The Good Patient

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Medical school interviewers often ask prospective candidates what makes a good doctor. Listening, compassion, knowledge, teamwork… there are plentiful buzzwords that most of us could supply. As always, the truth is more complex than a list of attributes.

But what makes a good patient? After all, all of us (doctors included) will find ourselves a patient at some stage in our lives. And when we are a patient, we play an important part alongside our doctor in the to-and-fro role play that leads to diagnosis and treatment.

So, next time you find yourself playing the role of patient, here are some tips to help you reach a happy ending.

  1. Be prepared

If you’re a cub scout, this may mean carrying a pen-knife and a woggle. If you go to the doctors, please spend a few minutes thinking about what information your doctor might need. If your symptoms have been going on for years, think in advance about the important dates, or sketch out a timeline in your mind. If your symptoms come and go, consider keeping a diary. If you have symptoms that you can’t describe yourself, bring someone with you who can. If you’re attending a hospital appointment remember that they won’t necessarily have all your health records and bring what you have. If you’re taking medication, know the names and doses, or bring a list.

  1. Be truthful

Sherlock-Doctor-Watson

Sherlock Holmes regarded medicine and detective work as allied professions. In his words, when talking to a dishonest client, “only a patient who has an object in deceiving his surgeon would conceal the facts of his case”. In both detective work and medicine, it is often difficult to disentangle a crucial clue from a red herring. That is your doctor’s job, but you can make it easier by giving them accurate information to work with. To quote Holmes again – “I am accustomed to have mystery at one end of my cases, but to have it at both ends is too confusing”.

  1. Be open minded

doctor google

You may have an idea of what is wrong with you and what needs to be done. You (and Dr Google) may be right, and you may not be – the truth is out there, but so are plenty of lies. Give the doctor in front of you the benefit of the doubt, and listen with an open mind. And demand that they offer you the same open mind in return. Doctors can be wrong, but so can patients. There should be give and take on both sides.

  1. Be polite

It shouldn’t need saying, and yet it does. Shouting at your doctor won’t get them on your side.

  1. Be punctual

doctor clock

There’s nothing less helpful than when someone turns up 30 minutes late for a 30 minute appointment. Come on time. If your doctor is late, it won’t be on purpose.

  1. Be organised

Your doctor may well suggest some tests – don’t forget to go to them. Don’t forget to go back for your follow up appointment. If you change address or phone number, let your doctor know. If you decide on a treatment, don’t forget to take the tablets. It’s common sense. And if you make a deliberate decision not to get the tests, or to take the tablets, please ‘fess up (see point 2).

  1. Be proactive

If you have tests, and don’t hear results, get in touch to find out why. If the test hasn’t happened, get in touch to find out why. If your follow up appointment hasn’t come through, get in touch to find out why. Probably, someone else is on the case. But they might not be. You’re the one with the strongest interest in your own health, so take some responsibility for it.

  1. Be prepared to shop around…

shopping trolley

If you don’t get on with your doctor, don’t suffer in silence. Ask to see someone else. The chances are, if you’re not satisfied, they’re not enjoying the relationship either. They probably won’t be offended, and if they are offended they are grown up enough to deal with it. If your doctor doesn’t seem expert in your particular problem, find yourself someone who is. There are plenty more fish in the hospital.

  1. … a bit

If your first doctor doesn’t work out for you, try a second. If the second doesn’t work out, try a third. But by the time you’re on your seventh, the chances of a perfect outcome are getting slimmer. There’s a law of diminishing returns, and there’s a point when each new opinion will confuse matters rather than clarify them. There comes a time when you need to pick your partner.

  1. Be in it for the long haul

If you’re lucky, your visit to the doctors might be a one-off. But for many people with chronic conditions, visiting a doctor is a repeating event, occurring month after month, or year after year. It’s a relationship that develops into more than a transactional one, for both parties involved. So invest in it and make it count.

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The mysterious doctor shortage

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There’s been a lot in the media recently about the UK’s doctor shortage.

If you follow medical news, you’ll have heard phrases like “rota gap” and “brain drain” being bandied about. You’ll have heard that European doctors and nurses are planning to leave Britain as they feel unwelcome. You’ll have heard headlines about GPs planning to retire, emigrate, or just quit.

