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The Houseman’s Job

December 4, 2012

In the days before F1s and F2s, wet behind the ears doctors were called Housemen. Funny there was no feminist denouncing that I’m aware of. We were probably all simply so relieved to have qualified they could have called us anything. I blogged here https://sarahspoutsoff.wordpress.com/2012/07/24/and-suddenly-i-am-a-doctor/ about the moment I became one.

I arrived in North Yorkshire to be a Surgical Houseman for six months. I had trained in an inner London teaching hospital that was a tertiary referral centre; somewhere patients get sent when the local hospital can’t deal with it. It meant I saw lots of rare and interesting diseases. But it also meant I thought they were much commoner than they actually are simply because I saw them so often. There is a mantra in medicine that ‘common things occur commonly’ as the most likely diagnosis will be the commonest reason for the symptom or symptoms. Thus seeing a doctor is the opposite of Googling your random aches and pains as the doctor will say ‘Fuck off it’s a virus’ and be right 99.9% of the time, whereas Google will come up with lupus or leukemia. And the Daily Mail will let us all know how the doctor missed the diagnosis. But I digress.

When I started as a Houseman I was more like Google than a GP, but very quickly re-assessed the probabilites of a likely diagnosis as I saw more and more ‘bread and butter’ medicine as it is known. I was working for two different surgeons who each had their own ways of doing things and which it was essential to get right. This was back in the days of Consultants having complete autonomy and there being no ‘guidelines’ or protocols to follow. Doctor knows best, and as a Houseman you did what you were told. Thus it would be that for the same operation, the surgeons would have different preferences for preparing the patient in terms of antibiotics, anticoagulation, bowel clearance, shaving. And it was up to me to make sure the right drugs were prescribed for the right patient depending which Consultant they were under.

The normal working day would start at about 730 to go on the wards to take bloods. No medical students or phlebotomy technicians here to do that task for you.And there could be lots of them. But I always enjoyed the practical side of the job so was happy to toddle off to the treatment room and search out my required bottles, needles, swabs and plasters. Then once they were done and all in their bags ready to be sent to the labs, I’d go in to the nurses station (after hand over had finished) and start looking through the notes of the patients on the two wards I was covering. Looking to see if there had been any intervention over the weekend or anything had happened to them overnight or results had been filed. Then I would actually go and see the patients to say good morning and ask how they were doing, look at their charts and briefly examine them to check on their progress. Patients who had been admitted overnight or over a weekend when I wasn’t working would be throughly re-examined and their notes interrogated so that I would feel completely up to speed with their case. Usually the nurses would ask me to take a look at people they were worried about, or to re-site drips that had tissued, or write up stronger pain medication for those who needed it.

And on top of that are the Ward Rounds. The process of ritual public humilation by bastard Consultants trying to make you look inadequate and negligent. Or great learning experiences led by thoughtful, caring and interesting Consultants. Both were available. And both instilled the fear of God to make sure I knew exactly what was happening with each of the patients, their lab results, their blood pressure, their drugs………. everything. So they certainly concentrated the mind, but more importantly ensured the patient got the benefit of the Consultant’s experience and expertise at least twice a week. And during the Ward Round, numerous tests, X-rays and investigations would be ordered, or surgery scheduled and I would have to ensure all those things got followed up once the Consultant had swept out of the ward.

Every day except one there was either an Outpatient clinic or Operating theatre session that I had to attend. Outpatients are either a morning or afternoon but theatre can go on all day. And of course you still have to look after all the patients in the wards even when you are doing something else so getting time to grab a sandwich or a coffee can be difficult.

Then of course there are the patients who have been booked to have their operations. They would arrive for their surgery the following day and I would have to ‘clerk them in’. This is the systematic questioning and examining of a patient to find out what the problems are, check they are fit to have the surgery and do any of the work up required beforehand. Like bloods, put up drips, write X-rays, order enemas. And most importantly mark the side of the body to be operated on. You may think this is a joke, but it’s not. I had a thick black permanent marker that I would use to draw an arrow pointing to the Left knee, the Right breast or to circle the numerous varicose veins that needed stripping out. Because it is obviously vital to operate on the correct side, but once a patient is asleep they can no longer confirm which side it is and sometimes notes can be poorly written and it can be surprisingly hard to decipher an L from an R. It is also true to say that for things like hernias, they may not be apparent when the patient is lying down, so it is impossible to tell which side it might be even if you examined him under anaesthetic.

