch these tools to the bosom of an organisation looking to use them on every medical graduate in the country and thousands of others besides, by novices, as the entire selection process, in a government employer. I am an English Graduate, and it being largely a creative writing exercise, I scored exceptionally well on it. It was none the better for that.

(4) Increasing workload. Overall, our hours worked are probably fewer than previously. I know of very, very few F1 and F2 rotas which are honestly EWTD compliant, but few go over 60 hours a week on average (although many go over that regularly). However, we’re now paid less for working fewer hours, training is a disaster, registrars and consultants are less available because they’re working the same diabolical shift patterns we are, and we keep getting told how much better we have it, and that we aren’t working more than 48 hours a week when we patently are. I didn’t work under the old system, but I suspect this feels like harder work.

(5) inadequate supervision, assessment, appraisal and career advice
I’ve covered supervision before – putting the seniors who teach on a shift pattern, and then putting the juniors who need to learn on a different shift pattern, and reducing the hours worked by each, cannot but reduce the amount of clinical supervision the juniors get. Think of it as an equation. On top of that, almost half of trainees who make errors cite inadequate supervision as a reason for it (Table 14, p.29). Assessment is a mixed bag: the tools, with the exception of the “mini-ePAT” (or “feedback”, in English) are a waste of everyone’s time, and you’re that much less likely to get a genuine assessment of your performance as a result. Appraisal, however, is made immeasurably better by having educational supervisors, in my humble opinion, although these should *always* be firm heads for at least one rotation in each year. Career advice, as ever, is best when obtained from the horses’ mouths. The career sessions have seemingly been aimed at telling us what questions we need to ask to decide on a career, which in a group of highly educated graduates is a little insulting if you think it through. What we need, of course, is not to be told we need to think about our work-life balance and whether we want to work independently, or earn lots of money, but answers to these questions in terms of what careers involve, and that doesn’t yet happen and indeed is not something the Foundation Programme is best placed to offer.

(6) insufficient opportunities for flexible training. This is better, and at the moment flexible training through Foundation is a reality. It is also one which the trainees really need to organise themselves, but once funding has been obtained centrally, most people I know have been able to persuade Trusts to let them do whatever rotations they want, making it more flexible than it was perhaps intended to be – something which, given the state of the rest of the system, I’m practically obliged to be heartily in favour of. And so I am.

(7) unsatisfactory arrangement for meeting the training needs of non-UK graduates,
MTAS cleverly improved this arrangement by denying them all careers in the UK, making them emigrate, and causing the British Association of Physicians of Indian Origin to take the perpetrators of this disaster to court in a case which was a classic pyrrhic victory. In terms of European graduates coming over now, I would be fascinated to see stats on Foundation trainees who fail years. My experience has been that they are almost invariably from outside the UK – and I don’t think that’s necessarily because they’re worse doctors. Is the training actually helping meet their needs, then?

(8) the variability in the relationship between Royal College examinations and their relevance to training programmes.
You’ll be relieved to hear that for the first time I don’t feel in a position to comment on this, except to point out that baldly listing pass rates for different Royal College examinations without looking at the differences between those Colleges and what they’re assessing isn’t much of an “analysis”.

3. What are the future needs of the service and trainees from the first two post-graduate years (PGY1 and PGY2)?
Respondents may wish to consider both educational objectives and other objectives (e.g., service provision, workforce planning, etc.)
First, prompted by the “PGY” TLA, and most importantly: no more name changes to the years. “House officer”, and “Senior house office” work fine.
The service needs are simple: there aren’t enough trainees to fill the rotas. What the service requires is, er, a way of appointing doctors to non-training “service roles” for short periods to increase the quality of training posts. That would also stop them haemorrhaging cash on locums when budgets are being cut left right and centre.
Trainees need less layers of management in their Foundation Years. I would guess that fewer than 1% of trainees could accurately describe the relationship they have as individuals with Trust, Deanery, and Foundation Programme, never mind what the LAB, LFG, and LNC do. I’m not sure I can answer either question despite taking an interest in these things, having been to meetings of all three of the latter committees, and having served as a rep in both my foundation years.
We need to be allowed to play the game. We are not responsible for the system; we have no ability to change it at present. When the benefits of postgraduate exams in terms of securing specialty training are so huge, therefore, we must be allowed to use our education time and study budgets to prepare for these exams. No one will get a ST job in surgery because they went to a session on reflective practice, and no one will get a ST job in obstetrics because they understand the different types of antipsychotic. You are welcome to tell us that we are adults and need to take responsibility for our own ongoing education, but please understand that we will therefore expect you to put in place a system which does not prescribe education to us regardless of our needs as the current one does.
We need a system where we can spend time at the bedside with senior doctors. That means less shift patterns, and perhaps longer hours: fine. Let us get our training in a way that works, and stop making training juniors into something seniors are obliged to do.

4. How successfully is the Foundation Programme delivering against those future needs?
It’s making limited progress in a small number of important areas (continuity of educational supervision/appraisal, flexible training), and it is losing important ground in a large number of others (training, service provision, encouraging self-reliance and self-determination).

5. What changes are needed to ensure that PGY1 and PGY2 deliver against future needs?
Respondents may wish to consider changes to the purpose, curricula, length, rotational structure, assessments, educational environment, selection processes, governance, career advice, and implications for training both pre-and post PGY1 and PGY2
FY1 teaching can be generic: it is appropriate then to have a series of pre-determined lectures on core topics. These should be assessed by F1s, and their own feedback should be available to them immediately alongside that of previous years for the same sessions, thus allowing them to establish whether it had improved or not. Trusts should engage them in the process of designing and improving teaching sessions. Medway was excellent at this in 2008-2009. FY2 teaching should be entirely self-determined – if trainees want to go and do a course for MRCP, let them and pay for it. Don’t hire someone to hector them about career choices, nor ship in a (rightly) terrified infection control nurse, nor tell GPs that for some reason they’re not allowed study leave for their membership exam.
FY2 as currently limits our ability to explore our career choices prior to being obliged to choose one. The process of organising swaps within and between Trusts must be easier, clearer, and should not require the approval of anyone beyond the two trainees involved and their educational supervisors, with an appeals process if one or both educational supervisors disagree. No deanery involvement, no FP involvement: if you tell us that the programme is generic and that one rotation is the same as another, you cannot then add “…but they’re different enough for us to have to approve swapping them”.
The relationship between FY2 and ST1 needs to be more carefully thought out. We are being made to choose careers before we’re ready. The Tooke report revealed how few F2s knew what they wanted to specialise in at the start of F2, and how many of them changed their mind during it. Why then have we moved to a system which brings forward that decision while reducing our ability to explore it beforehand?

The government's response to the EWTD petition

2009-08-06T22:39:00.002+01:00

The government have just published their response to the petition asking them to allow surgeons to work more than 48 hours a week.

It's a pack of lies, and here's why:
The European Working Time Directive (EWTD) is health and safety legislation introduced in 1998. It will benefit patient safety

Will it? As the president of the Royal College of Surgeons has already pointed out, this is legislation "mainly concerned with the health and safety of manual workers. It was designed to protect Spanish lorry drivers or labourers working heavy machinery." I'll come back to the evidence on patient safety shortly, but fundamentally what we have here is some office-based staff in Whitehall, who have never looked after a patient in their lives, trying to tell surgeons across the country how they can best be trained to do operations the Whitehall mandarins have not the first idea about.

In addition, this completely fails to address the fact that there are huge gaps in the rota. There are not enough surgeons in the UK to have safe numbers of surgeons on duty if they can only work 48 hours a week. That is unsafe.

and the wellbeing of those healthcare professionals who treat and care for them.

Those selfsame healthcare professionals are adults. They are perfectly capable of deciding how their wellbeing is best safeguarded without your ill-informed opinion on it. Over 80% of a survey of over 1,000 surgeons in training recently supported a complete opt-out from EWTD.

By complying with the EWTD average 48-hour working week averaged over 26 weeks, we can ensure we have well-rested doctors who make good use of their training time and provide high-quality care for their patients.

Ah, the insinuation that the problem is just that doctors aren't making good use of their training time! Lovely. Also, I can vouch for the words of John Black: "Do not believe the Department of Health propaganda that under the EWTD doctors will be less tired. They will be more tired than when they worked apparently longer hours but had space to think, pause, rest and talk to colleagues."

No one wants or deserves to be treated by a tired doctor who may make mistakes.

There is certainly a cutoff in terms of hours at which mistakes become more likely. However, this implies that reducing hours to 48 on average means mistakes are impossible - which is of course nonsense. It also misses the point - the EWTD does not limit you to 48 hours in a given week. My last rota meant I worked one day on call a week plus 1 in 4 weekends, so that over a two-week period when I was working a weekend I would on paper work 9 to 5 monday, tuesday, and thursday, 9 to 10 on wednesday, friday, saturday and sunday, and then 9 to 5 all days in the second week except wednesday when I'd again do 9 till 10. So in the first of those weeks I worked 76 hours, and in the second 45. The average is worked out over four months, so you can and will do far more than 48 hours in a given week. The number has been plucked from the air, not as this implies based on any evidence doctors are more prone to mistakes.

Implementation of the Directive means that all NHS staff can enjoy a sensible work-life balance.

The survey I've already mentioned found that 71% of doctors reported that the reduction in working hours had not led to an improvement in their work life balance.

Junior doctors in training are the only group within the NHS whose working hours are not yet fully compliant with the EWTD. There have been reductions in maximum average hours to 58 hours in 2004, to 56 hours in 2007 and finally to 48 hours by 1 August 2009.

Meaningless, and misleading - consultants (who are the only group excluded from the above claim, I presume, as registrars certainly do more than 48 hours a week at present) regularly do additional private work on top of their NHS commitments, and again they are not less safe for it - quite the reverse.

NHS North West is demonstrating that EWTD compliance can be achieved consistent with the provision of effective services and training. By October 2008, about 95 per cent of doctors in the North West and 36 out of 38 organisations were compliant, a year ahead of the 2009 requirement. Most UK doctors in training already comply with the EWTD, and the overwhelming majority will do so by 1 August this year.

NHS North West? They must be brilliant - what Trusts can I go to there to take advantage of this terrific compliance rate? Oh - Mid Staffordshire NHS Trust, you say? Could this be the same Trust of which the DoH website recently wrote "It was a catalogue of appalling management and failures at every level for which the Secretary of State apologised on behalf of the Government and the NHS in his statement to the House the next day"? Er, yes. In addition, there is evidence those compliant figures are falsified because 10% of respondents say pressure was put on them falsely to under-report their hours.

We recognise that EWTD has meant challenges. We have listened to and acted upon concerns raised, for example through many surveys, conducted at different times. We appointed Dr Wendy Reid from the London Deanery as national EWTD Clinical Advisor. We have also established a EWTD Reference Group co-chaired by Dr Judith Hulf, President of the Royal College of Anaesthetists, and Professor Patricia Hamilton, Director of Medical Education at the Department of Health. The Reference Group includes the British Medical Association (BMA), the Royal Colleges, Strategic Health Authorities (SHAs) and the Deaneries. In addition, there is a task and finish and steering group.

Yes - but just as with MTAS, you have made these appointments token by ignoring their advice at every turn. Just appointing people doesn't solve problems - you have to act on what they say.

I now skip a lot more boring guff.

The NHS Workforce Census issued in 2009 highlighted significant increases in consultants and doctors in training. There are 34,910 consultants, which shows an increase of 3.7 per cent on the previous year and represents a 56.4 per cent increase over ten years. The overall number of doctors in training is 49,178, an increase of 5.1 per cent from last year and 59.4 per cent compared with ten years ago. There are more doctors than ever working in the NHS.

Of course there are - you've slashed the number of hours they're permitted to work, so more of them are needed. That's GCSE maths, not an indictment of your flawed policy change. The issue which this petition raised was over the quality of those doctors, not their numbers. In addition, there is already evidence that our training is suffering as a direct result of service reorganisations.

The Government has also provided funding by including £110million in allocations to Primary Care Trusts in England in 2008/09 to help support NHS compliance with the EWTD. This has been increased to £310million for 2009/10 and includes £50million to support changes needed for specialties such as paediatrics, obstetrics and anaesthetics.

And the old "we've spent money, look, it must be all right" card.

Finally, the Health Select Committee’s report on patient safety said, of EWTD and the Working Time Directive rules, that the Committee was not convinced by the more alarmist claims being made that these will seriously jeopardise patient safety when they are introduced on 1 August. The Committee consulted with a wide range of stakeholders in coming to its conclusions.

But you didn't look at the evidence, which all shows that you need to be working old-school hundred-hour-plus weeks for errors actually to increase. Instead, you cobbled together a study of 19 doctors in Warwick where you had to count patients falling over as 'errors' to get a significant result.

It's pathetic, and the sooner we get rid of this shower the better.

Complaints

2009-06-01T18:34:00.002+01:00

Shortly after noon today I walked past a group of people who were milling around in a corridor asking one another questions in the confused way that those who are lost in hospitals share with particularly slow labradors which are confronted by a glass door they keep walking into.

As I'm prone to do in such situations, I asked if they were lost.

"Yeah", said one, "The thing is - y'know that hand gel you put on to clean your hands?"

I nodded, wondering for a moment if they were after a boxfull to sell to the winos - don't laugh, it honestly happens.

"The things is, I was putting some on and it got on my top, and it's burnt my top."

I stood watching her a moment in incomprehension, probably looking not unlike a confused labrador myself, although it was true she had a small darker area of green about the size of a 50p piece on her XXL fuschia pink top.

"I'm looking for somewhere to complain. It's a brand new top."

I directed her to the general office, which alas she'd just come from, so I said I was sorry, but I didn't know, and left them to it.

It seems incredible to me that we live in a society in which people come into hospital and, in the process of using something designed to protect them and their nearest and dearest from seriously nasty illnesses (infection control is mostly a total crock, but there's no doubt that handwashing works), manage (a) to get it down their fronts and (b) to think this then gives them a right to complain to the hospital. Where's the sense of perspective? Where is the sense that they shouldn't be wasting people's time with a small stain to a T-shirt?

Perhaps bibs are the answer?

Where are the whistleblowers?

2009-03-24T01:20:00.000Z

They're all down the dole office. This is what happens if you speak out in the NHS - that, and then a DoH idiot or junior government sleaze will go on telly and brazenly lie through their teeth about whatever atrocity their policies have produced...

Sorry: it is late and I am slightly sleep-deprived.

Hiving things off, or where the India posts have gone

2009-03-19T00:51:00.002Z

None of you will have noticed, but I've moved my 2006 India missives off to their own separate blog; I felt they made more sense there. They're linked from the top left and doubtless in many other ways if you are interested in re-reading them. Others, particularly Toulouse, may follow if I continue to fail to go to bed.

"Central government strategically enabling and catalysing better services"

2009-03-18T23:22:00.003Z

The internet disgust for the hypocrisy of a government which can continue to trumpet that "central government [is] strategically enabling and catalysing better services" despite the death toll in Staffordshire General Hospital is mounting. While internet disgust is, per my last post and more to the point David Mitchell's recent blog, a dangerous thing to take seriously at the best of times, the criticism has been surprisingly restrained given that death toll. I'd encourage you to read:

The Ferret Fancier: 'Individual management failures', where he outlines the absurdity of Gordon Brown saying that no reasonable person would deny A&E admissions should be seen within four hours in a week when that precise policy has been shown to kill by obliging Trusts (very intentionally plural) to prioritise the meeting of targets over everything else including patient care in order to get funding.

Dr. Grumble: Mid Staffs Investigation, which links a channel 4 news story and observes that junior doctors were pressurised into taking decisions they knew to be wrong to meet targets.

NHS Blog Doctor: It couldn't happen in Britain: Staffordshire General Hospital, which links the "dirty tricks" campaign used against Rita Pal, who tried to blow the whistle on Midlands hospitals several years ago, to the absence of doctors as whistleblowers

The Witch Doctor: A letter to Mr Brown, Mr Johnson, and Mr Bradshaw, which suggests that despite all the jargon (and although I am again criticising the government and civil servants, God Bless the Local Government Association, at least for today) and management-speak the government and the DoH are producing about leadership and "Leading Beyond Authority", part of the problem in Staffs and generally is that the real leaders in the NHS are being overlooked.

Angus Dei: NHS: Mid Staffordshire NHS Trust: The Killing Fields, observes that Monitor, the body set up by the government at a cost of millions to provide effective regulation of NHS Trusts and better patient care took the decision to award Staffs Foundation Trust status while all this was going on, and observes that this makes them look like a colossal waste of money. He also notes that the Healthcare Commission didn't pick up on any of these problems in their annual healthcheck (that channel 4 news story linked to from Dr. Grumble's post suggests it was an independent medical statistics group in London who highlighted the problem).

The Jobbing Doctor: All together, points out that the supposed figureheads of our profession, the senior figures who have chosen to case their lot in with the government and to support their reforms, have been in post for a decade, and must take some responsibility for permitting the system to be put in place which caused these deaths.

