Close to home

 Being a cancer doctor, I thought I knew a thing or two about grief. Beyond my professional experiences, I lost close friends in an accident when I was a newly qualified doctor - grief was something I shared with my friends at the unexpected age of 24. 

I am now in the middle of messy, aching grief.  Just over two months ago, my father was diagnosed with cancer, and he died a month later. In the month that followed, we went on to lose two other close family members. It feels a little like we are bathing in grief.  

Losing my dad feels somewhat unreal, probably because I've only just scratched the surface of what it means to have lost him.  We have all read notices like this - died at home after a short illness.  You realise who can read between those lines, and imagine the struggle that went on behind the scenes to achieve that brief, peaceful sentence.  As a doctor, and a cancer doctor at that, it was to live a double life.  It was to have the world's worst insight into the future, to know what was coming, to know what it would look like, to know what needs to be done (and how to ask for it), to feel both powerless and responsible. Of course all of that can't prepare you for the reality of it all. The truth of the struggle is hard to put into words. What to say, and to whom, and when. People imagine that as a doctor, you have this ability to override things, but that suggests that our families are passive, unintelligent people who don't want to have agency and autonomy, and that we function in isolation rather than the necessarily multi-layered system of healthcare.  The bottom line is you are traversing this divide of supporting those most precious autonomous principles whilst trying to steer things with your professional skills and knowledge.  Anyone who thinks that is easy - well, let me tell you, it is not.  The result is constantly second guessing yourself, worrying that you are doing too much or not enough, and ultimately whatever you do will never feel adequate. It is a sort of trauma. 

Grief right now does not feel beautiful or wonderful, nor did it during my dad's final days.  I am grateful for friends who sit at ease in that space with me, without sugar coating it in magical or romantic words. The thing about grief that I resent the most at the moment is my inability to embrace unfettered joy in other people - I resent this for how selfish and mean-spirited it seems.  Sometimes I can play pretend, as I suspect it's a bit of a self-fulfilling prophecy - you can't feel joy if you don't at least try to share in it. Sometimes it is easier to share these selfish musings with friends who have overcome, or are overcoming, some sort of adversity themselves - I find when I confess these feelings, they confess the same. That doesn't mean I don't want to hear about the happy things happening in friends' lives. It's just that I can manage it in a trickle rather than a flood. I know that sounds terrible, but perhaps these are helpful things to understand if you, dear reader, are wondering how to approach a grieving friend. It's also important to hear about the struggles. I think people might feel they shouldn't share their difficult times in fear of overwhelming me, or feeling they are trivial, but quite the opposite - it gives me an opportunity to be a friend back, and that is also important. Friends are getting me through these times - what helps is the regular timbre of daily life, feeling included in things, being invited in a very specific way, even if the answer is sometimes no. When I visited my best friend a few days after dad died, there was something wonderfully regular about the fact she had to spend the first twenty minutes frustrated on the phone to her internet provider, leaving me to mooch around her new house and make us a brew. It makes you feel that friends are not afraid of you, that life will go on, and that you are a part of it. 

One of the errors I made, along with many of my peers, when we lost our friends in 2013, was to think I was somehow indispensible in my work.  My whole professional world, both research and clinical, is cancer and my life was full of it.  That all seems so far away right now. I had one day recently where the sum achievements of my day were emptying the dishwasher and doing some laundry.  I am exhausted all the time.  I can find joy in meeting with a friend, and indeed I endeavour to get out of the house every day to do *something*, but it's hard to stress enough how far that is from my usual daily routine. People have told me not to feel guilty about this - I don't, because I can't.  Losing my dad is one thing, but when other bereavements follow so closely, you start thinking every time you pick up the phone that it will be bad news.  By extension, it feels like good news is something that only happens to other people.  A handy thing about working in the field is that you have to explain very little to your colleagues, and people can imagine what you're facing without your having to verbalise a great deal more. I made errors in not seeking help in 2013, and I think as a result felt resentment and anger towards the system for not seeing my pain. I remember being told at the time by someone senior that 'these things happen', and being made to feel spectacularly invisible when grief caught me one day in front of clinical team members.  This time I have accepted my professional dispensibility, and have been warmly supported by my GP, seniors and supervisors.  Kids, this is a lesson for life. Work somewhere that supports you the way I have been supported.  I suspect it's a longterm win for all concerned.  It's really made me appreciate the fantastic teams in which I work.

It's taken a while but I've begun to find it helpful to read what others have written about grief.  My best friend directed me to the Reverend Richard Coles - however, it was accidentally hearing him on a BBC Radio 2 programme one evening that I actually listened to him speaking about grief for the first time. To my surprise, there was a form of relief in hearing someone else describe feelings to which I could relate.  He describes grief not being the 'work of a moment' - people want to ask if he is getting over losing his husband, and that this isn't something you 'get over' - it's more like getting used to living with the feeling. The importance of friends - and being surrounded by love, friendship and patience.  The grief of the future actually being the greatest unpleasant surprise than that of grieving the past. I can relate very much to all of these - and by extension I feel these emotions on behalf of others grieving my dad, which feels like an additional sadness. Facing grief for me must involve talking about it - and for this, Maggie's has been absolutely amazing. It is a tremendous thing to have somewhere to go where it's just about 'you' - you don't need to ask beyond the usual social niceties about the other person - and frankly have a good cry, as I have done every time I've been there. 

I'll conclude these musings by saying that I don't think this experience will make me a better doctor and oncologist - I hope I was compassionate and empathetic before all of this happened. Rather, taking time to digest everything is in hopes that I remain inquisitive, enthusiastic and passionate about working in cancer.  I am grateful to each and every person who has walked these last few weeks with me.  I am lucky to have a family who have supported each other so completely.  I await what this journey in grief next has in store for me. 

