Shock and awe

I have just been shocked and appalled (and I thought I couldn't become any more so today) by something I saw on Dr Crippen's blog. An amazingly talented, dedicated, extremely qualified gastroenterologist has been chewed up and spat out by the MTAS machine. That is just further proof that the whole thing is one enormous lottery. I re-read my own application form today, and honestly could not see what else I could possibly have put on it to make it better. I 'ticked all the boxes' - I have distinctions from medical school, audits, national and regional presentations, publications and an SHO rotation with a good reputation. I have no career gaps and have taken my postgraduate exams as quickly as I possibly could have - I only became eligible to take PACES (experience-wise) a month before I took the exam.

So I thought my CV was good. But this guy's...bloody hell. I am speechless.

What a stupid stupid country we live in.

Still wittering....

I don't know who came up with this, but it is beautiful:

Choose MMC. Choose MTAS. Choose a region. Choose a career. Choose a f***ing big lottery, choose portfolios, on-line application forms and years of uncertainty. Choose a cut in training posts, career choice and job security.

Choose FTSTA’s no one knows anything about, middle grade rotas being run by juniors who’ve never worked in the specialty before, foundation programmes you have no control over, and hospitals you don’t want to work in. Choose being treated by ‘trained doctors’ rather than ‘doctors in-training’, even though the average consultants training hours have been cut from 40,000 to 10,000.

Choose Hospital At Night and no-one knowing the patients anymore.

Choose being an SHO lost in the middle of it all, with nothing but a sparsely updated web-site to inform yourself. Choose seniors who know nothing about the system and seem powerless to influence it. Choose an internal office with no windows in your brand new PFI hospital while the doors fall off and middle managers sit in their swanky boardrooms munching on biscuits that your taxes are paying for. Choose paying £10 a day for the privilege of parking at your work-place while you work non-compliant rotas and get bullied into lying on your EWTD monitoring forms.

Choose sitting at that PC filling-in mind-numbing, spirit-crushing objective assessment questionnaires. Choose PMETB-approved curricula and competency-based assessments no-one has properly validated. Choose your third choice career path and wondering who the f*** you are on a busy post-take ward-round morning.

Choose rotting away at the end of it all, pushing your last in a miserable Non-Consultant Career Grade post, nothing more than an embarrassment to the under-experienced, ‘fit for purpose’ FY’s you’ve trained to replace yourself.

(Don’t) choose your future. Choose MMC…

There is also the 'hamster' theory of how MTAS allocated the interviews, but it is rather long and complicated (and fantastic). Or the 'monkey' theory (two monkeys shut in an office with all the application forms, left for a few days, whichever forms they don't eat/wipe their arses with/destroy are selected for interview).

Please please please, if anyone reads my drivel, read this: come to the march in London on Saturday 17/3. It's organised by Remedy UK (details here). I have no doubt that it will make not the slightest bit of difference to anything, but at least we'll be able to do some shouting, which always makes me feel better anyway. And then we can all go down the pub afterwards.

You fucking bastards

I am unemployable. I did not get shortlisted for any interviews, despite casting the net as wide as I could, despite applying for a job that I'm already doing, at a level that I am, if anything, slightly overqualified for (I couldn't apply to the next level up as no MRCP yet). Most of my friends will also be jobless come August. We are all very depressed and I burst into tears in the middle of the ward yesterday, which was embarassing. Then I went out last night and got pissed. Now I'm hungover and demoralised. I can't fucking believe it. Don't get me wrong, I didn't expect various London teaching hospitals to be clamouring to give me a job. I didn't expect to get my 1st choice of hospital or region. But I did expect to get at least one fucking interview, one chance to justify my existence and prove that I am worth employing by actually speaking to my potential employers face to face.

If I were single I would be on a plane to Australia now. As it is, I'm facing the prospect of accepting any bone the MTAS fuckers choose to throw me, be it 'career grade' or 'FTSTA' (AKA Staff Grade, AKA career suicide and contractual wasteland where they can pay you as little as they like and where you get no training whatsoever). I have a feeling this bone will be cast several hundred miles from my beloved's SpR training rotation. I honestly don't know if we can survive another long distance stint (we've done it before but I don't know how long we could manage it for again).

