Calculating risk in upper GI bleeding – which score should you use?

It’s been far too long since I wrote anything. There always seems to be a valid reason not to write, a reason to procrastinate. But the more I procrastinate, the harder it seems to be to start. Ideas gather, but can overwhelm, to the extent that it seems pointless even to try.

What to write about? Trump? Brexit? The general election? The NHS? Shape of Training? Junior doctor morale? Gastroenterology research? Where do you start with so much going on?

Well, I am going to try to write regularly, once a fortnight at least, and try to keep it brief. I’m also going to start writing a brief note about gastro papers that I think are of interest to a wider medical audience, partly because I enjoy reading other people’s blog articles on the literature, and partly to cement my own thinking about what I read.

And so we start.

Upper GI bleeding is a common presentation to the medical take. It has a significant mortality, in the region of 10%, and its management represents a significant cost to health services. Patients generally require an endoscopy, although whether that needs to be as an inpatient or outpatient, and how urgently that endoscopy needs to happen, are up for debate.

Medics love a scoring system. GI bleeding has several, designed to predict mortality, re-bleeding or the need for endoscopic therapy, the Rockall score and the Glasgow-Blatchford score (GBS) being the most commonly used in the UK. There are a couple of others, including AIMS65 and the exotically named Progetto Nazionale Emorragia Digestive (PNED) score. The original Rockall score and the PNED score incorporate endoscopic criteria, whilst the pre-endoscopy Rockall, GBS and AIMS65 use clinical, haemodynamic and blood test parameters.

From my perspective, there are 3 questions that I would like a scoring system to answer:

  1. Which patients can safely be discharged for outpatient endoscopy?
  2. Which patients are at high risk of needing endoscopic therapy, and may therefore may benefit from an early endoscopy?
  3. Which patients are likely to die, and would may therefore benefit from early endoscopy and critical care involvement?

There is some evidence for question 1. Patients with a Glasgow-Blatchford score of 0 are highly unlikely to need endoscopic therapy, and can be safely managed as outpatients. However only about 5-10% of patients have a GBS of 0, so this does not take much pressure off hospital inpatient services. Whilst small studies have suggested that a GBS of 1 or 2 may also be safe to manage in an ambulatory manner, this has not been robust enough evidence to change practice in many institutions.

This prospective, international study, from Adrian Stanley in Glasgow, published in the BMJ a couple of months ago, looked at 3012 consecutive patients presenting with upper GI bleeding at 6 hospitals in the US, UK, Europe, Asia and New Zealand. Follow-up data were good, with 95% follow-up at 30 days. I won’t go into the patient characteristics in detail, but the age, co-morbidities, presenting haemodynamic status, endoscopic diagnoses and re-bleed rates all seemed to be fairly representative of UK practice. Mortality at 30 days was a touch lower than most previously published studies at 7%. They collected all required data and compared the 4 scoring systems for 3 outcomes: intervention or mortality (a composite of transfusion, endoscopic, radiological or surgical therapy or death), endoscopic treatment alone, and mortality alone.

For the first outcome of intervention or mortality, the GBS outperformed all other tests with an AUROC score of 0.86. They determined the best threshold for this outcome was a GBS of either 0 or 1, which had a sensitivity of 98.6% for this, with a PPV of 96.6%. The numbers in this group were good also, 564 patients (19.2%), of whom 1.8% required transfusion, 1.4% required endoscopic therapy and 0.4% died at 30 days. This provides solid evidence that discharging patients with a GBS of 0 or 1 to ambulatory endoscopy is low risk, and certainly comparable to other discharge criteria for ambulatory management such as the CURB65 for community acquired pneumonia.

But what about the other 2 outcomes, of predicting endoscopic therapy or mortality? Unfortunately the scores performed much less well.

It would be fantastic to have a good score to predict endoscopic therapy – we could then aim to scope high-risk patients within maybe 6-12 hours as this would be a therapeutic intervention, and scope those at low-risk in 24-36 hours as a diagnostic test. We don’t want to scope everyone immediately as urgent, out of hours endoscopy is much more costly (and possibly of lower quality, although I have seen no evidence of this), so we want to maximise the value if we are using these resources. The GBS was the best performing test, with an AUROC of 0.75, however with an optimum cut-off for the GBS of 7+, this labelled 50% of patients as high-risk, of whom only 31% actually required therapy. Given that the overall cohort had a 19% rate of endoscopic therapy, this is not a sufficiently discriminatory test to allow triage for rapid endoscopy in my opinion.

The scores for mortality performed even less well. The GBS performed poorly for mortality, with AIMS65 and PNED a little better than the Rockall, however the PPV for mortality for AIMS65 was 18% and for PNED was 14%, and labelled 27% and 38% as high risk respectively. Again, it is hard to see how this can be used in clinical practice to commit critical care resources given its poor discriminatory ability.

Overall, this is a great study of practical use and the International Gastrointestinal Bleeding Consortium should be congratulated on putting together a well-designed study which answers real clinical questions. We can discharge around a fifth of GI bleeds to safe ambulatory care and hospitals need to establish these pathways in light of this evidence. However, we still lack tools to predict need for endoscopic intervention and mortality, and, to my mind, this work shows that these scores cannot be used to replace clinical judgement in who will benefit from early endoscopy or critical care involvement.


The vilification of Brexiters – nasty, pointless and divisive 


So we are leaving Europe. The cataclysm has come to pass and we are still reeling, with aftershocks coming thick and fast.

Before I start I must tell you that I voted to remain. For me this was not a straightforward decision, unlike so many people on social media and in the public eye for whom it was apparently a ‘no-brainer’. I spent a great deal of time weighing up my concerns about Europe (the undemocratic nature of the Commission and legislation proposals, the increasing power of European Courts, the expansion project of the EU towards Eastern Europe and nations with greatly different GDPs, standards of living and political attitudes, the possibility of a European military force under central control) with the many benefits of European membership that we have enjoyed (economic union, free trade, free movement of labour and capital, scientific and medical collaboration, working conditions legislation, etc.) I debated my views with colleagues, family and friends. Overall I decided it was best to Remain, and voted to do so.

