Review: This Is Going To Hurt

Last month, I got my hands on a pre-release copy of This Is Going to Hurt, the medical memoirs of Adam Kay which were published this week.

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It had landed on my doormat when I arrived home on a Monday morning after my first set of nights as the medical registrar, which was also the first weekend after August changeover and therefore my second shift working in a hospital so unfamiliar that on leaving induction two days earlier I had driven nearly as far as the ferry terminal to Troon before I realised that this probably wasn’t the road back to Glasgow. I left the book on the kitchen table, changed my shoes, and went in search of breakfast.

The next day, my day off for catching up on life admin and grocery shopping and for getting my body clock turned the right way up, I sat down and read the whole thing in one sitting.

Adam Kay is a writer and script editor of comedy. In a previous life, he was an obs and gyn registrar and is known to medical students all over the country as one half of Amateur Transplants. This Is Going To Hurt is taken from the diaries kept in his years of junior doctoring.

Now, the memoirs of doctors are ten a penny these days. We are required by our training boards and the GMC to reflect on our practice, and I suppose some of us think we may as well publish it. It would be disingenuous of me to say otherwise; you are after all reading my blog. I’ve read some of the ones that made it into book form, the oldest of which was published in 1992. (I have never read House of God.) I’ve liked some more than I’ve liked others. (This is unsurprising. I like some of my colleagues more than I like others.) This is the first one I’ve read that has made me want to invite it over to Sunday lunch with my four best loved doctors, and that is among the highest compliments of which I am capable.

My affinity with it exists on a number of levels.

It knows the value of a good footnote.

It’s written by someone who plainly loved his job and was good at it. (I realise that you might then ask why he left. That isn’t my story to tell.)

It’s funny and friendly. It reads as easily as a colleague telling me stories about their week, which I suppose is what it is. It contains at least a dozen anecodotes that sent me into a tailspin of, “oh, remember that time…”, which is the hallmark of good medic chat. Fair warning, one of those anecdotes contains a vagina, a railway spike, and Newtonian inevitabilities.

And it would be disingenuous of me to not admit that at least part of my affinity with this book comes from having read it just exactly when I did. Adam writes about what it’s like to be on nights, “sailing the ship alone: a ship that’s enormous, and on fire, and that no one has really taught you how to sail.” He writes about how as House Officers we all think that our registrars are geniuses, “like God maybe, or Google”, and the horrifying moment when, “before you know it, the registrar is you.” He writes about how as the senior on call he couldn’t sit down, but would “prowl anxiously around labour ward, flitting from room to room asking ‘is everything ok?’” It is a strange and immersive experience to read a book like this immediately after a weekend like the one I’d had. I kept thinking, “YES THIS ALL OF IT ALL WEEKEND,” and then looking up to say it out loud, only remembering after I already had that no one was actually in the room. The job I do is nothing like being an obstetrics registrar, apart for in all the ways that it’s exactly the same.

The existence of the book owes itself at least partly to the Secretary of State for Health. In his epilogue, Adam writes about the Conservative government waging war on doctors and his own realisation that everyone who works or has ever worked in healthcare needs to shout about the reality of the work that we do. His acknowledgements include no thanks whatsoever to Jeremy Hunt.

It isn’t a book about politics, except in the sense that we live these days in a time and a place when to tell the truth about being a doctor is a political act. For those of us who believe in what Nye Bevan believed, there is no option to be apolitical about healthcare. And there is no such thing as “just politics”, for, please, if the next generation learns anything from ours let it be the inconvenient truth that “just politics” was always a lie.

This Is Going To Hurt is written by Adam Kay and published by PanMacmillan. It is available now.

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#tipsfornewmedregs, please

On Thursday, I said goodbye to the staff in my current medical receiving unit. I’ve worked with a lot of them for four years, on and off. I’m certain I’ll be back again, someday. I pop onto the ward at the beginning of next week for a couple of days, and then on Wednesday it’s all change.

New commute. New colleagues. New corridors to get lost in. New job.