So, MTAS, you stupid jobsworth foolish monkey fuckwits, you educationally subnormal soulless bastards, not only have you effectively sealed the fate of my career and future livelihood, you've also decided the fate of my relationship. My entire fucking life. You cunts.

Mangling medical careers, part 2

I woke up in a good mood today. I didn't feel like having a cigarette (and I managed to resist smoking on Wednesday night, despite being very drunk - I just remember shouting, 'Stop smoking, you pigs!' at my smoking friends). I had had a good night's sleep and it was mild outside. I wore my favourite boots to work.

I was humming to myself as I checked somebody's blood results when a friend of mine walked onto the ward with a face like thunder. 'Have you checked your email?!' he spat. I replied that I hadn't. 'They've extended the fucking deadline for MTAS shortlisting. Which means they've shortened the amount of notice we get about interviews. I might find out on Monday that I have an interview in Yorkshire on Tuesday and have to beg for the time off, pay five billion pounds for a last minute train ticket and turn up at the interview with no time to prepare!'.

I agreed that this was pretty crappy and sympathised (the furthest away I have applied is Norwich, but I do have a car - nonetheless it is extremely irritating, though I have been feeling fairly apathetic about the whole thing of late).

My irate friend is an excellent doctor. He passionately wants to become a gastroenterologist and would make a very good one. He wants this job more than anything. But this morning he looked me in the eye and said, in all seriousness, 'Fuck them. They don't give a fuck about us. They treat us like schoolchildren. Why should I turn up and beg for a job when they won't tell me where I will be working, how many hours I need to work, what training criteria I need to meet and how much I will be paid. I'm going to go there, give them the finger and say "Fuck you all, I'm going to Australia". I can't be arsed with this shit anymore.'.

I don't blame him one bit. I do think he's serious about what he said and that this deadline change was the last straw after the whole MMC/MTAS/Hewitt nightmare of the past few months. I've just seen him printing out application forms for Australian medical job agencies.

I feel like shit now.

Done and done

I have done my exam. It wasn't brilliant, but wasn't hideous either. I was slightly concerned by the fact that I didn't have a clue what the respiratory case was. I was also concerned that I couldn't understand the questions I was asked by the examiners in the 'Ethics and Communication Skills' station. Neither of them had English as a first language and both of them had very heavy accents. Now it may well have been nerves, but I couldn't understand them. I am concerned that these people, who cannot communicate effectively with me, are put there to judge how effectively I communicate with patients. I await their respective judgements with bated breath.

I have also stopped smoking. I haven't had a cigarette since Saturday 17th February at 1825. I feel I am still experiencing physical withdrawal symptoms, but I may be imagining this. How long are they supposed to last for?! I went for dinner in London yesterday and had to run through the train station to get straight on the Tube in case I found myself in the tobacco shop. I am also going out for dinner tonight with friends (two of whom smoke) - I am worried but confident, if that makes any sense. I feel like I'm nearly through the physical cravings so don't want to 're-set' everything by smoking tonight. God I really really want a fag though....

Smoke on the water

I am a smoker. I started smoking at school and developed a 30-a-day habit at medical school. I gave up in May 2000 and didn't touch a cigarette for six and a half years, but then at the end of 2006 I suddenly started smoking when I was drunk and out with friends who smoked. A bad day in November made me think it was a good idea to buy a pack of twenty and I've been smoking ten a day ever since. I did try to give up around New Year but soon started again. The trouble is, I enjoy it. I like the solitude and space that going out for a 'fag break' brings. It also confers a kind of weird solidarity between fellow smoking pariahs - for example, I went on a PACES course recently and found myself chatting to a man with Eisenmenger's syndrome and an acromegalic while we stood outside having a quick fag.

I don't like the smell, which sticks to my clothes and hair and makes my breath like an ashtray. My boyfriend hates it. And there is, of course, the whole lung cancer thing. I don't know whether the large warnings on cigarette packets actually deter anyone from smoking - I can't imagine anyone asking for twenty Marlboro lights and then saying to the sales clerk, 'Oh my God, it says 'SMOKING KILLS' on the packet. I had no idea. I won't buy them after all.'.

