Wednesday, September 26, 2012

A ninja..and a hero

"Rewarding our health heroes"…that’s what the local newspaper said..or perhaps was the tagline of the awards ceremony. It was an amazingly lovely surprise, when one learnt a few months ago, that I had been nominated by one of my patients, Laura Cleverly who had decided to give me far more credit than I have ever been due. For sure, she is a “changed” person, for sure, she is engaged with her diabetes and is trying her utmost to deal with it, for sure she is a Ninja..the creator of Ninjabetic…but to credit me for that, albeit heartwarming, has always come across as more of a disservice to herself. Its not every day that someone manages to pick themselves up and turn their lives around. To me that shows amazing self belief and a never-say-die spirit, which is only worth applauding and appreciating.

Came the big night and I sauntered in, wearing a suit..continually adjusting my tie. Hate those noose like things….I always thought they affected my coolness…but it was a black tie dinner. Ho Hum..sometimes I suppose you do have to conform! And then the awards ceremony started…we went through a gamut of awards- community team of the year, ward of the year, pharmacy of the year, GP surgery of the year…but what touched a chord was the “Unsung hero” of the year. Someone had nominated the chap who every day religiously made sure the hospital grounds were clear, clear of the cigarette stubs in front of the No Smoking signs of the hospital..that ever present sign that public awareness messages are still not fully successful. But it was nice to see him recognised…and when Fred Dinage, the compere of the evening asked how he felt..his reply was simple but true…”Happy, but just doing my job”…ahhhh the NHS…continues to battle on with significant amounts of hard working, non complaining people topped up with oodles of passion for their jobs and dollops of love. Carry on working folks.

And finally, as if to showcase hierarchy still existed well and truly in the NHS, the hospital doctor award came up right at the end...billed as "the big one"..or maybe it was a sign that doctors..still..inspite of all the negative publicity, still held a special place in the heart of the general population.
Up went the runner-up…and then all I heard was the word Winner…attached to my name. Rest was a blur..remembered walking up on stage (was my tie ok?) and accepting the award. Chatting to Fred…answering his questions with something clever and humorous….but admittedly was a blur. Spoke to the local news Health reporter, Priya Mistry, about what this award meant to me…and it was done.

As I sat down in my chair, it sank in…320 odd Consultants in my Trust and a patient nomination had won me the top prize amongst them. And I felt something I rarely do…a whole lot of humility. Closed my eyes and thanked all those who had stood by me, supported me during these years…my wonderful team with whom I have such a pleasure of working and that silly girl Laura for thinking I even remotely deserved this. So many more challenges in front, so many to cross…the instinct was to say that others deserved it, I had much more to do..and I know for a fact that there are far more hard working Consultants than me in the Trust, far more dedicated….but this I do humbly..accept. 

I never set out to be a Hero…my persona, inherent arrogance, penchant for staying outside the tramlines makes me a perfect fit to be an anti-hero…never a hero.I aint any hero.... But its heartwarming to know that I have helped to change someone’s life..and frankly, not many of us get the opportunity to do so. This isn’t “just a job”..this is my life, my passion..and to be recognised for that is extremely appreciated. Thank you to the Portsmouth News for organising the event and it’s a big tag to live up to. I can’t say that I can help everyone, I cant say I will succeed always..but for sure I will give it one heck of a try. As Groucho Marx said “I intend to live forever, or die trying”. And with ninjas standing by my side, it's going to be one hell of a ride.

Thursday, September 20, 2012

I will miss you

Sometimes life has a funny way of giving you perspective, doesn't it?

10:01 email arrived in my inbox this morning. Still vividly remember the checked it in the hope that it was a spam email. But it wasn't. It said Niru Goenka had passed away. Everything I was planning for the day, everything I was hoping to do, the new battles for nurse hours...just went into suspended animation. I had to read the email again. And again. Please..must be a joke? An inappropriate one? But it wasn't. It still held out the haunting message, still held out the same message which just gave me an awful feeling. Niru Goenka?? He was just a few years older than me..what the heck,,,but it was..alas..true. More messages poured in..and it was true, one of the brightest lights of diabetes care in this country had gone out. Just like that.

