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Wilkommen to my blog - my name is Karin Purshouse, and I'm a doctor in the UK. If you're looking for ramblings on life as a junior doctor, my attempts to dual-moonlight as a scientist and balancing all that madness with a life, you've come to the right place. I'm currently a doctor/research trainee in oncology after spending a year doing research in the USA. All original content is licensed under a Creative Commons Attribution 4.0 International License.

Wednesday, 19 April 2017

Why is Generalism not a more Valued Specialty?

When I describe what I do, even to other doctors, they'd probably say it was quite niche.  It's going to become even more niche as time goes on, as research takes me down a particular cancer subtype, even down a particular genetic route.  It's quite possible that when I'm a Consultant, many moons from now, I might only specialise in one or two cancer subtypes, and in the research world, my area of expertise might be reduced down to a very specific area of molecular biology.

One might call this 'Extreme Funnelling' in the sense that when I did my medical finals 5 years ago, I was still being examined and assessed as a doctor who could work in obstetrics, paediatrics, psychiatry or surgery.  During my first two years as a doctor I worked, amongst other things, in surgery and ITU.  Since starting core medical training, I still rotate through 'General Medical specialties', and, particularly when I'm on call, cross cover for a bunch of medical specialties.  But, all being well, after my next year of clinical work, I'll be predominantly working with cancer and nothing else as my training continues.  This is true of most of my friends who have ended up in the research world - they started off as generalists, and now subspecialise in things as diverse as veterinary neurology to paediatric epidemiology.

In complete contrast to me, my partner-in-crime is all about generalism and what I would consider the action-packed coal face of medicine.  He works in intensive, emergency generalism - specialising, if you like, in being a generalist - much like GPs or geriatricians.  And yet, he quite reasonably debates with me, why is it that most people who do research or are quoted as being 'world leading' or whatever, go on to subspecialise in something extremely narrow?  And why do we value that so highly over the actually far greater skill, and perhaps more promising challenge, involved with receiving someone in a heap and dissecting apart what's going on, making a diagnosis (or diagnoses) and initiating treatment?

I have to admit that this is a very good question.  Why do we end up in super-specialised areas of medicine?  For the wider world, obviously it's much more appealing to have one person who can deal with all the cases of rhabdomyosarcoma, a disease diagnosed in 100 children across the UK each year, who therefore knows how to manage such a rare and aggressive condition, versus a generalist who might see one or two across the span of their career.  But for the individual doctor, surely it becomes quite routine when that's all you see.  It's like calling a cardiologist to ask them to see your patient because they've had a heart attack - when that's all you ever see, heart attacks become pretty routine and samey.

'When I am old I will wear purple...' - graduating
as Members of the RCP with my two best pals from 
medical school. 
People say they specialise because they like the focus of dissecting apart a a particular problem or area, and exploring it in infinite detail, but a generalist might argue that this is exactly what they are doing, just from a broader start-point - and yet we seem to value it less.  If I had a pound for every time someone has asked me if I want to specialise or become 'just' a GP... as if being a GP is easy! Amongst medics we would say that being an average GP, much like anything else in life, is probably a manageable goal, but being a 'good' GP seems incredibly hard.  Balancing good clinical practice with pragmatism is not easy.  Teasing apart that benign-sounding chest pain from a pulmonary embolism or that slight foot drop with a brain tumour - or the patient who is dying at home and should be palliated in their own surroundings, versus the patient with a terminal illness who needs to be admitted to hospital to treat just their reversible chest infection - are just some of the challenges that spring to mind.  And those are just the clinical challenges, let alone the administrative ones!

I think the other issue with generalism is the associated clinical lifestyle.  Generalists - such as GPs, Emergency Doctors and Acute Medics - are increasingly dumped upon by everyone else.  That means working more evenings, more weekends, more night shifts, more scape-goating by the media, more pressure, more rota gaps, more late finishes.  I hear it gets better, but it's hard to believe that after years of being a junior doctor rotating through general specialties on intense rotas.  As such, people make other choices.