Which brings me to one of the most eddifying moments of my career. I was clerking in a guy for a routine inguinal hernia operation and needed to confirm it was there and mark it up with my big black pen. He was probably about 35 and otherwise fit and well. I asked him to stand up and drop his pants so that I could examine the hernia. I knelt in front of him as he pulled down his boxers. His erect penis actually hit me on the nose as it flicked past in its bid for freedom. Funnily enough this scenario hadn’t been covered during my five years of medical training. But I did what came naturally. I pushed it to one side with my left hand and asked him to cough whilst I palpated (felt) his left groin. “Ah yes Mr X, I can definitely feel it,” I said, “We’ll soon get rid of that for you.”

He couldn’t tell whether I was talking about the hernia or making him an offer.

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4 Responses to “The Houseman’s Job”

  1. janetditch Says:

    Bet he wished it was the latter…

  2. Lorna Kyle Says:

    Please tell me you were still wearing your Belle Stars outfit……..and ……I would like to point out that I did not realise until now that you had put ‘snowfall’ on this post and I have spent the last 5 minutes rubbing my eyes frighten that my failing eyesight is finally leaving me…..


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Life on the wards

December 4, 2012

In the days before F1s and F2s, wet behind the ears doctors were called Housemen. Funny there was no feminist denouncing that I’m aware of. We were probably all simply so relieved to have qualified they could have called us anything. I blogged here about the moment I became one.

I arrived in North Yorkshire to be a Surgical Houseman for six months. I had trained in an inner London teaching hospital that was a tertiary referral centre; somewhere patients get sent when the local hospital can’t deal with it. It meant I saw lots of rare and interesting diseases. But it also meant I thought they were much commoner than they actually are simply because I saw them so often. There is a mantra in medicine that ‘common things occur commonly’ as the most likely diagnosis will be the commonest reason for the symptom or symptoms. Thus seeing a doctor is the opposite of Googling your random aches and pains as the doctor will say ‘Fuck off it’s a virus’ and be right 99.9% of the time, whereas Google will come up with lupus or leukemia. And the Daily Mail will let us all know how the doctor missed the diagnosis. But I digress.

When I started as a Houseman I was more like Google than a GP, but very quickly re-assessed the probabilities of a likely diagnosis as I saw more and more ‘bread and butter’ medicine as it is known. I was working for two different surgeons who each had their own ways of doing things and which it was essential to get right. This was back in the days of Consultants having complete autonomy and there being no ‘guidelines’ or protocols to follow. Doctor knows best, and as a Houseman you did what you were told. Thus it would be that for the same operation, the surgeons would have different preferences for preparing the patient in terms of antibiotics, anticoagulation, bowel clearance, shaving. And it was up to me to make sure the right drugs were prescribed for the right patient depending which Consultant they were under.

The normal working day would start at about 730 to go on the wards to take bloods. No medical students or phlebotomy technicians here to do that task for you.And there could be lots of them. But I always enjoyed the practical side of the job so was happy to toddle off to the treatment room and search out my required bottles, needles, swabs and plasters. Then once they were done and all in their bags ready to be sent to the labs, I’d go in to the nurses station (after hand over had finished) and start looking through the notes of the patients on the two wards I was covering. Looking to see if there had been any intervention over the weekend or anything had happened to them overnight or results had been filed. Then I would actually go and see the patients to say good morning and ask how they were doing, look at their charts and briefly examine them to check on their progress. Patients who had been admitted overnight or over a weekend when I wasn’t working would be throughly re-examined and their notes interrogated so that I would feel completely up to speed with their case. Usually the nurses would ask me to take a look at people they were worried about, or to re-site drips that had tissued, or write up stronger pain medication for those who needed it.

And on top of that are the Ward Rounds. The process of ritual public humiliation by bastard Consultants trying to make you look inadequate and negligent. Or great learning experiences led by thoughtful, caring and interesting Consultants. Both were available. And both instilled the fear of God to make sure I knew exactly what was happening with each of their patients, their lab results, their blood pressure, their drugs, their symptoms, their signs, their fears………. everything. So Ward Rounds certainly concentrated the mind, but more importantly ensured the patient got the benefit of the Consultant’s experience and expertise at least twice a week. And during the Ward Round, numerous tests, X-rays and investigations would be ordered, or surgery scheduled and I would have to ensure all those things got followed up once the Consultant had swept out of the ward.

Every day except one there was either an Outpatient clinic or Operating theatre session that I had to attend. Outpatients are either a morning or afternoon but theatre can go on all day. And of course you still have to look after all the patients in the wards even when you are doing something else so getting time to grab a sandwich or a coffee can be difficult.

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