Now Ye're Talking - to a Junior Doctor (Children's Medicine)

Boards.ie: Niamh

Our next AMA is with an NCHD or junior doctor. He has worked both here in Ireland and abroad in New Zealand. He has sometimes worked under some pretty stressful conditions in Ireland, particularly prior to the strike.

Our junior doctor works in children's medicine.

He is happy to answer questions around the Irish healthcare system plus questions on working abroad, emigrating and being a returned emigrant.

**Medical advice cannot be given so please do not ask, this AMA is about experiences only. If you are worried about a medical issue please see your GP.**

Gloomtastic!

Morning Doctor!

My first question is how many points did you get in your leaving cert? And did that dicate what course you would take or is medicine something you always wanted to do?

Drumpot

Good Afternoon Doctor,

I agree that priority, care and attention should always be given to the patient, in all circumstances.

But in training what consideration is given to family/friends of patients? Particularly when trying to find out information before/during/after operations?

I find that family/friends can interpret information better then the patient. Like when you are telling somebody bad news or information regarding their own illness, an impartial friendly observer takes more in then the person being diagnosed/informed what's wrong.

With regards to treating patients in A&E, are doctors supposed to be in some way empathetic to children or are they supposed to treat them like another number and be cold?

I had an experience where I brought my 3 year old into A&E with a nasty cut on his forehead. After hours waiting, the doctor who actually checked him, investigated the area of the head like he was squeezing a spot on somebody's face. He was squeezing the skin to see the bone (at least that's what it looked like). He actually didn't say anything to my son or myself at the time. Walked over, squeezed his head (and my child howled) and casually walked off chatting with random staff about different things. Around 10 mins later somebody (a nurse) finally told me the story.

I appreciate many in the healthcare system are overworked and need to keep their emotions in check for professional and self preservation reasons, but is it really hard to show a little bedside etiquette? I wanted to punch that doctor. I was already stressed and worried about my child, this makes non violent (like myself) people on edge. I am glad I didn't lose the head, but surely there is some training put into showing some sort of compassion for patients and their families?

I'm a Junior Doctor, AMA

Gloomtastic! wrote: »

Morning Doctor!

My first question is how many points did you get in your leaving cert? And did that dicate what course you would take or is medicine something you always wanted to do?

Hi Gloomtastic, that's a question on many young minds at present! I did my LC in 2006 when the HPAT didn't exist. I got 600 points and went to UCD. I was influenced in that there were doctors in my family, but originally I wanted to be a teacher! Life is full of second chances and with postgraduate medicine there are many routes to being a doctor. It's important that you pick something you think you will enjoy, don't be pressurised by dreams of money or respect. Doctors, unfortunately, in this climate have very little of either!

Drumpot wrote: »

Good Afternoon Doctor,

I agree that priority, care and attention should always be given to the patient, in all circumstances.

But in training what consideration is given to family/friends of patients? Particularly when trying to find out information before/during/after operations?

I find that family/friends can interpret information better then the patient. Like when you are telling somebody bad news or information regarding their own illness, an impartial friendly observer takes more in then the person being diagnosed/informed what's wrong.

With regards to treating patients in A&E, are doctors supposed to be in some way empathetic to children or are they supposed to treat them like another number and be cold?

I had an experience where I brought my 3 year old into A&E with a nasty cut on his forehead. After hours waiting, the doctor who actually checked him, investigated the area of the head like he was squeezing a spot on somebody's face. He was squeezing the skin to see the bone (at least that's what it looked like). He actually didn't say anything to my son or myself at the time. Walked over, squeezed his head (and my child howled) and casually walked off chatting with random staff about different things. Around 10 mins later somebody (a nurse) finally told me the story.

I appreciate many in the healthcare system are overworked and need to keep their emotions in check for professional and self preservation reasons, but is it really hard to show a little bedside etiquette? I wanted to punch that doctor. I was already stressed and worried about my child, this makes non violent (like myself) people on edge. I am glad I didn't lose the head, but surely there is some training put into showing some sort of compassion for patients and their families?

