What’s Next?

You may remember that not too long ago — it feels like forever ago —  I was being admonished by my emails to prepare properly for a job interview and spending evenings being grilled on clinical scenarios by long-suffering friends.

It is with something beyond joy and no small measure of disbelief that I tell you that this afternoon I was offered a job as an ST3 in Acute Medicine in the west of Scotland. I am a bit terrified, and a bit gobsmacked, and a bit weepy, but I am mostly just really bloody happy.

Entirely Bonkers (But All The Best People Are)

It was quarter to eleven on a Sunday evening, a year or so ago. I had spent the weekend in one of the busiest of the old hospitals in Glasgow, and a half hour earlier had finally handed over the medical receiving bleep to my nightshift colleague. I talked to one of the nursing staff, checking on the management plan for a patient who hadn’t yet come over from the emergency department with their notes.

I’d come back to my department to document a few things that existed in my head but not yet on paper. I looked over a few blood results. My post-work plans were to attend with all due urgency to the food that was waiting a mile down the road for me and my FY1 before seeking horizontalness.

And standing at the nurses’ station at the end of the thirteenth hour of my Sunday, I blinked.

“I could do this forever,” I thought. And then: I can do this for a job!

And then: “I’ve gone mad.”

I was mentally and physically exhausted, bursting with joie de vivre and exultation at the sense of a job done to the best of one’s ability. I was flying high and obviously preparing to crash. It was clearly not the moment to make life-altering decisions about my career path, and so I fetched my coat and went off to my pizza and my bed.

But over the next few weeks that thought kept coming back to me and I kept poking at it, like a bruise that won’t go away.

The remit of acute medicine is (and here I’ll paraphrase from the JRCPTB website) that it concerns the first 72 hours of assessment, diagnosis, and management of adults who are admitted to hospital with a medical illness — the definition of “medical illness” being a very broad church but essentially meaning anything that couldn’t, in theory, be fixed with a scalpel. The idea of being a person who is trained in acute medicine with a view to that being the thing they have expertise in and then does it as their whole job is a very new one. Indeed, it wouldn’t have been possible when I started medical school in 2007. In the autumn of that year, I was given a tour of the recently opened acute medical unit in one of the local DGHs and the fact that that existed was considered hugely innovative. It didn’t become a specialty in its own right until the mid-2009.

I did an acute medical job in FY1, and loved it. I did an acute medical job in FY2, and loved it. In the year I took out of training last year, I spent 80% of my working hours in a really lovely job that I honestly enjoyed and for the rest of the time did locum shifts in my old receiving unit where I bounced around like the Energiser Bunny on steroids before ending up in my car at midnight marvelling that people were actually paying me to do something that I loved so much. All the career options that I’d mulled over and not been able to settle on during FY1 and FY2 had one thing in common: the part where I’d kept saying, out loud, even, that my priority was to be able to keep doing acute medicine. My favourite thing in the world (other than chocolate, maybe) is the part of my job where I start with a completely white piece of paper. And then from various sources there’s a whole muddle of information that doesn’t make sense, may not all be relevant, and more often than I’d like contradicts itself, and I get to try to organise it into a coherent narrative and work out what to do next and, on the very best days, actually fix it. And to a certain extent all of medicine is about that, but acute medicine is about that.

And a part of the reason that that was my priority was that I couldn’t choose an organ. My internal narrative went along the lines of: “I like the idea of endocrinology but haematology is still super interesting and the lungs and heart are kind of important and do things that I’d like to know more about but the liver is cool too and the kidneys work by magic which is amazing.” My personality is best described as Definitely An Adult Physician, But Eternally Indecisive About What Kind Because The Medical Specialties Are All Brilliant.

I like getting to start at the beginning. I like unpredictability. I like that even the things that are about pattern recognition aren’t the same, because people aren’t the same. I like listening to peoples’ stories. I like talking to patients and their families, and trying to demystify things for them. I like doing simple things that make big differences. I like doing practical things. I like being busy and useful. I like lists of problems and complicated things that I can start to unravel. I like teaching. I am fond of the occasional shot of adrenaline in my coffee.

