Pseudonymous Doctors: Another Point of View

I am very happy to host the thoughts of the Nice Lady Doctor, who has now left twitter. Here follows her views on the new GMC guidance:

"On another blog, a colleague has suggested we should be using social media for “meaningful work on behalf of the profession".” Sounds terribly po-faced, doesn't it, and not something I would wish to claim for myself. However, much worthwhile thinking and writing can be done without such seriousness, and to good effect. More to the point, even second-rate creativity is necessary to produce the first-rate stuff.

For most of 2012 I tweeted life in NHS General Practice to up to 2000 followers, many of them laypeople who were by turns amused, intrigued, educated, kept up to date on medical matters, and occasionally infuriated. In my own turn, I learned a huge amount from many bright and inspiring people, often non-medics such as @MentalHealthCop, @NotSoBigSociety, @AlysonPollock and a multitude of third-sector experts, campaigners, journalists and of course patients. Some of these people were anonymous or pseudonymous, and I can't say it occurred to me to bother about that. You can spot a troll or troublemaker easily enough without needing to know whether their username is their legal name.

Anyway, I tweeted quite a lot for a while: probably wasted far too much time on it, but I also felt I was contributing a unique viewpoint, expertise tempered with humanity; some gentle humour but not satirical; professional but not inaccessible to the lay(wo)man. There may have been a few hasty tweets, but I don’t recall saying anything unprofessional, abusive, illegal, or that I regret.

The major downside of gaining followers - which may not be apparent to those who have less than a few hundred, or who network mainly with fellow doctors - is that you become a target for certain types of people who have an axe to grind and who decide that you can be their grindstone; and many more, with innocent motives, try to enlist you in their campaigns of various sorts. In just a few months I was accused (wrongly I believe) of racism by one person, of bullying by another (for a single comment about her blog), and threatened with referral to the GMC. Twice I was asked to intervene in the lives of complete strangers who were apparently on the edge of suicide. I was telephoned late at night by an acquaintance who knew my real name, to warn me off upsetting someone powerful. A high-up person in medical politics contacted me in the middle of my holiday to give advice: well-meaning, but not very relaxing on a family break.

Then, a few months ago, the GMC issued their draft guidelines which made it clear that they had decided that anonymity was no longer to be an option, for fear of troublemakers (ironically, those who had given me trouble were not anonymous). I do not believe this was accidental, rather an attempt to extend their control of doctors’ behaviour far beyond the consulting room. I should make clear that to me the consulting room is sacrosanct: in there I suppress my politics, my religion, my philosophy, my ‘rights’. I censor my own language, opinions and dress sense, to put the patient first. Always. And I leave in there my patients’ stories, their pain, their fears, their secrets. These are not for sharing. However, when I leave the room and come home and log on, may I not ‘put on’ with my tatty jeans, my personal beliefs which make me in fact the doctor I am?

I wrote my own response to the GMC 'consultation' but received no reply, so cannot know whether it was read, considered or ignored. I pointed out a number of problems, not least that it effectively discriminates between those whose registered name is common (Dr John Smith will remain impossible to identify) and those like me whose registered name is unique in the UK. Given that the GMC itself publishes my name, maiden name and graduation year, and that doctors’ workplaces are also usually available, this means that giving my ‘real name’ on Twitter amounts to publishing my address, telephone number, my children’s school, my parents’ address, my colleagues’ names and addresses, with every tweet. I already know (as above) that perhaps one in a thousand twitter users is liable to cause me problems. Do I and my family want to risk any fallout from the occasional disagreement or misunderstanding with a member of the public over (for example) abortion rights? No. Do I wish to continue tweeting whilst forever stepping on eggshells to avoid mentioning anything real or controversial? No again. And while it seems unlikely that the GMC would be able to win a court case on this as a human rights issue, do I wish to bet my whole career on that by becoming a test case? No again.

My twitter account, on hold for some months, is now closed. A fond farewell to tweeting friends from ‘the Nice Lady Doctor’.

@theniceladydoc

Anonymity

The new GMC guidance advising doctors on social media sites to use their real names has caused many to review their position and perhaps withdraw from these sites altogether when the guidance comes into force on 22nd April 2013.

I don't pretend to talk for all of us who remain anonymous but I will tell you the events that made me realise anonymity is important to me, and you can make your own judgement.

In 1998 I returned to the UK after a 'gap year' in Australia. Back then Basic Surgical Training rotations were in their infancy. You were expected to micromanage your own experience, training and education. Serial 6/12 SHO posts was the norm. I had been a surgical SHO for 4 years. Sitting the old FRCS Part 2 I had done the Thomas's course where of the 36 SHOs on the course, 31 wanted to do T&O. With its 88% pass rate I knew I would be seeing these same SHOs at reg interview after reg interview so I ran. All the way to Australia. Just so I could be a registrar.

Another historical point: being a T&O SHO back then was no picnic. It was a house job. We all came in at 7am to get as much ward work done as humanly possible to allow us to get into theatre, with evening catch-ups on the day's patients. No F1s, no phlebs, no ECG technicians, pre-assessment clinics and regular clinics with your own template ... and you were glued to your boss. If he did an evening ward round, you did. If he had a Saturday PP list, you were there. That was just how it was.