I wish I could tell you reams of stories of how we spent nights together drinking, chatting...but I can't. Niru was a friend but not a close one. 2004  was when I first met him..I was the Chair of the Young Diabetologists..and I remember bouncing into this Asian chap, a face full of joy...walking up to me..and saying what a great initiative the YDF was..and if I ever needed any help,"just ask" is what he said. Over the years, I have met Niru multiple times, listened to him speak, read his articles but for one reason, he will always be special to me.

I have always mulled about sharing this with the wider world, wondered whether this was too personal, too dark..but maybe today is the day. 2012 March..a very difficult time for me professionally..and possibly the most I have ever struggled...struggled with losing friends, senior and junior Consultants taking sides over certain issues, feelings of betrayal, anger, being lonely and the more the situation escalated, the more it burnt me. I had enough...and I was ready. Ready to create a new enterprise of "Young Guns"..and there was no one I was ready to listen to. I was Partha Kar..once my mind was made up...I had never gone back...never walked away from an enterprise. To hell with the old codgers, to hell with the ones who had turned their backs...I was going to forge my own path. 30 young guns signed up..all ready to press the button. 

And then one evening my phone rang. It was Niru. A long chat ensued..I vented..I shared my angst...I talked to him about betrayal....I had had enough. And he listened. And at the end he said a lot too..and finished with these words.." The future is ours Partha..why create something else? Lets get our own patches sorted..then we can tell the rest what to do. You know we can do this together.Trust me on this one. Let it go. Put your energy somewhere else". And I don't know why...but I listened to this calm , sensible fella...for the first time, I stood down. And just like that...I was at peace...with myself, peace with everyone else. Niru Goenka had somehow, just with his words, done what so many had failed to do. 

I never knew Niru that well..but I have yet to meet anyone who didn't like him. Universally liked and loved is a clich├ęd term..but for Niru it was so true. A wise head way beyond his years, a gentle soul with a passion to improve diabetes care which burnt through and someone who was dedicated to improving training...he was special. 
I wish I got to know him better. I wish I had the chance to work with him more. I wish so many things...but right now...I wish and hope..that wherever he is, he is at peace. Never got the chance to say it, Nirupam Goenka...but thank you for that evening which meant so much to me, helped me grow a bit more. I am sure the whole diabetes world will miss you...but right now, while writing this blog...I miss you, my friend. Rest well x

Saturday, September 15, 2012

The impossible debate

Its nigh impossible. Actually correct that. Its impossible. Its impossible to anymore have a rational discussion about the NHS. There’s very little room for manouveur..its either, as a tweet from a colleague mentioned, a jewel in the crown, a national heritage, something to be proud of, nothing should be changed..or its absolutely the pits needing a complete overhaul.

The reality,as ever, continues to be somewhere in the middle. It is, have no doubt, a fantastic institution, built on sound principles…but it doesn’t provide high quality care everywhere with the same level. Some of it is down to variation in quality of staff, some of it is down to lack of patient engagement and a lot of is down to finances. A mature adult debate about all those issues seem to be impossible to have and we continue to duck them, continue to be blinded by facts, continue to be sucked into politics with the NHS, as ever, being a lightening rod to attract polarising views and opinions.

A question about variation of quality raises hackles of many…we all feel we work the hardest..but read any patient blog, they are full of as much praise as much as criticism..different staff, different attitudes. But we struggle to raise those issues in public..we struggle to debate them, simply shy away from them, wrapped away in the theme of “we have to work together, we have to go forward together, we must not upset anyone”…to me…that’s a fudge..we “work together” to make patient care better. If there is genuine evidence that someone is not working hard enough, providing poor care consistently, then sweeping them under the carpet is not about “working together”…this isn’t a childrens party where we must get all the kids to play together..this, last time, I checked, was far more serious- and we must be able to debate that.We must be in a position to challenge that and stay true to the core of improving patient care...and if that upsets a few poor performers, so be it. When was the last time you saw Alex Ferguson be afraid of throwing a player out who did not perform well or wasn't part of the team's ambition to be the best?!

