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?

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