A couple of weeks ago, I attended a work experience week at a local hospital which was designed for prospective medical students. I thought that it would be a good idea to reflect upon and share some of the events of the week.
The first day involved mainly talking to staff in a lecture hall, finding out what becoming a doctor involved, and some of the challenges that doctors face. I know that being a doctor isn’t a 9-5 job, and many of the people I spoke to emphasised the fact that the NHS runs on the goodwill of its staff. As a junior doctor in particular, your life has to revolve around your job, rather than the other way round like it is for most people. It’s a lifestyle. Hospitals can’t stop; so neither can their staff. I learned about the huge range of staff within the NHS- who are all absolutely fundamental. The system is like clockwork. If one piece is removed, the system breaks. Everyone relies on each other in order to achieve the best patient care possible, which is why teamwork within hospitals is so important. As well as this, each member must respect the others, which permits them to achieve the best dynamic possible, which, in turn, will help co-ordination, thus improving patient care. There was one surgeon who compared the operating theatre to a formula 1 tyre change- everyone knows their role, so they act as a unit to complete the task at hand with maximum efficiency.
We spoke to an F1 doctor who talked a bit about applying to medicine, having completed her course at Cambridge, as well as the time that she’d had as an F1 doctor. One very important thing that I learnt was that you can never know everything, and you shouldn’t try to know everything. There will always be someone who knows something that you don’t; but it’s important to find your own limits. Medicine is so competitive and I think that’s partly down to the nature of the people who undertake the course. Everyone who succeeds must be resilient. This F1 doctor described how she had been in a group of 5 friends, of whom 2 graduated. 1 decided that she didn’t want to do medicine, and the other 2 became ill, partly due to being overworked. This is why I think it’s so important to be sensible when studying for medicine. Work will always need to be done, but down time is so important to ensure our own health. Bearing this in mind, I believe that a doctor can never provide the best care to patients if they themselves are not at their best. I discovered that being an F1 doctor isn’t easy- you’re thrown right into the deep end, with new people, in a new environment, but most importantly, it’s what you’ve worked for. Despite the basic jobs which you have to do, the dreaded night shifts, the placement rotations and the moving round hospitals, it’s crucial to remember that you’re now a doctor, and unless you really do something stupid, nobody is going to take that away from you.
We then heard from a radiologist, who advertised a more relaxed life compared to what we had been told by the junior and F1 doctors. No ward rounds or clinics to attend, but very limited patient contact- something which doesn’t really appeal to me. I learnt a bit about the different types of scans used, and the differences between them. As well as this, we got shown some real scans of patients, including an MRI and various x-rays. CT and x-ray scans both work by looking at density of various tissue, whereas MRI uses chemical composition of tissue to create its images. More MRI and ultrasound scans are used in paediatrics compared to CT and x-ray, because they don’t give off harmful radiation. One problem with MRI however, is that it takes a long time to scan, which can means that patients have to stay still for a very long time- a potential issue when working with children, or anyone in a lot of pain. There’s also nuclear medicine, which involves injecting a radioactive isotope, and then tracking its movement through the body. The radiologist emphasised his dislike for nuclear medicine, stating that in 50 years time, he doubts it will still be used. It did seem rather counterintuitive to inject someone that you’re trying to make better with a radioactive isotope, which could potentially cause then to develop a cancer. PET scans involve injecting these radioactive isotopes, as well as taking a CT scan at the same time, in order to trace the movement of the chemical. Another method for diagnosis is a biopsy, which can involve needles or even surgery, as tissue or fluid is removed for examination. The radiologist let us play with some stents for a bit, used in interventional radiology, which is increasingly used in modern medicine. It allows for wires to be used under x-ray guidance, and stents to be put in, in order to widen blood vessels. The reason that it has become so popular is that it decreases the need for surgery, which takes longer, can involve a longer recovery period, and generally tends to scare patients more. Within radiology, there’s a wide variety of patients, as all sorts of patients in the hospital need scans. I think that this is definitely a benefit, as it allows you to work with a diverse group of people, so that each day won’t be as repetitive.
