Empathy for Dr Grumpy

A patient called our secretary today asking for someone to give her advice. She had a large tumour removed from her bowel almost a year ago, and was taking imatinib (a non-chemotherapy 'anti-cancer' tablet) to reduce the risk of recurrence. She was supposed to be taking it for a year in total, and was due to complete the course in early November.

The message the secretary gave me was that the lady was puking up the imatinib (and her other medications) whenever she took it, so she wanted to know if it was OK to stop the imatinib as she was nearly finished the course anyway.

I called her. I had to speak to her via her lobotomised husband as she was too ill to come to the phone. I eventually managed to get out of him that she had been throwing up for 2 days, not keeping anything down, had crampy abdominal pain and had not opened her bowels for 2 days either. Their only concern was about the imatinib and whether they could just stop it.

Me: 'Have you been to see your doctor about the vomiting and stomach pains?'

Mr Lobotomy: 'Er...no, no, you see, last year she had the exact same symptoms and we were told they were brought on by stress, so you see she just needs to rest in bed for a while and all we want to know is can she stop the imatinib?'

Me: 'You mean she had the same symptoms just before she was diagnosed with a large tumour in her bowel and had to undergo extensive abdominal surgery?'

Mr Lobotomy: 'Er, yes. But she's sure this is all due to stress. We've just moved house, you see. So what about the imatinib, is it OK to stop it?'

Me: 'I think she's already stopped it, hasn't she? Seeing as she's not keeping it down? I don't think that's the main problem here, I'm worried your wife may have a blockage in her bowel, either related to the tumour she had before or possibly from adhesions from her previous surgery. She's probably very dehydrated now too. Are you able to bring her to hospital so we can assess her?'

Mr Lobotomy: 'Oh, er, I don't know about that, she's not very well, she might throw up in the car.'

Me: 'OK, if she's not well enough to come in the car I would advise you to call an ambulance to bring her to A+E and I will see her there.'

Mr Lobotomy: 'Oh, er, um, I don't think she'd like that very much....'

Eventually I managed to get the patient on the phone. She sounded very unwell. I explained that she might have bowel obstruction, which was potentially very serious, and that she should come into hospital. She said she couldn't come today, she needed to rest in bed. She might come tomorrow, and could she have my phone number in case she decided to come tomorrow?

The end result was that they agreed to a home visit from their GP, so at least a doctor would examine her today. Mr Lobotomy assured me he would contact the GP surgery to ask for a home visit. I felt sure that his wife would veto that as soon as he put the phone down to me, so I told him I would call the surgery as well to make sure they had details of her medical history.

I called the surgery. I spoke to the receptionist, explaining who I am, and asked if I could speak to the duty doctor regarding the patient (her own GP was no longer with the practice) and to request a home visit.

Receptionist: 'I'll just put you on hold and ask Dr Smith if he can speak to you.'

Me: 'OK.'

After holding for several minutes....

Receptionist: 'I've spoken to Dr Smith, he's busy at the moment I'm afraid.'

Me: 'Well can he please call me back as soon as he's free? It's rather urgent.'

Receptionist: 'Oh, I don't know about that....hang on...'

Several more minutes of holding...

Receptionist: 'What symptoms is the patient experiencing?'

Me: 'Pardon?'

Receptionist: 'Dr Smith asked me to find out from you what symptoms the patient has.'

Me: 'He wants you to take a history for him?!'

Receptionist: 'Yes. What symptoms has the patient been experiencing?'

Dull thud as my head hits the desk.

I gave the history to the receptionist. Eventually a GP (not Dr Smith) called me back (asking to speak to a completely garbled version of my name - I'd even spelled it for her), I told him the details, and he's gone to see the patient at home.

I need a stiff drink now.

'Clapton is God'

I went to the Albert Hall recently to see Eric Clapton. When I told people at work that I went, they were like, 'Oh, that sounds cool. Did you enjoy it?' To put it in context - the guy is my idol, he is a legend, I have been listening to his music since I was about 14 and I just could not believe I was there actually watching him play. Yes, you could say I enjoyed it.

Our seats were amazing - I could have walked over and touched him in about 10 seconds (I didn't try). I've never seen a live performance so close (apart from dodgy local bands in my home town). For the 1st couple of tunes I was a bit overwhelmed I think - I literally just sat there with my mouth open and tears in my eyes, and all those years of listening to his stuff over and over again on my Walkman on the way to school, in my room, in the car, etc were running through my head and it was like oh my God Eric fucking Clapton is standing right in front of me playing a Fender Strat! Don't wake me up from this dream!