Cancer and COVID19 - what's the risk?

I've been back in the clinical world for just over a week, and it's been really good to be back with my clinical colleagues.  It feels fully unreasonable that we are being hailed as heroes when we get to leave the house, be busy and engage with other people face-to-face (a safe distance apart).  Everyone is motivated, there is a sense of being 'extra kind' and I think many of us feel lucky that we have employment at this time of immense financial and social uncertainty for so many people.  Yes, it's a bit scary, but aren't we all a bit scared?

I think we can all agree that one reason that COVID19 is so stressful is how uncertain everything this.  This is no less true for cancer patients.  Oncologists and their patients are having to make really tough decisions together about how to proceed based on unknown risk.  Some authors have discussed the process of prioritising treatments - but the idea of stopping or delaying cancer treatment is, of course, every bit as frightening as COVID19 itself.  Cancer IS uncertainty, as everyone who lives with, or works in the area of, cancer will know.

Uncertainty begins even with committing to an anti-cancer treament.  You might have seen my earlier post about cancer clinical trials - for the most part, anti-cancer treatments are approved on the basis of phase 3 clinical trials - that is, big trials involving hundreds or thousands of patients, where the new drug/therapy/treatment is compared with the existing 'gold standard'.  That allows cancer doctors to discuss with patients the likely benefit of any new cancer treatment.  For example, say Wonderdrug works in 20% of patients - that's 20 in every 100 people who received the drug.  What was it about the 20 people that meant they responded to the drug, and the other 80 people didn't?  Maybe (ideally) it's something measurable like a certain marker in the cancer or blood that you can check in advance?  But often we just don't know.  We discuss with patients what we think the benefit might be to them, and discuss the risks of a given therapy.  The issue of side effects, while often known and manageable in general, are also impossible to say with certainty how significant they will be until you start - it's the same problem.  We might know from studies or experience that 20 out of every 100 people get really nauseated from Wonderdrug, but how do we know which 20 people that will be, for example?  So cancer patients live with uncertainty from the moment they get their diagnosis - I'm acutely aware of how this must be one of the toughest, if not THE toughest, thing(s) about cancer.

This isn't just true for oncology, I should say.  This is true for all of medicine and surgery - indeed all of life!  It's all probabilities and likelihoods, balancing risks and benefits.

So then comes COVID19.  Everyone's terrified.  Everyone's scared.  We see the huge number of people worldwide who are suffering from COVID19 infection, and in severe cases ending up in intensive care and/or dying.  Cancer is scary enough, but now this?

The evidence for COVID19 plus cancer right now is limited.  Big analyses of who was worst affected in China and Italy have suggested patients with cancer are more vulnerable with regards to COVID19, but that requires serious context - cancer means many things (advanced or curable? on or off treament? what kind of treatment? other health conditions? etc etc etc).  We need to understand more about about these previous patients so we can make decisions with, and for, future cancer patients.  Clinicians are sharing their experience of COVID19 as quickly as they can, but when you really look closely, the studies of patients who have cancer AND had COVID19 are actually very small.  For example, a study of 1524 cancer patients found 12 patients who developed COVID19, and looked at these more closely.  Another study looked at 1572 patients with COVID19, of whom only 18 had cancer, and another looked at 28 patients with cancer who also had COVID19.  It's a big thing to conclude anything at all from such a small number of cases.

For example, take the study with 12 patients.  Two patients sadly died of COVID19 - that makes a mortality rate of 16.7%.  But what if just one more patient had died, or survived - that would change your mortality rate to 25%, or 8.3% - a huge difference.  And in that particular study, the authors say that one patient actually died of non-COVID19 causes, and only five were having treatment when they got COVID19 (none of whom died). 

So whilst the studies suggest people with cancer are at an increased risk, we need to know more.  Oncologists, like the whole healthcare service, are working incredibly hard to learn, fast, about the risk from having cancer, from anti-cancer treatment, and the mere fact that having anti-cancer treatment means leaving the house and coming into contact with other people.

But the take home message here is: people living with cancer, we've got your back.  It's scary but oncologists are massive evidence nerds. The evidence is coming and we're with you all the way. Stay home, stay safe.



Disclaimer - I would be DELIGHTED if anyone wants to update me with any important references I've missed.  

Roofs and Redeployment

At the time of writing, nearly 30,000 people have been diagnosed with COVID19, and just over 2,300 people have died in the UK.  The NHS has done the biggest reshuffle in its history and my card has been dealt - redeployment is finally here. 

I'm shortly going back to the cancer department, 8 months after I paused my clinical work to start a PhD.  The overarching emotion is relief.  There's also decent dollops of guilt (at the worry it causes my family, and at the time I've been out of the clinical game), anxiety (will I know what to do?) and a general sense of overwhelmedness. 

As discussed, Mr KP works as a doctor in the Emergency Department, so we've already started a system of minimising the risk at home as best we can.  We've established a COVID19 decontamination area in our house, and a system of cleaning our clothes and ourselves when we get home.  We've dug out old pairs of scrubs which we've previously debated throwing away - thank goodness we didn't! - so that I have something to wear when I'm on call (oncologists generally just wear office clothes... until now!).   Like a hospital, we now have COVID zones, just within our own house! 

