I start on urology. Mostly we collect the steady trickle of kidney stone patients admitted via the surgical take. Desperate and sweating individuals \u2014 wincing as they try to force tiny calcium razor blades from kidney to bladder. Kidney stones are agony, the type of pain men perhaps accurately, but unwisely, compare to childbirth before being quickly bludgeoned by the death stare of any mothers in the room.<\/p>\n
The round is led by Mr Aggarwal, a short Indian man with a chest like a fridge and a moustache like Tom Selleck. He is an \u201cassociate specialist\u201d in urology, a title that in his case means a fully qualified urologist on the specialist register, but whom it suits the hospital to keep from becoming a fully fledged consultant because he can be handed the less interesting surgeries and the undesired task of babysitting the junior doctors.<\/p>\n
Up and down the UK, departments are propped up by immigrant doctors like him, experienced but held in limbo at a lower grade and, in the eyes of some, standing.<\/p>\n
One factor that might not help him is his temper, which is tested almost constantly. To spend each day overworked and underappreciated when just trying to do the best for patients will get to you.<\/p>\n
So far, so dead<\/p>\n
At night, the intensity increases, and decisions (and mistakes) most definitely do become life or death. Dead patients present a conundrum. You do have to see them. But how quickly? Certainly, some of the nurses would prefer you to come now, as would any neighbouring not-dead patients. On the other hand, the patient isn\u2019t getting any deader. And there are others with body and soul still very much united to see urgently. Some nurses also have less of a problem hanging on to a less demanding patient for a while (they tend to leave the call bell alone). Once I confirm the death, the body is replaced by someone breathing with needs, pain and functioning thumbs.<\/p>\n
How much you talk to the dead is personal. I tend to check they\u2019re definitely not responding to their name. But I remember supervising one FY1 who talked the whole way through, explaining things in extra detail to the body as if he were soliciting for a particularly good Yelp rating from beyond the grave.<\/p>\n
On this occasion, the nurse in charge sits serenely in the glow of a lamp, diligently scrawling in patient notes and plucking Quality Street from a nearby tin.<\/p>\n
\u201cMr Riley, can you hear me?\u201d I squeeze over his trapezius muscle. So far, so dead. I look under his lids and the eyes have the clouded-glass quality that can be so shocking the first time you see it.<\/p>\n
I put my stethoscope to my ears and press the bell to the waxy skin over his rib cage. No sound from within. Then my ears tune in to the sound of the radio. A voice so perfectly timed I struggle to believe it isn\u2019t a fabrication of my addled brain. \u201cHello darkness, my old friend\/ I\u2019ve come to talk with you again.\u201d<\/p>\n
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<\/p>\n
\u201cManagement are people who couldn\u2019t read an ECG if the trace spelt out happy birthday\u201d<\/p>\n
EVA PENTEL FOR THE TIMES MAGAZINE<\/p>\n
\u2018Are you sure he\u2019s trained?\u2019<\/p>\n
Like many young medics, when in hospital I have a stethoscope draped over my shoulders. It is a statement \u2014 one that says what your job is and, almost as importantly, what it isn\u2019t. A desire not to be mistaken for other roles is indicative of a different problem \u2014 illustrating how much of a perceived hierarchy still exists, but it can\u2019t be ignored.<\/p>\n
Sitting behind a public-facing computer, just my unadorned shirt collar visible, to many visitors I\u2019m the ward clerk. Many female doctors I know, despite stethoscope and the full history-taking, clinical assessment and presentation of a diagnosis and plan (and that they introduced themselves as \u201cDoctor\u201d), will finish only to be asked, \u201cThanks, nurse. Now when am I going to see the doctor?\u201d<\/p>\n
I have one memorable encounter when a 22-year-old comes into A&E with a severe headache. He\u2019s abrasive, angry. When I examine him, he tells me to piss off. I can do that, but he\u2019ll still be bothered by the hourly neurological observations necessary to be sure a murderous little berry aneurysm in a blood vessel hasn\u2019t burst, decanting claret into his skull.<\/p>\n
The morning ward-round consultant arrives and is taken aback by the patient gesturing to me, saying I\u2019m \u201cvery scruffy\u2026 Are you sure he\u2019s trained?\u201d<\/p>\n
I\u2019m wearing scrubs, the pyjama-like, hospital-issue uniform \u2014 something pretty difficult to put your own personal flair on, scruffy or otherwise. This leaves only a few things he can be objecting to: skin, hair or general\u2026 \u201cvibe\u201d.<\/p>\n
The consultant becomes noticeably stern. \u201cFrom the history, I\u2019m worried you\u2019ve had a bleed into your brain \u2014 perhaps damaging the area responsible for manners \u2014 and we need to know for sure. We\u2019re going to do a test called a lumbar puncture.\u201d<\/p>\n
