Everybody is wrong about obesity…sort of

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The controversial Cancer Research UK advert.

Obesity – a body mass index (BMI) >30kg/(height in m)2 – is both common and a controversial topic.

Questions about obesity

Is BMI accurate?

Well…yes. And no. So sort of both.

The body mass index is inaccurate in certain circumstances but not as wildly inaccurate as is often implied. I’ve worked mostly in deprived areas. The issue is rarely that my patients are bodybuilders or rugby players. Their increased BMI is almost invariably due to excess abdominal fat.

Like any measure in medicine – heart rate, blood pressure, Glasgow Coma Scale, blood sugar, cervical dilatation in labour – it fits as part of a wider clinical picture. No, it shouldn’t be used alone but it remains useful for assessing and stratifying patients.

If you’re Mathieu Bastareaud then perhaps BMI is irrelevant. If you’re not, you should probably take your BMI seriously.

Does being fat cause cancer?

The advert pictured is the one that made me start writing something about this, alongside comedian Sofie Hagen’s objections to it which made various news outlets. The issue? “It’s only a correlation” or “no causative link has been proven”.

Well…Cancer Research UK begs to differ. It proposes three main ways. Fat secretes oestrogen, secretes insulin and IGF (insulin-like growth factor), and causes inflammation. These 3 processes cause more cell division. Cancer is uncontrolled cell division (essentially a growth that will not stop). So the more these 3 processes occur, the more cell division there is and the more likely it is that cancer will develop.

 

Obesity is correlated with cancer; few dispute this. Moreover, there are pretty solid biological mechanisms by which this may occur . Whilst more research should be done, it comes down to this: nothing in medicine is perfect.

Few things that we make claims for or do in medicine have the sort of evidence that the obesity-cancer link does. Indeed, if this is insufficient, then close every intensive care unit (ICU) in the world.

About the only things we’re sure about in ICU is timing of percutaneous tracheostomy makes no difference, lung-protective ventilation is good and restrictive transfusion strategies are probably better than liberal ones. There is lower-level evidence for other stuff but, like obesity, there is so much going on in ICU, it is difficult to isolate specific causality. However, far, far more research has been done into obesity, not least because there are way, way more patients.

Can you be “fat but fit”?

Or more correctly the MHO or “metabolically healthy obese” individual. These are folks who, when they have a variety of investigations, appear “metabolically healthy”.

Whilst this study and this study both in well-respected journals in their specialties suggest MHO is not associated with increased mortality compared to the healthy non-obese, there are plenty more which dispute the definitions, its existence or whether it is any healthier. This paper suggests that MHO is mostly a transient state that will become metabolically unhealthy obesity with time.

It’s not uncommon to see articles cherry-pick a study supporting MHO. Always be skeptical. Obviously, being fit and obese is better than being unfit and obese. But being fit and non-obese remains the healthiest option.

Bottom line: obesity is very likely to be bad for your health and is a cause of cancer.

How to lose weight (in your mind)

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This “obesity map” shows all the factors which lead to obesity. Source

Sure, at a personal, physical level it’s about reducing calories, reducing calories and reducing calories. And slightly about exercise. But seriously – it’s all about reducing calories. But on every other level, obesity is terribly complicated as this image shows.

However, the National Institute for Health and Care Excellence (NICE)’s guidelines have very little about what psychological advice to give to a person trying to lose weight. We know that we unfairly stigmatise the obese, that that stigma becomes internalised, and that the stigma is harmful to our patients. Moreover, the internalisation itself has correlations with poorer physical health morbidity and mental health morbidity (i.e. morbidity meaning other diseases). Thus, fat-shaming almost certainly does harm and is probably associated with poorer health.

What should doctors actually say to obese patients?

I mean, actually, literally what words should come out of the doctor’s mouth? If a patient walks into a GP’s consulting room with a lower respiratory tract infection requiring antibiotics, is this the time to bring up a patient’s weight? What about a woman with a BMI of 43.3 (5’7″, 20st) who attends for her 12-week scan? Or after 3 months coming off a ventilator because, at their weight, they really shouldn’t have been having their hip replaced (I speak from experience on this one)? And if none of these…when?

This paper by Rand and colleagues entitled “It is not the diet; it is the mental part we need help with.” looks at the myriad non-physical causes of obesity. To put this more crassly, why do obese patients keep picking up the fork?

If somebody presents with obesity, giving them advice about dietary changes is rather like telling footballers they need to score more goals than the other team or this advice from Sir Ian McKellen on acting in Extras. Whilst superficially true, it gives no insight on how to complete the task.

(As an aside, it is worth noting there are patients, particularly in poorer areas, who genuinely will not have insight into their condition. It is still worth pointing out they need to lose weight to be healthier/score goals to win.)

A 2015 systematic review by McGuigan and Wilkinson demonstrates that obesity is associated with healthcare avoidance, in part due to perceived or actual discrimination. If patients think healthcare professionals will be mean to them, they won’t seek healthcare.

Obese patients will respond poorly if they’re depressed, anxious, suffering from post-traumatic stress disorder, and/or any other mental illness or psychological issue. The causality goes both ways. Depression probably causes obesity as much as obesity causes depression. The latter will be created or at least reinforced by aforementioned societal stigmas.

Bottom line: psychology and mental health are probably as important as calorie-counting in managing obesity (and doing exercise but honestly it’s almost all about diet, exercise is good for you on its own terms).

What does it all mean?

If you deny BMI is useful, you’re wrong. But we ought to ask more about mental health, rather than simply doling out dietary advice.

Ultimately, the UK does a bad job of tackling these factors but in part, for healthcare professionals in all professions, one shouldn’t underestimate how difficult discussing obesity is to do well. I’d be intrigued to know if there is a study where the first step in discussing a patient’s obesity was to talk about their mental health.

PS: the lower respiratory tract infection was probably a virus.

Follow me on Twitter @rajacexplains

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Dr Hadiza Bawa-Garba – part 2: what the courts said and why it matters

Reflection FICM screenshot

So as you may have figured out from the title, there is a first part which you should read first because it is the first part. Read the first part!

There, I vaguely summarised the court cases. Here I go into a more detail.

I’m also less comfortable with this bit as I am not a lawyer but I’ll do my best to hit the salient points.

Coroner’s Inquest – July 2013

Firstly, there was a coroner’s inquest where details such as Dr Bawa-Garba’s mistake in stopping resuscitation and her admission that her care was sub-par come to light. The Crown Prosecution Service (CPS) only decide to prosecute after the findings of the inquest (see para 34 of the High Court judgment).

Crown Court – 4 Nov 2015

Dr Bawa-Garba is convicted of gross negligence manslaughter in Nottingham Crown Court. A month later, she is sentenced to a two-year suspended prison sentence on 14 December 2015.