So much of this feels like mental preparation - personally, that means avoiding the news. Apart from the fact it doesn't change my management plan (I'm still going to be socially distancing... I'm still going to go back to the hospital...), often it's hard to watch the hype.  For example, the hype around escalation and resuscitation decisions.  I think this speaks more to the fact we need to talk about this more in non-COVID times if its headline news that intensivists have to make reasoned decisions about who will benefit from intensive care.  This is no more true now than it was before, although admittedly we all worry about these decisions becoming more challenging.  Perhaps we, as a medical profession, need to learn how best to convey that in times of peace as well as times of war. 

I'm stumbling over the kind messages of support from everyone at the university.  It's quite overwhelming when people keep saying they are proud of you when you haven't even done anything yet.  I certainly don't deserve any praise; it's my clinical colleagues who have been managing the daily changes in policy, rotas and ward movements.  My only positive contribution has been towards a UK-wide coronavirus cancer monitoring project - an attempt to learn as efficiently as possible from cases of covid affecting patients with cancer.  It's been amazing to see a project like this, one that would normally take reams of paperwork and months of admin, get off the ground in a matter of days.  It's reflective of the ability of how the NHS has adapted like never before. 

My PhD swansong will be Journal Club - it has felt somewhat surreal preparing a figure-by-figure analysis of a paper about genetically engineered stem cells whilst simultaneously joining webinars to refresh my understanding about clinically managing COVID.  Maybe someone in journal club will ask me about identifying bilateral pneumonitis on a CXR, or how to interpret an ABG, or vice versa someone in the hospital might want to know about intratumoral genetic heterogeneity?  Unlikely, but a girl can hope!

Life goes on - we've just discovered that our roof will probably require major repairs in the imminent future - and I've got no idea when we'll have time to resolve it.  In reality, it's just going to have to wait until we're the other side of this.  But we're very fortunate - not least to have jobs and ones that keep us busy at that, which I realise not everyone are lucky enough to have. 

So wish us, and our roof, luck.  Fingers crossed we all keep it together in the weeks ahead.

Love in the time of Coronavirus

I have a friend who works as a cruise ship doctor (he's one of life's top humans, by the way. He created the bar for our wedding despite running two businesses and having at least two other jobs. And he is generally chief orchestrator of FUN).  In fact, he's on a cruise ship right now.

Now I know what you're thinking - working on a cruise ship, now? Bold!  And then think that through - can you imagine three months ago thinking that working on a cruise ship could be considered an extreme activity?

It seems prudent to write at this time, if nothing else to serve as part of the record of this once-in-a-lifetime event.  I'm a cancer doctor but as chance would have it, I'm currently a laboratory-based PhD student doing brain cancer research.  I have been doing work on-call (weekends, evenings) since I started in August but basically I'm a scientist in training right now. I feel utterly helpless.  I've had all the support I could dream of in terms of going back to the clinical world, and have indeed been told that I'll probably be drafted in to work clinically.  But it's all about timing, and the time is not now.  For now, I need to try to calm myself and generate some kind of PhD-from-home strategy, and for how long no-one knows.  Meanwhile, Mr KP, who works as an Emergency Doctor, has been living the effects of the day-to-day changing of decisions, policies and patient flow.  Having just finished nights, we've therefore both been at home.  

Mr KP and I are so very lucky.  For one thing, we're a 'we'! Social distancing is a lot more tolerable when there's two of you. And although we are generally not people who talk about work in our home, it's a relief to have someone who understands as much as anyone can right now about how we're going to emotionally deal with this.  Love!  

Our survival strategy - games and gardening!

 

Physical on-your-own isolation must be tough, and I'm reaching out to friends who live alone; but what's been interesting is that this event feels (for me at least), The Opposite of Loneliness.  I've actually had to mute essentially all of my WhatsApp groups and put my phone in another part of the house for large parts of the day.  One evening there were easily 200 messages floating between my two labs and my clinical work WhatsApp groups.  Love, but for me, it's a bit too hot to handle.  

We are incredibly lucky to have such a big group of medical friends who, quite honestly, have been my source of calm in all of this, in spite of the fact they are the very ones on the coalface.  I had a big gathering of my best buds from university in late January (again - timing! Phew!) - forty of us when you include kids, plus a couple of dogs for good measure.  That's the sanest big WhatsApp group of which I'm part.  We've started doing regular video meet ups and it would be a strange irony that being so limited in our ability to physically be together will probably bring us closer together in just about every other way.  Love! Social distancing is so important, but we can find trust and comfort even in physical isolation. For me it's helped me manage my worries about what's ahead.  

Fuelling anxiety helps no-one.  That's what makes it galling when you see the over- or under-playing of the situation either by excessive Twitter anxiety or lack of social distancing respectively.  The result? Anxiety - and actions driven by anxiety - or inaction.  I've seen any number of articles by Dr Blah Blah Blah saying the government strategy is wrong, or it's not enough, or it's too much, or everything in between.  I used to read these articles.  Now I don't.  Why?  Because this is an unprecedented situation, and I am not an expert.  I see in my day-to-day life that uncertainty and ambiguity leads people to be unsure about what to do - so either they fail to change their actions, or feel anxious, or any number of unhelpful things.  We would never trust one individual person's view (our own or someone elses) in our own lines of work, so why do we do so now in an area so complex and multifaceted? Show yourself some love and switch these sources of reading OFF.  

People keep saying to Mr KP in particular that things must be very stressful given his line of work.  Honestly, I think it helps to know that he, and eventually me, are able to be useful.  I appreciate this particularly currently as I feel useLESS.  The need to feel needed is a powerful emotion, and surprisingly stressful.  That in itself makes me feel guilty - and so the cycle continues.  My utility right now is probably to Stay Well, reach out to the lone livers and find a sustainable way of living distantly.  And encourage those I can to Calm Down and #StayTheFHome.  