What about patient engagement? Now that’s a sacred cow..which we again, struggle to discuss. This is an amazing healthcare system based on a public taxation system and sometimes when you have so much, you tend to forget what benefits they bring. When a patient doesn’t turn up in my clinic and I ask them next time why…a shrug of the shoulder accompanied by " had other things to do, doc" makes me sad. It makes me feel that I could have given that slot to someone who genuinely deserved it and heck there are plenty of them out there. It makes me think of places where I have worked, such as Calcutta, where a patient would sell their belongings to have a chest X ray done, it makes me think of my time in a village in West Bengal where the only drug available for chest pain is paracetamol. We have so much in this country and yet we choose to abuse it, choose to shrug our shoulders. Diabetes UK,the bastion of patient group in diabetes care, has recently shown data mentioning that 60% of patients haven’t hit theor cholesterol targets..accompanied by a statement saying that most GP surgeries though have hit their "targets" which results in payments to surgeries. Sure, thereby opens the debate about the fallacies of performance based payments, sure theres something not right..but what about the patients who don’t take their tablets? What about the group who turn up in clinic and say that “diet isn’t their thing?”. Is it always the healthcare professionals it always about the right information not being passed on..or is it sometimes about an adult patient making a conscious choice not to follow the advice that the decision they have made? Again, a debate about that is impossible to out of the woodworks steps the evangelical patient groups…I have no problems with them..but come on guys…a sensible debate and a bit of reality check too?

And then finally, the biggest of them all...finances. The fact is that there isn't enough space either in the community or in the hospitals for an ever increasingly ageing population with multiple morbidities, a population whose expectation continues to be fuelled by what they read in the papers and doctors in hospitals heading towards specialism with primary care left holding the baby in most cases. Here's an example, Dan Poulter, a new entrant in the Health Ministry team, a doctor himself, recently said that hospitals weren't on the brink of collapse as most hospitals were running to 85% occupancy..and the NHS had enough beds to cope. Well, Dan..I don't care about politics...but...mate, man to man, doctor to doctor, join me on my daily ward rounds, when I am covering the wards, spread over 11 different wards..and if you find one patient, just one, you can discharge quicker than I can, with existing provisions in the community and most importantly safely, I will work for free in the NHS for the next 3 months. Promise. Scouts honour. I am one of the quickest guns as regards discharges go...and on a daily basis, I take a calculated risk..on a daily basis, I inwardly cringe at the pressure I am putting back on my primary care colleague..and then I hear that it isn't about the resources. Lets stay away from politics on this one, shall we?

Come on fellas..come on you folks who understand issues better than me...why not contemplate that we don't have the resources to offer everything at the same level of quality all around with the same money available? Or at the very least have a sensible adult debate about it? But alas, we can't. I keep on hearing words such as inefficiencies, cost savings, productivity, innovation...which at the end of the day sounds more like doing the same thing, perhaps even better...but with the same finances..or less. 

Of course, the majority of professionals are hard working, of course there are patients who miss their appointment because the letter ended at the wrong address..and of course there is wastage in the NHS which can be minimalised...but at some point..after you iron out all of those..there simply just isn't enough to do everything. Or at least, that's my view. Can we at least raise that issue? Can we at least debate that? Can we at the very least raise those topics...touch upon those sacred cows..or do we wait till it's all reached the point of no return? 

Or more worringly...are we not debating those..because we are already there?

Thursday, September 6, 2012

I am special

"Is there any blood anywhere"...drawled the person at the other end of the phone. "Sorry, what blood?"..asked I, an SpR in my second year, 2 am in the morning, slightly puzzled why the Consultant physician on call was asking me about blood when I was trying to discuss a case of meningitis with him. Maybe there was something obvious I had not done?  "I there any blood anywhere"...this time..the voice clearly had a bit more menace, a bit more edge, a bit more growl. Far from the Partha Kar version 2012, I mumbled.."Ermm..not really...why..?". The answer that followed is still imprinted in my mind..." I am a gastroenterologist...don't phone me if there is no blood"..followed by a slam down and the lonely dial tone purring away. I looked at the phone...pretty much mocking me...turned around to see a friendly Emergency department Consultant. My face must have painted a picture, as she, even in the middle of an uber busy department, stopped..and asked me what had happened. I related the incident..she smiled..gave me some much needed advice..and before walking away said 2 things..." You know there's not many generalists left any more...and by the way, your Consultant..he is actually a good doctor..he's just a bit special". The first bit I didn't quite get at that time...(I mean..come on...surely we are all physicians?!)..the second bit was odd as somehow it made the fact that a Consultant didn't support his registrar "all ok".

