Doctors cry (especially junior ones)

Ok, so I am really bored of crying at work.

Since I started working back in August, I have probably had a cry-per-month ratio higher than I have ever had in my life.  The thing is, I don't cry.  Normally.  So by way of learning to 'Man Up', here's my cry diary from the last few months.

Cry number 1 - Day 1 of work.  Ward that normally has quite a few doctors on it - find myself completely on my own for a chunk of the afternoon.  Feel overwhelmed by number of jobs to do and no idea how to do them, along with being asked questions I don't know the answers to.  New SHO arrives and makes the fatal mistake of asking me if I'm ok.  Cue tears.

Cry number 2 (and 3, 4, 5) - First set of nights.  At the end of a busy, horrible first ever medical night shift, I realise in front of the entire team that I made a small mistake - an error based on lack of knowledge of a particular routine.  A non-dangerous mistake that breaks me at the end of a long 13 hours.  Two nights later, and I'm similarly being dragged all over the hospital.  At 3am, I have a choice between the patient who is desaturating down to 50%, a blood pressure of 65 or chest pain.  That means the patient with the minor-sounding problem is unfortunately not a priority.  Said patient lets it known she is not very happy about this when I finally reach her at 7am.  For me, it's the final straw.  Didn't feel I'd been very supported in this  decision making process by the nursing staff, and once I've calmed down a bit, I have a chat about supporting each other during the night shift.  I think the patient realised I was upset and once I'd sat down going through her problems for half an hour, seemed to be more content with the situation and that I hadn't apologised for my tardiness without meaning it.  A few people subsequently asking 'if I'm OK' triggers Cry 4 and 5.

Cry number 6 - having had no deaths on my clinical team, we have three deaths in one week.  One patient who I'd seen over a weekend on call, and happened to see during an on call later the subsequent week, dies literally in front of me.  Then we had a couple of admissions that week of patients with dementia who had stopped eating and drinking.  Taking a history was impossible.  Persuading them to have bloods taken was tricky.  The underlying feeling of 'I can't actually make this situation any better' and 'What am I actually doing? What can I bring to this situation?' proves a little more than I can bear.  In fairness, I don't actually cry, but the only place I can find to hide to take a few deep breaths is the patients' bathroom.

Cry number 7 - there's a long pause before cry number 7.  Another weekend on call.  It's been a very busy Saturday and once the day registrar has left at 5pm, I'm on my own to sort everyone out til 9.30pm handover.  The bleep is out of control with non-urgent jobs.  Then at quarter to 9, someone is spiking a temperature.  I decide this is the most urgent job, and the others on my list will need to be handed over. I speedily do an assessment (my bleep obviously continuing to go off), take some bloods, take some cultures, get a new drip up.... and as I'm getting these things sorted in the office, I'm still being called - 'Doctor, can you just....'.  I don't know how I can say it differently - that unless the problem is more urgent than the one I'm dealing with right now, it will have to wait 5 minutes.  I head to handover, and I'm not angry, just tired and frustrated with myself for not being able to do 3 things at once.  The SHO reminds me that I can't expect to be able to do everything.  My night counterpart brings some water and tissues, and I get it together.  What a wimp.

Cry number 8 (8???? This is ridiculous) - new job, working late.  My senior and I assess a patient.  Once her blood tests are back, my senior decides she needs an urgent scan.  The person who would do the scan disagrees.  He does not communicate these feelings in a very sensitive way.  Some poor documentation on my part confuses the situation (which I apologise for) and overall I feel quite stupid and like my professionalism is being questioned a little unfairly.  It's the last of these which sets me off.  This has all happened over the phone, and I'm with my senior seeing another patient on another ward by this point, so a whole set of healthcare staff and patients alike are completely mystified by this sobbing doctor.  When I see said person later (scan finally done and entirely justified), I apologise for my part in any confusion.  I receive no apology.

You see?  I totally need to man up.

