I’m not a girl, not yet a woman.

Through our years of medical training we have assessments that are designed to give us feedback, both on our clinical skills and on our personal traits and interactions within the department. It is a testament to how poorly they are generally completed that I am in my 5th year of training, and in the last 2 weeks have received my first ever genuinely constructive, slightly negative, feedback.

And it wasn’t enjoyable.

There is a tendency in medicine towards feeling that negative feedback is a reflection on your character. Nobody likes to receive criticism, however constructive, but as a medic you spend the vast majority of your life attempting to be a good doctor, to manage patients in an appropriate and empathetic fashion, and you are continually striving to be the clinician you want to be. We go weeks and months, if not years, without useful direction or advice about our clinical skills, and speaking for myself, are fooled into thinking that no news is good news. Then along comes an appropriate feedback session, and you learn that you are not as good as you think you are. For someone with chronic imposter syndrome this means you feel like the shittest doctor in the world.

My current stage of training is a funny one, I am at the end of my SHO years and from August, if I stayed in the UK, I would be embarking on registrar training. I feel competent as an SHO and totally out of my depth as a registrar. In the words of Britney – “I’m not a girl, not yet a woman.”

My current department gives ST3s (my year of training) the opportunity to step up as registrars. However, they quite unhelpfully don’t distinguish on the rota or in practice between an ST3 and an ST6 – a doctor with 3 more years of emergency medicine experience. As a result, in an already very stressful environment, you feel like you are consistently underperforming and being held to an unacceptable standard.

I personally do not feel that it is appropriate for me as a doctor with a total of 20 months of ED specific training to be leading a resuscitation room alone in a major teaching hospital. I don’t feel that I should be managing majors alone and making decisions about all the patients seen by the more junior doctors. I definitely shouldn’t be doing this without appropriate induction or training. This is where it feels different to other specialties. I have friends in medical and surgical specialties who become registrars at this level. However, they have had much greater exposure to their chosen profession (at least 2 solid years prior to becoming a registrar), plus, I hope they will forgive me for saying, their knowledge base and patient variety is not as vast. As emergency medics we have to know a bit about everything, and be confident risk stratifying everything from chest pain through to ectopics. This takes time, and patient numbers, to achieve with any degree of certainty or safety.

I have really struggled with this year, and that was unexpected. I came from a hospital that had a bad reputation and no senior support, into an emergency department with some of the best consultants in the country, with 24hour consultant cover, and I expected more.

My first 6 months was in paediatrics and I had the best time. The teaching was unparalleled. The department was super supportive, and I never felt outside of my comfort zone without knowing exactly who to call about it. Admittedly, I had no paediatric experience, so they weren’t trying to get me to act more senior than I felt.

Going from that state to leading a busy ED area is stressful for anyone. And then when you receive feedback that you are not doing that effectively, it makes you defensive, and you fail to see the usefulness or accuracy in the feedback you are given. No I am not performing at ST6 level, and nor should I, or anyone else, be expecting me to. However, there are things that I can strive towards improving, in order to perform better and eventually become a competent registrar.

There is a reticence to acknowledge when we are out of our depth. Not the crushingly scary, sick patient in the middle of the night, out of our depth – everyone recognises that, if they don’t they have no business being in medicine. I am talking about the consistent, low grade effects of repeatedly operating just that little bit out of your comfort zone, and feeling unable to voice it because everyone else seems to be coping fine. Not having anyone check on you and make sure you are ok. Being the only senior in a department for others to ask questions to because the consultant is in resus. Just being expected to cope.

It takes a lot to voice unease when everyone around you is giving the impression of you being able to cope. And you can cope. But really, coping isn’t what we should be aiming for. Confidence is the aim. And my experiences this year have totally stripped me of mine. I have been made to step up into a role that I was eager to take, without any significant training, without acknowledgement that this was new and difficult, without someone touching base to see how I was going. And I coped. And now I feel less confident in my medical abilities than I have in a long time.

