Friday, August 31, 2012

Spare us this deluge....

It's absolutely mind boggling....anywhere you look nowadays, it seems to be the rage....guidelines, documents, position statements...there seems to be absolutely a deluge of them. And everybody's at it...NICE, Department of Health, Kings Fund,local Commissioners, name it and there is an abundance of it..coming at us from all angles. As a clinician, you are trained to do things which are basically quite simple..see a patient who has come to you because of their problems, give them the best possible treatment you are aware of or your training had provided you with, ensure you are doing no harm ( remember the physicians primary no harm?)be courteous with all concerned..and hopefully you see the said patient later who has benefitted from your expertise.That sounds quite simple, doesn't it?

But oh no, there are documents, guidelines, performance based incentives we must follow. Look at screening guidelines..there's now evidence pouring out that breast screening, bowel screening etc are resulting in over investigation, over treatment and beyond all, engendering anxiety in a population which is avoidable.  Recently I was asked for my opinion on an frail elderly lady admitted with a fall due to a hypoglycaemic event on the orthopaedic ward, Her overall average stood at 8.5% and to me, it sounded quite reasonable..why give her more drugs, more costly interventions when a) there's no evidence and b) it may cause her to have hypos and make a frail lady suffer?

In a sensible world free of multiple guidelines and may even say in the olden days....these sort of cases would involve a GP chatting to a specialist and both agreeing over the phone that this wasn't reasonable and it was best practice to "leave alone". But nope, not anymore...the QOF says we must get that level down....and the practice nurse concerned feels obliged to add in another make her control "better". Look what guidelines and documents have done...reduced the individual to a longer is it about the "person in front of you", in fact we have now moved on to actually causing harm. Ask that poor old lady, I am sure she isn't worried about her "numbers".. But for sure is frightened of having another "nasty turn".
Any type 1 diabetes patient will tell you about their angst at being "told off" for their "poor numbers"...the reason they start getting afraid of seeing a healthcare professional...don't believe it, come on to social media, read a few blogs...and see what guidelines and targets have reduced us professionals to. Are they all bad? Of course not...but as a professional, what I want is something that is evidence based and frankly, one source will do, thank you very much.

And then you have data...anyone you meet nowadays is dead keen on showing you data.."local variation" is the buzz word...and your head spins...which one is correct, which one isn't? For most folks, whenever data is published and it shows them in a poor light, the standard response is the data's wrong or someone's hatching a conspiracy against their services. Here's an per data published in different quarters, local GPs have been checking feet in about 85% of cases (Portsmouth GPs are amazing) the mortality rate inside the hospital for anyone admitted with diabetes is one of the lowest in the South coast ( Portsmouth Diabetes team is beyond compare).. But hang on..the amputation rates are one of the worst in the country ( Portsmouth diabetes care is rubbish). How on earth do you marry all those numbers together?? A red top paper would look at that and come up with perfect headlines.."Data from Portsmouth has shown that high amputation rates has resulted in less people dying, thus all diabetics must have their legs amputated"....and looks like we have finally entered the world of Monty Python.

I was asked recently whether I wanted to take into the GP surgeries I visit '"data to reflect poor practice". Now our whole local ethos is built on building bridges with our primary care colleagues...and the very thought of an opening gambit whereby I plonk down a sheet to the GP showing poor practice...sent a shudder down me. A polite no was offered back to the individual....don't get me wrong, all for challenging poor practice...but you need to show me data which is true, data which will stand any scrutiny and more importantly perhaps share in a less confrontational way than "here you go mate..explain that!". How about a different approach where you all agree to a set level to at tin, wipe the slate clean, approach all surgeries to get to same level of competence...and when you do approach individual surgeries, you will, perhaps, be able to find surgeries which may already be that level ( fabulous..less work for specialists to do as educators)  or someway to get to that level ( ergo needs input, time and patience). Far less controversial, far less confrontational...and certainly far less time will be spent on everyone thinking the data produced is either a cock up or a conspiracy.