I am giving up, for real this time, on the day of my PACES exam. After the exam, of course. There will be a lot of drinking and celebrating the week after, which may throw a spanner in the works as it did in January. But we shall see. I can't be arsed with patches or gum or anything. When you haven't smoked for very long the physical withdrawal symptoms aren't really too bad, and are over within 48-72 hours. I think nicotine replacement just prolongs the withdrawal period. It's the psychological side of things that's the real bugger - you want to want one. Especially after a few glasses of wine.

I can't carry on like this though. It really does get to my boyfriend, who is vehemently anti-smoking. He's also a doctor and therefore knows as much as I do about the health risks and has probably treated more lung cancer patients than I have.

I'm not sure what I make of the upcoming anti-smoking legislation. It will be nice to come back from the pub and not stink of smoke. I'm not sure if it extends to smoking in the street - I think that would be a little Draconian to say the least. Our hospital Trust is now 'smoke-free', so we have to either be discreet or walk off hospital grounds to smoke. I do agree with it in a way - it probably helps patients who've come in with a heart attack to stop if they don't see a gaggle of nurses standing outside puffing away. I do think it's cruel, however, to force terminally ill patients to stop. What is the point? We are very bad at providing nicotine replacement to these patients, many of whom have smoked for years and therefore have nasty withdrawal symptoms. We are rather good at treating alcoholics with withdrawal from booze, so why not smokers? It is nigh on impossible to get nicotine replacement from the hospital Pharmacy - we tend to ask patients' relatives to bring it in. I think that's disgraceful.

Anyway, seven days til I give up. I don't want to end up as a pink puffer or a blue bloater. I don't want to exsanguinate horribly from an eroding bronchial carcinoma (I've seen that happen - it is not nice). If I give up now and don't start again, I have a good chance of not getting any of the above. Of course, I may already have contributed to my ischaemic heart disease (particularly in view of my family history), but that should reverse itself in time. I will be able to tell patients they should give up smoking without being a hypocrite.

Oh, did I mention I want to be an oncologist when I grow up? Smoking is most definitely not part of the plan.

10 days to PACES....

I have ten days until my PACES (Practical Assessment of Clinical Examination Skills) exam. I am scared. It will be very embarassing. Not because I'm a crap doctor, and not because I haven't worked hard. I am a good doctor. I get on well with my patients. I have good clinical skills and I have done a lot of work. I have invested more money in this exam than I have in any one thing before (exam fee, courses, hotels for courses, travel to courses, books). It's just that so much of this exam depends on lady luck. She has been good to me in the past, but she tends to abandon people on PACES day for some reason.

I should be studying now but I feel too wired. All I want to do is chain-smoke and play 'Spider Solitaire' - I keep getting into a cycle of 'I'll stop playing and do some revision when I win a game', but then inevitably I lose game after game and suddenly it's 1am and I have to be at work at 8am and oh dear it's too late to study now and I'm tired anyway never mind....

One thing that pisses me off is that this exam will be scrapped within the next few years, presumably to be replaced by some kind of super 'mini-CEX' and 'DOPS' extravaganza thanks to the fuckers in charge of 'Mangling Medical Careers'. I finished my application form last week to MTAS (AKA pick a random doctor's name out from a hat, give them a job anywhere between 5 and 5000 miles of the one they applied for and hope they can speak English) (I couldn't think of anything clever starting with M, T, A and S). The application form was basically like a submission to a creative writing competition, except 1st prize is a job (just a job, anywhere - if it happens to be several hundred miles from your house, who cares, it's a job! Be thankful to Mrs Hewitt, boys and girls).

For the uninitiated (you lucky bastards), MTAS is the new application 'service' for doctors. From the newly qualified to the nearly-Consultant, from now on ALL doctors in the UK can only apply for jobs once a year - that is every single doctor and every single doctor's job in the UK. You can apply for up to four different specialties - which it encourages, to 'maximise the chance of success'. Never mind the fact that you want to be a cardiologist and you end up working as a dermatologist - hey, you got a job and therefore MTAS is a success. Or, if you really want to be a cardiologist, you can apply to up to four areas (or 'units of application'). Never mind if you live in Devon, you should 'maximise your chances' and apply to areas as diverse as London, Kent, Surrey and Sussex (ALL one single unit of application), Eastern (AKA Norfolk), West Midlands (AKA Birmingham) and Wessex (AKA Southampton and Portsmouth). Bad luck if you're Scottish - the WHOLE of Scotland, from the northernmost Scottish Isles down to Edinburgh, is ONE unit of application. So theoretically you could apply when living on the Scottish/English border and end up in Wick. And remember you must MAXIMISE those chances, so you should also apply to the whole of the north of England (one unit), Yorkshire (one unit) and, oh I don't know, how about Mersey as well? If you really just want to be a cardiologist.