I am grateful to be taking some time out in August. The thought of continuing to ST4 training is enough to make me hand in my training number. I am approaching this move to Melbourne as an opportunity to see more patients, hone my diagnostic skills, and come back a better, stronger doctor and person. Or alternatively I will run away to the sun forever and never come back…

This week I have been mostly reading…

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One of the unexpected bonuses of my article being run by The Guardian, was that a psychologist got in touch with me asking if I would review her new book, which will be published later this month. Caroline Elton has worked with doctors for many years, providing counselling and occupational career support, and she is writing about the psychological effects that medicine has on those who work in it.

I read her book, “Also Human” on my way to and from work last week, and it was a surreal experience. So many themes in my life, and so many of the ways that I approach and justify situations, that I had assumed were unique to me, were on the page in front of me. The themes of the book are explored through her interactions with various doctors over the years, and her unique insight as an outsider commenting on the peculiarities of medical training really made me take stock. Several of her observations resonated with me – from the assumption in medical school that you will make a good doctor purely because you have an aptitude for science and perform well on standardised tests, to the lack of psychological preparation for medical students as they are flung into their first foundation jobs, and have to cope emotionally, as well as practically, with people’s lives depending on their decisions.

She explores the issue of empathy fatigue, which is something I am struggling with at the moment, and the comment by one of her patients that “Medicine is a bit like a cult”, struck a chord deep within me. Often, staying in medicine is easier than leaving, and sometimes that is all that keeps us going.

The lunacy of all new doctors starting on the same day in August, and allowing senior doctors to take leave that week; the lack of psychological evaluation for prospective doctors, and the unwillingness to accept that some medical students just may not have what it takes to complete their training – whether academically or emotionally. The inability to accept that doctors are human, fallible, and capable of falling sick, and above all, the reticence to call it a day, and change profession. Even when it is psychologically damaging, and we know beyond doubt that medicine is not for us, still we persist.

I would encourage anyone considering medicine as a career, and anyone within medicine feeling unfulfilled, or considering a change, to read this book. It contains within it things that we all know, but fail to consider, and it has truly changed the way I think about medical training.

Blame Culture

Today we woke up to the news that the GMC has won its appeal to the High Court, and has struck off Dr Bawa-Garba.

Imagine, if you can, returning to your job after a prolonged leave of absence (maternity leave in this case), beginning your role afresh in a new environment with which you are not familiar, and being told that your colleague couldn’t be in today, and could you please do their work too? Additionally you find out that your boss is uncontactable, the other members of your team all started 2 weeks ago and are just finding their feet, and the IT systems are down. Someone else, in a different team, makes a mistake for which you are punished, and at the end of a gruelling workday you make an entirely avoidable mistake, which leads to catastrophic consequences. Are you no longer qualified to do your job? Do you lack the qualities and experience necessary to carry out your day to day duties? Or are these exceptional circumstances, and an entirely understandable lapse in judgement?

This is what happened to Dr Bawa-Garba. She made a mistake, on the back of incredibly hard working conditions over the course of a 13 hour shift, and a 6 year old boy died. Initial investigations into the case found that her mistake may not have influenced the end result of the resuscitation effort – the outcome may well have been the same. As so often happens in medicine, the SUI team found multiple contributory factors leading to this horrific outcome, and ruled that no specific person was at fault. However, Dr Bawa-Garba was convicted of manslaughter, suspended from the GMC register for a year, and has now been completely struck off.

We hold clinicians to a higher standard than most. It is understandable – our mistakes carry higher stakes. There are horrendous consequences to our failings. However, can we blame individual doctors for an outcome that has occurred in a working environment that no sane person would find acceptable?

We, as doctors, often work shifts where you go 13 hours without eating, drinking, weeing, or sitting down. I have often joked, whilst on call, that I am treating a patient for hypoglycaemia or acute kidney injury, but that my blood tests may well be worse than theirs. We prioritise the need of our patients consistently above our own basic, human needs. We work in conditions that you would be sued for trying to impose on any other profession. And the worst thing is, we impose those conditions on ourselves. We consistently state that our working arrangements are unsafe, no one in their right mind would think that staffing a 500 bed hospital overnight with a medical team of 3 people is a good idea. Wards of 30 beds go from a team of 3-5 doctors during the day, to sharing the 3 on call doctors with the other 470 patients in the hospital. Even on days when the rota is fully staffed and all the systems are working, it is a disaster waiting to happen. Medical ward cover consists of running from one fire to the next, never feeling like you are winning. How are you supposed to prioritise your need to eat when a succession of patients are, literally, trying to die on you?