All I have to add is that - as with the MMR scare - the media are part of the problem here: we as a society must learn that beating up on people who are working under conditions outside their control (doctors and managers both) will not solve the problem. These situations arise because the government has set up a system whereby meeting pointless targets is rewarded financially, and conversely if doctors do what they are trained to do, that is treating patients according to the degree of their clinical need, their Trust misses targets and gets its funding cut. Let us be completely clear: the managers are not to blame. The managers do not create the rules of the game - they are employed to meet these targets, and even at Staffordshire they did it well. The government rewarded them for their behaviour. The system put in place rewarded them for meeting their targets, and indeed by the standards the Department of Health has chosen to judge Trusts by, they still are an excellent Trust. The inevitable stripping of their Foundation Status will not change that fact, and while it is probably the right thing to do, all it does in reality is to give them less money to address the problems with.

There is no point trying to demonise the managers (I disagree with Angus Dei here) nor the hospital - that is scapegoating. The system is at fault here, and it must be changed, as indeed must the soi-disant political (Brown, Johnson, Bradshaw) and medical (Donaldson, Carol Black, Paice, Needham) 'leaders' responsible for the state of our health service. Until they and the targets are changed, we - you - are part of a society that continues to incentivise seeing people within four hours because it wins votes over keeping them alive.

Mind you, it is an old political truism that the dead cannot vote, so perhaps the government are just playing the system they are part of perversely well...

Choose and Book is rubbish

2009-03-17T17:52:00.003Z

A week or so ago a young woman came in to hospital with cholecystitis. It isn't serious, but for most people you wind up removing the gall bladder to stop it happening again. However, you don't do this acutely unless you have to because the complication rates increase by a third (as the gall bladder tends to be harder to separate from the liver when inflamed) - so you let it settle down and bring them back to have it done.

This particular young woman was one of the unfortunate people who, while waiting for her operation, had had another attack and so had come in to see us. From talking to her it sounded like the first one had been diagnosed and treated by her GP, so well done him or her, and she'd been booked to have the gall bladder taken out.

She was obviously keen to have it done sooner given that she'd had the repeat episode, but was happy once we explained the reasons we tried not to do that. I did say I'd try to bring her date forward if possible, but ran into problems - I couldn't find any record of the operation with the secretaries. I went back to ask her about this, and it turned out this was because she wasn't booked with us, but at Other Hospital half an hour down the road. I asked if she'd rather have the op done there, and she said no, we were more convenient.

This begged the question - why had she been booked there to start with? The answer, inevitably, was Department of Health stupidity, specifically the diabolical Choose and Book. She'd been booked through that because the government now makes GPs use it if they want to hit their targets and get paid, and the quickest appointment had been at Other Hospital. So even though that meant her travelling three times as long to get to hospital, and being operated on somewhere they didn't know her (because acutely she comes in to her local hospital, us, when she's sick), it lets the government say people are treated faster!

I booked her with us and cancelled the Other Hospital appointment.

Rating doctors and the "enormous democratising power of information"

2009-03-17T13:02:00.006Z

While his partner in crime has been dancing his way to glory (genuine glory) for Comic Relief, David Mitchell has been commenting on the Supreme Leader's plans to make public services more transparent.

To my mind, Mitchell hits the nail pretty much on the head:
"He's invoking the collective wisdom of the nation to pass judgment on and improve our public services. Unfortunately, he'll mainly attract the same self-selecting bunch of inexplicably livid weirdos who infect the comment sections on all websites."

He goes on to discuss a comment on his own work which was censored as it ended with the words "you fat cunt", and observes:
"So if I, as someone whose work doesn't really affect people's lives, am subjected to this online abuse, what are GPs, nurses, consultants, police and teachers in for? They're obliged to tell people things that they don't want to hear: to arrest them, give them homework, make them stop eating fried breakfasts, announce that their gran died on the table."

Which is all pretty much spot on. The only reasons I am reposting what he said here are that (a) he is exponentially funnier than me and (b) he neglects to comment on the actual pronouncement Gordon Brown came up with. The BBC report on it is titled "EBay-style feedback for services". This raises a couple of questions.

Firstly, how will doctors, or postmen, or teachers, be able to feedback on their "customers"? As more profane bloggers than I have observed, we can hardly respond to a potential "one-way torrent of cyber-vitriol from semi anonymous heartsinks" by observing that "Mrs Lardbucket is a malingering, workshy waste-of-space, who manages to lower the quality of life of everyone at the practice when she drags her trivial, hypochondriacal existence into our threshold." The point is a serious one, and was also made by David Mitchell: there are people who will not want to hear what we have to say, or who will not listen, or who will blame us when things go wrong. The best doctors, arguably, are the ones who do this routinely, who tackle the patients whose default mode of engagement with the medical profession is to come in to see someone and then to ignore or argue with what they say. This system will punish those doctors with poorer ratings even though they are doing more difficult jobs.

Secondly, do we have "customers" in the same way that an ebay vendor does? Ebay introduced its feedback system because they are a peer-to-peer transaction site, and you are buying from someone you have never met who could, frankly, be taking you for a ride. Fraud has always been a problem on the site. Is Gordon now deciding that the default position of patients needing medical attention should be that doctors are all frauds who are looking to take their money in exchange for nothing? The model is difficult given that, er, we don't take any money from them and have nothing to gain from misleading them - unlike the ebay fraudsters who made 300,000 smackers conning people out of money for non-existent goods.

In addition, there is already a rather good "feedback" mechanism in place. If you don't like your NHS doctor, you can go and see a different one. For free. Without spending any money at all. In some cases this requires that you negotiate that bastion of Department of Health stupidity, "Choose and Book", but you can already vote with your feet. (So oblivious are the government to this simple fact that they actually reward unpopular GPs as things stand - if you have available slots, so that patients can see you the same day, for example, you are deemed better than the person in the next consulting room who is booked up until thursday. Never mind the fact that the person who is booked up is booked up because patients prefer to wait to see them than to see the crap partner - that doesn't let the government trumpet that you can now see a GP within 24h, so it must be rubbish!)

If you can bear it, read the document in which Brown lays out this wholesale stupidity. There is no rationale for it - just a lot of patting-self-on-back coupled with cross-promotion of several other of the DoH's lunatic policies, including polyclinics, dressed up here as "health centres" and offering "a nurse-led minor illness service". This is wonderful given the success of dumbing-down medical treatment in A&E at the Mid Staffordshire NHS trust, where prioritising was often done by totally untrained staff thanks to budget cuts: I wonder if these will kill as many patients? There's also a bit of stating the obvious (it turns out we have an aging population - why did no one tell me?). My favourite bit, though, is this:
"The NHS, having turned 60, is therefore embarking on a further major stage of improvement set out in the Government’s Next Stage Review of the NHS, driven primarily by empowered patients and front-line staff working together to improve health, with central government strategically enabling and catalysing better services." I cannot think of a single service which central government 'enabling' has improved at all, unless some DoH oaf thinks "catalyse" means the same as "cripple".

It also suggests "Self-Directed Support and Personal Budgets" are a good idea, paving the way for capping state-funded medical provision, congratulates itself because two-thirds of GP surgeries are now open in the evenings when it is this government that gave GPs the too-good-to-believe offer of opting out of providing 24-hour care in exchange for six grand less a year. Most despicably of all, it has the gall to say that "Government will publish information about public services in ways that are easy to find,easy to use, and easy to re-use, and will unlock data, where appropriate, through the work of the Office of Public Sector Information." On Sunday some such information was released by the House of Commons' Health Committee. It showed that the gap between rich and poor had widened over the past decade despite ministers throwing money at the problem. In this case a DoH spokesman said "Our health inequalities programme is backed by a wide evidence base and an independent scientific group. Major programmes - such as Sure Start, and efforts to tackle obesity - are based on research and are being evaluated." This is indicative of the government's response to any policy criticism, which is to ignore their own data - as in this case where it is "based on a wide evidence base" and "being evaluated", ignoring the fact that there is data right now that it isn't working - and to repeat that they've spent a lot of money as if this is somehow a good thing when it's being wasted. As an aside there is an interesting-looking book out suggesting that it is precisely this gap which is at the root of most societal problems.

So the document is loathsome, meaningless, and fails within its own pages to do what it claims to be setting it to - so it is also hypocritical. No great surprises there. But this rating idea is wholesale stupidity, and ignores the glaring differences between feeding back on commercial transactions and healthcare ones, ignores the inequity of a system allowing anonymous feedback without the right of reply or any independent verification, it undermines the bond of trust that doctors work very hard to create with our patients (further proof that Ara Darzi's comment that we need to "separate that fantastic relationship between the doctor and the patient" was not a 'mis-speak'), and worst of all suggests that what is right for you is right for me. If you like your GP, excellent, but I may not - interpersonal relationships are like that. Some people love doctors who tell them what they should do, others hate them. Some people want a no-nonsense approach to sorting out specific problems, others just want a chat. The great thing about the healthcare service at the moment is that all these people exist, and if you go to see your doctor and don't like him or her you just go and see someone else: you aren't committing any money to the process as you are if you're buying a pair of shoes off ebay.

Once again, central policy is being driven by people without any understanding of what it means to develop a relationship with your patients and to earn their trust, and for that reason alone it should be canned now.

Maternity in a spin

2009-02-08T10:51:00.000Z

So it appears that the NHS is struggling to meet demand from expectant mothers, with almost half of trusts surveyed by the Tories reporting having had to shut their birth units at least once last year. That's not necessarily worrying in and of itself, except that the number is rising compared to 2007, and there obviously comes a point where you can't divert a mother in labour to a different hospital to give birth because the next hospital along has also run out of beds. My experience is that we aren't at that point yet, but it is nonetheless a worrying trend.

More to the point, the DoH response to it is revealing. They trumpet "we are also investing more money in maternity care than ever before" and talk about the number of midwives they'll be recruiting. There are two key things they don't tell you:
(1) What the money is being spent on
(2) That they are simultaneously reducing the number of hospitals with doctors present in the maternity unit
In 2007, the government's "children and maternity tsar" announced plans to close maternity units locally in favour of regional centres. She called them "super-centres", but that's a meaningless puff-phrase which I refuse to apply, particularly when part of the package is "more support for home births[...]to give women greater choice". To deal with that last point first: home births are dangerous. They have repeatedly been shown to be dangerous. They are dangerous for simple, easily-explained reasons: if something goes wrong in pregnancy - which is admittedly and thankfully rare - typically the foetus dies within 5 minutes (placental abruption and cord problems are two examples). If you are in hospital, that can be dealt with urgently - but only if there's a doctor present to do a C-section. Most women do not live within five minutes of a hospital, so most women who suffer serious complications during a home birth will lose the baby. Medically, therefore, this is a dangerous option and one which we should not be offering - but politically, it's brilliant. Why? Because you can dress up something which costs less money as "patient choice", and you can pretend you're enabling individuals to take decisions about their own care while at the same time costing the NHS less money. If it weren't for the fact it endangers the lives of mothers and babies both, it would be perfect.

There's also the recurrent theme of the dangers of the European Working Time Directive here - the tsar, Dr. Shribman, comments "EU restrictions on working hours meant specialist services could not be safely provided in every local hospital". The obvious solution, therefore, would be to opt-out of the EWTD in the interests of patient safety (as an aside, the surgeons feel the same way) - but no, instead the solution is to dress up what are simply cuts to services as "networks of care" and "integration of services".

The first point is important too - where is all this money that the DoH claims is being invested in maternity services going if we're having to cut local services in hospital? Well, firstly it seems doubtful that what the DoH are saying is true given that there were early-day motions tabled in March last year expressing concern at cuts in the NHS budget to maternity care. That doesn't take specialist knowledge to find, incidentally - if you google "NHS maternity spending", it's item six on the list. So why did the journalist responsible for the article not quiz the DoH PR person on what exactly the numbers were and where the cash was going? And why was the damning report from the government's own health watchdog from the middle of last year not mentioned? Why was the author not aware of research showing that this promised money isn't reaching frontline maternity services because it hasn't been properly ring-fenced?

We're left with a situation where there is clear evidence of a service struggling to meet demand, with endemic ongoing problems, centrally-mandated cuts in local services, frontline staffing levels which are falling year-on-year, and data obtained under the Freedom of Information Act showing that government funding is not being spent on frontline staff. So why, then, are journalists letting the Department of Health get away with responding to these damning data by saying "but we're spending lots of money"?

Estuary towns

2008-10-20T18:07:00.002+01:00

On the walk from the station to the hospital I'm currently at this morning I routinely pass groups of schoolchildren doing schoolchildren-y things: e.g. listing swearwords they know, smoking and showing off to one another.

Today was really special, though. At quarter to nine in the morning I passed three girls of 14 or 15, in school uniform, and as I passed one looked guilty and slung the can of white lightning they'd been swigging from onto the pavement.

Fucking white lightning! That's seven-point-five per cent of pre-school pre-alcoholism goodness.

A little voice in my head at that point said "welcome back to [name of awful town redacted]".

"Double-weakness"; and the proof of the pudding

2008-10-16T08:54:00.001+01:00

It has just been announced that six trusts around the country have been rated "double-weak" by the Healthcare Commission, meaning that they have been judged weak on both "quality of service" and "use of resources".

One of these trusts is the Royal National Orthopaedic Hospital, Stanmore. Now, I am not an orthopod. I have never worked at RNOH. I have no particular desire to. However, I can tell you that if I had a bust cruciate, or a child with a bone cancer, or indeed anything else orthopaedic and I was able to get referred or to get my child referred to Stanmore, I bloody well would, and I know the majority of doctors I have worked with would feel exactly the same.

Stanmore does many different things. Perhaps the most emotive is the one I've already mentioned: it treats bone cancers in children. This is relevant not because it's emotive, but because it is important in understanding these ratings, which are based in part on patient surveys. Bone cancer in children is by and large a brutal diagnosis for the child and for the parents. They are frequently incredibly aggressive, crippling, and basically deeply nasty diagnoses to make and to have. To get an idea of how bad, check the blogger's friend Wikipedia, in particular the page on Osteosarcoma.

Stanmore runs a national service covering sarcoma. This means they get referred children from around the country who have developed cancers with have some of the worst survival rates of any childhood cancer, and they have to manage these children and their parents through surgery and follow-up treatment.

I wonder why their patient satisfaction ratings are lower than a trust that deals primarily with deranged and grateful elderly patients?

This sort of research will put people off going to Stanmore who absolutely should, and will mean they get treated at centres less able to deal with their problem. It is for that reason utterly contemptible. So if you're thinking of not going to RNOH because of this survey, ask your doctor first what they'd do, and then ask whether you want to be treated by someone who deals with your condition every day of the week, or someone who sees four a month.

The GMC are incompetent too

2008-05-19T11:53:00.000+01:00

I have just received an e-mail from the General Medical Council regarding my Fitness to Practice application. In English, that's the checks they do to make sure I'm a fit and proper person to become a doctor in the UK.

The process seems simple enough: every final-year medical student in the country completes a questionnaire promising they've been good little boys and girls, and the GMC charges each of them one hundred and thirty-five pounds, in exchange for which it takes everyone at their word and lets them become doctors. Quite what the 135 quid goes on I'm not sure, but I'll be astonished if it is on any form of check beyond the one they pay whoever provides them with their champagne and smoked salmon.

The e-mail they've just sent reveals they aren't spending the money on IT either - they said:

I am writing further to your recent application for registration. In your application you completed a Fitness to Practise (FtP) declaration.

Unfortunately, due to a technical fault in our system, whereby we cannot confirm your answer to question 3 of the declaration, we need you to complete that part of it again. I regret the inconvenience this causes and am sorry to have to trouble you. However, I do require that you provide your answer to Question 3 again. The question is as follows:

‘Have you ever been issued with a penalty notice for disorder, or harassment notice, in the UK or another country?’

Please answer this question by replying to this email with the word ‘YES’ or ‘NO’. Please do not attempt to revise the original declaration that you completed online.

I presume that what this means is that whatever bunch of shysters they paid to build their online application system - which requires a username, password, pin, and the answer to a personal question just to get onto - has lost everyone's question 3.

At least, however, they haven't followed the government's lead and simply given everyone's answers to the general public.

Medical incompetence: the GMC join the party

2008-05-19T11:51:00.000+01:00

I have just received an e-mail from the

GPs opening hours, or why Alan Johnson is a liar

2008-02-05T00:48:00.001Z

So it seems dear old Alan Johnson has written to GPs asking them to bend over and accept the new pay deal he and his cronies have refused to negotiate with the BMA.

At this point it is worth noting the sheer gall of the oleaginous Ben Bradshaw when he says that he and his ilk have "a concern" that the BMA "don't really speak for the profession at large". He is of course quite right - but the profession at large feel like this because the BMA are led by folk who are far more interested in crawling up the arse of the nearest politician than in actually representing their membership, which gives you an idea of just how unreasonable the government must have been in their negotiations to get the spineless bastards at the BMA to stand up to them.

More galling yet, however, is that Alan has written in his little letter that, "significant numbers of patients consistently tell us that improving access to GP services should be a priority for the NHS".

Why is this galling? Well - because he's lying.

I know he's lying because his own poxy department paid MORI to survey the general public last year and found out that 84% of people were satisfied with opening hours at their current practice. And that no individual practice in the country - not a single one - had less than 60% satisfaction with opening hours.

So how exactly is he defining "significant numbers"?

