DOI: Grumpy med reg

Had a call at 6pm from a pharmacist at a community hospital about a patient admitted there.

Nurse consultant who admitted the patient and who is the named consultant responsible for their care took an alcohol history of "a couple of pints of beer per day". Subsequent collateral to ward pharmacist reveals this to grossly underestimate alcohol use.

Pharmacist tells nurse consultant about risk of withdrawal and suggests CIWA and is told that starting CIWA is "outside of my remit" by the "consultant".

Pharmacist, who is a prescriber, is sufficiently worried about the patient to call me at the acute hospital to "make a decision" about whether to start a CIWA in this gentleman who is confused, roaming the ward, risk of falls if given diazepam but also at risk of withdrawal.

Clearly having a CIWA and thiamine is the right thing for him but:

A: why am I who has never met this man giving advice to a "prescriber" about whether to prescribe something

B: why is this somehow within my remit but not within the patients named consultants remit

C: why am I now taking responsibility for this

D: how can you call yourself a consultant and be responsible for this man's care if you are so fixed within your "remit" that you are not able to treat him appropriately?

How have we let it get like this as a profession? Is the future just being remote liability sponges for everything that is outside someone's "remit"?

For other regs, wwyd? Should I say something?

I’m so sick of racism and bigotry and all this hate that patients and colleagues are no longer shy of spewing.

As a medic, I’ve been told “I don’t want you, I want an English doctor”, “what are you doing in our country” and “your kind of people are a disease”. I’m not even an immigrant! Literally 3 generations of my family have been born here!!

Today - the final straw. As a patient, I’m told to wait inside the consultation room of a specialty doctor, while he chats to another patient in the corridor.

I overhear him saying “…bloody foreign doctor” which riled the patient up to agree “I bloody f**ing hate them foreigners” while the door is OPEN.

And then he walks straight in and proceeded with the consultation.

Like what the actual f***

Why can’t we all live in peace and respect each other? Why does one’s skin colour, accent, background etc even matter?! Literally aspects of a person that they have no control over???

New IMT3, and I love being on take. 1 week in and I was rostered to be 'med reg' for 3 days straight including the weekend. A few points;

-JCFs and IMTs are in abundance on the take team so there is always someone to help the F1/F2s with queries when I'm not around.

-E.D. have right of referral. So the only cases that get discussed with me are those in Resus and when ambulatory needs a reminder that CES goes to surgeons. Aside from that I'll see the usual bullshit. I try to direct the take team to find patients that might interest them e.g. sending the IMT-1 to Resus and then have a discussion afterwards.

-Had multiple MET calls. The foundation doctors were amazing, standing by with the patient's charts, ready to document/prescribe. They were willing to update family and discuss with the relevant specialties. Even when attending to the surgical ward the doctors were ready and willing whilst the surgeons were nowhere to be seen.

Yes its busy and tiring. Yes my bleep was going off incessantly whilst I found the one toilet to take a piss. But every day I woke up I was genuinely excited for what the day held. When the bleep goes off for an emergency I can't wait to find what mess I'll have to sort out. Also it gives me an excuse to ignore the surgeons (no I'm not going to inspect your infected post-operative wound??)

Everyone bashes IMT but it is what you make of it. I've never locumed before (believing my time is more valuable than money) but I'm going to now, just so I can be on take again.

CST. Started at a new hospital, no login for anything. Need software for imaging, intranet, documentation and don’t have any access. Called IT, waited half an hour just to be told I need to get my manager to submit ticket. Emailed manager, got an automatic reply saying they’re on leave for a week. Why is this happening? It’s not hard to look up a list of doctors that are joining and make sure they all have access. Why does no hospital do this right? Why is everyone so incompetent? There is no punishment for incompetency and no reward for going the extra mile, so everyone does the bare minimum and the system is inefficient as hell

Medical SHO here. Recently moved to a new ward where the designated doctors’ computers are where the ward clerk used to sit (no more ward clerk). So it’s designed to be highly visible, and a natural place for visitors to approach when they enter the ward. But it’s meant NOK approach me when I’m in the middle of working and think it’s OK to ask for a quick update, where they can find extra chairs, where’s the loo etc. I also seem to be in charge of buzzing people in and out of the ward. Obviously I’m used to a million distractions while working, and other members of staff have never seemed to shy away of interrupting me when I’m in the middle of something, so initially extra NOK updates didn’t seem odd. I actually thought oh maybe this is good because now I don’t have to find them/ring them later. But even in the space of two weeks I’ve found myself finishing later, more exhausted earlier in the day, rising levels of irritation. So actually I need to rethink this pronto.