But hungry, exhausted, overstretched doctors make mistakes. It should not be news that we aren’t at our best when our last meal was 12 hours ago. I remember clearly finishing one day on call on the maternity ward, and passing out on the walk to my car. On reflection, I hadn’t had a meal since dinner the previous night. I was concerned about my ability to drive, and called a cab home. 45 minutes previously I had been responsible for resuscitating a patient, solo.

During my time as an intensive care doctor, I frequently covered a ward of 14 critically unwell patients, with no Consultant cover on site. I started the job, on a night shift, with no induction to the computer-based notes system, no idea how to review medications or change doses. No understanding of how the filtration machines or ventilators worked. The fact that both I, and the patients, survived those on calls is testament to the incredible standard of nursing care. The nurses on that unit saved me more times than I can recall. But it should not be the responsibility of the nurse to educate the doctor. By that logic, there is no point in me being there. I reflect on that unit, and the fact that nobody died as a direct result of my lack of training or experience is frankly baffling.

The GMC has gone on nothing short of a witch-hunt. Bowing to tragically bereaved parents, making an example of someone who did nothing more wrong than any one of us has done on countless occasions, but got away with due to circumstance. The CEO of the GMC released a statement following the outcome:  “We are totally committed to engendering a speak-up culture”.

How do you expect to foster a culture of speaking out, when you victimise people attempting to reflect on, and learn from, their mistakes? Doctors are human. We will all make errors in our careers. I have personally made management decisions that have contributed to a patient’s death. We are a cohort of professionals that go into medicine in order to improve people’s health and lives. Nobody can make us feel worse about our failings than we already do. Nobody can berate us more than we berate ourselves. We worry about doctors’ mental health. We worry about a culture where no one wants to accept responsibility or blame. And then we have a doctor, with an exemplary record, who reflected on a difficult case, gave evidence to an investigation panel, and then had her reflective evidence used to bring a court case against her.

We are all Dr Bawa-Garba. I don’t need to know the case specifics to know that similar situations are happening across the NHS on a startling scale. That the people responsible for safe staffing and rostering are not the people living with the effects of shortages on the frontline. That the people who have made a scapegoat out of this doctor get to go home at 5pm each day, and never have to hold a person’s life in their hands while trying to remember the last time they had something to eat.

It’s okay not to be okay.

I am British to a fault.

I have been ruminating on aspects of our character that we may be unaware of. My other half is an Aussie, and when we first got together we had numerous arguments based around the different connotations of the word “fine”. Myself, a Brit, would tell her that something was fine, and expect her to infer that it was anything but. She, in typical Aussie fashion, took everything at face value and then was unable to understand why I was miffed (another classic British understatement).

When she moved over here she commented on our typical British greetings “Hiya, you alright?” and how there was no acceptable response to that other than “Yeah fine thanks, you?” We are not asking after the other person’s well-being, and if someone were to deviate from the script it would be awkward to say the least.

These discrepancies can be amusing, but our idiosyncrasies sometimes inhibit our ability to let other people in. This can have devastating consequences, particularly in Medicine. In addition to the British avoidance of talking about feelings, people in Medicine are also reticent to admit what they perceive as weakness, and emotional responses and feelings often get bundled away and taken home, not aired and explored in a positive atmosphere. Mental Health is still not addressed as it should be, and we continue to perceive the demonstration of emotion as a sign of fragility.