Hi Drumpot, firstly I'm sorry to hear of your negative experience. Whilst I would never condone a lack of empathy (and have often pulled colleagues, juniors and other staff up on it in the past), we are all human. When I trained (2006 onwards), we were only beginning to be taught empathy and professionalism.

I know you may say you either have it or you don't, but these days medical students are being taught skills which enhance their own natural empathy and which enable them to recognise and respond to other people's emotions.

Many paediatric trauma cases outside of Dublin are dealt with by adult trained staff. They may not have the skills to interact with children or may be too busy to take the time to interact - a failing of the system, not the individual. Certainly if one of my staff behaved in the way that you describe I would have very, very stern words with them.

Specifically, children's doctors should, by and large, be able to calm a child of any age (within reason). A hospital experience should be positive for a child regardless of the reason for visiting. I have often found myself belting out songs from Frozen as I take blood from a childs hand so that they are distracted! I regularly go hunting for carrots when looking in ears, or bunny rabbits in mouths in order to get things done without frightening the child. Hospitals provide stickers, teddies and DVDs for childrens wards.

If anyone reading this is thinking of a small, worthwhile, 100% direct charitable act - buy a portable DVD player for your local emergency department along with a few children's DVDs. Or perhaps crayons/stickers/books for kids to read. The impact these things have is immeasurable and will change a childs experience from negative to positive.

Hollister11

Hi

My brother is just starting 5th year. He want's to study medicine in RCSI, in two years time. I have friends in Trinity who claim that an education in RCSI is inferior to Trinity and UCD, and that he won't be as sought after for jobs upon graduation.

Is this correct? Surely medicine is unique to other subjects and that the standard of education is the same around the board.

GLaDOS

What's the longest continuous shift you've ever done?

What's the most amount of hours you've worked in a week?

What was your most memorable experience of successfully treating a patient?

Thanks!

I'm a Junior Doctor, AMA

Hollister11 wrote: »

Hi

My brother is just starting 5th year. He want's to study medicine in RCSI, in two years time. I have friends in Trinity who claim that an education in RCSI is inferior to Trinity and UCD, and that he won't be as sought after for jobs upon graduation.

Is this correct? Surely medicine is unique to other subjects and that the standard of education is the same around the board.

Hollister, I want to be absolutely and utterly clear about this - a medical education from RCSI is indistinguishable from other Irish universities.

Those comments do nothing but reflect poorly on your friends from Trinity, to be honest. Graduates are ranked nationally on their position within their year (someone coming 5th in RCSI will place above 6th in Trinity for example) when applying for intern jobs.

Of course, as a UCD graduate I would have this advice - come to UCD or indeed anywhere but Trinity, or he runs the risk of developing attitudes like your friends :D

I'm a Junior Doctor, AMA

GLaDOS wrote: »

What's the longest continuous shift you've ever done?

What's the most amount of hours you've worked in a week?

What was your most memorable experience of successfully treating a patient?

Thanks!

On my first day of work (newly qualified, green behind the ears) I arrived to work at 0545 in the morning. I worked, with 15 minutes for a hurried sandwich, until 9pm that night. At 9pm I had another sandwich, wolfed down in the canteen, before working continuously until 4am, where I got to sleep for 90 minutes. At 0530 the next day, I got up and worked until 7pm. I worked over 36 hours on 90 minutes sleep. On my first day.

I couldn't remember anything from the second afternoon. Nothing. I must have cared for over 30 patients without retaining much memory of what I had done.

I did one of those shifts every 10 days or so for 6 months. I did 110 hours one week.

