Serious inequalities in the provision of elective versus emergency care

Serious inequalities in the provision of elective versus emergency care

If you have rectal cancer, the ideal scenario is that it is picked up on screening (biannual FOB tests from 50 years of age followed by colonoscopy if positive), you then enter into a smooth and well oiled machine of investigation and treatment. Within 14 days of that colonoscopy and biopsy you will have had a CT scan of your chest, abdomen and pelvis, an MRI scan of your rectum and your case will have been discussed at a multi-disciplinary meeting of surgeons, oncologists, pathologists, radiologists and other interested and relevant parties.

You will be given a plan for your treatment and a specialist colorectal cancer nurse who is on speed dial for you with your questions and concerns. You will then begin either long course chemo radiotherapy followed by surgery or proceed immediately to surgery.

Wham, bam, we’ll whip your rectum out before you can say “pain in the ass”. It is as smooth and controlled and informed a ride as it can be, and you can be reassured that at every stage you will be looked after by the right person, who has been trained accordingly and is audited and checked up on.

If, however, you are unlucky and on the days of the FOB testing your rectal cancer isn’t in the mood to bleed, if you ignore the weight loss and the rectal bleeding and you present as an emergency with an obstruction, then your outcome is far from guaranteed. Your survival depends on where you decide to present to, which is terrifying and appalling.

If you were me, or a relative of mine, you would drive to somewhere like Bighospital and bend over one of their beds to present your obstructed rectum to one of my colleagues. The reason you would do this is because a hospital where there are more HDU beds, more ICU beds, that do more CT scans per bed per annum, that have more operating theatres per bed are significantly more likely to get you out of hospital alive than a hospital where that does not happen. (Symons et al 2013. British Journal of Surgery 100:1318-1325). And an early CT is associated with a decreased risk of death (Ng et al. 2002. BMJ:3251387

You wouldn’t be taken to one of these local hospitals with a knife in your chest or following a road accident, no way. Trauma goes to a Level 1 trauma centre because we know that these people die in District General Hospital Land.

You are much more likely to get rectal cancer than have a knife in your chest; and yet off you will be referred in the dead of night, vomiting shit out of your mouth to a tiny little dump that does no CT scanning out of hours and cannot stent your cancer anyway because they don’t have interventional radiologists and has no middle grade resident cover overnight.

This figure shown below is of a funnel chart, the line in the middle is the average mortality for emergency admissions, the dark dots are the badly performing institutions, the empty ones are the exceptional units. Age, social deprivation, comorbidities and female sex all correspond with poor outcomes but there still remains a worrying variety in mortality outcomes across the country. Without being a stats bore, everybody should be inside the funnel, that means you are within the average, some better some worse. It is the outliers outside of the funnel that are concerning or superbly impressive.

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If someone published the same data on breast cancer survival, or as happened many years ago on trauma survival, there would be an uproar. We urgently need to reshape and rethink how we organise emergency generally surgical provision and centralise services. We need more acute surgical beds, improved access to out of hours radiology (yes radiology I mean you, get out of your beds) and more HDU and ICU beds for emergency admissions. What we need most urgently, is for surgeons involved in the provision of this care (which makes up half of our workload) to start caring as much about the standard of emergency care as we do about elective care. One ass hole I work with said “what a great year, not a single elective death”, he couldn’t understand why I thought that was not worth bragging about.

The other people who need to listen to us are the politicians who do not allow us to ring fence resources and budgets towards emergency care. They have been beating us with the twin sticks of waiting times in A&E and waiting times for operations for years and it is time that we told them to shut up and show the public that the real problems are in emergency unscheduled admissions. The ASGBI issued a consensus statement to this effect which I would urge interested parties to read, but it failed to ignite a political and media debate on this issue.

This is an exciting time to be involved in general surgery as perhaps emergency care is slowly getting the attention it deserves. The government has to listen to us, we and they have to explain to voters that going to your local hospital might be nice, it might be handy for you to visit Granny, but it means that you have an increased risk of dying that a 30 minute drive can reduce by over half. We managed it with trauma care and we have managed it with cancer care we just have to do the same with provision of emergency surgery.