I've thought about this, and I'm going to send a letter back to Alan Johnson myself, as another blogger has suggested he will, to say roughly the following:

Dear Alan,

Thank you for your kind letter. Unfortunately, significant numbers of voters consistently tell me, and indeed the pollsters, that improving access to Westminster for someone other than you should be a priority for the government. In light of this, perhaps you would be good enough to ask someone to explain the word "significant" to you before you come back bothering us again.

Yours most sincerely,
Nick.

Leslie Ash

2008-01-18T00:54:00.001Z

Is loathsome. That is all - carry on.

That said, a thought strikes me - could we, as taxpayers, ask a panel of experts how likely it was that it was her falling out of bed and hitting a table caused multiple injuries including a collapsed lung and a cracked rib as opposed, say, to pluck an example from the air, to her having been beaten up? And could we then find the person responsible and sue him for our five million quid back?

FY1 applications: Proofreading, Professionalism, and Fucktards

2008-01-10T00:08:00.001Z

I have just logged in to the Foundation Application system. Before I can find out which tenth of the country I will be within next year, I had to fill in a questionnaire.

Bear in mind at this point, that this questionnaire will be viewed by every one of the doctors allocated to jobs by the system - every medical student in the country will see it. Bear in mind also that last year the rank incompetence of the unaccountable DoH imbeciles who set the system up shafted a generation of young doctors. Bear in mind therefore the importance of this year's system as a marker of improvement.

Then read the fourth and fifth questions on the questionnaire below.

I wonder what they meant to ask?

I wonder just how unprofessional, lazy, and shit at your job you must be not to bother proofreading something even once before it goes out to thousands of junior doctors around the country?

Why people are missing the point about Radiohead

2008-01-01T00:24:00.000Z

Ok - In Rainbows. Biggest music news of the past pick-a-number-and-square-it years. The Death of the Music Industry (±as we know it). "A good move" (Joe Goddard of Hot Chip, who calls it this despite paying, er, nothing for the album himself). "Not like eggs" (Lily Allen, who also called it "arrogant". Given that she achieved her fame by writing good music and then, er, giving it away via myspace, this makes her "hypocritical".). "Kind of demeans music" (Nicky Wire of Manic Street Preachers, a band who should know about demeaning music per everything they've released since Everything Must Go). "Are you on fucking crack?" (Gene Simmons of Kiss, a man who almost certainly is or has at some point been on crack). "One-trick pony" (the splendidly-monikered Maynard James Keenan of Tool). "[bungee-jumping]" (the ever-quotable Courtney Love). "Genius" (Jay-Z).

Aren't musicians a great bunch? That's comedy gold right there, although irritatingly Rolling Stone's Lily Allen gag is much funnier than mine ("Little does Allen know, you do choose how to pay for eggs. You can use cash or credit, or checks if you have photo ID. We could discuss supply and demand and how bands make money off live shows and merch sales, but until Lily Allen can find us an egg that wrote “Paranoid Android,” we’re not even starting that fight.").

A lot of this misses the point, however: they understand how the digital age works. They understood it way back when they were one of the pioneers of viral advertising with Kid A (when their virals had a click-through rate of 153% versus the web-wide average of 5%). They understood it when they set up their own website independently of EMI, and ensured it was representative of them, and relevant; they embraced fansites like ateaseweb; they built an online brand reputation which was in keeping with their onstage band reputation (like that?). They ran with mp3s and napster early, and although I can't find it on teh internets, I'm keeping the lovely memory I have in my head of Thom Yorke calling Lars Ulrich of Metallica a tosser when they sued napster.

Radiohead didn't just tolerate bootlegging - they embraced it not just with the album, but with the whole recording process. Thom Yorke said in a recent NY Times interview, Pay What You Want For This Article, "The first time we ever did 'All I Need,' boom! It was up on YouTube. I think it's fantastic. The instant you finish something, you're really excited about it, you're really proud of it, you hope someone's heard it, and then, by God, they have. It's O.K. because it's on a phone or a video recorder. It's a bogus recording, but the spirit of the song is there, and that's good. At that stage that's all you need to worry about."

By contrast, their record label have just rush-released a 7-CD box set of all their albums so far, including online access to a stream of a live show from 2003! (And claimed Radiohead left after they wouldn't give them 10m quid despite the fact that they have since taken, er, not a penny from their new distributors for the record...) Whatever hip-hop-and-happening cat at EMI thought the box set up had the brilliant idea of including it on a USB key in the shape of the grinning bear! Apart from the obvious flaw in this plan (everyone already has all the albums. Why pay for them again, particularly when the files on that USB key are guaranteed to be copy-protected to fuck?), they've ruined the only appealing part of it - the live album. I would consider buying an official Radiohead live album. I would consider it even though I have 123 different albums, singles, or live shows by Radiohead in my mp3 collection (I didn't count - computers are good like that), and seven other live shows or parts thereof just from 2003.

What I won't pay for is temporary access to a stream of a live show. If you're going to include the album and I'm paying for it, you need to give it to me. Yes, I could record the audio feed from the live stream - but I don't want to do that. Not when you're asking me to pay £80 for it. That's the second problem, incidentally: the USB key is twice the price of the actual cds (£40), and the digital downloads are still £35. Why would I not just pay the extra fiver, get the cds, and spend half an hour ripping my own mp3s? Could they get the digital age any less? Why would I pay double for a USB key I am going to use precisely once, to transfer the files on it to my mp3 player? Mike Leonard, Managing Director at Parlophone, said "We are particularly excited about the USB stick, which gives fans an easy and portable way to carry the box set and provides another way of bridging the world between on-line and off-line content."

Two words, Mike. mp3 players? That's how people carry music around these days, and indeed for the past decade or so. Good luck with your second career.

Compare and contrast. I've just watched a high-quality webcast of Radiohead which they released at midnight on New Year's Eve. For free. I can't download it - yet. But I got the last one within a couple of weeks of it being broadcast, i.e. as soon as I looked for it. I recorded this one - slight jitter in the second song, but otherwise I now have session versions of every track off their latest album, free.

That's how they wrote the album - they debuted tracks as they went along. Reckoner used to be pretty much a stomp-along rawk song (e.g. on 23rd June 2001 in Washington - see what I've done there, EMI?); it has evolved into something containing the line "because / we separate / like ripples on a blank shore". The point isn't that the songs are unrecognisably different - the point is that the evolution of these tracks has always been a matter of public record if you happened to be hoarding radiohead mp3s in 2001. Radiohead have taken that on board and are using it to help them control their own music - they knew people would watch webcasts, they enjoyed doing them, and it gave them an audience which stayed in touch with them - and then bought the album direct from them without blinking. The model doesn't stop there - they've discussed releasing tracks as and when they're ready.

There's a second, more important point to this. Other artists have shafted the record industry before (Prince gave away his album on a newspaper magazine, for free, to publicise his 21-night residence at the London O2 arena), just not in a way you could do without being famous already. The assumption with Radiohead has been that they'll make their money touring and in merch sales. I'm not convinced by the former. Their merchandise is and always has been fabulous (especially the baby clothes). But the band hate the eco-footprint of touring - and they already have a route for getting tracks to people via the webcasts.

The big question for the music industry, then, shouldn't be "how can be blacken the names of the best band in the world?", it should be "how are they going to make money giving their live shows away?". Because history suggests they'll get it right.

I have ideas, but it's late (early 2008), so another time...

A change of direction: no more medicine on here

2008-01-01T00:20:00.000Z

Yup. I think it's time to stop posting medical stuff on the blog (I will think of a new title in due course) - on reflection, despite all my it's-fine-none-of-it's-personally-identifiable bluster, from now on I think I'm going to vanish into the anonymous blogosphere when talking about the UK healthcare system.

Of course, this may simply be a cunning double-bluff to make you all think someone who turns out to bitching about the rank incompetence of the DoH and the government far more effectively than me is me. But it's not. Honest.

So next - a post about Radiohead!

Dumbing down

2007-12-04T23:38:00.000Z

I know on occasion I can be harsh on my medical school, accusing them of allowing bitter, stupid failures far too much say in the design of the course.

Never let it be said, however, that they don't offer help when it's needed. Next week we have to present a poster of our elective experiences; I plan mine to be as provocative as possible. The guidelines on this thing are already lengthy and shambolic - but we all got an e-mail this afternoon which included instructions on how to hang them, and best of all, this:

I'm just not sure I can add much of value to this, except to comment that it takes a very special person indeed to assume people about to present posters on their experiences acting as doctors in the third world might need help on where to stick the fasteners, including that they should go on the, er, back of the poster.

Sweet Jesus.

Festive update: Christmas songs

2007-11-30T00:37:00.001Z

I got the form to work.

It was so bad they should have made the deadline halloween. The worst thing about it isn't even how bad it is at selecting decent junior doctors: the worst thing about it is that it takes what are incredibly important attributes in a doctor - integrity, reflecting on your own practice, teamwork, dedication, empathy, critical ability - and turns them into a revolting mark-grubbing, box-ticking exercise. It makes you a worse doctor and a worse person to try to take examples from your experience, which are complex in the way that anything involving people tend to be, and to turn these delicate, affecting, complex, nuanced events, which demand an understanding of their context in every sense of the word, and then to strip out everything which makes them important in favour of cramming as many bullshit buzzwords as possible into 150 words.

Or, to put it more simply, if you set questions like: "Describe one example of a recent clinical situation where you demonstrated appropriate professional behaviour. What did you do and what have you learned? How will you apply this to foundation training?" and then give people 150 words, you do select people who are good at something. That thing is called being a sociopath.

Anyway, by way of lightening the tone, here are some Christmas records which I find myself wanting to listen to in June as well as throughout the festive period, with the annual blight that is Cliff Richard returning to the airwaves...

- Low, Christmas EP. Highpoint: Just Like Christmas
- Sufjan Stevens, Songs for Christmas LP. Highpoint (tied): That Was The Worst Christmas Ever! / Star of Wonder
- Tom Waits, Christmas Card from a Hooker in Minneapolis - on Blue Valentine. Highpoint: "but someone stole my record player, now how'd you like that?"
- Manic Street Preachers, Last Christmas (live) - on Lipstick Traces. Highpoint: it isn't George Michael singing.
- Arab Strap, Christmas (baby, please come home). Highpoint: Aidan Moffat's voice. It's very festive.
- Christina Aguilera, Have yourself a merry little Christmas. Highpoint: let's face it, she can sing. And this works.
- Porn Orchard, This Holiday Season. Highpoint (apart from the *flawless* impersonation of Tom Waits and Peter Murphy): the couplet "the hooker in my bed is ugly and fat"
- Eels, Everything's gonna be cool this Christmas (live) - on Electro-Shock Blues show. Highpoint: sod new year, Christmas is a good time to be optimistic. And this rocks.
- George and Antony, Happy Christmas, War is Over - on Help: A Day In The Life. Highpoint: Antony manages the switch to the titular "war is over" line simply perfectly, and the song's just as optimistic in a different way to the Eels track.

Welcome to December. Good luck with the shopping.

MTAS II: Foundation Job Applications

2007-10-29T20:31:00.000Z

It being almost Halloween, it's appropriate that the spectre of having to register to apply for jobs as a Proper Doctor next year has loomed up in front of every medical student in the country (except the bastards with academic jobs) like an unholy battle against terrifyingly inept organisers, hideous wannabe-yuppie-executive questions ("Tell me about a time when you...", and nightmarish technology.

For instance, the terms and conditions you have to accept to register (and, by extension, to have a job in August next year if you're a UK medical student) opens with this Disclaimer:

"While the Department intends this site to be continuously available, virus free, and to contain accurate information, the Department does not guarantee that it will. The Department and its contractors accept no liability for any consequences arising from inaccuracies, viruses, the unavailability of the site, misuse of the site, or any User's inability to access or use the site."

Summary: if we fuck up, it isn't our fault.

They might as well have written: "last time we made a horrendous, amateurish mess of the whole thing. If we do that again, you can't blame us for it, because you checked the box, you checked the box, nya-a-a-ah."

I checked the box, and tried to register using an eight-character password containing both digits and punctuation.

"Your password has to be at least nine characters."

I wonder if anyone fell for that. "Hey! They made it more secure - your password has to be longer!"

I changed my password and registered.

Then I waited for the e-mail with my authentication code in, and clicked the link to authenticate my account. It worked first time! - so I closed the window it had opened, and tried the "My application" link on the left hand side. The result is below.

So at this point I have registered and authenticated my account. Now I need to enroll, too? Hey - this is the most secure system in the world! They really sorted out that MTAS fiasco, huh? Good on 'em!

Now, where do I enroll...

Oh.

There, um, isn't a link.

Wait! If I go all the way back to the "register" page (strange thing to do given that I've already registered, mind you), there's a link there! Hallelujah! Join me in celebrating by finding it in the picture below:

That took me to the next screen, which confused me.

Can you spot the deliberate mistake? HAL, as I had by now dubbed son-of-MTAS, is telling me I'm logged in as a guest! Damn! I must have not logged in, or some-

Hang on. If I'm logged in as a guest, how does HAL know my name?

Uh...guys? Making a system which doesn't let me authenticate my account - that's taking security-consciousness that bit too far? I mean, I see what you were thinking - if no one can get onto the system, that means it's guaranteed to be secure, right? And heaven knows I can see any number of Brave New Labour apparatchiks standing up and saying, well, we listened to what you wanted, junior doctors of Britain! You complained that our system was too secure, and we gave you more security. Verily, you are grunting savages who should be grateful that we are even considering giving you jobs, even if you have no way of knowing what you'll be paid, what your hours will be, or whether you have accommodation in Colchester until five months after your application goes in.

But it would be helpful if all these fucking error screens - heck, even just one of them - had hyperlinked the word "enrolled" so it took me to, er, the enrollment page.

They must have let that evil old witch Patsy design the interface.

Year 5 introduction - time-saving summary

2007-09-21T18:46:00.001+01:00

Well, there I was sitting by the beach in Senegal doing very little of anything, when to my delight I got an e-mail from the university outlining my schedule for the first couple of weeks when the final year starts again in October.

As I'm feeling in the holiday spirit, I figured I could save everyone a lot of time and effort by summarising what I'm confident will take place during each of the sessions. Actual descriptions are in italics.

3pm-6pm Opening Session (Dr Richard Phillips) – an overview of the year, including how to make it a success for you. There may also be a surprise guest…
"Welcome back! I hope you all had good electives. Crap joke about suntans and/or diarrhoeal illnesses. Gosh, if you thought year 4 was hard are you ever in for a shock in year 5. Blimey, it's difficult! I hope you're all ready to do lots of work."

"So this year is split into three bits (although we may change our mind about this midway through). You'll do medicine, surgery, and GP in that order (or another order - we'll let you know as soon as we've decided) for three months at a time, with the rotations starting on the 17th October 2006 (that date will be confirmed on the VC by friday by way of an e-mail promising it for a new deadline of monday, when further e-mails will first release and then retract the dates for this year, much as happened with the elective periods)."

"It's extremely important not to cheat. We take it very seriously, and have extremely sophisticated anti-plagiarism methods in place; not only do we make you sign a piece of paper saying "I promise I didn't cheat" and hand it in with everything, but we bought the costume of that psychic out of Minority Report and I dress up in it at least once a month, drink an entire bottle of absinthe, and lie in a paddling pool for several hours. So just be careful."

"Similarly, on no account should you forge your logbooks, because even though you may have gotten away with signing them off yourself in the past, this time it's different, darling you'll see."

"You should turn up to everything in the Campus Blocks - we take a very dim view of you going on holiday in them, and two years ago we may actually have ritually disembowelled a student who went skiing in January like lots of you did last year. While this may seem like we're treating you like children, ultimately we rely on you having the common sense to lie to us if you do go on holiday, and the maturity to recognise that the sleuthing abilities of an organisation incapable of deciding what date something starts on more than a week in advance are going to be less Sherlock Holmes and more Inspector Gadget."

"The most important thing, as it is every year, is that you should not worry about the exams. The total ineptitude of the university administrative bodies should be far more alarming, particularly given that we use the same exam paper every single time. Have fun!"

Tuesday 9th
9am Full morning session on Chemical Pathology from Prof Swaminathan (LFTs, thyroid and endocrine) and on Death Certification from Prof Lucas
Prof Swaminathan is one of the most tedious lecturers alive, so we have paired her with Prof Lucas and not told you who's speaking when in an attempt to sucker you in.

2-3.30pm Application for Foundation – Dr Jan Welch, Director, and Marc Terry, Manager, of the South Thames Foundation School talk about applications, about STFS in particular, and answer many of your questions
We know you've been to two talks by Jan Welch already, and that at both she failed to know how exactly she was going to do her job, that being to organise your careers for the two years after this one. We hope that her willingness to admit the catastrophic system failures she's presided over already will be refreshing.

The cynical among you may be thinking that she still won't know how we're going to apply, what systems are going to be used (last time she said "MTAS"), or what the contingency plan is. This time it's, um, different, darling you'll see...

4-6.30pm Principles of Surgery. A hugely successful session in March last year, Ms Seema Biswas is back to talk you through basic surgery; part one this evening, part two on Thursday.
Ms Biswas is the first of a number of hugely successful and/or popular speakers, the number in this case being all of them.

Wednesday 10th
9.30am Psychiatry refresher – a favourite and entertaining lecturer, Dr Sarah Stringer, will help remind you of some psychiatry basics that you will need this year, for the exams, and for work on the wards.
See? Dr. Stringer's wonderful too! Aren't you all lucky?