Ah...but I already hear people asking about "performance management"... How do you know or measure whether those doctors and nurses are doing what they should be doing? Well can I venture or suggest something simple? How about something radical like actually measuring things which actually matter to the patients? For eg, how about measuring whether patients with type 1 diabetes are actually being reviewed after their admission from a ketoacidosis event? how about looking at whether GP surgeries and hospitals are helping to lessen heart attacks, strokes etc..rather than chase numbers? how about some outcomes based on...evidence? Outcomes based on the reason a patient comes to see us or we went to medical get someone "better". People want better health, not necessarily healthcare systems.

So to those who love doing those documents and guidelines, spare a thought for the physician on the coalface. We are simply put, deluged. A bit of respite and a bit of forethought is asked for. Something simple, practical, evidence based is all we ask for. For those who like spewing out data, please, don't use it for political gains, don't use it to bash healthcare professionals to "score a point". Draw a line, let's use some common sense..and let us see patients without the sword of Damocles hanging over us. That cannot be too much to ask.

Tuesday, August 21, 2012

Allegiance: With whom do you lie?

Kevin Pietersen…what can you say? On the face of it, an uber talented cricketer, a rebel character, a bigger match winner than Freddy Flintoff as per statistics, has been cast adrift from the establishment- as he did not “conform”…the main allegation being that his allegiance was compromised. And the pundits have been out in force weighing up on both sides. For the traditionalists, he has no place in the team, for the non-conformists, such a talent needs to be handled with care. Didn’t all the “greats” have their foibles? Warne, Botham, Richards..all quintessential rebels…all great masters of their craft…and uniformly feted as the darling of the masses.

The rebel within finds that endearing….till one reads that the root cause or at least the alleged one…whereby one hears that he gave tips to the opposition how to get his own team mate dismissed. Perhaps thereby lies the crux, perhaps it’s not about the rebellious nature, its not about the talent or the arrogance, it’s about what has been compromised. It’s about the loyalty to your team mates, compromising on something sacred, something dear, and compromising on your allegiance. And for that Kevin, I am are done.

“Allegiance”. It’s interesting to discuss this particular word in the context of what we do nowadays- and as doctors, we face this question pretty much every day…such is the nature of the “business” we are involved in, I suppose. The basic question being…as a doctor who does your allegiance sit with? Is it with the patients, the institution that is the NHS, the Trust that employs you, your line manager, your colleagues or is it your specialty? 
Or are they all the same thing but in different garbs? I must admit to not knowing the answer to that conundrum…instinctively, you would think your primary “allegiance” is to your patients...the reason you went to medical school etc etc…but if that’s the case, how come you see only handful of examples where doctors have come out in raging protest against the system they seem to think have dealt the patient an unfair hand?

Here’s an example…the diabetes world continues to be divided as regards where best care sits…and although a broader debate, excluding the individuals who resist as they are self-protective about their jobs, the majority genuinely believe that moving patients out to primary care will result in poor care. A perfect example where the system is being resisted as clinicians believe that patients will be compromised, thus any move to switch patients out without adequate cover or resources cannot be a good clinical decision- whatever the pressures maybe. So far, so good. Let’s drill into that a bit further. There are some areas who have let that happen…without so much as a murmur, because their Trust wanted to reduce activity, or the present policy of the NHS said so. Most of those areas now have poor care in diabetes. So where does the allegiance lie in that case? Is it because the doctors concerned don’t care- or has the cynicism taken such a hard bite that they are past the point of caring? Who is the vanguard of the speciality if the specialists stand aside? Who fights for the patients in an arena such as a PCT board or Trust Board meeting... where they have no voice? Answers on a postcard please.

