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Posts by Beth Routledge

Tales Of Clinic

I have in the decade-and-a-bit since I left the city in which I was born been mistaken for Irish (a lot), Indian (casual racism in the general direction of call centre staff, which was my old job), “from New England” (by a Canadian), and Scandinavian (yesterday).

Occasionally, someone gets it right. For example, when, as is usual for me these days, we have been talking at some length about their cancer.

 Beth: Your bloods all look quite good, and…

Patient: *develops fit of giggles*

Beth: Um?

Patient: Oh, gosh, I am sorry, but it’s like I’m talking to Sarah Millican.

*

In which I am minding my own business as I dictate letters and inhale coffee.

Nurse: Oh, excellent! Oh, I just saw you there, Doctor, and I was reminded of sputum!

The Great North Run — Again

In a little over two weeks time, I’ll be on the start line of the Great North Run.

(Or, if I choose to be accurate, I’ll be standing about a mile back from Seb Coe and his starting gun. My number is forty-five thousand and something.)

If you have been around that long, you may recall that I ran a bit when I was a medical student. You may also recall that my last race was this same race in 2012, a month into FY1. It was peppered with disasters, like, for one thing, my training plan, such as it was, and also like leaving my shoes behind a photocopier in Stirling and so spending the first part of the weekend trawling Newcastle for an identical pair. Nevertheless, it was an incredible experience (I high-fived Mo Farah!) and I swore then that I’d be back, one day, for the Red Arrows and the Tyne Bridge and Local Hero and that amazing final straight along the South Shields seafront.

Afterwards, I mostly hung up my running shoes for a year. I was too exhausted for a lot of FY1 to do much of anything at the end of the day besides collapse into a tiny heap in the middle of my sofa. But eventually I developed some kind of stamina and then, slowly, sometimes painfully, through my FY2 year, I laced up my shoes and began to be a runner again.

And now it’s 18 days until I am indeed back for the Red Arrows and the Tyne Bridge and all the rest of it.

My training this time around has been far from textbook – for example, there is a hole in it that I can identify as my cardiology weekend on call – but it has been an awful lot better than I did last time. The highlights of my training will be the time I’ve spent running along the Clyde, particularly the day when I wasn’t expecting the Commonwealth Games flotilla to suddenly appear over my right shoulder. And, for sheer bullheadedness, the night I accidentally ran nine miles in hammering rain. I feel that I’m more psychologically prepared for it this time, and that is as important as anything.

I am running this year on a charity place that was kindly given to me by Kidney Research UK. They were the first charity I ever fundraised for, twenty years ago, and I’m doing this for them because kidney disease was the thing that brought to an untimely end the life of my dad, Bob, twenty years ago next summer. You can read more about his story and about the work of Kidney Research UK on my fundraising page, and if you feel moved to do so you can also donate there.

18 days.

Two more long runs.

And shoes. I really must remember my shoes.

Dear Vicky

Dear Vicky,

I was quietly checking my Twitter feed before bed last night when I learned that with few fireworks and little fanfare, you had spoken to the Independent about being a gay Christian woman and thus launched what I imagine must have been 24 hours of somewhat of a circus.

In the world in which we live (and which I rejoice in living), there are going to be a lot of folk scratching their head over why what you have done is important, because, after all, being gay (or lesbian or bisexual) isn’t a big deal anymore, right? Alas, not in the Church. Also, for the record, not in professional sports or in Hollywood, thus completing the unlikeliest trifecta since eggs, bunnies, and Jesus. I know you know that. I know, because it’s the history written in your scars and your soul and now across the world in newsprint.

In the church that I now attend, it took me six weeks to sneak up to one of the clergy after Mass and say, “Um, so, about this LGBT Group…” St Mary’s has never been in the closet about its liberalism; on my very first Sunday we prayed during the intercessions for a blessing of a civil partnership, plus, well, there was an LGBT Group, so it’s not like I didn’t know. But, at the time, being out at church felt like a big deal in a way that being out in the rest of the world didn’t. Even now there are plenty of delightful liberal well-intentioned people who presume until told bluntly otherwise that “gay Christian” isn’t a thing. This year at Synod, on the first day, I got up and proposed a motion that was viewed by parts of the establishment as terrifyingly radical and, had it passed, would have put us on a trajectory to allow the marriage of same-sex couples within the Church — and then on the second day I had to actually out myself, because apparently that part hadn’t been clear to everyone.