The thing that frustrates me more is, I am coming to believe now that actually, I am an alright doctor.  This is quite a big deal for self-depricating little me.  I had my end/start of rotation appraisals recently, and yesterday saw my feedback from the doctors, nurses, ward clerks, pharmacists from my previous rotation.  Their feedback was really nice! Of course, I am now sort of back to square one in a new job and the amount still to learn is overwhelming.  I am still just a junior doctor.  But I'm ok with that, because I know that, despite all of the above events, I learn from my mistakes and that I'm not terrible.

So really there is nothing to cry about.  I just need to learn to back myself, and cope better when things get a bit stressful.  And perhaps carry some Kleenex around in my on-call bag.  

Hello job, goodbye life

I finished my first rotation this week and it was with a degree of sadness and trepidation that I left the hospital and job I was only vaguely starting to feel on top of, in exchange for a new job in a much bigger hospital.

I now work in surgery, and my hours are, as one might say, 'plus plus antisocial'.  There is literally no regular evening hobby I can do any day of the week, because all my shifts either start, finish or occupy the evening time.  

Means of coping with this?

Go home and find your mama and give her a big hug.  Go for a stroll and contemplate life.  Generally escape the bubble that is 'work'.  

Buy yourself a truly excellent Christmas jumper.  And stop getting too bah humbug everytime they play 'Driving Home for Christmas' on the radio.  Because I will not be driving home for Christmas.  Even if I did, only the cat will be there because my family are (rightly) taking the opportunity to visit our extended family.  

Go to the pub and have a snuggly mulled wine with good friends.

I am determined not to be a whiner!  It's been quite an intense time, but my new musical and literary flavours of the month are helping plenty - I've just bought Lucy Rose (old favourite for complex reasons) and Alex Clare (@alexanderclare for all you twitter fans)'s albums, and can highly recommend both.  Book wise, a charity shop trawl proved fruitful.... 10pm finishes for me for the next 7 days, so I'm spending my early mornings with my nose in a (non-medical) book to keep my sanity and a smile on my face.  

The final leg of Two Weeks in the Life...

Day 10: Wednesday.

Really flagging now.  My two direct seniors are on call today again so I have them with me briefly then I'm on my own to prepare for the consultant ward round in the afternoon, and I have my medical student again to entertain.  I have compulsory teaching at lunchtime which is rather inconvenient but the ward round in the afternoon goes off reasonably without a hitch. I've been invited to a friend's for dinner and I don't get there til after 8 before meeting some other friends for a drink.  Struggling to suppress an insatiable urge to get 'out of my head' by now, and probably head home a bit later than I should have done.

Day 11: Thursday.  Final on call of the 2 week mega-work-a-thon, and I'm post take, so start at 8am.  It's reasonably painless but post-take days are always a bit more chaotic than I would like, with a combination of managing all your new patients and sorting out all of your existing ones.  One of our existing patients is quite unwell and it's quite handy that I'm on call in the evening as I can reassess him later on knowing all about him already.  I feel completely snowed under in the afternoon as my SHO is sorting out the few remaining new patients (most of whom are on other wards by now and therefore no longer our responsibility) and my Reg has other work to do.  A lot of our patients are to be discharged in the next couple of days and if I don't get on top of my discharge summaries today, I'm going to be in a right fix tomorrow.  I'm not really able to offer my medical student much by way of time as I have so much paperwork to do.  There's also an important end-of-life discussion that needs to be had with one of our patients' relatives; it's always upsetting to have to accept that your efforts are proving futile and ultimately someone may just be nearing the end of their life, but we have a very frank discussion and all agree a plan of action with my Reg.

Post 5-pm, I have a few jobs handed over, but nothing too overwhelming.  A lot of warfarin dosing and a few IV fluids to prescribe, and a couple of patients to review.