It\u2019s always refreshing witnessing Caucasian seniority wielded in the name of good. He lists the risks in an unempathetic manner and sweeps out of the room. \u201cI was reading\u2026 a CT angiogram is as good as an LP for detecting a subarachnoid, without being invasive,\u201d I offer, still possessed of a puppy-like eagerness to please. The consultant permits a half smile. \u201cWell, it\u2019s a shame we don\u2019t have the facility to do that sort of scan \u2014 and that nice man will have to have a painful procedure instead.\u201d<\/p>\n
The cavalry arrive \u2014 in stab vests<\/p>\n
Occasionally in medicine, a level of fatigue sets in that stumbles into drunkenness. A man has barricaded himself into a corner of the ward corridor, hiding among a mess of chairs and wielding a drip stand. A colleague and I stand a good five metres back, trying to work out what to do. A reversal of the norm, this 6ft 3in skinhead is apparently petrified of me and a 5ft 2in Chinese-Singaporean woman. To be fair, one of us is holding a syringe full of sleepy juice. Not that you ever want to have to sedate someone, but when it seems likely that a patient may kick someone\u2019s head in, it helps to come prepared.<\/p>\n
A smoker, he has come in with breathing difficulties \u2014 and the level of CO\u2082 in his blood is high (very high levels have the inconvenient effect of being fatal). He has a long history of mental health problems, including psychosis and alcohol dependence. We have an agitated man mountain thinking we are out to kill him, but who needs to be calmed down to allow us to strap a mask to his face to \u201chelp him breathe\u201d \u2014 something an evil scientist trying to kill him might certainly try to do.<\/p>\n
Security are on their way. In the meantime the man vaults the barrier and pads down the corridor. His options are limited, so as we follow him it becomes a sort of bare-cheeked hospital Pac-Man.<\/p>\n
The cavalry arrive in stab vests. It might be the shift in numbers, perhaps boredom, or maybe the guy is just tired, but he finally stops pacing and sits on one of the banks of chairs, panting like a stuck buffalo. I give him a stern matron-like lecture and eventually he staggers back into the ward and his bed. I am bleeped, so I leave the nurses holding the 100kg baby. Thankfully, the man doesn\u2019t try to kill anyone, at least not while I am on shift.<\/p>\n
\u2018Discharge patients wherever possible\u2019<\/p>\n
As a registrar, I marshal the tides. It is not a bad hospital \u2014 if it were, I\u2019d tell you. Because they do exist. How do hospitals get so bad? A dark synergy between lack of funding, serving large areas with ailing populations and an inability to attract and retain talent among their permanent staff \u2014 both clinical and managerial. No, the Trench is home to some of the best doctors \u2014 experts in their speciality. It\u2019s just extremely busy \u2014 Black Friday opening time busy.<\/p>\n
The hospital is always on some shade of bed alert, the two worst being red and black, with messages from managers imploring us to \u201cdischarge patients wherever possible\u201d \u2014 as if this is some revelation. In this case, \u201cblack\u201d means we have \u201cnegative bed capacity\u201d and patients are sitting in ambulances outside A&E, waiting to be unloaded like foreign produce held up in a customs queue.<\/p>\n
Grappling with the manhood of Essex<\/p>\n
A night sleeping, even on a quieter, non-acute hospital ward, can be as destabilising as a sleepless one. The first thing to do is to claim an on-call room \u2014 leaving enough in the way of personal effects for anyone who comes sniffing to show it is occupied. These have the atmosphere of the most crisis-triggering Travelodge.<\/p>\n
The electric hum and creak from the pipes of the on-call room intermittently shake you alert. It is almost a relief when my bleep goes off.<\/p>\n
\u201cHi, Matt\u2026\u201d The senior house officer (SHO) sounds sheepish.<\/p>\n
\u201cIt\u2019s a catheter,\u201d he says. \u201cI\u2019ve tried twice and it just won\u2019t go in.\u201d<\/p>\n
I try to conjure a tone that conveys helpful approachability while subtly suggesting I am doing him a favour (rather than it literally being my job, which it is).<\/p>\n
A urinary catheter \u2014 a tube that helps get urine that\u2019s stuck in the bladder into the outside world (exactly along the route you\u2019d think) \u2014 may not immediately spring to mind as an emergency. That is until you have been in need of one yourself.<\/p>\n
When I arrive, the SHO is hovering awkwardly, the detritus from the two failed attempts in a bin bag. The patient, a grey man in his sixties who has had a hernia operation, greets me with a wince.<\/p>\n
\u201cPlease\u2026 It\u2019s unbearable, and that felt like he was drilling for oil.\u201d<\/p>\n
I have a closer look at the bin bag and am relieved. On this occasion, I am thankful for that four-month urology rotation grappling with the manhood of Essex. We are just dealing with the wrong tools for the job.<\/p>\n