The first Wednesday in August — as it was in the beginning, is now and shall be forever, world without end.

My final weekend before changeover will be spent doing an online induction module, building furniture, and taking deep breaths.

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This is what the inside of my brain looks like right now.

I’m pretty sure the new FY1s think they are the only ones who are nervous.

I am thirty-two years old and have a hip that aches if I sit cross-legged for too long, and yet every summer I still get ready for my first day at new school and worry if the other kids will like me.

So.

If anyone has any #tipsfornewmedregs, this would be the time.

People Make Bad Choices If They’re Mad Or Scared Or Stressed

All over the UK, newly graduated medical students are starting to look ahead to the first Wednesday in August and their first day as Actual Proper Doctors.

If they are anything like I was, they’ll be having increasingly terrifying nightmares about holding the cardiac arrest bleep on their first night. And getting lost. And they’re the only one on the arrest team. And they can’t remember how to do CPR. And there’s a dragon in the corridor. No? Just me? OK.

A couple of years ago, I wrote a long piece that contained practical advice for new doctors. If you are a new doctor and you are looking for bullet points on where to get help, how to ePortfolio, the unsettling but central role that half-coloured in ticky boxes will come to play in your life, and other things, that piece is here and still contains the best advice I have to give. Over on Twitter, search the #tipsfornewdocs hashtag, and remember that we all remember this and that almost none of us bite.

Today, I want to talk about something a little bit different. I want to take a bit of time to think about resilience and self care.

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The idea of ‘resilience’ is a psychological one that has to do with the capacity of the collective and of the individual for what I’ll call ‘coping’. It was defined by Andrea Ovans in the Harvard Business Review as “the ability to recover from setbacks, adapt well to change, and keep going in the face of adversity”. In the last few years, it’s developed into a buzzword in the language used to talk about and to public sector workers. The first time I became aware of it as a thing that was being said to doctors was during the junior doctor contract negotiations in 2015.

Now, the first thing to say is that I’ve never met a junior doctor who didn’t possess resilience. It is a requirement of the job. It is a requirement of getting the job. So, the second thing to say is that when the government talks about junior doctors not having resilience, they are lying.

But if what they mean is that junior doctors have proven increasingly unwilling to be actual martyrs — well, yes, that might be true, and that might also not be a bad thing.

As a teenager, I wanted to be John Carter from ER. I wanted to live all the hours in the day for my job. There is a picture of a recruitment poster for Emergency Medicine going around at the moment that invites applicants to “choose surviving on coffee and adrenaline”. It is a terrible message to send, but half my life ago it was absolutely what I wanted for myself. And even as a slightly more elderly medical SHO, there are days when that kind of thinking still has its seductive qualities. On the seventh day in a row of thirteen hour days, I can enter a mental state that is some sort of meld of beautifully Zen and utterly psychotic. I know all my patients inside out and back to front, and half the patients of the other teams, too, and I am completely on it and, look, I just live here now and I’m pretty sure that’s actually fine. (I have a bad-coffee-and-sleep-deprivation-fuelled memory of this precise thought process going through my brain, about eighteen months ago, and also I think I was skipping down a corridor at the time.)

It is perfectly possible to live like this for short periods of time. I clearly do and so do lots of other people, not all of whom are doctors. It is not sustainable. A period of work like that has to be punctuated by a period of rest and rejuvenation, or else the whole thing falls apart. I love my job, but my capacity to do it for thirteen hours a day without a day off is not infinite. I believe that that is true of any human in any job, no matter how much they might love it.

It is partly because no one has an infinite mental or physical capacity. In this job, that part of it is a patient safety issue as much as it’s anything.

It is also partly because you do eventually go home from your job, and it is at that point that you remember there is no food in the fridge and that you have no clean pants.

And that’s the part we don’t hear about enough when we hear about resilience. We don’t hear about self care: about how to keep ourselves alive and fed and sane and happy. In fact, we too often hear the opposite of that: that to do the things we need to do to take care of ourselves is selfish or lazy or uncommitted or in some way not being a team player. That is a perception that I want to challenge.

