I've met with my junior doctor, dutifully undertaking an hour's supervision each week, assiduously documenting what we discuss.
What he wants out of supervision is, most meaningfully to him, being equipped to pass his exams. Without that, his career is thwarted and he can't progress his training to become a Consultant Psychiatrist.
What the Royal College wants out of supervision is unrealistic, with a full lever arch file failing to contain all that's meant to be covered, but in essence there's an expectation that all elements of the GMC's Good Medical Practice and all core generic medical competencies and old age psychiatry will be delivered. Most meaningfully to the RCPsych is progress of the curriculum (evidenced in doctor's portfolio and online workplace based assessments).
What the Trust wants is a safe practitioner doing appropriate work so, most meaningful to the Trust, is a supervised practitioner who's learnt and is fully aware and using in their practice the hundreds of Trust policies we have.
What the patients want of him isn't really factored in.
What I want is different and diverse and aspirational. In 3 or 4 years, my junior doctor is likely to be a Consultant Psychiatrist. What should such a junior doctor be mentored, informed or developed in, through ongoing weekly supervision?
Showing posts with label Junior Doctors. Show all posts
Showing posts with label Junior Doctors. Show all posts
Thursday, 2 September 2010
Saturday, 23 January 2010
Ward doctors
Ward nurses are busy. Medical and surgical wards I visit don't have the staff to do the work that's needed. It's manifestly evident to everyone, but since it costs to pay for more nurses, wards are chronically under-resourced. Our mental health wards are not, thankfully, with a 2:1 patient:staff ratio at the moment.
We staff wards sufficiently 'cause that's what we need to get the work done. Any less and we have worse outcomes.
Our neighbouring acute Trust seems to enjoy collecting data from their medical and surgical directorates. Almost as much as it enjoys documenting events, or non-events. Curiously, it thinks the best people to do this aren't clerical staff or IT staff or medical informatics folk, they reckon it's best to get the nurses to do it. One perk of having nurses on the wards is that they can provide nursing care. On the acute hospital site, I don't see nurses doing a whole heap of nursing now ('cept for the neuro rehab site where they're delightfully anarchic and simply crack on and sort patients, huzzah!) since they're mired in process and paperwork. The Productive Ward has sought to reduce this, but largely hasn't worked on their wards, instead it's generated more process. Ho hum. Maybe it'll get better. They've got less front line nurses and even more Modern Matron managers to sort this out.
Yesterday I saw a lady presenting with confusion, on a medical ward. She had a chest infection, against a background of worsening chronic obstructive pulmonary disease. She had dementia. She had no idea where she was, who was around her, why she was there, how long she'd been there, what was happening, what the different kit around her and the other 3 ladies in her bay was. She had no notion of what day it was, or what time of day.
Ward staff found her difficult to manage, since every 15 to 20 minutes or so she'd anxiously walk to the nursing station, loiter until a nurse passed by, then ask them what she should be doing. It took them time to talk with her. Time they did not have, since their Trust mires them with process that's seemingly more valued than the direct clinical care. They wanted to, but were rushed, they knew they weren't giving her the time she needed and deserved. Much frustration.
But when I saw her, she was settled. She wasn't wandering around the ward, seeking reassaurance any more. She wasn't even sat out in her chair, she was still in her bed. Because the nursing staff had been frazzled, so moaned to the junior doctor. The ward doctor is very young and very inexperienced and has no notion of person centred dementia care. The ward doctor is a doctor and she can prescribe. Haloperidol 10mg had been given, which had flattened her. Spectacularly. Well it would, being about x10 the dose we'd normally give, but ho hum. She was then lying in bed, keeping her nasal cannula on, causing no problems what so ever.
The junior doctor knows no better and can't. She's still too junior.
I get that the junior doctor has to support her nursing colleagues when they're fraught and frazzled. Yet, treating the staff's agenda to the detriment of the patient seems a step too far.
We staff wards sufficiently 'cause that's what we need to get the work done. Any less and we have worse outcomes.
Our neighbouring acute Trust seems to enjoy collecting data from their medical and surgical directorates. Almost as much as it enjoys documenting events, or non-events. Curiously, it thinks the best people to do this aren't clerical staff or IT staff or medical informatics folk, they reckon it's best to get the nurses to do it. One perk of having nurses on the wards is that they can provide nursing care. On the acute hospital site, I don't see nurses doing a whole heap of nursing now ('cept for the neuro rehab site where they're delightfully anarchic and simply crack on and sort patients, huzzah!) since they're mired in process and paperwork. The Productive Ward has sought to reduce this, but largely hasn't worked on their wards, instead it's generated more process. Ho hum. Maybe it'll get better. They've got less front line nurses and even more Modern Matron managers to sort this out.
Yesterday I saw a lady presenting with confusion, on a medical ward. She had a chest infection, against a background of worsening chronic obstructive pulmonary disease. She had dementia. She had no idea where she was, who was around her, why she was there, how long she'd been there, what was happening, what the different kit around her and the other 3 ladies in her bay was. She had no notion of what day it was, or what time of day.
