Why I don't like 'trainees'

Professional identity is a matter of pride for most doctors. Medical training is long, hard and demanding. Many are therefore keen on their medical status being clearly identified. Some are unutterably tedious about it; some couldn’t care less. But most will quickly correct you if you get their title wrong.

The details of medical career structure are largely opaque to those outside the profession. To be honest, patients don’t stand a chance. I’m lucky if they even vaguely acknowledge that radiologists are doctors.

For this reason, it should be clear who does what from the name alone. The best professional names are the shortest, preferably one word: ‘Nurse’, ‘Porter’ and so on. The worst have 4 or more words and verge on being ‘non-jobs’. Does anyone really know what a ‘Senior Imaging Support Worker’ does?

You should also be able to distinguish the degree of seniority of the individual from their title. That is, it should be clear if you are speaking to the monkey or the organ grinder.

For decades, the hierarchy of UK medical training was reasonably straightforward. After graduation you became a House Officer, then Senior House Officer (SHO), Registrar, Senior Registrar and Consultant in that order. If you became a general practitioner (GP), you turned left after SHO and became a GP registrar then finally a GP. This was the model in many English-speaking countries. Not the simplest but it was embedded in medical culture and healthcare folk knew who was who.

Once upon a time, you were a House Officer as you practically (if not literally) lived in the hospital. But with the European Working Time Directive and removal of cheap hospital accommodation, this isn’t the case anymore. Similarly, Registrars are no longer are responsible for recording hospital admissions but the term has stuck.

Nowadays we don’t have House Officers, we have Foundation Year One (FY1) doctors. We don’t have SHOs, we have Foundation Year Two doctors, Core Medical Trainees, Basic Surgical Trainees, Clinical Fellows and a whole mishmash of intermediate grades. We do have Registrars but in 1996 they became Specialist Registrars (SpRs) before morphing in 2007 to Speciality Registrars (oddly abbreviated to ‘StR’ or just ‘ST’).

UK radiologists are uncomplicated folk and their career structure is simple. It is a model that has worked well for the last 18 years and we’ve no desire to change it. You apply after a few years as a junior doctor, do 5 years as a ‘radiology registrar’, pass the FRCR diploma and then become a consultant. Simple.

Never too old to learn a new trick

However, for the rest of the hospital, there is an unholy maelstrom of medical monikers. Endless reforms of UK medical post-graduate education in the last 18 years have resulted in utter confusion.

I should say outright that I’m not afraid of change. If something is broken, by all means fix it. If something is out-dated, please do update it. Just try to not to make things worse whilst attempting to fix it. And for goodness sake please don’t uproot the trees you’ve just planted.

So what is my evidence that the naming system is broken? Well, 7 years after the grade was officially abolished, why do junior doctors routinely introduce themselves as ‘SHOs’? And have ‘SHO’ on their name badge?

This isn’t the worst bit at all. It is the nefarious practice of using the word ‘trainee’ to describe a post-graduate doctor. I don’t think it is a deliberately malicious trend. Things like this are generally cock-ups rather than conspiracies. But I contend ‘trainee’ is a rubbish word to describe our registrars.

Firstly, ‘trainee’ is confusing to staff and patients. It doesn’t give the right impression. When I summon a mental image of a ‘trainee’, I am thinking of a pimply teenager, just out of secondary education, wearing a temporary badge and an ill-fitting uniform. To me, ‘trainee’ is below ‘student’ in the pecking order. At least ‘student’ implies scholastic effort, rather than some mickey mouse vocational apprenticeship.

Secondly, ‘trainee’ belittles their status. It doesn’t do them justice. They are experienced doctors who are often working with large degrees of autonomy. When I became a consultant, I had 15 years of medical experience and more letters after my name than in it. Seriously. I’m not unusual in that respect.

Lastly, education differs from training. Training is a technical task, preparation for a specific job. Education is much more than that; education broadly prepares individuals for future complexity. We train horses and dogs; we educate doctors.

