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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!