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Tabloid Tits

Tabloid Tits

Goodness what a fuss has been made this week regarding the British institution of Page 3. American readers may not be familiar with Page 3, it is not the sort of thing you would have over there for sure. In “The Sun” newspaper, the UK’s most widely read tabloid, there is a topless “beauty” featured on Page 3, known as a Page 3 girl. They are usually called Nikkala, Becci, Jaqqui or some other variation and we only know their first name and age, as well as their thought on that day’s pertinent news issue. For example “Nikkala, 21 from Loughborough says why can’t we all just get along and muslims do what they want and we will do what we want?” Insightful stuff.

The Sun is owned by Rupert Murdoch and this week he pulled Page 3, there were no nipples, no naked ladies. He also owns The Times (which is his newspaper for clever people) which informed us that Page 3 was gone, only for it to return on Thursday. White van man, generally thought of as the typical British male, was sad at the disappearance of the tits and most relieved when they came back. “What’s the harm? It’s just a bit of fun? It’s harmless innit?” said most white van men everywhere.

Then the nation came over all prudish when Rita Ora, a pop star had on a low cut top at 7pm, viewers were apparently shocked and the BBC fucking well apologised for it! Now, I have no issue with Miss Ora going on TV in a low cut top, she has fabulous tits and she has every right to look how she wishes on TV within the constraints of what is socially acceptable. The daily mail of course were outraged and led the tutting. How dare those prudish morons at the BBC apologise for what an adult woman wore, she looked great, she isn’t a poltician she is a singer, she looked appropriate and sexy.

I hate Page 3. I hate that patients of mine will have The Sun opened at Page 3 when I do a ward round, I feel it is rude and derogatory. I hate that the doctors mess buys The Sun and that there are tits out during my tea break. I love breasts, I think they are fabulous, I am all for seeing them on TV in great little white suits and in the flesh either popping out of sexy tops and looking hot or feeding babies and pouring milk all over the place. I love mine, I love my friends boobs, they are fabulous things, I can see why men obsess about them.

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Friends who are consistently late

Friends who are consistently late

Three of my friends are always, always late. I have an absolute aversion to being late, I try and always be on time for everything. Which usually means that I am a few minutes early as I factor in for potential delays.

My late friends are not any busier than me, they are not reliant on public transport and they always suggest meeting at a particular time. This is my cunning way of making sure they are on time, if they picked 2pm then why aren’t they on time?

Why are they always late? It’s usually by at least 10 minutes and they never let me know that they are running late until it is the time we were meant to meet. If I knew in advance I would use the ten or twenty minutes wisely!

Sensible advice is that I should politely say “your lateness makes me feel like you don’t value my time. Maybe you could let me know next time you’re running late” and they’d say “gosh, sorry, how rude of me, of course I’ll never be late again”.

The reality is that they’d not see it that way and would probably suggest that I am uptight, stressed out and need to learn to relax. I also would struggle to remain polite and calm when really I feel like shouting “fucking hell, why can’t you just be on time or let me know that you’re running late it drives me mental!”. There is no solution.

My friend is ten minutes late so far, she has not yet texted to explain. I harassed my children to hurry up and get organised, parked my car in a paying car park as I erroneously thought I didn’t have time to park further away for free and walk. I could have gone to the shops and got some things I needed in the ten minutes I have been here. It really is very, very annoying.

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Leave the January Gym Goers Alone

Leave the January Gym Goers Alone

I know that lots of people are complaining about the people who clog up gyms in January, but it really is unfair. When we were all down the pub in December, dancing and laughing and drinking alcohol, none of the regulars were mean to us and tutted when they couldn’t get served at the bar. So instead of moaning that spin is full, that your metafit class has been made easy for the new people, that everyone shouts “No” to your lone “Yes” when the instructor asks if you want to do another set of abs, just get over yourself.

As I tell my children repeatedly, if you have nothing nice to say, say nothing at all.

10 things I hated about science

10 things I hated about science

My recent post on “Should you do a higher degree” has got me reminiscing about my time in the lab. From a surgeon’s point of view it is not as exciting as our usual day, it’s lonely at times, deathly boring and ultimately not what we want to do. So here is my guide to what sucked about science from a medics point of view.