Does the UK really have a doctor shortage?

Within Europe, a couple of years ago, Britain ranked 24th out of 27 countries in doctors per population, with 2.7 doctors per 1000. By comparison, Germany, France and Italy all have over 3 per 1000. And in the last 2 years things have got worse.

But what number should we be aiming for? Perhaps more important than any metric is the fact that hospitals are increasingly struggling to find doctors to fill gaps in their workforce, either permanently or on a temporary basis to cover empty shifts. It’s not just that we have fewer doctors than Germany, it’s that we have fewer doctors than we know we need. These “rota gaps” or unfilled posts increase the stress on the remaining doctors who have to cover extra work during their shifts. In the worst cases, understaffing is dangerous for patients. There have been recent examples of hospitals or departments temporarily closing because of a lack of doctors.

The UK has some of the world’s most prestigious medical schools and teaching hospitals, and is the origin of plenty of ground breaking medical research. Surely we shouldn’t be short of doctors?

famous five

Five and The Mysterious Doctor Shortage

How can you get more doctors?

Firstly, you can train more new doctors. There are more people who want to be medical students than places at medical school, so we could train more doctors by increasing the number of places available.

Of course, it isn’t quite that simple. Each medical student needs teaching. It’s not just about lectures (you could always use bigger lecture theatres), but also about time spent in small groups doing practical work, like examining patients. Many doctors give their time for free to teach medical students, but as the workforce becomes more stretched this becomes a bigger and bigger ask. Even if you can create more space in medical schools, it still costs quite a bit of money to train a new doctor. And even if you find the money, it takes 5-6 years to create a doctor, and once created, they are still junior and inexperienced.

An alternative approach would be to find fully trained doctors elsewhere, and import them. Immigration seems rather unpopular at the moment, but historically the NHS has recruited a lot of its workforce from abroad. Foreign trained doctors haven’t always had the same rigorous training as UK doctors (although in many cases they have), they may not always speak perfect English (but in many cases they do), and they may take time to settle in the UK and the NHS. Another downside is that the countries that these immigrant doctors come from, which often pay for some or all of their medical training, are often very short of doctors too. So poaching their doctors isn’t necessarily a friendly or ethical thing to do.

A final possible source of doctors is to identify doctors who are in the UK, but not currently working, and persuade them to re-join the medical workforce. There are more people in this group than you might imagine. For example, they might be having a career break, on maternity leave, doing research, or working in another industry. In the same way, part-time workers could be persuaded to extend their working hours.

How about reducing the number of doctors leaving?

We’ve established that it’s not simple to find new doctors to join the workforce. So perhaps we should focus on the other side of the equation.

One reason that doctors leave the workforce is to retire. You can push up the retirement age, and keep doctors working a bit longer. This is a strategy being rolled out all around the public sector, and it may help a little, but it’s only a short-term solution.

Another reason people leave the NHS is to move abroad. UK medical graduates are easily employable in many other countries. Canada, Australia and New Zealand are popular destinations, with a reputation for better wages, cheaper living costs, a more fulfilling work environment and a generally better quality of life for doctors.

doctor with bags

Some people quit medicine altogether and go and work for banks, pharmaceutical companies, universities or consultancies. They have varying reasons for leaving clinical medicine. Some may simply feel that they are not cut out for it. Others leave in search of better wages, better lifestyle (working for a University or a pharma company usually doesn’t involve night shifts), or a reduction in stress.

Another group of people walk out of clinical medicine temporarily. People step out to do research, to do higher degrees, to learn about non-clinical topics like management or education. Some come back, others do not.  There’s a growing trend for people to have a “year out” – a bit like a university gap year, to go travelling, or simply to unwind after years of slogging away at medical school and on the junior doctor treadmill.

It’s also worth considering people switching to part-time working. If two people switch to “half time” working, that is the equivalent of a doctor leaving the workforce.

Don’t give me problems, give me solutions!

