In this month’s blog, Dr Hilary Williams, RCP vice president for Wales, writes about the skill set of the senior physician and the art of clinical decision-making. She reminds colleagues that tickets for the 2023 Update in medicine – Cardiff are now on sale and looks forward to seeing everyone on 9 November.
Medicine is an art, not just a science. Somebody once said it’s ‘the most scientific of the arts and the most artistic of the sciences’, which I think is true.
Consultant physicians spend more than 10 years in training; this is on top of medical school, and once you factor in flexible working patterns, parental leave, time out for research, education or travel, many of us spend decades learning our trade and building our skill set.
So, what makes a senior doctor valuable? Does the system fully understand what it takes to be a senior physician in the UK right now? Let’s start with something I think we don’t talk about enough. What does it mean to be the consultant on call for the acute medical take? It can feel like the least celebrated, but most demanding of skill sets. With every patient, you want to do the right thing, but increasingly, this is about more than managing a single reversable illness: it’s about deciding what the patient needs right now (and what we can realistically do for them with scarce resource and time).
The NHS workforce is at the front of all our minds. We are living with constant rota gaps and understaffed services. We have fewer doctors per head than our European neighbours, yet patient demand continues to grow, and the case mix becomes more complex every day.
I asked our regional adviser for south-west Wales, Dr Sam Rice, for his take on this. Sam is a consultant endocrinologist and on the GIM rota in Llanelli. He explains that even after 15 years of medical education, ‘I still felt underprepared for GIM consultant on-calls when I started. You are at your most exposed: immediately expected to have the same skill set as someone with 20 years’ experience, but there is no way you can be as good’.
As a new consultant, Sam increased the number of his GIM on-call shifts to gain experience more quickly. He said: ‘It felt like learning to drive. It’s only after you pass your test that you really learn the rules of the road.’ An ability to make complex judgements based on a patient history comes with practice. ‘All of our hospital systems rely on the physician at the hospital front door to make these decisions safely and quickly,’ he says. ‘Diagnostic skill is not about textbook presentations; it’s the atypical presentations that can throw you.’
As doctors, we often don’t have time to look things up in textbooks. Decisions are made in noisy wards with alarms going, waiting for computers, waiting for lifts, tracking down patients in surgical wards, early in the morning, late at night and sadly with bewildered and distressed patients in corridors. We need the right diagnosis made quickly enough to start treatments. Time matters. Rapid and safe decisions matter. Senior physicians need an in-depth knowledge of disease, on-the-job experience, and the ability to take pressured decisions based on critical factors surrounded by the noise of service pressure.
Our regional adviser in south Wales central, Dr Andrew Lansdown, is a consultant endocrinologist in Cardiff. ‘To me, just keeping the human touch alive when there are 30 patients waiting is an extraordinary skill in itself,’ he explains. ‘The expertise we need as doctors – clinical judgement, compassionate care, the holistic management of multiple conditions – these skills take years to develop, and if we’re honest with ourselves, they are a work in progress throughout our careers and lives.’
And of course – it’s never just about the patient standing right in front of you. As a consultant, you are a team leader, a decision-maker, a teacher, a communicator. Leading the on-call is only part of what we do: what about service improvement, audit, ethics, governance, supervision, research, team development? How do I remember to keep questioning everything around me? I am a less good clinician when I forget to ask questions.
In a strange way, the longer I am a doctor, the more I value what I do. It’s about shutting out the noise and finding the final piece of the jigsaw. Making a diagnosis when something doesn’t quite make sense. It’s an important discussion that we need to have with each other at the RCP, and with the wider clinical community. We have a skill set that patients value and need – so how can we better champion and recognise the critical thinking, knowledge and depth of experience that we senior clinicians can bring to our patients?
Finally, speaking of learning new things, let me remind you that our 2023 Update in medicine – Cardiff is just around the corner. We’re back at the Marriott Hotel in Cardiff this year for another full day of interesting speakers on Thursday 9 November. Check out the programme and book your space now. This conference always sells out, so to avoid disappointment – don’t leave it to the last minute! Every year we have delegates who miss out on tickets because they left it too late. If you’re an SAS doctor, we’re also hosting an in-person networking event with the RCP president, Dr Sarah Clarke on Wednesday 8 November. With just over 7 weeks to go, I’m already looking forward to seeing you all!
Dr Hilary Williams
RCP vice president for Wales