1. Your project is probably going to be shit

I did not discover a new treatment for colon cancer or a new test for breast cancer. I did not end up with a fabulous publication in the British Journal of Surgery or Gut. My expectations were that I would contribute something great to the world of science which was insanely naive, but that’s what I was when I embarked on this project.

2. Bitches with an attitude

I worked with some really nippy cows, I mean really nippy. The idea that scientists are failed doctors is an erroneous one, they are not like us, they are genuinely interested in the signalling pathways of the cell cycle.  We are just there to tick a box, find a protein and get back to our real work. You have to throw yourself into science world, do what they advise, dress like they dress and never, ever, refer to yourself as Doctor if you are there as a research fellow. I had one particularly nasty woman in my lab who let me waste nearly an entire day trying to find a chemical called “MilliQ H20″….it’s filtered water.

3. Coffee breaks.

The scientists work funny hours. They come in about 9am (we start at 7.30am) and have a coffee, followed by an official coffee break at 10.30. Followed by lunch at 1pm, coffee at 3pm and they leave about 7pm. All that coffee! All those breaks! Just get on with it and leave at 4pm!!! This is not how science is conducted. There is probably an etiquette regarding how this is paid for and supplied, which you will fall foul of, so bring your own coffee mug and don’t touch any of theirs.

4. All those meetings

They like having meetings a lot. They like to schedule them well in advance and ensure that they are well organised for them. This necessitates more meetings about the meeting. They don’t like to meet for more than an hour, so they will reconvene at another meeting rather than keep going. I do operations that take 10 hours sometimes and we don’t have a break, don’t mention this sort of thing to them.

5. Departmental presentations

Tedious. Your own research is at least moderately interesting to you, sadly you will be expected to attend weekly departmental lab meetings to listen to other people’s research; this is boring, unnerving (their stuff will look much better than yours), exposes your utter lack of science knowledge (what is SDS lysis?) it is just another coffee break excuse and there isn’t even a free lunch from a drug or device company.

6.Thesis_final_Sept2004.doc..Thesis_final_final_June07.doc…FinalThesisJan2008.doc

This is painful, it takes ages. You must grasp the thesis with two hands and sit dow every day for several hours to write. It cannot, for example, live in your dining room hidden behind your piano. Thesis_final_Sept2004.doc is the wrong time to return to clinical work, I can assure you from personal experience that you will not be finished 6 weeks after you return to clinical practice regardless of the optimistic name of your current draft. It is finished when it is submitted. You can do the corrections from clinical work in 6 weeks no problem at all.

7. The unexpected set backs

I was going to do x,y and z within 6 months, but that turned out not to be the case. Be prepared for setbacks, disasters, things not working, colleagues not doing what they said, equipment not working etc.

8. It can be lonely

My experiments took ages to run, it involved me in a lonely, contaminated specimen evacuator hood for hours with nobody to talk to. You can’t listen to the radio or music because you are constantly counting and checking. It is dull; it strengthens your character though I am sure. I also missed patients, my colleagues, the nurses and the comfort of doing my job well.

9. The pay cut

I had no Mr KBW or children when i did my research, still it was a shock going from an old fashioned “Band 3” (an illegal rota and thus paid at basic salary plus 100%) job to basic pay. It was made more difficult because I had all those weekends off that I had previously been working and so had more time to spend less money.

10. The lack of a daily sense of achievement

In a job where we maybe fix someone or something on a more than daily basis, we are quite focused on goals and driven by the rewards and gratification that looking after a ward of people can bring. In science this daily sense of achievement is not there and even after 6 or 12 months it can be hard to see what you have achieved. Set small goals and reassess your progress frequently.

It isn’t all bad though, there were lots of things I did like about research too, the travel, my supervisor, no weekends and nights, the control over how I would organise my day (unimaginable to most surgical trainees), the joys of academic study. I would have no hesitancy in recommending it you wholeheartedly, if you remember my top tips above.

As yet, the editor of Nature is unaware of my contribution to science..

As yet, the editor of Nature is unaware of my contribution to science..