Deciding to train more doctors would only create the first additional doctor in 5 years’ time, and it would then take an additional 5 years to turn that rookie doctor into, for example, a GP. So increasing supply via the medical school route is a bit like trying to turn around a huge oil tanker, where you have to start the manoeuvre 10 years in advance. And not only is the oil tanker hard to manoeuvre, the target is moving. What will the NHS look like in 10 years’ time anyway? And when did a Government ever sincerely plan 10 years in advance?

The UK has historically imported some of its doctors from the Indian Subcontinent, and more recently from the EU. But this flow has slowed a little, perhaps due to stagnating wages and low morale in the NHS. It’s possible that anti-immigrant sentiment is also having an effect. Perhaps if we could be a bit more welcoming this trend might reverse?

How about stemming the flow of doctors out of the NHS? The government hasn’t done a brilliant job there recently, picking a fight with doctors over their contracts, bad-mouthing them to the press, freezing pay or offering below-inflation pay rises. We’ve seen record numbers of doctors quitting medicine, or looking for greener pastures in which to practise. There’s a vicious cycle here – as doctors leave, the remainder become more stretched, morale falls, more leave and the cycle begins again.

This exodus of talent needs to be stopped. The causes are complex, but the solutions don’t have to be. The Government needs to make being a doctor in the NHS a more attractive proposition. That might involve better contracts, pay and working conditions. It might involve a little more respect. It might involve quietening down some of the absurd anti-immigrant rhetoric that is scaring away many excellent foreign doctors. It might be as simple as putting the necessary resources into an organisation that is creaking with overuse and underinvestment, so that every shift doesn’t feel like a struggle.

It shouldn’t be that hard to sell medicine as a career to people who have already chosen to spend years training to be doctors. In many ways, being a doctor is the best job in the world.

Give us the resources to do our jobs properly, and the mystery of the shrinking medical workforce might solve itself.

 

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Another date with death

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A couple of years ago, back when weekend hospital staffing was big news, and the undefined “7-day NHS” was being used as a stick to beat doctors with, I wrote a blog post explaining why people admitted to hospitals on weekends might be more likely to die than those admitted on weekdays. I called it “A Date With Death“.

Hospital staffing certainly might be a factor here (and we’d all like hospitals to be better staffed, on any day of the week), but the most likely explanation is that people attending hospital on a weekend tend to be sicker, and sicker people are more likely to die. If you want more detail, I suggest you check out my original post.

death

This week, a paper has been published in The Lancet which provides some data to support this common sense theory. Most previous papers tried to compare equally sick patients from weekdays and weekends, but the only way they had to measure this was using coding data, which is the data hospitals generate to show how much they should be paid. It’s a pretty low level way of assessing how ill a patient is. The Lancet paper adds in an extra set of clinical data – blood tests taken on admission. Once you add this information to the analysis, nearly half of the “excess weekend deaths” in Jeremy Hunt’s rousing speeches disappear.

Unfortunately, the news that the weekend effect is smaller than previously thought isn’t likely to trouble any government ministers, who probably knew their claims were shaky before they made them. It’s likely to pass by most of the health media too, particularly when everyone is focusing on cybercrime.

Nonetheless, for those of us who always suspected the “weekend effect” proved only that sicker patients are more likely to die, it’s nice to have an extra piece of evidence to point to. it’s a small blow for common sense against hyperbole.

If you want to read the Lancet paper, it can be found here.

 

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Reaching Down the Rabbit Hole – Allan Ropper

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A Book Review

Why would anyone choose to be a neurologist?

Setting out to explain this to the public, Allan Ropper has some famous footsteps to follow. The late Oliver Sachs immortalised a series of his most interesting patients, the most famous being the man who mistook his wife for a hat. Henry Marsh, a British Neurosurgeon, has written about the almost religious experience of navigating inside a living person’s head.

Ropper’s book meanders gently through a series of cases he encounters during a few weeks on the wards – a tiny sliver of his career. Readers meet two confused patients in next-door rooms. One will recover, the other will not. The clues are in their minds, and the only access is by listening. We meet a man who fell on the ice, and irreversibly damaged his brain, but left his body untouched. Is he dead or alive? There is room for some philosophy here, before cold hard facts intervene and parts of his body are used to help others. We encounter two people with motor neurone disease, and come to understand their different decisions about life and death.