2pm Practical Prescribing – another of last year’s successful innovations, Gillian Cavell from King’s College Hospital, and a leading expert on teaching prescribing skills, starts you off with some basics so you can become more confident at this vital skill.
On reflection, it may not be entirely right to call Gillian Cavell an "innovation", in that we didn't think her up last year whereupon she sprang fully-formed into existence, but it sounds better than "another of the things we only thought about doing last year". You should expect "innovations" to include advice like "try not to kill your patients", "ask for advice", and "look things up". And probably "write clearly".

6pm Deans Drinks – Prof Greenough and Prof Rees and others will be around to hear your elective exploits, and welcome you back.
But only after they've popped more prozac than a particularly grief-stricken hippopotamus.

Thursday 11th
9am Professional Development – Diana Bass and her colleagues will run the first of three sessions designed to help you look at your own development from student to doctor, facing the challenges and stresses of practice, exploring things often not touched on in the ordinary curriculum, but which constitute an important part of your education.
Prepare To Be Patronised As Never Before.

2pm Ophthalmology Refresher – Prof Miles Stanford’s lecture is perennially popular and useful
As, indeed, is everything else. Doubles and trebles all round!

4-6.30 Principles of Surgery – more from Seema Biswas (see Tuesday)
(for how brilliant, popular, and useful she is).

Friday 12th
9am A full morning of Public Health sessions from experts in their fields; topics to be covered include Needs Assessment, the governance of the NHS as well as something on clinical governance, public health emergencies, and Communicable Disease Control. Your elective might have changed your views on Public Health.
What won't have changed is your impression of the teaching you get on it, which is by and large a succession of utterly unmemorable and pointless terms used in lieu of the perfectly serviceable alternative, that being 'English'. Rest assured that unless you went to Bognor on elective, this morning will be about as relevant to your last three months as concorde.

1pm-3pm ILS handbooks to be available – hopefully a presentation on ILS also
[No jokes here: I can't remember what ILS stands for. See above re: refusal to use English]

3pm Skills Demonstration (Sally Richardson) on one of the vital Y5 skills
Hopefully, this will be on Effective Methods for Forging Signatures in your Logbook.

4pm Microbiology – the ever popular John Philpott Howard
Of course, he's only actually popular at christmas, when he dresses up as Santa and works afternoons away from the lab at the local shopping centre.

5-6.30 Haematology – Dr David Rees and colleagues on the use of the lab and the old chestnut of Anaemia.
This may be useful; it is emphatically not a chestnut.

The second week follows the same template as the first (innovation, innovation, always popular, special guest) and adds in communications skills which will almost certainly be taught by someone in whom communications skills were the only ones which couldn't be definitively be excluded on close examination, and some roleplay.

Niger elective

2007-06-22T20:22:00.000+01:00

For those interested, I'll be updating you all on how I get on in Niger over the summer in a separate blog, just so you don't have to read all the political stuff if you don't want to.

MMC: executive summary

2007-06-20T14:43:00.000+01:00

Philip Smith, the junior doctor who took Patricia Hewitt to task over the MTAS fiasco on question time (available on youtube), has written a rather moving summary of the whole disaster. I'd recommend you read it.

Revisavoidance, junior doctor's salaries, and quality vs. quantity

2007-06-19T20:50:00.000+01:00

I've posted a couple of times on Dr. Crippen's blog recently (it makes a great substitute for revision), and one of these was during a discussion about the relative cost of nurses versus doctors. An anonymous blogger wrote:

So how about this? Doctors can have the roles back that the HCPs are taking off them, and the autonomy that they think the managers are taking away. The quid pro quo will be that they henceforth earn "upper half graduate salaries" rather than "very top end graduate salaries".

This irked me slightly, as having spent five years retraining as a doctor, I will be starting paid work again next summer on pretty much exactly the same as I was on as a graduate in January 2000 - and 18,500 wasn't an "upper half graduate salary" even then. It's certainly not upper half compared to the 24k someone posted to say that nurses get.

Another blogger, Becky, then posted:

I can't help but wonder what real affect this has on the quality of doctors that are graduating out of medical schools now. Would this lead to a "quality" problem, or really just too few that will be graduating?

To which I'd say simply "both". People are going to piss off out of the profession and go earn genuine upper half graduate salaries working for the pharma companies, where I'd expect someone with a medical degree could earn £30k minimum with rises exponentially greater than staying in the profession. There's your quantity issue.

The quality issue is even simpler: we're already going to have a third of the experience when we hit consultant level because the government have pissed around with medical training in pursuit of favourable-sounding headlines and short-term vote-grabbing. If we don't get paid any bloody money either, why on earth should we put the extra hours in? My first grad job was a piece of piss - you could get away with working a bare 37 hours most weeks, and a good third of those you'd be surfing the net or asleep. As junior doctors, we'll be doing up to 48 hours a week for less money, and with far worse hours (e.g. the week of nights) - now when you're being paid a decent amount of money to do that, you'll go the extra mile, and some of us will anyway - but would you, honestly, work the 49th and 50th hours in a week for eighteen grand a year?

Incompetence, Backup Plans, and Foundation Training

2007-06-06T17:02:00.000+01:00

Early last week I a good proportion of the other 400 people in my year at medical school attended a talk on a subject close to our hearts - namely whether we'll have jobs worth the name when we finish our years of study, and how exactly our futures are determined. The talk was partly about the general application process for Foundation jobs, and partly about the specific process for academic jobs: for the non-medics among you, Foundation covers the two years immediately following graduation from medical school; these years normally involve blocks of general medicine and surgery, a stint in A&E, and a handful of specialities. The academic jobs are designed for those interested in pursuing a more research-oriented career in the future, and include a block of research work within the two years.

The person giving the talk was Dr. Jan Welch, who runs the South East Thames Foundation school which we're in. I had never met Dr. Welch before, and am now rather wishing I hadn't. The early part of the talk was pretty much without exception ghastly, arrogant, patronising guff which told us precisely nothing about how to apply for jobs or how the system ran.

There was also a wonderful moment when she was discussing the academic foundation jobs, and said "Now, the people who get these are real high fliers - most of ours have firsts from Oxford and Cambridge." Understandably, in a room largely full of students from our university of whom only perhaps 10% had attended Oxbridge, this brought the house down. As someone who ostensibly fits that category (an English literature first still counts, right?), I couldn't believe that she thought it was a good idea to stand up in front of the year and effectively say, "the people we want doing academic jobs at this medical school are ones who trained somewhere else". It later emerged during questioning from the floor that they had no way of objectively assessing people's academic performance, as they don't interview and take applications too early to get exam results...

This sort of thoughtless-at-best denigration of her entire audience was mixed in with a healthy dose of hypocrisy - thus she could in one breath tell a group of people aged between 22 and 42 that "the scheme is designed to help you move from university to adult life" and then tell us with apparent amazement that "people tend to apply for things at the last minute". The fact that most school-leavers could have told her that seemed to have escaped Dr. Welch, who continued: "you should all make sure you submit your application forms early! Two years ago, everyone tried to do it at the last minute, and the system crashed - and it nearly crashed last year - so don't leave it to the last minute!"

She proceeded to tell us: "despite what you may have read, MTAS worked very well for us", and chucked out the statistic that 95% of applicants got their first-choice deanery. Interestingly, she didn't reveal the data from a BMA survey on the process in 2005-2006 which was pretty well-powered, and revealed that only half of respondents thought the process was "good" or "very good", with 32% thinking it was "bad" or "very bad". (Credit where credit is due to the BMA, too).

At this point, I wondered why she hadn't mentioned that MTAS was not currently online, and so currently would not be useable for our applications.

So at the end I asked a number of questions, one of which went roughly as follows: "You mentioned that the computer system had crashed two years ago and nearly crashed last year, and obviously there have been very well-publicised problems with MTAS over the last few months. Do you have a contingency in place if the system does crash again?"

I got a woolly answer about how "it had worked for us, and it's just a process of trying to improve things for you" coupled with an acknowledgement that "at the moment MTAS is down which is very difficult because no one can get the information out of it". You'll notice, as I did, that my question - which was roughly "are we all going to be as fucked as people applying for specialist training have been if the system crashes, or have you learnt from their mistakes?"

Deeming that a little too strong for a public forum, I replied: "Yes - I think MTAS is down because it's insecure and doesn't work. What I was really asking was whether there's a contingency in place if you can't use the computer system?"

More flannel. So she tries to fob off responsibility for having presided over a computer system which by her own admission has not been resilient enough to be fit for purpose over the last two years, and then tries to reassure us that a system which has had to be taken down because it was (perhaps criminally) insecure and used a job-matching algorithm which doesn't work will be fixed in time for us to use it to apply for jobs in the autumn, while admitting that she doesn't know exactly how the system will work in the autumn and doesn't have a backup plan in place if she still doesn't know come the autumn.

It's incompetence on a grand scale, and more to the point it is being cavalier with the future of every medical student in the country. Looks like the USMLE for me; I'm a medical student, get me out of here...

BMA response to the MTAS debacle

2007-06-05T00:05:00.000+01:00

It seems the BMA have realised that people weren't too happy with their grotesque mismanagement of the MTAS debacle, and so have paid enormous amounts of money publishing an open letter to the medical profession from Famous Doctor Parveen Kumar in the Times.

I am one of the thousands of medics who cancelled their membership over the last letter the BMA sent to the Times - and this one runs through their "handling" of the situation in detail. It left me with one (admittedly quite long) question in mind...

If you genuinely felt the system was as disastrous as the letter makes out (and this is possible, given that every single doctor in the country with any visibility of the system was saying so at the time) - why the hell didn't you do anything effective about it? Are you really suggesting that waiting until the whole thing has gone to hell in a handcart and then taking action by supporting the government architects of this disaster in court can be redeemed by then saying "oh, we knew it was shit all along and so we did lots of utterly ineffectual things which completely failed to stop it?"

What wonderful rank arse-covering after the event! Where do I sign back up...?

Find Madeleine

2007-05-26T01:02:00.001+01:00

As the search for Madeleine McCann begins to fade from the public consciousness, I just thought I'd say how unutterably sad the whole thing is. Reading the diary Gerry McCann has been keeping is a fist around your heart - and the worst part is how little all the family's courage and resourcefulness can do to bring her back.

And the photos just make me want to cry.

Writing to your MP about MTAS

2007-05-24T01:01:00.000+01:00

I've just sent a letter to my MP using the free online service http://www.writetothem.com/ , basically asking a former cabinet minister (I think Kate Hoey was Kulcha, something I forget, and Sport?) to force a current cabinet minister to resign. Fat chance, but it made me feel better - and I'm bloody serious about not voting for these useless bastards until those conditions are met, just as I still have 25 years or so in the not-voting-Tory embargo (I added two years every time I heard William Hague say something I could construe as racist during his election campaign).

Anyway, I will try to resume normal service soon away from all this political stuff. The only problem is that something needs to be done - the whole medical profession needs to band together and stop these unaccountable fucking incompetents from shafting the NHS and our careers in it. For starters, we should all support the nurses if they do go on strike over the lies they've been sold about their pay.

Dear Kate Hoey,

I am writing to you regarding the recent and ongoing debacle surrounding the application system for NHS junior doctors, MTAS. I am sure you are aware of the publicity surrounding the system, the Secretary of State for Health's conduct during the process, and the highest-profile of the legal challenges to the system by Remedy UK.

The flaws in the MTAS system have been known and have been made known to the government since at least February 2006, more than a year ago, when John Black sent an e-mail (http://ferretfancier.blogspot.com/2007/05/mtas-sarah-thomas-must-resign.html) which proved scarily predictive of the subsequent problems: "We have only eighteen months to go. All the talk about e-based selection and assessment centres is cloud cuckoo land. No government computer system ever works. Who will pay? Is it validated? Is it fair? Who can run an assessment centre? How are they validated? What is wrong with our present methods?" It is worth highlighting that it is clear the computer system didn't work, the taxpayer had paid financially and junior doctors with their careers, it was unvalidated and grossly unfair, and has been infinitely worse than the present methods. I hope you will bear with me while I explain why I have come to this conclusion, and lay out some of the evidence which has brought me there.

(1) Opposition to it has been vocal and obvious since the full scale of the disaster became apparent - for instance, 136 hospital consultants from a single hospital wrote to urge the Secretary of State for Health to review the system at the start of March (http://www.telegraph.co.uk/news/main.jhtml;jsessionid=LK3AMSGEE43M1QFIQMFCFFWAVCBQYIV0?xml=/news/2007/03/05/ndocletter105.xml), a request she ignored.
(2) The BMA at the same time called it "badly organised, fail[ing] to draw out expertise and [unable to] cope with demand" (http://news.bbc.co.uk/1/hi/health/6436549.stm), notwithstanding their later betrayal of their membership in print and in the courts.
(3) A review was instituted only after several of the interview panels point-blank refused to interview using the MTAS system because they - quite rightly - regarded it as unfair and unjustifiable. (http://www.telegraph.co.uk/news/main.jhtml?xml=/news/2007/03/06/nsurgeon06.xml) While I have the utmost respect for and confidence in Neil Douglas, it is unacceptable that we had to wait for a review of the process until it was beyond salvage and those who it had been forced upon had rejected it. It is further entirely unacceptable that Patricia Hewitt attempted to avoid taking responsibility for her mistakes by pointing to the review (http://news.bbc.co.uk/1/hi/programmes/question_time/6656937.stm); Prof Douglas has done a sterling job with the situation he has found himself in, but that situation is entirely of the government's doing, and they must be held accountable for it.
(4) Alan Crockard, formerly the professor in charge of MMC, resigned at the end of March, and his resignation letter (http://www.telegraph.co.uk/news/main.jhtml?xml=/news/2007/03/30/ndocletter130.xml) is indicative of how little control the clinical staff who should have been running the system had over it, noting that the Gateway Review of MMC in September 2006 had raised one "serious red risk. This was to "identify a clear break point for the MTAS project beyond which the contingency arrangements should be activated". It also commented on the unclear leadership between DCMO and two senior responsible officers."
(5) The full scale of the debacle is revealed when it becomes apparent that the system was totally insecure, and that anyone could access the application forms and personal data of all applicants. The whistleblower, a Dr. Crippen (http://nhsblogdoc.blogspot.com/2007/05/hewitt-lies-to-house-of-commons.html) who reported this finding immediately to the DoH, is accused by Patricia Hewitt of breaking the law. Once again, she fails to acknowledge that the only reason he or Channel 4 were able to access the system was thanks to her own incompetence.
(6) Informal reviews on the internet have suggested that the MTAS system was so insecure as to be in breach of the law (http://timworstall.typepad.com/timworstall/2007/05/mtas_canned.html), and from my own experience working for IBM for three and a half years, it is unthinkable that you would put a system in place without even the most basic security, as was done here.
(7) A number of other legal actions have been brought against the government over MTAS, including a Cambridge professor who is spearheading an attempt to have it classified as an abuse of power (http://www.timesonline.co.uk/tol/news/uk/health/article1784956.ece).
(8) James Johnson, until recently the head of the BMA, has been forced to resign over his letter to the newspapers and the BMA's failure to support Remedy UK in the courts - a decision which has led to thousands of doctors, including myself, withdrawing their membership of the association.
(9) The Secretary of State for Health has, by her own counsel's admission (http://www.remedyuk.net/images/banners/JR%20Findings.pdf), pushed for costs against Remedy UK.

This system was developed outwith the control of senior medical staff, repeated warnings from clinical and independent reviewers were ignored, and a system being sent live without even the most basic security, which was irresponsible, even cavalier with people's personal data, which didn't even have a working algorithm to match candidates to jobs (the raison d'etre of the entire MTAS system), and without any contingencies in place for when it inevitably went wrong.

Other people have already paid with their jobs for the gross, brainless, destructive, and craven errors of Patricia Hewitt and, I'm afraid to say, the labour government which have sanctioned her healthcare policies. Now she is seeking to have the very junior doctors whose careers she has ruined to pay for the legal costs of mounting a challenge against her incompetence.

I am therefore writing to ask you to push for the Secretary of State for Health to resign, or failing that to support any such motion when it is raised by someone else.

I would further ask that you support any future motions to return responsibility for medical training to the Royal Colleges.

I have voted labour in the past, although I voted for the liberal democrats at the last election. I will not vote for them again under any circumstances until, (1) Patricia Hewitt is no longer a member of the cabinet, (2) responsibility for medical training has been removed from PMETB and returned to the Royal Colleges and (3) an unqualified apology has been made by the government for their handling of medical careers in all fields from nurses through to hospital consultants over the past three years.

Yours sincerely,

Nicholas Grundy

The importance of choice in healthcare

2007-05-16T09:18:00.000+01:00

The government think that choice - be it of where or when you're treated - is the single most important healthcare issue out there today - certainly more important than protecting people's intimate personal information, or ensuring the doctors who treat them are trained properly.

Unusually for government policy, someone has taken the time to find out whether patients actually choice. Of course, they've done this after years of implementing the exact policy they're only now investigating, but hey - better late than never, right?

The survey was commissioned by the Healthcare Commission, an independent offshoot of the DoH, and revealed just how important choosing an admission date to hospital, and having enough information about hospitals to make an informed choice, were to patients: they ranked them bottom of a list of eighty-two (82) issues.