Thankfully I did calm down a bit after the 1st couple of songs. As predicted, he made that guitar sing. The band were amazing as well - Andy Fairweather-Low had a couple of great guitar solos himself, Chris Stainton and Tim Carmon were phenomenal on keyboards (a couple of great solos there too), as was Willie Weeks on bass, Steve Gadd on drums and the backing vocalists (Michelle John and Sharon White) were pretty powerful. One of his old band members (Doyle Bramhall II - great name) was playing in the support act (Arc Angels) and he joined them for Layla, Cocaine and Crossroads at the end of the set.

I actually looked up the set list from reviews of previous nights and was a bit disappointed that he made 'Layla' part of his acoustic set, but hey, it sounds lovely on the acoustic guitar anyway. But on the night we went he played the full on, storming electric guitar version - I couldn't fucking believe it (cue me welling up like a big girl again). They seemed to have fattened up the sound of the long, meandering piano/guitar bit at the end of the song, which I enjoyed (I always used to fast-forward that bit - a bit long), and then they segued straight into a stonking rendition of JJ Cale's Cocaine - cue all the middle-aged people jumping out of their seats and having a bit of a boogie :)

He did a couple of Cream numbers - 'Badge', which he'd jazzed up a bit so it had a massive sound - loved it, and Crossroads, which was the encore song. I would have loved to hear 'White Room' or 'Sunshine of Your Love' as well, but the guy has a massive back catalogue I suppose, can't please everyone completely.

All in all, Eric rocked his 'front room', as he likes to think of the Albert Hall. I was a bit worried when I read a couple of reviews before the show - they didn't pan it or anything but they did say it was a bit pedestrian and that he looked 'too comfortable'. One of them criticised him for being too casual and turning up in his 'gardening trousers'! Well they can shut it, quite frankly, because he was sublime. I don't know what they expect from a 64-year-old guitarist - acrobatics? Playing the solos with his teeth? He's never been amazingly energetic on stage - he lets his guitar playing speak for itself. And I didn't go there to check out his designer gear - who gives a toss what he wears? Jeans and a shirt are fine with me - and he did look very comfy in his loafers :)

Muppets

At the risk of sounding like some crusty old fart saying 'in my day...', WTF is happening to house officers and SHOs these days?

There seem to be a lot more incompetent/lazy/unprofessional/downright SHIT ones working at the moment. Is it MTAS? Is it the EWTD? Is it just a general change of attitude and loss of professionalism on the part of doctors in general?

In Oncology, for example, the ward SHOs should generally be expected to have done a reasonable amount of general medicine so that they can deal with medical problems which (frequently) affect Oncology patients. I am not on the ward very often - I spend most of my time in Outpatient clinics, often in other hospitals. I need competent SHOs to deal with the ward patients most of the time, with telephone advice from me whenever it is needed. I expect them to know all the patients, to know what's happening with their schedule of investigations, what their blood tests are doing, what their vital signs are doing, and what the plan is regarding their treatment and eventual discharge. I also expect them to get the important jobs done - and this means that if it comes to 5 o'clock and the important jobs are not done, they fucking well stay until they are done, or they hand over to the SHO on call who should get them done. I did that job less than a year ago - I know these are perfectly reasonable expectations that are relatively simple to fulfil.

One of my SHOs is fantastic. He doesn't know very much about Oncology - that is fine, that's my job. But he is a good general medic and he is safe. He gives a shit too, which is becoming increasingly uncommon. The other one, less so. I came to the ward the other day around 5pm (yes, late, but clinic finished at 5) and asked this SHO to sit down and quickly run through the patients with me before I saw them (I wasn't going to make him stay late and go round them, I just wanted to talk over each one briefly). He just sat there, all attitude, blatantly pissed off that he was having to stay one second beyond 5pm. Told me complete bollocks about the patients, e.g.

Me: 'Was her renal function any better today?'

Him: 'Yeah, fine'

Me: checking result on computer 'Actually, it hasn't been done and she was in renal failure yesterday'

Him: shrugs

I eventually got fed up and told him to go home. I then spent 2 hours seeing everyone and correcting his fuck-ups. For example, a lady with an electrolyte imbalance who was losing calcium, potassium and magnesium by the bucketload and needed constant topping up via a drip. She had a 12-hourly bag of plain saline (no additives) running, was dry as a crisp and also had carpopetal spasm and a positive Chvostek's sign - suggesting a dangerously low calcium level. Her bloods showed very low calcium, potassium and magnesium levels. He hadn't fucking checked them. He hadn't written up any fluids or additives to replace her electrolytes.

Having a very low potassium can kill you. This is something medical students know. Writing up intravenous fluids and replacing electrolytes is something the lowliest, greenest house officer in their first week on the job should know how to do. It isn't fucking rocket science - and that's the point. It's not that he wouldn't have known how to sort out this patient's electrolyte balance. He just didn't care.

When I was an SHO (here we go...yes I know it was only a year ago), I would have been mortified if my registrar had to go round writing up fluids for my patients. I would be almost insulted if they checked the bloods on a ward patient - that was my job.

