The registrar's reflections - August 2017

Medical trainees and the shape of training are the focus of RCP registrar Dr Andrew Goddard's reflections for August, along with the value of spending time with colleagues outside of work and his acronym of the month.

As I write this it is still the first couple of weeks of the new intake of trainees in hospitals throughout the UK, or the new house if you prefer (which I do). The subject of training has therefore been at the forefront of many people’s thoughts so I thought this set of reflections should be themed likewise.

Recruiting the SHOs of the future

Amongst the current crop of trainees are a cohort of new core medical trainees (CMTs) who are all very welcome as, given the right conditions, they will be my colleagues for many years and then will be looking after me as I age and (more) bits of me stop working.

As an aside, I’ve noticed that when a CMT phones me up they usually introduce themselves as ‘the medical SHO’. Someone spent a lot of time and effort coming up with the term CMT and it is not a bad description of said trainee. However, it is interesting that many still see themselves as SHOs even though this term [senior house officer] was supposedly abolished over 5 years ago. Still, what is in a name – how long before ‘consultant’ becomes ‘salaried inpatient care provider’? But I digress.

Choosing the right people to be CMTs is one of the most important jobs we do as consultant physicians, although it is often a thankless one and is about to get a bit more challenging. The CMT and medical registrar recruitment processes in England are funded by Health Education England (HEE) but are effectively run by local consultants acting in senior educational roles, with the assistance of their colleagues who are either clinical or educational supervisors. This involves a little bit of travelling to other hospitals in the region but is doable. Knowing that most trainees will stay locally when they become a consultant also means that many have seen an SHO/CMT become a consultant colleague (I can think of at least five in my hospital). 

Unfortunately, HEE have made the decision to reduce the number of centres for recruitment to five (yes, five) in the country, so both interviewers and interviewees will have to travel much further. It is hard to see how this will save money, and training programme directors (TPD) and heads of schools (HoS) will have a much tougher job getting the recruitment process staffed. So if you get a beleaguered TPD or HoS asking you to travel to Outer Mongolia please don’t blame them and do your best to see if you can help.

We need to help people go into hospital medicine, not increase the barriers – have we not learnt anything from the last time the ‘medical training application system’ was tampered with? Talking of tampering with training…

The shape of training

Back in the halcyon days of 2013, when Brexit was a dim and distant fantasy and most people hadn’t heard of rivaroxaban, a report was released that was somewhat buried in the maelstrom of post-Lansleyism NHS reorganisation. The Shape of Training report was a review of the reform that was needed in medical training to meet the changing needs of society. For medicine (as opposed to psychiatry, surgery etc) it summarised that we had too many specialists in hospitals and too many older multimorbid patients not having their needs met. The solution: train more generalists.

The UK nation governments established a group to deliver this vision – the Shape of Training steering group (SOTSG) – and they have been hard at work. The main thrust of the intended changes for medicine recommended by this steering group is that more people will take part in the acute medical take and thus become expert generalists as a result. No additional time will be given for training (there is no extra money) and the total number of higher medical trainees will remain the same (there really isn’t any extra money). Perhaps it should have been called the ‘Shape of the Acute Take’.

I suspect some of you are seeing a couple of potential flaws here. If it currently takes 4–5 years of specialty training to get trained in a specialty, how is a trainee going to make up for the lost specialty training time spent on the acute take? Also, given that 45% of advertised medical specialty consultant posts in 2016 were not filled due to lack of trainees, we seem to have a rather significant lack of specialists let alone generalists. The acute take is currently not a good training environment for many (if you disagree, just read the 2016–17 RCP census report to see what trainees think of GIM training at the moment) and is arguably not the best mode of generalist training. This is not a reflection of acute medicine training per se, which is good (again, ask the acute medicine trainees), but of the generalist training experienced by specialty trainees in the -ologies when they are on the acute take. 

There are upsides: more registrars on the acute take will make the job easier and more doable. It should then be possible to improve the quality of training, but it is still a risk. We do need consultant physicians that can manage a wide variety of comorbid conditions, especially in the older patient, so the analysis of the problem in the original report was correct. However, unless we increase either the number of trainees or the length of training we will end up trying to do more with less and end up worse than we are now. 

Earlier senior review or early junior disempowerment?

I’ve been contributing to a piece of work on improving the modern medical team and recently chaired a roundtable meeting to help identify some of the barriers to effective team working. One of the strong messages from the trainees present was that there has been a loss of the opportunity to make decisions in patient management due to the increasing presence of consultants on the wards. The idea of 'early senior review' is, on the face of it, a good one. Patients spend less time in hospital and are diagnosed incorrectly less of the time. However, this practice has led to a paralysis of decision making by some of those seeing the patients before this review. 

