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.

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.

O&G: a rotation of fingering vaginas and covering my ass.

So, I am coming to the end of my rotation on O&G. I have exactly 5 shifts left, and that is 5 shifts too many. O&G is essentially A&E but more stressful, and with exclusively hysterical women, babies coming out of teeny tiny holes, and various permutations of bleeding and diseased vaginas. You aren’t really taught much of the theory at medical school, so starting as an SHO on Gynae basically entails feeling like a moron 100% of the time. You are put in a position of authority, asked to examine and assess patients for conditions, most of which you have never even heard of. Dr Google has legitimately been my best friend. It is ludicrous. There is a baseline expectation of competency.  You are a SENIOR house officer now; you must know shit. Clearly somewhere in the small print of my contract it told me how to pull knowledge about complex gynaecological presentations out of my ass but I must have missed it.

The pressure is immense. There is a culture of litigation, and as such I would say that 70% of all decisions made in the specialty are about covering the clinician’s behind. Everything has to happen immediately. With no prior training you are expected to juggle women in dangerous pre-term labour, women hosing litres of blood from their uteruses (uteri?), women potentially unstable due to ectopic pregnancies, to distinguish between idiotic and urgent referrals, and do all of this calmly and competently, all the while smiling sweetly at the midwife who was called you to perform an urgent ECG that has been waiting all day because for some reason no one thought it necessary to train midwives how to use the machine, or to print off a discharge summary STAT because the patient absolutely has to go home immediately and midwives don’t have access to the discharge system, or to come and take blood cultures off of someone who has spiked a temperature because instead of re-cannulating them the nurse decided to switch their IV drugs to oral because, they’re the same thing, right?

This leads me to a side rant about the ridiculous lack of competency assessment we have as doctors. I have lost track of the number of times I have been asked to administer a drug because a nurse hasn’t been trained how to, or perform a procedure that a midwife isn’t competent to do, that I myself have had no training in. As doctors, we are expected to be able to just get on and do things. There is very little sympathy for the line “but I don’t know how”. And this is insane. If anyone asked me to produce evidence of competency in giving calcium gluconate, or administering methotrexate, or misoprostol, I would be screwed. Yet I do it frequently. 

O&G though, is on a whole different level. There is a guideline for EVERYTHING, but it is never exactly followed. You can assess a patient, make a correct diagnosis, initiate management according to the guideline, and be entirely decimated by a Consultant who has decided, on a whim, that it is not appropriate to give this particular pre-term labourer steroids. And that will be your fault. Acceptance of incompetence, and acceptance of culpability even when it is not your fault are necessary attributes for a successful rotation.Oh, and skin as thick as a rhinoceros.

So, I have compiled a list of possibly helpful, hopefully amusing tips for anyone who may be about to enter an O&G rotation. 

Top tips for anyone doing O&G as an SHO:

  1. ALWAYS put in the biggest possible cannula – when these women bleed, they lose their entire circulating volume in minutes. Plus, its so satisfying doing locum shifts in ED, waltzing into resus and placing a grey cannula without batting an eyelid. SKILLS.
  2. Regardless how young, virginal, or skanky a woman is, she is pregnant until the labs have excluded it.
  3. Following on from this, it is an ectopic pregnancy until proven otherwise.
  4. You will be referred at least one woman who is legitimately on her period. A&E will inevitably want you to admit her.
  5. Speculums are things we are ALL taught to do in medical school. The line from ED/UCC/Surgical/Medical Docs of “you’ll only repeat it anyway” is pure laziness, and their impression will be at least as good as yours. Whether you fight this one is personal choice. Frankly, it is irritating but not worth your breath.
  6. “Asian Pain Syndrome” is multiplied exponentially in pregnancy. 
  7. Headaches in pregnant people = NIGHTMARE. Even if it is definitely a migraine, you will go home convinced they have a thrombus and are going to die.
  8. Specialty tennis between surgeons and gynae for the women with abdominal pain helps no one. Gynae is seen as the easier option, which can be frustrating, but remember that there is a woman, possibly in agony, probably scared out of her mind, sat somewhere waiting for answers. Accept the patient. Get an USS. Yell at the surgeons later. 
  9. Secondarily to the above: Right Iliac Fossa pain in someone who still has their appendix is appendicitis until a surgeon has written that it is not. Regardless of how snarky they are on the phone. No one likes appendicitis because it is a difficult clinical rule-out, but that does not make it an ovarian cyst. Sort your shit out.
  10. “Gynae pathology” is NOT a diagnosis. I have had a lot of fun with this one. If they cannot give you a legitimate differential, then you don’t see the patient.
  11. Run absolutely EVERY decision by someone senior. Even prescribing antibiotics. Even following a guideline. They will look at you like a moron, but you get used to that pretty fast. There is no room for autonomous decisions in O&G, unless you want to be on the receiving end of a court case. Better to look like a moron than be proven one in court. 
  12. Remember this rotation is temporary. This is not your life. Soon you can be back doing something you enjoy, unless, of course, you are an O&G trainee, in which case, I salute you, and am getting you a psych evaluation.