So I got my Part 2 & five days later I was on a plane to Oz. 18/12 of registrar-level trauma experience. It was amazing. Had juniors and everything.

Came back and started applying for registrar rotations. Had a great logbook, broad range of surgical specialities under my belt and the Exam.

More history: no online applications in 1998. Each post wanted 10-15 paper copies of your CV and application form. That is some weight of paper, for starters. 33 registrar applications later, my confidence was waning. Jobless, I went back to an old hospital and was welcomed with open arms by A&E where they knew I could keep Minors flowing without concern.

Then this article came out in "Hospital Doctor". Two page spread from a Prof of T&O encouraging people to apply. So popular, 300 applicants per post, 1:8 regs were women, la la la.

The red mist came down. I wrote a letter. My experience. How could they encourage trainees to put their life on hold in a perpetual hamster wheel of house jobs whilst application after application went by the wayside. SHOs had to have career progression and realistic guidance. Churning out pointless papers in the name of 'research' was an exercise in futility.

And "Hospital Doctor" printed it. In its entirety. With my name on the bottom.

The phone calls were of two varieties. Former registrars thought it was the longest career suicide note in history. A Regional Advisor from an area I'd never worked in got in touch and was hugely supportive and helpful, as were two former bosses, who were kind enough to help rewrite CVs and application forms.

Then I got shortlisted for a registrar rotation. I couldn't believe it. After 33 applications and a public baring of the soul, the invitation to interview.

I had maybe a week, ten days, of being quite jolly, making plans and booking appointments with those on the 22 member interview panel who were seeing candidates.

Then a phone call. Thank goodness for that phone call. From the Programme Director's senior registrar, someone I had known a little, earlier in our careers, who I did then and still do respect hugely. 'They have short listed you to see who you are. You are not going to get a job'.

So I went in prepared. Well not totally, as who can be strong enough to withstand the opprobrium of 22 senior academics and clinicians seated on 3 sides of a giant square table, handing round copies of the magazine with your printed letter open just in case someone hadn't seen it.

It was a massacre.

The following day one of the panel rang me to offer me a Trust grade registrar job. With his help & support, and the backing of that unit, my next interview for a training rotation the following year was successful. I've now been a consultant for six years.

Now we have outlets for our concerns, our anxieties, our anger. It's healthy I think to have somewhere to vent & share, to have things put into perspective, to receive support in an otherwise isolating environment. But anonymity is key. I put my name to my feelings, and stalled my career.

I will not make that mistake again.

On the Beginning of the End of the NHS

Sad day.

There is no reason why you should know, as there has been absolutely zero media coverage on the event, but yesterday, Wednesday September 7th 2011, the NHS Health and Social Care Reform Bill was passed through the Commons on its first Reading, by 65 votes.

No party had a mandate for it, nor any manifesto mention. The parties that became the Coalition Government promised us "no top-down reorganisations" at the 2010 hustings. But they all lied. All over Whitehall pants are on fire, a bonfire of the pre-election pledges.

We have taken the first step to a US-style healthcare system. A system that is based on a price for everything and where nothing has a value. Including professionalism. It will undoubtably work efficiently for the earning, worried well but for those with co-morbidities that look unattractive to Any Willing/Qualified (Private Company) Provider, things are going to get very tough.

In a market economy, many smaller NHS hospitals will close to concentrate resources in cost-efficient centres. Community based projects (cottage hospitals, rehabilitation centres) will be nonviable, more useful as real estate. Private concerns will be able to cream off the high turnover, lower risk procedures, driving the contracts down with loss leaders, leaving the NHS to deal with the elderly and those with multiple morbidities. Accountants for GPs whose budgets run out before the end of the financial year will find a plethora of creative ways to defer organising investigations and treatments. It's already started in NHS Yorkshire " Before you consider surgery ... remember there are significant risks attached ... surgery can be painful ..." NHS 'cynical' tactics are up and running.

And training, how on earth are we going to train future surgeons when the 'routine' operations are removed to the private sector where only consultants are insured to practice...

This is only the first Reading. I realise it has to get past the Lords but the staggering lack of engagement in this last vote by the media and the general publlic has left me gobsmacked. Honestly. Nothing today on any of the national papers' front pages. No discussion of any of the BBC's flagship news programmes. Liberal Democrats crowing on twitter that they showed the Tories what they're made of (really, REALLY? You abstained in protest, oo how tough were you). Dead silence from the Labour leadership.

They all want it. They all want the NHS albatross removed from around their collective neck, it's their dirty little secret.

And now it's our future. Or is it ...

Read the Bill go on, have a go. If you like what you see, well at least you are informed. If you don't, then:

Adopt a Peer and email them your thoughts. Please engage in this process: there is no doubt that the Old Girl needs reform after 63 years but this, truly, is not the way.

