Choosing a career path is one of the hardest (non-clinical) decisions many doctors will face in their professional lives. With almost 100 specialties and sub-specialties available, settling on any one career can seem pretty daunting, particularly as in the majority of cases the choice will set a path you’re likely to be on for the next 30+ years. But, with only a very small range of these specialties and almost none of the sub-specialties available to undertake as rotations during any one foundation programme, finding out what actually working in different specialties is like can be difficult. It’s likely you’ll have at least identified an area you’re kind of/maybe interested in before starting the foundation programme but, to use a total cliché, you wouldn't buy a car without taking it for a test drive, right?
There is good evidence to show that any experience, even if only brief, can be very influential on career choice and this is why all deaneries offer new doctors to undertake a ‘taster week’ at some point during the Foundation Programme. This is usually from 2-5 days, taken as study leave, in a specialty of the doctor’s choosing which they haven’t and won’t work during their foundation programme. Most hospitals will allow doctors to do this at an external hospital or organisation if the desired specialty isn't available locally. Tasters are often organised by the trainee but deaneries are encouraged to provide a list or register of structured taster programmes to its trainees. A timetable split into half-day activities, including time for 1:1 discussion with both consultants and trainees, should be provided or agreed with a supervisor, which gives the doctor as broad an experience of the roles, responsibilities, highlights, challenges and lifestyle of the specialty as possible. This should then give the doctor plenty of food for thought and provide an opportunity for (you guessed it) reflection to confirm or exclude that specialty as a career choice and identify (if the former) what steps they need to take to get there. At the end of the experience the doctor should fill in a feedback form and formally reflect in their portfolio.
Taster weeks aren't limited to particular specialties and sub-specialties either; there are plenty of more over-arching opportunities such as experiencing leadership and management roles or getting involved in academia, research or medical education. As long as you can identify and describe what you’ll aim to learn or understand from the experience, almost any taster is possible.
So, how do you go about it? Each deanery should have a policy relating to taster weeks, or have an responsible administrator who can provide advice. Talking to your educational supervisor can also be really useful. Considering early on in FY1 which area or specialty you want to explore is important; time runs out scarily quickly and taking time out of rotations needs careful planning and co-ordination to make sure there is enough cover for your day job. You may already know or have identified an appropriate supervisor who will facilitate the experience but if not, your supervisor or administrator will almost certainly be able to point you in the right direction.
You’ll never get to experience every possible career path before starting out on one; the specialty or sub-specialty you eventually work in may not even exist yet. But getting an idea of what you’ll definitely consider, or definitely won’t, will give you a better chance of identifying something that will suit you personally and professionally, and, particularly in the more competitive and run-though specialties will give you another example of commitment to specialty. Don’t be afraid to think outside the box or look at something really niche – it may give you a taste for something unexpected that you’ll love for life.
When is it medically advisable to eat some one else's poo? When you need a poo transplant.
Poo transplants could be the solution to one of the biggest problems facing the NHS today- the bacterial infection Clostridium difficile. C.diff, as it's known to its friends, infects about 18,000 people in England and Wales every year and is involved in the deaths of about 2000 people.
C.diff typically arises due to imbalances in the normal gut bacteria. The gut is like a city, a city with about 100 trillion bacterial residents happily munching away on a banquet of bowel contents. The average person has about 1000 different types of bacteria in their gut, and about 3% of healthy adults have C.diff in that mix. The C.diff doesn't cause them any problems because its numbers are kept in check by the other gut bacteria. However treatment with broad spectrum antibiotics such as clindamycin, cephalosporins, ciprofloxacin and co-amoxiclav, can disrupt this happy community- killing off vast swathes of bacteria but crucially not the C.diff. Given free rein the C.diff multiplies rapidly and produces toxins which damage the gut. In some people this causes mild diarrhoea and abdominal pain, in others it can lead to torrential diarrhoea, perforation of the colon and death.
Traditional treatment includes stopping any broad spectrum antibiotics and possibly prescribing antibiotics which target the C.diff such as metronidazole or vancomycin. However with antibiotic use comes the risk of resistance. Moreover our current approach isn't entirely effective and about 22% of patients treated suffer a recurrence. This can result in a cycle of illness and hospital admission which is costly to the patient and the hospital.
So it's time to start thinking outside of the box. Cue the poo transplant. The thinking goes like this- if the cause of the problem is disruption to the normal community of gut bacteria, why not just pop those bacteria back in to crowd out the C.diff? Simples. Practically, the first step is to identify a donor, usually a close relative of the patient, and screen them for a range of infectious diseases and parasites. It's also advisable to make sure they haven't recently consumed anything the intended recipient is allergic to, before asking them to make their "donation". You then pop it in a household blender and blitz it down, adding saline or milk to achieve a slurry consistency. Next you need to strain your concoction to remove large materials- one medic in the UK uses coffee filters. Top tip. Then you're ready to administer it- about 25ml from above (e.g. via nasogastric tube), or 250ml from below.
