This Is What’s Next

You all already know how this story ends.

The endings are rarely the interesting parts. Did you read the first six and a half Harry Potter books to find out that the good guys win in the end? (Uh: Spoilers.) You did not.

It started on a hotel balcony in Madeira. I had deactivated my NHS email account in the baggage check queue at Glasgow Airport, but the second last thing I’d done before flying away for a week to a warmer, sunnier annual leave than was offered by February in Scotland had been to submit my application to higher specialist training in Acute Medicine. And because I am paranoid, I had submitted the application under my personal email address. Under a cloudless Portuguese sky, my phone buzzed. I had been long listed and I would hear about an interview in due course.

Or it started in the medical receiving unit of a Glasgow hospital that no longer exists. At quarter to eleven on a Saturday night a few summers ago when I hadn’t sat down all day and had clearly not yet made it home to my rapidly cooling pizza and I realised that this, this, was what I wanted to do with the rest of my life.

Or it started in the medical receiving unit of a dozen other hospitals scattered hither and thither across the West of Scotland where through my years at medical school and in the Foundation Programme they had welcomed me in and given me work to do and shown me the nuts and bolts of how to be a doctor for real, and, where I had learned that, if you wanted, this was what you could do with the rest of your life.

And then it was spring and I was back under a Scottish sky, the April version of which is every little bit as steely-grey and rain-saturated as the February one. I had spent the previous two weekends printing out and putting together the required portfolio of evidence, a folder that might have served well as a blunt weapon if I’d run into a riot on my way to the East. I had spent evenings pacing my living room floor, trying to formulate an answer to the question, “Why do you want to do Acute Medicine?” Ideally, one that wouldn’t make me sound deranged. I had spent the previous evening as the SHO on call for oncology, replacing venflons and trying not to pull out all of my hair.

An early morning train to Edinburgh. A heavy wodge of paperwork. My good suit, and my lucky socks, and my very best terrified face, and a pressing concern that I shouldn’t vomit all over myself.

The most significant days of my life seem to begin thus.

It is five years since I graduated from medical school. I have just about persuaded myself that I really am a real doctor. I mostly don’t have the urge to giggle anymore when I introduce myself as one of the doctors, and most days these days I don’t actively expect to be stopped in a corridor by someone there to tell me that my finals results were all a terrible mistake. But as a brand shiny new junior doctor, I remember believing that the registrars were really the real doctors. They were proper adults and were very organised, and they knew everything. If it all went wrong and I needed to call someone (or maybe just scream really loud), the med reg would come. I still believe all that, and because I still believe all that I do not in any true sense believe that I am qualified to be one.

This is an awkward thing to not believe when you are on your way to a job interview.

But there is a little bit of point of no return to this kind of thing, and on I went through the door of the Radisson on the Royal Mile, my black suit and green-tinged face incongruous amongst the gaggle of short-and-T-shirted and frostbitten-looking Americans, and my imposter syndrome out in force.

An interview for a medical training post begins with an administrator who checks through all the documentation, and there is a lot of documentation. There is proof of identity and proof of registration with the General Medical Council, and, even though being on the GMC register in the first place depends upon your having one, your original medical degree. My original medical degree is A3 sized and entirely in Latin. And then there’s that blunt weapon of a portfolio, which contains proof of everything you have ever claimed to have done including things which are wholly unrelated to medicine. Two years ago in my interview for Core Medical Training, they asked what I was proudest of that was unrelated to being a doctor and I had to decide to talk about changing the world because I suspected no one would have believed me if I’d said, “being Ginger Rogers except with a thurible”.

My fellow interviewees and I took our places outside closed doors, waiting for the knocks that would signal the beginning of our half hour of torture.

“Why do you want to do Acute Medicine?” asked a consultant who I’d not met before.

I did sound deranged. But as the Cat said, we’re all mad here: we must be, or we wouldn’t have come here. I decided to go with it.

After ten minutes — and I think that at some point in those ten minutes I flapped my arms around and tried to design an ambulatory care service out loud — there came another knock. I gabbled out a run-on sentence about — oh, who am I kidding, like I have any memory of it. And ran.

The same corridor, another door. Andrew Lloyd Webber probably wrote a song about that. This time, I had a card to read about the clinical scenario that I would be presented with when I entered the room. An elderly man presenting with collapse, ?cause. This was more straightforward than any of the scenarios I had been trying to revise, which immediately sent me into a sort of flailing tailspin. My panic did not improve when I entered the room to be greeted by a man who used to be my boss and the information that he would be playing my 75 year old patient. I wish I could tell you what I said. I really do. I remember that I mustn’t have taken any time to organise my thoughts, because I vividly remember that I got a good third of the way through before I stopped and apologised and announced that I was going back to the beginning and starting again. I also vividly remember that the interviewer who wasn’t doing the roleplay looked thoroughly relieved after I had made this announcement.

Back in the corridor, waiting for the signal to enter the last room. Footsteps. A bang.

“Housekeeping!” a voice shouted.