This is a criminal conviction. In criminal law, the standard is proof “beyond a reasonable doubt”. The excellent The Secret Barrister, in an article I now can’t find, makes the point that even if the jury think a defendant probably did it, that’s insufficient to warrant conviction. (They also have a rather thoughtful piece about the context of Dr Bawa-Garba’s case.) Contrast this with “on the balance of probabilities”, the usual standard for civil law.

It is a criminal offence for jurors to discuss the case they hear. You sometimes hear lawyers say one cannot “go behind” the jury’s decision. That is to say, you cannot and should not make assumptions about why the jury made a certain decision.

(There is the 2013 case of R v Huhne and Pryce, a prominent Liberal Democrat and his wife, in which the judge ordered a retrial because the jury, to put it bluntly, asked him such stupid questions they clearly didn’t know what they were doing. But this is very rare. Both Chris Huhne and Vicky Pryce went to jail following the subsequent retrial.)

What is gross negligence manslaughter?

I try to avoid Wikipedia references but Page 7 of The Sentencing Council guidelines on manslaughter essentially corroborates the following:

…gross negligence manslaughter involved the following elements:

  • the defendant owed a duty to the deceased to take care;
  • the defendant breached this duty;
  • the breach caused the death of the deceased; and
  • the defendant’s negligence was gross, that is, it showed such a disregard for the life and safety of others as to amount to a crime and deserve punishment.

Manslaughter by gross negligence, Wikipedia, 6/2/18

Or: you were meant to look after somebody; you didn’t; because you didn’t they died; that you didn’t was super bad. (NB: super bad is sort of a technical legal term. The “gross” mandates the negligence be “truly, exceptionally bad”.)

That means that if you screw something up but a patient doesn’t die, you can’t be convicted of gross negligence manslaughter. (But don’t do that because you can still face other consequences. And also it would still make you a bad doctor. And person.)

There is of course a great deal of interpretation as to what is meant by “amount to a crime and deserve punishment”. We’ll get to that later.

Why was her sentence suspended?

Judges have to consider whether sending somebody to prison will actually make much of a difference. There are broadly 5 reasons to send somebody to prison: punishment, deterrence, rehabilitation, public protection and to give something back to the community. Given the consequences of a criminal conviction for a doctor, it’s likely the judge saw this as sufficient.

The Court of Appeal – 8 Dec 2016

So this bit of the case may seem slightly odd . Dr Bawa-Garba’s lawyers made what amounts a series of fairly technical challenges around one issue: that the instructions the Crown Court trial judge gave to the jury were misleading. Firstly, there are two submissions on the use of the phrase “significantly sooner”. If you really want to, you can go to paragraph 23 of the judgment for the details, but the arguments were rejected.

There was a third submission: that the judge did not specify that if the effect of the enalapril was the dominant cause such that then Dr Bawa-Garba’s actions would not have made a “significant contribution” to Jack’s death, she should not be convicted. And finally that given when the arrest happened, Jack was past the “the point of no return”, the judge gave insufficient direction to the jury that any actions that happened after this point should not be considered in the decision to convict. The Court of Appeal rejected both these arguments too.

Little of this questions the facts of the case – they examined whether the Crown Court judge had explained the case, the law and the jury’s duty sufficiently clearly to the jury. Really, I don’t think any non-lawyer or indeed most lawyers can argue that the Court of Appeal was wrong.

The Medical Practitioners Tribunal Service – 20-22 Feb 2017 & 12-13 Jun 2017

The Medical Practitioners Tribunal Service (MPTS) suspended Dr Bawa-Garba for 12 months following her conviction and appearance at the Court of Appeal.

What are the PSA, GMC and MPTS?

Let’s break down the acronym bingo. The General Medical Council (GMC) is the regulatory body for doctors in the UK. Every year, I send them some money and they keep my name on the Register of Medical Practitioners. As such, I maintain my licence to practise medicine. You can check any doctor’s registration status here by simply searching for a name. Try it with your GP!

These days, all doctors have to revalidate every 5 years. This involves collating evidence that you are keeping up-to-date such that you can safely practise. This only started in 2012. When I qualified in 2010, no such process existed.

There are other bodies for other healthcare professionals – the Nursing and Midwifery Council (NMC) (for nurses and midwives), the General Dental Council (GDC) (for dentists) and some others for pharmacists, opticians and optometrists and bizarrely for osteopathy and chiropractic (bizarre because they’re not real medical treatments).

The Professional Standards Authority for Health and Social Care (PSA) is an overarching body that is responsible for the above regulatory bodies. In short, it regulates the regulators.

What did the GMC do here?

They argued that Dr Bawa-Garba should be struck off the medical register. Dr Bawa-Garba’s lawyers argued suspension was the appropriate sanction. The MPTS agreed and suspended her for 12 months, such that should she complete sufficient remedial training in that time, her suspension would be lifted.

The High Court – 7 Dec 2017 & 25 Jan 2018

The hearing happened in December but the judgment was published in January.

In its simplest terms, the GMC argued that the MPTS gave too much weight to the systemic failings present (which the Crown Court had already heard) and insufficient weight to the Dr Bawa-Garba’s personal culpability. For me, the key line is here:

“…the [MPTS] Tribunal did not respect the verdict of the jury as it should have. In fact, it reached its own and less severe view of the degree of Dr. Bawa-Garba’s personal culpability.”

para 41, GMC v Bawa-Garba

The phrase “did not respect the verdict of the jury” in essence suggests that the MPTS decision had to make sense in the context of the Crown Court decision. The MPTS cannot come to a decision which relies on the jury’s verdict being wrong; it cannot de facto retry the case.

The judgment notes that it’s not that gross negligence manslaughter necessitates being struck off the medical register (though it’s rare not to be). It’s that the MPTS’s conclusion relied on Dr Bawa-Garba being less culpable and the systemic failure being a bigger issue than was found in the Crown Court.

Is this the GMC’s fault?

There has been a lot of shade thrown the GMC’s way, particularly the way of Charlie Massey, its Chief Executive. I’ve even seen Facebook screenshots of his pay with comments complaining about it. He was previously an aide to Jeremy Hunt.

However, when one reads many of the criticisms doctors have of the GMC, they are largely about the events which led to Dr Bawa-Garba being convicted. Given those systemic failings were considered in the case, it is then very difficult for the MPTS to use those as an argument against her being struck off, even if the MPTS is an organisation specifically designed to deal with doctors’ fitness to practise in a way the Crown Court is not.

As is often case when anger and fear abound, it’s difficult not to take aim at the nearest target. I am unclear that the GMC is at fault here. Indeed, if it is, then so the High Court judge.