So why am I choosing a life of specialism?  Perhaps it's because I want to know 'everything' and the only way to get close to that is by exploring something in a lot of detail.  I like the idea of knowing the limits of my knowledge about something and knowing how I can tweak away at those limits.  I also want to influence the treatments and management strategies we use and make them better.  The only way to do that is to specialise. But it has made me think that a healthy dollop of generalism is fundamental to my future practice - something I reflected on a little last week as I attended my Royal College of Physicians graduation (membership of which required a mountain of further postgraduate exams on the *entire*, and thus very general, scope of clinical medicine!).

When discussing this, my partner and I also couldn't escape the importance of early formative experiences in making these sorts of career choices.  In many ways, the technical work and fast pace of intensive care, surgery or emergency medicine should completely appeal to me, and yet here I am, training as a cancer specialist.  I'm sure that's in no small part due to the cumulative effect of both positive and negative experiences both in and out of the hospital - one supportive registrar here, a dismissive consultant there - these things can make all of the difference.  Perhaps something for us all to remember as  we try to encourage those junior to us to consider following in our footsteps.

Wednesday, 29 March 2017

Imposter Syndrome

Well, exciting times folks.  We found something cool!  Well, I should say Gary the Cell started off something cool, which some clever colleagues of mine have transported into a very exciting discovery.  In short, the genetic mutation that is considered one of the earliest steps in the development of brain cancer might actually render brain tumours targetable by drugs that are currently used in patients with, for example, ovarian cancer.  This might transform the way we treat brain cancers.  Isn't that awesome?!

That's the good version of my 'clinician attempts to do science' story.  Clinician scientists have a unique role because we connect the patient world with that of lab bench land - this is often called 'Translational Science' because the aim is to 'translate' research findings from the lab into something of relevance and importance to patients. 

But man, it is not always easy.  When I was doing research in the USA, I was largely protected from the quandary of splitting yourself down the middle between two jobs because my type of visa meant I wasn't allowed to work clinically.  This year, I am predominantly doing oncology research; we're trying to understand what happens when cancers outgrow their blood supply.  This means that increasingly cancers adapt to survive without oxygen.  These 'low oxygen' parts of tumours are particularly resistant to treatment.  We're trying to capitalise on this cancer-unique situation so that we can develop new ways of reaching these untreatable parts of cancer.  But alongside that, I do a colorectal cancer clinic once a week under the supervision of an amazing couple of Professors - seeing patients on your own in such a specialised setting is ultimately what I hope to do for the rest of my career, but it's a huge responsibility that I take very seriously as well as enjoy a great deal.

Exciting stuff, but there's a reason why people spend 5-6 years at medical school or 6-7 years (if you count Bachelors/Masters/PhD degrees) at university to become a doctor of either medicine or science.  I often feel a bit like Bambi on ice trying to stay on my feet, and now that I'm doing research back in the UK, I have to keep my toe in the clinical world.

Can medical doctors be good doctors AND be good scientists?  Perhaps I'm not in the best position to judge.  I became a doctor because I love people, science and the interchange between the two, but I also think it's important to use that to see where the gaps and problems are and look towards solutions - which is where the science bit comes in.  But of course I don't know anywhere near as much about the science itself, or different scientific techniques, as people who have committed their entire career to the discipline.  It's something I sometimes feel guilty about because resources and funding are increasingly tough to come by and you want to know they're being used as efficiently as possible.  I'm also acutely aware that modern day drug discovery results in therapeutics often beyond the financial scope of even very wealthy countries, and that actually improving service provision and accessibility to existing therapies offers huge life saving opportunities.  Would my research skills be better used improving the utility and efficiency of what we've already got?

The worst and weirdest thing about splitting yourself between the two is that when you're doing one of them (say, clinical medicine), you worry that those with whom you do the other (science) think you're just having a wee break, and vice versa.  Certainly I sense from some of my doctor pals that I'm on a relaxed year of research.  Everyone (I think) knows how hard doctors work, but scientists are absolute machines with a phenomenal work ethic who, at a PhD and post-doc level have minimal job security and tough job prospects.  It's a privilege to be part of that and know that if your whole experiment goes down the pan, you can still sling a stethoscope round your neck and do another job that you also love.