And all of that was just for me, with no reputation at stake and nothing to lose and quite comfortable in the knowledge that conservative evangelical America has never cared who I am. You have done a big thing and a brave thing, and nobody gets to minimise that. If they try, ask them when the last time was that a Church of England Bishop came out voluntarily and they’ll soon shut up.

Vicky, I hope you have seen the outpouring of goodwill for you on the Internet over the last 24 hours. I pray that that goodwill is reflected by what you encounter out there in the world. I know that it won’t be so everywhere, and so do you.

I talked to a friend last night as your story was breaking. “They’re going to throw rocks at her,” I said. (Metaphorically.) “They are, and she knows it and she’s done it anyway.”

But when they do, I want you to remember this: I want you to remember that for every Scott Lively, there is a young gay man who has thought for years that he is somehow broken and who knows now that he is loved and blessed and perfect just the way he is. I want you to remember that for every Ann Coulter, there is a teenage lesbian who was told that she would be condemned by her God and who knows now that she was made in His image and likeness. I want you to remember that for every Westboro Baptist, there is a family who rejected their gay son or daughter and are now maybe starting to think differently about what God would want for them. For every person who condemns you, there is a person whose life you have just made better by telling them that God loves you and God loves them and God loves all of us anyway.

It is no easy feat, to live the story that you’ve now shared with us and to come up on the other side with grace and faith.

As you move forward in the world, gather in the love and the love and the love that we all offer you, and may God bless you, today and always, in everything that you do and in all that you are.

With prayers and good wishes,

Beth

Dear FY1s

Eat breakfast.

You are not expected to function on Day 1 of FY1 at the same level as the people who today were on Day 364 of FY1.

It is normal to want to giggle the first time you introduce yourself as a doctor.

Write everything down.

For at least the first month, you will be exhausted all the time and you will have sore feet all the time.

FY1s cannot live on chocolate alone.

You can’t fill in a DNACPR or an AWI or an Emergency Detention Certificate, even if your consultant asks you to.

There is no shame in needing a hug.

Your fellow FY1s are your allies, with whom you will mourn in times of tragedy and celebrate in triumph.

The learning curve is vertical. In a year’s time, you will look back on this day and you will not believe how far you came.

There are lots of people who will tell you that when you go home, you should turn it off and forget about it and not talk shop. And you probably should, as far as you can. But it is okay sometimes to need to talk shop. It is okay to need to tell someone about the awful day that you had or the awful week that you’re having. And if the choice is between calling work to check that that patient is okay or that that thing got done and not sleeping for worrying about it, it is okay to call work.

Do your best all the time, and then remember that that is all you can do.

It is not abnormal to cry after your first arrest, or after the first time you pronounce someone dead.

There are no stupid questions.

Take a deep breath, ABCDE, and phone your senior.

This is the best job in the world.

Enjoy it.

Asking For Help (And Getting It)

The well thumbed hashtag on Twitter will give you its own advice about treating your pharmacists and physios and senior nurses as the pillars of wisdom they are, doing a warfarin and fluid and insulin prescribing round before you go home for the night, remembering #hellomynameis, not leaving ePortfolio until the last minute, not putting yourself into acute kidney injury (no, really), and a great deal more.

I have one piece of advice – a #tipfornewdocs, but, perhaps more importantly, a #tipfornewshos – and a few short stories to go with it.

Get help.

The highest compliment I was paid in FY1 was being told, while asking a consultant surgeon to come and review my medical patient, yes, I know it’s half past three on Friday afternoon, that I was quite bolshy for an FY1. I am almost certain that it wasn’t meant as a compliment. It also disguises the truth that I am as prone as anyone to prefacing any question I ask my seniors with, look, I think this is probably a stupid question… But developing the ability to get help and get it quickly requires getting over that apologist instinct we all have to presume we’re being a bit silly.