Ward staff found her difficult to manage, since every 15 to 20 minutes or so she'd anxiously walk to the nursing station, loiter until a nurse passed by, then ask them what she should be doing. It took them time to talk with her. Time they did not have, since their Trust mires them with process that's seemingly more valued than the direct clinical care. They wanted to, but were rushed, they knew they weren't giving her the time she needed and deserved. Much frustration.
But when I saw her, she was settled. She wasn't wandering around the ward, seeking reassaurance any more. She wasn't even sat out in her chair, she was still in her bed. Because the nursing staff had been frazzled, so moaned to the junior doctor. The ward doctor is very young and very inexperienced and has no notion of person centred dementia care. The ward doctor is a doctor and she can prescribe. Haloperidol 10mg had been given, which had flattened her. Spectacularly. Well it would, being about x10 the dose we'd normally give, but ho hum. She was then lying in bed, keeping her nasal cannula on, causing no problems what so ever.
The junior doctor knows no better and can't. She's still too junior.
I get that the junior doctor has to support her nursing colleagues when they're fraught and frazzled. Yet, treating the staff's agenda to the detriment of the patient seems a step too far.
Thursday, 24 September 2009
Doctors' work
I find myself increasingly reliant on good nursing colleagues, with investment in our service over the last 5 years involving reducing medical staff numbers whilst increasing nursing staff, OT and social work staff numbers substantially. Still fretting that I don't have enough pharmacy time, but that's a battle for another day.
My junior doctor does very little work. It's not a criticism. He's there in a training post, to learn. Gone are the days when junior doctors worked every hour and were the cheapest resource; I was paid less than porters, student nurses and domestics for my work out of hours and on bank holidays. Come to think of it, I still am. But my junior doctor's hours are scrutinised and all have to be purposeful in progressing his training needs.
Also, all junior doctors in psychiatry now have to do Old Age Psychiatry in their first year. This mean my junior doctor has done his medical training at university, then his Foundation training as a doctor, then started in psychiatry with me last month. He had an induction so he's being doing psychiatry for all of, oooh, about 4 weeks. Clearly he's not in a position to give meaningful input, on his own, in out-patient clinics or the like.
The Royal College of Psychiatrists recognise this and define what it's reasonable/desirable for junior doctors to do at different stages of their training. In their first year, as mine is, they're to learn core skills. It's even called Core Training, so if after a year he thinks psychiatry's a terrible mistake and he want instead to be, say, a gynaecologist, off he can go and his year in psychiatry is useful and translates into a year of gynae training through teaching him consultation skills, approach to examinations, documentation, governance frameworks, evidencing rational prescribing practice, undertaking clinical audit and other such skills a medic is expected to develop.
As such, he can't do clinics on his own. Or skip off and see new referrals in the community. Or do liaison psychiatry, seeing folk on medical/surgical wards.
It's genuinely a training role which has the advantage that the service ticks along quite nicely whether he's here or not, it gives him time to read and study and shadow loads of folk to get a good understanding of practice, and it's hardly a stressful post. It also means patients get medical psychiatric input from a Consultant Psychiatrist, not a junior doctor.
As well as junior medical staff having a training (rather than a service commitment) role, as a Consultant Psychiatrist I input into other peoples' work. Mornings and afternoons our teams meet up and discuss the work to do/work done and consider what needs to be changed. As such, every patient has both this informal discussion when a Consultant can think if specific investigations need to be done, or psychiatric/other medication reviewed, or physical health symptoms unpicked or whatever. Every patient has formulation and care planning discussed with a Consultant Psychiatrist. Equally, all mine are discussed with nurses, OT, support work, pharmacy and social workers so they can chirp up with their thoughts on input into care.
The consequence of this is that all medical decisions within our service are through a Consultant Psychiatrist, and through both formal and informal forums there're mechanisms for medical input into every patient's care, every day.
At least when someone's stuck and refers in to our service, the diagnosis is made by a Consultant Psychiatrist (for good or bad, in my corner, nobody else does diagnosis) and medical dimensions are considered by the Consultant. I think this is of value, enabling non-medics to work at the top of their game doing what they do best, with medics contributing their bit, and the whole working synergistically.
I have seen a gentleman with mild cognitive deficits. He's in his 40s. He's unfortunately got dementia. He had a jerky tremor and poor balance/coordination. He said his mouth wouldn't work; he often chomped down and chewed his cheek, sometimes he couldn't swallow solid things easily. I thought he had something other than Alzheimer's disease or another neurodegenerative dementia unfolding, it looked like he'd neurological deficits. Huntington's disease sprang to mind, or p'raps normal pressure hydrocephalus. More sleuthing by clever physicians was in order.
I wrote back to his GP giving the results of his assessment, mental state examination, cognitive testing and brain imaging, suggesting that an assessment and neurology opinion would be helpful.