I'm very lucky to have two completely different areas of professional interest that make my brain swizzle so much in completely different ways.  Perhaps feeling like a bit of an imposter in both is the trade-off - and perhaps a trade-off that will evolve over time.  Especially as it's only one part of the life jigsaw!

Tuesday, 10 January 2017

#openconmed - or - Open Access for doctors, medical students and associated interested parties!

Happy New Year, folks.  As I'm doing research at the moment, we were lucky to have a family filled festive season, although returning to work is somehow more painful after you've had two weeks off!

Walking in the wilderness of publishing...
Doctors are part of our own sort of family though, and nowhere was this more evident than in the inaugural OpenCon Community Call for Doctors and Medical Students at the end of last year.  When we started running OpenCon Community Calls in 2015, we hoped it would bring an amazing community of Open Access, Data and Education fanatics together between major events.  It's been a privilege to be part of this community of motivated, visionary researchers, librarians, students - people who believe that we can drive change in academic publishing. 

Doctors, and the medical profession as a whole, are often cited as being THE group who need access to publications.  Put simply, without access to research and review articles, we can't see the evidence which informs our clinical practice, which means we can't provide the highest quality care.  But my experience of being involved with the Open Access movement since my medical student days is that there's a major drop off in involvement once medical students become fully fledged doctors.  Where is the medical voice in Open Access? Most doctors I speak to have never heard of Open Access, and those that have are usually research types who have funding which, in the UK at least, increasingly requires publications to be published openly. 

Why is that?  When I explain to my doctor colleagues about Open Access, they agree that it's a big problem.  They've often just not thought about it before.  We're used to hitting pay walls.  Perhaps many/(most?) doctors, especially junior ones, rely on hospital protocols rather than looking for the evidence themselves, but one day these junior doctors will be senior ones.  Then, we'll be the ones making the protocols, the review summaries, the trends by which our junior doctors will practice.  What do we do then if we've never looked into things for ourselves?  And of course this problem is even more acute in the developing world, where walls are being hit left right and centre.  Why has this community not been more vocal then? Lack of time, I think!  When I'm working clinically, I feel like I'm firefighting to keep going - being a doctor is only 50% 'being a doctor' - the other 50% is audits, exams, portfolio.... etc etc.  There just isn't time.  There also isn't spare money to pay Article Processing Charges (APCs) to make things Open Access - as we're not funded by research bodies, if we publish something it's in our 'spare time' with our own funds. 

This community call was designed to bring this important group of people together.  I'll admit, I was a bit nervous.  I appreciate that it's quite daunting to talk to a group of strangers in person, let alone online.  But I needn't have worried - doctors are generally a chatty bunch! To start with, I was amazed by the geographical diversity of the participants.  New Zealand, Germany, USA, Benin, Kenya... to mention a few.  After some initial chatter about how the issue of Open Access affects us in our respective countries, we heard about some of the projects and workshops happening in various corners of the world.  It was great also to share tips and resources, such as PubMed Central and the Open Access Button.  So much great work is already happening out there, and it was the perfect opportunity to connect people who can help each other with policy and advocacy work, organising events and how to engage our local medical communities. 
We walk together, and we walk hopefully!

Some examples - we heard about a workshop where Public Health emergencies such as the Ebola Crisis were used as the basis for a discussion about Open Science in Global Health.  We heard about a Hack4Health event which aimed to bring the IT and health worlds together to synthesise digital solutions to the problem of open-ness.  There is amazing work happening all over the world and the message was always the same - we need more people to get involved, more ideas, more input.

You can check out the full minutes here - I left our call feeling heartened that there was an enthusiastic community out there, and we were creating a home for it together.  It is vitally important that those of us at the relative infancy of our medical careers see ourselves as game changers in the research and publishing world.  I'm excited to see where it takes us!

Thursday, 24 November 2016

Happy Thanksgiving!

A German Fall
Hello, lovely blog land!  Apologies for my absence.  It's been a little bit busy since last I scribbled - 'quelle surprise' I hear you cry!  I must admit, I've missed writing here - it's sort of a barometer of how crazy my life is if I have no time to write.  Dang! I thought I was getting better at work life balance!