The person who's on nights is late - he's never late.  I carry on with a couple of small jobs I might have otherwise handed over when the night SHO appears at around 10pm - it turns out the night version of me has had a car accident in all the bad weather.  Fortunately he's alright, but obviously can't work, so the SHO tells me to hand over to him instead.  I drive home at the pace of snails as the weather really is awful and I'm feeling a bit shaken by the news of my friend, and when I get home I call him to make sure he's ok.  So by the time I have my sad dinner of microwave rice, it's gone midnight.

Day 12: Friday!  The last day!  I'm doing a quality improvement project with one of the other doctors so I arrive for 8am again to collect data from around the hospital before my day starts proper at 9am.  I get some unprecedented praise from the pharmacist for getting all of my 7 discharge scripts to her before lunchtime - you've got to take these small positive moments!  My SHO and I try to see everyone before this afternoon and pre-empt the jobs that might need doing, and by lunchtime I'm feeling quite on top of things.  A quick lunch, and I'm ready for the boss in the afternoon.  My SHO and Reg are both on call, again, today, so I'm on my own to direct the boss round everyone.  Even though we've discharged a lot of people, the remaining patients are all quite complicated and unwell, including my unwell patient from yesterday.  The boss seems reasonably content with how we've managed him.  Some relatives want a detailed update about one of our patients - I spoke to them at the weekend so know them already.  By this point it's after 5 and we still haven't seen half of the patients - it's important obviously to give a full update, but it's a challenge balancing this with the time owed to each of the other patients, and the general brain fatigue that has set in from being at work everyday for 12 days in a row.  The boss handles the situation like a pro, and everyone leaves happy.  It's after 6 by the time we've seen everyone, and it's left to me now to mop up the remaining jobs and prepare the weekend jobs list and put out the blood cards for the phlebotomists to take.

I finish, triumphant, around 7pm.  I'm going away to Devon this weekend with some of my junior doctor chums, and I am greeted by them with a flat cap and a beer.  Relief!  My twelve days are done, and addressing Life Beyond Work can now commence.

Weekend-a-geddon +2

Day 6: Saturday morning.  Slept terribly, got to bed late and awake at 6am. At work I am delighted to find I have a senior person to review patients who we've been asked to review over the weekend.  This is excellent news as it leaves me free to do the more menial jobs of chasing blood tests and receiving the rather endless stream of bleeps.  We're doing well (with just one crash call to run to) and by the time he goes home at 5pm, I've even eaten some food, had some fluids and feel vaguely on top of things.

Post 5pm, I'm on my own to mop up the remnant jobs and address any arising issues.  The problem is, there's only one of me, and I only have two hands.  The hospital has been so busy that a lot of the patients I've been asked to check bloods for over the weekend have been moved (many to the other side of the hospital), but their blood test cards haven't, so it's down to me to find out where they've gone and do the blood tests myself.  In addition to that, there's patients who are unwell, drips that need replacing and families who want updates.  My bleep is going off every five minutes and I've no sooner started a job than my bleep goes off again.  I have to risk-stratify my list of jobs and decide which ones I will have to hand over.  I get to 9.30pm and I am beaten.  A few tears are shed, not because someone has upset me, but just because I am tired and frustrated with myself.  My seniors always remind me that I need to just CHILL and accept that I can't do everything; although I know that, it's just frustrating that that's the case and ultimately, it's irrelevant to the patient or nurse at the end of that bleep you've just received that you've been on the go for 12 hours.  Just as we sit to hand over, an arrest call goes out and we all peg it to the relevant ward to start CPR. We're unsuccessful and it's a slightly sombre end to the day.

After all of that, I go back to my own ward to check a couple of things and leave hospital after 10.  Home after 11.  Quick pizza dinner, bed.  Same again tomorrow.

Day 7: Sunday morning.  Cream crackered and eat the remnants of last night's pizza for breakfast before heading into work.  Classy.