“The reason we might seem a bit on edge is that you are describing to me something that is relatively uncommon and that could be extremely serious,” I say, sometimes. “I could easily be wrong, but indulge my paranoia until we’ve got these investigations done, okay, because there are worse things than being worried and wrong and I wouldn’t be doing my job properly if I weren’t.”

“I’d rather you were paranoid, too, Doc,” they say, sometimes.

And sometimes I’m right, but often I’m wrong and we can all breathe a little easier.

I’m okay with that. (I don’t want to be proven right about the parts of my differential that are 1) Awful Thing, 2) Awful Thing, 3) Really Awful Thing.) The broad strokes of acute medicine are in the sometimes diagnosis but more often elimination of the things that are statistically improbable but acutely life-threatening. The trouble with any kind of medicine is that it isn’t a science, which means that nothing looks like it does in the textbooks and anything that does isn’t what the textbook says it ought to be.

And speaking as the person who has very often this past year been the first in line to be paged by a worried FY1, it is never wrong to ask for help.

I’m certain that most of us have had at least one nightshift when nobody seemed able to maintain their blood pressure. My new wee FY1 colleagues, I promise that you will have this experience in your storybox before long.

Sometimes, this is because there is a local policy that routine four hourly obs should include overnight obs. Do you know who gets hypotensive at 2am? Everyone. Or, on one particular occasion when I was the only doctor actually in the building, nine people, all at once. The skill lies in working out which of those nine people dropped their blood pressure because it’s two o’clock in the morning and they’re trying to sleep, and which of them has dropped it as a precursor to falling off the proverbial cliff. It is a triage skill and it is not one that anyone learns overnight, and I am still learning it. But if a good nurse tells you that two fluid challenges haven’t done anything and the systolic BP is now in the sixties, that’s a hint and you should take it. It might be that the only way to get help is to point out that if nobody comes when you ask for it you will sooner rather than later be summoning it from the arrest team. I’m not saying that that ought to be your opening gambit. I am saying that if things are actually getting to that point, it at least has the merit of being true.

For my newly minted SHO friends, you should know that the help you think you ought to be asking for does not always come. It doesn’t happen often and I wish that it were not so, but it does happen and it is so and you should know that. And the reason you should know that is so that I can tell you this: get help from someone else. One of my newly minted SHO friends will remember the time when they were my FY1 and found me crying in the sluice because I had not been able to convince help to come. This was after I had quoted a remarkable array of very terrible numbers and deployed the phrase “this is incompatible with life” and explained my inability to fix the situation. The help I thought should be coming never did, and I got the med reg and muddled through and kept the patient alive until morning. A few days later, on a morning when my educational supervisor had asked me if I was always able to access senior support, I blurted out the whole story. He looked at me in moderate horror. “If that ever happens again, ignore them and ring the consultant instead,” he said. It had never occurred to me that I could do that.

Incidentally, and this is just as important for FY1s, the med reg is always in the building and will always come (unless someone else is dying), even if it isn’t a medical patient.

Remember this, too: If a patient is unwell, the question is never what you think you should be able to do but only what you can do. On that day when you vowed to make the care of the patient your first concern and became professionally bound to act within the limits of your own competence, you were agreeing to let go of your own ego.

A few weeks ago, I phoned my registrar who then phoned a consultant because I had convinced myself, largely based on a chest X-ray, that one of the patients I was looking after had a pneumothorax and I have never put in a chest drain. Very quickly, the nicest consultant in the world arrived from home and looked at it and then found me. “Ah, Beth. It was you who ordered that X-ray? Come, show me where you think this pneumothorax is.” I brought up the film and showed him the line between the lung and the chest wall. “And where does that line go?” he asked. I followed it down. “It goes… er, well, it sort of bends,” I said. This was a teaching moment for him, and he asked me: “And which anatomical structure might you expect to find there?”

The blood drained from my face. “Oh, no, God, the scapula,” I said.

And spent the next ten minutes apologising.

“It’s all right,” said the nicest consultant in the world. “You have to learn these things. Anyway, I’d rather you were paranoid and got help and were wrong than the alternative.”

Tales From Pride

I Love Martha Jones

As we made our slow way back to where I had abandoned the car, laden with placards and banner and toddler, I was stopped by a gentleman asking whether we were going to a protest.