A few weeks later, I got a copy of my own letter back, as part of a referral to me, with a covering letter asking if I could give an opinion on this gentleman who had been invited into the GP's surgery and seen and discussed referral, so could I please see and advise. A mistake had been made. It should have gone to a neurologist, not back to me. It happens. The mistake had been made by a First Contact Practitioner. It rang bells because this is not the first time she's made a mistake.
I shouldn't, but I do feel somewhat piqued if I spend 2 hours assessing and investigating a patient, identify organic disease that merits more sophisticated assessment than I can do (it's many years since I worked in GP land, now), but the history and examination and formulation and care planning is undertaken by someone who consistently doesn't seem to be doing a brilliant job. Maybe it's bias and prejudice, maybe it is factual, maybe it's idealistic but unfounded, but I do reckon it all worked better (for our patients) when GPs did this work.
I'm all for clinical teams doing work that they do best, but inadequate assessment/management of neurological deficit, trying to gain tighter glycaemic control of a diabetic patient and making things worse, review of a patient's use of triptans with a poor outcome, and stopping someone's lithium (that had kept them stable for decades) are all recent undertakings of a First Contact Practitioner that perturbed me.
Most GPs in my area are really, really good. I'm fearful that in the future most Primary Care won't be. Much badness.
My junior doctor does very little work. It's not a criticism. He's there in a training post, to learn. Gone are the days when junior doctors worked every hour and were the cheapest resource; I was paid less than porters, student nurses and domestics for my work out of hours and on bank holidays. Come to think of it, I still am. But my junior doctor's hours are scrutinised and all have to be purposeful in progressing his training needs.
Also, all junior doctors in psychiatry now have to do Old Age Psychiatry in their first year. This mean my junior doctor has done his medical training at university, then his Foundation training as a doctor, then started in psychiatry with me last month. He had an induction so he's being doing psychiatry for all of, oooh, about 4 weeks. Clearly he's not in a position to give meaningful input, on his own, in out-patient clinics or the like.
The Royal College of Psychiatrists recognise this and define what it's reasonable/desirable for junior doctors to do at different stages of their training. In their first year, as mine is, they're to learn core skills. It's even called Core Training, so if after a year he thinks psychiatry's a terrible mistake and he want instead to be, say, a gynaecologist, off he can go and his year in psychiatry is useful and translates into a year of gynae training through teaching him consultation skills, approach to examinations, documentation, governance frameworks, evidencing rational prescribing practice, undertaking clinical audit and other such skills a medic is expected to develop.
As such, he can't do clinics on his own. Or skip off and see new referrals in the community. Or do liaison psychiatry, seeing folk on medical/surgical wards.
It's genuinely a training role which has the advantage that the service ticks along quite nicely whether he's here or not, it gives him time to read and study and shadow loads of folk to get a good understanding of practice, and it's hardly a stressful post. It also means patients get medical psychiatric input from a Consultant Psychiatrist, not a junior doctor.
As well as junior medical staff having a training (rather than a service commitment) role, as a Consultant Psychiatrist I input into other peoples' work. Mornings and afternoons our teams meet up and discuss the work to do/work done and consider what needs to be changed. As such, every patient has both this informal discussion when a Consultant can think if specific investigations need to be done, or psychiatric/other medication reviewed, or physical health symptoms unpicked or whatever. Every patient has formulation and care planning discussed with a Consultant Psychiatrist. Equally, all mine are discussed with nurses, OT, support work, pharmacy and social workers so they can chirp up with their thoughts on input into care.
The consequence of this is that all medical decisions within our service are through a Consultant Psychiatrist, and through both formal and informal forums there're mechanisms for medical input into every patient's care, every day.
At least when someone's stuck and refers in to our service, the diagnosis is made by a Consultant Psychiatrist (for good or bad, in my corner, nobody else does diagnosis) and medical dimensions are considered by the Consultant. I think this is of value, enabling non-medics to work at the top of their game doing what they do best, with medics contributing their bit, and the whole working synergistically.
I have seen a gentleman with mild cognitive deficits. He's in his 40s. He's unfortunately got dementia. He had a jerky tremor and poor balance/coordination. He said his mouth wouldn't work; he often chomped down and chewed his cheek, sometimes he couldn't swallow solid things easily. I thought he had something other than Alzheimer's disease or another neurodegenerative dementia unfolding, it looked like he'd neurological deficits. Huntington's disease sprang to mind, or p'raps normal pressure hydrocephalus. More sleuthing by clever physicians was in order.
I wrote back to his GP giving the results of his assessment, mental state examination, cognitive testing and brain imaging, suggesting that an assessment and neurology opinion would be helpful.
A few weeks later, I got a copy of my own letter back, as part of a referral to me, with a covering letter asking if I could give an opinion on this gentleman who had been invited into the GP's surgery and seen and discussed referral, so could I please see and advise. A mistake had been made. It should have gone to a neurologist, not back to me. It happens. The mistake had been made by a First Contact Practitioner. It rang bells because this is not the first time she's made a mistake.