The book is not just a series of case presentations. It is shot through with the history of neurology, including Dr Parkinson’s original description of his disease. Clearly nearing the end of his career, Dr Ropper looks forward to the next generation of neurologists, but also back to the previous generation who taught him. There are pearls of wisdom from the past and the future.

Some of chapters contain triumphs. Ropper orchestrates a dramatic “save” when a patient develops life-threatening pressure inside her brain. What she needs is a hole in the head to release the pressure. He steps in where others have failed, and makes instant diagnoses. He spots things that others have missed. But he is not afraid of describing failures. The patient with the hole in her head should have been treated more quickly, and the drama wouldn’t have taken place. He talks a man into having surgery that he doesn’t want, and the surgery leaves him badly damaged. He agonises when he misses a rare diagnosis for 18 hours, and his patient becomes paralysed.

Ropper is clearly an extraordinary and successful doctor. Compared to other recent medical books, such as Marsh’s Do No Harm, or Paul Kalanithi’s When Breath Becomes Air, this book does not have such elegant prose, or the same originality of voice. It is co-written (for which I read ghost-written), which may dilute the book’s power.

The cases are well chosen to illustrate some of the amazing things the human brain can do, and what happens when parts of it go wrong. But that is not really what this book is about – it’s about the highs and the lows, the exhilaration and exhaustion, the privilege and the burden, the camaraderie and the loneliness of being a doctor. It’s about the wonder of sitting and listening to a patient’s brain telling you what is wrong with itself.

When talking with a mentor about which specialty to choose for his career, Ropper is told “Why would you choose nephrology over neurology? The kidney makes urine, but the brain makes poetry.”

This book is not quite poetry, but it will do.

ropper

 

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Reasons not to be cheerful

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You might easily have missed the news, published this week, that half of UK doctors finishing foundation training (the first 2 years after qualifying) are not continuing their medical training. It’s a big and troubling statistic, and one that makes government promises of more home-trained doctors look like wishful thinking.

A year ago, during the heat of the junior contract crises, Jeremy Hunt announced an “urgent” review of junior doctors’ morale. It made for good headlines, but nothing has been heard of it since. So, to save the government the trouble and expense, here are ten reasons why doctors are not cheerful.

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  1. Lack of respect

At no point in my medical career have I felt a lack of respect from my patients.

But junior doctors, and NHS staff in general, are aware of a lack of respect from other places. There are the crass comments about the medical profession coming out of the mouth of Jeremy Hunt, and his minions, blaming doctors for a crisis that we did not create. And there are the misleading stories in the media about doctors in the UK. And then there is the forced imposition of a contract we didn’t sign up for.

  1. Lack of support

Sometimes, things go wrong. This happens in any job. And sometimes, it might be your fault. This happens to everyone. It certainly happens to all doctors. And, in medicine, the stakes are high.

In those circumstances, what all of us would hope for would be to identify the mistake, learn from it, apologise, and move on. What you need from those around you is helpful advice about how to avoid similar mistakes in the future, and reassurance that you are still good at your job.

Without support, mistakes can fester, confidence can be lost, and it is difficult to move on.

  1. Lack of a team mentality

Being a junior doctor can feel quite isolating. Every one of us has experienced that panicky moment when a patient deteriorates in front of you, and you don’t know what to do. The good news is that you’re always one of a team, and there are always others to help.

Team mentality is what gets you through that night shift from hell, that endless ward round, or that lengthy operation. You are in it together. You don’t want to let your colleagues and friends down, and they don’t want to let you down.

The increase in shift-working means that we are increasingly working with people we don’t know. We get less support from them, and we offer them less support in return. It’s a lose-lose situation.

  1. Lack of a team

missing

Even if you can hang on to the team mentality, it’s not much help if you’re missing your team. Understaffing has been a big issue for junior doctors for years (and has even developed its own twitter hashtag, #mindtherotagap).

We’re used to teams shrinking, working alongside “unfilled posts”, working overtime to cover our imaginary colleagues.  We’re used to receiving last-minute emails and phone calls asking us to fill weekend or night shifts because colleagues are ill and there is no slack in the system. We’re used to our employers making minimal efforts to fill these holes, because it’s cheaper for them if the skeleton crew just suck it up.