Fast forward to 8 years later...and the NHS, as we still call it, is struggling. Reports are pouring out suggesting we need more generalists, better trained general practitioners as unfortunately as much as we would like to, the patient coming in through the door rarely has one pathology any more. The "olden days" used to have general medicine clinics, general physicians..the ones who use to "specialise" in having the bigger picture, the ones who could join the dots, the ones who could come up with the clever diagnosis.

And then specialism happened..properly. We all became specialists..doing only a little niche, little else. The Cardiologists left general medicine, no longer were they dual accredited..they only looked at the heart. The dealt with heart failure but if it was due to a pulmonary embolism, it now had to be the Respiratory physicians issue. If by chance, the patient had a minor bleed secondary to the warfarin, they had to be seen by the Gastroenterologists, if, heaven forbid, their blood sugars were high, call the diabetologists....and if they had anything resembling silver hair, it would be a travesty if the elderly physicians weren't looking after them.

So what the heck happened to us as physicians? I take my hats off to Medical Assessment Unit colleagues who still do and understand general medicine but are being reduced to triage doctors due to the incessant pressure of either discharging them or moving them to another speciality. But medicine isn't that easy...not everyone fits nicely into a category, a pre defined speciality, do they? The patient sits and watches while physicians argue and debate abut who they can see, who they cannot...while time ticks by. Consultants face off against each other like big beasts in the Savannah battling over a waterhole...while juniors walk around looking embarrassed, awkward..not sure what to do.

Lets look at the "moral" argument. For once, if we stand back and accept that we are ALL physicians..then maybe it would be easier..but nope, that would be perhaps far too complicated. I have no problems with anyone being a super expert..but that shouldn't translate into one forgetting the reason why they got their degree in medicine. For sure, there is specialist training, for sure no one can "pop a tube down the throat" like you do...but does that preclude you from forgetting how to treat something that doesn't fit into your chosen niche...say...cellulitis?
How about the "money" argument? about this...most physicians  have been trained in their speciality AND general medicine. Did they get paid while they were doing their training? Well, of course...and a tuppence for guessing who paid them to be trained in general medicine along with their speciality. Correct..that would be the taxpayer. So in that case, let me ask this simple question...when someone "not quite in your speciality category" comes under your remit but has a general medical you walk away saying "I am special"..or do you apologise to that patient for wasting their taxes, which were spent on training YOU to learn about general medicine too?

In super hospitals or big regional training centres, absolutely 100% there needs to be super specialists. Don't get me wrong, I don't want a cardio-thoracic surgeon to be dabbling in gall bladder surgery, I don't want the ace pituitary Endocrinologist to be looking at a DVT...I would rather they saw, diagnosed and treated all the tertiary, complicated referrals they have as a centre of excellence. But for District General Hospitals?? give me a break. Be a specialist in your outpatient clinic, be a specialist on the wards too...but for gods sake, don't please say you "don't do anything else". Its dishonest to your own training, its dishonest to the public who have paid for your training. And believe you me, it will help a lot of GPs to know who to ask an opinion on the person who has multiple pathologies rather than make 4 referrals for 1 patient.

I have said this before..and I have no qualms about saying it again...who looks after that old lady with multiple pathologies who doesn't fit into a pre-defined speciality category? The answer isn't "lets play a game of poker to see who blinks first and accepts the patient"...the answer is all of us, as physicians do. The ability to do so is what makes us "special"....Or maybe Chuck Palahniuk, author of novel Fight Club had the right idea..."We are not special. We are not crap or trash, either. We just are. We just are, and what happens just happens". Maybe its time for us to stop taking ourselves so seriously...and just do what we are supposed to do.Now that wouldn't be a bad start, eh?