Rays of light as storm clouds gather

As Hugh Grant (or The Prime Minister) wisely said in That Film - 'General opinion's starting to make out that we live in a world of hatred and greed, but I don't see that. It seems to me that love is everywhere. Often, it's not particularly dignified or newsworthy, but it's always there - fathers and sons, mothers and daughters, husbands and wives, boyfriends, girlfriends, old friends.... If you look for it, I've got a sneaky feeling you'll find that love actually is all around.'

So go and give your loved ones a virtual hug, and thank modern technology that we can!

Hi, I'm a 31-year-old doctor... and a PhD student

At a PhD induction I was chatting to a fellow new PhD student. She asked me about my background and I explained that I was actually a doctor and was taking time out to do a PhD.

'What, you're already a doctor? Why do a PhD? You already get to call yourself 'doctor'!'

I had a little giggle and then realised that to many people, I am an 'old' new PhD student, and the fact that I have a whole other professional identity (that, yes, technically comes with title of doctor) is a bit bonkers.  I mean, why put yourself through a PhD?!  Four months in to a PhD I only have 3 years to complete (most science types this side of the pond take at least 4) and it already feels daunting to get something finished in that time.  Clinicians often say it must be nice to have a break from clinical work - but all I'd say is that it's very much 'out of the frying pan, into the fire'!

It's surprising how controversial it is to be a doctor who is back to being a student. I already have a job and a career, and an all-encompassing one at that.  Looking after cancer patients with all the crazy shifts, difficult decisions, and emotional ups and downs is surely enough!  But to the wider world, the controversy is greater still.  Yup, I am more expensive than a straight-from-undergrad PhD student, and clinician scientists are inevitably more expensive than pure scientists.  Are we really worth it, with our divided loyalties and dual demands on our attention?

I'd counter that with some of the following arguments.  I'm one of the few people in my building who have worked at the oncological coal face and know how it feels to sit down with another human being and tell them there are no options left.  I know what it means for someone to have anti-cancer treatment and what people endure to get better, or get more time.  On a more practical level, being a doctor means being organised, comfortable with stress and at ease with long hours (and recognise when it's time to stop).  Hopefully it means being able to plan and manage your time, and function independently.  I'm used to swizzling clinical jobs every few months and starting again, again, with new skills/routines/colleagues, which is useful when you have endless new protocols with which to engage in the lab. Obviously these are skills all PhD students hope to hone during our studies but it's a good place to start.  And importantly, at the other end, we are able to be the connection between scientific innovation and those who might benefit from it: patients.  So we may seem costly, but I'd say it's potentially a pretty good package deal. 

The real reason, for me, is passion for change.  Having a difficult conversation with a patient about limited, or indeed no, treatment options, or treatment not working, is part of the role of an oncologist.  But obviously it sucks.  I think I'm quite good at breaking bad news.  However, it's a seriously weird thing to feel like you're good at, and obviously a gut-wrenching one. It feels deeply unsatisfying to accept the status quo, especially when even in my short clinical lifetime there has been such innovation and progress. I'm keen to be a driver of that change. 

So yes it's a bit weird doing a PhD as an 'older person' (ha! As if 31 is old) with a mortgage, a wedding ring and a second career on the go, but it's also lovely to have the perspective of where a PhD sits in the rest of your life.  I'm under no illusions that this will be stressful, but nothing is as stressful as clinical stress, with real human lives at stake.  I also think back to the anxious twenty-something who felt she had to be everywhere (work and social) all the time, whereas now I have let that guilt slide a little and just trust in myself - I work hard, which is just as well, because science is hard, but it's not everything.  I'm writing this now also to hold onto these important truths when all my experiments start to fail and I enter the Dark Zone of a PhD...!

One thing I will say - I envy the energy and vivacity of my fellow PhD students.  I'm sure that the seven years since I graduated from medical school and the many night shifts, long shifts and weekends of work that have happened since then have somewhat worn me down.  That's certainly something I will latch onto, if they'll let me :)

Hello, student life!

Well blog friends, a lot has happened these last few months.  In a strange backwards approach to growing up, having bought our first home a few months ago, and getting married a number of weeks back, I'm now a student again!  Aged 31 and two months, I am a full time PhD student.  Hurrah!

Teeny tiny married people 

And it really is hurrah.  I'm really excited about being back in the lab, and two weeks in, it's like learning a new sport, only it's one involving only my brain.  My PhD is looking at stem cell-ness in brain cancer.  It's quite a different area of research to what I've done before (the common theme being 'cancer'), which was very much intentional, but I'm hoping that my various previous research experiences are going to be useful platforms for the years ahead!

What of saying goodbye to clinical life for the most part (and just for now)?  Hmm... I'm probably coming at it from a slightly negative angle, which is hard to avoid when your last little spell of clinical work was Extremely Stressful.  I've been a doctor for 7 years now, and training to be a specialist in cancer for the last 18 months of that.  There's a graph of confidence (y axis) versus competence (x axis) and they say that after an early peak in confidence, it's quite natural for your confidence to stack it even while your competence continues to grow.  The problem is, where patients i.e. human life is involved, it's quite hard to ride that low confidence wave and remain objective about your competence.  Inevitably, with greater seniority comes more responsibility, and a degree of taking one for the team.  Generally I feel like I manage that pressure quite well, and even start to think I'm a good doctor. 

But I worry that I've worn down my resilience.  I think I'm a good clinician and good with my patients. I care a very great deal and I learn so much from not just my clinical colleagues and seniors but everyone around me.  But the gremlins are lurking and I'm happy to step into the sunshine and away from them for a while.