  1. Lack of a safety net

In the aviation industry, like in medicine, small mistakes can be very costly. Pilots work within a very comprehensive safety net of checklists and controls.

Medicine ought to work in this way too. A patient coming into an emergency department will be triaged and assessed by a nurse, then a junior doctor, then perhaps a more senior doctor, before a consultant makes a final management plan. If they are admitted they will be assessed by a ward nurse who will carry out regular observations, and a pharmacist will screen their medication. This should all happen with 24 hours. If one person makes an error, there should be multiple opportunities for this to be corrected.

But what if this safety net isn’t there? What if other members of the team are missing, and steps have to be skipped? If something goes wrong, it’s hard to accuse the empty posts, the colleagues who didn’t show up, the managers who didn’t fill the rota gaps, or the people who designed an inadequate system in the first place.

The finger of blame points squarely at the people who did see the patient, and who were trying to do their job under difficult circumstances. Working without a safety net is nerve-wracking.

  1. Lack of sensible assessments

If you try to define a good doctor, you’ll probably focus on their interactions with patients. And looking after patients can be a very full time job.

But quite apart from patient care, a junior doctor is meant to be jumping through a number of hoops. They are expected to compile a portfolio of their experience, complete numerous on-the-job assessments, collect proof that they are competent to perform many procedures and document their “reflections” on meaningful events.

In addition to this extensive portfolio, they also have to complete a number of professional exams, for which they study in their own time, and for which they pay exorbitant fees out of their own pocket.

And every few years, for no obvious reason, the hoops are shifted and the rules are changed. It doesn’t make us happy. Doctors need to be assessed. But there must be a better way than this.

hoops

  1. Lack of control

In the past, a junior doctor finishing their first year after qualifying had choices. Some might apply straight for a training program, and head off into the sunset in their chosen specialty. Some might not be sure which specialty they wanted to pursue, and they could apply for stand-alone posts in various specialties until they made up their minds. For some, particularly those with families, geography might be more important than specialty – they could apply for any job they liked that was local. There was no time limit on training.

A decade ago, medical training in the UK was dramatically changed. Doctors are now forced to choose a specialty just two years after qualifying. Many programs have national applications, meaning a London trainee with a family might apply for neurosurgery, be accepted, but be sent to Cardiff or Leeds to train. It’s not surprising that he or she might decide to take a break from their career instead.

  1. Lack of money

You don’t see doctors begging on street corners, and no-one would claim that they aren’t paid enough to get by. But the cost of studying to be a doctor is shooting upwards, leaving many junior doctors with massive debts before they have wielded a stethoscope in anger.

NHS salaries are lower than those paid in the private sector, pay-rises are slower, and working conditions are often worse. It’s easy to look at your peers, who work predictable hours in shiny offices, who never work on weekends or nights, who aren’t likely to be dispatched to work hours away from friends and family, and wonder why they are earning more than you are.

The freeze on NHS salaries (a real terms pay-cut) while private sector pay rises, and the increase in tuition fees, make that equation more and more lopsided. It’s not surprising that some people are pulling the rip-cord and bailing out.

  1. Lack of long-term vision

Medical training is a marathon, not a sprint. GCSEs and A-Levels. Five or six years at medical school. Two years as a foundation trainee. Seven or eight years as a specialist trainee. Give or take a PhD.

It’s a long-haul. As tough working conditions at the bottom of the pyramid take their toll, it’s not easy to see the end of the long road ahead. And, as working conditions from the top to the bottom deteriorate, it’s not clear whether running this marathon is worth it.

  1. Lack of optimism

It’s hard to find happy people in the NHS at the moment. As waiting times spiral and targets are missed, while the Government demands more and more for less, not many people are optimistic about the future. It’s not only junior doctors – everyone is feeling squeezed.

You’ve spent years studying hard in medical school, paying for the privilege, and when you arrive at your destination everyone is miserable. When your role models are muttering about leaving medicine themselves, what are you going to do?

DISCLAIMER: It’s not all doom and gloom. If you are depressed by reading this post, for balance please also read Abrainia’s earlier post “Reasons to be cheerful”.