I shouldn't, but I do feel somewhat piqued if I spend 2 hours assessing and investigating a patient, identify organic disease that merits more sophisticated assessment than I can do (it's many years since I worked in GP land, now), but the history and examination and formulation and care planning is undertaken by someone who consistently doesn't seem to be doing a brilliant job. Maybe it's bias and prejudice, maybe it is factual, maybe it's idealistic but unfounded, but I do reckon it all worked better (for our patients) when GPs did this work.
I'm all for clinical teams doing work that they do best, but inadequate assessment/management of neurological deficit, trying to gain tighter glycaemic control of a diabetic patient and making things worse, review of a patient's use of triptans with a poor outcome, and stopping someone's lithium (that had kept them stable for decades) are all recent undertakings of a First Contact Practitioner that perturbed me.
Most GPs in my area are really, really good. I'm fearful that in the future most Primary Care won't be. Much badness.
Tuesday, 5 February 2008
Tuesday, 8 January 2008
It's all about MEE
Well the new glossy Tooke Report is out, have a read of it here.
Their 2 new recommendations seem to be :
1) Recommendation 46, be aware of the European Working Time Directive and look for a more flexible way to manage this.
2) Recommendation 47. Lose the roles of the Postgraduate Medical Education and Training Board and have a new body (Medical Education England, MEE) that, "interface between policy development and implementation" and "coordinate coherent advice to Government" amongst others. See pages 64, 65 for the details.
I've spent time reading through this (and I'm slightly bitter that I've wasted time that is now gone and I'll never get back again, ever) but have yet to understand the implications or benefits to junior doctor training of having MEE. Can someone clever explain it to me?
Their 2 new recommendations seem to be :
1) Recommendation 46, be aware of the European Working Time Directive and look for a more flexible way to manage this.
2) Recommendation 47. Lose the roles of the Postgraduate Medical Education and Training Board and have a new body (Medical Education England, MEE) that, "interface between policy development and implementation" and "coordinate coherent advice to Government" amongst others. See pages 64, 65 for the details.
I've spent time reading through this (and I'm slightly bitter that I've wasted time that is now gone and I'll never get back again, ever) but have yet to understand the implications or benefits to junior doctor training of having MEE. Can someone clever explain it to me?
Tuesday, 13 November 2007
The circus comes to town!
All Educational Supervisors (i.e. all Consultant Psychiatrists) in our wee corner of the world were summoned to learn about Workplace Based Assessments, last week. Although it kicked off in 2005 with PMETB (the Postgraduate Medical Education and Training Board) the behemoth of change rumbles over us, crushing past success and introducing change. Because, erm . . . change is good. I'm told. So it goes.
"Roll up, roll up, come see the greatest show on Earth!" We sat dutifully whilst clever folk told us about Why It Had To Be and flirted with selling the whole thing to us. No matter what magic and words were woven, this trick didn't work. To say the reception was "frosty" is rather like saying the void of deep space is "a tad chilly."
"See, see how friendly and enticing this is! Gasp at the splendor of it all! Why, it's even in colour, don't you know!" We then were directed (erm, I think they called it something more pleasing like instructed, though, or mentored, p'raps) in the use the plethora of Workplace Based Assessment forms that our otherwise sensible College is foisting 'pon us.
"Watch them perform! Come, come see the clowns!" Oodles of Consultants, who've all been training juinor doctors for many years, watched. All had just been indoctrinated (erm, mentored, facilitated, coached, did they say?) in Workplace Based Assessment then immediately we were given videos of trainee/trainer interviews to rate. Excellent, then, cutting to the chase. Let's just crack on and do that then, so we can get our trainees through the myriad of hoops they've now to jump through. "Jumping through hoops, high how can they go? Oooh, watch them skip and dance! What a performance, what a show!"
Our ringleader whipped us in to shape, working us in a score of small groups, scoring the performance of the trainees in the videos. We get through a few videos, a few different mini-ACE and Case-based Discussion. "Did they frolic, cavort and entertain? Did they leap to the hoops, only to fall? What scores, what ratings one and all?" We compared scores. A score of 4 is a pass, meeting the necessary standard. 5 or 6 is great (above standard and mastery). 1 to 3 is a fail, below standard. In one video we all watched the room scored the trainee from 1 to 5. Some failed the trainee as the worst ever, some passed her as above standard. This pattern unfolded itself again and again. We all watched the same video, had the same training and used the same scales at the same time (and discussed it in small groups so no one voice generated extremes). Yet there was huge variation in whether the candidate would pass (well) or fail (catastrophically). Not just a few voices in each camp, either, with most in the middle . . . there really was huge spread. So it goes.
"Ah, what mirth, what merry japes, 't is but practice, after all" And, in point of fact, it's the clinical practice of the whole next generation of doctors that's being flippantly fiddled with. Doctors who will be treating me. Treating my kith and kin. So it goes.
I've tried to register with the Healthcare Assessment and Training (HcAT) website who say they've sent me details to log on, but they lie. So since all forms are online I can't do any assessments with my trainee. None what so ever. So it goes.
Am I the only one who feels that form and theatre and checklists wholly eclipses merit and content? We live in interesting times. Junior doctor training has been modernised. So it goes.