The first thing I'm learning, and in some ways relearning, at the start of my PhD is how to chop out and plug in important bits of DNA into very precise areas of a cancer cell's existing DNA.  This was something I learned to do when I was in the USA, only now we're applying it to different important areas of brain cancer cells to understand what impact it will have.  It's an exciting time, and I know a PhD is a big mountain to climb.  But damn, it feels good to have my hiking shoes on again.

The Big C and Crowdfunding versus Clinical Trials

Cancer crowdfunding is something that crops up in my professional world from time to time - where patients choose to raise funds to get experimental treatments generally abroad.  I've met a handful of patients who have chosen that path, like in this video article of a young woman's family who sought crowdfunded care in Germany.

To understand my uncertainties about cancer crowdfunding, it's possibly helpful to explain how any drug comes to being available to a patient in the first place.  Clinical trials are how we get drugs from concept-in-the-lab to standard of care treatment.  We generally divide it up into a number of chunks (image from Cancer Institute NSW, 2018)

Pre-clinical - The lab bit.  So whenever I've rambled on about lab research on this blog (got to pick this entry from near the end of my MSc entitled 'This is NOT panicking' - a title which for me, at least, epitomises lab research!) - that's pre-clinical research.  One could pick this apart further, but essentially this is where you test things in a lab.

Phase 1 - The 'first in humans' bit.  Patients involved in phase 1 trials are, in my opinion, absolute heroes.  This is where studies will test new treatments in humans for the first time, gradually increasing the dose from patient to patient to understand more about the drug and its side effects.  The main purpose is to work out if it is worth proceeding to phase 2 and at what dose. Often they are given alongside established drugs - for example, chemotherapy plus new drug - so even in a trial setting they are getting previously approved anti-cancer therapy.

Phase 2 -  The 'Is it safe and does it work on a small scale' bit.  This is where the team says 'Ok - this is safe. Now let's give it to more people at the dose we sussed out in phase 1 and work out how to give it (how often, where, when), what the side effects are like and start to get a sense of whether it works or not'.

Phase 3 - The 'Does it work' bit.  These are big studies to find out if the new treatment works.  Usually patients are divided into those receiving the current gold standard treatment in a particular situation (or placebo if there is none) and the proposed new treatment regimen.  To be a good study, this division should be random, and 'blinded', which means not knowing which treatment you're on.  If the new treatment comes out on top, the researchers will argue the case for the new treatment becoming the new standard of care.

Phase 4 - The Afterparty - The drug is 'Out There' - and phase 4 is basically where toxicity and efficacy continue to be evaluated.

Phew.  So as you can see - it's difficult.  Very few drugs which start out looking promising make it out the other side.  It's really, really expensive.  At every stage, everyone involved has to remain as unbiased as possible to avoid pushing on with a treatment that ultimately doesn't work.  That's harder than it sounds when everyone wants a miracle.

My worry with cancer crowdfunding is that the above steps are bypassed.  During the tragic case of Charlie Gard, the people in my lab and I would discuss and debate, as I think many people were, the lengths that are worth going to in search of medical miracles.  I know some people round the table felt there should, and could, be no limit.  I'm less sure.  Perhaps I am inevitably biased by my job and the fact I cannot say I've ever seen a 'miracle cure'.  I've seen people promised what I know to be scientifically impossible or illogical, and hope being used to persuade them to proceed in spite of this.  Most people that have sought outside-the-box options spend inordinate amounts of money and 'feeling well' time, with no extra time gained.  Indeed, some studies demonstrate good early palliative care can actually buy patients the most time.  When people say that they think people should do anything to find a treatment, I find it hard to forget the many patients whose care I've been involved with in their final days of life.  I wonder what those patients would say.  I also wonder what patients and families who want to be allowed to let go feel under the pressure to seek treatment at all costs.

We should be encouraging clinical trials, because it's the only truly rigorous way of working out the best novel and innovative ways of treating people, and often allows patients who are out of standard treatment options access to the most experimental agents out there.

That's why I feel some anxieties about the cancer crowdfunding thing - proceed with caution.  

All That is Cancer Is Not Lost

Merry Christmas and Happy New Year, folks!  Phew, the last 4 months have been...well... crazy.  We've moved across the country, new jobs, planned a PhD (ish), moved house 3 times, bought a house, planned a wedding.... I can't necessarily recommend doing all of these things simultaneously, but equally doing so much 'adulting' in a short space of time feels like something of an achievement!

The cherry on this life cake was that I drew the short rota straw and was on call on Christmas Day - maintaining my 100% clinical Christmas working record!!  However, I really can't complain - for one thing, as ever, festive cheer was in great supply and I even met Santa :). And secondly, I was able to 'leave the building' and do the remainder of my 24 hours on call from home.  That means phone calls at 3am, but it also meant Christmas dinner courtesy of Mr KP!

A lot of being 'on call' for oncology involves being called by other doctors from essentially any clinical department for advice - A+E, GPs, any medical or surgical specialty, intensive care, etc etc.  We are often asked to give a view about prognosis and expected outcomes to help them guide their decision making. Prognosis is really hard to gauge, particularly at the end of the phone, sometimes in the middle of the night.  Clearly at my stage if it's unclear I'll seek higher wisdom.  But my main take home in the year I've been an oncology registrar is this:

• Metastatic cancer does not mean someone is at the end of life.  In some cases, they are still curable.
• Palliative treatment does not mean that someone is at the end of life.  
• Palliative treatments (yes, plural, for many cancers) can significantly extend life, and quality of life.  
• Patients with metastatic cancer on or considering palliative treatment can, in some cases, live for many years and may even die with, rather of, cancer. 