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Reasons to be cheerful

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It’s grim oop NHS.

You can’t spend more than a few minutes looking at facebook or twitter on the topic of the NHS without people mentioning crises, battles or strikes.

You can’t look at a newspaper without seeing headlines about huge deficits, failing trusts, closing hospitals, doctor shortages, spiralling waiting times, implausible efficiency savings or politicians with their heads in the sand.

As a new batch of raw medical students climb onto the bottom rung of the career ladder, it’s hard for the more seasoned professionals to summon up much enthusiasm about what they have in store.

But there are some reasons to be cheerful.

  1. Your country needs you

your-country-needs-you

The UK is short of doctors. It has fewer doctors per member of the population than most comparable countries, and that’s before you take into account the job vacancies that can’t currently be filled, and the disillusioned people apparently planning to walk away. And although they won’t admit there is a shortage of doctors, the government is so worried by this that they are talking about chaining new medical graduates to the NHS for four years after graduation. And it’s nice to be wanted, right?

  1. Your patients need you

An emergency department crammed with patients. Screaming babies, whining children, grey-faced adults, beeping monitors and alarms, and somewhere the sound of retching. It’s not a recipe for relaxation, but they all need your help and attention. And (see point 1) it’s nice to be wanted, right?

  1. Helping people

If you turn up at your medical school interview and say you’ve chosen medicine because you want to help people, you’re more likely to be met by rolling of eyes than by open arms. But most doctors choose medicine at least partly for this reason. It’s great to do a job that seems so unequivocally good, even if the government sometimes seems to be trying to get in the way. When did superman ever complain about having to battle against the forces of evil to help those in need?

  1. Governments and politics are temporary

Yes, it’s a pretty depressing time for the NHS. If you listen to people around you, you’ll hear talk of privatisation, of rationing, of cuts to services, of departments struggling to cope with the weight of demand. But governments change, and politics change. Meanwhile, the NHS has been around for 60 years, and in many ways is bigger, better and stronger than ever. Outcomes are still better than in many other health systems, and the vast majority of patients are receiving excellent care. The NHS will still be there when Theresa May is nothing more than a political memory.

  1. Medicine is a broad church
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No, not that kind of Broadchurch…

So you make it through medical school and discover that talking to patients drives you mad…don’t panic. You can always be a pathologist (only interact with dead patients, or removed bits of living ones), a radiologist (only interact with pictures of patients) or a microbiologist (only interact with microbes). If patients are your thing, you can sit and listen to them (psychiatry), drug them (medicine) feed wires, balloons and tubes into them (cardiology), put them to sleep (anaesthesia) or cut them up (surgery). If you leave medicine completely, you’ll find that those letters after your name stay with you, and banks, consulting firms, and pharma companies welcome you with open arms. What career could offer more options?

  1. Getting paid…just about enough

doctors-pay

If you didn’t know that medicine pays less than other comparable professions, you didn’t do enough research before you applied. If that bothers you, you probably won’t be a doctor for long. Doctors’ salaries in the NHS aren’t huge, but they are enough. Whether that will remain the case as NHS costs are cut, while student fees are hiked, remains to be seen. In the meantime, before you moan, next time you’re at work in a hospital, look around you and you’ll see many people working just as hard, for less money.

  1. The NHS

Imagine telling a patient they have a treatable condition but there is no money to pay for their treatment. That’s a reality for many doctors, in many countries. It’s worth taking a step back and remembering that this was the case in the UK too, before 1948. And if you happen to be uninsured, it’s still the case in the US. But in the UK, despite what the Daily Mail may claim, this doesn’t really happen. If a treatment is proven to work, we can offer it even if the patient is penniless. It’s a privilege to practise medicine in this environment. Long may it continue.

  1. Transferable skills

More or less as soon as you put those magic letters after your name, the world is your oyster. Not literally – that would be slimy and unpleasant. But a qualified doctor can walk into a well-paid job in many many countries. If you find you’ve had enough of working in the UK, isn’t this a reason to be cheerful?