I head to the surgical ward storeroom and am soon ostentatiously brandishing what I hope will be the solution. Silicon catheters, unlike their droopy latex counterparts, are rigid enough that they won\u2019t roll up like a curled slipper at the first sign of resistance. With the combination of this secret weapon and some firm but necessary \u201cmanipulation\u201d (yanking), we are rewarded with liquid gold. The expression of relief that floods the man\u2019s face as the bag fills is, I imagine, the visage of a man as he attains nirvana.<\/p>\n
\u201cSometimes it helps to \u2018straighten the path\u2019,\u201d I tell the SHO. \u201cBut without doing it so much they start to worry you\u2019re playing with it.\u201d<\/p>\n
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<\/p>\n
\u201cNobody wants to be \u2018that registrar\u2019 \u2014 the one whose name makes everyone groan\u201d<\/p>\n
EVA PENTEL FOR THE TIMES MAGAZINE<\/p>\n
Trainee in Difficulty<\/p>\n
Night shifts have always been ruinous to my mental state. I am naturally an anxious person. During the days, having \u201cslept\u201d in the hospital, I ricochet around the empty house in which I live with my girlfriend, Louise. The reality of our two junior doctor rotas means there are weeks we barely see one another.<\/p>\n
Admitting you have a mental health problem risks you being labelled a Trainee in Difficulty. Nobody wants to be \u201cthat registrar\u201d \u2014 the one at whose name consultants and juniors alike groan when they see it on the rota. There is also the chance of your training being extended, prolonging the torture of annual uprooting to new hospitals and night shifts. And memories are long, the world small when it comes to applying for consultant jobs.<\/p>\n
My new educational supervisor for general medicine is a geriatrician in his forties from Northern Ireland. He is 6ft 3in, with the physique of a prop forward.<\/p>\n
I ask him if he has a minute.<\/p>\n
\u201cNot exactly.\u201d<\/p>\n
This can\u2019t be taken as callous. We are in an asymmetric landscape; he can have no idea I want to discuss that dreaded subject: feelings.<\/p>\n
\u201cPlease. It\u2019s important.\u201d I give my most earnest of looks.<\/p>\n
With a huff, he gives in. Outside in the corridor, I stutter. \u201cI\u2019ve got a problem with anxiety. It\u2019s now at the point I\u2019m worried it\u2019s going to interfere with work.\u201d<\/p>\n
His expression shifts from impatience to confusion. As I feel the familiar heaviness threatening to flood and escape my lower lids, he settles on genuine concern (accented by the agony of awkwardness, inevitable in almost any middle-aged man presented with this situation).<\/p>\n
\u201cOK, I can see this is upsetting you. Why don\u2019t you head back to the office? We can speak properly in a bit.\u201d And we do. We agree I\u2019ll have to see occupational health if I am feeling this bad (I\u2019m conditioned to emphasise I don\u2019t take any time off).<\/p>\n
Such is the concern among doctors around seeking help, and yet the need so great, that a bespoke covert service has been set up. The Practitioner Health programme allows us to self-refer, slinking off in secret like some psychiatric love rat, without having to go through a GP.<\/p>\n
In the general population, black people are more likely to experience mental ill health on any given day than their white British counterparts (23 per cent compared with 17 per cent). Your ethnicity can have an impact on the diagnosis you receive. As a medical student, I remember a well-meaning but by modern standards inappropriate consultant psychiatrist exclaiming during a teaching session, \u201cSchizophrenia is a black man\u2019s disease,\u201d in a tone that wouldn\u2019t have seemed out of place in a 19th-century phrenology lecture.<\/p>\n
Doctors are not immune to the medical clich\u00e9s that afflict patients. This Practitioner Health service is a response to above-expected levels of mental health disorders among healthcare professionals. I say \u201cabove expected\u201d, but it isn\u2019t really. In fact, it feels like a fairly predictable response to sleep deprivation, overwork and the social isolation caused by weekends, nights and forced relocation to the other side of the country, away from friends and family.<\/p>\n
I see a kind but firm nurse who makes me promise, no matter how much I resist, that I will seek help. But by the time of my first video appointment with the psychologist, I am fine \u2014 a few weeks of living in the daylight has done the job.<\/p>\n
\u2018Old school\u2019 tendencies<\/p>\n