The wider world should be encouraged that oncologists are consulted on these sorts of matters, but I can't help but feel we should be doing more to spread the gospel that all that metastasises is not lost.  Of COURSE one can never give a blanket, catch-all statement about all patients with cancer - cancer is not one disease.  It's lots of different diseases really, with different biology, different molecular profiles and different treatment options. Plus patients may have other medical problems that must be taken into account.
But (for example, and broadly) - metastatic testicular cancer is often still curable.  Patients with metastatic prostate cancer have a prognosis of years at diagnosis, as do many other cancer types.  Yes, some cancers have a less positive outlook, and it's important we are up front about that too.  Also we can't predict how everyone's individual cancer will behave - sometimes they progress faster or slower than anyone can predict.  The point is that it varies HUGELY.  I sometimes wonder whether we need to change our language as oncologists.  Heart failure is a chronic disease which is generally irreversible and can be life-limiting but can be medically treated and extend life - in what way is metastatic cancer different?

So consider this blog post the start of my efforts to get the word out there.  My professional New Years Resolution is to talk more about prognosis and manage expectations for patients and medical types alike where cancer is concerned.  I am determined to be a pragmatic advocate for my patients. 

Adventures of 2018 offering inspiration to those of 2019!

2019 is going to be full of adventures, with hopefully more hill stomping, sea swimming, music playing and, now that I have a view to paint, a return to creative moments! Because if doing a job like mine doesn't teach you that the most important thing to embrace Living, I think you're probably doing it wrong.  

To Scotland we go!

I'm not sure if it's just because I've moved to sunny Scotland, but it definitely feels like Autumn is on the horizon.  In life terms, for me it's definitely 'Spring'- new job, new city, new adventure awaits!  Who says turning 30 means life gets quieter....

Scottish sunset loveliness 

The Mister and I have migrated Up North in search of that career/life utopia known as Work Life Balance - or rather, having everything we could dream of from both of our jobs with everything we could dream of for our lives (read: buzzing city, mountains, the sea and such) all on our doorstep.  My new job means I continue my Oncology specialisation training and do research all the way to Consultant-dom - exciting stuff! As anyone who has ever moved house will know, it's been rather epic - after all, the downside of being 'in one's thirties' is that a significant accumulation of 'Stuff' has happened.  Long gone are the days of fitting everything in the back of my Fiat Punto.  I've reached the stage where we have to put furniture in storage, and need not just a van but actual human help to move our belongings from A to B. Ahhh! I'm a grown up!!

A few weeks into my new job, it's all starting to slot together.  My new colleagues and department could not have been more welcoming, and the training environment feels very supportive.  We've certainly had a thorough induction which is never to be taken for granted, and always appreciated! It may surprise those who don't work in healthcare to know that there is amazingly little overlap between the day-to-day computer and information systems in different healthcare trusts.  It's amazing how many different ways there are to communicate a blood pressure, prescribe a drug or request a chest x-ray.  Purple forms (Do Not Rescuscitate forms) are now Red Forms.  Aria (chemotherapy prescribing software) is now ChemoCare.  EPR (electronic patient record) is now Trak.  Everything is different!!! Of course, that's in addition to all the newness that comes with any new job - new people, new logins x1000, new buildings (yet to work in a hospital that isn't a maze!!!).

Moving = chaos... 

I became an Oncology Registrar six whirlwind months ago and I've had the rather odd realisatisation that I may have actually learned something during that time. Becoming a specialist was incredibly daunting. I was forced to have faith in myself, and trust in what I did, and didn't, know.  I survived a steep learning curve, and by the time I moved up here, I felt like I was better than when I started (with a blimmin long way to go!).  I felt like people (the patients as much as my colleagues) trusted me, and I started to trust myself.  I felt like, to a few people at least, I might have made a positive difference.  Conversely, I felt like I had been honest and reflective when things hadn't gone so well, and, overall, I felt accepting that it was OK to still be learning and ask questions.

Reflecting on my first months as a registrar, the most useful and important thing I learned, courtesy of a superb consultant I worked for, was this - I should trust in the relationship between me and a patient. Listen to their anxieties, meet them with your own, and have faith in each other when you make decisions together.  I also remain convinced of the best baseline triad of rules for any doctor (coined by an Emergency Medicine physician I think) - don't be a d***, and be kind to yourself and others. The middle of these is the one I think many of us struggle with, and I hope an area in which I'll improve.

Leaving a place I knew was incredibly daunting, having done all of my postgraduate medical training there (2 plus 3 years), meeting some incredible mentors and making precious friends. But it's exciting to look forward and get a fresh perspective. I'm hoping to blog a bit more often about working in cancer care, and about cancer research, and I hope you'll enjoy reading along.

Turning 30 ain't so bad! 

Registrar Reflections

Happy new year, bloggers!  Or rather, Happy Spring!  As ever, I've been a bad bean at keeping up with things.  Updates from my end:

- I'm a Medical Oncology Registrar - yikes! (i.e. the last bit of my specialist cancer doctor training)
- I'm heading back to the homeland - wowsers! (i.e. I got a Clinical Lectureship in Scotland to facilitate ongoing nerding out alongside clinical training with mountains in situ!)
- I said 'yes' to getting married - woohoo! (I'm not sure this one needs explaining...)

So it looks like 2018 is going to be a busy year.  But the first of those three things is the main thing keeping me entertained at the moment.  People say becoming a registrar is the scariest step up after qualifying from medical school in the first place.  Seems to me that makes it an important experience to reflect on, and four weeks in, here are my early thoughts on being a new registrar.