“No!” I said. “It was Gay Pride!”

He read the text of one of my by now quite soggy placards.

St Mary’s Cathedral: Open, Inclusive, Welcoming

“And, erm, were you protesting it?” he asked, looking hopeful.

“Of course not,” sayeth I. “We’ve been suppporting it.” And, pulling out one of the lines that I’d been using on people all morning when I’d worried that they might think that I was trying to save them, “We’re the good kind of church!”

He didn’t like that at all.

It’s true, though.

And don’t forget about this:

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Pride and the Commonwealth

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For your diaries, there are three events in Glasgow next weekend all well worth coming to:

  • The annual gathering of Piskies at Pride takes place next Saturday (19th July). This year, the parade for Glasgow Pride starts from Clyde Place on the south bank of the river and then heads across the Clyde into the city centre and into Merchant City. If you would like to walk with a group of Scottish Episcopalians, we will be meeting at the south end of the Tradeston Bridge (the wiggly pedestrian bridge) at 9.15am on Saturday. This is a ten minute walk from Bridge Street, which is the nearest subway and is also likely the easiest place to park. If you are at the Clyde Arc (the squinty bridge) or can see the SECC/Hydro, you are in the wrong place.
  • On Saturday evening at 6.30pm, Peter Tatchell is giving a lecture on Human Rights and the Commonwealth at St Mary’s Cathedral. Taking place on Pride Saturday and immediately ahead of the arrival of the Commonwealth Games in Glasgow, this will be a compelling evening which has been arranged by the cathedral Justice and Aid Network. St Mary’s is on Great Western Road, between St George’s Cross and Kelvinbridge subway stations. Tickets are £5 on the door.
  • Peter Tatchell will be at St Mary’s Cathedral again on Sunday morning, at 12 noon, in conversation with Kelvin Holdsworth. This is one of the Forum events which we hold on occasion, with past speakers including Bishop Christopher Senyonjo of the Episcopal Church of Uganda and Professor John Curtice of Strathclyde University, known to many more people from his frequent work with the BBC.  The Forum is a free event, as is the glorious Sung Eucharist which will take place beforehand at 10.30am.

Promises and Prayers

On 5th July 1948, the National Health Service launched in England and Wales.

As a country, we had been nudging towards the establishment of universal healthcare for decades. The first real step had been taken by David Lloyd George in 1911 with the passage of the National Insurance Act. The real conversations took place against the backdrop of the Second World War, culminating in 1944 with the publication of the White Paper by Henry Willink, the then Minister for Health. And when the war was over, it was the son of a Welsh coal miner who brought together the ideas of the last thirty years into a vision of a body that would provide healthcare to all, irrespective of their social class or employment status or origins, paid for by everyone as they were able and in return delivering healthcare free at the point of need.

That was 66 years ago tonight.

Tonight, I remember Nye Bevan whose dream became a life-saving reality.

I give thanks for my colleagues in the NHS and for those who went before us. I give thanks for the joy of spending my days in its service. I remember with gratitude and hope and sorrow and joy all those who have passed through the doors of my corner of the NHS, for lives lived and lives lost and lessons learned. I give thanks for my life, too, and for the lives of those whom I love. I pray that we will not be blinded to our faults and imperfections, or afraid to do better.

The future of the National Health Service has never been more uncertain. It has survived through economic crises and political “reform”, and yet the threats to it loom larger than ever before — all the larger for so often being insidious and only visible in the corner of our eye.

And with profound thanksgiving for all that it is and with fear for all that it must not be allowed to become, I remember these words from the revised Hippocratic Oath:

I will respect each of my roles, as expert, communicator, scholar, partner, manager, teacher, professional, and health advocate.

I recognise that I have responsibilities to humankind that transcend diktats and orders of States, and which no Legislature can countermand.

I will oppose health policies that breach internationally accepted standards of human rights.

Life After The Foundation Programme (Good Things Come To Those Who Wait)

As of last Friday, I have completed the (form-filling parts and educational requirements of the) Foundation Programme.

Do you remember when I was just starting it? It was five minutes ago. Yet, here I am, ePortfolio all ticked off and six weeks of acute medicine away from being not quite so much of a baby doctor anymore.