Should doctors just get over it?

Context is king. The Secret Barrister‘s account of the Bawa-Garba case implies that juries may not be the correct way for cases around technical issues such as medical negligence to be heard (though they do not outright argue for this).

Is it possible within the time constraints of court for a barrister to truly convey the context within which doctors and indeed all healthcare professionals work? It is very well saying, “working the NHS is difficult”. But to explain how tought it is to think straight when your bleep won’t seem to stop going off, you have multiple sick patients, you’ve not eaten or passed urine because you haven’t had the time to think about it, and you are not being sufficiently supported by your seniors or they are too busy to help: that is surely impossible to explain at trial.

I don’t know how you show the frustration of sitting at a computer screen that has taken 5 minutes to log in, then crashes, then you log in again. Then you think about whether or not to try another computer, knowing you will have to go and find one that’s free and possibly go through the exact same scenario. When you get in, the blood results system takes another 5 minutes to load. So you’ve now taken 10 minutes to find one set of results.

You then realise the results aren’t back so you decide to ring the lab. You don’t know the number and there’s no phone next to the computer. You try to find a free phone on a ward you don’t know. You don’t have the number for the lab so you dial 0 for switchboard.

You wait on the phone for another couple of minutes but then you get a bleep. You answer your bleep and it takes 10 minutes to get the information about the patient that you need to see. You then ring switch but they’re busy so it takes another 5 minutes to get through. They put you through to the lab but you are on the phone another 5 minutes and decide this must be the number they use during the week and not the weekend.

You ring switch for a third time, take down a couple of numbers and eventually get through to the lab. They give you some of the results you want but not all. 30 minutes after trying to clarify one set of results, the consultant whose post-take ward round you’re supposed to be on has seen two other patients and asked you to order some tests – unfortunately, you don’t know why they need ordering and in the midst of the ward round you forget to ask the consultant before she left to see another patient.

This is just a sample of the chaos. How can it be possible to demonstrate this sort of frustrating disorganisation to a jury of your supposed peers? And how can one explain that this doesn’t stop because people are sick? People are always sick – these are the facts on the ground in a hospital.

Comfort zones

It is also not clear how a registrar on maternity leave is supposed confirm she is ready to come back to work. Many days, you will be outside your comfort zone; indeed how else can you get better at your job? But this what Donald Rumsfeld refers to as a “unknown unknown” – talk to any doctor back from a period of time off. Gauging the limits of your own competence is incredibly difficult. And most of your colleagues just think you’ll be fine because they remember you as a highly competent practitioner.

Reflection

Written reflection is a mandatory part of training for junior doctors and increasingly all doctors. All reflections which include patient information should be anonymised but it can be clear from a reflection which patient is being discussed if the case is sufficiently unique (which it undoubtedly is if you’ve reflected on it).

Pulse, a GP magazine, has reported that though written reflections weren’t used against Dr Bawa-Garba in the trial, expert witnesses were allowed to see other parts of her e-portfolio. Further, Dr O’Riordan – the consultant on-call – documented a verbal reflection with her which was submitted in court. This is troubling given it would be difficult for Dr Bawa-Garba to contest facts within it. It is unclear how much this influenced the jury’s decision.

I personally will continue to write written reflections. However, what I write which be much more considered.

Medical notes

These used to be about communication with other doctors. Now, more than ever, I treat these as an argument to a coroner or judge as to why I have taken a particular course of action. More and more, I explain my reasoning in medical notes, often in much more narrative form than is traditional. Bad documentation was noted through this case – as somebody who is already quite meticulous, I intend to be even more so, particularly in difficult cases.

Why openness matters

Doctors need to be able to discuss mistakes honestly and mostly without fear of reprisal. On hearing that Dr Hadiza Bawa-Garba’s practice would have to be “truly, exceptionally bad” and “criminal” to warrant it, the jury found her guilty. Doctors reading the case will think about cases where they have come close to doing serious harm – when only luck prevented them from being in Dr Bawa-Garba’s shoes. Can twelve lay people really judge the diagnosis of septic shock (albeit with expert testimony) in the same way as they can judge dangerous driving?

I question whether court, in the context of medical negligence, is fit for purpose. Let’s be clear, this is an unusually stark reaction from the medical profession. Often, you read about these cases in the BMJ, shrug your shoulders, and accept that the care was indeed quite bad.

Learning from mistakes is how we keep people alive in the future. So many patients simply want their negative experiences to stay theirs alone. If litigation increases, so do unnecessary tests and an attitude that giving somebody all possible care is the same best possible care. Keeping a 90 year-old with dementia on a ventilator and attached to lines for three months only for her to die anyway cannot be considered best practice. But if intensivists fear prosecution, it may be what becomes the norm.

It is good that Jeremy Hunt has launched a review into manslaughter in healthcare though doctors will be loath to trust him following the junior doctors’ strikes. Nonetheless, I hope to see changes in the legal system that mean doctors can really, truly discuss when things have gone wrong.

The tax on doctors’ time

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A couple of days ago I was listening to the excellent New Statesman podcast which had a section on the NHS winter crisis. In amongst some very good points about why major system overhauls are not technically or politically feasible in the UK, they ended:

Stephen Bush: But there are multiple reasons that doctors are leaving to go to other countries many of which are to do with policy choices actively made by the government. But the policy choice not to tackle the housing crisis does mean that if you are in possession of a medical degree, the attraction of staying in London and not being able to buy anything other than a small flat within commutable distance to the hospital where you work quite antisocial hours to being able to buy a fairly large house –

Helen Lewis: yeah, and there’s been a great decline in hospital accommodation as well. I was talking to someone who’s got –

SB: in New Zealand or wherever.

HL: – yeah, exactly – two siblings who both are doctors and for various reasons have ended up practising abroad it is, that it is, very difficult with, and it’s the kind of the other side of globalisation, we talk about importing workers in lower-skilled industries to undercut us. We’ve got the problem at the other end which is we’ve got workers with high-level qualifications. It costs us a lot to train a doctor and then we’ve got a problem retaining them working in the NHS. Yeah again it’s another thing where just small things if you to talk to doctors who get to like only having a single bed in hospital accommodation. You know like they change around the way that on-call works that kind of stuff. You’re just slowly pissing off a group of people who have got a lot of individual power to go “huh, yeah bye. See you later”.

(That was totally not worth the effort to transcribe. But anyway…)

Helen Lewis is right – but lets talk specifics.

Ten years’ ago hospitals stopped providing accommodation to their F1s (Foundation Year 1 doctors – the first year of being a UK doctors). Arguably, this was a hangover from when we did 24 hour on-calls but it was still nice and to be honest, most F1s would rent privately rather than use often quite poor standard hospital digs.