1) People are a lot nicer to you when you're a registrar than when you're an SHO.  Not that they were horrible to me before.  It's just a totally different vibe, both within and beyond your department.  Within my department, everyone has been supportive and helpful, offering help and general wisdom.  Beyond my department, people are willing to hear you out with a kinder word.  I guess it's just a general conveyance of being wanted.  Something I will definitely reflect on in my interactions with junior colleagues. 

Disproportionate excitement at having my own one of these.  

2) It actually feels like I'm being trained to be a specialist with specific skills and knowledge, rather than a bum on a seat that will learn things by osmosis.  It's really made me think about the point of middle-stage training - in my case, Core Medical Training.  I've been a doctor for nearly 6 years, but I'm pretty sure this is the first time I've started a clinical job and felt like I haven't been chucked in head first in hopes that I'll just work it out. It's also the first time I've had a desk!  And a locker!!!

3) It's quite scary that people take your word so seriously.  But that's part and parcel of getting more responsibility, right?

4) There are a lot more men than women the higher you climb up the ladder. 

5) Associated with being higher up the ladder - it does not stop you getting a lot of advice you didn't ask for.  I've been pondering if this is an issue suffered more by female professionals, because I don't recall my male colleagues ever grumbling about it.  Don't get me wrong - I am in serious need of help, wisdom, support and advice, particularly at this juncture of my professional life.  And to an extent I probably don't know what I need to know, and should listen to random nuggets of advice.  But I'm getting a little tired about being given advice about work, life, work/life balance, family life, social life etc etc... without being asked about my background in any of these areas. 
Seems apt at this point to give kudos to my last Educational Supervisor, who, three years ago, spent the first few minutes of our introductory session getting a summary of my life so far.  Meant that when he did give me advice, it felt like it meant something and was actually relevant (and it was indeed life advice I think I'll remember for a long time to come).  Again, something I will reflect on moving forward. 

6) Also I need to chill about the whole 'unwanted advice' thing.  It's always well meant.  I think.  And it's going to keep happening.  I think.  So might as well not raise my blood pressure over it. 

7) The main difference of moving from generalism to specialism is the loss of one's barometer.  I feel like in general medical situations I'm pretty ok at feeling it out - you know, 'bad' versus 'not bad', and knowing when to worry versus when to be reassured.  When you move to becoming a specialist, your barometer is not yet fully formed.  I'm sure it will, in time.  Right now I feel like I'm anxious pretty much all the time, and asking a thousand questions.  But I think it's probably better to be neurotic at this stage of things that over-relaxed. 

No #snowmaggedon will stop me getting to work...

8) I'm not terrible at this.  I did my first 7-day stint as the oncology registrar on call recently, which involved being the acute oncology ward registrar as well as taking referrals/giving advice all over the region and making admission/discharge decisions through the oncology triage unit.  It was full-on information overload, with my bleeps, mobile phone and emails all going off, often simultaneously, in addition to nurses and junior doctors coming to me with problems that needed solving.  Going home at night-time over the weekend knowing my phone could go off at anytime was a whole new experience.  I didn't do it all perfectly and there is a LOT of room for development - but I did it.  There were no tears, we even had a few laughs.  When one of the F1s said I'd been a good registrar, I wanted to hug her.  I left thinking 'I can do this'. 

There will be many nerve-wracking 'firsts' over the next few weeks, but I'm going to have to embrace the familiarity of these emotions.  I KNOW what it's like to be absolutely terrified - my first week of nights as an FY1 (= intern) I basically didn't sleep for terror, and cried after almost every shift.  I've got to take some confidence from the fact that I've come so far from those scary days.  Plus I think a lot of the nerves comes from being a perfectionist.  Not an awful quality, as long as you keep it in check...

Also high fives and hugs to Mr KP and friends who have provided important moral support.  Maybe that's the difference - it's much easier to go to work and do your thing when your house is in order (metaphorically as well as literally).  Yippee!

Mental Health and the Medic

Wonderful post-nights fall frolicking

I've just finished another week of nights and for some reason, they really knocked me for six.  I've done night shifts ever since I qualified as a doctor five-and-a-bit years ago, so I can only conclude that ageing is starting to hunt me down. To an extent, I think I've got my routine sorted, and my night shifts on my current job are far from my most stressful. Nonetheless, there are still moments when you get a bit anxious about the decisions you made in the middle of the night, or feel a bit low when you're looking after particularly unwell patients who pass away despite your best efforts.  But I think these are normal feelings shared by most doctors.  The difficulty is recognising when the feelings of 'down and anxious' are the rule rather than the exception.

In the last few months, it has become increasingly apparent to me how many of my friends and peers are suffering from mental health problems.  Of course, I am not here to 'out' them - but more to reflect on this silent wave of illness that simmers beneath the surface, just as much as any cancer, before it makes its presence known.  Depression and anxiety in themselves affect a huge number of people - and yet they go completely unspoken as if they were an embarrassment or a failure.  What is notable to me is that most people I know in this situation are, on the surface, absolute high flyers.  They are the best of the best in what they do.  They have never known professional failure.  They are held in the highest regard by their peers.  They are outwardly A Massive Success and yet they are not well at all, and see this as a failure.  