So how does one go about trying to marry all those- and more importantly can they be married? In these times of flux, it will be a struggle. Many a decision are bound to be taken which to the clinician, will challenge the ethos they believe in, firmly strike against, in their opinions, good clinical care…for example, if a Trust feels that a department doesn’t need a diabetes nurse anymore, how far would the diabetes team go to fight it? Take on their employer? Take on the NHS policies…or consider picking their fights which are winnable? As the film cliché goes “A storm is coming”…and the need to make less money work for more will inevitably lead to services being rationed, cut…and all of these allegiances are set to be challenged hugely. Each one of us will need to make a decision, need to make a call –as the time to sit it out is probably past. This storm will pass…and if we choose to be on the sidelines, we may come back to tattered services.

Individually, its easy to simply say patients matter and nothing else. Reality suggests it’s difficult to do so for many, simply because of the multiplicity of vested interests involved. And I suppose this is where we have moved away from the ethos of healthcare or for that matter the NHS. What was supposed to be a system based on taxation to improve the health of the population has now become a battleground of multiple providers, people looking at the their bottom lines in the financial charts, profits, losses, closures…it suddenly is no longer, simply, about getting someone’s health better. So far, touchwood, I have been able to stay close to that- and maybe that’s because of my relative inexperience. So far, my allegiance has lay with the patients, my specialty, my department and my colleagues- with the ones named after patients- intrinsically linked with patient care. I have had no compunction about snapping or snarling when any of the above has been compromised or threatened. The question long does one continue doing so? A colleague recently worried whether my “pugnacious” nature would hold me back in my career….to which my rakish answer was “I wasn’t aware this was an audition for the X factor”. But it got me thinking…has it finally come to this? I looked back at all the instances where I had picked up a fight- and either it were because of a personal insult or mostly it was down to not compromising patient care. Do I care that much about my career progression that I abandon the customary growl?

Such questions and dilemmas are sure to grow- and challenge each one of us…where does our loyalty or allegiance lie…where do we draw the line..and make no mistake, with all the flux upon us, the questions will become louder. I cannot “advise” anyone senior to me but for anyone who is starting off, my suggestion would be to hold the line, and when questioned..always work to one basic rule..the allegiance has to lie with the patient. If that involves fighting battles, one needs to have the broad shoulders to fight that. Or as in KP’s case..if you compromise on the quintessential issue of loyalty…I am afraid, it doesn’t matter how amazing you are..its unlikely you will be back in the fold.

In the words of J K Rowling…”It is our choices that show what we truly are, far more than our abilities.” The time to keep avoiding or ducking the allegiance question is fast approaching….are we all ready for it? The Pietersen saga makes us think what compromising trust can do...are we ready to repose the faith and trust placed in us by our patients? Or are we ready to test our allegiances? Tick tock...

Wednesday, August 15, 2012


August 15th...will always stay as a landmark day in my life. Nope- its not because its the day India gained freedom from the British..but was the day when I started as a Consultant in the confines of Portsmouth Hospitals Trust. Perhaps some Freudian irony there which I will fathom out someday but either way it's a red letter day for me. Every year since then, I have chosen this day to pause and do something I rarely do..i.e. look back. Its been 4 years and tomorrow I step into Year 5...and what a fantastic 4 years it has been. It's also somewhat weird that this is my 26th blog post- sort of moving into the second quarter- and what started as more of a vessel for eulogising personal thoughts has actually grown into something I have enjoyed. This has been "me"...cathartic, beyond the bravado, beyond the swagger, beyond the unflinching's been more of a window to what I am..perhaps with a bit of the guard down.