The advent of a 12-hour shift pattern has obvious benefits – doing a 24 hour shift where you’re up the whole time is physically and mentally punishing. It was also accompanied by the European Working Time Directive which mandated an 11 hour gap between a 13 hour shifts and limited the number of hours one could work in the week.

Disseminated in time…

There are a couple of things to note, however. Firstly, the mandated time off doesn’t mean you’re not just generally tired. I did one, fairly quiet night shift on Friday night. Unexpectedly, I was still feeling quite tired 26 hours later.

When you do weekday (4 nights Mon night to Fri morning) or weekend nights (3 nights Fri night to Mon morning), at the end you spend two days jet lagged, trying to do as little as possible to recover. At 31, many of my colleagues have kids who don’t exactly understand this, let alone the other stresses and strains of home life.

…and space

Further, there’s an uncertainty which I’ve mentioned elsewhere in my blog. An acquaintance living in South Yorkshire told me that her husband, a paediatric surgeon, had been told with a week’s notice that he was moving to Newcastle for 2 years. They had at least one child, I think they may have two.

Yorkshire and the Humber Deanery is split into 3 schools, West Yorkshire (based around Leeds), South Yorkshire (Sheffield), and North and East (around Hull and York). The first two of these have historically filled their posts. Indeed, when I applied for anaesthetics, Sheffield and Leeds were competitive.

The difficulty was and is, fewer people apply for East Yorkshire. There has recently been a drop in the number of applications to Yorkshire and the Humber Deanery.

Because training posts were not being filled in the East, the deanery decided new applicants at an ST3 level (Specialty Trainee Year 3) would be expected to train across the deanery, with some reimbursement of travel and accommodation. There are two different ways to complete your first two years of anaesthetic training (Core Anaesthetic Training or the Acute Care Common Stem) but the point is, anaesthetists ready to move to the next stage were being asked to train, potentially, anywhere between Chesterfield and Scarborough.

Yes, we have been lucky in Sheffield; that all hospitals were commutable was a significant attraction of the school. When compared to the Northern Deanery (which includes hospitals in Carlisle and Middlesborough), the North of Scotland (an entire school of anaesthesia albeit limited to Aberdeen and Inverness from what I can tell) and Wales, Yorkshire and the Humber is not significantly bigger. It’s 186 miles from Rhyl to Cardiff, compared to the mere 100 from Chesterfield to Scarborough.

Your choices are to move every year; live in two places, coming back on weekends off; or commute long distances (possibly staying over on night shifts). None of these are straight-forward particularly for colleagues my age who have kids.

It takes 9 years of postgraduate training to be an anaesthetist, meaning you’ll be 32 before becoming a consultant and having a permanent contract. If you have the temerity to want to do research or an educational qualification, you have to increase that. In specialties such as cardiology or surgery, whilst not technically mandatory, to get a job you’ll need to time outside of training whether as research or a subspecialty fellowship. Completing training before having children is not always possible.

To an extent, none of this is unique to medicine. Soldiers earn less and are away from home longer. Other jobs mandate long commutes. Factory workers do night shifts for little pay. Nurses get paid less for an equally stressful job.

However, when one combines recurrent jet lag from night shifts, prolonged training before being able to settle down, the uncertainty of where one will be in 12 months, the inflexibility of training, the increase in retirement age, recent disputes with government over payincessant workplace assessments and exams, lack of rest facilities, and the possibility of dying on the way home from work, Helen Lewis’s “slowly pissing off [doctors]” encapsulates the factors that are chipping away at doctors’ numbers and doctors’ morale.

PS: for the non-medics, the phrase “disseminated in time and space” is a description used in the diagnosis of multiple sclerosis. This post has nothing to do with MS – the phrase just seemed apt and will ring a bell with medics.

Some thoughts on This Is Going To Hurt

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Firstly, This Is Going To Hurt by Adam Kay is a great book. A former obstetrician who gave up medicine in 2010 to pursue comedy, his description of what life used to be like is as with any well-written memoir of medicine heartbreaking and funny. Indeed, variations on “heartbreaking and funny” have become something of a cliché in reviews of the medical memoir.

It is worth noting how variable our experiences in the NHS are. A persistent theme in This Is Going To Hurt is the absence of bosses. This varies widely between specialities. Anaesthesia has always been ahead of the curve in terms of consultant presence out-of-hours but consultants in all acute surgical specialities (including obstetrics and gynaecology) seem, from my point-of-view anyway, to be more readily available than in years past though many internal medical specialties still seem to lag behind. “I didn’t want to disturb the boss” is no longer a legally defensible position.

When Kay started medicine (in around 2004), 24 hour on-calls were the norm. Not bothering the boss was the norm. Now, the European Working Time Directive means that 12 hour shifts are in place for nearly every acute specialty. Though much-maligned, the new junior doctor contract has led to exception reporting which fines trusts for junior doctors who persistently working hours longer than contracted.

(The fines go back to the junior doctors’ mess and the doctors in question should they accrue sufficient hours get days in lieu.)

Many of the bugbears he discusses are still in place. The lack of study leave for exams – public health get two days a week for three months coming up to their exams; I get the day of the exam off plus a day for travel. The difficulty in getting swaps for annual leave, made even more complicated by the fact that on a 1 in 7 rota with 12 hour shifts, for any given day off, 1 or 2 of the other 6 doctors are likely to be unavailable for swaps.

Some are worse, particularly the inflexible and pernickety nature of postgraduate education. Not got a DOPS in Management of Cardiorespiratory Arrest despite having a valid ALS and this being a thing that happens out of hours so there is almost never a consultant around to watch you do it? Too bad, you may have to repeat the year. Not got any assessments in major trauma despite not having worked in a major trauma centre? Too bad, you may have to repeat.

I guess the bottom line is – some things are better, some things are worse and the experience is dependent on specialty and location as much as anything. Slowly (too slowly) the machismo in medicine is dying away. But there is still a feeling of too much work for too little pay with the addition of tiresome educational assessments, the value of which is never truly made clear to assessors and those being assessed alike.

The NHS needs money. It also needs to change

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In 2011, the UK had 2.8 physicians/1000 population compared with Germany 3.8, France 3.4 and Australia 3.3. The UK spent 9.4% of its GDP on health compared with France 11.5, Germany 11.3 and Australia 9.4; the UK’s spending was forecast to drop to 6.6% by 2020/21 though all bets are off with Brexit looming.

The NHS in England needs more doctors. I work for a large trust across two hospitals where the 6 different anaesthetic rotas at middle grade/registrar level should theoretically provide plenty of cross-cover. It doesn’t: I regularly receive requests to fill gaps in rotas, often with “HELP!!!!” in the subject line. This is no different at smaller district general hospitals.