I have sometimes struggled to know how best to support my friends as they make the journey to recovery.  Perhaps that comes as a surprise to lay people that I, as a doctor, don't know what I'm doing when it comes to this aspect of health, particularly when it hits close to home.  It's difficult to know you're doing or saying the right thing, that you're making yourself available enough both physically and emotionally, and that you're striking the right balance between simply listening and actively advising. It makes you question your ability to be not only a good friend but the right kind of friend.  I'm still not sure I've nailed that balance.  I've definitely found I've needed my own support network to offload the impact of these precious, complicated feelings that have been entrusted to me.

An Austrian vista

The conclusion I've come to is, much like grief, the most important thing is to look it in the face and acknowledge it.  It's easy to focus on the 'good days' to avoid accepting the greater majority of 'bad days', particularly when 'bad days' are really, really bad - and being unable to 'function' on such days is a sign that it's time to find help.  We are worth so much more than living in misery and struggle.  And 'looking it in the face' goes for those of us supporting peers, friends and loved ones too.  We mustn't shy away from it because we're scared that we'll react, listen and respond in the wrong way.  Far better to engage imperfectly than not to engage at all.  

I am glad that the Royals (cheers, Wills, Kate and Harry) are making mental health an area for national discussion - it affects everyone and anyone, and respects nothing and no-one.  There are those that might read this and think that to complain about high flyers with mental health problems is barely a problem worth talking about - but I would disagree.  We're all people and this is a problem that will only worsen with time.  Not talking about it feels like a far greater risk.  

Our mental health is a precious and delicate thing, and I'm aware that I need to find my own ways of looking after mine.  My dad is the one who taught me not to work too hard - to work 'quite' hard, and with commitment and passion, but not to lose sight of the balance of things.  Having got that balance wrong quite often during my training, I hope that I'm establishing a sustainable work-life balance, and it's that sustainable element that made me quite comfortable to admit this 'don't work too hard' ethos over an academic dinner to my neighbour, who worked for a major research funder.  And you know what? She welcomed it.  And that makes me think that the Big Guys understand that this is a problem too.  

Take care of yourself, and take care of those around you.  Don't be afraid to ask the questions 'are you ok? Is there something else going on?' - asking these questions is unlikely to make things worse, and may just be the trigger that turns someone's life around.  

The sneaky approach of Black Wednesday...

Another year in the lab is about to come to an end, and what a whirlwind of a year it's been.  For a clinician scientist-in-training like me, it can often feel like you're treading water rather than actually swimming forwards.  But for the first time, as my last phase of general medical training (Core Medical Training) approaches, I feel I can see the light at the end of the tunnel.

Bungles here, Bungles there, Bungles everywhere!

Do you ever look at yourself in the mirror and wonder how on earth you ended up, well, HERE? Wherever 'here' is for you.  In my case, I'm 29 years old - TWENTY NINE!!  And I'm a doctor, and still quite a junior one, but not a very junior one.  And I'm also a scientist, and still quite a junior one, but I guess also not a very junior one.  Hmm!  And hopefully I'm also a lot of other things - being, as I hope, not entirely defined by my professional roles.  For one thing, I think I've nailed 'the doctor game' with my 3 and half-year-old niece (her idea, not mine!), and my colouring in skills are second to none.  The point is - I've progressed!

 A friend of mine quite wisely pointed out recently that while it can often feel that we are being pulled and pushed along a path we have not designed, ultimately we have made choices that lead us to where we are now.  It's just easy to forget them.  So when I read statistics such as an increase in unfilled junior doctor positions of 31% in one year, I know that's also no accident.  For the training programme I'm soon finishing, they have seen an increase in unfilled posts of nearly 10% in ONE YEAR.  Go one step further back in the career ladder, and only half of doctors completing the foundation programme (sort of like internship programmes) applied to higher training as GPs or specialists.

Dreaming spires, even when the summer sun is hiding

I'm part of a new generation of doctors, unfamiliar to the last, that is taking the scenic route through postgraduate medical training.  I too took a 'gap year' between foundation and specialty training - as did most of my friends at medical school.  Taking time out is not 'wasted time' - we return to training with new skills, new knowledge and new energy.  For me, research offers the opportunity to exercise a different part of my brain and I don't think it makes me a worse medical doctor (as discussed elsewhere in this blog).  For those who take time out to do short term clinical jobs in specialist areas, what they bring back to the table is hugely valuable.  In fact, I recently spoke to a friend who is now finding it difficult to be competitive in applying for a position outside her training programme because they have gone straight through without any time out.  I strongly feel that if the System closes its doors to these creative routes through medicine, those statistics of unfilled training jobs will only become more worrying.  

I am also part of a generation of doctors who has lived through this contract and NHS reorganisation fiasco.  And of course it's made me think about my priorities - because the system in which I work does not have time to worry about them on my behalf.  For me, having time to cycle, go for a run or play music are things that make a busy working life sustainable.  In the rotation I'm about to start, I got my rota a few weeks in advance, had a degree of choice over which rota I started on and I've already had some very precious annual leave approved.  They sound like little things, but they make me feel like a person with a life.  It's these little things that can make all the difference.  

Hopping from one job to the next...

So as Black Wednesday finds me, I'll be nervous to return full time to the clinical world and leave my cells for someone else to worry about.  My tips for new docs?  Gosh, I can't believe it's five years since it was my first day on the wards.  The top tips I'll be referring to myself are:

1) Ask a zillion questions over the first few days.

2) Learn how to do the basics! Prescribe things, request things - the actual LOGISTICS of doing these things are often the hardest!

3) Learn everyone's name - nurses, cleaners, HCAs, doctors - they are all friends you will need along the way.  

Wherever 'here' is for you this Black Wednesday, good luck - and remember everyone's had a 'first day' :) so be nice whichever side of it you're on!

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.

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!

#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!

The Third 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'.