Just before Christmas, I was involved in a Twitter conversation organised by the Society of Acute Medicine. A consultant who evidently has more poetry in his soul than the JRCPTB described the specialty as, “It feels like you’re standing in the hospital’s engine room every day.”

That’s it. That’s what I want.

As someone who is not yet in specialist training, the most frustrating thing about it is the number of people who look at you as if you’re having a psychotic break when you tell them that it’s what you want to do. I get why it isn’t for everyone, I do, but it’s for me, I think. In retrospect, the most surprising thing about my epiphany at the nurses’ station on that Sunday evening was only that it had taken me so long to have it. And if I am a little bit mad, I think that’s okay. As the Cat said to Alice, we’re all mad here.

Four Hours in A&E

I was driving home last night when I heard on the Radio 4 evening news that one of the top stories was a failure of emergency departments in England over the last week to meet the fabled “four hour target”.

The four hour target, which was introduced by the Department of Health in 2003, states that 95% of people attending emergency departments in the UK should be seen within four hours.

Or that’s what I hear every time there’s a news item relating to this target, so let’s clear up a couple of things.

And the first thing is that the four hour target states that 95% of people attending emergency departments should be triaged and seen and treated and moved out of the department within four hours.

I’m not quibbling the rights or wrongs of the target; we could go round and round on that forever. It’s an arbitrary number. It’s been the same arbitrary number for eleven years. That allows us to measure and compare and I suppose gives part of the impetus to improve performance. It has as much value as any other number that might have been chosen, which is to say that it has enormous statistical value and absolutely no moral value.

The target is what it is, but if we’re going to let the media take the NHS to the cleaners every December for a target that it’s failing to meet then I think they should be obliged to talk about that target as it is.

Even with those parameters, the four hour target was achieved for 91.8% of people attending emergency departments in England in the first week of December.

And that figure says something, but it doesn’t say that 8.2% of people attending English emergency departments last week were still in the waiting room at the four hour mark.

We don’t have any December figures for emergency departments in Scotland yet, but the media presume that they will be comparable with England. Last weekend, I was the receiving medic for an inner city Scottish hospital. I spent the first weekend of December trapped in ED (and I do mean trapped — I ate only because my FY1 delivered lunch and caffeine to me, which probably qualifies as abuse of one’s juniors on my part). I cut through the waiting room a lot. That less than 10% of patients were in the department for longer than four hours is fairly remarkable to me.

So far as I can tell, the patients who are well enough to be discharged home straight from ED are not the ones for whom the target falls down (although it isn’t difficult for me to envision a situation in which that process as a whole could take longer than four hours). The target falls down for the patients who are seen and, having had their treatment started, need to be admitted to the hospital.

There is a bed crisis in hospitals in the UK. I don’t know if you’ve noticed. It hasn’t been caused by doctors or nurses or AHPs, who consistently work their socks off and then some. From what I’ve witnessed, it is for the most part being caused by inappropriate attendance at ED less than politicians would like us to believe. It is being exacerbated by those same politicians, who bafflingly seem to think that closing hospitals and reducing the number of available beds is the way to fix it.

(Spoiler: It’s not.)

If a person needs to come into one of those beds, they will be found one.

If the specialty to which they need to come does not have a bed available right now, two things will happen.

First, we will come to you.

You’re having an asthma attack? We’re not going to withhold oxygen and nebulisers until you get to the respiratory ward. You have a raging infection? The cupboards in ED have antibiotics too.

Second, we will keep you in a place of safety.

And it breaches the four hours and governments don’t like it and patients don’t like it and the media sort of love it, but emergency departments are a place of safety. And are better for patient safety than transferring unstable patients to a non-ED bed across a city, or giving a less sick patient a higher priority for a bed than a sicker one merely because of waiting time, or discharging patients inappropriately. And the days when those things are true are more frequent than anyone who works for the NHS would like them to be, so when they are true we do the very best we can with what we’ve got and we go home at the end of the day knowing that we worked for the good of our patients and not for obedience to a government target.