The response from the DoH to their own study demonstrating that the single largest driver of government healthcare policy in modern times has been something patients didn't even want? It's special enough to quote:

"Of course patients want doctors they can trust, but that doesn't mean they don't also want choice or believe that hospital cleanliness is important. These are not either/or questions."

It's beautiful, isn't it? You have:
(1) A total failure to address the fact that their own research has shown that the driving force behind policy has been a misconception
(2) An attempt to cover this up by lumping it in with emotive, obvious things - people want clean hospitals? Who knew?
(3) A brazen lie - patients "also want choice". Well I'm sorry, but not according to your own research, they don't.
(4) A meaningless cliché to round things off.

If the government had thought to investigate whether patients actually cared about choosing which hospital they went in to before implementing policy, they could have decided how to spend our money constructively; instead they wait until the policies have been in place for years, and then ignore the results of their own research.

Responsible government, wouldn't you agree?

Think of the children...

2007-05-14T22:32:00.001+01:00

My colleague Dr. H has recently begun paediatrics, and writes briefly but ~~broodily~~ movingly about it on her blog. Just how deeply she cares for the children was brought home to me on Sunday afternoon, when we were doing practice clinical exams in the living room, and in one of these I took the role of a young father with a sick child. Our house being thus far mercifully free of three-year old children with whooping cough, and not wanting my acting skills to be upstaged, I found an empty wine bottle to play the part of the baby. Like a true communication-skills-trained trooper, Dr. H was very empathic about poor little Eric and his cough, and said all the right things to put me as a notional worried father at my ease.

Less communication-skillsworthy were the brief interludes to discuss how cute babies were with J, one of our housemates, and the occasional interjections of "GIVE ME THE BOTTLE!" in petulant I-want-a-baby style...

Richard Littlejohn

2007-05-07T23:08:00.000+01:00

I hate him. Always have, always will, for all the obvious reasons (I would go into it, but this is a family blog, etc). When Will Self (who I don't like that much as an author or as a massively pretentious columnist) took Littlecock to pieces in a radio interview about their last books, Self went up enormously in my estimation, and I was happy for days thinking about Littlejohn blundering into every trap Self set for him.

I'm not sure which bit of that interview is my favourite, but it may be this exchange:
CAMPBELL: But what do you make of what David Aaronovitch has said? It is front page in the Independent. He says Richard Littlejohn's novel is a 400-page recruiting pamphlet for the BNP.

LITTLEJOHN: What else do you expect from an overgrown student union leader who used to be a member of the Communist Party? I think it is a badge of honour to be attacked by people like David Aaronovitch to be perfectly honest. I might put it on the cover.

SELF: Well he is right.

LITTLEJOHN: Is he?

SELF: It is a 400 page... I've read 200 pages of it and that is a 200 page recruiting leaflet for the BNP.

LITTLEJOHN: Well, you can't comment until you have read the other 200.

SELF: Why? Does it suddenly turn into Tolstoy?

Anyway - if you want a bit of light relief, and you don't think that Richard Littlejohn's novels are, as he claimed in the interview above, "more complex than Tolstoy", there is a very amusing if slightly childish review of his latest effort in which the reviewer decides to judge the book purely by its cover.

NHS computer systems, NPfIT, and Greeks bearing Gifts

2007-05-07T00:49:00.000+01:00

I am in the process of writing a long post about MTAS and what a disaster it is. While doing so, I got sidetracked slightly writing about what a disaster the National Programme for IT is, and so I decided I would post that first and move on to MTAS shortly.

For those who don't know, the National Programme for IT (NPfIT) is supposed to be a wonderful, clever, all-singing all-dancing computer system for the whole of Britain which allows everyone to use the same software to store patient information on. In theory, this means that when you go into hospital with a stomach pain, the doctor there can immediately see all your GP's notes about you, all your past medical history, all your old X-rays and blood-tests, and so doesn't have to dig through a blue folder the size of a small Eastern European country in order to get them.

In practice, of course, what it means is the government pissing away billions of pounds of taxpayers money to private companies for something that hasn't been delivered yet, is already two years late, and doesn't work anyway.

This sounds unfair, given that one of the companies involved (Accenture) actually leapt from the “National Programme for IT” (NPfIT) gravy train in late 2006 (following repeated denials from "Connecting for Health", the DoH department responsible for the system) citing losses of £1.1m a day; their portion of the work went to CSC, who now stand to make £3 billion if they deliver the system without incurring any fines.

Poor IT companies! However, I can shed a little light on this, as I worked for three and a half years for another very similar IT services company who at the time were very keen to get into the public sector work on offer. It was openly admitted at internal meetings that neither we nor any other major IT supplier had any idea how to do the actual work, but it was also acknowledged that once you were 'in' with the government it was almost invariably more expensive for them to get rid of you than to keep paying you, and after all they would never be sacked, so you could rely on their paying you while you figured out what it was they wanted and how you might be able to do it. Still feel sorry for Accenture?

Nor do I.

As an aside, another advantage of allowing doctors to run the health service would be the avoidance of such BS-reeking names as "Connecting for Health".

The whole thing is indicative of a wider problem, whereby some clever minister or civil servant decides that it would be much better if, rather than taking advantage of the NHS’ own, in-house expertise to get a computer system designed and built, they’ll contract it out. They then go off and ask all the main IT services companies to come up with how they’d do it.

Then they appoint all of them bar the one I used to work for. While I commend that decision, by appointing four main suppliers they just ensure that no one is actually going to take responsibility for anything: the first port of call when something goes wrong and there are other contractors around is to Blame The Other Guy. It forces the person complaining to make sure you’re to blame, and buys you time.

Then the IT companies realise that they can’t do large chunks what they’ve said they can, so they pay someone else to do it – in this case, UK company iSoft. The two global multinationals then proceed to blame the littler company for everything that goes wrong, and the littler company gets hit by a rash of resignations (including that of their chief technology officer, who gets £250k plus benefits for going) and gets investigated for accounting irregularities. Bear in mind that throughout all this the littler company are not accountable to "Connecting for Health", because they haven't signed any contracts with them - they're accountable to CSC and Accenture - so the government has no way of punishing them financially for their incompetence.

In the meantime, if anyone at an IT company has the integrity to admit ~~Fujitsu~~ their company don’t know what they’re doing, they get suspended.

Then, the oleaginous Richard Granger of "Connecting for Health" tells Accenture not to worry, and that even though the contract they signed said that they’d be liable for 50% of their total contract in compensation, there’s not much he can think of that the NHS could do with the £1 billion that represents, and so Accenture can pay £63m instead. This despite their already having made allowances of $450m in anticipation of future losses on the project.

Meanwhile, Accenture bugger off with £110m for having delivered next to nothing, and that several years late. The clincher, of course, is that the industry executive in charge of sucking up a bunch of public money in exchange for a total disaster gets…a job offer from the government!

James Hall, who masterminded the whole disaster at Accenture, has joined the Home Office as head of the Identity and Passport service, where he’ll be running the introduction of compulsory ID cards.

This is a man with a track record of failure who would by now have been sacked by Accenture for screwing up a £2 billion payoff. I would guess he’s now unemployable in the private sector – but happily for him, your taxes are now paying his salary in the public sector.

NPfIT was always a disaster waiting to happen. How does the government respond?

It ignores a report it commissions from McKinsey and company which reportedly concluded that there was no IT contractor in the UK capable of doing the work. It then repeatedly refuses requests from large numbers of leading academics around the country for an independent review, ignores data from the end users of the system – doctors – showing that less than one percent of them believe progress is at least "good", and responds to reports from public committees outlining the extent of the disaster they’ve presided over by claiming that their information was a year old. They don’t, of course, give any new data.

It's a shambles. The PAC report is utterly damning, and is available in full, although its conclusions are fairly summarised on the Burning your money blog. It's not even clear how much the project was meant to cost in the first place - most sites suggest around £6bn, but more recent reports have doubled that. The response, of course, is more head-in-sand denials that there's a problem from Richard Granger, who said recently of the Accenture rat-leaving-sinking-ship scenario: "We will know there is a real problem when there isn't a queue of people waiting to take over the work, and when anyone that wants to take it on wishes to do so for a greater consideration".

Really, Richard? So are you surprised that, now you've shown that private companies won't actually be punished at all as they should be under the terms of their contracts for failures which impact upon the entire provision of healthcare in this country, they're queueing up for work?

The failings of the system are manifest, and have been summed up in the document Information Technology in the NHS: What Next? by Richard Bacon, Conservative MP for South Norfolk, and John Pugh, Liberal Democrat MP for Southport. Essentially, the government's mania for centralisation means that we're trying to put the same system in place everywhere without proper consultation of local needs or involvement of local staff when it would have been far, far easier to let hospitals take regional decisions within an agreed national framework. Or, in English - you can put in what you like, but it has to do this and the data has to come out looking like this so the other systems can read it.

Anyway, this has obvious implications in terms of MTAS - but more of those later.

MTAS, computer systems, and government incompetence

2007-05-01T23:57:00.000+01:00

So - I'd guess a lot of you will have heard of MTAS, the absurdly badly-designed and poorly-implemented system which the government put in place this year to ensure the likes of me get trained properly and the likes of you get treated properly.

When you put it like that, it all sounds so simple, doesn't it? After all, the system's been working pretty well for pretty much the whole history of the NHS - by and large, consultants had the good sense to pick people for specialist training who they thought were capable, knowledgeable, experienced, and keen to do their job. They didn't do this purely out of a sense of civic duty - some of the more reactionary, Carry-on style consultants probably did pick doctors for specialist training because they wore a particularly low-cut top or (worse) because they were a "good egg" on the rugby pitch (one surgeon I have played rugby with told me that "if someone turns up for matches every weekend and can pass a rugby ball, they've basically shown they have the skills needed for surgery, so it makes sense to take them on"). Ultimately, though, the people making the decisions knew that they were ultimately responsible for the work of the people they picked, and the better the calibre of doctor they picked, they less they themselves would end up getting called in to the hospital in the middle of the night, and the less fuck-ups they’d have to explain.

It's sounding even more simple now, isn't it? You let the person responsible (professionally and also, lest we forget, potentially legally) for the work of their team pick the people in that team, relying on their own professional experience to allow them to select from a pool of extremely talented and able junior doctors those who have demonstrated that they would be best suited to the particular demands of a particular profession. The old system was something quite close to survival of the fittest – and the people who made mistakes were responsible for them.

So what went wrong?

Well, first of all, New Labour, in their mania for centralisation over something which actually works, decided that they needed a centralised application process, and in so doing ignored that most basic of maxims: if it ain't broke, don't fix it.

What happened next is best explained by looking at the resignation letter of Alan Crockard, the professor who ran the whole of MMC. He resigned resigned at the end of March, and wrote in his resignation letter:

"MTAS was developed and procured by DH outside my influence" - in other words, some unelected, unaccountable, faceless government appartchik sourced the system from an IT company who proceeded to shaft the government and the taxpayer for a lot of money in exchange for a system which is amateurish and shambolic.

Here’s how it all unfolded:
(1) 22,000 jobs are available under the new system
(2) 35,000 junior doctors apply online (MTAS loses large chunks of their applications, locks them out of the system, and then makes their sexual preference and answers to all questions available to everyone else on the system).
(3) However, about 11,000 of these are foreign doctors (the exact number is unclear because the brand-new, expensive MTAS system, er, doesn’t record it). Thanks to the government having merrily shafted all the doctors it has been stealing from India and Africa over the past few decades by suddenly denying them the ability to work in this country, they should be ineligible for training posts – so the numbers suddenly look a lot better – there are only 24,000 people going for 22,000 jobs! Of course, they don’t look so good if you’ve uprooted your entire life to come and work here from abroad, but hey!
(4) Unfortunately, MTAS can’t filter these candidates out – so in the first round of shortlisting, these ineligible candidates are shortlisted over eligible ones! The numbers now look rather worse – because you only have perhaps 18,000 eligible people in the system for 22,000 jobs. In other words, at this stage it looks as if MTAS has actually managed not to have enough eligible people in the system despite having an initial surplus of 11,000.
(5) Unfortunately (or fortunately, depending on your point of view) for the government, however, the British Association of Physicians of Indian Origin appeals the decision to ruin thousands of medical careers because New Labour didn’t do their sums properly (or at all?). This provokes a shameless climbdown in the high court from the loathsome Patricia Hewitt. On the upside, no junior doctor is being shafted based on their country of origin. On the downside, we’re back to 11,000 of them being unemployed from August, at a cost of £250k per person trained in this country.
(6) MTAS fails to shortlist dozens of candidates, provoking uproar from everyone involved bar the unaccountable government imbeciles responsible for the fiasco. Everyone hates it – the consultants (including 136 at one hospital), the BMA (who say they cannot sign up to it as it stands, calling it "badly organised, fail[ing] to draw out expertise and [unable to] cope with demand"), the organisation Remedy UK set up to force a judicial review of the shambles (which has already gained 9,000 members – and a smear campaign from the government, who claimed it was politically motivated), the professors, (one of whom is mounting legal action against the government, claiming it has been so badly managed as to be an abuse of power), and all the junior doctors about to have their careers decapitated (who march on Westminster to protest).
(7) Several of the selection boards inform the government that the system is so unfair as it stands that they point-blank refuse to conduct interviews using it, prompting an “urgent review”. Why were these people not consulted about the system beforehand, one wonders?
(8) The review suggests giving everyone in the system one interview to determine the rest of their medical career. Instead of being in the hat for four places, you pick one, they interview you – live or die. No insurance interviews, no backup – if you don’t get the place you put down, you are out of the system.
(9) This suggestion is of course just as inequitable, stressful, and absurdly ill-thought out as anything that went before – but the government plough ahead regardless!
(10) Then it becomes apparent that their computer system is appallingly insecure, when one of Dr. Crippen’s readers points out to him that every candidate’s information can be accessed openly on the internet. He then passes this information to Channel 4, who broadcast it the same day, and to the government department responsible, who thank him and take the site off-line.
(11) Patricia Hewitt is questioned about this in the House of Commons and lies through her teeth about the whole fiasco, claiming that Channel 4 had broken the law by hacking the system. Heaven forbid that you acknowledge that you’ve compromised the security of the personal information of every junior doctor in the country, Patricia.
(12) So where are we now? Well, we’re two and a half months away from needing to have doctors in jobs for the next year, and large numbers haven’t been able to book the one interview which determines the course of their career. Why? Well, because they had to do that on-line, and the MTAS system is “down for essential maintenance”! This also means, of course, that those doing the interviewing haven’t been able to interview yet, and so they’re facing not having any junior doctors in post in a couple of months. Factor in summer holidays and the enormous workload required to organise interviews, and we have a full-scale disaster on our hands.

So how did we get to this stage? Surely there was some review process of MTAS?

You’d think. In fact, Prof. Crockard’s resignation letter states quite plainly that – despite being the senior academic on the MMC programme – he was not able to influence the MTAS process:

"The MMC programme has been the subject of an OGC Gateway Review in September 2006 (DH331), they concluded "that the programme has made significant progress since the OGC health check in August 2005". The report overall was supportive of MMC, but there was one serious red risk. This was to "identify a clear break point for the MTAS project beyond which the contingency arrangements should be activated". It also commented on the unclear leadership between DCMO and two senior responsible officers."

Allow me to paraphrase:
"The MMC programme has been the subject of a review which said "bit better than last year". Heaven knows just how bad the 2005 review said it was (we’re not going to tell you that), but at least we are - in true New Labour style - Making Progress!

"MMC is a Good Idea, except that the point at which we accept that MTAS is absolutely fucked and throw it out in favour of a contingency plan hasn't yet been decided, and thus nor have the contingency plans. We're not sure who's responsible for this, nor for anything else. But we do know that it is not the government, and not our Dear Leader, who can brazenly go on record as saying that Labour have saved the health service at a time when the full repercussions of their incompetence are becoming clear."

Doctors and clinicians have been trying to get this sorted out almost since its inception. A leaked email from John Black, the chair of the SAC in general surgery, from February 2006, predicted almost exactly the problems which would occur:

“We have only eighteen months to go. All the talk about e-based selection and assessment centres is cloud cuckoo land. No government computer system ever works. Who will pay? Is it validated? Is it fair? Who can run an assessment centre? How are they validated? What is wrong with our present methods?”

The government has taken a system which had worked for decades, and had allowed junior doctors to work and gain experience in multiple fields before choosing a speciality. They have removed this opportunity from it purely in the short-term interests of being able to say in a few years "ah, but look how many more consultants we have!".

What's the solution, though? The solution is exactly what doctors have been trying to tell the government since the inception of this fiasco – please consult us about this, please give us some degree of autonomy, please don't change too much too quickly because you have an abysmal record when you try to and this is too important to get wrong.

The tragedy, of course, is that it already looks too late to avoid a catastrophe – perhaps the whole system won't come crashing down, but medical care will be compromised by the government's action, and patients will, as always, ultimately be the ones who suffer because government hubris refuses to let them acknowledge the magnitude of their errors.