"Roll up, roll up, come see the greatest show on Earth!" We sat dutifully whilst clever folk told us about Why It Had To Be and flirted with selling the whole thing to us. No matter what magic and words were woven, this trick didn't work. To say the reception was "frosty" is rather like saying the void of deep space is "a tad chilly."
"See, see how friendly and enticing this is! Gasp at the splendor of it all! Why, it's even in colour, don't you know!" We then were directed (erm, I think they called it something more pleasing like instructed, though, or mentored, p'raps) in the use the plethora of Workplace Based Assessment forms that our otherwise sensible College is foisting 'pon us.
"Watch them perform! Come, come see the clowns!" Oodles of Consultants, who've all been training juinor doctors for many years, watched. All had just been indoctrinated (erm, mentored, facilitated, coached, did they say?) in Workplace Based Assessment then immediately we were given videos of trainee/trainer interviews to rate. Excellent, then, cutting to the chase. Let's just crack on and do that then, so we can get our trainees through the myriad of hoops they've now to jump through. "Jumping through hoops, high how can they go? Oooh, watch them skip and dance! What a performance, what a show!"
Our ringleader whipped us in to shape, working us in a score of small groups, scoring the performance of the trainees in the videos. We get through a few videos, a few different mini-ACE and Case-based Discussion. "Did they frolic, cavort and entertain? Did they leap to the hoops, only to fall? What scores, what ratings one and all?" We compared scores. A score of 4 is a pass, meeting the necessary standard. 5 or 6 is great (above standard and mastery). 1 to 3 is a fail, below standard. In one video we all watched the room scored the trainee from 1 to 5. Some failed the trainee as the worst ever, some passed her as above standard. This pattern unfolded itself again and again. We all watched the same video, had the same training and used the same scales at the same time (and discussed it in small groups so no one voice generated extremes). Yet there was huge variation in whether the candidate would pass (well) or fail (catastrophically). Not just a few voices in each camp, either, with most in the middle . . . there really was huge spread. So it goes.
"Ah, what mirth, what merry japes, 't is but practice, after all" And, in point of fact, it's the clinical practice of the whole next generation of doctors that's being flippantly fiddled with. Doctors who will be treating me. Treating my kith and kin. So it goes.
I've tried to register with the Healthcare Assessment and Training (HcAT) website who say they've sent me details to log on, but they lie. So since all forms are online I can't do any assessments with my trainee. None what so ever. So it goes.
Am I the only one who feels that form and theatre and checklists wholly eclipses merit and content? We live in interesting times. Junior doctor training has been modernised. So it goes.
Thursday, 4 October 2007
Teaching
Working with patients is, mostly, straightforward. It's what I've been trained to do, for years. Working with managers is, mostly, straightforward. Again there's training but mostly it's because our manager is ace. Working with nurses is, mostly, straightforward. My teams are fantastic and genuinely work collaboratively with me. Working with students is, mostly, straightforward. They are usually inquisitive, bright young things full of enthusiasm and keen to engage in training opportunities.
Powers that be are making my life less straight forward.
I do a fair bit of teaching. I do all the medical student teaching and, unlike colleagues with Staff Grades, I've always had a "training grade" junior doctor and rigorously undertake formal weekly supervision and informal teaching.
This is largely for the love of it, and to help our next generation of medics, since there's no additional resources for the time invested and just as the junior doctor's getting up to speed they leave . . . hence the enthusiasm for stable Staff Grade doctors in many camps.
Now I am becoming stuck.
To get around possible inconsistancies in training (which I've yet to find any evidence for) and to make training shorter and cheaper (where evidence tragically is legion) we've now got Workplace-Based Assessments to do.
We objectively assess trainees in blah. To prevent favouritism and prevent rubbish/dangerous doctors becoming Consultants and prevent untrained doctors progressing this necessitates a series of assessments that I am to do with my trainee.
I have read what I can but am still none the wiser.
For years I've had structured RITA assessments for SpR's and almost identical start/mid/end point appraisals with SHO's but now that's jettisoned in favour of these new fangled workplace whatnots that nobody's written or spoken to me about. Neither informed about nor trained in this, what am I to do?
I am stuck.
Powers that be are making my life less straight forward.
I do a fair bit of teaching. I do all the medical student teaching and, unlike colleagues with Staff Grades, I've always had a "training grade" junior doctor and rigorously undertake formal weekly supervision and informal teaching.
This is largely for the love of it, and to help our next generation of medics, since there's no additional resources for the time invested and just as the junior doctor's getting up to speed they leave . . . hence the enthusiasm for stable Staff Grade doctors in many camps.
Now I am becoming stuck.
To get around possible inconsistancies in training (which I've yet to find any evidence for) and to make training shorter and cheaper (where evidence tragically is legion) we've now got Workplace-Based Assessments to do.
We objectively assess trainees in blah. To prevent favouritism and prevent rubbish/dangerous doctors becoming Consultants and prevent untrained doctors progressing this necessitates a series of assessments that I am to do with my trainee.
I have read what I can but am still none the wiser.
