Saturday, 3 October 2009

The first week on the wards

I've told you a bit about the differences in British training, so now I guess would be an appropriate time to let you know what I've actually been up to. I showed up this past monday for my first day of work to find that the attending I was assigned to was not even in the country and the ward I was assigned to had no idea I was coming. Not a great start but it ended up working out well, as the junior doctors on the ward have been great to me.

To be honest, the day feels much like a typical day for me back at UVA, except that my hours are better (9-4!) and I don't have to preround as the medical students here are not expected to see their own patients. In fact the junior doctors are also not expected to have seen their patients before ward rounds because ward rounds are horribly disorganized and not planned out well. The ward I'm working on operates almost like an older private hospital ward, with multiple different attendings but no one "in house" all of the time as they also run clinics or work in the emergency room. Interestingly the consultants are not required to see each of their patients every day, and the junior doctors have said some of them will go an entire week before checking back on a patient. They never inform the junior doctors when they are coming to do ward rounds and when they are not, which I imagine is very stressful and leads to some dropped care for the patients. The junior doctors come in at 8 and proceed to complete their own rounds, though very rarely as a team, which again leads to disorganized care because each member of the team doesn't even know the names and diagnoses of the patients let alone their treatment plan. They do keep a sort of log of things that need to be completed but not a good database like i am accustomed to. Because I'm used to carrying more responsibility than many of the med students here they almost treat me like a junior doctor who just doesn't have prescribing power. I come in at 9 and get assigned to 3 or 4 patients to go round on and report back. If a consultant shows up I drop what i'm doing and go shadow his rounds, which has actually been educational to see how they will complete things. My only difficult experience with that was on my 2nd day when a full professor with a large personality came to rounds. He's a brilliant man, serving as a general medicine attending and a toxicologist over here, but is very intense. He also asks questions which you have no hope of answering such as "Why do I hate metoprolol but everyone else uses it" (answer:apparently in some parts of the UK up to 10% of the population has an enzyme mutation that leads to a longer half life) and "Why do alcoholics develop a macrocytic anemia even if they are not nutritionally deficient" (answer, after me fumbling in front of 10 people for 5 or so minutes..."nobody knows". are you kidding me?). He ate me alive for an entire morning during rounds, and only on my 2nd day, leaving me feeling like I had made a mistake coming here until 2 things happens: first, a junior doctor said to me "Thank you for being here today, because he always chooses the lowest person in the ranks to grille, and without you that would have been me", and second, the same consultant showed up on thursday and asked me the EXACT SAME QUESTIONS. I answered them all and he looked at me like I was some sort of genius, obviously having no idea he had asked them just 2 days prior.

My afternoons are spent doing a first H&P on the new patients, though it is much different here than in the states. Here they have both an emergency room (called A&E, accidents and emergencies) and the "combined assessment" ward (essentially a holding area for patients needing to be admitted or observed overnight, to get them out of the ER). While in combined assessment their initial workup is begun and the patients ALWAYS seen a consultant. By the time they hit the wards they often already have a diagnosis, multiple lab and radiographic studies, and a treatment plan. Our responsibilities are to continue with that plan and manage anything else that comes up, but this difference is the reason why its not quite as imperative that a consultant comes to see the patients the day of admission or even the day after, and the reason it works that the first year junior doctors are only 23 or 24.

Apart from that, the most exciting thing for me is that I've gotten to do much more hands on work than I would have in the states. I'm not doing central lines or anything but any blood draw, IV, ABG etc that needs to be completed comes to me. I've already placed more IVs in a week than I have in the last 2 years and have completed 3 ABGs. I'm hoping to get a few shifts in the A&E and Combined Asessment and perhaps get even more attempts at the technical skills.

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