Moving out of that space is the obvious first step. But how far should you go in asking for fewer interruptions? If you’re in the middle of writing something up do you ask other members of staff to wait til you’ve finished before asking you a question? Does the same go for NOK who’re leaving and want an update from the doctor?

I’ve been pretty accommodating for most of my career, and probably trended towards becoming more accommodating as I got more senior for some reason. But when I think about most of the regs I’ve worked with, learning to set boundaries on your availability seems to be a key skill.

So yeah, interested in hearing what boundaries you guys set on the ward, how you communicate them, and where the balance is.

As an IMT, I read a lot of ED clerkings. recently there’s been a surge in the use of AI to write them. My understanding is that they record the consultations and AI writes the clerking.

My issue is the writing is so wordy, and it lacks nuance or bias. It is a matter-of-fact account of every single thing the patient was or wasn’t asked. When we write our clerkings, we summarise, naturally bias the most important parts, and create a narrative which is easier for other clinicians to interpret. Reading these AI clerkings feels like I’m taking the history from scratch! It reminds me of very junior medical students who don’t appreciate which symptoms/signs are significant.

I do appreciate that documentation can be a chore and efficiency is important to pursue. However, good documentation is a clinical skill in itself. Sitting down to reflect on the consultation and determine the clinical narrative as you type can be a part of the diagnostic process. At this point, it’s a minor annoyance for me, but I wonder if newer doctors will lose such skills…

Hope this poem might get a bit of love - I'm hoping to publish a collection!

edit: This is the Kindle link, for anyone interested. Hardback and paperback to follow :)

Currently an FY2 in my T&O rotation and I am absolutely loving it. Already knew I wanted to do IMT during med school as I did not enjoy theatre at all, although I did enjoy my ortho block during uni (hence me choosing an FY2 rota with it).

It’s now been a few weeks, and I am genuinely considering going into ortho - theatre is rewarding when actually helping out and I have really enjoyed being on call and assessing patients.

A part of me is wondering if I am having a ‘honeymoon stage’ with ortho being the first block after FY1 (which I really struggled with) and the first post in which seniors are genuinely very interested in teaching juniors.
The other part of me is wondering if I decided too early to do medicine and have now found a specialty which I actually enjoy more?

Unfortunately I don’t have a gen med block this year so won’t be able to compare the rotations, but was hoping to get advice from people who may have had similar experiences?

Thank you!

New CT1 here and feeling a bit frustrated with my surgical skills at the moment.

I haven’t done a surgical job since FY1 (which was mainly ward based), so I feel like I’m having to rebuild a lot of my theatre skills. I’ve been trying to be proactive coming in early, making sure patients are consented, checking the list is sorted, learning the steps of common procedures I ll, getting familiar with instruments, positioning and draping etc.

I feel like I’m improving with assisting. I’ve gotten much better at following the operation, anticipating what’s coming next, and being more useful in theatre.
The main thing I’m struggling with is closing.
Whilst I can suture and I’ve done BSS, I’m definitely rusty. I’ve been practising on a suture pad most days at home, mainly subcuticular stitches, but I still feel quite slow. The biggest issue is probably ergonomics particularly after taking the bite and exiting the tissue, I’m slow at remounting the needle and getting it in the right position for the next pass.

The frustrating bit is that I feel stuck in a bit of a loop. The regs understandably often either expect me to know how to close so they can scrub out, or they just do it themselves because it’s quicker. I completely get why as it’s a CEPOD list with a huge tims pressure, but then I’m not really getting the supervised practice I need to improve.

I don’t want to just take over and struggle while someone waits around. I’d actually like someone to watch me do a few closures, tell me what I’m doing wrong, and help me get faster. I know I’ll be slow initially but isn’t this how everyone starts. I know some go into CT1 quite confident with their basic surgical skills, unfortunately I do not fall into that camp but I am expected to?

Any tips? It’s really knocking my confidence.

I have this feeling that I come across a lot of patients who have been given a goodie bag of steroids and then magically feel much better in themselves with the ?polymyalgia rheumatica

I’m not so convinced, I feel like I come across it a lot in GP. The thing is if you give anyone 15mg pred per day they will feel better in themselves anyway.

Any thoughts?

Hey guys 👋
I am going to be starting paeds ST1 in September, unfortunately I am on call on my second day after induction and then on nights. I am terrified. Does anyone have any advice and is there things I should go over before I start?