We three candidates abruptly tried not to meet one another’s eyes, lest we giggle. That answered the question that had been niggling at the back of my mind ever since I’d arrived earlier that morning — been directed away from the business centre, been surprised when guest-looking people stepped out of the lift with me, noted empty trays and copies of the Times lying on the carpet outside rooms that were right next to the rooms we were all going in and out of. It seemed that we were indeed having our job interviews conducted in what were usually hotel bedrooms.

Not quite so weird as that one time I sat a postgraduate exam in a football stadium, but quite weird enough.

And then I ended with five minutes to conduct a “driving advice” conversation with a twentysomething professional HGV driver who had been newly diagnosed with diabetes, or so my card said. But when I made the mistake of asking an open question, he turned out not to yet know that he had diabetes at all. “This is a conversation that I’d normally take longer than five minutes to have but I’m on a timer here,” I tried frantically to project with my eyes to the consultant playing my HGV driver as I talked at speed.

Even this far on this side of knowing what the outcome was, my strongest memories are of all the spaces where I forgot to say things.

The end of the story is that I was disgorged back onto the Royal Mile, befuddled and blinking in the sun that had finally come out.

The beginning of the story is that in a little under three weeks, I’ll be a specialist registrar in Acute Medicine in the West of Scotland, spending the first year of my training in a district general hospital and my first six months trying to learn something about cardiology.

The end is where we start from.

Take AIM

Just before Christmas, I spent a weekend down in Bristol at Take AIM, a conference aimed at junior trainees who have an interest in acute medicine.

The second year of core medical training is notable for a sharp uptick in the number of times per week a person is asked if they’ve had any thoughts as to the specialty training they might consider. I tell them that I’m applying to ST3 in Acute Medicine, and they’re startled — either by my questionable life choices or my level of decisiveness, I’m never quite sure.

“Oh, and — really?” asked my most recent clinical supervisor. “Do you think I could get you to change your mind?”

I should be clear, my choice of medical speciality is hardly the first time I’ve had a questioning eyebrow raised at my life choices. My life choices have, after all, led to me sitting on the M74 on my day off looking for exit signs to Lesmahagow with my only provisions being a boot full of wedding paraphernalia, and being in the back of a Jeep reversing backwards around the corner of the shelf of the Ngorogoro Crater while the part of my brain not occupied with screaming asked if this was really how it was all going to end, and nearly getting arrested in the middle of Tianenmen Square. And those things all turned out brilliantly. So.

The raised eyebrows can be flattering, in their way, if their purpose is to persuade me out of my specialty and into theirs, which is sometimes.

But — unspeakably frustrating in another way.

At this point in CT2, some people haven’t made up their minds, which is fine: that’s why staff grade posts and taking time off from training are good things to do. I have, though. I had my time off from training, remember, and I needed an Archimedean epiphany fuelled by sleep deprivation and adrenaline, but I’m done. I’m sure. I’m not a foundation trainee who ought to be prudently murmuring about keeping her options open. I’m in, and with my eyes wide open. If my mind wasn’t changed by perpetual backshifts in a hospital that was literally closing down around me and where we occasionally had to see patients in the cupboard for lack of bed space, it is unlikely to be changed by the prospect of thirty years as an oncologist.

I know when I was ten that I thought that a doctor was a doctor and it was all basically the same thing, but it’s not like that’s actually true.

Yes, isn’t it nice that we don’t have to all be the same thing?, I want sometimes to say.

I’ll be honest, mind: I understand in my brain why my particular thing isn’t for everyone. In my heart, I don’t really understand why anyone would ever do anything else.

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Heart and Brain: TheAwkwardYeti.com

The frustration of being a core medical trainee is that it feels — and is — a terribly peripatetic existence. I don’t yet have my tribe, or whatever the collective noun for my specialty colleagues would be. An insanity of acute physicians, perhaps. I still don’t have that, five years in. My experience is that nor do most CMTs. You sort of have to go looking for it, and therefore my weekend in Bristol was precisely what I needed.

Take AIM was the initiative of registrars training in acute medicine and has the stated intent of promoting what is a still relatively new and rapidly expanding speciality to juniors. It gets funding from Health Education England and support from the Society of Acute Medicine, and it has consultant input, but it’s still principally led and run by senior trainees — which, as someone who isn’t yet but hopes soon to be in specialty training, is a helpful thing for me, to hear from people who are in a position to tell me what the next five years of my life are likely to look like and who are willing to do it in a warts and all kind of a way. My first real contact with them was in October 2015, when I joined in an hour-long discussion on a Sunday evening on Twitter and came away from it feeling that thing you feel when you have found your people and they get you.

Bristol was like that, too, but better.

It had a bit of careers advice in it, and a bit of debunking of the more commonly held myths of acute medicine. Personally, I’m considering getting the sentence No, I’m Not Just Going To Be The Med Reg Forever tattooed across my forehead. It was also very well populated with very lovely trainees who were keen to chat about training and careers between the main sessions.

A lot of the day was education on acute medical topics. The philosophy went something like: “We are going to expect you to engage in acute neurology teaching first thing on a Saturday morning, but we are going to make sure that you are very well caffeinated for it.” That’s basically what I mean when I call them my people.