Criticisms from the BMA of Jeremy Hunt during the doctors’ strike and Theresa May are correct. Seven-day elective services do little for emergency care provision. Moving GP opening hours to 8-8pm is not the same as increasing capacity. If two GPs work 9-5 and then change their working hours to 8-4 and 12-8, the surgery will still be open 8-8 but there will be the same number of appointments.

Opposition to change in the NHS is widespread

That said, trying to change something in the NHS is nigh-on impossible. Healthcare professionals blame managers. Managers blame healthcare professionals. Everybody blames IT.

Let me give you an example. Patients in acute medicine are allocated to consultants in 24 hour blocks, 8am-8am. Patients who arrive in that time, fall under that so-called “take” consultant. If not discharged on the day, they are added to a “post-take” ward round the day after.

There is software which produces an active list of patients who need to and have been seen by Acute Medicine. There is a list for yesterday and today. From 0800-0900, it moves forward to the next day. The issue is, at 0730, secretaries print the previous day’s “take” list. Between 0730-0900, patient’s deemed seen by a junior doctor may get added to the previous day’s list after it has been printed. Today’s take consultant thinks the patient has been seen by the previous day’s consultant. The previous day’s consultant – now on the post-take ward round – doesn’t know about the patient

This could be solved simply by having the system refresh at 0630-0730. However, this doesn’t happen. Instead, at 8am, junior doctors print a physical list and after 0900, add the information. Of course, doctors may forget, may be new and not realise or there may simply be a clerical error on paper leading to patient not being seen.

At another hospital, the portering system had gone electronic and theatres had lost their dedicated porter. If there were no operations, previously that porter went and helped with other portering jobs.

On the new system, the most urgent your patient will be picked up is “urgent”. However, I have frequently waited an hour or more for patients who were acutely unwell. Theatre staff were instructed they should not be leaving theatres to collect patients – this makes sense as if the patients arrived in a timely fashion, theatre staff would be preparing theatre. This was not an issue prior to the introduction of the electronic system.

These issues may seem minor but they are legion. Each one adds a layer of inefficiency. Occasionally, you get workarounds (like in the first example) but these aren’t really solving the problem. Steven J. Spear’s excellent book The High-Velocity Edge looks at how to improve processes – to paraphrase him, this is not a solution, rather solving the same problem every day.

Efficiency savings or quality improvement?

As a junior doctor, largely you feel powerless to change these things. You usually spend 4-6 months per placement, too little time to effect change. This is made worse by healthcare professionals who aren’t willing to at least try change. Change is not always good – yes – but that’s necessary risk to take. Indeed, in research, it’s acknowledged that change is necessary. Without it, we would not have seen the medical advances of the last 70 years. Ultimately, the “low-hanging fruit” of research have been taken. With quality improvement, we have barely scratched the surface of what the NHS is capable.

The difficulty is two-fold. First, any criticism of the NHS is perceived as bad. “Efficiency savings” have become a euphemism for cuts. However, what kind of organisation isn’t constantly trying to make efficiency savings?

Under Tony Blair, healthcare organisations worked on expanding services, a very different set of managerial skills to improving current ones. It takes time and effort but mindless calls to #SaveOurNHS, whilst useful at times, perpetuate the image that the NHS doesn’t need change, it just needs more money.

Secondly, many healthcare professionals engage in management begrudgingly, interested in clinical practice only. Though we receive little training in management, our reluctance to change processes kils our patients as much as any funding gap. They are as important as our clinical skills.

To be effective, these changes need to solve problems from the bottom up. Managers should call for small problems to be highlighted and praise staff for doing so. Staff, when change is implemented, should go with it, at least at first. And managers should listen to the things that do and do not work. No amount of money can change this.

A really fun post about death

princess-leia-1

Last year, there was quite a bit of chat about famous people dying. The BBC examined this and found they had published more pre-prepared obituaries than usual in the first 4 months of last year in particular.

This sounds callous but I find it difficult to care.

Don’t get me wrong – if Sarah Michelle Gellar (I liked Buffy) or Claire Danes (I like Homeland) die, I will be taken aback. However, I am not going to be personally affected should Gellar die. And whilst it would be sad if Homeland got cancelled due to Danes’ untimely demise, this is not reason to grieve.

When people on social media express their sadness at a celebrity’s death, mostly this is in tribute to their body of work. However, there sometimes seem to be genuine expressions of grief as though they were a loved one.

In hospital, whilst most relatives are realistic, it is not uncommon to encounter impossible expectations of healthcare. Arguably the most challenging aspect of critical care medicine is making the decision about when to provide or more crucially when not to provide critical care.

Being on a Critical Care Unit/Intensive Care Unit (vs being on a standard ward) involves a host of unpleasant interventions. Whilst this is worthwhile if a patient has a reasonable chance of survival, in futile cases, this is tantamount to torture, a word I use when explaining ceilings of care.

I worry that both the unrealistic expectations and grieving for celebrities are symptoms of our general aversion to discussing death. How can one seriously grieve for somebody unknown to them?

In the original Get Carter (1971), Michael Caine’s character (the titular Jack Carter) has to attend his brother’s funeral. The body is kept in the family home. These days, bodies are kept in mortuaries and taken by funeral directors prior to burial or cremation. It would be unheard of to keep a body in the family home.

I am not trying to make you feel bad for your sadness at George Michael/Alan Rickman/Victoria Wood’s death. Still, posts can seem as grief-stricken as those from the genuinely bereaved.

Death is a fact and it is something we consider too little and discuss too infrequently. It leads to the situations where people with cancer are abandoned by their friends. I have had multiple conversations where bereaved friends have found others unable or unwilling to discuss the death of a loved one.

And because of this, it seems uncouth and unhealthy to act as though a celebrity death should be treated similarly to personal bereavement.

Talk about death; when your relatives became unwell, doctors are going to ask what you think they wanted. That is a much easier discussion if you have had the decency to talk about it. It is for them as much as you.

You and everybody you know and love is going to die: get comfortable with that. On that note, I am going to have a banana and go to bed.

 

Rage Against The NHS Fax Machine

fax-amarys

So I haven’t posted on this blog in a while, largely due to recently getting my first full-time position in a year as a Specialty Trainee in Critical Care i.e. the path to becoming a consultant in Intensive Care Medicine (yay!). Also, there’s been a lot of depressing Brexit chat to avoid.

This post is just me complaining about a relatively minor but still important thing.

I hate fax machines

To become a critical care trainee, you need a background in internal medicine, emergency medicine or anaesthetics. It’s all very complicated but because my background is anaesthetics, I don’t have the requisite competencies in medicine. This August, I started work on an acute medical unit doing acute medicine, a specialty I’ve not been involved with for three years.