I had a call from an A+E SHO the other day:

SHO: 'I have a man here in A+E. He was diagnosed with skin cancer in March. He's 63. He came in because he's not very well. He's acidotic and I've given him oxygen and some fluids and I think he should be transferred to the Oncology ward.'

Me: 'What kind of skin cancer does he have?' (Thinking, perhaps metastatic melanoma, post-chemotherapy, neutropenic sepsis perhaps...)

SHO: 'I don't know.'

Me: 'Well, has he had any Oncology treatment? You know, like radiotherapy or chemotherapy?'

SHO: 'I don't know.'

Me: 'OK...what's your working diagnosis? Do you think he's septic? Or could he have had a pulmonary embolism maybe? Has he had a chest x-ray?'

SHO: 'Er...he doesn't look like he's had a PE, but I'm waiting for the bloods to come back. I haven't ordered a chest x-ray. But he has cancer and he's going to breach soon [ie about to hit the 4-hour limit in A+E] so he should really go to the Oncology ward.'

Me: beginning to lose it slightly 'Hang on...so you have this guy, you don't know what's wrong with him, you think it must be related to his cancer or his cancer treatment because you're referring him to me, but you don't know what kind of cancer he has or if he's had any treatment for it, and you want me to sort him out for you?'

SHO: 'Er, yes.'

Me: sounding a wee bit terse now 'Get your registrar to look at him, get a working diagnosis, find out some information about his Oncology history, and call me back.' Click.

Me: 'AAAAAAAAAAAAAAAAAAARRRRRRGGGGGHHHH!!!!'

I mean, WTF?? You make a referral to someone, you get the relevant information and have it in front of you and get your fucking story straight before you pick up the fucking phone! Our letters are on a computer system - even if the patient was confused and had no relatives with him his clinic letters would all be there at the click of a mouse. And at least have an idea about what might be wrong with the fucking person before you try and send them to me to sort out.

For the record, I spoke to the A+E registrar later. He was apologetic. The patient had pneumonia and was admitted under the respiratory team. His cancer diagnosis? He had had a BCC (very slow-growing, usually innocuous skin cancer) removed from his forehead by a dermatologist in March. Never been seen by an oncologist - did not need to see one.

I know, these could be isolated cases of someone who is just shit and someone who just doesn't care. But I have seen the same kind of stuff again and again. My colleagues tell me similar stories (and much, much worse). The over-riding impression I get is 1) junior docs are less competent these days and 2) they don't give a shit.

Are we losing our professionalism? Have we as a profession decided that we're sick of thinking of medicine as a 'calling', sick of papering over the cracks in the system by staying late without being paid to and by sacrificing our personal lives? Do we just want to do a 9-5 job? Perhaps, and perhaps enough is enough for some of us. But that doesn't explain the shitty attitude of doctors who have barely been qualified for five minutes. Surely they haven't had time to become that jaded. Who knows?


I know the system is far from perfect. I know that to deliver the care that patients expect and deserve in today's NHS, you often have to sacrifice your personal life. You have to stay late, go in early, bust a gut. And actually, why should we? How is the system going to improve if we keep 'covering' for it? Fine, so we fire-fight. We make sure we are safe, that we are not negligent, that patients get treated and of course 'first, do no harm'. But we do not go the extra mile to make things perfect. I can understand that approach.

But I'm sorry, there is no excuse for being fucking shit.

Better things

I have finished my sentence with my dysfunctional, irrational, erratic yet sometimes stangely pleasant boss....and I survived. More than that, I think I did a good job and managed to impress him. I learned a hell of a lot, and I've had some great feedback from nurses, CNSs and radiographers as well as from my boss. Most importantly, I'm still sane (just about!) and I think I'm a better oncologist. So, mission accomplished I suppose.

My new boss is absolutely lovely. Pleasant, normal, keen to teach, enthusiastic....I feel much less stressed, despite having started a new tumour site which I haven't got much experience of yet and having to prove myself all over again, which would normally send me into paroxysms of paranoia and tension (as you may have guessed, I am not the most laid back person on the planet). I just feel better.

And the weather's getting warmer, I've already booked my annual leave for the summer (2 weeks!!), my salary hasn't been cut (yet - not until September) and I'm going to start running again once it's light enough in the evenings. Better, better things.

AND The Apprentice is starting soon...:)

To someone I never knew

I met you three times. I spoke to you once since then.

You were professional, and seemed wise beyond your years. You were efficient, and explained the process clearly and compassionately.

When the day finally came, you were there. Sombre, and wholly appropriately dressed, with an appropriate expression. You followed us in one of the appropriately sombre cars.