For years I've had structured RITA assessments for SpR's and almost identical start/mid/end point appraisals with SHO's but now that's jettisoned in favour of these new fangled workplace whatnots that nobody's written or spoken to me about. Neither informed about nor trained in this, what am I to do?
I am stuck.
Wednesday, 26 September 2007
Private Practice
I have never worked in private practice and have no intention to do so. When my wife needed to see an orthopaedic surgeon a few years ago we waited 18 months to see one on the NHS. I like the NHS and think when it gets it right it can be fantastic. It's nice when it all just works.
I've nothing against private healthcare, I just am sufficiently naieve and idealistic to see the NHS as the laudable preferred option.
What piques me is the pervasive whispering that episodically surfaces, insinuating itself into speech and media stories, that "going private" is, of course, going for a better service.
It isn't.
It's going for a different service.
I worked with an SHO (ST2 junior doctor in new speak) who moonlighted and covered a huge private hospital for a huge city on nights and weekends. Maybe he still does. He was the resident medical officer. He was the medic on the site. When ever there was a need for medical care, he did it (as he was the only one there).
When I was "on call" working on NHS medical wards I'd spend hours on Coronary Care and on the Haematology ward and covering scarily ill patients, but my medical Registrar and her Senior Registrar would do scary things (like cardiac pacing). It would happen almost instantly, we'd get bleeped, we'd dash to Coronary Care, we'd get pacing wires and run them in to the person's heart, fiddle with dials to capture pacing, exciting but scary stuff. I'm so glad there were House Officers, Registrars and Senior Registrars as well as my good self. Once we were busy through the night and at 8.00am the Cardiology Consulant arrived to meet us in Coronary Care. When his patient had (another) cardiac arrest the Consultant let us crack on and manage the event . . . the "junior" medical staff were much more familiar with such emergencies than the senior Consultant staff, thankfully the Consultant wasn't too proud to show that. An NHS hospital. Lots of staff, all doing lots of emergency work (we worked like Egyptian slaves) so got pretty proficient at what we did. If I had a heart attack and arrested, I'd want that sort of team managing me.
Cut to a private hospital. There's a SHO/ST2 junior doctor there. He's an SHO in psychiatry. He's never even seen cardiac pacing. He vaguely remembers how to resuscitate someone since he's got to attend an update every year or so, but it's not somthing he's seen or done for years. As a psychiatrist his knowledge of surgical and medical problems is modest. He was the only doctor in that hospital.
Now, in the private hospital, the surgery was done by a Consultant not by a trainee junior doctor. The food was excellent. The rooms were sumptuous. Flat screen TVs on the walls. Great selections of books and magazines.
Routine and elective care was excellent.
But in an emergency, would I rather be in an NHS hospital with a horde of experienced junior/senior trainees who could capably sort the problem out, or would I rather be in a private hospital with a psychiatrist who could ask me how I feel about it?
I've nothing against private healthcare, I just am sufficiently naieve and idealistic to see the NHS as the laudable preferred option.
What piques me is the pervasive whispering that episodically surfaces, insinuating itself into speech and media stories, that "going private" is, of course, going for a better service.
It isn't.
It's going for a different service.
I worked with an SHO (ST2 junior doctor in new speak) who moonlighted and covered a huge private hospital for a huge city on nights and weekends. Maybe he still does. He was the resident medical officer. He was the medic on the site. When ever there was a need for medical care, he did it (as he was the only one there).
When I was "on call" working on NHS medical wards I'd spend hours on Coronary Care and on the Haematology ward and covering scarily ill patients, but my medical Registrar and her Senior Registrar would do scary things (like cardiac pacing). It would happen almost instantly, we'd get bleeped, we'd dash to Coronary Care, we'd get pacing wires and run them in to the person's heart, fiddle with dials to capture pacing, exciting but scary stuff. I'm so glad there were House Officers, Registrars and Senior Registrars as well as my good self. Once we were busy through the night and at 8.00am the Cardiology Consulant arrived to meet us in Coronary Care. When his patient had (another) cardiac arrest the Consultant let us crack on and manage the event . . . the "junior" medical staff were much more familiar with such emergencies than the senior Consultant staff, thankfully the Consultant wasn't too proud to show that. An NHS hospital. Lots of staff, all doing lots of emergency work (we worked like Egyptian slaves) so got pretty proficient at what we did. If I had a heart attack and arrested, I'd want that sort of team managing me.
Cut to a private hospital. There's a SHO/ST2 junior doctor there. He's an SHO in psychiatry. He's never even seen cardiac pacing. He vaguely remembers how to resuscitate someone since he's got to attend an update every year or so, but it's not somthing he's seen or done for years. As a psychiatrist his knowledge of surgical and medical problems is modest. He was the only doctor in that hospital.
Now, in the private hospital, the surgery was done by a Consultant not by a trainee junior doctor. The food was excellent. The rooms were sumptuous. Flat screen TVs on the walls. Great selections of books and magazines.
Routine and elective care was excellent.