But 17,410,742 people voted the other way. The die is cast – we are leaving Europe after a historic and democratic referendum. There is uncertainty and turmoil, and this is not what I had voted for, but now we have an opportunity to make the best of the situation. To leave the European Union calmly, to reform our legislation to remove the worst of EU law, to forge new partnerships with European nations and the EU to our mutual benefit whilst we form links with the rest of the world. There is much work to be done, and a huge opportunity to make Britain the best that it can be.

But this is not where the debate is on social media currently. Indeed there seems to be no debate at all. There is only a violent, nasty vitriol, directed against those who voted to Leave. Now I am a doctor and a scientist, with interests in education and history and politics, so I follow and read the output from a relatively genteel, rational and scientific group. Normally I read lots of polite debate, interspersed with a few cute kitten photos. But a considerable number of these people are not just writing about their disappointment that we are leaving, but are attacking the people of this country who disagreed with them and won.


I have seen subtle attacks such as scatter plots showing how areas of the country with less affluent and less educated people voted to leave, whilst rich, educated people voted to remain. How is this relevant? The vote is complete; the only reason for this kind of analysis is to undermine the vote with an argument that the votes of the poor and less educated are ‘less valuable’ than those of the rich and well educated. I have seen analyses of Google searches – people googled ‘what is the EU’ on the night of the vote – which some claim shows Brexiters did not understand the issues. Quite apart from the fact that these people could have been Remainers, again this boils down to the idea that some people’s votes are worth more than others.

I have seen open attacks too – a thread on one site about how there should be an exam to be able to vote. Journalists finding people who apparently voted Leave to reject the establishment and the current politics (but not searching out those Remainers who will have given their decision as little thought). Articles suggesting that this makes us a ‘cruel’ country (all Leavers are cruel, right?) Anecdotes of people who voted Leave but didn’t really want to Leave (as if only one side of the political spectrum has the monopoly on thoughtlessness!) And comment after comment that this was not fair or democratic – that we should not have been allowed a referendum as people “can’t be trusted” to know what’s good for them, or that we should have another referendum as some people might have voted for the wrong side last time! There have also been a plethora of ageist comments stating that it is unfair that older people voted for Leaving and young people voted for Remaining, which is apparently unfair as young people are ‘the future’ (clearly all older people are about to drop dead and have no right to a self-determined future – see Michael Rosen’s excellent tongue-in-cheek piece yesterday).


Now, I can deal with the ‘sore loser’ comments (most of which these are) but let’s be clear, if it was the old who had voted for Remain and the young for leave, we would be listening to comments about how ‘experienced’ and ‘world-wise’ people had made the right decision and the foolish youngsters had been tricked by Gove and Johnson. These are pointless and rather mean arguments. The million people who have petitioned for a second referendum are also rather missing the point – unless more than 17,410,742 people sign it their protest is meaningless. And if the result had been as close the other way, these same people wouldn’t have been complaining.

What I have real difficulty with now is the anti-democratic argument which suggests that the views of Leavers are less valuable than Remainers. That the city-dwelling, centrist, rich, well educated, young population who mainly voted Remain are worth more than the views of the rest of this country. That (to paraphrase a rather good book) whilst all people are equal, some people’s votes and opinions are worth more than others. It was my dislike of some of the anti-democratic elements of the EU that made my decision in this referendum so hard, and it concerns me that so many in the country seem to think that the views of the population are worth less than that of the elite, the political class and the technocrats. When people start saying that elections and democracy cannot be trusted, and that we should just follow the advice of our betters – well that really is frightening.

So let’s all move on. Leave have won the referendum, but there is much to debate about what our country will stand for and how we will interact with the world beyond our new borders. We who voted Remain need to take time to understand the views of the other half of the country and the issues that made them vote to leave. We who voted Remain must engage in the debate to shape our future, rather than fight pointlessly against the decision, or further divide our society through insulting Brexiters.

To all fellow Remainers: let’s take our defeat on the chin, and get on with life.


Shape of Training Review – how fast can you train a gastroenterologist?

I intended to write about Professor David Greenaway‘s Shape of Training Review a year ago when I first had a chance to read it and reflect on the implications for training and the future of the NHS, but the start of family life and more time spent on SCBU than I would have cared for rather derailed that plan. At the time I led a discussion at my hospital journal club about the review and it’s implications which flagged up all sorts of interesting and worrying concerns, but I have rather missed the boat on that discussion and there are now a number of very sensible comments, reviews and official responses to the shape of training review including those from Royal Colleges, trainee organisations and the BMA which cover most of the concerns that I would have mentioned.

So instead of discussing the review’s broad aims and my concerns about such widespread structural reform of postgraduate medical training, I wanted to focus on something much more practical – can you train a consultant within the proposed structure?

Now I want to get to the nitty-gritty of the problem, so I want to avoid too many broad statements and platitudes and focus in a very practical way on what you are going to teach this would-be ‘CST’ consultant and how long it would take. As such I am going to focus on what I know: general medicine and gastroenterology. I will not focus on surgery and paediatrics and I will not focus on the details of the other medical specialities. I want to see if you can train a general physician with a broad-based specialist knowledge of gastroenterology in the proposed structure.

For non-medics the current route to a gastroenterologist/general medicine consultant is as follows:

  • 2 years of foundation training (4 month placements in medicine and surgery and a selection of GP, A&E, paediatrics, etc)
  • 2 years of core medical training (4-6 month placements in a range of general medical specialities, generally all on a general medical on-call rota as the medical SHO)
  • 5 years of gastroenterology training (5 one-year placements in different hospitals with generally a 1:8 general medicine on-call rota as the medical registrar)

Most will do at least a 1-year fellowship in a subspecialty area of gastroenterology (advanced endoscopy, inflammatory bowel disease, liver disease, nutrition) and possibly as many as half will do a period of research for an MD or PhD.