At some point, the medical profession in this country – the doctors, the nurses, the physios, and everyone else – need to take a stand. If the government won't listen to us when we spend more than two years telling them their system won't work, and their system then doesn’t work, we need to make them listen. It may be that involves going on strike, and making very plain the reasons we're doing so – yes, patients would suffer from that too, but long-term they’d suffer less than if we allow the craven, self-serving, unaccountable imbeciles in government to continue removing the NHS’ ability to treat patients effectively.

Vanilla wotsits

2007-04-20T15:23:00.000+01:00

Over the last couple of weeks I've been spending the odd half-day at Great Ormond Street Children's Hospital with a friend of mine who's doing a phd there. We're looking at a rather arcane and prodigiously expensive drug given to stop kids who get new organs from spitting them straight back out again (that's lay-speak, natch) - and part of this involves going through their notes to figure out exactly when they got their dose of the drug. Needless to say, children who have organ transplants tend to have medical notes weighing approximately as much as a small car, and it should by rights take ages and be crashingly boring.

Oddly, it's not been too bad. For instance, I was read the following by my friend:
' "Tommy is awake, and sitting up in bed eating toast." Or, you could just write "Tommy is eating toast"...'

The best thing we've found so far has been in the allergies box on the drugs chart: one boy had written on every sheet "Vanilla wotsits".

Happily, the chances of us giving him vanilla wotsits while he's in hospital are limited. I also wondered how they'd found this out - had they given the vanilla and the wotsits at the same time?

The mind boggles.

Needles

2007-04-11T02:27:00.000+01:00

Tonight in A&E, a guy showed up who was covered in tattoos - really bright, quite well done, colours all down his arms, that sort of thing. He'd had a cheek piercing done, and while chewing on the bar bit that went into this mouth, he'd managed to pull the thing through his cheek, leaving the screw-in ball bit behind. In his cheek. The X-ray was a doozy.

Anyway - when the doctor told him we were going to inject a bit of local and dig around for it with a scalpel, he blanched somewhat. So I thought I'd reassure him by asking:

"Are you okay with needles?"
He pointed at one forearm covered in tattoo with another covered in tattoo.
"Yeah."

Pecking Orders

2007-04-05T01:25:00.000+01:00

Yesterday I got started on A&E, and after a fairly gentle morning during which I got used to the idea of 1630-2330 shifts as a medical student, we had a teaching session on head injury from an emergency medicine consultant. He did exactly what you want a teacher to do, pretty much - he was entertaining, explained difficult concepts simply, and put on silly voices now and then.

At one point, he was talking about not liking the classification of head injury into "mild, moderate, or severe", pointing out that if any of us had a GCS of 13, we'd be pretty seriously disabled compared to how we were now. (Ednote: GCS stands for Glasgow Coma Scale, with 15 being normal). He continued:
Dr.: "I mean, you'd go from being medical students to - what's below a medical student?"
Me: "Law students?"
Dr.: "Ah, yes! You'd go from being medical students to law students, and then you're halfway to doing an English BA."

At this, Toyin produced a noise which I can only describe as an outright cackle, and I was forced to admit that yes, that had been my first degree.

Although with hindsight, I should have said it was an MA...

An introduction to emergency medicine: starting simple

2007-04-02T23:04:00.000+01:00

Today was the first day of EMTL, or Emergency Medicine, Trauma, and Locomotion. As is always the case with the medical school's acronyms, the four letters don't manage to accommodate at least one significant portion of the rotation: in this case it is anaesthetics. But hey.

Initial signs are promising: the anaesthetist who gave the introductory talk eschewed the usual bollocks in favour of giving us some Actual Teaching, in this case on drugs used in emergency medicine, with a bit of a side-track into resuscitation (CPR = cardiopulmonary resuscitation = one of the many medical procedures which is much, much more effective on TV than in real life. Generally you're dead if they zap you in Casualty, but on course for a miracle recovery in ER.) My favourite bit of the talk:

...of course, a lot of the patients the nurses put out CPR calls on are in rigor mortis.
[pause for contemplation]
Don't blame the nurses! If you were the only nurse on a ward of 26 patients at night, could you tell me when they're all alive? It's not as if they go round poking them all night...

The Elective Handbook (with footnotes)

2007-03-31T22:19:00.000+01:00

Don't worry. I'm not going to reproduce all of it here - I'm only for sharing the misery up to a point. I'll summarise the first few pages; my comments are [in square brackets and italics]:
p1: picture of smiling black children with a stethoscope [it's good that they start with something so painfully stereotyped, particularly given that the medical school is refusing to let third years spend their peripherals in Africa! Way to go, hypocrites!].
p2: apparently, bad things can happen while you are abroad; thankfully, given that I had never considered this possibility, it provides a list: "severe personal injury, high-risk needlestick,
potential rabies exposure, natural disasters, outbreak of war and major terrorist attacks". Having given me this morale-shattering list - what if I'm struck by lightning? is that a natural disaster or an act of god? do acts of god count? - they then reassured me by giving me an e-mail address to use in case of emergency. Which will be checked regularly. During office hours.

This got me thinking about the last natural disaster - the Tsunami. If I'd been on elective during it, I could have swum out to the nearest internet cafe which they wouldn't have had anyway, dived down to the computers which wouldn't have been working due to the lack of power and the six feet of water, and sent an e-mail which wouldn't have been checked until the middle of January when the registry staff got back to work.

Phew. That'll set mum's mind at ease.
p3-4: phone numbers and banalities.
p5: a nice letter from Prof Jones telling us to get our jabs done, that the elective will be quite fun, and pretending we get free HIV prophylaxis packs (which we now have to pay for).
p6: list of dates and deadlines for submission of the reams of crap they want before they let us go on holiday.
p7-8: exercise in stating obvious stretched out over two entire pages. Examples: "many of you will be planning an Elective abroad."
p9: The below is verbatim, except [my comments].
A “portfolio” includes not just the outcome of your thinking, but it is also a record of the journey you have taken, rather like the instruction in GCSE maths to “show your working”. [I will buy a bottle of (probably cheap) champagne to anyone - anyone at all - who can explain in the comments section of this blog how "showing your working" while doing - say - simultaneous equations in GCSE maths is the "record of the journey you have taken" to find out that x=5 and y=-2.] The Elective Portfolio should consist of the sections listed below. Recommended word counts for each section are given in brackets as are the relative contributions to the final
mark.
Diary and Personal Reflections (usually 1000 words) (20%)
This should include:
• Initial ideas and discussion of choice of initial aims and objectives
• Record of evolving plans with discussion of any changes and reasons
• Discussions with Clinical Advisor, potential elective supervisors etc
• Personal reflections on what has been learnt during process of planning Elective and
creating Portfolio [What? We're talking about my deciding where I wanted to go, right? You people realise that I haven't been yet? All I've actually learned is that the sort of person who believes that planning a 2-3 month trip abroad requires a reflective diary to be kept, and might produce learning experiences, is either educationally subnormal ("I have learnt that if I pick up the phone and call a travel agent, they will sell me something called 'tickets' which allow me to travel in a metal tube with flat bits on the side called an 'airplane' to a foreign country!") or the sort of self-indulgent, ego-stroking hippie who should be kept as far as possible from the running of a medical course as possible.]
Final Aims and Objectives (usually 250 words) (5%)
The Final Plan
This should include:
Account of Elective plans (usually 1000 words) (20%)
• Discussion of choice of country/countries and institution(s)
• Demographic and public health data
• Local health issues
• Description of institution(s) including facilities & services provided
• Description and / or timetable of eg. Intended clinical attachment(s) or research [This bit's all fair enough.]
Personal Safety, Health and Wellbeing (usually 1000 words) (20%)
For example:
• Personal safety, health and wellbeing and any modifications for Elective
• Vaccinations
• Anti-malarials
• HIV considerations
• Travel and accommodation
• FCO travel advice by country
For students doing London or UK based Electives:
We appreciate that a word count of 1000 words may seem difficult, given that you will not require any specific vaccinations, anti-malarials or FCO travel advice [My executive summary: we accept this entire section is totally irrelevant, and that the sensible thing would be to allow you not to write it and to ask for more information in the other sections...]. However HIV, accommodation and travel to and from your attachment(s) are issues [Perhaps they want someone staying in London to complain about how unpleasant the tube is...? Actually, these morons would cream their pants if you wrote a reflective account of overcoming your fear of using the tube following the 7/7 bombings...] wherever you are and in addition we suggest two other options:
1. Consider what an overseas student might have explored if they were coming to do your
elective. What would they have found, where would they have sourced the information
etc.
2. Put greater emphasis on your personal health and wellbeing plans for the longer term,
including the elective and perhaps also preparing for finals and your first year as F1. [My executive summary (contd.): ...but we're going instead to make you do an exercise which you may remember from primary school!]
-----
I'm not going to prolong the misery (chiefly because I have another 1500 words to write by monday morning) - some of the rest of the book is useful in a blindingly obvious ("Don't give anyone your luggage to look after") or frighteningly paranoid ("Don't trust anyone") kind of way.

So, I suggest that we petition the university to sack whoever they employ to mark this thing, and use the money to continue giving us free HIV prophylaxis packs to take in the event of an emergency. I don't think we need the prophylaxis, but we need it a lot more than a bunch of smug, elderly, self-satisfied, paranoid, would-be-counsellor, sadistic hippie idiots.

Elective Portfolios Make Me Want To Smoke Crack

2007-03-31T21:40:00.000+01:00

The latest round of exams ended on monday, and miraculously the exam paper was well-written, fair, and unusually thought-provoking. This meant that there were no questions like this one-two from the obstetrics & gynaecology paper:
Q50: [blah blah blah]. The ultrasound appearance is consistent with fibroids. What is the most likely diagnosis?
A: Leiomyoma
B: [blah]
C: [blah]
D: [blah]
E: [blah]

"Leiomyoma" is just a classical way of saying "fibroids", so the question is akin to asking "My name is Robert. Which of the following is a short version of Robert?"
A: Rob
B: Kevin
C: Robertson (this is the tricky one)
D: Daphne
E: Erica

Better yet, the previous question had as one of its possible answers "Leiomyoma / Fibroids", so it was nearly impossible to get wrong.

As Toyin pointed out while she was revising for the USMLE, the questions there are good because they give you information which requires you to do something, most commonly make a putative diagnosis, and then the actual question will require you to take another step. For instance, you might be given a child with trouble breathing, and then you're asked what your initial treatment would be - so you might have to figure out that they have asthma, and then be able to recall good management options for them. It's a more genuine test, and much more satisfying to do, largely because that's what you will actually have to do as a medic. For the first time, the paeds exam did that, and the downside of this is obviously that it was harder as well as more satisfying to do. But no complaints if I fail.

I am going to complain about the bugbear which has been plaguing me since then, however. This summer, all the fourth year medical students get to go on elective, which is a three-month period between nasty sets of exams during which you can travel the world, sit on a beach, climb mountains, dive deep-sea wrecks, eat locusts or sheep's eyes, learn to dance salsa, and perhaps fit a bit of medicine in too. My plan is to go to Niger, which will feature a bit more medicine than some, but sadly also a lot less deep-sea diving. Anyway - prior to going on this we have to tell the university what we're doing - which is all well and good, as they need to make sure we've actually organised something, even if that something is finding a hospital doctor in Australia who's willing to sign your book when you show up on the first day before spending three months on the beach. The problem (with the university, not with people doing three months of beach-time and no medicine) is that they make you tell them about it by writing almost 5000 words of reflective-diary, lessons-learnt, behaviour-modifications-needed, self-disclosing guff. It is so unbefuckinglievably awful that by the time I'd read the outline I no longer wanted to go on the elective because I was so suicidal at the prospect of having to - in Toyin's words - drink the kool-aid and write this shit.

I will do another post in a moment reproducing the relevant bit of the elective handbook in Private Eye style, with footnotes. For now, suffice to say that I've spent most of the week trying to write it, wanting to pluck out my eyeballs with a biro, and going to make tea and bitch about how ghastly it is with some of my housemates (chiefly "Dr. H", who's the only other medic). The musicican Beck Hansen wrote a song called MTV makes me wanna smoke crack in which the "chorus" was him repeating "fake it till you make it" over and over again. This wilfully stupid, pointless, joyless, miserable process reminded me of it.

Next post: less vitriol, more humour. Maybe.

Simplicity, effectiveness, and my place in the medical hierarchy

2007-02-13T09:37:00.000Z

8th February
Joewatch! Probably time the baguettes and apricot jam for breakfast got a mention. Simple but effective. 8/10.

Hospital life is progressing apace – we've begun abandoning cardiology in the mornings to go off on ward rounds with whichever set of physicians we like the look of at a given time. The pattern of teaching here seems to be that the students turn up in the mornings for ward rounds which last until half twelve or one-ish, whereupon they go home. Being extremely conscientious, Pete and I go for lunch with our team, and follow that with a bit of e-mailing and then some more echos in the afternoon. Lunch is a definite part of the day here, and teams tend to eat together in the internat de Purpan; it's a pleasant, helps you unwind a bit, and is (if you'll excuse the management speak) a simple and effective way to foster team spirit. The ward rounds are pretty interesting and my understanding of what's going on is growing gradually – I now understand that the two 11-year olds running around with nasogastric tubes cause the nephrology registrar to grumble because they're both anorexic and are allowed to spend their whole time together, including mealtimes. My French isn't perfect, but the gist is that this is a simple and effective way to foster team spirit, which in this context is undesirable.
Echos have continued, and I can almost read them now – certainly I'm understanding the colour pictures you can get them to produce showing flow across the valves and occasionally through places it there shouldn't be flow. Most enjoyable exchange of the week: a two-week old baby coming in with mother and grandmother in tow for an echo because she had a murmur. Said murmur turned out to be due to a very small hole between the ventricles, and Prof. Acar set about reassuring the nervous mum and the husky-voiced matriarch that all would be well and it'd sort itself out. Granny looked a bit worried, however:
Granny (growling mistrustfully): "But will this become something worse, doctor? It's in the family – my husband and I have both had problems with the arteries of the heart."
Dr. Dulac (with Gallic flair): "But that's because you smoke!"
Granny (ruefully): "Bah oui."He went on to explain the difference between congenital and acquired heart disease while I struggled not to smile. Another (male) baby who came in had an unusual penchant for destroying the disposable sheets you pull over the bed – these things have the consistency of old boots, and unless you find the places they're meant to tear, are very difficult to rip – this kid of perhaps six months was shredding the thing, drooling on it, and alternating between distributing it around the room in bluely dripping lumps and proffering it to anyone within reach like a cat with a dead bird. My earlier comments about having a funny face have been vindicated by my wandering in to find the two Chantals passing a squalling baby between them. He took one look at me and put his arms out in the classic "pick me up" gesture beloved of infants everywhere – and lo and behold, when I did, he shut up almost until his mother got back – and because we've been given white coats to wear, he wasn't even wiping his snotty nose on my shirt. The two Chantals were very impressed, and have begun using me as a backup baby-quietener if the giant fish from the Little Mermaid doesn't work: it's nice to have a sense of where I fit into the French medical hierarchy.

Anxiety dreams, echoes, and the art of losing

2007-02-13T09:30:00.000Z

5th February
Joewatch! The thick, lean slabs of rare roast beef for dinner. Loses marks because the pasta was merely okay. 8/10.

Pete has just been telling me about a dream he had involving his ex-girlfriend in which they met up for a Valentine's Day meal. She kept talking about how they were going to get back together, and Pete was eventually forced to demur:
Pete: "So eventually I had to say no, I thought we were just meeting up for a meal. And after that in the dream she didn't return any of my calls."
Me: "It's an anxiety dream."
Pete: "No – it's just weird because I don't dream about people often."
Me: "What are your actual plans for Valentine's Day?"
Pete: "Have dinner…in the canteen…with you."
Me: "It's an anxiety dream."
Ignoring for the moment Pete's refusal to accept my interpretation (could he be more in denial?), the discussion has made the first interminable leg of the interminable bus ride back from the hospital a little more entertaining. Although the place we're staying is great, it's also at the wrong hospital – Rangueil is south of Toulouse where Purpan is west – and so when we don't manage to cadge a lift it takes two buses and a good hour to get where we need to be.
Today we met Prof. Acar, who is a dark-haired man who I'd guess is 50ish but could pass as younger; Dr. Dulac, who has clown hair and a pleasing tendency to tell me what he's doing as he does it; Gabriel, a delightful Romanian senior house officer who stays in the same place we do and has offered us lifts, and Juliette, a slightly stressé house officer who speaks relentlessly and unforgivingly fast. I spent most of today with Dr. Dulac watching echocardiography in clinic. Echocardiography involves moving a probe about the size and shape of a TV remote control around on someone's chest, and producing a series of 2D images of their heart on a monitor. The advantages are numerous – it's doesn't involve exposing patients to radiation, in its vanilla form it's entirely noninvasive, it's extremely useful, and it's totally painless. You might, however, wonder about this if you saw some of the patients. Today one little girl was wheeled in clutching her mother's jeans around the corner of her buggy. She took one look at the two delightful nurses (both middle-aged, markedly thinner than their English counterparts, and conveniently both called Chantal) and began sobbing. They got her up on the couch, and despite their using all the tricks at their disposal (Saying before attaching the ECG labels "Look at the little fishes!"; offering her a print-out of her heartbeat; waving all the toys at their disposal) she continued wailing until the last sticker was off. Then she went and sat on her mother's shoulder and peered warily around the room, bursting into tears experimentally when anyone came within five yards of mum. I sat out that echo, I confess. It is interesting how differently the kids react to coming in – the amount of crying bears no relation to how ill they are nor how old they are – the sickest kids often cry least, and the youngest ones (weeks old) tend to cry only if you let them get cold, hungry, or if they need changing – and the only thing that seems to make a real difference is distraction. As soon as you give them a chance to remember that they're having something done which doesn't involve short-term gratification, they begin wailing – so they have a lot of mobiles which spin around ("Look at the little boats!"), toys with spinning bits, music, and flashing lights, and a wide array of silly faces to pull and cooing noises to make at them. I kept thinking of three things:
(1) The words of wisdom imparted by one of my neurology consultants while we were discussing headaches. When the group attempted to win points by running through the adult causes we'd just outlined, he interrupted saying, "What you need to remember is that in this, as in most areas of medicine, children can be considered not human."
(2) This made me think of those Japanese electronic "pets" on keyrings which you have to spend inordinate amounts of time virtually nurturing to keep alive.
(3) The movie Speed. If the kid's visual or auditory stimuli drop below 50, it'll go off.
The longer I spend around children, the more amazing it is that they actually become real people later on. Happily, though, they seem to like me; the most plausible explanation I've had for this came from Kirstie, then newly a mother, who suggested Josh would like me because I had a "funny face". She was right then, and appears her maternal instincts are still right now…

The only other thing of note to happen today was Pete having to go and meet Bernadette, the admin person for the hospital with whom he'd had long e-mail discussions with about our accommodation (which he'd sadly failed to write down anywhere), to say hello and ask for a new set of keys. Despite all the trouble we had finding them on Friday night, by the time we returned home on Saturday night (strictly Sunday morning), he had contrived to lose them: I've been impressed by how systematically he's been building a reputation for us among the locals as halfwits.