Having stated the above, I’ll no doubt get people tut-tutting and alleging pedantry over semantics. However, I feel passionately about treating our registrars well. They deserve respect and the best education we can give them. And who knows? As future consultant colleagues they just could well be looking after you and your loved ones in the future.

CARAFE

--> It was just an ordinary ultrasound list but it provided me with an extraordinary experience. As per usual I arranged a few inpatients as ‘extras’ on the end of a morning outpatient list. I don’t think working through a notional lunch break is unusual; most radiologists that I know inadvertently use their PACS keyboard as a plate for their sandwich crumbs. However, one particular scan really got me thinking. The request didn’t sound urgent or even remotely serious – “Abnormal LFTs” in an 80-something year old. However, she was an inpatient who had been waiting a day or so; I feel uncomfortable just leaving such scan requests.

The porter and accompanying nurse slowly reversed her hospital bed into the room. In the dim light, I thought the bed was empty. Hidden amidst sheets and an oversized hospital gown was a curled-up and distinctly cachectic elderly woman. I boomed “Good morning!” expectantly, giving my best smile so as to break the ice. Nothing. Not even a grunt or glance. The nurse then mentioned that the lady had advanced dementia: unable to communicate, immobile and totally dependent on others.

Mentally shrugging, I lapsed into autopilot and started to scan. I managed a few glimpses of normal liver then suddenly thought, “What the hell am I doing?” This was a pointless exercise: nothing I found would change her management. What this lady needed was compassionate nursing care, palliation of symptoms and nothing more. Radiology and the other investigative arts had no role in her care.

As is my wont, I reflected on this particular case at length. I have been struck by a general increase in investigation of those in extreme old age. Scanning someone over 100 years old used to be a distinct novelty but now barely raises an eyebrow. Not only are there more old people than ever before but populations are greying. In 2030, 1 in 12 of the UK’s population will be over 80. But I think there is more to it than that.

Perhaps part of this rise in investigation of old folk is a correction of outdated and paternalistic ageism. A medical generation ago attitudes were different, disease in old age was treated symptomatically and was minimally investigated, if at all. It wasn’t long ago that hypertension in those over 80 wasn’t treated and pneumonia was ‘an old man’s friend’. Although, to be honest, both examples are not quite as black and white as they seem.

Anyway, the point is that there is a fine line between unacceptable ageism and over-investigation. Chronological age should never be an absolute contraindication - truly fit and healthy octogenarians are now commonplace. Many welcome investigation of their symptoms. However, most of our referrers have a rather rosy picture of the level of functioning of their elderly patients. I see a great number of requests that start “Previously fit and well …” but omit minor details such as Grade IV heart failure, lower limb amputation or dense hemiplegia. Often there is a capricious mix of all three with a light dusting of dementia on top.

Dementia is an ever-present undercurrent in old age. It has a 1 in 8 prevalence over the age of 80 but is downplayed, even in medical circles. Probably due to the stigma, it isn’t a welcome diagnosis for anyone. ‘Bit muddled’ is moderate dementia dressed up; “pleasantly confused” is, in reality, severe dementia. But I deliberately single out dementia in old age for reasons other than its increasing incidence:

• Firstly, dementia is progressive with no prospect of a cure. Folk with dementia have a worse prognosis than many cancers – average survival from onset is just over 4 years. Aggressive and burdensome investigation is therefore just plain wrong for this group of people: the antithesis of good medical care.
• Secondly, the lack of mental faculty that accompanies dementia makes such patients vulnerable. They cannot easily consent to (or refuse) investigations or treatment. This medical duty of care in vulnerable adults should not be shrugged off.
• Thirdly, old folk with dementia don’t do well in radiology departments. Just wheeling them into the department makes them distressed. They certainly don’t like CT scanners and don’t even think about putting them anywhere near an MRI scanner. Oh and don’t sedate them either. Paradoxical agitation is a very real phenomenon and no fun for anyone.