So an average progression would be 8 years of training post foundation programme, with the minimum as 7 and many doing 10 years if time in research is included.

For those who have not read the Shape of Training review the proposed scheme would be as follows:

  • 2 years of foundation training (4 month placements in medicine and surgery and a selection of GP, A&E, paeds, O&G, etc)
  • 4-6 years of broad-based specialty training focusing on what the report calls ‘patient care themes’

On the face of it this is shorter and simpler. However, it is all a little more messy when you look under the metaphorical bonnet of the ‘Broad-Based Specialty Training’ bandwagon.

First, the concept of ‘patient care themes’ is not fully explained. It uses examples of women’s health or child health as such themes and these do make sense. But these make sense because these are natural divisions of medicine and indeed are already represented by specialties (paediatrics and O&G respectively) with their own training pathway. However, the biggest chunk of medical work (especially acute medical work) falls into ‘general medicine’, either general practice in the community or general internal medicine in the hospital setting.

General internal medicine has many specialties within it. Unlike child health and women’s health these specialties do not all naturally divide into manageable groups and indeed the boundaries between specialties are often blurred. Put simply, you cannot train a physician to consultant level in all specialties; general medicine is too large a beast to be mastered by any one individual. Instead doctors specialise in one field and maintain a broad knowledge of ‘acute general medicine’ – a working knowledge of how to manage patients with emergency and urgent presentations of all medical problems with a good understanding of when a patient needs referral to a specialist team.

So let us assume that for general medicine the patient care theme would look something like ‘acute general medicine and gastroenterology’, something very similar to the current system of dual accreditation.

So what does the Shape of Training report want to do differently within the 4-6 years of broad-based specialty training (BBST)? Here is a list of the key points the report emphasises.

  • General medical training with GP experience – “The broad, generalist nature of the early years of medical training, during medical school and the Foundation Programme, should continue into the later stages of training”, which suggests that exposure to a range of the core specialties within general medicine is recommended. The report goes on to say that training within primary care should continue beyond the foundation programme, suggesting a GP placement within BBST.
  • Emergency department experience – Doctors in all acute specialties will need to provide both acute and emergency care. It states that as doctors progress in their training they should provide more service in acute and emergency care. The use of the term ’emergency’ is telling; this is about providing care in the emergency department rather than just on the acute medical take, blurring the lines between the specialties of emergency medicine and general medicine. Indeed the College of Emergency Medicine has stated that all trainee doctors in acute specialties (general medicine included) should rotate through the emergency department and uses the Shape of Training review as evidence for this.
  • 6-month minimum rotations – Rotations within training programmes should not be too short (minimum 6 months).
  • A year out for education, management, etc – ‘During postgraduate training of between four and six years, doctors should be given opportunities to spend up to a year working in a related specialty or undertaking education or management work’. This suggests that included in the 4-6 year BBST training, up to 1 year of this would be for related specialty training, education or management. This would be similar to the current OOPE/OOPR model, however the time would be part of the 4-6 years of training.

So what do I need to include in my gastroenterology/general medicine training?

  1. A GP placement
  2. An emergency department placement
  3. Placements in acute general medicine
  4. Placements in relevant specialties to ‘acute general medicine’ (cardiology, respiratory medicine, elderly care, endocrinology, gastroenterology, etc)
  5. Up to a year in medical education, management, related specialty
  6. Enough gastroenterology training to bring the trainee up to the equivalent level of a current consultant in ‘general gastroenterology’. This is implicit in the statement “… the outcome of postgraduate training [and] would result in a Certificate in Specialty Training. This is the same level of competence as doctors who are currently awarded a CCT that allows them to work as consultants.”

Already this is looking like it will be an action-packed 4-6 years. Now, we have to decide what we want out of this new beast, the ‘CST Gastroenterologist’. I apologise to the non-medics in advance, but I wanted to really nail down what I think a consultant gastroenterologist should be able to do, even if they are only working in ‘general’ gastroenterology and do not manage any specialist problems themselves. Below are some domains in which I think they would need to be competent.

To be able to rapidly and safely assess patients with common presentations of gastrointestinal disease in the inpatient and outpatient setting. This would involve the interpretation of relevant investigations, the diagnosis and explanation of diagnosed conditions and the basic management of such conditions. 

  • Dysphagia
  • Odynophagia
  • Nausea and Vomiting
  • Weight loss
  • Reflux and heartburn
  • Dyspepsia
  • Abdominal pain
  • Abdominal distension
  • Diarrhoea
  • Constipation
  • Rectal bleeding
  • Alternating bowel habit
  • Faecal urgency and incontinence
  • Ascites
  • Jaundice
  • Deranged LFTs
  • Anaemia
  • Iron deficiency anaemia
  • Hypoalbuminaemia
  • Thrombocytopenia

Be able to provide expert input into the management of patients with acute presentations of gastrointestinal disease including:

  • Upper GI bleeding
  • Lower GI bleeding
  • Absolute dysphagia
  • High GI obstruction (gastric outflow obstruction)
  • Infectious diarrhoea
  • C diff (incl severe and recurrent disease)
  • Flares of UC and CD, including severe colitis and intra-abdominal sepsis
  • Nutritional problems including Wernicke’s, refeeding syndrome, enteral nutrition and understand when and how to start PN.
  • Acute liver dysfunction and failure
  • Cirrhotic decompensation
  • Alcoholic hepatitis
  • Obstructive jaundice
  • Cholangitis
  • Pancreatitis
  • Ascites
  • Gastroenterology complications during pregnancy and the puerperium

To be able to provide core diagnostic endoscopic investigations safely and effectively and deal with any complications. 