The ward registrar and I get tactical - I hate being disorganised and today I've consolidated the ten sheets of hand over patients into one 'ultimate list of lists'.  It's pretty frantic for the first five hours as we go round reviewing the patients we've been asked to review, chasing bloods, the odd cannula and trying valiantly to encourage people to put non-urgent jobs in a ward-based book rather than bleeping me all the time.  Another crash call takes us jogging into A and E - this patient survives.  When the ward registrar leaves at 5, I've got a fairly manageable to-do list.  I'm majorly flagging but there are still bloods to take and chase, and just at the end of the day, I'm asked to review someone who's breathing has changed.  It's quite a satisfying bit of teamwork as we get his bloods, ECG, chest x-ray and diagnosis within the space of about an hour.  The night junior doctor greets me with a cup of tea.  My hero.

An accidental snap, but accurately reflects the fatigue!

Day 8: Monday.  Everyone else is looking bright eyed and bushy tailed - the week is no shorter if you've done the weekend on call so I'd better keep up the pace!  Over the weekend my ward has essentially discharged half of its patients so it's all new faces - but luckily I know a lot of them because I've been involved in their management over the weekend.

My registrar and senior house officer are both on call today in the admissions unit so we're a team until midday and after that I'm on my own.  There are only a couple of patients left to see, a few discharges to sort out and the care for everybody else to coordinate.  Finish about 6pm and the boss turns up - luckily I have something useful to say about the day!  Time to head home, walk in the door about 7.30pm.  First time I've been in the door before 11.30pm since Thursday.  And then to the pub.

Day 9: Tuesday.  An unusual week this week as I'm at a meeting today for the whole day.  Although it's still a full day of work, it's refreshing to think about something else (although it is still basically medicine chat).  Issues discussed include women in medicine, something I feel increasingly passionate about.  It is different being a female doctor, because ultimately, I predominantly serve an age group of population for whom female doctors was a rarity.  Persuading them that I'm a doctor can be a challenge.

Get home no earlier than if I'd been at my normal day job and go to a friend's house for dinner.  Inevitably, medical chat predominates, although we reflect a lot on how we got to being here and how it's going to impact on the rest of our lives.  It's funny to think that we chose a career when we were just teenagers, and it's one which almost defines my whole identity now.  We talk about our respective 'Medical Finals breakdown moments' - the two weeks when I was doing my final exams at medical school were absolutely painful for my family to have to hear about over the phone.  It's weird how now that I'm doing it as a job, I don't feel they need to hear about the bad days.  They've done their time, and they don't need the worry of a wailing daughter down the phone!

Two weeks in the life of...

I'm embarking on that most feared 12 consecutive day work-a-thon.  Thought I'd keep a little diary, more for my own benefit in future years, but also because sometimes people are interested in what I actually do everyday.  Read at your peril.

Day 1
Post take.  That means all the patients who have come in to hospital over the weekend are now my team's responsibility, and I arrive an hour early (8am) to start the post-take ward round.  Not as painful as it could have been, and we've seen and sorted all of our patients by 5pm.  Find out a patient of mine died on the ward over the weekend, so this also needs to be addressed during the day.  Lunch is spent at Journal Club, where we discuss a paper on risk stratification for pulmonary embolism.  On call in the evening - it's busy, and I'm on ward cover.  Issues include a spiking high temperature, low blood pressure, agitation and a few patients I've been handed over to review/chase tests for.  Finish at 10pm.

Day 2
9am start today.  I have a medical student, so amongst doing a ward round of our patients (including a few who have been put on wards the other side of the hospital), we're trying to do some teaching as we go along.  I supervise them seeing some patients on our ward.  A bit upset as another patient has passed away - it's difficult to see a family you have got to know deal with this difficult part of life.  A couple of our patients are quite unwell and need urgent investigations, so there's quite a bit of running around making sure they are getting sorted out.  Today lunchtime is spent at our 'Tricky Cases Meeting', where we discuss cases of interest and do literature searches on these topics.  Finish around 6pm, and have planned to go to the cinema with some friends. Soooo tired but determined to do something relaxing away from work.