So today was a day to look back. It doesn't feel like ages ago that I walked into that department...eager but slightly worried as to how I would be received in a unit where I had been a trainee for so long, done my research...would familiarity breed contempt? To begin with the colleagues who I had to start work with. Iain Cranston...the chap who had given me the first entry to Portsmouth back in 2003...a casual meeting in Winchester...I happened to meet a healthier version of Harry Potter..glasses, floppy hair, smiley face. This was at a time I had finished my locum training post in Bournemouth, was looking for an option- and increasingly thinking of going back to where I had done my SHO training days- Worcester. Not many encouraging words around either..and then I met Iain. 10 minutes later, I was asked to come to was a short term job but Iain was full of was a "brilliant place to work" I gave it a go. And the very first day I met Darryl Meeking. In those days, his reputation was nothing short of legendary..a tough as nails Consultant who worked hard and played really hard...and at first glance, it was confirmed. A man came and robustly pumped my hand welcoming me to the unit...all smiles..but there was something odd...this man had a goatee and a few remnants of hair...dyed..I kid you not..lime-green! A quizzical look from me was followed by a story which involved a stag party, Swedish hair dressers...and with a bellow of laughter, he was off. Next up...Mike those days, he was only but a simple "Doctor"..but again..a hearty welcome and then came the big daddy of the unit, Professor Ken Shaw. I had heard about him and expected someone stern, professorial...but instead met a kind, genteel man who only had good words to say...for those of you have seen Kung Fu Panda...this was Master Shifu!!

And one thing stood out..which I hadn't seen anywhere else...this wasn't just simple colleagues working together...they were friends...they respected each other...and over the years, as I have come back to Portsmouth in different garbs, my wish to be a part of that had only increased. So it came to pass....
And it's been a fantastic ride so far. Yes, there's been a lot of pride in what our department has done, a lot of glory...but nothing would have been possible without the team I have been blessed to work with. Anywhere I look within the department, there have been fantastic individuals..Nurses, Admin staff, Dietitians...the Portsmouth Diabetes team have been blessed and the strength has laid in the sum of our parts. 

Too many people to name them all...but I have listened, I have learnt and continue to be amazed by the dedication towards their craft and the singular minded dedication to help others. Jean, Lisa, Jo, Sarah,Sue, Jeanette Anita, Jane, Mandy...thank you all. Some fantastic folks have left such as Kate,Francesca, some others have joined- but the ethos hasn't changed..we work together, we get things better..together.Every single individual of our department has a place..when the HCSW  in your clinic always makes it a point to ask whether you have had your lunch or want a coffee, the debate whether you have to go into a pitched battle with Trust management about their "hours" isn't a debate at all...its a given. So thank you Jan and Geraldine for making sure the physician is  not forgetting the mantra of heal thyself. And then we have an administrative team..which to me is the perfect example of how folks in the background make a team tick. The Bradley Wiggins of the world may win the accolades..but that wouldn't happen without the physios, the trainers, the dietitians behind different to us either.
So there you go. I don't say these enough...and my gruff nature perhaps doesn't portray that either. But I do appreciate, I do believe..and foremost I am thankful to have been given the chance to be part of this team. Ladies and gentlemen, it has been and continues to be a privilege.Humility doesn't come naturally..but once in a while, when I can let the swagger rest...all has been achieved because of the support I get from you all.

Tomorrow brings Year 5..and with it new challenges. Anything to regret? None whatsoever. You do what you do...and mulling over the possibilities of failure or regret is not what I do. I have made friends, lost few..but today is not about the negativity, not about remembering a minority of four who owed a lot, but forgot everything conveniently...Partha Kar neither forgives nor forgets ...however today is about the good is about thanking the folks with whom I work.

Finally...the people for whom I do all this. Every single battle I have picked up..whether it be with PCTs, Hospital managers, HR personnel.. has been for only one reason...the desire to make sure  patients are not compromised. Much more to do- but it gives me great pleasure to fight these battles..knowing its for the right reason, for the right cause. Someone recently asked me what being a clinical director meant..whether I worried about my reputation. The answer has been and will always been the same..being a "Manager" does not mean compromising your colleagues...and becoming unpopular in a bid to improve patient care is am occupational hazard I am willing to take- and in fact do so regularly. Challenges lie ahead..clearly we need to get our local amputation rate sorted, better care for our Type 1 patients...but have faith...I am trying..and we will get there.
Recently I watched the new Disney movie called "Brave" the end,princess Merida says "Some say fate is beyond our command, but I know better. Our destiny is within us. You just have to be brave enough to see it". It helped evoke a smile...and you know couldn't be more true. 