My blood pressure is particularly raised by the presence of 'chest pain ?cause' in the differential diagnosis and the subsequent 'await senior review' as the management plan. We need to allow trainees the opportunity to make the important management decisions in patient care. One way is to allow the trainees to run the consultant ward round whilst the consultant observes (and even requests some of the investigations). This is termed a 'reverse ward round' and while it takes longer and is occasionally a bit uncomfortable for the consultant, it will reap benefits for all in the long run.

Other things I have learned this month – French dishwashers, Japanese phones and guesstimating death

You will probably have seen from my previous reflections that I like a good graph. At the British Society of Gastroenterology annual meeting I went to a good talk which among other things tried to explain the ‘French paradox’, ie the fact that cardiovascular mortality in France seems much lower than would be expected given that nation’s relatively high prevalence of smoking and high alcohol intake. One fascinating theory is that the way the dishes are washed reduces the exposure to detergents (as opposed to the lazy British way of not washing off the soapy water before drip drying or using a dirty tea towel). The incidence of coronary artery disease seems to inversely match dishwasher usage in most developed countries. I was happy to go along with this hypothesis until one of my colleagues in Derby led me to a great website about spurious correlations. For example, per capita cheese consumption correlates with death from strangulation by bed sheets. Association is not causation.

Adalimumab, or Humira if you know it that way, is an anti-TNF [tumor necrosis factor] monoclonal antibody, or biologic, that is used predominantly in rheumatology and gastroenterology. It is currently the 'best-selling' drug globally, or rather it is the drug that makes the most money ($16 billion in 2016), and the profitablility of the biologic drug market has got some surprising companies interested in diversifying into it. One of these, I hear, is Samsung – better known for mobile phones and the like. Let’s hope this competition brings drug prices down. It would be a bad thing if mobile phone companies put drug prices on hold.

An interesting report crossed my desk a couple of weeks ago – the National Audit of Breast Cancer in Older Patients (NABCOP) – which confirmed what many of us know already: that we don’t do as well as we would like. It included a fascinating set of graphs (sorry) which showed one explanation for this. The audit authors produced several case histories and asked the breast cancer multidisciplinary teams (MDTs) to estimate life expectancy. This varied between 6 months to 10 years in some of the scenarios. I’ve sat in quite a few cancer MDTs in my years (and still do) so can reflect on why such variability of opinion occurs. Often it is because people who don’t know what they are talking about insist on talking about people that they don’t know. 

The keys to getting such decision making right are having someone present who knows the patient, having someone present who knows the risks of treatment, and educating everyone present as to what comorbidities are important. I’ve been reading a really helpful book on this topic written by a who’s who of medical oncologists and geriatricians from the Association of Cancer Physicians (ACP) and British Geriatrics Society (BGS), which I would recommend. After some useful summary chapters it contains 32 cases and talks through them and the evidence for management options. I disagreed with some bits on iron deficiency anaemia (intravenous iron does not work faster than oral iron!) but otherwise learnt a huge amount. I got a copy from the library (apparently you can still do that) – worth a read.

It’s not all doom and gloom

My favourite acronym of the month is BOGSAT – used to describe a policy or guideline designed by a ‘bunch of guys sat around a table’. I think we’ve all seen one of those.

Over the past week I’ve been cycling around the south-west and have had the opportunity to catch up with old friends from my days as a medical registrar and young consultant, as well as make new friends who share the fascination of ‘the getting there’. The glue that is medicine seems to bind us together such that even if we haven’t seen each other for years (29 in one case) those years drop away and we can share great memories and have a smile at stories old and new. It reminded me that medicine is a family and that spending time with colleagues out of work can be hugely enjoyable and rejuvenating. I will endeavour to do this more.

Lastly, I was told an apocryphal story a couple of weeks ago. An orthopaedic F1 calls the medical registrar to say that there is a patient on the ward vomiting and asks if she could help. The registrar replies: “Yes of course, but have you discussed it with the orthopaedic registrar?” “Yes”, replies the F1, “but his response was 'is the patient vomiting bone?'. When I told him no, of course he wasn’t vomiting bone, his reaction was ‘well it isn’t an orthopaedic problem then is it; call the medics’.” Now I accept that such orthopaedic stories are not reflective of most modern surgeons but I also recognise that some of the phone calls we get from other parts of the hospital do share a hint of ‘it’s not my problem’ mentality. We are all in this together.

As always, comments and feedback are welcome.

Dr Andrew Goddard, RCP registrar
Twitter: @bodgoddard
Email: andrew.goddard@rcplondon.ac.uk

You can read more of Dr Goddard's reflections on the RCP website.