Should you do a higher degree

Should you do a higher degree

Let me declare my interest here, I did do one at the end of my basic surgical training and before my higher surgical training. In those days (the early noughties) it was impossible to get a registrar job in general surgery without an MD or a PhD. (In the UK medical doctors graduate MBChB, bachelor of medicine and bachelor of surgery, unlike the states it is not a post graduate course and “Dr” is a courtesy title.)

So should a trainee in 2015 take 2 or 3 years out to do research and a higher degree? You need to read and think over the following questions;

1. Do you work well alone?
This is crucial, the answer is that you probably don’t. Most of us medical professionals work well in teams, that is the nature of our job. Research means quite a lot time spent working alone, only you are responsible for completing the work. Your supervisor cares a bit, they will pressure you but ultimately it comes down to you.

2. Can you cope with a drop in salary?
You are likely to suffer a drop in salary when you embark on research. Although most research jobs come with a salary, it usually is less than a banded, full time registrar post.

3. Are you someone who sees things through?
One colleague of mine referred to doing research as a sword of Damocles hanging over your head. Certainly there is a sense of dread when you contemplate the consequences of not finishing your thesis. You have to see this process through to the award of your MD or PhD. I was not very good at seeing things through, for example I frequently lose interest in wrapping Christmas gifts after the 30th one or find I run out of enthusiasm for gardening after an hour or two.

However, the discipline required to complete and submit your thesis is character building. If you are already good at completing boring tasks then you will be at an advantage during your research.

4. Are you considering a career as an academic?
I was not and am not going to be an academic surgeon, at least not any more than all surgeons need to be academic. I will not be pursuing a university position with the ultimate aim of being Professor KBW. If you are, you definitely need to do a higher degree. But, research isn’t just for those who want to spend every waking minute at work, or thinking about work, or wondering how they can do even more work. Ordinary surgeons can get a lot out of research too, it is crucial that we are involved with science and progress.

5. Are you prepared to spend an additional 2 to 3 years as a trainee?
I feel that this shouldn’t really be a consideration, but then I have had 3 years of maternity leave and am training part time. Time has lost its meaning to me in many ways, I’m enjoying the journey as opposed to rushing to the destination.

6. I am not on the academic foundation program, I feel it is too late for me?
There are some people who enter medical school aged 18 and know that they are going to be a neurosurgeon who does research into obscure receptors in the amygdala, they are in the minority. The truth is you can do research at any point, as long as you are approved by your training scheme for time out.

7. Should I do an MD or a PhD?
I don’t think it matters. It is more than simply a decision of 2 years MD versus 3 years PhD. The opportunities open to you will affect this decision, as will the type of project.

Nobody looks down their nose at an MD, nor is a PhD significantly better. It depends what you do with it. An MD that results in 4 papers and multiple international presentations and a prize is worth more than a PhD that got 2 publications and a poster.

8. Do you want to be competitive at consultant interview?
I assume you want to be in a position of picking and choosing jobs when you reach the end of your training.

You don’t want to be forced to locum in an obscure dump because everyone else you are competing with has a PhD. It is often hard to find time to publish quality research papers when working in the NHS and many people find that research allows them to get all the necessary publications.

Saying that, there is nothing worse on your CV than an unfinished project and far worse than not having done an MD/PhD is having done 2 or 3 years of research in a laboratory and not getting your thesis.

Some people think that having a higher degree makes them better, smarter and uniquely qualified to comment on others research which of course it doesn’t.

My view of it is that it is the equivalent getting a tattoo of your boyfriends name to prove you love him. It hurts, it costs you time and money but in the long run it toughens you up and proves something to yourself and your employers and colleagues.

At the end of it you will have those letters after your name, which mean you get you the consultant job interview you want. It gives you much more than that though; it teaches you how to write grant applications, papers, plan posters, “do science”, understand statistics, how to make projects happen, how to follow through, thesis writing, working with scientists (that is a whole other world), travel, communication skills…I would recommend it, even though it was not the best time of my career in terms of enjoyment.

Speak to your local professor of surgery, your medical school and your colleagues. There are frequently jobs advertised in the BMJ careers for PhD’s and MD’s.

Listen to Auntie KBW though, do not start something that you aren’t going to finish and make sure you turn up in jeans and a T-shirt on the first day in the lab or they will kill you.

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