With the improbable but still very looming prospect of Life After Foundation, I’ve been committing what is probably a grave sin. I’ve been telling my FY1s about what happens come autumn when they sit down with intimidatingly long job application forms and start to be bombarded with well meaning careers advice. I’ve been saying that the thing to remember is, if they are offered a job that they do not want, they are under no obligation to take it.

You are not told this.

I did not realise it myself until a few months ago, and it blew my mind when I did.

You see, applying for FY1 jobs, fresh out of medical school and/or still suffocating underneath a pile of finals revision, we did have a bit of an obligation to take what we were given and be grateful for it. We had provisional registration with the GMC, and to achieve full registration (and so be employable as doctors) we were required to complete our allocated FY1 jobs. No questions. No arguments. Bags packed and off to Shetland, if Shetland was where the UKFPO believed your destiny to lie. I was given precisely the job I wanted and within reasonable driving distance of the city I wanted to be in, but others did not have such good fortune. After working for two years in a job that was allocated by that kind of system, you do find when the two years are over that it’s played a few tricks on the mind. It was a lingering bit of that mentality that led to me saying things like, “Well, I’d like to be able to live in Glasgow, obviously, and that’s what I’ve applied for, but I’ll have to go wherever I’m sent.”

A lot of people do take the first job they’re offered, of course. Like me in FY1, some people are offered the training post they want or the location they want or a one-way ticket to Australia, and I am thrilled for them. And I’ll grant that there’s something to be said for not going too far in the other direction; after all, quite aside from the rest of it, the bottom line is that you need to be able to pay rent in August.

In February, I learned that I did not have a place on the Core Medical Training programme in Scotland.

(An aside for the non-medics and the non-Brits. CMT is the next step for a person who wants to be a hospital doctor in a medical specialty. Where the Foundation Programme theoretically included a little bit of everything, this is the stage where I’d drop things like surgery, paediatrics, GP, etcetera. There are equivalent programmes although of varying lengths for folk who do want to be surgeons or GPs or paediatricians. If you’re familiar with the North American system, whether legitimately or because of Gray’s Anatomy, this part is a bit like a residency in internal medicine.)

The offers for CMT in my region were released on a Tuesday afternoon in early February. On that particular Tuesday, I was in the middle of my Advanced Life Support course. It was also the Tuesday that I was due to collect a new car, my old one having died a final death on the hard shoulder of the M74 in the rain at the end of the previous week. It was also Equal Marriage Day in Scotland. It was a week of mixed emotions. But the offers for CMT are released by text message, and let me tell you there are few more crushing ways to learn of one’s imminent unemployment than to be the only person in a room full of your peers to not get that text message.

The good news was I was not considered unappointable by the good people who had interviewed me. A pleasant surprise, considering I’d forgotten the word for amiodarone in the middle of my interview.  I was merely quite far down on a reasonably lengthy list. So, you wait for good news to come to the people whose applications to CMT were a second choice or who had expressed an initial preference to work somewhere else in Scotland. The automatic next step is to go into the second round of applications, where the jobs that are left over are opened up to people who haven’t got one in their first choice of region. I expressed my intention to do this and even had a bit of a poke on the CMT website. Scotland was oversubscribed and so my options in Round 2 would be restricted to England and Wales. In my head, I was saying, “But I don’t want to go to England!” (Sorry, England.)

Eventually, I nudged high enough on the Scottish waiting list to be offered a job in the North.

Aberdeen, Inverness, and places where a 3G signal goes to die.

By that time, I had had a good talk with an excellent friend. She had sliced through my mad panic to remind me that with GMC registration comes decisions and options and not taking that which is foisted upon you. I had started to look into some of those options — fixed-term staff jobs and clinical teaching positions and locum work, and my well-worn and fatalistic mantra of “well, I’ll have to go where they send me” had been abandoned and deservedly so. I had stopped muttering about England and I spent perhaps five minutes considering the job Oop North — not an indictment of Aberdeen but an abiding love of Glasgow, this dear green place with my beautiful city that adopted me with joy and contains my home and my community and my life, where, once I’d been reminded that I could choose, I was never going to not choose.