  • Be able to perform routine diagnostic UGI endoscopy
  • Be able to perform therapeutic UGI endoscopy for UGI bleeding
  • Be able to perform routine diagnostic flexible sigmoidoscopy and colonoscopy including removal of polyps up to 10mm in size and deal with complications

This is not an exhaustive list, indeed I think it only scratches the surface, particularly of the outpatient work. It does not include any long-term management of inflammatory bowel disease, cirrhosis, other chronic liver disease, viral hepatitis, etc. I am working on the premise that all these patients would be streamed to a ‘credentialled’ specialist in those conditions, leaving the CST to see more general gastroenterology.

So how much training do you need to achieve this? This is always a contentious question and one that probably varies with the attributes of the trainee and the quality of the teaching and supervision that they receive. I think, as a current gastroenterology trainee, that I am in a reasonable position to give a ball-park figure to the training requirements. These are the minimum numbers that I would think would be reasonable for a trainee to reach a basic level of competence that would enable you to say you were ‘CCT’ level competent in these areas.

Endoscopy training:

  • 400-500 OGDs.
  • 50-100 therapeutic OGDs for upper GI bleeding (where therapy is given)
  • 300 Flexible sigmoidoscopies
  • 250 Colonoscopies
  • 50 Polypectomies (Polyps up to 10mm)

For good training you need reduced number endoscopy lists – training lists. If the lists were 7-point endoscopy lists this would be 210 ‘perfect’ training lists with precisely the right numbers of procedures on each list, with no cancellations, problems etc. Probably 250-300 half-day endoscopy lists is more realistic.

Clinic training:

It is difficult to say how many patients you need to see with each type of presentation, but a reasonable number sounds like an average of 20 patients with each presentation, with commoner presentations (such as diarrhoea) requiring more experience and rare presentations requiring less. To get the best from the learning the trainee would need to follow-up their patients and would need to get some experience in seeing patients with newly diagnosed conditions to gain experience in discussing diagnoses and starting treatment of common conditions. From this I think the trainee would need to see 400 new patients, 400 follow-up patients and have experience in seeing patients within clinics for IBD, Hepatitis, autoimmune liver disease, cirrhosis and general gastroenterology follow-up (probably another 200-300 patients). If they are going to do a thorough job and learn as they go those clinics cannot be rushed, so probably 3 new patients and 4 follow-ups a clinic would be reasonable. This would mean approximately 200-250 clinics in total.

Now you can’t do either clinic or endoscopy for 10 sessions a week if you are going to learn, improve or, indeed, survive with your sanity intact. The trainee will also need some inpatient gastroenterology training for their acute gastroenterology competencies. So what would be a sensible gastroenterology week?

  • 3 sessions of endoscopy (training lists)
  • 2 clinics
  • 1 admin session for clinic and endoscopy results as well as audit/leadership work.
  • 2 inpatient ward rounds
  • 1 session seeing the gastroenterology referrals/reviews/admissions in hospital
  • 1 session of formal teaching on gastro and GIM

That is a pretty action-packed and training-focused week. With current working patterns (EWTD, 6 weeks annual leave, 1-2 weeks where bank holidays make training impossible, a week for sick-leave/exceptional circumstances and 2 weeks for study leave, courses, etc) a year only has 41-42 true ‘training’ weeks in it.

This means the trainee would need to do an absolute minimum of 2 and a half years and probably 3 years of dedicated gastroenterology training with no general medicine commitments at all.

Ok, now we have got that, what will the BBST training programme look like?

  • FY1 – as usual
  • FY2 – as usual
  • BBST 1 – Non-gastro speciality (e.g. respiratory) 6/12 & GP (6/12) + on-calls (SHO)
  • BBST 2 – Elderly care 6/12 & Non-gastro speciality (e.g. cardiology) 6/12 + on-calls (SHO)
  • BBST 3 – Emergency medicine 6/12 (SpR on-calls) and gastro 6/12 (no on-calls)
  • BBST 4 – AGM 6/12 (SpR on-calls) and gastro 6/12 (no on-calls)
  • BBST 5 – AGM 6/12 (SpR on-calls) and gastro 6/12 (no on-calls)
  • BBST 6 – AGM 6/12 (SpR on-calls) and gastro 6/12 (no on-calls)
  • BBST 7 – Gastro 6/12 (no on-calls) & 6/12 of management/leadership/research

This is as short as I can make it (I will explain why shortly). It is 1 year longer than the maximum permitted in the shape of training review and only has a 6 month management/leadership/research element rather than the full year.

So why can’t it be shorter? What could we cut? Possibilities to make it shorter include:

  1. Do no other speciality other than AGM and Gastro. We could cut the 2 non gastro speciality rotations and 1 elderly care rotation, saving 18 months needed. However, this would say that after FY2 a doc would have no other speciality experience other than AGM/ED/GP. As the bulk of acute medicine is elderly care clearly this is flawed. A good chunk of acute/urgent/general medicine is also respiratory, cardiology, endocrine and gastro with a smattering of neuro. Doing these jobs for a period as a senior trainee would clearly be of benefit. So cutting these jobs is going to make you a worse CST consultant. I did CMT jobs in gastro, ID, elderly care, respiratory and cardiology and that experience has without doubt improved my general medicine knowledge enormously.
  2. Cut GP and ED. This would bring training down by 12 months. However, the report specifically states in a quote that ‘All trainees should have the opportunity to spend time in community/primary care and hospital/secondary care settings, both during foundation, and subsequently.” Moreover, the CEM has said that all acute speciality trainees should do a stint in ED.
  3. Shorten all non-gastro rotations to 4 months. This would save a year. But the report makes it clear that longer placements are better and recommends 6 months minimum. I happen to agree – it’s a good length to get your teeth into something and consolidate learning.
  4. Shorten gastro training. As I have shown above, once you start to break down what you want a gastroenterologistto be able to do, you rapidly reach a point where you cannot shorten training beyond a certain point. So what could you cut fromgastro training if you had to?
    • Cut Endoscopy – You could just have gastro consultants doing OGDs. Colonoscopy would be a credentialing task. However we need more and more colonoscopists as screening programmes and increasing indications (mainly related to polyp FUs) are massively increasing demand. The NHS needs colonoscopists.
    • Cut ward work – Absolutely not. In my future plan there is already insufficient time on the wards to really get your teeth into just how sick and complex gastroenterology inpatients can be.
    • Cut clinic – hard to do as clinic is what you will want your CST consultant to do – run clinics independently in the community diagnosing and managing general gastro problems. It takes time and experience in real practice to build the knowledge and skills patients expect their specialist to have when they come to clinic. In chronic conditions early recognition of problems when they first appear can prevent serious complications as well as prevent the significant costs associated with those complications when patients are admitted as emergencies. Cutting training in outpatient management is likely to be a false economy; patients will be over-investigated, unnecessarily followed up in clinic and serious complications of chronic disease missed at the early stage when most can be done to treat them.

