The registrar's reflections - October 2017

RCP registrar Dr Andrew Goddard describes being put through his paces as a trainee examiner, studies some old photos and celebrates 50 years of emergency medicine.

The cyber-attack on the NHS earlier in the year created some issues with hospital firewalls for outgoing RCP emails. This meant that my August reflections may not have got to you (some of you may consider that a blessing of course). If you didn’t receive it: I reflected on the ongoing use of the term ‘SHO’ and am pleased to see the debate has now moved into the mainstream media.

On a note of sadness, I was upset to hear of the death of Dame Margaret Turner-Warwick. Dame Margaret was a staunch and active supporter of the RCP throughout her retirement and always had a kind and constructive word of support to offer. She will be sorely missed.

The MRCP(UK) exam

Those who remember ‘Pyke’s notes’ will recall that he would regale readers with the travails of unfortunate MRCP(UK) candidates and their examiners. Alas I have not been able to do that before now as, and it will shock some, this RCP registrar has not been a PACES examiner. I can give lots of excuses: post-traumatic stress from my short cases with one Celia Oakley; too busy doing all the other things the registrar does (Pyke had it easy); a tendency to try and see the best in people even when they are clearly hopeless; and having a wife who doesn’t see me during the week so shows violent tendencies when I am doing ‘even more flipping college work’ at the weekends (obviously I’ve paraphrased her language).

However, I have always tried to remain committed to the exam by helping to deliver local PACES teaching, always reading through the papers that come my way from the exam's quality assurance process and, of course, being the one who signs all the pass/fail letters. I hadn’t realised the latter was part of the job description until the correspondence from candidates first hit my desk – I get lots of sad/angry letters but for some reason I never seem to get any emails saying how lovely it was to hear from me. Furthermore, I think that the exam is one of the most important things we do as a college and that we need to encourage as many people to become examiners as possible to ensure we have a vibrant and resilient exam in the future. It is hard to make the case for this when you are not an examiner yourself, so I have stepped up to the plate (if you excuse the sporting analogy).

I can recommend being a trainee examiner – you get all the experience without any of the responsibility for candidates’ future careers. I did my training in Middlesbrough (an impressive and well-run centre) over the summer and am utterly indebted to Dr Hamad, the local lead, and John Reckless, the senior examiner, for putting up with me (although ‘putting me through it’ may be more appropriate). They did make me do the examiners’ after dinner speech but I let John tell the dodgy jokes. My observations were: if you do PACES teaching you will have most of the skills needed; the patients and surrogates (actors) are amazingly patient and we are indebted to them; most candidates seem to have the tendon hammer wielding skills of Frank Bruno; and it is surprising how many candidates think that obviously well patients need ‘admitting for immediate investigation and treatment’. As an aside, I understand this caution but I do wonder how much risk-averse behaviour contributes to the current NHS bed crisis.

Talking to my fellow examiners I’m not sure we (the RCP) give enough feedback on how the exam is performing, so here are a few facts which you may find interesting. The pass rate for PACES is around 45% for all candidates, and around 65% for UK graduates at their first attempt. Given the recent press about female surgeons having lower mortality rates than male surgeons it is interesting to note that the female pass rate is substantially higher than the male pass rate. Pass rates are fairly stable over the years. Around 60% of trainees entering core medical training (CMT) already have Part 1. After 2 years of CMT 85% have got Part 2 and 70% have gained PACES.

Finally on this topic, thank you to all those who are already examiners and if you are not an examiner please do consider becoming one. I’m already itching to do it for real, so pity the poor candidates that get me. 

Intrathecal injections – why can’t we get this sorted?

I get many emails asking me / the RCP to highlight a particular issue. One that struck a particular chord with me recently has been the patient safety alert from NHS Improvement (NHSI) regarding lumbar puncture needle connections. Surety connections are currently used by many hospitals to prevent connection with all but a certain type of syringe. These are being withdrawn from the UK by December 2017. A replacement called ‘NRFit’ is being brought in but won’t be available throughout the NHS until at least April 2018.
 
I was a medical registrar on call the night that Wayne Jowett catastrophically received intrathecal vincristine in Nottingham in 2001. That event will be forever burnt in my memory from the life lost and the impact it had on all involved, both family and staff. It has staggered me repeatedly ever since that even with such a high profile (Liam Donaldson – the chief medical officer of the time – is passionate about this too) we still don’t have systematic processes in place to prevent it happening again. The fact that we are withdrawing one of the few safeguards we currently have before fully implementing a replacement really worries me. Please highlight the risks of intrathecal injections to your trainees.