On questioning the role of surgeons

Why is there so much antipathy to the Surgeon and so little value placed on the performance of Surgery?

http://www.telegraph.co.uk/health/8735934/NHS-using-cynical-tactics-to-put-people-off-surgery.html

Not for the first time the job that we do is portrayed as optional, sham, cosmetic, a luxury. Pain isn't optional. Osteoarthritis, neuralgia, tendinitis, functional incapacity, inability to be economically active through musculoskeletal insufficiency: these are not conditions to be put off to another day. A torn meniscus isn't cancer, doesn't provide the emotional photo ops of a children's ward, and yet for that patient it means pain, it means swelling, it means not driving, it means losing income, it means lack of sleep, sleep deprivation that most penetrating of all psychological abuses.

Surgeons are not charlatans. We do not exist to create a demand, a need, where there is none. We have training in a skill that maintains the human skeleton beyond its warranty: it was only designed to last for 35-40 years. After that, it loses much of its adolescent ability to repair. It starts wearing out, at the height of our economic earning potential, when our outgoings are at their lifetime peak. Mortgages, childcare, tax demands, insurance... Who will underwrite that when you take to your bed after discovering all the Nurofen in the world won't let you sleep.

Value your surgeons. If a surgeon offers an operation, it is because all reasonable non-operative options have been exhausted. It's not because we're looking for a job creation scheme. Be honest about what you are doing when you ask people to think again about surgeries to improve quality of life. You are talking about Rationing, Cost and Corner cutting. Storing up worse trouble for the future, even if it is a future government of another colour. You are talking about an NHS that can only deal with cancer, kids and crashes.

Value the current, the existing NHS. In the words of Joni Mitchell, you don't know what you've got till it's gone...

On the importance of perspective

Holidays... A vital necessity. I thought I'd been so smart, booking leave for every single half term for 2 years straight; then realised far too late how loooonng the summer holidays are. By the time it occurred to me (May) that I really should plan something, August had already been comprehensively diced and sliced by my colleagues' ever more super-organised wives.

Depression

But sneaking a couple of days off ahead of the Bank Holiday weekend has meant I've been able to get on a plane, baste on a beach and let the mounting frustrations of the past few weeks melt away like the ice in my cosmopolitans for five glorious days... so first day back I've adopted a zen-like calm which has freaked out everyone in theatres (I've been particularly toxic of late, but today, untrained newbies, of which there seems to be an inexhaustible supply, lack of professionalism and the gay abandon with which hundreds of pounds' worth of implants seem to be dropped on the floor, just washed over me in my protective bubble of holiday euphoria)

How long can this last ... ?! Just have to hang in there till half term ...

On futile gestures

It's all going to pot. Cutbacks (cost improvement programmes, lean efficiency measures, the euphemisms are endless) mean a cut in the quality of service. But not the quantity of service, noooo, we function on the Lidl Marketing strategy: pile em high, sell em cheap. Our door never closes.
Today's bombshell: senior staff are more expensive than school leavers. Wow. Wonder why that is because experience counts for nothing in today's NHS. So, wizard wheeze, sack 20% of your senior nursing work force, employ numpties and Carry On Regardless

That strategy couldn't possibly have a down side, could it.

And of course, we now function in a Foundation State (ex-Libyan leaders welcomed) with the footsoldiers too scared to speak else they are suddenly invited to reapply for their own job.

For the first time in the history of the NHS, the hospital doctors' jobs aren't safe. Merge to grow - and rationalise. We've lost our voice

On venting spleen

My day consists entirely of listening. Listening, absorbing, assimilating, cogitating and after due consideration ... treating. I decided today, after twenty years of doing this (20 years and 23 days if we're nitpicking) I'd like to start venting.

Today, after twenty years of having every aspect of my working life overseen by here-today-gone-tomorrow, mediocre, middle-aged middle-management... I'm ready to vent. It just doesn't do to vent in the workplace. I think it scares people (management) to hear concerns spoken out loud, makes them real. Rather generates complaints in that quaint but effective catechism of attack being the best form of defence.

So I thought I would write down all the bonkers things that take place in my world, and perhaps, once I see it on the page, it will seem merely ridiculous rather than hellishly frustrating and I can laugh it all off.

Here we go...

August

Everyone knows August means entry into the Danger Zone, right? Hundreds of college students, kept infantilised by the protective cocoon of spoon-feeding medical schools, are belched forth into the Real World. This is a frightening place where People Are Really Sick: not a simulation, not a Virtual online game (sorry, 'module') but your actual real sick people. In a Hospital.

As final year students we were housemen to the Houseman, learning the nuts and bolts of patient care so come August 1st it was scary but not paralysingly terrifying. These guys have no idea they should be scared, their experience has been so far removed from real life.

And in the brave new world of Foundation training, we have these bright shiny young things for four months in which we have the opportunity to fire their imaginations, to demonstrate what a fantastic job we have, the amazing and awesome privilege of operating, fixing and mending broken and worn out People. To inspire the next generation...

Except we don't. With the EWTD, days off after nights on call, annual leave, educational half days (da di da di dah) we have them for 24 working days. 24. That's it. And they don't realise it. You can spell it out all you like but they just don't get it.

They're gone. Next job. Mad panic come the following July as they discover none of their beginning, middle and end assessments have been done, tears, pleas, threats of legal action when they realise the boat's been missed... but they always get let through by the skin of their teeth

And then it's August again...