So, is it possible to train an acute physician/general gastroenterologist to consultant level within the proposed Broad-Based Specialty Training proposed by the Shape of Training review? My assessment is no. If you wish to develop these skills you need to commit to the training time – there aren’t many shortcuts here. If you want to shoehorn the training into the BBST framework you will not be training a consultant, but something else. You will, in fact, be training a senior registrar, a materially less experienced and less capable physician.

Sometimes massive structural reform is needed within an industry or profession. Sometimes such reform is the only way to make fundamental improvements in a system. Sometimes such reform works, such as the original formation of the NHS. But post-graduate medical education does not need this structural reform.

Indeed, I think the implementation of the Shape of Training review as it currently stands would be the most damaging change to the medical profession and the NHS in recent history, even more so than MMC or the recent changes in NHS structure. The qualities that make a consultant would be eroded and we would create a new breed of under-trained acute physicians and ‘specialists’ who would lack the clinical experience and thorough training needed to make safe and cost-effective decisions about patient care. This would not be beneficial to the NHS or to UK PLC, and most importantly it would be bad for patient care.

A final thought; I have taken as the premise of my calculations that gastroenterology training would be allowed to be stretched to the full 6 years of Broad-Based Specialty Training but it might well be decided that such a long training programme would only be for surgical training and that medical specialties would be limited to 5 or even 4 years of BBST training. If we shortened it to 5 years that would mean that I (4 years out of the foundation programme) would be just over a year from ‘consultant’ status. Whilst I think my training is going well, I am way off that level of knowledge, skill and decision-making. And if the training were shortened to 4 years BBST that means I would be a ‘consultant’ this summer, a thought so ridiculous it is making me laugh out loud just thinking about it.

Medical training is long and onerous. There are huge bodies of knowledge to be assimilated and complex skills to be learnt. But medicine cannot just be boiled down to a list of facts and skills to be ticked off, the art of medicine takes time to develop and cannot be rushed. There are without doubt areas of medical training to be refined, there may even be parts that can be safely trimmed off training programmes. But if you trim too much, if you cut too drastically, you do not make something leaner and more efficient, you make something different, something fundamentally less good than what you had before.

We cannot risk fundamentally damaging the qualities of medical training and the attributes of the consultants it creates through a poorly thought out structural reform. I respectfully suggest to those within government on whose shoulders the implementation of this review falls to pause. Pause, then listen. Listen to those who know that these reforms are unnecessary and will damage medicine and healthcare irrevocably. Then, once you have listened, work with us to tweak the existing structures of medical training. There is so much that can, and should, be improved, so many ways we can make better consultants and GPs for the future. We should debate this review, we should consider and reflect on its thoughts on better integration of training and novel ways of working, but we should vehemently reject its proposal for a fundamental change to medical training.



Are you a doctor in another specialty? Would the proposed system allow adequate training for your field? Are you a patient? What would you think of your specialist consultants having shorter training? I’d be keen to hear your views whatever you think. Thanks.

Richmond Park in winter mist (2011)

Richmond mist 002

We are having a full on declutter at home, so I have looked through some of my old photos to clear out the mediocre. I have managed to accumulate tens of thousands of images in the last few years and the sheer number is overwhelming, a weight around my neck when I open the computer to look at my photos. Once enough time has passed it is surprisingly easy to delete the poor images for ever, which has given my mind the time and space it needs to appreciate the photos that I kept.

These photos were from a walk in Richmond Park in mid-winter, in fog, at dusk. Shooting with a high ISO and a mediocre lens in such conditions I was not expecting much, but I do like these images and looking at them again has given me ideas of what I would do in similar conditions this winter. It turns out that decluttering is not just good for your hard drive, but for your photography also.

The beach at Vik (Iceland 2013)

So, it turns out that having a new baby interferes with your blogging. Who knew?

Anyway, it’s been a while since I posted any photos. These are not recent; they are from our trip to Iceland almost a year ago. I took them at a little town called Vik, on the coast at the South-Eastern tip of Iceland, where snow and foaming white waves strike this utterly spectacular beach of black volcanic sand. It is quite extraordinary. I’ve put them monochrome as it seems to emphasise the inverse, almost ‘negative’ quality of the beach.


_MG_8171 Beach at Vik 001 Beach at Vik 002 Beach at Vik 003 Beach at Vik 004 Beach at Vik 005

What makes a good educational supervisor?

I wrote this essay earlier in the year as an entry for the Royal College of Physicians’ Teale Essay Prize and I decided to post it now as it seems topical at the moment. As you may know, the Shape of Training Review, led by Professor David Greenaway, was published a few weeks ago. Within its wideranging recommendations it did suggest that doctors and their trainers should have an apprenticeship based relationship, something that I discuss in this piece.

I will write more about the Shape of Training Review at some point, but in the meantime here is my Teale Essay Prize.


What makes a good educational supervisor?

“The teacher…has an affinity for students. The sages said ‘let the honour of your students be cherished like your own’.