Bring on Year Five. The first four years have been good...but warm up time is over. It's time to play..if you fancy standing in my way...go on...I dare you.. :-)

Wednesday, August 8, 2012

Olympics: Black or White

The country is awash, awash with a sense of euphoria....the feel good factor is all upon us...and boy didn't this country need it. Banking issues, NHS in strife, phone hacking name it...and everyday the doom mongers were having a field day. Every single day, the news was only about disaster and pestilence...the 4 horsemen of the apocalypse were here...despair ruled supreme. Drill it down to the healthcare system and no different...there was no money, Newsnight was about doctors squabbling amongst each other, the reforms, the pensions, the poor care....doom and gloom....and then...suddenly, just like happened. The Olympics was here...

The media in the initial stages would have none of it though...the first few Golds..and some wit on TV suggested we all break out in renditions of "Always look at the bright side of life"...evidently this is British humour..I don't know...just sounded like cynicism to me. Even the opening unmitigated success in the eyes of the world came under the scanner. An elected MP chirped it was multicultural crap..the Daily Mail ran an online article challenging that multicultural families didn't exist. On the other hand my kids rolled over in laughter watching Mr.Bean and my inner geek freaked out when Bond and the Queen met each other. A good opening ceremony? heck it was awesome...and the seeds were sown...the cynics were outnumbered with the first wave of positivity. Sky TV still ran features as to how London would collapse under the stress and strain of all the folks arriving, how the Immigration system would go into melt down...there was some sort of perverse enjoyment in looking for faults....and then the messages started coming back from the folks going to the big smoke. It was smooth, the volunteers were amazing, the mood was buoyant..and the wave of positivity steadily but surely gained momentum.In between, some dimwit took a pop at young Dailey, secure behind his PC or IPhone at home...allegedly unaware his dad had passed away. Kids 18, lost his biggest pillar of strength and still stood up to represent his country...when his diving partner got it wrong, in an interview, the boy became a man in front of our eyes when he said they were a team...they won or lost..together. Still, it rankled that someone had thought otherwise....the lingering remnants of negativity smouldered. Social media had chosen to show it's darker underbelly.

And then the ladies showed the way. First gold from the rowers...and voila, the floodgates opened. The determination to win shone through all, rowers apologised for coming second...and you suddenly stood back and thought...I have never experienced anything like this....the goosebumps were there..and nothing more than on Super Saturday. In a flash, Team GB represented what modern Britain aspires to be...when the whole of Britain egged on a mixed race woman and then a Somalian Immigrant to win...when the county perhaps, finally, embraced all those diverse people who have made modern Britain. There in the studio was Aamir Khan, there was Denise Thomson..and there was no distinction between them and Jonathan Edwards or Chris Hoy. They were British, they were champions..and as the song didn't  matter if you were black or white.

And that to me has been the biggest achievement of the Olympics..taking on publicly the naysayers and the doom mongers who profess that immigrants make this country worse, that Muslims are to be treated with suspicion...picking away at a festering wound, somehow revelling in the chaos and anarchy.
I have many a times been asked this question...has colour or my race been a bar to my career or life in this country? And it always has bothered me. It's not because of whether it's been a barrier, but because of the belief that it could be. And that is the legacy of papers such as the Daily Mail...somehow they have created the belief that such issues are still relevant, still rife and perhaps even acceptable. Are there cases of bias based on colour? I am sure there is, and much more needs to e done...but the prevalence is no where near professed or believed. Britain has been nothing but good to me. If I had faced bias based on my colour,let me put this simply..there is no way I would have got to to where I have in my career so far. When I have used that answer to folks who have asked me the "colour" question, the reply has been...but you are have the gift of the gab..and you can unlock doors. Well, thank you for that...but even for a second, if I accept all those, let's give you one more bit of factoid. There are around 15 folks in this country who I trained with in Calcutta...their present status? Either a Consultant or GP..ergo at the top of their career. Languishing in back water hospitals, doing rubbish jobs? I don't know but hospitals such as Imperial College or Kings College or titles such as Consultant surgeon or Consultant Orthopaedics sounds all quite good to me.And nope, they aren't all "smooth talking, long haired smart-asses"..on the contrary, they are far more traditional but have got to where they are on sheer dent of quality.