The frail elderly (with or without dementia) need a different approach. The goals of care are predominantly palliative – improving quality of life, maintaining function and maximising comfort. And whilst radiological tests are getting gradually less barbaric, they aren’t all that pleasant and certainly neither risk- nor pain-free. If you’ve ever had to drink Gastrografin or had a scan whilst unwell, you’ll understand. Therefore the approach to radiological investigation in this group is a balance. On one hand, you don’t want to under-investigate symptoms and risk missing treatable disease. On the other hand, you don’t want to over-investigate and cause needless distress and suffering.

Investigating elderly people therefore needs careful thought and discussion. We need to resurrect the radiological motto of ‘how it this going to change your management?’ and thereby be bold when rejecting tenuous indications for futile scans. Invitations to join clinicians on investigational fishing trips should be politely declined. We need to think about ‘light touch’ investigation: doing the minimum number of investigations that are as minimally invasive as possible but aimed at providing maximum symptomatic benefit. This could be termed ‘palliative radiology’, quite different to our normal curative investigational paradigm.

We need to nudge the investigational pendulum back into proper alignment. Unnecessarily numerous or invasive tests of the elderly is Bad Medicine; tantamount to abuse. Hence I propose you join my new campaign. I’ve even invented an acronym “CARAFE – Campaign Against Radiological Abuse of the Frail Elderly”.

How to buy a scanner

Scanners and radiologists exist in an uneasy symbiosis; one cannot function without the other. Scanners and radiologists are expensive; both need to be chosen carefully. Scanners and radiologists can malfunction; an engineer with the right spanner can usually sort one of them out. Scanners and radiologists eventually wear out; both are needlessly difficult to replace.

In an ideal world, if the old scanner was any good you’d simply ring up the company and order exactly the same, but more modern. Like the family that buys the same brand of car each time. There is a lot to be said for this approach. You know what you are getting, you develop a close relationship with the local dealers and you generally get a good price. It generally works well.

Better the devil you know?

However, it won’t do in the modern NHS. Acquisition of new kit has to be transparent, fair and completely above board. Choosing between different manufacturers has to be for better reasons than “we always buy one of those”, “we liked the colour” or “the MD is a family friend”. And to be honest, if you are responsible for spending several hundred thousand pounds of taxpayers’ money then it is only right and fair that we procure diligently.

In recent years, my hospital has bought more than its fair share of scanners. We have a new hospital building than opens in a few months that is equipped with entirely new scanners. And, yes, I admit that there is an element of joy in getting new kit. The inner geek admires its scanning prowess, the inner aesthete admires its sleek construction and the inner child revels in having new toys.

But the procurement of new scanner isn’t all cakes and ale: it is like pregnancy. It is a months long process (and feels much longer), you can feel physically sick at times, you worry about the new baby and are never quite relaxed until it is delivered. Only to find it is a lot more complicated than you expected.

So here are a few hints and tips to help you through this difficult time:

• Set a realistic timescale. Allow plenty of time to evaluate and chose your new scanner. On no account rush this because of extrinsic factors. Just because the money has to be “spent by the end of the financial year” is irrelevant. 

• Construct an objective rating scale. This may match the features of the preferred scanner but it is wise not to produce a facsimile of it’s operating spec. 

• Don’t believe the brochure. Of course they’ll show the best images produced by that scanner. You have to go and see it in action.

• Watch out for flattery and bribery. The more the beautiful rep laughs at your jokes and the more expensive the meal you are treated to, the less you should buy their scanner. A good scanner should sell itself.

• Avoid technological innovation. It is very tempting to look at a new feature as inherently better. Innovation is a value-laden term: ‘early adopters’ are groovy and cutting-edge. Or at least that is what the scanner sales team wants you to believe. Be a “late adopter”; stick to proven and mature technology.

• Beware bells and whistles. The assumption is that the more features a scanner has, the better it will work. In reality, 95% of scanner use is pressing no more than 5 different buttons. Complex stuff gets ignored or often just doesn’t work.

At the end this long process of visits and evaluations, the manufacturers will make formal offers which is when it gets quite exciting. After this lengthy period of techo-lusting, the decision point is nigh. At which point, your manager secretly throws all the evaluation out of the window and buys the cheapest scanner.