God I am so pissed off with this steaming pile of horseshit. I love my job. I love being a doctor. I think I'm quite good at it now. I just don't know if I can put up with being treated like a child by the Government, condemned by the press and bullied by managers.

Fuck it. I'm going to play some Spider.

The weekend from hell

I recently finished the worst weekend on call in living memory (my living memory in any case). Saturday was spent shoving various lines into a 76-year-old man's neck and groin and filling him with fluid, antibiotics and anti-fungal medication. He was an old patient of mine who had ulcerative colitis. He first came into hospital in October with a flare-up. Various things happened; he ended up having his colon removed and a very stormy time with a perforated ulcer, double pneumonia and Candida septicaemia. I saw him just before Christmas and he was much better - he just needed intensive physiotherapy to get him back on his feet, so my consultant sent him to the rehabilitation ward. When I was called to see him urgently on Saturday morning he was unconscious, with a very low blood pressure, acidosis and very low blood oxygen levels. He was severely dehydrated and in septic shock. He had not had his vital signs measured for two days (on meidcal wards nursing staff routinely do these every four hours, but this does not happen on the rehab wards). In short, he was about to die. I moved him to an acute ward and spent most of the day trying hard to keep him alive. He died just before my shift finished. I had to tell his family, who were devastated and could not understand why this had not been caught earlier. Neither could I.

Whilst I was still dealing with the above gentleman, a man came into A+E with complete heart block . He was seventy years old and had never been ill a day in his life. We couldn't get his heart to speed up despite drugs and external pacemaker pads (which basically shock his heart at intervals to stimulate a heartbeat). He stopped breathing several times before we got a pacing sheath into his jugular vein and got him to thex-ray room to insert a temporary pacemaker, which was unsuccessful because we couldn't get his heart to respond to the pacing impulse. He did however regain a normal heart rhythm spontaneously, but the ECG showed signs of a heart attack. Those same ECG changes can also indicate that the pacing wire has put a small hole in the right ventricle, a recognised complication of this procedure, which was performed by an experienced registrar. He was discussed with a cardiology consultant at another hospital, who recommended clot-busting treatment for a probable heart attack, despite the risk that it may not have been a heart attack at all but a hole in the right ventricle. This caused him to bleed profusely into the sac around his heart. A drain was inserted into this sac and he drained two litres of blood from his heart overnight but remained fairly stable. We gave him blood and clotting products to reverse the effect of the clot-busting treatment. Later the next morning, his heart stopped. We began to resuscitate him. I got a large syringe and began sucking blood out of the sac around his heart.

It was like a scene from a bad horror film. I had a bucket of blood next to me on the bed, into which I would throw full syringes after sucking blood out of the man's chest. Each time, someone would hand me a new one, and I would carry on. I was covered in it. After I removed about half a litre of blood, his pulse returned and we recorded a blood pressure. My registrar got onto the phone to London to arrange for him to be transferred for urgent cardiothoracic surgery. Ten minutes later, he lost his pulse again. We never got it back.

His family were waiting outside, and one of the nurses went out to tell them that he had died. We frantically tidied him up, mopping up the blood and hiding the bucket. We covered his body so that only his kind, sweet face remained exposed so his family could see him. His wife was so distraught she couldn't support her own weight. All the nursing staff and the entire arrest team were in tears. He had never been ill a day in his life.

After that, I dashed outside with one of the junior doctors for a much-needed cigarette. She was upset, but more than that, she was upset at herself for being upset. She told me what many people might think if they read this - 'This is our job, this is what we signed up for. We shouldn't be getting emotional or upset about things like this - does this mean I'm not cut out for it?'. I told her the truth, what I believe anyway - 'Nobody should be cut out for this. If you get used to things like this, then it's time to change profession'.