After this talk, we heard from an anaesthetist, who talked to us about sepsis. Again, anaesthetists are found all over the hospital, as well as outside hospitals- they’re involved in trauma teams, ambulances, helicopters, pain rounds, surgeries amongst many other things. This doctor spoke about the importance of diagnosing of sepsis, as the effects when untreated are lethal. 4 million people in the UK die each year form sepsis, yet despite this, only around 50% of the population have ever even heard of it. If a doctor suspects that a patient has sepsis, the most important thing is to start the treatment fast, and get them on antibiotics. Even if it isn’t a full diagnosis, starting medication early could save their life. The rapid progression of sepsis can mean that someone is feeling a little grubby at the start of the day, but is then dead within 24 hours. This is why the first hour is known as the ‘golden first hour’, as it can determine someone’s survival. It’s one of the biggest killers, but also has very little funding and research compared to other diseases like cancer or diabetes for example. The doctor also described to us the various problems that he faces when treating sepsis. There are only 15 ITU beds in this specific hospital, which all cost the NHS £2000 per night, compared to an average ward bed, which is £400. Sepsis uses a huge amount of resources, straining funding as well as staff. People with sepsis are often in and out of consciousness, hallucinating, and losing the rhythm of their day and night cycle. Frequently, if the patient survives treatment, they develop PTSD due to the trauma that they experienced in ITU, which appeared to them as torturous at the time. This means that they then need to be followed up by psychiatrists, with studies showing that after having had sepsis, 10% of patients lose their jobs, and 20% of patient’s personalities change drastically. I personally found this shocking, as I wouldn’t have ever associated sepsis with any kind of mental health problem. The main point that was made was that, for a doctor, if you suspect sepsis, treat it like sepsis. If the right precautions are taken, then lives can be saved, but otherwise, a patient ca rapidly decline. This doctor told us that it’s not all about science. Especially with sepsis- often they start treatment based on an ‘educated hunch’. He told us that it’s crucial to look at the patient as a whole, not just the numbers and readings which have been taken from them.
The next morning, I went to A&E. I’ve always wanted to get into an A&E ward, having seen 24hours in A&E many times before. I now realise the differences between how Channel4 portray A&E, and how A&E actually is. Yes, the doctors are always busy, there are always patients waiting, but there aren’t traumas happening every minute, or people suddenly having cardiac arrests. It does happen obviously, but nowhere near as frequently as the media portray it to. In A&E, you have to be a people person. There’s such a diverse range of patients who arrive, and you’ve got to be prepared for whatever comes- whether that’s a minor injury, a drug overdose, or anything else. One member of staff gave us a short presentation, talking about life in A&E- both the advantages and disadvantages. He said that you often get frequent flyers, who will come in often- these are usually drug addicts, alcoholics, people with chronic pain or people with mental health problems. Other than that however, one of the main drawbacks of A&E is that you don’t get to follow up your patients. There’s very little continuity from day to day. I guess that could also be a good thing though, as it’s very unlikely that you have repetitive days. We got told about the 4 hour target, which is the target time to have all patients seen and treated within before they leave the hospital. However we obviously can’t apply this to every patient, as some will be admitted onto wards for longer care. The main problem that hospitals face at the moment in A&E is bed blocking. One of the issues is that the department have patients unnecessarily filling beds, as their waiting for a place elsewhere, such as in a community bed, or a bed on a surgical ward. Despite this, often they can’t discharge the patient until another place becomes available elsewhere, hence patients have to wait longer to get a bed and see a doctor. It has a knock on effect. As well as this, many patients use A&E inappropriately, wanting a second opinion after seeing their GP, or to treat their chronic problems. This again can clog up the system. The doctor explained to us how they prioritise patients- using a triage system. When a patient comes in, they have their history taken and are perhaps given some pain killers whilst they wait, before being categorised. Each is given a colour: red, orange, yellow, green or blue. Based on this, a list is formed, so the most urgent patients will be seen by the doctor first. Some patients won’t even need to see a doctor, and will simply be treated by specialised A&E nurses. We got told about the specialist paediatric equipment that they have, which can improve efficiency when treating paediatric trauma cases. An example of this is the rainbow mat, which a child will lie on. It has colour gradations along it, and depending where the child comes up to on the mat, in terms of height, the doctor immediately look at the recommended amount of drugs needed and the equipment size which should be used for this particular sized child. I thought that this was a great idea, although doses may differ between weight as well as height, so this also needs to be considered.
After having this talk, I got to shadow an A&E doctor for an hour, which was really interesting.The doctor was treating a patient who had overdosed on a drug called speed. Her heart rate was abnormally fast, she had high lactic acid, low electrolytes, shortness of breath, back pain and arm numbness. Blood was taken from the patient, although she was petrified of needles. I found it incredible how well the doctor dealt with this. He told her that everything would be ok because he was smiling, so throughout the procedure, to reassure her, he continued smiling and chatted generally as a form of distraction. It seemed to work, as the patient didn’t make a fuss about having her blood taken. The doctor was checking her renal function as well as doing general tests. He showed me the toxicology database, which doctors use in order to find out which tests should be done on each blood sample. After sending the bloods off to the lab, I was told that it would be about an hour before the results came. During this time, the patient was waiting in the bed, taking up valuable space. One important thing that I observed was that the doctor didn’t know everything. He had a book of emergency medicine in his pocket, which he often referred to, and at one point he used his phone to look up how speed is taken. I think that in A&E, it’s so important to be on the ball. You can’t know everything, but you must know what you’re doing, and what to do to help the patient.