And that, my friends, is reality. The vast majority in this country actually don't care about all these issues...they look beyond their skin colour and make friendships, work as colleagues or whatever. They are not "tolerant" as there is nothing to "tolerate"'s a demeaning word in it's own right...equality is based on mind sets...nothing to do with tolerance. There will always be people like Aiden Burley who feel organising Nazi stag parties, or demonstrating his stunning wit on Twitter are signs of maturity. Beyond that, he could also have been misunderstood and could be a lovely man who happens to have many "colours people as friends". Frankly I don't know...and honestly, I don't care either. I am not here to change anyone's beliefs and if anyone believes that their skin colour gives them some sort of superiority or otherwise, then they are welcome to their beliefs. It's a free world..everyone's entitled to their my mind and experience, they form a tiny minority who are encouraged on by the attention given.

And that's what the Olympics have provided for me. The euphoria will surely settle and after the weekend, there will be that hollow feeling..and maybe the negativity the media so likes to pervade will seep it's way back. I sincerely hope not...but even if that does happen...for 2 weeks, it didn't exist...for 2 weeks a nation stood together and admired their heroes and heroines for who they are, not from where they came, not who their parents are. And frankly you couldn't have scripted a better was like an alternative Daily Mail Universe....a Black Muslim Immigrant taught us the "Mobot", a mixed race girl dazzled us with her smile....and we pumped our fists with as much intensity for Queen Vic as we did for Jess. Heck, even ginger haired folks who have been the target of jokes had their hero in Greg Rutherford. They were Brits...and were loved by all.

You couldn't have asked for a better advert of to all those involved, Seb Coe, Becks...thank you for bringing the Olympics to London. Thank you for proving all the doubters wrong. Thank you for a fabulous party...I have loved it....and it didn't  matter  if you were black or white.

Wednesday, August 1, 2012

A Wonderful "Wiggins" Wednesday

So we can now all breathe a sigh of relief…Black Wednesday has come and gone…and phew! Aren’t we lucky another year has passed?!  Damn those newbie doctors…killing all those hapless folks being admitted…shame on the NHS for once again failing the public!
Well, the papers have been all over it…no prizes for guessing that the Daily Mail is right in there, but so is the Telegraph and its interesting how few in the medical community has actually said anything in words of protestations or otherwise. So, is it true? Anecdotally, we all worry about that first week…but is it really true? Whenver we see statistics that criticises us, the first reaction is its either a cock-up or a conspiracy- a phrase I borrow from a speaker and good colleague..It can’t POSSIBLY be true, can it?

So..on to the evidence. It traces back to a study done by Researchers in Imperial College London in 2009 entitled: “Early In-Hospital Mortality following Trainee Doctors’ First Day at Work”. They reviewed NHS hospital statistics from 175 hospitals over the period 2000 to 2008; comparing admissions from last week of July and the 1st week of August.
All patients were followed up for a week- and taking all variations into account, there was a 6% increase in the first week of August compared to the last week of July. The 2009 study however did not include a breakdown of each patient death. As such, it gives no indication of the cause of each death and is impossible to see whether this was due to the error of a junior doctor.