Well, a few kilograms and brain cells lighter, perhaps November is actually a good time to take stock before the year's end and contemplate the last 12 months.  I don't (deliberately!) write a lot about my private life on this blog, but an important meeting today reminded me that it's actually OK for your Life to be a decision directioner.  Strangely, having the foundation of a truly content home life does throw a lot more balls in the air than I was expecting!  It's a source of hilarity to many of my friends that, as they enquire as to how many PhDs I've written/types of cancer I've cured/papers I've published since last we met, that my biggest achievement of 2016 has been to move in with a boy. Imagine!
When in doubt, find mountains

Professionally, my life has been peppered with the consequences of an NHS that has never been closer to the edge.  When I meet up with my university friends, it's clear we've come a very long way since we rocked up at medical school 10 years ago.  The 'tears at work' phase was probably one we thought we had traversed, but as people become more stretched, covering more patients with the same single pair of hands, my friends have seemingly endless tales of distress and despair.  Now we have all started specialty training, there is something even more daunting at looking down the barrel of five, six, seven or even eight more years of this onslaught and that's just to finish our training. I know that it's not much better for Consultants, despite what certain newspapers choose to write. 
An Oxfordshire Fall....

Frankly, I'm just a bit scared that I haven't got the stamina for it.  I've been enjoying working in a research lab, although recent exams mean I've been once more stretched to what me and those close to me can tolerate.  If I have failed these exams (as I'm expecting to have done), I am resolute in my plan to ride out this research year with no further exam distractions and find who my happy professional self is again. 

For me at least, having a joyful nest to come home to at the end of the day puts a real microscope on how precious your time is, both professionally and personally.  It also makes you think about the future and developing a happy, sustainable work situation.  My meeting today was with someone who successfully managed to combine messages of understanding at how difficult things are in the NHS, encouragement to get my shizzle together and motivation that I do have choices. 

...and a Yorkshire Winter...
I love being a doctor in the NHS, and I believe in the NHS, but it's hard to see something that you love being squashed.  All of the patients I saw on a recent evening in the Medical Assessment Unit were seen in temporary bays and were waiting in a room where others sat with drips running.  When I left my shift at around 10pm, there were about 5 ambulance crews already waiting to hand over to A and E, their patients waiting in trolleys in the doorway.  Amidst all of this madness, there's an army of junior doctors who are expected to 'train' around an NHS that is bursting at the seams.  Consultants are too stretched to address the training desert.  Going above and beyond is the standard required just to get through the working day, so there's none left to help with things like training and exams.
... with friends!

I don't want to complain without solutions, and am very excited to play (an extremely amateur) role in promoting www.juniorreviews.com, which is trying to motivate trainees from the bottom up to champion great training - because without great training, the NHS can have no future. 

My other solution for now is to love my laboratory research, heal myself a little and shore up the defences.  My meeting today, if anything, reminded me that the System still cares.  The System, in my case, is hugely embellished by my research interests.  I have no idea how my purely clinical colleagues are staying sane.  It's a shame but I fear the System is not going to be quite so robust in hospital land, so I'd best be ready for it when it finds me again. And, as I was reminded, having stepped out of the System for a while to do research in the USA, my mind is open to the world of possibilities out there, which makes me very lucky.  As a timely reminder of that, I will be celebrating Thanksgiving this weekend with some of the great folks I met out there.

Best quote from my meeting today: 'Life doesn't get more complicated, only richer'. 

Tuesday, 13 September 2016

Sick of striking

Well now I'm really hacked off.

Striking, again?  Arguing, again?

As someone who can't strike (I'm doing research at the moment) I am somewhat spared the dilemma of every junior doctor in the UK of whether to go on strike or not - the relief is nonetheless palpable following the cancellation of the September strikes.  What I'm not spared is another round of pan-media debates of junior doctors on the one side being pushed and prodded to the end of reason with an ill-(/nil?)-funded plan for a 7-day NHS, and journalists/politicians/whoever-else-wants-to-have-a-go on the other side telling me about the immorality of doctors striking.

I am sick of it all.