*

First, put on your own oxygen mask.

Maslow's Hierarchy of Needs

Maslow’s Hierarchy of Needs. (Wikimedia Commons)

There are lots of ways to look after yourself well, and I can only talk about what works for me and what hasn’t worked for me. This is the part that is non-negotiable. You need to eat. You need to drink. You need to sleep. You need to put on your own oxygen mask first. You need to remember to go to the toilet.

I am pretty sure that if anyone had said any of that to me in the week before I started FY1, I would have rolled my eyes too. I was worried I might accidentally kill someone, not that I might forget to pee. Trust me, you will forget to pee.

The need to eat and drink and sleep is about more than keeping yourself alive. It is about that, too, of course, but it’s also because everything seems so much worse when you haven’t.

This is a crap job, sometimes — for all sorts of reasons. A tip of the hat to @DrTonyGilbert on Twitter who aptly described this as “those nights where you’ve been punched and your shoes are full of ascites and you think, ‘I could’ve worked in a bank'”. The world will be much more manageable on the other side of a good meal and eight solid hours of sleep. I’m not saying those things will fix everything, but they will make most things look a lot less dire.

So:

  • FY1s cannot live on coffee and Mars bars alone.
  • Eat breakfast. You don’t know when you’ll next get a chance to eat.
  • But do eat lunch. There are really very few things that can’t wait until you’ve eaten a sandwich and had a drink.
  • If you can get off the ward for a break to eat lunch, do that. The days when you eat with a sandwich in one hand while writing a discharge letter with the other hand will come, but they should be the exception rather than the rule.
  • Drink. If your patients’ kidneys need fluid, so do yours. The correct response to, “Doctor, Mrs Jones has only passed 30 mls of urine in the last 3 hours,” should not be, “Well, that’s more than I have.” Get a reusable water bottle and use it.
  • Meal plan. If you can make food with leftovers, you can come home from an on call shift and have a home-cooked meal in the time it takes to transfer a plate from the fridge to the microwave. This is a wonderful thing. It also means that you’re less likely to collapse on your bed and fall asleep without eating.
  • The existence of supermarkets that will provide you with ready-prepared food and people who will bring delivery food to your house is evidence of the kingdom of heaven on Earth. It isn’t sensible to live off them, perhaps, but they have their uses.
  • Comfy shoes. Get some.
  • Take care of your physical health. Register with a GP. If you are a doctor with a chronic illness or a physical disability, take the time you need to take care of that. A friend of mine, Dr Beth (no, we are not the same person), wrote a blog post recently about this which was aimed particularly at doctors who have diabetes but which I think is worth reading for everyone.

Learn how to say no.

Take your days off. Take your annual leave. If your work emails are connected to your phone, learn how to unsync them.

There will always be situations where someone needs a shift to be covered on short notice. People get sick. People have family emergencies. Rota coordinators fail to take into account the fact that the staff grade’s contract was only for six months and ended last week. You will end up being the person who covers these shifts some of the time. You do not have to be the person who covers these shifts all of the time.

At some point, you will be asked to participate in rota monitoring, where you fill in a form for a couple of weeks with your rota hours compared with your actual hours. Your Trust is supposed to use this to ensure that your rota is legal, that your department is staffed appropriately, and that you are being paid correctly. If you are asked to work differently to your usual practice or you are asked to lie about your hours, say no to this too. (However, do not expect the person from the rota monitoring department to understand your job. I gave up fighting that battle on the day one of them tried to insist that I should be leaving the cardiac arrest bleep behind when I went to eat lunch.)

Likewise, there will always be work that needs to be done outside of normal work time. This will sometimes be valuable, and sometimes not. Like the online induction module that even as I type I am side-eyeing in my learnPro account, which will take time that I could instead have spent learning something about cardiology before I commence my six month cardiology rotation. The point is, there are exams, and ePortfolio, and quality improvement projects, and things to read and learn. This isn’t entirely a bad thing. It is part of what being a professional is. But develop some sort of system to deal with it so that it doesn’t end up taking over your whole life, because it absolutely will if you allow it to.