But in an emergency, would I rather be in an NHS hospital with a horde of experienced junior/senior trainees who could capably sort the problem out, or would I rather be in a private hospital with a psychiatrist who could ask me how I feel about it?
Monday, 17 September 2007
Influences
I recently was talking to junior doctors about career options. They've been sharply curtailed and the freedom to explore specialities as active doctors in one speciality (rather than as a more passive student) has largely been lost. Speaking with one doctor it dawned on me how much even early clinical contact can have formative influences that resonate with how I work now.
My first clinical attachment as a 2nd year medical student was General Surgery. I loved being on the wards and seeing patients and finally getting "stuck in" to proper medicine.
The quirks (having to illicit Boas sign on a ward round), the theatre of it all (ward rounds with an entourage whirling around the deific Consultant at the epicentre), the needles (learning to take take blood and cannulating) . . .
. . . the patients were the thing, though. Finally doing history taking and examining folk, being proper medics, then clever folk sussing out what was going on, it was being a part of magic!
For me, over time I loved the patient work up on the wards, the sleuthing out why a patient had jaundice, then what could be done to sort it.
Sadly, the "sorting it" didn't interest me. Surgery as a speciality was great, 'cept I didn't enjoy the cutting which kind of wrote it off for me :-)
Still, that attachment was fantastic both for teaching a wealth of skills and for learning from surgical folk who were interested in their patients. At variance with the sterotype back then, good modern surgeons would delight that even way back then there were surgical teams that valued undergraduate medical education and were essentially patient centred (but never would have called it that). The patient focus stayed with me, drawing me to train as a GP before back to hospital medicine and mental health.
What was my conclusion with my trainee? It was that the sum of my training and experiences means that for me the heart of good medicine and the quiddity* of psychiatry is a genuine interest in the patient narrative.
* A great word I really must try and use more :-)
Edit : Milk & Two Sugars just blogged about surgical training this morning, too. Snap! Her more lucid medical student perspective is here.
My first clinical attachment as a 2nd year medical student was General Surgery. I loved being on the wards and seeing patients and finally getting "stuck in" to proper medicine.
The quirks (having to illicit Boas sign on a ward round), the theatre of it all (ward rounds with an entourage whirling around the deific Consultant at the epicentre), the needles (learning to take take blood and cannulating) . . .
. . . the patients were the thing, though. Finally doing history taking and examining folk, being proper medics, then clever folk sussing out what was going on, it was being a part of magic!
For me, over time I loved the patient work up on the wards, the sleuthing out why a patient had jaundice, then what could be done to sort it.
Sadly, the "sorting it" didn't interest me. Surgery as a speciality was great, 'cept I didn't enjoy the cutting which kind of wrote it off for me :-)
Still, that attachment was fantastic both for teaching a wealth of skills and for learning from surgical folk who were interested in their patients. At variance with the sterotype back then, good modern surgeons would delight that even way back then there were surgical teams that valued undergraduate medical education and were essentially patient centred (but never would have called it that). The patient focus stayed with me, drawing me to train as a GP before back to hospital medicine and mental health.
What was my conclusion with my trainee? It was that the sum of my training and experiences means that for me the heart of good medicine and the quiddity* of psychiatry is a genuine interest in the patient narrative.
* A great word I really must try and use more :-)
Edit : Milk & Two Sugars just blogged about surgical training this morning, too. Snap! Her more lucid medical student perspective is here.
Wednesday, 5 September 2007
Diagnosis
Psychiatrists diagnose mental health problems.
We have been trained to sift through symptoms and signs in order to ellucidate relevant psychopathology and ascribe significance to this, then weigh the constellation of relevant symptoms and signs and intensity and duration to generate a robust diagnosis.
One comment from my ST1 doctor (Specialist Trainee year 1 doctor, what used to be an SHO) stirred my thoughts. He's just finished his Foundation training which included a stint in GP land.
He was surprised at the diagnostic rigour in psychiatry.
A lot of diagnosis in Primary Care is based on clinical impression formed from history, examination and occasionally relevant investigations to confirm or refute a diagnosis. Many diagnoses are formulations made with the best evidence available before the GP, which can be a bit thin. Diagnosis of, say, Irritable Bowel Syndrome or a Chronic Fatigue Syndrome can be difficult to make in a robust fashion. Even before diagnosis, symptoms can be hard to quantify (such as dysmenorrhoea that means different things to different people).
My junior doctor was surprised that in Primary Care most GPs diagnosed problems intuitively through each consultation, seemingly at whim. Psychiatric diagnoses are determined within the World Health Organisation's International Classification of Diseases, 10th Edition, ICD-10.
In psychiatry we need to tick many boxes before we can say, "This patient has a diagnosis of F33.11 Recurrent depressive disorder, current episode moderate, with somatic syndrome."
It was interesting to see a young doctor realise that determining diagnosis of mental health problems is oft times more considered and robust than diagnosis of physical health problems.
We're not just musing and making stuff up!