In the afternoon, I went to orthopaedic theatre for a bit. It was great to see surgery again, although the cases were relatively minor. Before the surgery, all the equipment was counted, and written on a whiteboard, to ensure that at the end of the procedure, all the tools could be recounted again. Everything had been sterilised, in special blue packets, which we were told to avoid touching at all costs. The first patient had carpal tunnel syndrome, and was having surgery to release one of the nerves in her wrist. I believe this to be called a decompression. Before making an incision, the surgeon reassured the patient, telling her what he was doing, and making sure that she couldn’t feel anything. There was a sheet of tissue put between the patient and her arm, to prevent her watching the surgery, which is important to avoid unnecessary distress. There was a nurse at her other side, who talked to her throughout the surgery, which again was very important to act as a distractor and to reassure the patient. The patient had a tournaquay around her arm to restrict blood flow, which would make the surgery easier, and less messy when making the initial incision. The surgeon was wearing special magnifying glasses, and was being extremely careful when cutting into the patient. To me, it seemed like a very delicate form of art. He told us that the patient had a very tight ligament in her wrist, and he showed us which was the median nerve. I found it amazing to watch such an intricate procedure. The next operation was someone who had broken two bones in his hand, and had surgery a while back to implant some wires deep into the bones so that he could get his hand moving again more quickly. They were removing the wires today. I asked about the healing times, with the doctors telling me that bone takes roughly four weeks to heal, but that it takes longer in smokers. The bars which had been implanted were made of stainless steel, and would be surrounded by scar tissue. The surgeon was telling us about the different sutures that they used in theatre, and the benefits of them. There are non-absorbable sutures, which are smooth and made of nylon, and need to be removed after surgery. On the other hand, you have absorbable sutures, which don’t need to be removed, as they simply dissolve. There are also braided sutures which can be tied easily and have ‘memory’, as they retain their shape. However there are gaps in the material in which bacteria can grown, so braided sutures aren’t always used. The third surgery that I saw was of a patient who had broken their scaphoid bone. I was told that this doesn’t heal well due to the blood supply being at the other end. The surgeons were doing a graft by taking some bone from the main bone in the arm and putting a screw into the scaphoid. There was a lot of x-raying in the procedure, to avoid mistakenly damaging the joints of the wrist, so I was sent in and out, to avoid unnecessary radiation exposure. They took out the fibrous scar tissue between the bones so that when the graft was put in, the would heal. When taking the bone from the arm, they made a ‘trapdoor’ shape and scooped out bone from the inside. This would then heal over time, but there would still be a risk of fracture after the surgery, due to the removal of bone, so the patient would have to be careful with it. The bone was grafted because it has various growth factors and cells which would stimulate the healing of the bone in the affected area. The surgeons packed in as much bone as they could before putting the excess bone graft back inside the ‘trapdoor’ which they had made. Unfortunately I didn’t get to see the end of the surgery, but I enjoyed watching those three operations.
The following day, I met three psychiatrists, and got shown round some psychiatry wards. Unlike A&E, there is commonly a great deal of continuity with patients, who you get to see at their worst and their best. This makes the doctor-patient relationship all the more important, and it can often be rather intimate, as you get to know your patients well over time. Another key quality to have as a psychiatrist is empathy, as discussions with the patient have to take place frequently. This shouldn’t be muddled with sympathy, because all doctors need to be emotionally resilient in order to detach themselves from the situation and provide the best care that they possibly can. Again, the team is very holistic, as you have a whole team of people around each patient, including nursing staff, community staff, OTs, psychologists and social workers. This makes teamwork crucial. The work-life balance is difficult, as you can have intense periods of being on-call, but you don’t necessarily need to be in work for all your on-calls, which could make it potentially more manageable compared to a surgeon who is on call, for example, who needs to be in work. I got told that the patient backgrounds are one of the most interesting parts of being a psychiatrist, as you can learn so much about an individual in this way. It gives a sense of humanity to the profession I think. With psychiatry, you look at many different disciplines, including neurology, consciousness and clinical things too. Nowadays, people are much more aware of mental health problems, which means that more and more people are seeking help. Of course this is a good thing, however in terms of the NHS budget; the country is struggling. There’s such a variety of mental health problems which a patient can have, and this adds diversity to the job. A psychiatrist isn’t limited to psychiatry wards though, as their often present in the general hospitals, where patients may have a mental health problem as well as a physical problem, or if someone, from A&E for example, has been found to have a mental health problem. It’s not like being a GP- although you see many patients; you can’t simply diagnose them based on a 10 minute appointment. Often, discussions are longer and much more in-depth. Therefore, as a psychiatrist, it’s crucial to be a people person; someone who can talk to others.The psychiatrists also talked about general life being a doctor- getting used to bad smells, working in a team, experiencing suffering and talking to patients. They said that despite all this, the most important thing is to be caring, and to want to help your patients. I couldn’t agree more.