One of the frustrating things about working in acute medicine is drug histories. Trying to determine what drugs a patient is on is difficult if they don’t bring a prescription or their medications with them. Trust me, no doctor knows what “the little blue pill” is unless they’re science-fiction fans and you happen to be Neo from The Matrix.

As such, during the day if you’re seeing a patient, you’ll often have to phone their GP’s surgery (though now some trusts have a centralised record system). If the list of drugs is long, rather than bother a GP, secretaries will often just send you the list.

However, they always, always insist on fax. I had to organise this for the first time in a long time a couple of weeks ago; fax is bad for a number of reasons.

Why not just use email?

Evidently, confidentiality is an issue in healthcare. Clearly, you shouldn’t send confidential information via Facebook chat. However, we have trust NHS email addresses. These end .nhs.uk and generally have the initialisation of the trust ie Leeds Teaching Hospitals use @lth.nhs.uk, Nottingham University Hospitals @nuh.nhs.uk etc. These are given to staff when they start at a particular trust and deleted when their contract ends.

It’s generally considered safe to send confidential information via email within the trust using this system (though nobody has actually confirmed this with me). However, for sending information outside of the trust, you need an NHSmail email address. These end @nhs.net and are personal ie they go with you as long as you work within the NHS.

At least, that’s my understanding. A few days ago, I tweeted NHS England and received a response from @grant_me who according to his bio is an “IT Professional working in NHS Primary Care”. That’s the best I’ve got to go on after not really trying very hard.

Given the lack of clarity about this, secretaries stick to the tried and trusted method of fax.

What’s wrong with fax?

1. It’s really annoying

I don’t use fax machines because it’s not 1992. I’m not particularly technophobic, I like my smartphone. However, I’ve used a fax machine about twice in my entire life.

Whenever a doctor needs to use the fax machine, we find a friendly ward clerk or secretary and look forlorn at them until they realise we’re not going away until they send the fax. I can be very good at looking forlorn.

(NB: any medical students reading this: make friends with the secretaries. I’ve seen them ignore a surgeon they didn’t like who asked for a form, saying they didn’t know where it was. They then found the exact same form for me 10 minutes later, and sent it for me because I’m all sweetness and light.)

2. It’s hilariously unsecure

I rang the GP. I explained I was a doctor at the local hospital on the acute medical unit. I gave my name and – after them insisting they wouldn’t send it to an email address – faxed me a copy after I eventually found out the fax number.

I could have been any muppet who bought a fax machine. There was no security or check to see if had gone to the right machine. No check to see I was actually a doctor. Literally, you could ring up a GP and do this yourself if you have a fax machine (but don’t because you’ll go to jail).

3. It can be incredibly complicated

At the hospital I work at, to make a referral to the anticoagulation clinic on discharge, you have to fill out a form, fax it to the clinic then ring them to make sure they’ve received the fax. This means that if you discharge a patient at 6pm, after the clinic has closed, you can’t ensure a referral unless you’re in the next working day.

There’s no guarantee you’re going to be in. The patient will have gone home. If it’s a Friday and you’re on nights the next week, it means you may not be able to check for about 10 days at which point, the patient hasn’t got their anticoagulation appointment and they’re at risk of stroke or blood clots or being struck by lightning. OK, anticoagulation does not decrease lightning strike risk but it is important.

Communication within the NHS

This is generally bad, particularly because we deal with a lot of sensitive data. I have worked in hospitals where non-urgent referrals were done by an A6 piece of card to the secretary of the relevant specialty. Like they never got lost. Some services ask for fax (like anticoagluation). Some are on the hospital intranet. Some are Word forms filled out and sent via email. Some are via an online request system. And don’t get me started on the bleep system (something for another time I feel).

I worked with a cardiology team who set up an email address at the trust that was “cardiology@trust.nhs.uk” to replace the aforementioned card system. They went from seeing something like 60-70% of their referrals within 24 hours to seeing 100% of their referrals by the end of the next day, and 100% within the same day if the referral was sent by email.

Firstly, given NHSmail exists, all NHS staff who handle confidential information should have an NHS.net account. This should be the standard form of written communication between NHS bodies. Fax should be banned. Tomorrow.

Secondly, trust emails should exist for all specialties and services to which referrals can be made, with delivery reports. This gives a clear trail as to whether a service has received an email. Creating an email address is presumably not a massive step for an IT dept and it’s a familiar system to most people.

Obviously, this is more complicated than I’m making out. But also, you know, it’s not. Especially, given it’s been done already. Pff. Unfortunately, I’m not sure anybody’s that bothered and so many people seem to love fax machines. Sigh.

MEDICINE: a complicated guide to junior doctors’ pay

UPDATE 13/2/16: NHS Employers has sent more specifics about the contract out rendering this post somewhat inaccurate. Will be adjusting it soon.

UPDATE 14/2/16: now adjusted to take into consideration the specific changes NHS Employers sent out on 13/2/16 to junior doctors.

A significant component of the current dispute between Health Secretary Jeremy Hunt and junior doctors is pay. It is not the whole dispute.

Part of the new proposals involve a hospital ‘guardian’. The ‘guardian’ would be responsible for ensuring doctors do not breach their hours. Where they do, guardians would enforce financial penalties. (It’s really hard to Google ‘guardian’ and ‘junior doctors’ strike’ without just getting articles from the Guardian.)

However, they would be employed by hospitals; the conflict of interest between an employee deciding whether to fine his or her employer is obvious. As yet, this issue has not been addressed by government. The practical effect on hours worked that having a guardian will have is unclear.

There are many other issues too. However, the question for this post is, what are the differences in pay going to be?

I’m going to use the last full-time rota I was on as an example. (NB: this is not the same rota for the whole country.)

I’m going to be using ‘old’ to represent the system at the moment and ‘new’ to represent to prospective system. Using the term ‘current’ could get a bit confusing.

If you can’t be bothered look at the maths, just go to the end. There’s a section called, The punchline, which summarises the key numbers.

The old system

This worked via something called ‘banding’. If you Google ‘NHS banding’ you get the bands for nursing and other healthcare professions.

The old banding system for doctors looked like this:

OH MY GOD WHAT EVEN IS THAT?

It looks complicated but the hospital tallies up the number of hours you’ve worked, the proportion that’s ‘antisocial’ and gives you a pay supplement based on that proportion.

Antisocial hours are considered the weekend and 1900-0700 during the week.

How do you figure out whether you’re moderately, most or least antisocial? You can use the following helpful chart:

SERIOUSLY THEY ARE JUST TAKING THE MICHAEL NOW!