Old photos, new ways of working, borrowed bed space and blue lights

I have seen two old photos recently which have made me stop and think. The first was shown in a presentation on liver problems given at the 50th anniversary of the Ceylon College of Physicians in Colombo. Taken in 1970 by a Dr Epstein, it showed a renal arteriogram from a patient with hepatorenal syndrome (HRS). The kidney was not perfused at all with the contrast stopping abruptly at the end of the renal artery and yet the post-mortem (the success of treatment for HRS was even lower 50 years ago) arteriogram was normal. The remarkable vasoconstrictive state that is HRS is sometimes hard to explain to juniors and students – the photo made it obvious.

The second photo arrived in a large and intriguing cardboard box during the summer holidays. On opening it transpired that the box was a collection of RCP-related material collected by Sir Harold Boldero, who was registrar from 1940–62 (don’t worry, I won’t last that long). His son had been cleaning out the loft and found these items and felt the RCP would find them useful for its archives – and indeed we do. As well as an article in Country Life (oh how times change) it contained several books, some of Sir Harold’s personal notes and a photo of RCP Council from 1942. In the photo it is obviously wartime (there were several college officers who were dressed as non-college officers) and Lord Moran – president of the time and a key instigator of the NHS – is holding court. There are only 10 people around the table and they are all men. The current Council is rather different, for the better (although with my Council secretary hat on I can’t help thinking a smaller Council would mean less travel expenses).

The personal notes were fascinating and gave a breakdown of the RCP registrar’s various responsibilities. I am obviously biased but I did smile a bit at his opening statement: ‘The registrar is the most important person in the College but this must not be let known otherwise all is lost’. Anxious not to lose everything then, it is important for me to say that the registrar is no longer the most important person in the RCP. That role is filled by the registrar’s PA (thank you Kim).

In my last reflections I mentioned that I had had the honour of chairing a roundtable about new ways of team working. I am pleased to report that that group has produced a set of resources to improve team-working. This will be made available in November and consists of four documents each focused on a different aspect: building the team, team culture, communication and team development. I hope you will find them helpful and we will be building on these in the following months. 

When discussing the exam earlier I mentioned the (never-ending) bed crisis in the NHS – and I know I have discussed it in this column before. Things can be worse. Another presentation I saw in Sri Lanka concerned the dengue fever outbreak they have had in Colombo this year. They would usually expect 20–30,000 cases per annum but already in 2017 they have had over 170,000. Finding beds for these patients is, as you can imagine, a challenge. The solution is two to a bed, topping and tailing. The practicalities of this leave me a little aghast.

When I am on call I always worry slightly as I leave the hospital and a blue-lit ambulance passes me in the opposite direction; I spend the next couple of hours waiting for the phone to ring to call me back. I will look on blue lights in a different ‘light’ now following a family event that I would like to forget. My student son decided to have a massive tonsillar haemorrhage (30 case reports in the literature if you’re interested) while at university and redecorate both his flat and the Leeds General Infirmary emergency department. A rapid response by the Leeds ambulance service and the ED showed how the NHS can come up trumps when it is needed. Thank you to all involved. It is rather apt that last week the specialty of emergency medicine celebrated 50 years since the creation of its first association (now the Royal College of Emergency Medicine) – in Leeds. Happy birthday emergency medicine.

It’s not all doom and gloom

As part of the RCP Charter Cycle I visited the Leicester Royal Infirmary (LRI) with the RCP500 Charter and attended the medical grand round in mid-September. I have a soft spot for the LRI although I have never worked there. My brother and sister-in-law met as young SHOs there and my long-suffering wife worked in the radiotherapy department for many years. Although the young Bill Goddard won’t like me for saying it, the LRI seems to have survived his departure. The quality of the grand round presentation was outstanding. Focused on Parkinson’s disease, the main message was that the most important thing for patients admitted to hospital with Parkinson’s is that they get their usual medication at their usual times (and that often means allowing them to self-medicate).

Two other things will remain with me, though. The first is that although James Parkinson was the first to describe his eponymous disease, it took Jean-Martin Charcot (who holds the eponymous naming of conditions gold medal) to name it after him. Was this a joint proposal then? The second was the collection of quotes from patients that had been seen in Leicester (although I wonder if some may have been second-hand from other Parkinson’s sufferers). My favourites: ‘I used to be a mover and a shaker. Now I’m just a shaker’; ‘I like to be optimistic about my Parkinson’s and look forward to new treatments. You could say that I’m a glass half full kind of person, but that is only because I spill the other half’. As a physician the ability of patients to smile in adversity is humbling. 

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.