Don’t forget to look after your mental health, too.

There are lots and lots of doctors who have mental illness. It is not a shameful thing. It is not an unusual thing. Don’t ever let anyone tell you otherwise. You will not be the only doctor who takes medication to maintain your mental health, or sees a counsellor or a psychiatrist or goes to therapy. Do what you need to do to keep well, just the way you do for your physical health.

If the above does not apply to you, don’t presume it never could and don’t ever be ashamed to ask for help.

My sanity has been saved — so many times and in so many ways — by having brilliant friends.

If you are struggling, please talk to someone.

If you think you aren’t struggling, please talk to someone anyway.

Your most readily available resource is your colleagues. You may not have met your fellow new FY1s, yet, but you will become each others’ most reliable support. (The thing about getting off the ward for lunch if you can? It’s even better if you can get lunch together.) There is no one who understands this weird job like the people who are going through it with you. Use your seniors. Your educational supervisor is there to support you, not just to tick boxes on your ePortfolio. If they aren’t supportive or you think they’d be difficult to talk to, there are other consultants. If that seems too intimidating, your regs and SHOs did this not too long ago and I promise most of us are nice. The administrative staff, too. In my FY1 year, it was known that our postgraduate administrator’s office door was always open for a cup of tea and a biscuit and a bit of a cry and I think we all took her up on that at least once.

You won’t be the first person to have cried in a sluice; that’s what sluices are there for. If you cry in the sluice every day, that’s not okay and please talk to someone.

It is okay to not be okay, but people won’t know you need help unless you tell them.

Do the things that make you happy.

I suppose there is a professional bit to this, about finding your niche and finding your people and not worrying when you don’t like every single rotation you do as an FY1 or even FY2. I’m pretty sure that I grew up thinking it was all “being a doctor” and I know that I have friends and family who pretty much still think it’s all “being a doctor”, but one of the brilliant things about medicine is that it’s all so very different. I think that’s all true, and you’ll do that.

But what I really wanted to say was, remember that you’re still a person as well as a doctor.

I can’t tell you what it is that makes you happy.

The things that make me happy include but are not limited to:

  • Real books
  • Sunday dinner with people I love
  • Running around the parks of Glasgow or along the Clyde with music or a podcast and the sound of my feet on the tarmac
  • The work I do in “my” cathedral
  • Taking the extra five minutes in the morning to make real coffee
  • Cats who like to give me Eskimo kisses
  • A knotty bit of Beethoven and the adrenaline rush from singing it on stage
  • Netflix and Yarn

Your list will not look like that. You will have your own list. But remember to find the time and space to do the things that make you happy.

*

Listen, I am not good at all of this and some weeks I am not good at any of it.

You are about to do a thing that is real and hard and that you can never be properly prepared for, not really. For the first few months, you will be more tired than you have ever been in your life. You are going to do a job that is brilliant and terrible, and that will give you unsurpassable highs and will also completely break your heart. You owe it to yourself to look after yourself while you are doing it.

And for when absolutely everything else fails, I always keep emergency ice cream in the freezer. It’s a start.

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.

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.

And That Was Wednesday

I woke up this morning, got dressed, got on the bus to work, and sat down in what I am almost positive was urine.

That was 8.15am.

Thankfully, I work in a job where no one is going to think it’s all that inappropriate if I go about my day dressed in blue pyjamas. So en route I went into the theatre changing rooms and borrowed a pair of scrubs.

And then got in the lift to go up to my ward and stepped in the puddle of vomit that was on the floor of the lift.

I found a packet of the big alcohol wipes and wiped off my shoe.

And finally started my ward round and made a theatrical gesture and sent a patient’s full glass of Irn Bru flying.

There are days when you just have to call it good and try again tomorrow.

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Sitting in ill-advised places. I’m blaming it on the Bossa Nova.

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.

Have We All Survived Changeover?

*clears throat*

Doctors.

How are you all doing?