One of my personal reasons for striking, was so that my younger brother who had followed me into medicine would never have to do that sort of work. Thankfully, he graduated into a much improved system of shift work and has never worked more than 24 hours in a row. Isn't it warped that I would consider that a success :P

Probably my most memorable stories would have come from my days on the delivery wards. I would have been called if babies were born in difficulty - i.e. not breathing. I remember rushing to a baby who was limp and not breathing. A hairy 90 seconds followed when I did everything I could (almost starting CPR), only to hear the most beautiful wail from this little thing. I explained to the parents what may have happened, only to be hugged by a sobbing father. At this point I broke down myself and we just had a good cry as I hadn't been expecting this story to end well at all. Things like that make the 36 hour shifts and the personal abuse that we get regularly worthwhile.

I could tell you just as many stories where I've made mistakes - I'm only human. Thankfully no bad endings from those!

dreoilin

Hi Doctor,

How would you describe your experiences with nurse/doctor relationships?

Also, I'm studying in Trinity and I can promise you we're not all bad

ectoraige

Thanks for doing the AMA.

Working in paeds do you feel the job provides any support for the extra stresses involved in dealing with sick children? Do you have children yourself?

Is there an age group you find hardest to manage?

Have you encountered cases where you feel older children held back information that they are afraid of their parents finding out? How do you approach that?

I'm a Junior Doctor, AMA

dreoilin wrote: »

Hi Doctor,

How would you describe your experiences with nurse/doctor relationships?

Also, I'm studying in Trinity and I can promise you we're not all bad

I'm not sure I can answer this in just one post! Nurse/doctor relationships are incredibly complex.

Both of us want the same thing - to help people. Unfortunately personalities and previous experiences often make simple interactions difficult.

From a doctor's perspective, we would never be able to do our work without nurses. They spend much more time with their patients and can pick up on things that we cant. They have years of experience to help more junior doctors to make decisions.

One thing that I am jealous of (apart from a strong union, regulated hours and public support) is that doctors often carry the blame for events out of our control. We are sometimes held responsible for finding a tumour, or diagnosing diabetes, as if we had caused it in the first place! Often we are asked to explain nursing or other allied health professional errors to the patient. A nurse can then come in and sympathise with the patient without having to consider the complexities of decision making in their care.

It's not a slight or negative comment, it's just that doctors are held responsible for more than their share of errors or negative events.

XxMCRxBabyxX

How do you find treating older patients who are verging on adulthood (mid-teens) in comparison to younger children? Is it easier and would you prefer it?

I ask this as a former paediatrics patient who used to spend many days in waiting rooms and hospital beds surrounded by much younger patients. I always imagined that there was a huge difference depending on what age group you were treating.

matc66

Temple street or Crumlin? Do you have a preference?

XxMCRxBabyxX

Hollister11 wrote: »

Hi

My brother is just starting 5th year. He want's to study medicine in RCSI, in two years time. I have friends in Trinity who claim that an education in RCSI is inferior to Trinity and UCD, and that he won't be as sought after for jobs upon graduation.

Is this correct? Surely medicine is unique to other subjects and that the standard of education is the same around the board.

I have to say that I have also come across this attitude from some Trinity Med students about the other Universities.

I'm a Junior Doctor, AMA

ectoraige wrote: »

Thanks for doing the AMA.

Working in paeds do you feel the job provides any support for the extra stresses involved in dealing with sick children? Do you have children yourself?

Is there an age group you find hardest to manage?

Have you encountered cases where you feel older children held back information that they are afraid of their parents finding out? How do you approach that?

Any extra support is provided by the staff I work with. In fairness the HSE have an excellent Employee Assistance Programme which provides free counselling for staff.

I think the hardest age group is between 1-2 years. They have stranger anxiety and are difficult to distract as they're so wary of doctors and nurses.

Yes I've encountered those cases, and they're best managed by everyone - doctors, nurses, healthcare assistants, play therapists etc. I recall one allegtion of child abuse made by a child to a play therapist - this child had been in contact with us all on numerous occasions but only felt comfortable opening up to the play therapist with whom he had built a strong rapport.