We have been trained to sift through symptoms and signs in order to ellucidate relevant psychopathology and ascribe significance to this, then weigh the constellation of relevant symptoms and signs and intensity and duration to generate a robust diagnosis.
One comment from my ST1 doctor (Specialist Trainee year 1 doctor, what used to be an SHO) stirred my thoughts. He's just finished his Foundation training which included a stint in GP land.
He was surprised at the diagnostic rigour in psychiatry.
A lot of diagnosis in Primary Care is based on clinical impression formed from history, examination and occasionally relevant investigations to confirm or refute a diagnosis. Many diagnoses are formulations made with the best evidence available before the GP, which can be a bit thin. Diagnosis of, say, Irritable Bowel Syndrome or a Chronic Fatigue Syndrome can be difficult to make in a robust fashion. Even before diagnosis, symptoms can be hard to quantify (such as dysmenorrhoea that means different things to different people).
My junior doctor was surprised that in Primary Care most GPs diagnosed problems intuitively through each consultation, seemingly at whim. Psychiatric diagnoses are determined within the World Health Organisation's International Classification of Diseases, 10th Edition, ICD-10.
In psychiatry we need to tick many boxes before we can say, "This patient has a diagnosis of F33.11 Recurrent depressive disorder, current episode moderate, with somatic syndrome."
It was interesting to see a young doctor realise that determining diagnosis of mental health problems is oft times more considered and robust than diagnosis of physical health problems.
We're not just musing and making stuff up!
Monday, 6 August 2007
Teaching
I enjoy teaching medical students. Mostly, they're bright eyed and bushy tailed, keen to learn what they can from their short time in their placement. Last week I was pleasantly surprised at how much reading around the subjects they'd done. For undergraduate students their level of knowledge was good, their understanding was good, their questions were sensible.
Much goodness.
Last week I also taught the new cohort of junior doctors. Years ahead of the medical students, in terms of postgraduate training and experience, they were less bright eyed and bushy tailed. I'll forgive them that since they'd had inane lectures about lifting and fire extinguishers and the like that had driven them to catatonic states.
What surprised me was their understanding of assessment of capacity to consent to treatment. It was less than ideal. This was somewhat disheartening. Making sure that your patient can consent to what you're proposing is, obviously, a key task that doctors have to be adept at and use many many times every day. It's so central to our work it's seen as a Core Skill that medical students must know (and, indeed, they did). Many junior doctors were not adept at this process.
Much badness.
Just to summarise what the process is, for those who may be curious, the British Medical Association and the Law Society in 2004 generated a document clarifying standards for determining if a patient could consent to treatment. It's simple and surprisingly common sense :
• Understand in simple language what the medical (or other) treatment is, its nature and purpose, and why it is being proposed.
• Understand its principal benefits, risks and alternatives.
• Understand in broad terms the consequences of not receiving the proposed treatment.
• Retain the information long enough to use it and weigh it in the balance in order to arrive at a decision.
• Make a free choice.
I'm pleased that medical students are up to speed with this. I'm less pleased that some practising medics aren't.
I wonder of GP Registrars fair better, with more reflective practice? Non-medical prescribers I've mentored through their courses over the last few years (nurses and recently physio's too) have had mixed understanding of determining consent. If folks wishing to become prescribers can have a lack of clarity on this, I wondered how what Dr Crippen calls Nurse Quacktitioners make of this. All my senior nurse colleagues in the community were very clued up on determining consent.
Phew.
I am happy once again.
Much goodness.
Last week I also taught the new cohort of junior doctors. Years ahead of the medical students, in terms of postgraduate training and experience, they were less bright eyed and bushy tailed. I'll forgive them that since they'd had inane lectures about lifting and fire extinguishers and the like that had driven them to catatonic states.
What surprised me was their understanding of assessment of capacity to consent to treatment. It was less than ideal. This was somewhat disheartening. Making sure that your patient can consent to what you're proposing is, obviously, a key task that doctors have to be adept at and use many many times every day. It's so central to our work it's seen as a Core Skill that medical students must know (and, indeed, they did). Many junior doctors were not adept at this process.
Much badness.
Just to summarise what the process is, for those who may be curious, the British Medical Association and the Law Society in 2004 generated a document clarifying standards for determining if a patient could consent to treatment. It's simple and surprisingly common sense :
• Understand in simple language what the medical (or other) treatment is, its nature and purpose, and why it is being proposed.
• Understand its principal benefits, risks and alternatives.
• Understand in broad terms the consequences of not receiving the proposed treatment.
• Retain the information long enough to use it and weigh it in the balance in order to arrive at a decision.
• Make a free choice.
I'm pleased that medical students are up to speed with this. I'm less pleased that some practising medics aren't.
I wonder of GP Registrars fair better, with more reflective practice? Non-medical prescribers I've mentored through their courses over the last few years (nurses and recently physio's too) have had mixed understanding of determining consent. If folks wishing to become prescribers can have a lack of clarity on this, I wondered how what Dr Crippen calls Nurse Quacktitioners make of this. All my senior nurse colleagues in the community were very clued up on determining consent.
Phew.
I am happy once again.
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