It’s just about a month now since changeover. I hope that’s time enough for you to have figured out where the toilets are, and how to get hold of psych on call in the middle of the night, and which of your seventeen computer passwords is the correct one to make a CT scan happen. It’s not quite enough time yet to have unlearned the learned response for the way to do things in your old hospital, though; your hospital, where you knew everyone’s name and you knew the protocol for prescribing vancomycin without asking a pharmacist, two nurses, and an FY1. It’s not quite enough time for your new hospital to feel quite like your hospital yet, or for you to not still feel just a little bit at sea.

FY1s, have you stopped needing to suppress giggles yet when you tell people that you’re a doctor? Are your seniors being reasonable and helpful? Are you getting to teaching? Are you remembering to eat and drink? Are you okay? If you are not okay, have you found someone to talk to about that?

I am sort of aware, FY1s, that it would be comforting if I let you believe that the confusion and weirdness of August changeover is inversely proportional to seniority and that it gets less weird and confusing after you’ve done it a couple of times, but, for many many reasons, that would be a lie.

In August, there are new medical registrars who have never had to be the med reg before. FY2s have just completed their first month of being the SHO, and that’s a big step up. All over the NHS, junior doctors have started new training programmes and been given new responsibilities and some are doing it in new Trusts or Deaneries that are entirely foreign to them and where their support networks are not. August is scary as hell. This is why we all walk around the whole month looking like Sputnik just landed on our heads. And for the record, I’ve been working in my Trust for four years and I’ve been working mostly at an SHO-equivalent level for those same four years, and August is still scary as hell. I’m a quarter of the way through this rotation, and I still have not learned everyone’s names or the intricacies of my very specialty-specific and very new-to-me computer system or how a kidney, you know, works.

FY1s, let your comfort if you need it be that every year from now until the end of time we are all in this particular period of weirdness together.

So, therefore, how are the rest of you doing? Are your seniors being reasonable and supportive? Have you found your educational supervisor yet? Have you worked out who exactly it is that you’re on call for? Are you even as we speak lost in the rabbit warren of interventional radiology in a hospital whose layout you still do not quite understand and need one of us to come let you out? (Is that one just me?) Do you need a hug?

Welcome. Pull up a patch of floor. We’ve got cookies and coffee and mutual terror and spare copies of Cheese and Onion.

A Requiem for PACES, and Alleluia

In my third year of medical school, I volunteered to help with the running of the PACES exam at one of the big Glasgow teaching hospitals. It was an opportunity to spend all day dinging a bell, to eat an heroic quantity of Quality Street, and to, between circuits, be shown some clinical findings more complex than those we were usually given in our medical school OSCEs.

In June, I sat PACES.

You may recall that the last time I wrote, I had put myself into some kind of fugue state refreshing the results website.

I passed.

And, you know, saying that, it still doesn’t feel quite real, even two weeks later.

I passed.

And — well, let me explain this, a little bit.

In the UK, one of the criterion for progressing in a medical career is to complete the necessary postgraduate qualifications to become a member of the relevant specialist “College”. There is a Royal College of Surgeons, and a Royal College of Emergency Medicine, and a Royal College of General Practitioners, and so on. The membership qualifications for the Royal College of Physicians come in three parts, of which PACES is the final part. In all, they have taken three years, untold hours, and a significant amount of actual money spent on exam fees, revision materials, and all the caffeine in Glasgow. I also have less hair than when I started.

The first two parts are multiple choice. The first part is six hours long (with a break in the middle), and I have previously described it as being not unlike spending six hours having one’s brains kicked in by a rugby team. I took it four times. The last time was in the Newcastle United football stadium, one of the stranger places I’ve ever been in the name of my medical education. The second part is nine hours long, and I sat that only once but in a room that contained no air during the hottest two days there have ever been in the west of Scotland. After 27 hours worth of multiple choice exam, I had lost the will to live but had grown very comfortable with colouring in boxes in 2B pencil.

The third part is not like that.