The study also acknowledged that it could not ensure that the only difference between the two cohorts was the presence or absence of new medical graduates. There were other factors, such as the severity of the ailment or disease, which were not adjusted- and in fact the researchers themselves at no point blamed new junior doctors for the increase in death rates. But hey, has that stopped anyone from pointing the fingers at the newbies? Nope..not a jot.
The evidence is there- so let’s not rail against it…but could it be because the new folks lack the support?

“Killing season”- screamed a paper- and it made me wince. I have been a junior doctor and no, unlike some of my Consultants, who allegedly used to come in at 5 am every day morning to “clean the wards”, did a 1:1 shift, worked 140 hours / week etc etc (anyone ever heard the phrase “In my days?” )…I probably worked more hours than now per week- but with exactly the same intensity and passion as the present lot do. I have been a Consultant now for close to 4 years…and have I met junior doctors who are slackers or look on this work just as a “job”? Of course I have. Are they any more in numbers than what I had around me when I was a junior doctor? Not in the slightest. Do these guys have the same inclination to learn? Yes. It’s not their fault that the working hours prevent them from attending teaching. Here is an example. Our junior doctors are not allowed to stay after a night shift because it would breach European Working Time Directive. It used to be one of the best times that you on earth are you supposed to know what you did in the middle of the night was right or wrong? But no,,,evidently the portals to Hell will be opened  and the undead shall inherit the earth evidently (or something like that) they have to leave. Would the juniors love to stay back even for half an hour and learn? You betcha. Are they allowed? Don’t be silly.

When I started as a baby doctor, I met the most amazing guy ever. His name was Azman Ibrahim …he was only a Senior House Officer…just 1 grade above me…but boy, wasn’t he always there for his juniors. I still remember a particularly hard day- when every single time I had tried to draw blood, I had failed. It was busy, I felt like a failure…and this guy, in the middle of everything, brought me a cup of coffee, sat me down and said he would stand with me for the next set of bloods to be done. It took him 2 minutes…and I felt like a million bucks. And a lesson was drilled into me..never, ever abandon your juniors. Go that extra bit, they will give you much more than 100% when the crunch comes. These fresh faced folks need support- not start their career with the press labeling their start day as “Black Wednesday”. What a load of rubbish..and how demoralizing can it possibly be? An evidence base which could have been as much the fault of the seniors…but nope, its all the fault of the juniors, isn’t it? Well, no it isn’t. Its maybe our issue that we haven’t made the provision in our job plans for those initial weeks of those juniors lives to stand next to them, sometimes just put an arm around the shoulder and say “well done”..a little word of encouragement which can go such a long, long way. How many of us as Consultants have planned to make sure as a team we do something different to make sure there is extra support around at this time of the year? If we know mortality rate is worse, then the collective responsibility is ours to solve it, not shrug our shoulders and wonder how “junior doctor standards are dropping”.

I have had 2 junior doctors shadow our team over the last week or so, bright eyed, enthusiastic and if anyone tells me they are not scared, please, in McEnroe style, let me holler back..”You CANNOT be serious!”. Any evidence to the contrary, believe me, is just bravado. That is what we doctors do…if you don’t know something, put a brave face on…worries are for “wusses”…but no, its natural to be worried, natural to be afraid…I would be concerned if they weren’t. We have all been there, all walked those long corridors…and as Consultants, senior staff, folks who have spent those lonely nights fretting about the patient whose care I handled…sometimes you just want someone to say..It’s ok…you are doing fine. So for those who have started today in a new job, those who have just started…look ahead, take a deep breath and get back into the thick of things. It’s not a Black Wednesday. Its the day when you begin a life where you help others. It’s an amazing day..this day, should always be in your life known as the Wonderful Wednesday…or for those who started on the 1st August 2012…it will always be the Wonderful "Wiggins" Wednesday, a day of positivity and happiness.

Ladies and gentlemen, welcome to the NHS and may you all do fantastically well in a career you have chosen to help another human being. There is nothing, absolutely nothing negative about that. Amen.