Day 3
9am start again.  Busy, and trying to make sure my medical student is having an educational time as well as getting our work done. Compulsory teaching at lunchtime today on respiratory medicine.  We have a full ward round today with the whole team which starts quite late so we finish at about half five.  We're scheduled to do the case based discussion tomorrow, so my colleague and I sit in the office preparing our presentation.  Get home after 7, cook dinner for housemate who cooked me dinner last week.  I have assessed work due for a course this week, plus haven't addressed my mountain of emails, so spend the evening replying to emails, reading some literature and submitting the course work.

Day 4
Again trying to balance seeing everyone on my ward in a timely fashion and making sure my medical student is learning something.  We spend lunchtime presenting our case based discussion which goes quite well I think.  We see a couple of our more complex patients with the boss late in the evening and I get home about half 7.  I'd invited a couple of friends round to have dinner with my housemate and I, so it's in the door, cooker on, get chopping!

Day 5
We spend much of the morning sorting out an unwell patient who has come under our care, and then get cracking with seeing everyone else.  I'm on call today - just as there was a thought of grabbing lunch, a crash call goes out and I'm off to A and E with the rest of the on call team.  A brief sandwich-stop later, I'm back on the ward, but the boss is delayed and we start late in the afternoon with a final round before the weekend.  It's an interesting juggle between finishing all the jobs from my own ward, receiving on-call bleeps from all the medical wards and getting evening/weekend handovers from my colleagues.  It's quite depressing seeing everyone else slip away while you know it's just you and a bleeping machine for the next 72 hours.  Relieved when my night counterpart arrives, and I only have a couple of things to handover.  It's now a bit quieter, so we have a quick chat.  Dealing with your personal life - it gets a back seat at best sometimes so it's nice to catch up with a colleague who's also your friend rather than just having your game face on all the time.  Home after 11.  Reheat the remnants of last night's dinner.  Bed.  Up tomorrow at half 7 to do another 13 hours.

'You get me?'

The furore surrounding the Liverpool Care Pathway (or, as the Daily Mail are currently calling it, 'pathway to death'' or something like that) has caused much discussion in my hospital, as you might imagine.  My feelings on this issue are best shared another time.  But one thing it has made me reflect on is whether I really explain what I mean - i.e. 'You get me?'

Here's the problem - doctors are human, are not perfect and have feelings.  Shocking I know.  And no matter how many times you have been trained to deliver bad news, it ultimately goes against your instincts to tell someone, explicitly, something awful.

'I think you might have cancer'

'I think your dad/mum/wife/husband might be dying'

Those two words in particular - 'cancer' and 'dying' - are surprisingly hard to get out.

There's two reasons for this - first is, it's just really hard telling something these things.  And I know that's what we're trained to do, but you know that once those words have passed your lips, little else you say will be heard.  Even if the cancer is in its early stages, or very treatable, it's heard (understandably) as cancer, and that's that, despite what you say after that.

And secondly, despite popular belief, it's not actually all that easy to know, particularly with the latter, if it's true.  Dying is not a finite art.  Until I started training for this, I'd never seen someone die before.  What I do know is this - everyone will die.  And I wouldn't wish dying in discomfort or pain on anyone.  So if someone might be dying, yes, of course, do everything you can to actively manage the situation with whatever treatment is needed; but also consider that if this is going to be this person's last hours on earth, it should be with dignity and peace.  These two things are not mutually exclusive.

But either way, this whole issue of the LCP has made me think first and foremost of all the patients who have died since I started working, and how closely we have worked with the patient and their families to make sure everyone is informed and comfortable to the end.  It is so difficult to say these final, definitive words about what we think is going to happen next.  But it is not enough to 'think' we have explained what is going on - hiding behind medical words or terms which are not explicit enough is insufficient.  It is far harder hearing this sort of difficult news than delivering it - I will never ever forget that it is my job to be sensitive, explain clearly and make sure we are all singing from the same hymn sheet.  

