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.