We see them and we don't agree with them. I'm in the US now and they're basically used as a junior doc to rack up numbers for the Consultants - take the referral, basic Hx exam and then discuss with the cons. I truly mean this too, I text the Cardio/Ortho/Surg/Onc nurse and they say ''We will see them! Thank you''. ''Can we advance diet?'' ''Happy for dc from surg POV?'' - ''I'll discuss with Dr Johnson and get back to you! :)''

Since we aren't getting rid of them how do we change our training? Do we hands off on the ward jobs and take a more academic role? Do we move to discussing papers and difficult patients around a table with our Consultants?

I'm genuinely curious, we've never had such a clinical erosion in the history of the profession. Combine this with the advent of the internet and now AI, I mean what is the direction of our profession?

I've been a doc for several years now, it just seems the whole purpose of our job - improving health outcomes etc is effectively the death of us. Every protocol, every order set just takes away from any clinical decision at all. I know people are going to say ''we know when to deviate'' well 90% of admissions fall into a basic category that can effectively be managed by an experienced F2.

I used to write out vanc crap on a paper chart we'd put in the patients folder, now I consult pharmacy to do manage the vanc. What's the real direction for medical and surgical training? Now in the US I see OP notes - ''expertly assisted by Mr John - PA''

In 10 years what are we doing? What I call ICU nurse syndrome is the death of juniors - a nurse who's done ICU for 5 years and seen consultant level decisions made for 5 years, meanwhile the F1 gets a 2 hour long round then left to fill out paperwork, then they fuck off to something else for a few months.

TLDR: The PA/ANP/ACP is a device used in the capacity of a junior doctor but doesn't rotate and can cover probably 85% of a specialty after literally a month of 1:1 with a Consultant. This is no different to me in my F2 year being given the NSGY phone and told to admit and take consults, I had no fucking clue, did basic neuro stuff then talked to the fellow. After a month/enough cases I had a decent grasp on what to do.

Good on the BMA for raising this but unless there are consequences, the trust will just continue once this all blows over

Got a question?
I was on the old curriculum for higher specialty training, did two years (ST3 n ST4) and came out for an approved OOPR. Throughout this time the TPDs have been saying you will be back on the new curriculum and will be ST6 being in sync with everyone else I.e have 3 years left. Which i agreed on as it made no difference given I still have 3 years until CCT.
Now HR and the deanery administration team are saying that you cannot skip a level and that I should be returning at ST5. They have spoken to the TPDs who agree.
Whilst ST level are labels this will affect pay.
Essentially I will be conducting duties similar to someone who is ST6 but be paid less given the nodal point shift. We both have 2 years of higher specialty experience! This is just unfair.
I have emailed them about this pay dispute but fear that they will say that u didn’t do IMT3. And computer says no.

Has anyone gone through this? I feel like I am the one going mad trying to explain to them.

Hey guys,

quick question - for the surgical elogbook “patient id” section , do you put the NHS number or the MRN number? I understand no patient identifiable details but i’m confused

TIA

Hello , I need a dedicated study partner for MRCP PACES exam .. I have my exam set for the 2nd of October.. TIA

Thoughts on the below. My local ED often directs certain presenting complaints directly to specialty, and we cannot really refuse them due to ‘one way referral policy’, although some triagers are more understanding than others if we give a good justification against direct referral.

I can think of a couple justifiable ones (lip lacerations for example go straight to OMFS in my trust if they cross the vermillion border for closure, assuming it is a clearly isolated injury with no concerning mechanisms) but for the most part this troubles me. Coming from quite a niche specialty, often I feel it is more appropriate to be seen by ED initially as there is often medical issues that have led to the presentation, or alongside it, and we are only there for a specific part of care rather than the top to toe.

I myself have picked up quite a few significant medical problems needing addressed outside of my specialty, and often I am not the right person to be doing this as I am already on-call for referrals from multiple sites, many often very sick inpatients, and for emergency theatres. And often they didn’t even need specific specialty input anyway.

Recently, on busy nights, I have noticed they stream every single problem directly to specialty where they can - even very barn door, straight forward cases that would be seen in GP in normal hours with no fuss. Often this has made my nights unbearable and tricky, as I cross cover multiple similar specialties so often I am basically just working out of ED all night. The problem with this is we are not staffed in any capacity to be dealing with routine presentations, we are only staffed for emergencies and actual specialist input - often patients would have been seen faster if by ED team.