When you work it every day, it is easy to forget how emotionally taxing our job is. We see people at their worst, both physically and emotionally, and the range of conditions we have to deal with on a daily basis can often be a complete mind-fuck. You go from treating 4-day-old babies with sepsis, to trauma calling a teenager who tried to commit suicide, to dealing with the aftermath of a neglect case. There is often no time to think about it, no time to dissect your feelings about a case, and definitely no time to deal with the emotions that either of those actions would inevitably stir. You have to develop a way of coping that allows you to move on to the next patient, the next parent, and the next disaster. It is a fine balance. We traditionally shut off the parts of ourselves that struggle to process the things that we see, and we notice ourselves become less affected by our daily exposures. But this is not healthy, and it only takes a small thing to tip the balance.

Between 10-20% of doctors become clinically depressed at some point in their careers, and there is a higher rate of suicide than in the general population; particularly in the acute specialties, where there is a “stiff upper lip” attitude and a tendency to push forward in the face of signs that we are perhaps not as okay as we seem.

This has repercussions not just for us as physicians, but also for the way that we treat our patients. Up to 50% of Emergency Medicine trainees resign prior to completion of their training. As a specialty we are seeing the highest rates of burnout in the history of the healthcare system. EDs are becoming like warzones, and our already fragile mental health is about to snap. The higher rates of burnout correlate with self-reported depression rates of up to 40%, with associated lack of empathy and altruism, and increased rates of errors. Over the last few months, I have actively felt myself becoming more cynical, and less motivated to help people. A parent books in with their sick child and I am annoyed that they are there. The very reason that I trained to do this job has become a source of irritation.

This façade spills over into our home lives too. I am so used to shutting off my feelings about things that happen at work, that I attempt to do the same with things that happen at home. Over recent months I have been endeavouring to insulate myself from my feelings about both issues at home and difficult cases at work. And my mind simply doesn’t have the capacity.

I have recently considered going to a counsellor to help me unpack all the emotions I carry around with me, both from my personal and professional life. It has taken an almost daily struggle to keep those emotions under the surface to illustrate to me how important it is to deal with your responses to situations instead of packing them away, and using the traditional dark humour to cover them up. I have been less than keen to address these issues, due to both an inbuilt, British avoidance of talking about “feelings”, coupled with a desire not to seem nauseatingly American by attending therapy; but also due to the inescapable concern that it makes me a weaker person. That other people are managing, and by my admission I am not. That this somehow makes me a lesser doctor, a lesser person.

Acknowledging emotions is not a sign of weakness. Unpacking your response to a patient, or a situation, or your relationship, is the healthy way to deal with it and move forward. We need to stop prioritising relentless, emotionless work ethic above the ability to be normal, functional, people. We need to allow ourselves to be human.

Some of this needs to stem from a revision of NHS culture, for the establishment to recognise that lack of debrief, lack of NHS counselling, lack of self-care for our emotional selves is damaging to our productivity as a workforce, but most of it can stem from us, as individuals. If we are affected by something, take the time to feel it. Discuss it, dissect it, and get different perspectives on situations. Maybe not at the time, but we should prioritise debrief, prioritise acknowledgement of an emotional response. Allow ourselves to care.

We need to recognise, as individuals, that we are not built to carry all our stresses around with us. That showing compassion towards our patients begins with showing compassion towards ourselves, that when you are saturated by stress and emotional baggage you lack the capacity to truly help the patients that put their trust in you. We need to understand that overexertion and dependence on 3 coffees to get through the day is something to be avoided, not romanticised. That working hard doesn’t have to mean running yourself into the ground, and that taking care of our mental health is paramount to being empathetic, successful physicians.

Paediatric Pearls

Things I have learned so far in kiddies ED:

  1. Bubbles have magical qualities and fix tachycardias ALMOST every time.
  2. There is no such thing as a “quick look” at a child in triage.
  3. Play specialists = HEROES.
  4. Early ametop application in triage is one of life’s greatest gifts.
  5. ALWAYS take a second cap gas because the machine demands one as a sacrifice.
  6. Sometimes kids just get rashes, and we don’t know why.
  7. All children in London are constipated.
  8. Parents never give paracetamol, for fear of us not believing that their child was in pain/hot. We berate them for it, and then don’t believe them that their child was hot at home if they aren’t hot here.
  9. I can now identify which antibiotics someone has been given based on what colour it is, what it tastes like, and what bottle it comes in.
  10. Suctioning bronchy babies and watching them instantly perk up before your eyes is one of life’s great pleasures.
  11. Sometimes a sympathetic face and time to listen is all it takes. Parents’ scope to worry about their children knows no bounds, and reassurance costs nothing. Be patient.
  12. A good number of midwives scales are broken.
  13. If the umbilical cord looks infected, it usually isn’t. When it is, it is a BIG deal.
  14. Getting a line into a 1 day old baby gives you the best high.
  15. Paramedics and GP surgeries NEVER have paediatric sats probes and this frustration will be felt DAILY.
  16. When you get cocky about your abilities you will inevitably do something insanely stupid like glue a child’s eye shut.
  17. When you finally know the doses for paracetamol and ibuprofen without looking them up you feel like a GOD.
  18. SOME babies ARE cute, and you have to remember to give them back to their parents when you are finished examining them.

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With apologies to Taylor Swift, I present to you the following.

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Nice to meet you, what brings you here?
I could ask you almost anything,
Rashes, fevers, diarrhoea?
Saw you here and I thought
‘Oh my god, hear that chest,
He should be the next assessed’
The triage nurse is looking stressed.

Bring you in, sit you there,
Talk to Mum about what’s going on.
Assess your throat, look in your ears
And I know you are quite wheezy.
So hey, let’s give some puffs,
I’m hoping ten will be enough,
Grab your spacer, come with me,
I can make your breathing better for a little while.

Cause you’re young and you’re breathless,
You come to A&E.
Run out of inhalers,
No time to see a GP.
Got a long list of visits,
They all say the same.
I’ll give you burst and steroids
You’ll be glad you came.

Find your tribe.

Choosing a specialty is a funny old thing.

We spend a lot of time in medical school, and post graduation, trying to decide which area of Medicine we are suited to. It is an important decision, as it decides your career path and length of training, and although there is some potential for movement, it often entails further years in training if you get halfway down one path and decide you would rather be on another.

Some people are fortunate enough to be certain in their career aspirations, and know which path they want to pursue. I was never like that. I have found myself ambivalent about the specifics of Medicine. Nothing particularly excites or drives me more than anything else. I am generally doing the job because it seems a waste of a medical school education to do anything else.

It is bizarre then, that I have chosen Emergency Medicine. Ostensibly, this is the most stressful, involved, high pressured area of Medicine. You have to know lots about lots of things and for someone unexcited by various aspects of medicine, seeing patient after patient with a cough or a toe injury or a rash is hardly enthusing. Intersperse that with the seriously unwell patients who keep attempting to die on you, and on paper it sounds even less like something I would enjoy doing.

But the people. My God, the people. I remember walking into my first ED job, seeing the nurse in charge rip the shit out of the on call doctor with a crass and frankly too easy joke, and thinking “I have found my tribe.”

I firmly believe that it is not the type of job that you need to base your career decision on, but the type of people you will have to work with. And there is no better bunch than the ED team. Nowhere else in the hospital do nurses and doctors work so closely together. The relationship can be beautiful. You have the opportunity to understand each other, and ED teams become like family (a replacement for the family you have at home that you never see due to an unforgiving rota).

I have just finished a shift where it would be understandable if I was a broken person going home. Presentations were relentless, the board was out of control, not enough doctors, too few nurses, several angry patients – the usual ED shift. But instead, it was one of the better days I’ve had in a while. My personal life is a little rubbish at the moment and it is nice to be able to come into work, and have a good laugh with a genuinely great group of people. You don’t go into Emergency Medicine unless you are hardworking, sarcastic, fun, and have a thick skin.

I am in my 3rd year of ED training now, and during those years I have had to spend several months out of the department getting experience in other areas of medicine. And each time I have come back to ED I have felt the same sense of relief. Mainly the relief of no more ward rounds, no more clinics, and no more dealing with patients for longer than 4 hours (I have a ridiculously short attention span)! But also happiness that however rubbish the shift, however overworked, underpaid, generally under appreciated we all are, there will be piss-taking and merriment, and, if I have had time the night before, homemade cakes and biscuits. You can’t ask for more than that.