After a lengthy chat with the psychiatrists, we walked over to the wards. A patient can be sectioned under the mental health act, against their will, when they are so unwell that they are deemed unable to see things clearly and judge things sensibly for themselves. They are at risk of either harming themselves or someone else. In order to do this however, three members of qualified staff must agree that this is the appropriate action to take. Patients who had been sectioned were on a separate ward from others, as this allowed for more intensive supervision, although in the main ward, there were still a few people who were on 24 hour supervision. They had a carer within a meter of them at all times. Although I know that this is necessary for the patients well-being, I couldn’t help but think how invasive this must be for the individual. Because of the surge of patients being admitted to these wards, the psychiatrist explained that they try and keep people on the wards for the minimum amount of time possible, ideally only 1-2 weeks. The lady explained that this never used to be the case, as people were admitted for months. The reality is that we simple can’t do that anymore due to the strains that the NHS is being put under. Whenever you introduce a new system, people will want to use it and take advantage of it. We were told about a bed crises which had happened, on the ward recently, where they ended up with people sleeping on mattresses in the corridors of the wards. Apart from this however, the patients all had their own personal space, bedrooms and social area. Most people had much more freedom than I had expected, although many of them seemed very phased out. I guessed that this was due to the drugs that they were being given. I found it interesting to learn about the roles of a psychiatrist, although I’m not sure that it’s a speciality that I would like to take on in the future.
The next day we went to a hospice which is linked to the hospital. We were told again about the importance of teamwork within the patient care that they provide. The multidisciplinary teams consist of doctors, OTs, physiotherapists, chaplains, secretaries, drivers, maintenance staff, caterers, volunteers, as well as many others. They all work together to provide specialist palliative care, supporting families in a caring environment. Hospices aren’t there to cure patients. They provide symptom control and emotional support, to help a person who is close to the end of their life. The centre that I visited was very diverse, with a huge range of specialist equipment and activities to help a range of patients and families. This included art and music therapy rooms, a specialist swimming pool for hydrotherapy, a beautiful garden, fitness equipment and other rooms for visitors too. All the patients have their own privacy, as the bays were all individual, on top of a large living area with kitchens, bedrooms, living rooms, a chapel and a conservatory. On my work experience week, the hospice was the least clinical environment that I visited. It seemed like residential housing rather than a healthcare environment. This is important with concern to the type of care provided, as families and patients need comforting during hard times. They also provide bereavement support, which can be quite intimate. Despite this very real and human side of medicine, it’s still important for doctors to know their boundaries, not seeing patients as their ‘friends’ or being invasive in any form. One thing that was brought up was the difficulty to measure success in a hospice. You can’t simply tick off patients, and it’s unlikely that they will be cured whilst staying in a hospice. Instead, the goals of treatment are focused primarily upon the patient’s own wishes in order to achieve a high satisfaction rating. Despite this, it can be difficult to manage certain expectations, and although hope is important; reality is too. Bad news has to be broken, but patients aren’t forced to accept the reality of their disease. The key thing to acknowledge is the shift in focus from normal medicine; from length of life to quality of life.
To contrast this very human side of medicine, in the afternoon, we got shown around the pathology lab for a bit. Here, they deal with medical microbiology, cellular pathology and haematology. We were told that around 80-90% of all hospital admissions will involve a pathological investigation, making the centre very busy, meaning that efficiency is important. The average turn around for a set of results would be 2 hours, but if it’s urgent, then the sample is usually processed within 30 minutes. The hospital functions every hour of every day; so the path lab must too. Even though there’s a need for efficiency, quality is crucial. A patient’s treatment is dependent on their results, so the readings taken must be accurate, in order to assure that the patient receives the correct care. When people don’t work to the same standards, different centres will show different results, which could drastically change treatment plans. This speciality is very science based, and although I do love science, I don’t think that I would enjoy the limited patient contact, as it seems as though your almost detached from the actual patients, solely looking at their samples rather than themselves as humans.
Overall, I enjoyed experiencing a range of specialities. It’s given me a more in-depth insight into the array of choices which you can take as a doctor. Although I’m still unsure as to what exactly I want to do, I know that I want to be a doctor; and I can’t wait for it.
I hope that you’ve enjoyed reading.