For one must take care of the students and love them like one’s own children. Pupils add to the master’s wisdom and broaden his heart.”1

Maimonides, The Book of Knowledge

Eight centuries ago, Maimonides, the great physician of the age, wrote these words on the relationship between the teacher and the student of medicine. Whilst the poetic language and tone leave an indelible mark of antiquity on his writing, there is still a resonance with the contemporary definition of educational supervision as “the provision of guidance and feedback on matters of personal, professional and educational development”.2 Kilminster’s modern definition may lack the passion of Maimonides’ work, however both emphasise that the great teacher goes beyond the transfer of scientific knowledge to explore something deeper and more personal about what it is to be a doctor.

Great teachers beget great doctors, a fact long recognised; the 12th century Arabic physician, Ibn Jumay, wrote that to be successful in medicine one must be “fortunate enough to be apprenticed to a skilled master”.3,4 The attributes required by the good medical teacher and the responsibilities they should hold have been debated for millennia. One theme in historical descriptions of medical education is the personal relationship between the teacher and learner. Traditional Chinese medicine recognised forms of knowledge that could not be standardised and that certain personal or ‘secret’ knowledge was dependent on the relationship between the pupil and teacher, whilst a part of the Ebers Papyrus, an ancient Egyptian medical treatise, discussed what it called the “beginning of the secret physician”.4 This secret knowledge, transferred between a teacher and pupil who have developed a significant relationship and share a mutual trust, is not just an ancient concept. There remains a ‘hidden agenda’ in medical education today; a transfer of values, behaviours and attitudes that cannot be learnt from lectures or textbooks. As Kenneth Calman wrote in Medical Education: Past, Present and Future: “People learn from others; they watch and imitate behaviour. Habits and attitudes are passed on invisibly, for good or ill.”4 

An individual’s title plays a part in defining the nature of their relationships; a title carries with it a tacit significance that is not lost on those on whom they are bestowed. Titles used for teacher and student in Chinese medicine, apothecary training and traditional surgical practice included master, pupil, disciple and apprentice, titles that imply relationships founded on obedience and duty. The Ebers Papyrus states that students are “under the inspection and discipline of their teachers”, a statement that suggests that the teacher’s responsibility for the personal behaviour and values of their students was considerable.4 

Such emphasis on the relationship between student and teacher is not confined to the ancient world. Professor Noah Morris, in a BMA report on medical education in 1948, stated that “the best teacher is the individual who infects his or her students with the best habits of thought, the best technique and the best habits of life”5, suggesting that the good teacher should transfer not only knowledge and skills, but attitudes and behaviours that carry over into their personal lives. Three years earlier the Guy’s Hospital surgeon Mr W H Oglive, wrote in his article The education of the surgeon that “the relationship to be sought is not that between master and pupil but between master craftsman and apprentice”. 6

So, from ancient history and medieval Arabic medicine, through to the post-war medical education renaissance and the modern definition of the educational supervisor, there is broad agreement that for medical education to progress beyond the merely factual and to include the ‘hidden agenda’ of medicine where personal behaviours and values are examined, students and teachers must build deeper, more significant relationships. Yet the reality of educational supervision for most trainees is a world away from these ideals. Limited supervisor time and the litany of mandated requirements lead to a handful of meetings a year spent talking to a computer whilst learning agreements are signed and workplace-based assessments are counted. True interaction between learner and teacher is replaced with a tick in the ‘educational supervision meeting’ box in a parody of Maimonidean ideals.

Some argue that such significant interaction with students is not part of the educational supervisor’s role. They use the title of ‘supervisor’ as an excuse; they consider themselves as merely an overseer of education rather than a teacher who provides it, a task delegated to team consultants and training days. In the current system most junior doctors spend only 3 or 4 months in each post, often with multiple consultants in their team. Such fleeting contacts provide little opportunity to build the deep relationships required to grasp the thorny issue of physician values and behaviours.

Such values and behaviours have never been more important in the light of the Mid-Staffordshire public inquiry, increasing patient involvement in healthcare and a more transparent, patient-centred NHS7. Educational supervisors must reclaim the role of teacher and mentor and eschew the simplistic model of computerised meetings. They can fill this real need for trainees to establish meaningful relationships with their seniors so that they can delve into the ‘hidden agenda’ of medical education.

In an era when we have seen examples of healthcare’s dereliction of duty to the humanity of patients and where the fracturing of care risks the loss of the relationship between patient and physician, we must try to rebuild these valuable, formative relationships between senior doctors and their trainees. The good educational supervisor should go beyond the overseer role and embrace a deeper relationship with their charges, one that encompasses master and disciple, teacher and pupil, craftsman and apprentice. Such relationships will benefit both supervisor and trainee and will nurture and protect the core values of our profession, unchanged since the days of Maimonides, which remain so important to patients and society today.


  1. Maimonides. The Book of Knowledge. Translated Russel HM, Weinbery J, Edinburgh: Royal College of Physicians of Edinburgh; 1981.
  2. Kilminster S, Cottrell D, Grant J and Jolly B (2007) AMEE Guide No.27: Effective educational and clinical supervision. Medical Teacher. 29: 2–19.
  3. Jumay I. Treatise to Salah ad-din on the revival of the art of medicine. Translated by Hartmut Fahndrich. Weisbaden: Kommissionsverlag Franz Steiner GMBH; 1983.
  4. Calman KC (2007). Medical Education: Past, Present and Future. Edinburgh: Churchill Livingstone.
  5. Medical Education Committee of the British Medical Association (1948). The training of a doctor: report of the Medical Education Committee of the British Medical Association. London: British Medical Association.
  6. Oglive WH (1945).  The education of the surgeon. Lancet 2: 225-231.
  7. Commission for Healthcare Audit and Inspection (2009). Investigation into Mid Staffordshire NHS Foundation Trust. London: Healthcare Commission.




Engaging junior doctors in management and leadership – the role of the employing trust

This week I returned, energised and enthused, from the Faculty of Medical Leadership and Management (FMLM) conference in Edinburgh. One of the reasons I so enjoy attending conferences is that sense of renewal you gain; in our hectic day jobs we rarely have the opportunity to pause and reflect on everything we do and conferences give us that chance to look at the bigger picture and discuss our practice with fascinating people from our own day-to-day sphere of practice.