When we entered the chapel, I heard the music for the first time as it was meant to be heard - aloud, across a large space. Suddenly there were people turning to look at me, kindly, but wondering when I would lose it. I could feel their curiosity, compassionate though it was. At the end of the aisle was her coffin, covered in flowers. Stark.

Suddenly I was unbearably, baldly, nakedly in that moment. Suddenly I knew exactly where I was, why I was there, and what I would have to do in front of all these people. I turned around, whether deliberately to look at you, or to escape, I don't know. But I turned, and you were right behind me. You caught my panicked expression and held my gaze. It took a split second, but I knew you understood exactly how I felt in that awful reality-check moment, as my world shattered around my ears for the second time. You looked at me, and you just knew. You looked at me, you nodded, and you said 'Okay?'. That's it. With that single word, and that look, I was suddenly strong again. I walked dry-eyed to the front and listened to the rest of her music. I stood before my family, her friends and my friends and I spoke about her, about who she is and was and what she meant, and I didn't cry, I didn't lose it, I stood up straight and told them.

That was because of you. You didn't know it, and now you're gone too. Younger than me, and you're gone.

I can't think what else to say, except, belatedly, thank you. Far, far too late, thank you for what you did for me and for so many others. I hope, when your loved ones are walking down that hideous aisle toward your coffin, that they have someone behind them to catch their eye and ask, 'Okay?'.

RIP ADG.

Slightly less hysterical now....

Many thanks to Michael and Charakan for your supportive comments. I must admit the idea of buggering off to New Zealand was tempting!

Things are better. My background stress levels are still fairly high but I'm on much more of an even keel at the moment. I think I have finally 'settled in' after 2 months in the job. I am, of course, still very much a small and very junior fish in a big pond, but I'm learning.

As for my boss...well, he's OK I suppose. I've learned to read his moods a bit better and have developed a slightly thicker skin in that, if I need to interrupt him in clinic and ask a question, I just brace myself and do it. I ask perfectly reasonable questions and I do so in order to provide better care for our patients, so if he wants to be shitty about it that's his problem. Well, that's what I tell myself anyway.

Anyhoo...just wanted to make a note that things are indeed better and I'm a bit less mad. I still have the feeling that there's an invisible anvil hanging above my head just waiting to fall on me though. I constantly question my decisions and worry about whether I've done the right thing, but actually that is probably going to make me a better oncologist. So that's fine. Now I just have to work on not thinking about work when I'm not there and not dreaming about it so much. Will keep you posted, and will also try and find something more interesting to write about than my state of mind. I'm even boring myself.

And so it begins....

I started my Oncology SpR job on Monday. I managed to have three whole weeks off after my SHO job finished, which was lovely. I was totally relaxed and chilled out (well, as relaxed and chilled out as I get anyway). Now, however, I'm wound up tighter than a very tight thing. Already.

I feel, how shall I put it? Totally out of my depth. I feel like a moron 90% of the time. I didn't go into this expecting to know everything, not by a long chalk, but my God I didn't expect this. I feel totally stressed out and anxious pretty much all the time and sometimes it's a struggle to keep the hysteria out of my voice when I talk to people. I cry when I get home each night (and this evening I actually cried on the Tube, which was embarassing).

I don't know what I expected. I mean, if you spend 4 years doing medicine as an SHO you get pretty confident I suppose, so that when you're thrown into a 'new' specialty at a relatively high level it's a shock. But I've done plenty of Oncology as an SHO, not to mention a locum SpR job at a large London teaching hospital, so I kind of thought I had a head start I guess.

OK, OK, I know. Starting a new job is stressful. Starting a new job at a more senior level is stressful. Starting a job in a specialty when you're not really a specialist yet is stressful. Understanding why it's shit doesn't make it any less shit though.

Plus I think that I'm so freaked out by the new place, by learning how the system works, by coping with the new seniority and by the (very) steep learning curve, that I'm not performing at my best. I'm getting flustered by situations that would not have flustered me had they happened to me in my old job 3 weeks ago. I can't fucking THINK straight.

I just don't want to screw up. I want to be good, I want to learn fast and I'm trying but it's so fucking hard and I feel awful and I can handle that for a while but I'm so worried it's going to be like this forever, or for a long time anyway. I can't do that, I really can't.

My Consultant isn't thrilled to have been landed with a 1st year SpR, I can tell. He's pleasant enough most of the time, but whenever I ask a question, or for clarification of something he's said, he gets really abrupt and I can tell he's annoyed. He explains things at 500 miles an hour and expects me to understand and retain every single word, and if I ask him about the same subject later on because I've not remembered all of it he gets snappy - 'As I said before....'.

Well FUCK YOU. I'm fucking trying here, OK. I am NOT going to get upset in front of you, or anyone at work. I am going to keep my fucking head, I am, I have to, and I am going to be good. Just give me a bloody chance, you bastards.