It's frustrating for doctors who have to move around a lot as we can't build up relationships with our patients. We always rely on nursing and other colleagues to help us.

I'm a Junior Doctor, AMA

XxMCRxBabyxX wrote: »

How do you find treating older patients who are verging on adulthood (mid-teens) in comparison to younger children? Is it easier and would you prefer it?

I ask this as a former paediatrics patient who used to spend many days in waiting rooms and hospital beds surrounded by much younger patients. I always imagined that there was a huge difference depending on what age group you were treating.

Absolutely - changing your approach based on the age group is essential. I'll give some examples.

4 years old - Story time! Launch into a completely nonsensical story, usually involving Daddy having smelly feet, or how tall and strong the boys are, or involving their pets.

9 years old - treat like an adult but not quite. Address them directly but not in a complex fashion - simple questions and let them feel like they can make decisions.

14 years old - Often very difficult to manage. I personally sometimes draw on my own experience "Oh my mother still does that to me" or might make fun of school/parents (a little, not stand up comedy here) all to break the ice. The worry is if you give teenagers too much autonomy, they'll rebel in order to have some control over their lives.

There's a burgeoning area of Paediatrics called Adolescent Medicine. This caters for young adults who have chronic diseases as they are worlds apart from an 8 year old or a 28 year old.

ectoraige

Is there anything you feel Ireland can learn from the health system in New Zealand? Where would you prefer to fall ill?

XxMCRxBabyxX

I'm a Junior Doctor, AMA wrote: »

Absolutely - changing your approach based on the age group is essential. I'll give some examples.

4 years old - Story time! Launch into a completely nonsensical story, usually involving Daddy having smelly feet, or how tall and strong the boys are, or involving their pets.

9 years old - treat like an adult but not quite. Address them directly but not in a complex fashion - simple questions and let them feel like they can make decisions.

14 years old - Often very difficult to manage. I personally sometimes draw on my own experience "Oh my mother still does that to me" or might make fun of school/parents (a little, not stand up comedy here) all to break the ice. The worry is if you give teenagers too much autonomy, they'll rebel in order to have some control over their lives.

There's a burgeoning area of Paediatrics called Adolescent Medicine. This caters for young adults who have chronic diseases as they are worlds apart from an 8 year old or a 28 year old.

Interesting! I'm trying to remember how my Doctor dealt with me now as I only began attending hospital at 14 or so, though I do know that I was never much of a rebel.

On that same point, when do you stop dealing directly with parents? I know that you mention 9 there, but if you had bad news who do you speak to and how? Do parents ever get told first or are all spoken to together? Do you think that children can deal better with the news?

I'm a Junior Doctor, AMA

ectoraige wrote: »

Is there anything you feel Ireland can learn from the health system in New Zealand? Where would you prefer to fall ill?

New Zealand had some really interesting approaches. It has an area 10 times the size of Ireland, has the same population, some at risk groups (e.g. Maori) and wouldn't really have been able to spend money on the scale of neighbouring Australia.

They had similar pay scales to ours.

Some examples of things I'd like to see adopted:

• Pharmac was a national body tasked with negotiating hospital supplies from pharmaceutical bodies. If your competitor was offering Paracetamol at a lower price, well, then they got the national contract. Your drug is too expensive? Fine, we're not paying for it.
• 3 day wait for nursing home bed and funding. Yep, you read that right. If a 90 year old man came into us on a Monday requiring long term care, he was in that nursing home bed on a Thursday. The 650 bed hospital I worked in had only 20 beds who were there "greater than 3 weeks" which was their set marker.
• Consultant posts - Consultants were available to make decisions from 7am-10pm. This meant that patients could have outpatient investigations if needed rather than admitted to have them done.

To answer another question, I prefer Crumlin as it has the Oncology unit which is my area of interest!


I'd rather get sick here as a young person, to be honest. If I was elderly, New Zealand probably manages it better...

