Monday, 28 May 2012

Riding the tides

The morning you finish a set of nights is always an interesting time: there is a mixture of physical and mental fatigue, combined with the buzz you feel from having successfully survived the experience, and from the ward round in the morning. There is something about the social nature of the post take ward round that lifts you up. It doesn't matter how tired you might have felt during the night, when you leave the hospital, you are fizzing.

 When I first became a medical registrar, I assumed that the challenges of the job would get a lot easier, but in many ways, it just gets harder. I was chatting to one of the A&E SHOs last night about this realisation, and she gave it short shrift, saying that it must be a job that you get better at. And she is right, but perhaps her view of the role is skewed by her vision of what she imagines the role of medical SpR to be, which, in my experience, differs from what it actually is.

 Being a medical SpR is not just about being the on-call physician to the hospital, providing assessment and treatment of patients with acute medical problems presenting to the hospital via their GPs and A&E. It is a whole lot more than that. For example, you have to manage acute deteriorations and complications that occur to the medical in-patients out of hours (ie when their usual teams aren't there to sort things out). That's probably fair enough, but from here on in, there is a great deal of mission creep, and encroachment from other specialties.

 The medical SpR is also expected to manage medical problems that occur either as complications of, or in parallel with, problems that are being managed by other non-medical specialties. This can mean that you end up dealing with problems in very unfamiliar environments - the labour ward is probably the most alienating place that the medical SpR gets summoned to. This is definitely away turf, and sometimes you have to wonder whether the general principles that you are applying to patients with very different physiological parameters need modifying a great deal more than you have done.

 All of the above can be daunting, but they can also be prepared for: there is a great deal of learning to be done about managing medical problems in surgical, obstetric and gynaecological settings, so the issue remains one of experience and training. However, there remains an aspect of the med reg role which cannot be pre-prepared, because it is the med reg to whom the hospital often turns as the general fixer and problem-solver. It can be a nervy experience trying to apply yourself to a problem that no amount of training can predict, and which isn't actually predicated on your medical knowledge, but rather on your ability to busk and improvise.

 Many doctors I know prepare for the stress and responsibility of the job by learning as much as they can about the problems they are likely to face, but no text book teaches you about the rare and unpredictable occurrences that keep all medical SpRs on edge. However well you think that a shift might be going, as med reg, you know that you are riding a tide over which you have no control, and at any moment, the current could drag you under.

I have often found myself scratching my head over a problem, simultaneously wondering both how to fix the issue and how I got there in the first place. Sometimes it seems that all routes to disaster go via the med reg. It is the prospect of the unpredictable that ages the med reg. It is preparing for events for which there is no adequate preparation that keeps them awake. And that is why it doesn't always get easier with experience, because all experience teaches you is that you are a passenger on much greater forces that your medical knowledge and training could ever overcome. And that is why being a med reg is something that is only enjoyable after you have finished the shift. The satisfaction is all retrospective, when you know how it all turns out. And that is also why it can be so thrilling.

 A few people find out what it is like to play the perfect round of golf, drive the perfect race, or write the perfect prose. An equally small number of people experience what it is like to run the perfect medical take, because even if it all goes well, there is the background appreciation that however smoothly it went, it could have gone worse, and that it didn't was a function of forces much more powerful than one medical registrar.

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