Airport staff, the devil being in the detail, and the introduction of Joewatch!

2007-02-07T13:40:00.000Z

5th February
The first missives of 2007 come to you from Toulouse, which has confounded expectations thus far for several reasons. Firstly and most importantly for those of you reading from the UK and cursing me for being in the south of France while you are in Plymouth / London / Sidcup, all three mornings so far have been bitingly cold and misty, and haven't really improved through the day – so no danger of a suntan on my return. It will surprise none of you who read my Spanish or Vellore missives to learn that the journey out here was slightly fraught. At Gatwick, I failed to take the boiler-plate announcement ("we would like to apologise for the delays with the security checks, and assure all passengers that we are working to get you through to your flights as quickly as possible") seriously until we reached the queue, which was huge. A woman in a yellow day-glo jacket who Pete described as being "like a cockney Catherine Zeta-Jones" kept asking if anyone's flight was due to leave in the next fifteen minutes, whereupon a few dozen people would wearily say "yes" and be ushered through the grumbling ranks to the X-ray scanners. The root of the problem became apparent when we got there, and it was evidently that a lot of airport staff had banked on British Airways not resolving the strike talks, and so had gone on holiday while striking on Monday and Tuesday, meaning they'd needed to pull sickies for the rest of the week. The upshot was that only two of the eight scanners were manned at 6pm on a Friday night – or absolute mayhem, in other words.

On the frequent occasions that cockney Catherine Zeta-Jones was absent escorting a passenger whose flight *really* left soon through security, a man who looked a bit like Mackenzie Crook would if you cut out half his brain at random took over. His modus operandi revolved around spending as long as possible alternately moaning at his fellow staff ("You really need to be doing this yourself, yeh?") and instructing the few who were junior to him to engage in pointless tasks ("You remember what I told you about fixing the barriers whenever you get the chance? Just fix them for me now, yeh?"). He would then watch them shift the tensabarriers he was standing next to a few inches while the completely docile passengers watched him with thinly disguised contempt. In response, when forced to do some work himself, he would bark "Ladies and gentlemen, I need your full cooperation here!" and would wait spiderlike in the web of general incompetence for someone to come up with a 'gate closing' time of 1940, at which he'd say smugly "that's your gate closing time, not your departure time, yeh? Back of the queue. Back where you were." He would of course then have to call the very same passenger through a few minutes later.

Anyway, having had my stereotypes about the British workforce reaffirmed, we made it to the departure gate a couple of minutes before the flight was scheduled to leave, although disappointingly we weren't called by name. I tried to persuade Pete that this meant they couldn't really want us yet, but despite the repeated announcements along the lines of: "This is a final call for the 19:40 flight to Jersey which will be departing from gate 51 shortly. Would passengers [list of a dozen or so names] please make their way there immediately", he wasn't buying it. We then made up the lost time in the air, and in Toulouse I had my stereotypes about cabbies reaffirmed when a fat unshaven man pressed the magic "shaft the foreigners for an extra ten Euros" button on his meter as we pulled into the hospital at Rangueil. At Rangueil, it became clear that Pete's text to me when he'd "organised" our accommodation – which read:
Forget what you thought you know about who your daddy is. I am your new daddy.
had been a little bullish.

First, he didn't know where in the hospital we were going – which might have been fine had it not been so deserted it felt a bit like a set from 28 days later. We wandered through several buildings without seeing a soul (and thankfully also without any infected zombie-life creatures attacking us) before eventually finding the Internat de Medecine. This is basically the hospital accommodation for junior doctors (internes) – and unsurprisingly, there are therefore no staff on duty at 11:15 on a Friday night. Once we got there, Pete revealed that he was sort of expecting there to have been someone there to tell us where our rooms were. The few doctors hanging around shrugged and suggested trying all the doors on the second and third floors – Pete had sensibly remembered that we had one on each floor, and that the rooms were open with the keys inside. Pete's suggestion was trying to get onto the internet, which we couldn't do – and it turned out that this was because he had been e-mailed the room numbers but sensibly had decided not to bother writing them down. In the end a friendly red-haired guy who we met as I was packing my laptop away and considering using it to beat Pete with got us going on the trying-the-doors thing, and we found the rooms.

That piece of total arse-wittery aside, the internat is pretty much brilliant. The rooms are big and, although falling apart slightly, pleasant, light, and mine has a surprisingly good view over some woods by the hospital. This coupled with the en-suite bathroom makes up for the fact the balcony door doesn't lock, the shutters don't close and there are no curtains, and it looks like someone has at one point put an axe through the main door to the room. All this is compensated for by the fact that:
* It's full board – breakfast, lunch, and dinner are all provided on-site
* There is tea, coffee, juice, and beer (yep, beer) on tap at all times
* The meals are cooked by the internat's own chef
* There's free table football, pool, a (rather crap) arcade game, and TV

The food is so excessively good, in fact, that I'm going to introduce a new feature to these missives in honour of Pete and my clinical partners, both of whom are currently on peripheral in Sidcup. Toyin will be familiar to most of you from previous missives, but Joe is Pete's clinical partner, and to say he enjoys his food would be an understatement. It's not that he's in any way fat, merely that it would take a pretty sizeable natural disaster to stop him eating; the only thing that has managed it thus far in the three years I've known him was when Esther (who is also on the course with us) professed her amazement that not everyone could put their ankles behind their head, and proceeded to demonstrate how easy she found it. This interrupted Joe's roll-eating for a good three or four minutes. So, to emphasise the gap between hospital accommodation here and in the UK, I'm introducing "Joewatch!", in which I will tell you all about the best thing we have eaten each day in the misleadingly-rubbish-sounding canteen:
* Saturday: side of pork in a mushroom sauce with duchesse potatoes. The potatoes were creamy and melted in your mouth, the pork was tender and juicy, and the sauce tasty without being overpowering. 9/10. Dishonourable mention to the doner kebab Pete purchased from a ropey looking stall in town, which has thus far disappointingly failed to give him food poisoning.
* Sunday: escalope of veal with pasta. Hard to judge fairly as I was a little hungover – but very palatable even in this unfortunate circumstance. 8/10.
* Monday: german meats, sauerkraut, and courgettes, followed by an excellent camembert from the (daily) cheeseboard. I am not joking. 8/10.

The kicker is that the total cost over the course of the three weeks is 120 euros – which would probably cover cereal, a sandwich, and a Burger King every day for the same period in the UK…

Briefly, as this is already too long, the people here are delightful – over the course of the twelve hours or so spent watching rugby and sampling the bars of Toulouse on Saturday night, I was complimented on my French by people whose English was clearly better than my French so often I lost count, spoke to a good half-dozen total strangers, and have already received two offers of daily lifts to the hospital we're based at, an invitation on a possible weekend trip to the Pyrenees, and another invitation to a concert. Toulouse is, in this sense, very unlike Paris…

On which stereotypical note, take care till next time.

Packing

2007-01-30T01:30:00.000Z

So on friday evening I leave for the hôpital des enfants, Toulouse. Prior to this, however, I must move all the aggregated detritus of my two years living at Sumner Buildings back to my parents' garage, as my landlord (Stephen) is moving back in to his flat, not unreasonably. This involves packing - and jesus, I have a lot of crap. I keep thinking as I lose count of how many boxes I'm up to, that I should really throw away a lot of it - but I haven't left myself sufficient time to go through it properly, and it is actually somehow quicker just to assemble another cardboard shell to conceal what utter tat I'm keeping.

Still, I reckon there's only about two days' worth of packing left to do, and I have a full thirty-six hours to do it in. So that's all right, then.

Birthdays

2007-01-14T23:17:00.000Z

Do not allow people to buy you shots on your birthday. In particular, do not let the fourth person there persuade the next ten to buy you shots. It is all likely to end in tears and/or a horrendous hangover. In addition, your sister will take dozens of photos of you appearing to be on the verge of groping and/or snogging your friends, including your male ones.

Skiing

2007-01-06T01:48:00.000Z

I'm going skiing. Or rather, I'm not, obviously, as that would involve taking a week off and missing seminars about old-age psychiatry given by pathologically soft-spoken, studiedly nice-seeming people. Always the quiet ones.

In the grand scheme of things, I reckon this crime ranks only just behind forging one's logbook. Or it would, were I actually going skiing. Which of course I'm not - but thank heavens there's snow, eh?

Never trust a computer you can't throw out of the window

2006-12-10T18:41:00.000Z

Steve Jobs, co-founder of Apple, had the right idea.

My exams are on tuesday. Much of my note-taking has been on computer, in the form of a rather sophisticated wiki (for the luddites among you, this is a sort of database where you can very easily link pages to one another). This has meant that I no longer take notes on one subject on eight different bits of paper - instead (at least in theory) I type them up once I've taken them and they sit there waiting for me or someone teaching me to change their mind. It has meant that I no longer need to rummage through another folder when I find reference to an eponymous syndrome which I just know I've heard of - I can just click on, for instance, Steele-Richardson-Olszewski syndrome, and it will furnish me with whatever scanty details I've put into it. Sadly, it also means that when your computer dies on you, you are reduced to the days-old version you put on a USB drive as a backup.

My 6000 word essay on thyroid cancer is due on friday. It is also on the computer along with all my references, and it is not backed up.

What has happened? The company that supplied my motherboard shipped a load of them out with defective fans. Mine failed a month or so ago, and because it told me this I registered it on the Asus website and asked them to send me a replacement. This they promised they would do...but they still haven't. In the meantime, it appears that the high temperature in the motherboard have fried the chipset. This may or may not be terminal; if it is it will be a very expensive terminal for Asus.

For reference, then, don't buy the Asus A8 range. They're great motherboards - but can fry your whole system.

I have been listening to a lot of Kate Nash to make myself feel better. She deserves to be huge.

Things I have learnt on the current rotation

2006-12-08T16:47:00.000Z

(1) The scene: labour ward handover, 08:30 Sunday morning. The SHO on call had just asked the head midwife where a patient was.
Midwife: "She's gone!"
SHO: "But I thought you were worried she was bleeding a lot?"
Midwife: [breezily] "She looked very well, so she's gone. Go and see her on postnatal when she collapses!"

(2) There is something very bizarre about hearing someone with a strong Irish accent say:
"Let's hope the contractions are doing the job they're meant to do, isn't it?"

The rest are all from my current obstetrics consultant, who is my new hero.
(3) When presenting to your consultant, do not say that a woman "refused" antenatal screening for Down syndrome. She will proceed to rinse you because you should say "declined". Happily, being quite obsessive-compulsive about the nuances of words, I thought this was great.

(4) "Having that process where if things go wrong, as they inevitably will when you're doctors, where you try to learn from it and be better tomorrow than you yesterday is the coping mechanism."

(5) "We know that rates of caesarean section go up before midnight, and episiotomies go up just before the midwives change shift. Isn't that awful, that we carry out these surgical procedures on women because we want to get some sleep, or because we want to be able to hand them over neatly? Well, I suppose it is and it isn't, but it's worth thinking about."

(6) "One of the things you learn is how not to be embarrassed by anything. You must have that at the moment doing GUM and taking sexual histories? Where you say to a total stranger, so, are you having oral, vaginal, and anal sex?" [pause to make yawning gesture] "Because really it's only embarrassing if the doctor finds it embarrassing - if you bring emotion to the consulting room, it detracts from your ability to pick up on it in the patient."

(7) Talking to a New Yorker with a bit of a family history of mental illness who was extremely worried she would develop post-natal psychosis: "I'm going to refer you to the psychiatrists now. Like you, I just think we need to be very careful - how long have you been in England? Well - here we say that when you have an umbrella it doesn't rain, and when you don't have one it does. So let's not take any chances." The woman looked like she wanted to hug the consultant at this point, and agreed about as fervently as it was possible to do without involving e.g. a bible. Later, at the post-clinic meeting, the consultant said "No, no - I love neurotic New Yorkers because they don't die, and psychotic New Yorkers do.

(8) After a long discussion about the changes in the public perception of childbirth from something you needed to get on with to something which should be managed with drugs because it was so unimaginably painful, and how this was making it worse for women because they expected the pain to be so dreadful: "No, no - if you get through labour alive I'm all for it - it's the most wonderful thing."

On which uplifting note...

The benefits of Obssessive Compulsive Disorder

2006-12-08T14:59:00.000Z

I am currently avoiding revision. While discussing this yesterday with the ubiquitous Toyin and Sarah (who's also on my O&G firm), we decided that part of the problem was that we felt so well-taught, and that this was making revision that little bit harder (the proof of this particular pudding being in this very post). I am living in dangerous times...

By way of avoiding learning for a while longer, here are the highlights of the course since my return.

(1) My obstetrics consultant. She wasn't around for the first part of the firm due to illness, and returned as T & I left for India. She is one of the generation of women who made it to consultant level with the deck stacked against them (by a lot of chauvinist, racist, and actually pretty generally misanthropic old men) and as a result have a bulletproof knowledge of their area and a gentle air of imperviousness to mistakes. She is also extremely nice, very understanding, and devastatingly incisive when you try to make excuses for things. For instance, I turned up to our last teaching session with her on monday having prepared a patient just before the teaching, and our exchange after I'd finished went roughly as follows:
Consultant: "How do you think that went?"
Me: "Well, I only saw her this morning, so it felt a bit light in place."
Consultant: "Yes - it was. You only saw her this morning?"
Me: "Yes."
Consultant: "So you weren't there for her birth?"
Me: "Er - no."
Consultant: "So you didn't think you should maybe clerk a patient before the morning of the tutorial?"
Me: "Um - yes, of course - but last week was breast week..." [at this point I decided to try being disarming] "But I'm making excuses."
Consultant: "Yes, you are. But that's fine - something has to give in your medical education, and if you can't make it to see a patient until an hour or two before teaching, you're going to struggle to get a feeling for how they're doing, and your presentation's doing to be a bit flimsy. Anyway..."

Ouch. The best and worst bit was how pleasant she was throughout the whole thing. Happily my presentation was followed by an utterly shambolic one from someone else on the firm, so I looked marginally less shit than she did. I clawed back some points, I think, when she came to sign my logbook; this is a completely pointless document designed as far as I can make out to waste as much of everyone's time as is humanly possible. I complained about them at the start of term, and will continue to do so until I have succeeded in having the things abolished. The one for my current block is riddled with basic spelling mistakes, bits where some imbecile cut-and-pasted them from another book and didn't bother to change the text, and crucial information missing. My response to this has been twofold: I have prepared a blistering e-mail about how shit they are to send to everyone I can find involved in the aberrations, and I've petulantly corrected them prominently wherever I've found a mistake, and annotated them with comments as sophisticated as: "OUT OF SPACE. ENOUGH TIME WASTED ON THIS, I THINK".

Sadly, one of these were on the signoff for the end of the rotation (they had titled in "paediatrics" when it is "Obstetrics and Gynaecology", and had written "RHS" instead of "RSH"), so I had written across the middle of the box "Royal Horticultural Society?".

The consultant looked at this in some bemusement, whereupon - not having learnt from earlier that my attempts at charm were going to get me nowhere - I again attempted to be disarming.
"Sorry - I get annoyed at the fact they make so many errors in these things when they get us to spend so much time doing them."
Consultant: "Oh, have they - yes. What have they - they've missed the title off that one. That is bad... [decisively] You need to have people who a bit obsessive-compulsive around to pick up on this sort of thing. That's the sort of doctor you want - you want someone who's going to check all your blood results compulsively, do all the groundwork, and not make mistakes. I think it's good."