Now, its important to note that poo transplants are still an experimental treatment. To date only small case studies have been carried out, but with 200 total reported cases, an average cure rate of 96% and no serious adverse events reported to date, it's worth carrying out a large trial to assess it thoroughly.
Poo transplants- arguably the ideal treatment for a cash strapped NHS. It's cheap, plentiful and it seems to work. Now to convince people to consume someone else's poo... Bottoms up!
FYI: This was first posted on my own blog.
Image Courtesy of Marcus007 at de.wikipedia [Public domain], from Wikimedia Commons
Worst experience ever? - this is pretty difficult as I've worked in some of the poorest countries in the world and seen some things that should never happen like children dying of dehydration and malaria. But this recent experience was definitely the worst.
It was midnight and I was trying to get my 16 month old to sleep having woken up after vomiting in his cot. Despite paracetamol, ibuprofen, stripping to nappy, damp sponging and having the window open he went rigid and started fitting. It only lasted a minute or two yet felt like an eternity as he was unable to breathe and became progressively blue as my mind raced ahead to brain damage or some other horrible sequalae.
The fitting stopped and my mind turned to whether I was going to have to start CPR. I lay him on the floor and put my ear to his chest and was glad to hear a strong heartbeat but he was floppy with a compromised airway so I quickly got him in the recovery position. The ambulance arrived in 8 minutes and after some oxygen and some observations he was strapped in and ready to go. He had been unconscious for about 15 minutes but was starting to come round, much to my relief.
The ambulance crew were great and their quick response made all the difference but then they took nearly half an hour to get to A&E in the middle of the night because they took the most awkward route imaginable. I don't know if it was a deliberate delaying tactic or just a lack of local knowledge but even without a blue light I could have done it in half the time! Why do ambulances not have GPS - ideally with local traffic info built in?
We arrived in A&E and were ushered to a miserable receptionist who took our details and told us to have a seat. I noticed above her head that the wait time was 3.5 hours, though we did see a junior nurse who took his observations again. Not long after the screen changed to a 5 hour wait and a bit later to a 6 hour wait! I am glad to say that by about 3 hours my little man was back to his usual self (as evidenced by his attempts at destroying the department) and so after getting the nurse to repeat his obs (all normal) we decided to take him home, knowing we had a few more hours to wait for the doctor, and that the doctor was now unlikely to do anything as he was now well.
I tell the story in such detail in part for catharsis, in part to share my brief insight into being on the other side of the consultation, but also because it illustrated a number of system failures. It was a horrible experience but made a lot worse by those system failures. And I couldn't help but feel even more sorry for those around me who didn't have the medical experience that I had to contextualise it all. Sickness, in ourselves or our loved ones, is bad enough without the system making it worse.
I had 3 hours of walking around the department with my son in my arms which gave me plenty of time to observe what was going on around me and consider whether it could be improved. I did of course not have access to all areas and so couldn't see what was happening behind the scenes so things may have been busier than I was aware of. Also it was only one evening so not necessarily representative.
There were about 15 children in the department and for the 3 hours we were there only a handful of new patients that arrived so no obvious reason for the increasing delay. As I walked around it was clear to me that at least half of the children didn't need to be there. Some were fast asleep on the benches, arguably suggesting they didn't need emergency treatment. One lad had a minor head injury that just needed a clean and some advice. Whilst I didn't ask anyone what was wrong with people talk and so you hear what some of the problems were. Some were definately far more appropriate for general practice.
So how could things have been improved and could technology have helped as well?
One thing that struck me is that the 'triage' nurse would have been much better as a senior doctor. Not necessarily a consultant but certainly someone with the experience to make decisions. Had this been the case I think a good number could have been sent home very quickly, maybe with some basic treatment or maybe just with advice. Even if it was more complex it may have been that an urgent outpatient in a few days time would have been a much more satisfactory way of dealing with the problem. Even in our case where immediate discharge wouldn't have been appropriate a senior doctor could have made a quick assessment and said "let's observe him for a couple of hours and then repeat is obs - if he is well, the obs are normal and you are happy then you can go home". This would have made the world of difference to us.
So where does the technology come in? I've already mentioned Sat Nav for the ambulance but there are a number of other points where technology could have played a part in improving patient experience. Starting with the ambulance if they had access to real time data on hospital A&E waiting times they may have been able to divert us to a hospital with a much shorter time. This is even more important for adult hospitals were the turnover of patients is much higher. Such information could help staff and patients make more informed decisions.