The consultant has only the slightest hint of Scottish to his voice, the kind of confusing accent produced by their boarding schools. His black, swept-back hair creates a sense of motion, as if he is accelerating towards you, and the twitching bristle of his magician\u2019s goatee insinuates that whatever he does when he arrives might be unsavoury. Medical students and doctors alike are wary of him and his \u201cold school\u201d tendencies. He is, unfortunately, also a clever consultant \u2014 bordering on genius \u2014 so he gets away with it. This is a man who, during a lecture, displayed an image demonstrating the effects of leprosy and commented that the subject\u2019s dark skin \u201clooks like I found him swinging through the jungles of Africa\u201d. Nevertheless, his talks are religiously attended. I\u2019m embarrassed to say my feelings are more mixed than they should be. I undoubtedly learn a huge amount from him, but at what cost?<\/p>\n
On one ward round, he walks past a poster of the hospital\u2019s head nurse (who\u2019s Filipina) and turns with a half smile to one of the medical students (Korean). \u201cRelative of yours?\u201d He is rewarded with the thundering silence of the group\u2019s heads simultaneously exploding. He quickens his pace and we follow in his wake towards his next victim.<\/p>\n
This encounter isn\u2019t unique. Experience of racism among doctors is widespread \u2014 to the point it is almost universal among ethnic minority staff. When the BMA asked, 91 per cent of black respondents reported they had experienced racism at work. Accepting the limitations of a survey, most would agree that\u2019s a lot.<\/p>\n
The consultant stays around far longer than he should \u2014 but he isn\u2019t bulletproof. He is quietly asked to perhaps take a sabbatical, but decides there are more lucrative opportunities and leaves entirely.<\/p>\n
Avoid being non-white<\/p>\n
When things go wrong in hospital, you\u2019re on your own. That\u2019s worth remembering when a text message arrives from the hospital switchboard warning of \u201cbed shortage\u2026 Avoid admission wherever possible.\u201d You might even see management popping down to the department. People who couldn\u2019t read an ECG if the trace spelt out \u201chappy birthday\u201d \u2014 shirt sleeves rolled up, concerned faces with questions about, \u201cWhat can be done to get things moving?\u201d They will be awfully quiet about their levels of influence once something terrible happens.<\/p>\n
To help your career survive that process, make accurate notes, contact your medical defence organisation and, most importantly, if you can, avoid being non-white. It really increases your chances of being referred to the GMC, struck off and even prosecuted \u2014 and no one wants that.<\/p>\n
In 2018, the British Association of Physicians of Indian Origin examined cases over the preceding decade and found that of the 20 manslaughter prosecutions, 12 were non-white (this is out of proportion to the ethnic make-up of the UK doctor workforce), as were all seven of the convictions.<\/p>\n
Easy wins<\/p>\n
Mid-afternoon for medics is when the rush starts. Breaching \u2014 a fate so dreaded and fretted over you would be forgiven for assuming patients burst into flames \u2014 means a patient has been in the department for more than four hours without being admitted or sent home.<\/p>\n
The punishment for failing to meet targets means you are asked ridiculous questions. \u201cDoctor, is this patient coming in or going home? They\u2019re on 3 hours 45.\u201d \u201cI don\u2019t know. They have literally just been referred. No one from medicine has even met them. Would you like me to flip a coin?\u201d<\/p>\n
At the nursing station, a queue is forming \u2014 a drawback of sitting somewhere you can be found. Medics surge when I get off the phone and it looks like I\u2019m free to take a referral \u2014 the emergency department doctors clamouring like Eighties brokers trying to dump a bad stock.<\/p>\n
One SHO starts her sales pitch. \u201cHe\u2019s only 40, doesn\u2019t smoke, but says it\u2019s the worst chest pain he\u2019s ever experienced. Does he need to come in?\u201d<\/p>\n
As much as I dislike standing up unnecessarily, sometimes five minutes of leg work can save hours later. At the cubicle is a healthy-looking but very anxious young(ish) man with a physique that appears made up of 90 per cent creatine.<\/p>\n
I ask him all the standard history-taking questions. To be fair, he does have an aching pain in the middle of the chest that gets worse when he exerts himself. \u201cOK. A couple more questions. Have you been exercising recently by any chance?\u201d \u201cYeah, I go to the gym.\u201d \u201cAnd have you been working out your chest a lot recently?\u201d At this, realisation creeps across the man\u2019s face. \u201cI did bench quite a lot yesterday\u201d \u2014 a line delivered like a schoolboy who had just smashed a window playing football.<\/p>\n
At this point, you might expect me to bemoan time-wasters clogging A&E, calling ambulances because they can\u2019t change the channel on their TV. But situations like these feel like a win \u2014 problem solved, a bed saved and a number on the board with my name next to it, all in a couple of minutes. Of course, there is always the risk he\u2019ll turn out to have an aortic dissection and keel over on the street outside just to spite me.<\/p>\n