Common Sense Science. My very favourite kind!

Because I decided life wasn’t busy enough (!) and I have this irritating obsession with learning things, I’ve just started a course in translational medicine.  What, I hear you cry?  This has been the general reaction from my colleagues and chums.  So I thought I’d take a break from my first assignment to give you my take on what I’m increasingly seeing as ‘Common Sense Science’. 

I think to describe translational medicine; it’s probably easier to think of what one might expect medical research to achieve.  I’d probably kick off with understanding how disease functions on a molecular level, how it starts and progresses, what cells and proteins are involved.  I’d then move on to working out what parts of this mechanism we could target – what are the most important drivers of the disease process?  Next – how can we manipulate these?  Do we have to go back to the original genes that programme the components of the mechanism?  Can we block, change or remove certain cogs in the machine using drugs, chemicals or radiation?  And finally, how do we take all of that into something that you or I could walk into a hospital and benefit from, to either reduce our risk of, or treat, a certain disease? 

Sounds pretty common sense, huh?  Essentially, I think Translational Medicine is taking our understanding of how disease works and using that to make effective treatments for patients.  Sznol has described this better elsewhere as a four- or five-point process, but that’s my take on Common Sense Science.

But it can also work the other way around.  For example, a commonly cited case of pharmacology-gone-(slightly)-wrong is that of Imatinib, a drug designed to target an important disease-progressing protein in a form of leukaemia (Chronic Myeloid Leukaemia).  Cited as a wonder-drug and potential cure, they then realised that actually some patients didn’t benefit from it at all, or alternatively, stopped responding to it after an initially positive response.  Rather than abandon ship, research groups have sought to understand why certain patients are resistant, or develop, resistance to imatinib.  As a result of reversing the bench-to-bedside process, hopefully patients will benefit from imatinib, or drugs like it, in years to come. 

My initial delve into the translational world has raised some interesting quandaries for me.  First, the idea of human beings as a test model.  In the surgical world, it is now well recognised that with new techniques such as laparoscopic (key-hole) surgery increasingly used, and challenges to training opportunities ever-more prevalent, we must create an environment where patients are not practice models.  Innovations in virtual reality and simulators, as well as robotic surgery, are gathering a-pace.  But can the same really happen in the medical (i.e. not surgical) world?  Human beings are so complicated that no other animal, petri dish or fancy chemical model could ever hope to recreate us in our entirety.  But are we ready to accept that we must be willing to be the trial run for drugs?

Second, the idea of physician scientists.  Many authors talk of scientific progress progressing faster than clinical science – i.e. scientists are getting there faster than people like me (remembering though that I am a very junior physician.  In fact I don’t know if I even feel comfortable calling myself that!).   I am an academic trainee, which means that over the next two years, I have some protected research time.  But I have certainly been in situations where people have questioned whether it is wise, or even safe, for me to do this.  Shouldn’t I be training to be a safe physician first and foremost?  Is it appropriate for me to be taking time out of this early stage in my career to do research?  I find this astonishing, and even more so now that I’ve read a bit more about translational medicine.  How are we ever to bridge the gap between scientific innovation and clinical outcomes if there aren’t the people there to bridge the gap?  Stepping into a lab as a physician is a bit like stepping into a parallel universe, and frankly, I’d rather get on board now so I can learn from the start how to combine my life as a physician and a researcher rather than later.  You don’t need to tell me twice about patient safety – it’s what keeps me up at night, me and every other junior doctor. 

Me, Everything Everything and a cup of tea are getting on nicely in our quest to get this assignment done.  And yes, I have received a suitable amount of heckling from my friends that this is how I choose to spend a small chunk of my week of annual leave.