The ambulance took us to hospital which was probably appropriate for us but not for everyone. Unfortunately many of the other services like GP out of hours are not always prepared to accept such patients and again the ambulance crews need to know where is available and what access and waiting times they have. Walk-in patients are often also totally inappropriate and an easy method of redirection would be beneficial for all concerned. But this requires change and may even require such radical ideas as paying for transport to take patients to alternative locations if they are more appropraite.
The reasons patient's choose A&E when other services would be far more appropriate are many and complex. It can be about transport and convenience and past experiences and many other things. It is likely that at least some of it is that patients often struggle to get an appointment to see their own GP within a reasonable time frame or just that their impression is that it will be difficult to get an appointment so they don't even try. But imagine a system where the waiting times for appointments for all GPs and out of hours services were readily available to hospitals, ambulances, NHS direct etc. Even better imagine that authorised people could book appointments directly, even when the practice was closed. How many patients would be happy to avoid a long wait in A&E if they had the reassurance of a GP appointment the next day? And the technology already exists to do some of this and it wouldn't be that hard to adapt current technology to provide this functionality. Yet it still doesn't happen. I have my theories as to why but this is enough for one post.
In case you were wondering my son appears to have made a full recovery with no obvious ongoing problems. I think I have recovered and then he makes the same breathing noises he made just before the fit and I am transported back to that fateful night. I think it will take time for the feelings to fade.
Thousands of doctors are currently preparing portfolios and stressing about situational judgements as they go into core and specialty training interviews. As a medical student I wasn’t even aware when these interviews were and had only the briefest imaginings of what they might entail. Even at finals, specialty applications felt a million miles away; but it’s as if you’ve only just got through the misery of MTAS and you’re suddenly an F2 realising that the last 15 months have, to your surprise, disappeared.
Yes, the interview is certainly a stressful situation, and for many medics it’s only the second ‘proper’ interview they’ve ever had. Time pressures, the scope of stations and performing under the watchful eye of the great and good of the medical profession only add to the stress. But, there are ways to make this process bearable, and, dare I say it, enjoyable (kind of).
The most important step is preparation. Not just the preparation that starts in the days to weeks before the interview; this should be for refining your skills, getting your answers super-slick and getting to know yourself inside-out. Preparation starts at university (and no, which school you’re in doesn’t make a single difference). What the interviewers are looking for can be found in the person specification unique to each specialty (found at http://bit.ly/1eWF6aN). I.e. if you know you were born to perform heart surgery, start looking at what the interviewers for cardiothoracics are looking for. Even if you’re completely confused about your career path, it’s time to start thinking.
Many specialties still have a short-listing stage dependent on the application form. Whether assessed on the form or at interview each specialty will (generally) award points for other/higher degrees, publications, presentations, prizes, teaching experience, audit and ‘commitment to specialty’. At the CT1/ST1 stage it doesn’t matter what subject area you published/presented/taught in etc. to score in that section; but having something relevant will help you discuss your commitment to that specialty. ‘Relevant’ in itself is misleading however; every experience is likely to be relevant when you identify the transferable skills involved and what you learned from the experience. Some specialties are stricter and you’ll need demonstrable evidence that you haven’t just applied on a whim. These tend to be the more competitive specialties which demand evidence you’ve had a really good look at what the job involves and have taken steps to broaden your knowledge.
There is typically also at least one skills station which may be general (e.g. breaking bad news to a patient) or specialty-specific (e.g. interpreting images for radiology) but are still based on applicants demonstrating they fit the person specification. Many of the mark schemes are also freely available on the relevant Royal College website, and I encourage you to have a look and see where you could get a few more points (or give yourself a pat on the back that you couldn’t). It’s unlikely that the mark scheme/person spec. will be exactly the same every year, but the general overview is enduring.
NB. The GP application is a bit different, but that’s for another post.
The take home message is get involved early on, and be involved consistently. It may eat up some of your free time but you’ll appreciate it as soon as you look at the application form. If you’re struggling for practical ideas, take a look at the Royal College and specialty trainee websites for inspiration (some, for example the Royal College of Radiologists, have great audit ideas). The RSM and each medical school have a list of available prize essays and exams. A wise person once said to me “there’s no such thing as a wasted conversation”: Speaking to trainees and consultants about how they got to where they are not only gives you great insight into what they do but being friendly and enthusiastic can open up doors for you to help in audits and publications. And the final tip? Write everything down. Not only will this stand you in good stead as a safe doctor, but you’ll be surprised how much you can forget in a very short time. Then, unlike me, you won’t have to spend ages trying to think of reasonable examples of ‘when I dealt with stress’.
Written by Lydia Spurr, FY3 Doctor
Lydia is a Resident Meducation Blogger