I'm a Junior Doctor, AMA

XxMCRxBabyxX wrote: »

Interesting! I'm trying to remember how my Doctor dealt with me now as I only began attending hospital at 14 or so, though I do know that I was never much of a rebel.

On that same point, when do you stop dealing directly with parents? I know that you mention 9 there, but if you had bad news who do you speak to and how? Do parents ever get told first or are all spoken to together? Do you think that children can deal better with the news?

That depends on the diagnosis. It's a judgement call - if you're telling parents that their child has cancer, you'll often take the child away to play so that the nuts and bolts can be discussed and that the parents can decide how much they want their child to know. If I'm telling them that their 12 year old has pneumonia, I'll tell the child directly in a simple fashion before explaining further to the parents.

I think that some of the Transition clinics which prepare teenagers aged 16/17/18 for the adult services e.g. in CF or Diabetes will often make them come into the room on their own as a practice run, before bringing the parents in at the end. I'm sure it's torture for the parents but it's the only way that teenagers will take full control of their illness!

big syke

Firstly I think anyone in the medical profession in particular working with young children do an incredible job, with limited resources, working crazy hours in a stressful environment - thank you for helping the children of Ireland you guys truly are amazing.

Onto my questions:

Do you ever regret becoming a doctor?
If you could change three things about the Irish system what would they be?

I'm a Junior Doctor, AMA

big syke wrote: »

Firstly I think anyone in the medical profession in particular working with young children do an incredible job, with limited resources, working crazy hours in a stressful environment - thank you for helping the children of Ireland you guys truly are amazing.

Onto my questions:

Do you ever regret becoming a doctor?
If you could change three things about the Irish system what would they be?

Yes, I've often regretted being a doctor. Most of my non-medical friends earn considerably more than me and never work weekends. I work a minimum 1 in 3 and can often work more than that. The stress can get to you as well. I would often lie awake thinking about a child I had sent home and worry that I had missed something. I sent a child home recently with a tummy bug - he came back 4 hours later with appendicitis. It's important to not let those things affect your work but it can be hard.

1. More Consultants
2. More resources for smaller hospitals
3. More community funding.

See? It's all more more more. We simply don't have enough - enough nurses, enough doctors, enough money... World class healthcare is bloody expensive.



Its abundantly clear - we are trying to match the NHS without having the NHS conversation - "What do we need to sacrifice to pay for this service". The NHS talk about cost all the time. We should too.

Gloomtastic!

I'm a Junior Doctor, AMA wrote: »

One thing that I am jealous of (apart from a strong union, regulated hours and public support) is that doctors often carry the blame for events out of our control. We are sometimes held responsible for finding a tumour, or diagnosing diabetes, as if we had caused it in the first place! Often we are asked to explain nursing or other allied health professional errors to the patient. A nurse can then come in and sympathise with the patient without having to consider the complexities of decision making in their care.

It's not a slight or negative comment, it's just that doctors are held responsible for more than their share of errors or negative events.

I never would have thought that. How do those patients, who do blame you, react? Is it immediate or delayed? Is it just the patients or the relatives as well?

enda1

Thanks for doing this AMA!

Which health service would you like to try to emulate? Or which aspects of which would you ideally incorporate into ours?

It seems as per often in Ireland we look with blinkers only in the direction of the UK. However, it seems some of our other European neighbours have superior systems, namely France, Belgium and Italy. Having lived in Belgium, Italy and the UK I can say that at least from a patient's perspective, the UK system has serious shortcomings, particularly in primary care.

I'm a Junior Doctor, AMA

Gloomtastic! wrote: »

I never would have thought that. How do those patients, who do blame you, react? Is it immediate or delayed? Is it just the patients or the relatives as well?

It's usually relatives. They'll often feel they need to get angry on their loved one's behalf, which means they fail to see reason and accept that mistakes can happen. I'm not trivialising it, mistakes can be devastating but on the other end is a doctor or nurse who feels awful for messing up.