Suffice it to say, it’s fairly complicated. I say this with some trepidation but most first- and second-year doctors (F1 and F2 or Foundation Year 1 & 2) will be on 1A or 1B. I think.

This means, for the number of antisocial hours they work, they get a pay supplement of 40% of their basic salary.

The F1 year is usually split into 3 x 4-month placements. Assuming that all of these jobs have a fairly standard on-call rota for medicine or surgery, an F1 will receive a 40% supplement on the basic salary of £22,636

They’re paid 22636 x 1.4 = £31690 pa.

Placements vary. F1s often do jobs like medical microbiology or general practice which many only require social hours work – they do not receive a supplement for these jobs.

They may also work in emergency medicine (A&E) where they would receive an even bigger supplement but the shifts are largely antisocial.

The same applies to any hospital medic. They have a basic salary. The hospital calculates the proportion of antisocial hours; determines what band they’re in; and gives them the requisite pay supplement.

The key misunderstanding is that you get a percentage supplement on total hours under the old system, not just on the out-of-hours work as some of the press have suggested.

Now, I hope you enjoyed the arithmetic – there’s loads more to come.

The rise in basic pay 

When I originally wrote this post, the government had been suggesting a 13.5% pay rise. Subsequently, NHS Employers have sent out this pay letter which has more specifics about the new pay scale. The old pay scale can be found here on the BMA website.

I’ve summarised them in this table:

Comparative hours table

Pay and percentage increases relative to year

F1 and F2 refer to the first and second year of the foundation programme. If you look at the old pay scale, these consider pay for up to three years in each of these posts. These are relevant to part-time doctors which I’ve ignored, largely because it’s something I don’t have a lot of experience of.

CT/ST (core/specialty training) year refers to years in specialist training (surgery, internal medicine, pathology etc.). From the point of view of pay, the difference between core and specialty training posts is a technical one, not relevant here.

Otherwise, there are two changes. The first is simply there is an increase in basic salary across the board (though this doesn’t necessarily lead to a final salary increase).

Secondly, you’ll note the new ‘nodes’. Previously, there was a year -on-year increase in salary. Now doctors will have the same salary during certain blocks of training, particularly ST3-7.

Government argues that the responsibility of these doctors is the same regardless of grade. For anaesthetics and critical care, this is true when looking purely at on-call responsibility. However, it doesn’t consider the assessments and exams one has to pass to progress from year to year.

Most doctors require revalidation every 5 years. Junior doctors go through an equivalent process every year which is more onerous that revalidation.

How the new system’s supplements work

Oh, the fun I’ve had with this. My last job was as a CT2 anaesthetist. Looking at the table above, that means I would be paid 7.5% extra basic pay. I’ve also calculated my comparative pay as a CT1 anaesthetist which involves a 16.21% increase.

You can download the spreadsheet here but I’m going to use a couple of screenshots.

I’m not sure how well this will show up on whatever device you’re using. The top row is hours. 0700 means 0700-0800. I’ve put a ‘1’ for every hour I’ve worked and also to make the spreadsheet work.

Hours 1

As a CT2, under the new contract:

  • Basic hours, 0700-2100, Mon-Fri, +7.55% from the old system, dark green
  • Saturday and Sunday, 0700-2100, +30% (on top of the 7.55%), middle green
  • Antisocial hours, 2100-0700 Mon-Sun, +50% (on top of the 7.55%),  light green (this says light green though you probably can’t see it)

(NB: if I were to work fewer the 1 in 4 Saturdays – I work 2 in 7 – I would get no supplement 0700-1700 on a Saturday which would further complicated payment. Also, it’s possible that because one of those shifts is day and one night, that they would be considered different shifts and I would not get a Saturday supplement. That would be pretty shifty.)

So you can see, the arithmetic gets a little complicated.

Broadly my job consists of three different types of shift:

  • Normal day – 0800-1800
  • Long day – 0800-2100
  • Night – 2000-0900

There’s an hour overlap in the morning and evenings between the person coming and the person leaving. This is to facilitate handover. It doesn’t happen in every hospital but we got paid for it.

Hours 2

This is the bottom half of that spreadsheet. I was on a 1 in 7 rota. That means that there were 7 anaesthetists on the rota. Whilst I was on week 1, another was on week 2, another week 3 etc. This works out at 48.14 hours/week.

I should note, rota coordinators get a lot of stick in hospital but trying to design one of these things is hard. This one doesn’t show how, in order to be EWTD compliant (ie <48 hours/week), I have to get days off after weekend days and nights. Booking annual leave on top of that makes these things a nightmare.

In the ‘CT2’ column for Mon-Fri, I’ve used the following formula:

=1.0755*SUM(C2:P2)+1.5*1.0755*SUM(Q2:Z2)

That’s 1.0755 x the number of basic hours (to calculate the 7.55% pay rise) + 1.5 x 1.135 x the number of antisocial hours (to calculate the 7.55% pay rise and 50% antisocial hours supplement).

In the ‘CT2’ column for Saturday and Sunday I’ve used the following formula:

=1.3*1.0755*SUM(C7:P7)+1.5*1.0755*SUM(Q7:Z7)

That’s 1.3 x 1.0755 x the number of weekend day hours (to calculate the 30% supplement for weekend day hours and the 7.5% pay rise) + 1.5 x 1.0755 x the number of antisocial hours (to calculate the 50% antisocial hours supplement and 7.5% pay rise).

Phew!

In the bottom right, in box AA51, there is a number calculated from the formula

=SUM(AC2:AC50)

which is the sum of all the ‘CT2’ hours. I’ve done the same for CT1 except I’ve used the 1.1621 instead of 1.0755 (to indicate the 16.21% basic salary pay rise). This gives total equivalent hours of 443.51 and 410.411 respectively which I will explain shortly.

The old system – calculations

The ‘Old’column is a lot simpler because the supplement is added at the end. Every cell in the ‘Old’ column has the formula:

=1.5*SUM(C2:Z2)

which is 1.5 x the number hours worked that day (for the 50% banding supplement).

Then I’ve used:

=SUM(AD2:AD50)

to add up all the ‘old’ hours.

There is also an ‘hours’ column using:

=SUM(C2:Z2)

for each cell. This is simply to calculate the raw number of hours I worked without any supplementation. These are summed at the bottom of the column with:

=SUM(AA2:AA50)

How have I got more hours under the new system but I’m also working the same hours?

What I’ve calculated is my pay equivalent to basic hours under the old system. It is not the actual hours I worked but is way of comparing the different rates of pay.