I am really sick of the media circus that has this has become.  I am sick of people who do not spend their working days in hospitals telling me what my job as a junior doctor is like.  I am sick of people telling me that I lack vocation.  I am sick of people telling me it's about the money.  And I'm sick of what this is doing to the morale of my profession, and the far, far greater damage that is doing right now over anything else.  I probably wouldn't go on strike on this occasion, as is the feeling among most of the juniors I talk to, but that's not because we agree with the contract or are happy with how things are - there is just a feeling that the continuation of this argument is doing more harm than any anything else right now.

Ultimately, the effects of this will not be seen for another few years, but then it will not be salvageable.  The majority of junior doctors will see through their contracts, which are anything from two to eight years long (plus time out for research/babies/other), and then will simply apply to work elsewhere.  The real disasters will then be seen in the specialties that are already having a recruitment crisis - emergency medicine, acute medicine, obs and gynae - the truly out-of-hours specialties.  Rural areas that are already struggling hugely to retain any permanent staff will be in this situation across the board.  That isn't because people want to make a ton of cash.  It's because (according to Article 8 of the Universal Declaration of Human Rights) having something that resembles a private and family life is a reasonable need.  Working every other weekend simply does not make that possible.  Covering rota gaps is not safe and it's soul destroyingly dangerous.  Your body does not function the same when it's working at 3am versus 3pm.  And year after year of appraisals, exams, moving hospitals, audits - these things also have to be squeezed in somewhere, and for what?

The bottom line is, if these anti-social specialties get any worse in terms of rota-gaps/training gaps/terrible rotas/antisocial hours, people will just move with their feet.  Departments, like the maternity department in the Horton Hospital in Banbury, where I used to work, will close.  Communities and MPs protest about the unfairness of this, but the problem is simple - jobs are advertised, and no-one applies - because there aren't enough doctors to apply for these jobs.  Perhaps whole hospitals will close.  The rubber band will have been stretched too far, leading to an irreparable snap.

As a half-German Junior Doctor, it's starting to feel a lot like this little country is none too keen to have me around any more - and I know I'm not the only one who feels like this has just become too miserable for words.  Come on, government, doctors, people of England.  Get it together and end this battle so the NHS can win the war.
That 'work-life balance' lark in action in the Brecon Beacons

Tuesday, 16 August 2016

Doctors Fail Stuff Too

Hello, blog pals!

Apologies for my absence from the blog world.  It turns out full-time clinical medicine and blog writing on a regular basis are not wholly compatible.  Plus, to be honest, it's been rather a depressing few months, hasn't it? Junior doctor strikes, Brexit, the implosion of any sort of political sanity...  Every time I tried to write something I just had to stop - it felt like I was adding to the country-wide exasperation.

But in all situations one should try to see the positive, right?  Another year, another flurry of bright-eyed, bushy tailed new junior doctors have just started their working lives on the oh-so-optimistically-named Black Wednesday.  Working over the change over days of new doctors is always a good time to be re-energised by fresh enthusiasm, and I guess also realise just how far you've come in the last few years.

But one probably learns more from failure than success - I failed the first thing I've fully failed since 18-year-old Karin failed her driving test - I failed my final exam for my Membership to the Royal College of Physicians (PACES, for those familiar with the lingo) by a big fat... 2 points.  Not surprised, but also interesting to observe and understand my own response to failure.  The main challenge has been managing others' expectations (weirdly not my parents/family's, but those of my friends!), and of course a little smoothing over of one's pride.

I share this largely because doctors SUCK at talking about failure.  Certainly people seem to look at me and seem to think it's something to which I'm immune.  The worst thing about failing is actually the thought of doing it all over again - the revision around a full time job, saying no to seeing friends and family (I've seen my parents twice in the last 6 months - TWICE! - and they live barely an hour and a half away!), the tension and nerves of the exam waiting area, the money (altogether it cost me about £2000 to sit, as will the resit..!)...

If that's the worst thing that's happening in my life right now though (and it really isn't that bad!) then frankly, I think I'm doing pretty well.  It may not be the last time I fail it, and I need to be ready for that possibility too.  I'm back in the lab for a year which is hugely exciting - I'll miss patients a lot but frankly after working at least 1 in 4 weekends plus evenings/nights on call for a year, I'm looking forward to being a little less sleep deprived.  The NHS is a rather tense, over-stretched place to be at the moment, and I think it's safe to say that many of my NHS friends and colleagues are feeling at something of a crossroads.  To come back to the lab feels a bit like returning to a land of optimism and excitement.