(I was angry and determined when I came home from Synod. If I’d come home from Synod with the knowledge that I would soon leave my cathedral and the Diocese for a job two hundred miles away, I’d have been inconsolable. It isn’t entirely about that, but it is a bit about that.)

I am in no hurry at all to be a consultant. Please, let me put off that terrifying day for as long as possible. I think that doing different things is good and that more experience is good. I’ve spent a lot of time on the scenic route, and I’ve never regretted taking it.

A couple of years ago, writing in InspiresI wrote this: “If I’ve learned anything in that decade and a half, it’s that being a doctor isn’t a being but a becoming. [...] My journey hasn’t ended. I’ve only stopped to buld a cairn at the roadside, and when I get up, the horizon will have shifted and I’ll have settled new dreams and new responsibilities onto my back as I step back onto the path to continue a journey that may not have always taken me along the straightest or simplest of routes but that has been all the more worthwhile and memorable for it.”

Still true.

I’ll be reapplying to Core Medical Training this autumn with the hope of beginning it in August 2015. I’ll try not to forget the word for amiodarone this time.

In the meantime, I’ve accepted a job for the coming year as a clinical fellow in Haematology.

Not what I’d planned when I first thought about it a year ago. Not an option I knew was going to exist. But different and exciting and worthwhile. It might even be better than what I had planned. I’m looking forward to starting in August and I think it will be good for me

Why I’m Still Not Convinced By The Cascade Conversations

Kelvin has written nearly everything you need to know about the listening process that we endured at Synod today, and you all know what I thought of it before this started. If you haven’t already, read his first.

I knew precious little about what we were getting at Synod. I knew that we were expecting a presentation on what happened at Pitlochry and then small group table discussions, and I knew that there would be no time for discussion as a whole Synod or feedback from the groups. I knew the last part because I went hopping mad at my own Diocesan Bishop when I learned of it at our pre-Synod meeting last week.

Let me tell you something about a whole Synod discussion and about small group table discussions. The Scottish Episcopal Church is changing the way we train people for ministry, and this morning we had a conversation about that in our small groups and then we had an incredibly fruitful conversation and Q&A as a whole Synod. Because the changing of TISEC to the Scottish Episcopal Institute is important business that means a lot for the life of our Church and that a lot of people have a lot of questions about, and so we discuss it in this way, together, so that concerns can be raised and answers given and lively debate had. I ask you, what is less important about the inclusion of LGBT people in the life of our Church and the way we treat them and their relationships that means that we do not discuss that together and that it does not have to appear in Synod minutes?

Does it appear to you that the people who decide how we talk about these things might be frightened of what might happen if we actually talked about them? It appears that way to me.

The presentation on Pitlochry was worse than I expected. And “worse than I expected” is an awfully low bar to clear; I did not go into this with high standards. It became clear to me very quickly that nothing of substance was going to be shared with us in that presentation and I have my suspicions that that means that nothing of substance was discussed in Pitlochry. I began weeping during the presentation and I continued weeping all the way through the table discussion. I feel angry and disrespected and (unsuccessfully) manipulated by the people in charge of my Church, and I feel ashamed of what I have from this Synod to take back to the LGBT members of my congregation, which is nothing.

The table discussion was better than the one I sat through at Diocesan Synod, but I credit that to my having been on a table this week with good people. Unlike at Diocesan Synod, where I sat through chat about Holy Mother Church and sodomites. The fact that I was blessed with sensible people to talk to does not change the fact that we weren’t allowed to achieve anything of substance or to share our views, including the view that same-sex marriages are already part of the life of the Scottish Episcopal Church whether they like it or not, with Synod as a whole.

All around the room, the question was being asked of why are we not just getting on with this? But, of course, God forbid that any Synod members should be allowed to express that view to Synod.

What I have seen in the last two days is that the views of people in the Church are changing and that the Church is growing restless, and that a small number of people who have more power than they should are silencing our voices.

The Primus spoke afterwards about the value of this process in that it does not turn the issue into a debate with winners and losers.

He forgets about those of us who are already losing.

Losing our faith.

Losing our patience.

Losing heart.