I attended a particularly good discussion, chaired by Clare Marx of the RCS council, where our table discussed how we should prepare trainees for leadership. We had a fairly wide-ranging and heated debate but one key problem we discussed was why so many junior doctors are not interested in the management and leadership of the hospitals and trusts for which they work.

At this point the conversation turned decidedly dark. Most of our table were trainees at varying stages from FY1 to senior registrar, and we all had stories of how trusts we had worked for had generally failed to engage with us and make us feel part of the team. Now, I do not want to write a list of the calamities and irritations that I and so many of my colleagues have had to put up with when we move to a new trust, I think the NHS has quite enough vocal critics on the net, but instead I want to collate examples of good practice I have seen and heard about and put it into a description of a fictitious doctor starting at a hospital somewhere next August and show what good might come of it. Please excuse my use of a work of fiction (and references to a popular Radio 4 soap) to explore this topic, but it is more entertaining to write!


Jane was excited about her FY2 year job at Felpersham General Hospital, Borsetshire. She had always wanted to do paediatrics and this was her chance; after a year of general medicine and surgery at the other hospital in the county she was moving to do paediatrics, adolescent and child psychiatry and ENT. It was her first choice rotation which, she hoped, would give her some great experience to apply for her training post in paeds in a few months’ time.

She was nervous though. She hadn’t done any paediatrics since she was a medical student and the thought of being on the SHO rota covering sick children in A&E and on the wards was rather daunting. Not only that, but she worried about her applications due in a few months. She had not published a paper and knew she should get involved in a quality improvement project, but just did not know how to go about doing it. And that was just her professional life; her fiancé was working over 2 hours away and it was hard enough to see each other to catch up let alone plan their wedding next April.

She was a bit surprised when an email appeared in her inbox at the beginning of June, two months before her job was due to start. It was from the HR department of Felpersham General so she opened up the email and read it with interest.

Dear Dr Austin,

It gives me great pleasure to welcome to our trust, we are looking forward to meeting you at the induction on the 4th of August. I wanted to introduce myself and to give you the information you will need before you join us in a couple of months. I am the HR manager for junior doctors in paediatrics, psychiatry and surgery and am the key contact for you for all things administrative! Please, if you have any problems or questions just drop me an email or give me a call, we are here to help. 

First, we want to make the paperwork as smooth as possible for you. I have attached a list of documents that we require; please scan and email them to me and we will get all your forms processed as soon as possible. Please also send us a copy of your current payslip so we can ensure you get correctly paid from the first month, we want to avoid any problems. You won’t have to come in before induction to do anything, email copies of everything will be fine. 

Occupational Health require you to fill in a form and email them; they can then contact your current trust with your permission and get all the information from them to save you time and hassle. If there are any problems and they need to see you in person we will schedule you a time to see them on the day of induction. 

I am sure you are keen to know what the rota will be; it is drafted now and we will send it out in two weeks’ time, six weeks before you start the job. We like to be as flexible as possible to make things easier for you, so if you have a couple of important dates that you would really like off we will try to accommodate this for you. Please email me 2-3 days or weekends you would prefer off and once we have everyone’s preferences in we will do our best to make this possible. 

I have attached a timetable for induction for your information. If you are on night shifts at another hospital the night before you are allowed to be absent and we will share links to the videos of the presentations for you to watch. 

We have tried to minimise mandatory training as much as possible. We have therefore contacted your old trust to show us your certificates for data protection, child protection, fire training, manual handling, blood transfusion, documentation, communication skills and incident reporting and if these are valid you will not have to retake these. 

Finally, I just want to say welcome to the trust. We are a friendly place and hope that your year with us is a really positive one. Please do not hesitate to contact me with any questions or queries you may have. 

Many thanks and kind regards, 

A.J. McLean

HR Manager”

Jane stared at the missive with her jaw hanging open. She had never received such a lovely email from HR at her current hospital. Already she could feel the stress lifting from her shoulders. She wrote a quick email back thanking A.J. and asking if she could have the weekend of her wedding off and if she could have the weekend of her father’s 60th birthday off too. She had a reply from A.J. the next morning congratulating her on her engagement and asking whether she was planning on having a honeymoon straight away as he could pencil in her annual leave for the two weeks after the wedding as well if she wanted. She had no idea how worried she had been about the wedding until now; it felt like an invisible weight had been lifted from her and she walked to work that day with a smile on her face that not even the rain could dampen.

Sure enough a week later the rota came through; she could go to her father’s birthday after all and, joy of joys, she had her wedding weekend and honeymoon off! She phoned her fiancé straight away to tell him the good news (and to make a few more veiled references to Tahiti; she hoped he would get the hint!)

More surprising still was the email she received from her future educational supervisor a few weeks before starting. He wanted to know what her career plans were, what she wanted to get out of her rotations in the next year and what quality improvement and management experience she had so far. She told him her hopes of becoming a paediatrician and her worries that she did not have much experience in QI or in management. He emailed her back and suggested that she contact one of the registrars who was working on a project to improve prescribing and reduce drug errors on the paediatric ward. He also asked if she wanted to join one of the hospital committees as the trainee representative as a way to improve her knowledge of management. One of the two trainee posts on the Medicines Management Board would be vacant from August and he would help make sure she had time out of her day to attend their meetings once every 2 months.

She contacted the registrar who was just about to start the project and glad to have her help. He was going to be away for most of August but because they had made contact so early they were able to discuss the project and she even went into the hospital a week before she started to meet him and the ward pharmacist so she could start the project as soon as she got there. She also talked to the registrar about some of her worries about working in paeds and he reassured her that there was always someone to ask for help and gave her some useful tips for her first on-calls.