  1. Amazing science

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All doctors have had that depressing conversation with a patient or their family. The diagnosis is clear, but nothing can be done. Those situations will always occur – people will never be immortal. But technology, drugs and our understanding of science are accelerating faster than ever before. Untreatable conditions are becoming treatable. If you’re starting your medical career now, who knows what advances you will see before you retire? It should be an amazing journey.

  1. The most interesting job in the world

There are days when every patient blurs together. But there are also days when people stand out. The former fighter pilot with an aneurysm and a remarkable world view. The priest with prostate cancer and a serene attitude to his illness. The dancer with a spinal tumour and a determination to live a normal life in the face of adversity. What other job would introduce you to such extraordinary people in such an intimate way? What other job would pay you to help the people who need it the most, at the most difficult time of their life?

I wouldn’t trade my job for any other, and that is certainly a reason to be cheerful.

 

If you find this post overly optimistic, please try Abrainia’s reasons not to be cheerful!

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Herding Cats

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If you take a group of doctors and ask them all the same question, you can expect to hear more than one opinion. Even a single specialist, when faced with a tricky treatment or diagnostic decision, might offer more than one answer. We are trained to think hard and independently, to take difficult decisions seriously, and to communicate our thoughts clearly. We’re also trained not to force our views on others.

Until recently, there had been remarkable unity among the ranks of junior doctors in their contract dispute with the department of health. The original contract proposal seemed disastrous in every way – safety, pay and equality all suffered. Government allegations of the British Medical Association misleading its junior doctor members were, well, misleading. We read the plans ourselves and we were horrified. And if the facts alone were not enough to unite us, there was Jeremy Hunt, centre stage, conducting an orchestra of spin-doctors, calculated press releases and herd-following tabloids, firing out dubious statistics and allegations, trumpeting his imaginary plans for a “truly 7-day NHS”.

The story today is rather different. A year has passed. Several strikes, and many weeks of negotiations later, we have a contract that a sizeable minority of junior doctors feel they could live with (42% voted to accept it, 58% to reject it). Jeremy Hunt appears to have realised that his unifying effect is working against him, and has kept uncharacteristically quiet. And the BMA Junior Doctors Committee has been busy tying itself in knots, changing personnel like disposable gloves, and announcing strikes that then get abandoned within days.

And while the BMA vacillate, the NHS is in crisis. Nursing bursaries have been cut. Senior doctors are again being attacked via the media. Junior doctors are increasingly taking time out, or emigrating, even before the new contract has been brought in. Waiting times are reaching record highs, hospital are bursting at the seams with patients, and some departments have been unable to find enough doctors to stay open safely. Increasing numbers of senior NHS and even government figures are publicly admitting that the current trajectory of funding is going to lead to a train wreck.

There’s an excellent reason why the BMA appear uncertain what to do. It’s because it really isn’t clear what they should do. We were all prepared to strike against a contract that everyone could see would be a disaster. But what about a contract that nearly half of us think might be ok? Perhaps a series of rolling 5-day strikes in that context seems a bit – radical? But after fighting so hard for so long, should we really roll over and accept a contract that a majority of junior doctors voted against?

It’s important to remember the achievements of junior doctors during the last year. Without giving up our (quite demanding) day jobs, we have organised and fought a campaign including unprecedented strike action. We have maintained public support while up against a Government spin machine working at full tilt, helped by a compliant majority of the media. During strike action, doctors set up free classes to teach CPR to grateful members of the public. Doctors have attended marches, written blogs and made videos, appeared on TV, written articles in newspapers, set up a table outside the department of health and manned it for weeks waiting for Jeremy Hunt to appear for negotiations. But the most significant achievement was forcing the Government to return to negotiations, and getting a better deal for our contract. Not perfect. But better. Think 42% satisfaction, compared to 2% satisfaction with the original.

With the appetite for strikes fading, perhaps the junior doctor contract battle is over. A year ago, it felt like this dispute was at the centre of the crisis in the NHS. Now, with an improved contract, and worsening problems elsewhere, it feels peripheral.

 

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The future of the NHS feels less certain than at any time since it came into being in 1948. A debate is needed about how health care in the UK will be funded in the future. Junior doctors need to rediscover that elusive sense of unity, and make our voices heard.

 

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