Optimism and excitement is also fully present in 'life' in general.  I've hopefully just moved house for the last time for the next couple of years, and nest-building is just pretty darn wonderful.  The 'woah-there-it's-actually-summer' weather means life is being lived outside as much as possible - from slothing to swimming, blackberry picking to bicycle rides - who knew we could genuinely achieve al fresco dining with such regularity in the UK!

So there we go.  I, Karin Purshouse, failed an exam.  But it's really not so bad.  I feel reasonably reassured that I'm still an OK doctor.  I'm just going to try and convert that into a decent cancer scientist for the next 12 months...

A li'l bit of the North East coastline earlier in the summer

Friday, 6 May 2016

On Kindness

River deep and mountain high!
Work recently has been tough.  Working as a junior doctor on an acute cancer ward is never likely to be stress-free, but add in a couple of folks down on the on-call rota, a rota that already involves working 1 in 4 weekends and ever-escalating strike action - well, it makes things rather epic.  A lot of our patients are young and all of them are pretty sick.  There are often days when we feel like some of our patients have just had a pretty crap deal with life, and we can't really do much to take that away other than to do our work as best we can and be as supportive as possible.  Recently I was called to see a young patient who was a similar age to me who was dying of cancer - I think there would be something wrong with me if that didn't affect me.  I finally cracked after a long weekend where a lot of patients had become very unwell and passed away, and tried to support some very distressed patients and relatives.  It's just as well I don't wear much make-up, eh?  

A lot is made of the stress of the actual job of being a doctor, although I'd probably describe the above as emotionally consuming rather than stressful (and sometimes it's good to 'feel' - reassures me at least that I'm still human!).  In some ways, of far greater stress to me is my looming end-of-year appraisal, trying to get all my competences/outcomes done for my portfolio (e.g. assessments from other doctors, attending enough clinics, doing enough procedures), doing an audit/quality improvement project, somehow getting to weekly teaching, doing a massive exam, doing edits on a paper, organising my research project for August...  Without that lot, being a junior doctor would be a very different thing!

From the last of Winter's snow...
Morale is certainly at an all-time low amongst junior doctors with the current contract situation but what's awesome is a) how much I fundamentally enjoy my job, b) I'm starting to think I'm ok at it and c) how much being a doctor means to be part of a team that looks out for each other.  This big ol' exam? I've only got a bunch of 7 other junior doctors who are teaming up to help each other pass the damn thing.  Getting my stuff done for my appraisal? It turns out people are very willing to help you if you just ask.  And as for the emotional challenges at work - well, we look out for, and are kind to, each other.  Kindness - to yourself and to others - under-rated, if you ask me.  Life is just too short to tolerate its absence and live negatively!

In addition, life outside of work (for me at least) has been very kind to me indeed, blossoming and blooming apace with the Spring that is also finally making an appearance.  Even though I am both time and money poor (try spending nearly £2000 on your last (hopefully) big postgrad exam... gulp), I feel rich in laughs, love and adventures right now - what a lucky bean! A potent reminder of the importance of work/life balance which my old housemate generously said I 'seemed to be getting better at these days' - praise indeed!  My job may be tough but life is pretty wonderful right now :)

And so - to night shifts once more this weekend.  Hope you're able to spend yours in the same wonderful sunshine that is to be found in my corner of the world right now - I'll look forward to sleeping through it!
... to the fresh blossom of Spring!

Naomi Shihab Nye (1952) - 'Kindness'
'...Before you know kindness as the deepest thing inside, 
you must know sorrow as the other deepest thing. 
 You must wake up with sorrow. 
You must speak to it till your voice 
catches the thread of all sorrows 
and you see the size of the cloth. 
Then it is only kindness that makes sense anymore, 
only kindness that ties your shoes 
and sends you out into the day to gaze at bread, 
only kindness that raises its head 
from the crowd of the world to say 
It is I you have been looking for, 
and then goes with you everywhere
like a shadow or a friend.'