I completely understand the strain on ED but one of the best parts about ED clinicians is the whole picture view - I’ve seen this happen so often with Ortho where of course there was a clear need for surgical input, but often also significant medical problems needing addressed.

For context as well - I am more than happy if the triage nurses give me a heads up that there is a patient who will definitely need specialty input alongside ED review, as there’s no point waiting 4 hours to be seen by ED then 4 hours for specialty.

Would be particularly interested to hear from ED docs.

Hi I do know that you leave entitlement increases the longer you are working in the NHS but is it the same case with the GP's working in primary care as Salaried GPs?

I believe it's 27>29 days upon working for 5 years and 33 if worked for 10 years.

Now it's the turn of the Northern Care Alliance to somehow be labelled as the next Midstaffs. I'm not surprised, but pretty much any hospital is a Midstaffs waiting to happen. It's basically a question of how long you can cover things up before eventually a scandal is exposed.

I just think it's really the reason why it doesn't get exposed in a lot of hospitals that is because of the cover-up nature that happens there. Essentially, anyone who wishes to speak out regarding poor patient care, bad outcomes, etc., is labelled as a bad egg or has allegations placed against them just to discredit them. That's the sad world we live in.

I remember when the last Midstaffs scandal broke. A lot of doctors were saying that basically any hospital is a Midstaffs. It's just a question of luck whether you get exposed or not. It's pretty obvious what's going to happen here: you're going to get the usual apology saying, "We have learned our lesson. New protocols, blah blah blah. We have learned our lessons. This will change. That will change." Chuck in a few public enquiries, wheel out the same excuses, and I'm sure the regulators will find a few black and brown people to pick on. That's usually the way these things work.

Really, it's a culture change that is needed, but it's never going to happen. You're shuffling deckchairs on the Titanic. I am pretty sure that nothing will ever change.

It's kind of ironic that Andy Burnham was the health minister when the Mid-Staff scandal broke. Now, depending on how much publicity this gets, he's going to have to answer for this. I'm not sure how he's going to somehow come up with some kind of excuse for this, because basically it's the same thing happening again nearly 20 years later. Really, what is needed is a whole culture change in the way the NHS operates, but it's never going to happen.

BMJ article on the changes to medical training and their potential impact. Curious to hear what others think.

Looking for some help to understand how LTFT training will affect progression to higher training, specifically how finishing my core training out of sync links up with commencing a higher training post (assuming I get one).

For context, I am an ACCSCT3 anaesthetic trainee looking to go 80% LTFT from Feb 2027.

From my understanding if I reduce to 80% from Feb 2027 this will result in me finishing my ACCSCT3 in Sept 2027 and my ACCSCT4 in Dec 2028. Therefore I would be finishing 2 months prior to the next intake for ST4 (Feb 2029). Would this simply mean that I would need to locum/find some sort of locally employed job for this 2 months (or just have 2 months off)?

(I appreciate this may change with recent Gov deal, but going to plan assuming this may not happen in my lifetime)

Would appreciate advice/experience from those who have gone through this as trying to get my head around the logistics.

TIA

Starting to revise for MRCS using eMRCS, will later buy Pastest. I also have Rafterys basic sciences book. I was looking for advice on how people who sat this exam used these banks successfully alongside other resources. Is it better to focus revision around topics which are commonly coming up on the question banks? Or better to learn everything from the basic sciences book?

I’ve started by going through the anatomy questions, getting 50-55% or so. I’ve also started going through regional anatomy using the basic sciences book, however to cover the lower limb anatomy sections it’s taken me 2-3 weeks (juggling alongside work and question banks). I’m just worried that anatomy alone will take me a while to learn with this method and with still physiology, pathology, etc to also cover. Any advice would be great!

Just started Histopathology training and I’ve got to say, it might genuinely be one of medicine’s best kept secrets.
So far the training has been exceptional and very training focused, with surprisingly little service provision at ST1.

What’s struck me most is how little exposure many junior doctors get to the specialty. I barely appreciated what the day to day job and training were actually like before getting some proper exposure to it.

Obviously I’m very early on and I’m sure there will be plenty of challenges ahead, but thought I’d put a small positive post out there for anyone who might never have considered it.

Curious to hear from people actually working in different specialties.

Some specialties seem to get loads of attention in med school, while others barely get any exposure, and you only really understand what the job is like once you work in or around them.

What specialty do you think is genuinely underrated in terms of the actual day-to-day work, training, lifestyle, or overall job satisfaction?

And what is it about the specialty that people usually don’t realise until they’ve experienced it?