The punchline

  • I worked 337 hours in 7 weeks
  • That’s 48.14 hours/week
  • Under the old system, I was paid the equivalent of 505.5 old system basic hours with my 50% banding supplement
  • Under the new system,
    • At CT2 I was paid the equivalent of 410.411 old system basic hours with the plethora of supplement
    • At CT1 I was paid the equivalent of 443.5 old system basic hours with the plethora of supplement
  • That’s an 18% pay cut for CT2 and a 12.27% pay cut CT1

Now, you can’t just average the two pay cuts to get my total pay cut over two years. My pay was different for the two years under the old pay scale but hopefully this gives you an idea of the sort of cuts in pay we’re looking at.

There are caveats. There is a large variation between hospitals and an even bigger one between specialties. Surgeons’ rotas are different to anaesthetists’ rotas are different to medics’ rotas which are all different to the rota of a chemical pathologist.

Further, rotas will change. Given the new obligations, it is highly likely many hospitals will adjust their rotas meaning any sort of calculation based on new or old systems will be rendered irrelevant. That said, I doubt this particular anaesthetic rota will change very much. It already adheres to the new guidelines and it would be considerable hassle to change it.

This post isn’t making a judgement about whether it’s wrong. However, given the number of antisocial hours worked, I cannot fathom a situation where the acute specialties end up getting paid more unless the premiums are quite significant.

What I will say is I’m not sure how the new system is any simpler than the old system. Whatever. Maybe I’ll just go to Canada.

MEDICINE: Why you’ll be safe in hospital during a strike

Thousands of junior doctors will go on strike on Wednesday 10th February from 8am for 24 hours. I used to be one and may be one again. How, if juniors are so important, will a hospital run without them?

Broadly speaking, juniors hold a couple of roles. Firstly, it involves seeing patients every day with a senior doctor, ensuring they have been well since they were last seen and making plans for that patient. This usually takes most of the morning and occasionally into the afternoon.

After the ward round, these plans are put into place. Ordering scans, making referrals, organising discharges, taking bloods, prescribing drugs for discharge.

The more senior ‘juniors’ (for want of a better term) will do other things. A respiratory registrar may be involved in a bronchoscopy list or a clinic; a surgical registrar may have to do a day case list; or an elderly care registrar who needs to see referrals to his team.

If consultant take over this work, who’s going to do their job?

Much of what consultants do is elective work. It’s essential but non-urgent. It’s inconvenient for patients and unfortunately that’s the price of this strike.

Further, the cover that juniors will provide is the same as weekends, Christmas and Easter.

Let me reiterate this – it’s the same cover as every weekend, every bank holiday, Christmas, Easter, New Year. If this is dangerous, it’s dangerous all year round but it demonstrates the problem with the 7-day plan.

edinburghroyalinfirmary

What does 7 day NHS really mean?

Much has been written about the strike. The difficulty is that solving the issue of increased weekend mortality – which many dispute – involves changes to emergency cover. The 7 day plan is not a change to emergency cover. Rather it spreads the juniors covering the day-to-day tasks during the week over the weekend. It’s unclear how increasing elective work over the weekend would improve emergency care.

In other words – how do patients getting bunions removed on a Sunday improve your care if you have a heart attack?

The bottom line: government’s solution doesn’t solve government’s problem.

MEDICINE: the CEX life of junior doctors

“…not everything that can be counted counts, and not everything that counts can be counted.” – 1957, William Bruce Cameron, Informal Sociology

2000px-star_of_life2-svg

It’s been a year since I passed the FRCA Primary (I’ll explain what this is shortly). As such, I thought this topic was a good one to start the medical component of this blog.

For doctors, assessment doesn’t stop at medical school. The various Colleges (e.g the Royal College of Physicians, Royal College of Surgeons) are responsible for setting standards within their respective specialties

To that end, a variety of acronyms are used to test trainees. ‘Trainee’ means a fully qualified doctor on a training scheme to be a consultant. (It is not a medical student.)

Firstly, there are exams:

  • SOE (Structured Oral Examination) – a short semi-structured viva.
  • OSCE (Observed Structured Clinical Examination) – a multi-station practical exam on anything from procedures on dummies to communication to anatomy
  • SAQ (Short Answer Question) – short essays
  • MCQ (Multiple-Choice Questions)

Then there are workplace-based assessments (WBAs):

  • CBD (case-based discussion) – the trainee has a structured discussion with an assessor around a case in which they were involved.
  • Mini-CEX (mini clinical examination) – assessor watched the trainee take a history and/or perform an examination and then provides feedback.
  • DOPS (direct observation of procedural skill) – assessor watches the trainee perform a procedure.
  • MSF (multi-source feedback) – the doctor is assessed by 15-20 peers of varying disciplines who comment on competence and professionalism.

Tired of the acronyms yet? This is not exhaustive.

First, let’s talk exams.

You can’t revise at 5am

These exams are hard. Referred to as Fellowship or Membership exams depending on College, failure rates of 40-50% are commonplace in many (possibly most) specialties. They are mandatory to become a consultant.

They’re expensive. Anaesthetists pay £1935 (320 + 590 + 470 + 555) and GPs £2131 (489 + 1642) but this doesn’t include revision courses and retakes.

There is debate about the relevance of some content. (Do I really need to know how a horse hair hygrometer works to be a competent anaesthetist?) But this is not the full story.

Simply, doctors are allocated little or no time to study. As such, one ends up revising on night shifts and at weekends. As an example, the FRCA (Fellowship of the Royal College of Anaesthetists) examinations are split into two sets – Primary and Final.

The general advice is to set aside 6 months for each component. Not 6 months off work – 6 months of your social life on top of a rota working 2 in 7 weekends.

Organise your own exam room

Doctors also need to complete WBAs (including the CEX in the title). There is some issue as to the validity of these. They’re designed to be formative (to aid learning) not summative (to assess competence) but are used for the latter nonetheless.

Rather than being organised by supervising consultants, junior doctors arrange assessments themselves. To my mind, this is akin to asking an A-level students to administer their own exam.

Arguably, it’s an assessment of the ability to find a willing consultant, rather than ability as a clinician.

The sheer volume of WBAs has grown. Anaesthetists need an assessment every other day on top of exams. This doesn’t include reflection, supervisor meetings, personal development plans, probity statements…

The electronic or e-portfolio should make this easier. It doesn’t. Each assessment has to be linked to the correct part of the syllabus in order to pass an appraisal. Doctors have failed to progress due to clerical rather than clinical errors.

Oh, just stop being so whiny

On top of the issues leading to the junior doctor strikes, the number of these assessments is slowly increasing. Assessment does need to happen but the attitude of ‘more, more’, of ignoring the time required to pass exams and a lack of engagement from some consultants adds to what is already a stressful job.

Anaesthetics might be oversubscribed but the last thing we need is another reason for doctors avoid general practice or leave emergency medicine.