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Issue 127 Spring 2018

Endocrinologist > Spring 2018 > Opinion

Six impossible things before breakfast: bringing endocrine sensibility to acute medicine

Tony Coll | Opinion

Due to the unique and puzzling intricacies of the junior doctor contract, whilst I was on the wards in the latter half of December, the rota adopted ‘advent tendencies’, with each day revealing a new team to share the seasonal cheer on the ward.

Alice and the White Queen, from Through the Looking-Glass and What Alice Found There. Illustration by John Tenniel (Public Domain)

Alice and the White Queen, from Through the Looking-Glass and What Alice Found There. Illustration by John Tenniel (Public Domain)

Against the odds, this was a sociable and heartening experience, driven almost entirely by the boundless enthusiasm and energy of the younger doctors who still fill our hospitals. Smiling, even-tempered, tireless, they even offered me chocolate when I sighed too heavily at troubling blood tests and X-rays.

We had bonded and spent time working hard in a febrile environment, so towards the end of the day I did my ‘Let’s-ask-about-future-careers’ routine.

‘So have you ever thought about training/specialising in diabetes and endocrinology when you finish core training? You should think about it – you are bright/energetic/personable/capable.’

Awkward silence, shoe gazing, more chocolate proffered.

Something I said? Well, the responses varied…

‘You never seem to get anyone better – they just keep coming back.’

‘I have no idea what you really do as I’ve never been to your clinic.’

‘Don’t you get fed up just helping out specialties who do all the interesting stuff?’

‘Your SpRs [specialist registrars] do loads of the general medicine.’

So, how come the youth of today seem to have gone off what I, and others, considered the only sensible choice of career all those years ago?

Regrettably, the sentiments expressed by my junior colleagues are nothing new to many of us, but are these smart young doctors mistaken in their beliefs or just coolly interpreting the evidence presented to them? And are we hearing what they are saying?

There is a wonderful passage in Alice Through the Looking Glass, where Alice cries out in desperation when she is asked to believe the fanciful age of the White Queen.

‘There’s no use trying,’ she said: ‘one can’t believe impossible things.’

‘I daresay you haven’t had much practice,’ said the Queen. ‘When I was your age, I always did it for half-an-hour a day. Why, sometimes I’ve believed as many as six impossible things before breakfast.’

The National Health Service is often fantastic and fantastical in equal measure and, unlike Alice, I think many of us are well versed in rewriting the narrative into whatever it takes to get through the day. However, if we want to change our situation, we have to start believing we can do so. When it comes to training, that means cutting loose of the unhappy current reality and moving to ‘what needs to be’ rather than ‘what is’, and starting to make changes.

Let’s start with the easy ones and, in particular, that hoary chestnut about physicians involved in long term conditions being nothing more than overpaid chroniclers of natural decay. Enough already. We can and do make a difference all the time, enabling people to live their best lives for a long as possible. We do so using an ever-increasing armamentarium of drugs, pens, pumps, meters and sensors, and we provided ambulatory care in endocrine day units for decades before it was re-discovered as a magic cure for overcrowded hospitals. We are not bashful handmaidens, mopping the furrowed brows of those undertaking real work, but have the fortunate position of being able to orchestrate a whole range of multidisciplinary teams. So, how come all of this appears to be happening in a hidden valley behind a waterfall, beyond the currently imagined world of our junior colleagues? You cannot fall in love with something you have never seen. Winter pressure is now routine crisis, and the focus on flow above all else makes time off the wards virtually impossible.

‘To bring that endocrine sensibility to acute medicine, one needs to have been given the opportunity to train in the discipline in the first place.'

When I trained in the starchy white coat days of 6 months of surgery, 6 months of medicine, I still managed to get to departmental educational meetings and talks. Many of us attended clinics as Senior House Officers. Different times need different solutions. If we can have FY1 positions in haematology, intensive care and psychiatry, why not an FY1 in diabetes and endocrinology, based wholly and only in that speciality for 4 months with no acute takes and no general internal medicine (GIM), but based in clinic and being a part of the referral and outreach team?

Finally, there’s the biggest challenge to SpR training (GIM). Many say we are a key link to the front door general team. As a specialty, we are both willing and able to enter the fray here. But to be able to bring that endocrine sensibility to acute medicine, one needs to have been given the opportunity to train in the discipline in the first place, and this cannot happen while being elsewhere for long periods of time.

This is not shirking responsibility, but an essential need to propagate the next generation of endocrinologists. Training requires the time to acquire ‘clinic craft’ as well as ‘ward craft’, perhaps even more so in a discipline like ours, where the bulk of our specialty work is carried out in the outpatient setting. Just as surgeons need operating time, so our trainees need clinic time.

This is not to say that folk should not enjoy a thriving 30-year career, combining acute medicine with outpatient practice, but the training that launches this has to be right in the first place. However appealing it is in the short term, allowing more generic service to continually occupy the space where specialist training needs to be could mean there will be no specialist service at all in the future.

It is our responsibility to make changes now, by being imaginative and not worn down by the current pressures, by developing post-CCT (certificate of completion of training) posts if necessary, so we have the highly skilled diabetologists and endocrinologists of the future.

Tony Coll, Wolfson Diabetes and Endocrine Clinic, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge

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