I think the thing that will perhaps best describe PACES is for me to say that even while in the middle of actually taking it, I was aware that I was muttering frantic karmic apologies to every single doctor at whom I had dinged that bell back when I was a third year medical student.

“You will be fine,” my consultants had been saying to me in the week leading up to it. “You’re a good doctor.” This was kind of them, but I kept reminding them that being competent at my job and appearing competent in this exam were two very different kinds of competent.

You wake up too early in the morning. You try to eat breakfast. You travel to a hospital that is not your own, and may not be exactly in the back of beyond but certainly feels like it. I went off to the conference suite of a hotel that is attached to the national specialist cardiology centre — a place that I have spent a lot of time on the phone to, but, despite nine years of living in Scotland, had never seen for myself. “This is Dalmuir, where this train will terminate,” said the Scotrail tannoy, which felt ominous. You sit in a room where time stops, making nervous small talk with the other four people who are taking the exam with you, filling in your name and candidate number on sixteen separate pieces of paper and flicking frantically through Cases for PACES as you try to remember the indications for liver transplant.

The next two hours pass at warp speed.

The basic structure is the same for everyone: assessments of communication skills and ethics, examinations in the four major body systems, and a final station two-case grab-bag of can-be-absolutely-anything. The patients are sometimes actors, but are mostly real patients who have been recruited in for the day. In my version of the exam, I was asked to take a history from a woman who I promptly blanked on half of her presenting complaint, I was asked to counsel a young man who was angry with my boss, I struggled to find anything at all wrong with the patient whose abdomen I was examining, and trying to listen for heart sounds I briefly wondered if my stethoscope had turned itself off. In the middle of telling me about his syncope, one patient, who had also mentioned that he was on a blood-thinning medication, said that he had hit his head on the ground when he had fainted. “I haven’t really,” he said when I started trying to look for a head injury. “I’m allowed to tell you that I haven’t really.” The whole time, there were two examiners, watching, scribbling things on those pieces of paper that I had painstakingly filled in back in the room-where-time-stopped.

As each of my examinations was completed, I turned to them, tried for a winning smile, and began, “Mr Jones is a fifty seven year old gentleman. He is comfortable at rest…”

In this exam, stage fright is a real thing.

A week earlier, in Edinburgh, I had sat down after making a speech to the great and the good of the Scottish Episcopal Church and said that if failing my exam was the price I had to pay for being there, it would have been worth it. (I could, after all, have sat it again in the autumn, which would have been a pain but hardly the end of the world.) Now, on the other side of it, it’s not that I’d necessarily recommend spending three days at General Synod as a revision strategy for PACES, but the experience does throw a person’s whole idea of what counts as an intimidating room into rather harsh perspective.

They go on to ask questions. I said things like, “I would want to get an abdominal ultrasound,” and, “I would expect the left hemidiaphragm to be raised on chest x-ray,” and, “Oh, hell, I’m sorry, I totally forgot to ask him about that,” and, at one point, “Well, on a SPECT scan you’d normally see, uh — ” and, screwing my nose up as I tried and failed to articulate it, drew a picture of what you’d normally see on a SPECT scan with my fingers in the air.

And then that bloody bell dings and you get the hell out of there while shouting through the door, “I’d do an ESR and a CRP, too!”

Forget having your brains kicked in by a rugby team.

“I think I’ve been smacked in the face with a baseball bat,” I said, collapsing in the car.

It wouldn’t have been the end of the world, of course, to take it again, but am I ever glad that I haven’t got to.

Is That Even A Word?

You know, there are the days when I ask for specialist advice, and I nod and I ask at least vaguely intelligent follow ups and I write down all the investigations that they want me to arrange and I say thank you and I hang up the phone.

There are days when that comes with a side of nerding that’s based in never having seen That Really Cool Thing before in real life.

And then there are days when I ask for specialist advice and they know things that are so weird that I nod and I ask follow ups about spelling and I write down all the investigations that they want me to arrange and I say thank you and then the conversation is over.

And then I say, “Soooooo, just for my own education. WTF?”