What I'm saying is that often nurses are freed from the burden of having to make decisions regarding a patient. This allows them to sympathise whilst shouldering very little of the responsibility.

enda1 wrote: »

Thanks for doing this AMA!

Which health service would you like to try to emulate? Or which aspects of which would you ideally incorporate into ours?

It seems as per often in Ireland we look with blinkers only in the direction of the UK. However, it seems some of our other European neighbours have superior systems, namely France, Belgium and Italy. Having lived in Belgium, Italy and the UK I can say that at least from a patient's perspective, the UK system has serious shortcomings, particularly in primary care.

I'd agree. This is what I think.

Hospital A is situated in a large city in Ireland. It has a large, well staffed Surgical department, handling lots of complex cases. Feeding it are Hospitals B, C and D, all small hospitals in smaller towns. Staff from Hospital A visit each of the hospitals B, C and D on a weekly basis to run clinics and elective surgery. Trainees from hospital A spend short stints staffing these units. The quality of care is standard across the board.

Paediatrics in Ireland is subject to a really interesting report which hopes to develop services over the next 10 years. What we intend to do with the new children's hospital is develop a network of linked hospitals what provide the exact same standard of care to a sick child in Achill Island as in Donnybrook. This basically involves transport links and communication between bigger and smaller hospitals. You'd think this happens already, and it does, but it's driven by the staff. What we are hoping to do is make it a systemic process which reduces human error/poor judgement.

January

What are your views on the St. James' site for the new children's hospital?

I'm a Junior Doctor, AMA

January wrote: »

What are your views on the St. James' site for the new children's hospital?

I knew this question might appear!

Firstly I don't want my opinion appearing on any Facebook page either for or against the project.

Personally, I am a huge supporter of the NCH. I am also, cautiously, a supporter of the St. James site.

I have seen the plans, they're fantastic, really well thought out and will hopefully cater to the needs of our entire under18 population for decades to come.

The issues with transport and parking... there have been numerous traffic studies complied for the project and they have not found any significant disadvantage to accessing SJH compared with Temple Street or Crumlin (both of which require people to come via large arteries into the city as well, don't forget).

I remain to be convinced. What I do know is that colocation is a good thing, and that the plans for the SJH site are very impressive. Over 1000 car parking spaces will be available, 650 for patients (more than TS/Crumlin combined).

My feeling is that the silent majority of Paediatric doctors are also in favour of this. How representative the loud minority is remains to be seen.

To answer your question, yes I'm a supporter and I remain optimistic.

Sapphire

Have you ever had a 'House' moment where you solved a really obscure medical puzzle before anyone else?

What's your unforgettable case and why?

Are the on-call rooms a hive of amorous activity like on Grey's Anatomy?

Gloomtastic!

Have you ever witnessed a 'miracle' recovery?

Mr Rhode Island Red

Do you think the HPAT is an effective "cattle-grid" of sorts to keep certain people who wouldn't be suited to medicine out of the profession or do you think it's unnecessary?

What is your normal working week in terms of hours?

At what stage are you no longer considered a "junior" doctor? Is it after a certain number of years or is there another way it's defined?

Has your profession made it difficult to develop and maintain relationships with family, friends and otherwise? Does all the moving about completely eliminate the feasibility of long-term relationships? Is it possible to have a social life in med school and afterwards?

Did you do a "premed" year? If you were given the choice would you choose to do premed or hit the ground running in first med?

When do you choose your speciality? (paediatrics, emergency medicine etc.) Which specialities lend themselves to having the best work/life balance?

If you weren't a doctor, what would you be? Or is it something you've always wanted to do?

Sorry for all the questions...

KonFusion

Any opinions on the national EHR programme / eHealth strategies coming down the pipe/already in place?

What major impact do you think the EHR will have on your day-to-day?