The last few weeks of FY1 passed in a blur. In a way it was sad to leave the friends she had met during that first eventful year, but she could not hide her excitement at joining Felpersham General and starting paeds. The induction was nothing like she had expected; rather than a barrage of short talks about the different colours of fire extinguisher and how to lift a cardboard box without hurting your back, they had a brilliant talk from the Chief Executive and the Medical Director. They talked to her about the transparent and honest ethos of the hospital and their overall aim to improve quality and safety for patients. They stressed how much it was down to junior doctors like her to look out for areas needing improvement. They explained how in every department there was a manager who would do a patient safety walk around the department each month and they should make sure any problems be discussed then. They also told her about their programme to introduce junior doctors to management; they were keen that every committee in the hospital had 2 trainee members and that members of the senior management team would be coming to special teaching sessions once a month with the trainees to talk about their role in the organisation and to run a question and answer session.

With so little mandatory training on the induction day the afternoon was spent in departmental induction. They met the consultant in charge of the department as well as the manager of the paediatric division. They were then shown how the team worked by one of the registrars and given the paediatric department handbook which gave all the hints, tips and phone numbers that she would need for the job.

When Jane walked back to the accommodation that night with some of other new doctors, all they could talk about was how crazily nice this hospital was! They were all so enthused by the positive talks they had had that morning and were already planning projects to work on whilst they were working together in paeds. It all felt so much less daunting than she had expected and she was so grateful to her new trust that the induction process had been so painless and that her wedding and Dad’s birthday were sorted. She really did feel part of the team, even after just a day.

Now I am well aware that this story will not be winning the Pulitzer Prize, but I wanted to explore what might be achieved if trusts took a slightly different view to the junior doctors that join them each year. You might, quite reasonably, say that the above story describes good, old-fashioned, employee management, and you would be right. But that just does not happen most trusts I have been in or heard about.

Where this lack of understanding for junior doctors comes from is complicated. Part of it stems from the abnormal employer/employee relationship between junior doctors and their employing trusts. Doctors in a training programme are allotted to hospital trusts for a fixed period by the deanery (now the LETB). The trust does not have a say in who they get and they know they are only there for a few months, perhaps a year. After a while it must seem like a continual flow of itinerant workers, like fruit pickers coming for a season and then heading off into the wider world, never to be seen again. Maybe it feels like it is not worth the trust’s while to make the effort to make us welcome, to inspire us with the trust’s values and aims, but instead tell us the minimum possible and get us out onto the shop floor.

Rotas, induction, mandatory training and occupational health are normally the first thing that creates a rift between the doctors in training and the trust. Inflexible rotas with no opportunity to request dates off in advance are often only given out a few days before starting a job. This means that weddings, birthdays and holidays in August and September are virtually impossible to plan or attend. Junior doctors’ lives are put on hold because someone has not yet got round to writing a rota. It feels to us like no one cares about us, our stresses, our worries, our lives. (I have a friend who asked her future trust 5 months before her wedding day for the weekend off, well before they wrote the rota. They put her on night shifts on her wedding night. She had a really hard time finding a swap due to how tight the rota was. She went to HR and politely said that she was happy to work any time but would not work that weekend because of her wedding, swap or no swap. The person told her if she did not turn up she would be reported to the GMC. But I did say I would stay positive, so I won’t dwell on any more dark stories!)

Induction is normally uninspiring and functional – there is rarely a proper welcome to the trust from anyone senior. Occupational health departments ask people to attend appointments before starting the job, even though they are in full time employment at another trust so cannot attend and even though another occupational health department in their current trust has all the information that they need. Mandatory training has to be replicated at every trust and is simply soul-destroyingly boring. Generally it is now online, which means you have to do it in your own time, late in the evening, with a glass of wine just to get you through the pain of going through another powerpoint presentation about data protection or Caldicott guardians.

What is the end result of all of this? By the end of the induction day the trust has succeeded in uniting all the junior doctors in one respect: their universal dislike and frustration with the trust that they have just joined. They head to the pub to discuss how patronising the induction was, how late the rota was released, how long the mandatory training lasted, how frustrating the occupational health and HR paperwork was. The result is a culture of ‘them and us’. Junior doctors unite in their antipathy to management.

This is no way to train doctors in leadership. Those same frustrated, deflated, un-empowered trainees will be GPs, CCG members, consultants and management board members in a decade. And how have we trained them? We haven’t. Nor have we inspired them. All we have done is perpetuate the harmful divide between management and clinical staff, an artificial and unhelpful outcome of poor employee management.

My conclusion is that the first step to training doctors for management and leadership is to make them feel a part of the organisations for which they work. Make them feel proud to work at your hospital. Make them indebted to you for all the help you have provided them. Make them keen to work to improve the hospital and to get involved in quality improvement and management.

Now maybe my story about Jane starting at Felpersham Hospital is a bit trite. Well, very trite. But I hope it serves a purpose. Jane’s view of the hospital was shaped by simple but thoughtful interventions. We junior doctors are a relatively easy bunch to please! We don’t need bags of cash or a swanky office, just our rota, minimal paperwork, a sense that we are welcome and valued and a bit of forethought into how we can make the most of our time at the hospital. I don’t think any of this is complicated. I don’t think it will cost very much, if anything at all. All it requires is a bit of joined-up thinking and a change in priorities.

But the benefits that a legion of motivated, empowered junior doctors could bring could be enormous. This is just a first step in training doctors in management and leadership, but I believe it is the foundation onto which leadership training and management experience can be built. Without this foundation any intervention to improve the leadership skills of doctors in training will crumble into a rubble of disaffection and negativity.


PS: This is very much my opinion, not that of the FMLM or of the conference. What I would really like is your comments and thoughts about this. As a junior have you felt inspired and motivated by your trust? Have you felt ignored and disillusioned by rotas or induction? What else could employers do to improve things? Is there anything you think juniors should be doing to be more involved – do we expect too much from our employers? Do you work as a manager or executive and see this from a different perspective? I’d really appreciate any views about this. Thanks! Fitz