Happily, she avoided writing "Chronic laziness offset by borderline OCD" in the comments section...

Reports of my jaw have been greatly exaggerated

2006-10-19T09:49:00.000+01:00

Today was quite dull. This morning was a series of lectures on termination of pregnancy which promised much and delivered little. In essence, the problem was that it was all pap and no actual information - sadly, "our job isn't to judge - we help the woman reach an informed decision about her health!" was followed by such a flurry of self-congratulatory backslapping and hugging that we got next to no information to provide to these notional women about their notional terminations. Several questions focused on fairly key issues, often in response to thoughtful-n-emotive statistics like "50% of couples who have a termination break up" went unanswered (no one knew what proportion of couples who don't have a termination break up, for instance). Ultimately I felt let down as much as anything - there's so much we don't know that to be told things we all know - not to be judgemental of someone who's having their third termination of the year, etc etc. - and asked to endure reading sob / fortifying stories about people who've had abortions is of no use to me as a medical student and of no interest to me as an English student unless they're well written.

So you can see why the academic content of the day was boring. The afternoon was not much better - I was stuck in an airless room with a lovely doctor who I'm ashamed to say I infected with my falling asleep during interminable patient interviews. He actually confessed to me when they'd gone, "I was listening to her talk and my eyes were closing - that's never happened to me before!". Oddly, in this situation I was all for empathising and not-judging him.

Anyway, today's excitement came in the form of a succession of texts and answerphone messages which arrived during the morning's first lecture. Some were from my mother, saying (and I quote):

Call John at 0208 [number removed] urgently re X ray on your jaw..I don't know what you've been up to but hope you are oK - let me know on your mobile that you've got htis - love Mum and anzious!

Another was from the Guy's Registry, who she'd very sensibly called to see if they knew where my body was being held, and a third was from an estate agent. Those bastards get their noses in everywhere.

The messages left me baffled for four reasons:
(1) I hadn't hurt my jaw.
(2) I hadn't ever had any medical treatment, never mind an X-ray, at Lewisham.
(3) I had never heard of John in the X-ray department.
(4) The last time I'd been in Lewisham was January.

So I called John, and opened with: "I'm a bit confused. I haven't had an X-ray on my jaw." Sounding a little nervous, he asked "is your surname also Chernyshenevsky?" (name changed to protect the innocent, and because John couldn't pronounce it and I can't remember it).

"No," I replied, biting back, "why, what are you other surnames?".

So a simple case of mistaken identity - except that:
(1) The only place they can have got my emergency contact details is from the staff records from when I worked there.
(2) Those aren't easily confused with patient notes - in fact, I've no idea how you could confuse the two.
(3) Particularly when the only resemblance my surname bears to "Chernyshevensky" is that it ends in "y".

So if anyone gets offered my identity over the next few weeks, please either let me know or call Lewisham hospital and ask them to notify Aleksandr Chernyshevensky as a matter of urgency...

GUM and Genetics...

2006-10-17T23:55:00.000+01:00

...clinics today. It turns out "Male Genito-Urinary Medicine" means "people of either gender with HIV". Lots of them were surprisingly cheery, lots of them were unsurprisingly extremely anxious about their blood results, but all in all they seemed to be doing pretty well. The downside was I missed a teaching session with the registrar who is teaching us and who is amazing. Bah.

Then, at lunchtime, after the obligatory lecture to which no lecturer turned up, I went to get my PEP pack. PEP stands for "post-exposure prophylaxis", and it consists of antiretroviral drugs you can take if you get a needlestick injury from someone who you're worried may have HIV while you're on peripheral, e.g. in India where I'm going. This sounds like a wonderful idea, but in practice it is an organisational nightmare for occupational health and a pain in the arse for us. The clincher is that they only give you one day's worth of drugs, and part of the hilarious spiel you have to sit through to get your booty advises you to get further treatment from your local hospital. Now I suspect that the Christian Medical College, Vellore would actually have PEP we could take, but it's the exception rather than the rule, and it would be cheaper and better to give everyone a box of gloves instead. Although you'd still be trying to reduce the number of HIV infections from peripheral attachments from zero, as far as I can make out.

I enjoyed the genetics clinics, too, and bizarrely the consultant I sat in with had trained at CMC, and knew the doctor I'll be supervised by out there. Those of you so inclined may say "small world" at this point.

Places to say "have a good year" to someone with cancer

2006-10-17T01:18:00.000+01:00

Speaking as someone who has an extraordinary capacity for saying precisely the wrong thing at the worst possible time, there are still some things I wouldn't say to someone with cancer.

"Have a good year!" is one of them - or was until earlier today. For today was my first exposure to outpatient clinics for people with thyroid cancer, which is the subject of my first special study module of the year. These are like extra bonus classes you get to go to on a topic of your choice - many people do languages, or read proper books rather than excruciating medical textbooks, or learn how to do sign language. Personally, I chose to do thyroid cancer, and I admit that the first session didn't start too brightly. There were eight of us in the room, and the module organiser sat us all down and, starting from the opposite side, asked us all to say why we'd chosen the course. The first six people came up with combinations of "because it said we could get a publication" (n=6), "the same as him/her" (n=3), and "because I came to the thyroid clinics last year and really enjoyed them" (n=4). The next person had a relative who'd had it, and that left me on the end; I was obliged to say "I chose to do it because I don't know much about the thyroid or about cancer."

This would have been fine - marks for honesty, right? - had the next question, which I had to field first, not been "Why don't you all tell me something you know about thyroid cancer?". Uh - excuse me? Weren't you *listening*? I responded by trying to look flustered in a way that suggested I just couldn't decide between lots of different things I knew about it, and then said confidently "it can present with thyrotoxicosis".

"Not really. Well - you're right - very rarely, but I've never seen one in my career." The next person gave three reasons before being chastised very insincerely by our instructor, whose relief that not everyone in her class was a moron was evident.

Anyway - it's got a lot better since then, and the module organiser is actually great. So - thyroid clinics. The thing to understand about thyroid cancer is that most people do fine, and live pretty much normal lifespans - so the clinic was one long object lesson in reassuring people who were utterly terrified that they were going to be fine. The first lady was a particularly good example as she'd been told she had thyroid cancer, had been referred to Guy's, and they'd realised after looking at the biopsy that she in fact didn't. This had been some time previously, and she was still terrified - but the doctor running the clinic was unbelievably good at sounding completely professional without condemning the people who'd fucked up reading the slides last time:

"Obviously they have some excellent pathologists at the Mayday, but the reason you were referred here is that our pathologists are looking at hundreds of possible thyroid cancers a year."

She also has a charming habit of slipping into posh vernacular, which somehow works - "oh, you poor old thing" and "right as rain" were two which stuck in my mind - and the overall impression is of a benevolent, close-to-omnipotent schoolmistress. Even when she wanted to be nasty about people she wasn't that nasty - "She's a funny one - quite an aggressive affect" as a euphemism for 'she's a screaming nightmare', for example. In addition, she was never rude about people's GPs despite the fact that they constantly seem to advise their patients to alter their thyroxine dose, which - for reference - is about as good an idea as getting a pizza delivery boy to drive a tank. We had a run of three where she had to frown slightly, and say something like, "Yes - it's quite a bad idea to change the dose like that, because you can make yourself quite ill. Next time, just ask the GP to give me a call, and we can sort it out."

Anyway, a lot of the cases we saw were people she'd treated years previously and was seeing for their annual follow-up - and so she'd end those consultations with a cheery "have a good year!". The punters loved it, and I'd guess that's for two reasons - first, she knew exactly who they were, opening by asking how they were finding living in Turkey, or how named members of their family were, or how their acting career was going - things like that. Second was the fact that these people had just been told their cancer hadn't come back - particular skill was needed to reassure one lady who'd been told her sore finger could be cancer "because she'd had thyroid cancer in the past", and once again the consultant managed to avoid rinsing the A&E doctor responsible. "Well - I imagine he was just thinking out loud. Your last thyroglobulin level was undetectable, so it's definitely not your thyroid cancer coming back." I aim to store that 'thinking out loud' line and use it myself.

"Have a good year" worked because it was (paradoxically) life-affirming. These patients were effectively cured, although we never talk about 'cure' because it can come back decades after the initial treatment - but every time they came to the clinic they were told that they were well again, and ending the clinic like that highlighted that next year, back they'd come, and they'd probably still be well - and when you've had cancer, I imagine that's pretty spectacular.

That said, I am very happy to continue basing this on second-hand information.

What are the good things about pregnancy?

2006-10-15T01:53:00.000+01:00

Next on the morning's entertainment was something titled "Community Study and Health Promotion", which Laura greeted by saying wearily yet vehemently “Jesus.” In the fug of important-sounding words and vague instructions, it was hard to establish what it actually involved, but the short version appears to be: we follow a pregnant woman around for a bit. This also involves “applied health promotion”, and is “not about intervention in pathological situations” (it’s not clear whether this was merely a counselling-service-inspired attempt at a rhyme, however).

The health promotion work this year is based on "the seminar from year 3", which I remembered only when Laura turned to me, grimaced, and spat “that smoking thing”, whereupon I remembered a session where we were asked "what are the good things about smoking?", and then treated as if I had never even considered that smoking might have some good points. The seminar was particularly memorable, however, as the lecturer had a penchant for wandering around energetically and bestriding the end of the row of seats - sadly, his flies were undone, and after the third time I'd seen his Y-fronts peeking out as he hitched his leg up over the end of the row I got the giggles very badly.

I'm hoping, therefore, to get the same guy this time, chiefly because I want to find out what the good things about pregnancy are.

We pay three visits to our prospective mother, one before and two after the birth; an inordinate amount of time was spent stressing the importance of "the woman" (said in faintly sinister Frau Blucher tone) having had a baby by the second visit; I can only assume that this was so we can encourage her to do so in plenty of time should junior turn out to be comfortable in the womb.

They ended by saying what a “massive undertaking” it was for them, which I took as a promise to screw everything up at least once, and encouraged us to try to attend the actual birth. This prompted Laura to turn to me and say flatly: “Perhaps we can move in with her.”

By this stage, everyone was sick of the speaker’s screechy voice, so I switched off somewhat during the list of the possible problems: "ze vuman" withdraws / relocates / dies (couched in the less fatal-sounding “morbidity”) / “practice problems” (the problem presumably will be that lots of them will be shit and completely disinterested in medical students) / problems contacting the Health Promo etc. contact (see practice problems). The solution to all these was, essentially, “find another woman”, or talk to the organiser. Of the two, I think I'd favour approaching total strangers with prams in Peckham.

Happily, the afternoon was terrific, and was overseen by a refreshingly blunt Australian lady who opened by saying “If you want to go to sleep then that’s fine; the most important thing I’m going to tell you is where you have to be tomorrow, so I’ll wake you up for that.” This was not directed to me personally, in case you were wondering.

I warmed to her even more when she went on to say:

"Read the seminar programme in advance of each seminar. Just do it to keep us happy because it’s very easy and we’re getting old.”

...offered us advice:

“Be nice. Be helpful. Introduce yourself to junior staff on-call and the charge midwife or charge nurse. Be punctual and well-presented. Respect the women you’re dealing with. This is advice for life, really.”

When, at the end of her speech, she said “we hope you have a nice time over the next 13 weeks”, I believed her.

Introductory sessions in a nutshell

2006-10-12T02:47:00.000+01:00

At the start of every academic year, as we students shuffle back into the Greenwood lecture theatre to bask in its day-glo orange beauty, we have to endure a series of introductory sessions. In the first few years, these could without exception be summarised as: "We know you are all going to spend most of the year getting drunk and trying to sleep with one another, but please try to do some work as well, or we will fail you". The variations came in the levels of disgust and/or fear expressed, and the conviction with which they said the F-word (fail).

Now we are entering our penultimate year of medical study, and are again spending almost all the year in hospitals and clinics, these introductory sessions have thankfully got shorter. A lot shorter. While the poor third years have two weeks of them and have been driven steadily more and more deranged by their total lack of content - the only thing I can remember about the whole two weeks was that we were told to get off at Ladywell station, not Lewisham, for Lewisham Hospital - we have only a morning.

Even so, it was special.

The head of year 4 opened the session by introducing himself and welcoming us all to year 4. He then used the words “exciting” and “challenging”, and the phrase “varied clinical experience” approximately thirty times each in the space of the twelve minutes for which he spoke. Perhaps the most illuminating comment he made was "you’ve all just come from year 3". He also had slides showing what each rotation we have this year includes, but in time-honoured fashion left them up barely long enough to read, so I can reveal that I will be studying, in order:

(1) Reproduction & Sexual Health
(2) Child health, Development, & Aging
(3) Emergency Medicine, Trauma, & Locomotion

There were also some vertical strands, but they lasted approximately eight seconds before being replaced by a slide saying how varied, exciting, and challenging year 4 was. The nods to tradition continued with the annual recommendation / admonition not to leave our logbooks until the last minute. Logbooks are the bane of everyone's existence: students hate them because everyone has more important things to do than watch you attempt, for instance, to explain pessaries and suppositories to a patient, and doctors hate them because students are constantly asking them to waste time signing identical brightly-coloured books which both parties know are destined for a landfill in nine months time. Not content with the excessive waste of time and paper these things already represent, every year the university suggests that we photocopy them every time we get a signature, presumably so that we can be blamed if the halfwits in the registry lose the real things. If I lose mine I simply plan to get a new one, forge all the signatures, and photocopy it extremely badly.

This year they have excelled themselves by adding a new piece of admin to these things: we need to get our clinic and ward round attendance signed off to "help" our firm heads mark us at the end of each rotation. Just like the "list of patients clerked", everyone will ignore this until the last week of the rotation when they will fill the whole thing in retrospectively and almost entirely fictitiously, and then have a series of doctors who love teaching and hate paperwork will have to sign a dozen of these things in a dozen different places. I suppose this is at least preparing us for what life in the NHS will be like when we're all junior doctors...

We then got the again customary Stern Message about Being On Time, although the effect was undermined by the speaker's honestly rather endearing comment immediately afterwards: “I’m a bit disorganised myself – but I’m trying to change and so should you.”

Having waited for everyone to switch back on after the logbook talk ended, our speaker cunningly slipped more paperwork into his talk by revealing that I will be given an online questionnaire to complete about each rotation, and that once I've completed this I will automatically be e-mailed a receipt…which I need to print out and attach to my logbook so that the registry have more paper to burn at the end of the year.

The morning ended with several pieces of useful and homely wisdom, the best of which was: "There’s a lot going on in year 4."

Next we had a talk from the head of the registry, who I like enormously and who was obviously still flushed with success at Arsenal having dispatched Man U the previous day. He did surprise me by saying: "the most common form of cheating is of course plagiarism" during a commendably short discussion of why cheating was bad. I was a bit surprised as to my mind the most common form of cheating is logbook fraud. He then stated the importance of referencing your Special Study Module essays (SSMs) properly, and as Laura pointed out, then reinforced this point by including a dictionary definition of plagiarism (unreferenced).

The SSM man then replaced Dave and banged on for a bit about how it was organic and evolving (and probably varied, exciting, and challenging), and then told us all that we had to fill in our forms on time. By this stage most people in the room were either asleep, suicidal, or gnawing the seat in front.

Thankfully, things were livened up by the arrival of a lady who looked a little like a recovering alcoholic to talk to us about the Counselling Service. Her speech was charming, largely because it was basically a string of tenuously-connected quotations from Freud, Jung et al. One of her opening comments, perhaps designed to flatter her audience, was:

"Medicine is about ordinary people doing extraordinary things" (said by either Jung or Freud - I forget which)

She then pointed out the tensions and conflict involved in being an ordinary person doing extraordinary things. The simple solution to such tension seems to me to be an extraordinary person instead, but I suppose this would put the counselling service out of a job, and she seemed nice enough. She then quoted Freud, Jung, Freud twice more, ended with a long quote from a Leonard Cohen song:

Ring the bells that still can ring
Forget your perfect offering
There is a crack in everything
That's how the light gets in.

...and left without giving us the contact details of the Counselling Service, but they seem like lovely and refreshingly well-read people. I'll save the rest of the morning's excitement for another day, and leave you on that relatively upbeat note...

Frost's three words...

2006-08-17T21:43:00.000+01:00

It is important to start such things as blogs with a dash of the pretentious. After all, one must begin the endeavour as if secure in the knowledge that no one will read it but you and your friends, despite the wonders if the internet meaning that anyone with a mouse and a pulse could stumble across it. Of course, even when blogs are only read by family and friends, the reaction can be pretty crushing: my good friend Thomas Ridge removed all the interesting stuff from his because of the hilarity it provoked among his friends, although we are all now deeply nostalgic for it. Before it was all unusual film and book reviews, now it is all incomprehensible mathematicocomputerscience in which all the abbreviations are girls' names. "I spent the weekend with Isobel" does not mean what one might expect.

Anyway: Robert Frost. It was he who said "In three words I can sum up everything I've learned about life - it goes on." You may check if you don't believe me. This blog will, for the next few weeks, be nothing whatever to do with that as I'm on holiday - but after that, it will feature the odd person for whom life does not go on and how they react to (people like) me (prior to death) and how I/we react to them.

But for now I have to continue celebrating the end of first-year clinical medical exams by filing my tax return.