I would not dare to speak for everyone on this, as training experiences vary across the UK and everyone’s experience of their own training is different anyway, but the topics covered are ones that in my experience are covered badly, not enough, or not at all. To take an example from one of the earlier national conferences, in 2015, a session on “The Pregnant Patient on AMU”. It is not a thing that I’ve ever been taught and yet is a patient demographic that I happen upon all the time. It is incredibly exciting to me to spend a day being taught useful things by people who understand what happens at the front door of the hospital and want to help make it happen better, and that was what that day felt like. The presentations from the Bristol conference are all available online for those of an acute medical inclination, and a Storify, which includes video of a hundred people doing the dermatome dance, still first thing on a Saturday morning, has been put together of the day as told via social media.

It didn’t convince me that I want to be an acute physician; I knew that already. I think it reinforced for me that I’ve made the right decision.

I apply for a job in a month. For those of you who have been on this particualr merry-go-round with me for the last five years: Yes. Again. It’s a bit scary, this time. I remember when I was an FY1 that I definitely thought the registrars were the Proper Grown Ups. If you need me, I’ll be taking deep breaths with my head between my knees.

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.

The Sun Is Coming Up

You find me on a late summer evening, slumped at my dining table, in sock feet and an old race shirt and ancient leggings. My hair has long since given up on its plait. I have no idea what timezone I’m in. The only decision I am competent to make tonight is what kind of food I would like the delivery people to fetch me. I’ve either just flown halfway round the world, or else I spent my weekend going from dayshift to nightshift and back again by Tuesday morning.

Internet, let me let you into one of my dirtier secrets:

I really like working nights.

This is born out of my romantic notions about them, notions of which three years of, you know, doing it, have entirely failed to disabuse me.

Look, I know it’s a bit weird. If you say it out loud to people, they tilt their heads and say, “but nights are awful”, like I’m trying to be a brave little soldier, which couldn’t be less true, or like I’m a bit mad, which… well, I also have romantic notions about marathons, New York, the nature of democracy, empty cathedrals, London, and the NHS, so you go on and decide for yourself how mad I am.

Oh, they have their unpleasant bits. This past weekend there was a night when I went from actually sitting still for a bit to running up five flights of stairs and I promptly lost both my lunch and my dignity down the sluice. I have on one occasion been so tired that my four o’clock in the morning brain forgot how to use a tampon. And the sheer dragging-myself-through-treacle effort of transitioning back from nights to days, which really is awful.

But that would be like saying that New York is awful because of the jet lag on the way back, or that because of David Cameron we should all give up on the nature of democracy and move to North Korea.

In one of the last episodes of The West Wing, on a night that has lasted whole lifetimes and has seen friends and co-workers through unimaginable highs and unthinkable lows, when newly President-elect Santos makes his victory speech, he says this: “You know, if you haven’t left this room in a while, the sun is coming up!” And everyone applauds. And that’s how I feel when I see a nightshift sunrise; every time. At the end of a night when a great deal of work has been accomplished, for better or for worse, and I’ve spent it wide awake and being allowed to do my acute medic thing for twelve hours and wandering the dark corridors of a world that is very peculiarly mine, I think of that, and I think too of the dawn prayer: “we thank you for bringing us out of the shadow of night into the light of morning.”

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Early on Monday morning, I crossed the ambulance bay in the crisp early light of half past six in September in Scotland. I was as content in that sunrise, heading back to AMU for my microwaved porridge, as I was huddled over a mug of coffee the morning I watched the sun come up over the Serengeti.

This was originally going to be a nightshift survival guide for junior doctors, but it got away from me a bit in the writing of it. At some point perhaps I’ll do that properly, and, look, yes, I’m very lucky, it’s not heroic to like working nights if you can sleep anywhere and at any time and have a stomach that can mostly tolerate whatever and whenever you feed it. But the most important piece of advice I can give is to stop listening too much to people who tell you that they’re something to be endured and start trying to enjoy them a bit.

My Job Is Amazing

This weekend, I have…

  • Sat down for half an hour with a patient, their partner, and a pharmacist to come up with a robust, flexible management plan upon which we were all agreed.
  • Done my medical detective schtick.
  • Talked more than either of us would have liked to oncology on call.
  • Taught three medical students. Given one of them a logistically impossible task of the FY1 bureaucratic nightmare variety, and got to see him accomplish it and then grin so much I thought his face might fall off. Because teaching that impossible is relative is still teaching.
  • Been thanked.
  • “I have to ask you some daft questions. Do you know what year it is?” “2014.” “Who’s the Prime Minister?” “That bastard.”
  • Via well-timed phone calls and much help from other people, found alternative diagnoses that made more sense, were truer to Occam’s Razor, and led to changing treatment for the better.
  • Had important conversations.
  • Been called Madam Doctor. Lots. In bad French, once. Madam Doctor, comprendes oui?
  • Genuinely saved someone’s life, which is a thing that I get to say less often than you might think.
  • Had fits of giggles when I walked through an A&E waiting room that contained maybe fifteen patients who were all intently watching Casualty.
  • Drunk not enough.
  • Got home on time not at all.
  • Got better at being a doctor than I was on Friday morning.