How medical training works

[Mayadill]

Obviously people who’ve worked in medicine or allied fields know this but that leaves a lot of people who don’t and might be interested.

Keep it simple and deal with what used to be called the Big Five, the London teaching-hospitals, Guy’s, Tommy’s etc. They have large numbers of Consultants in each specialty and are the hubs of training rotations. Similarly of course for Manchester, Leeds, Edinburgh and other medical hubs.

Specialist registrars (SpRs) are the trainees on the rotation. Rotate is indeed what they do. 3 or 6 months, here, there amd everywhere. Thus at UCH there are 15 Rheumatology Consultants, mostly specializing in particular diseases, e.g. the lupus team. The SpRs spend time on the lupus team, time on the RA team and so on and also staff a number of satellite district general hospitals (DGHs), thus 6 months at the Whittington for instance. Additionally they may have journal clubs, training days and so on. They may also take time out to do research, therefore if you are very lucky you might get a Consultant highly knowledgeable about IL-6. The time at DGHs exposes them to the full range of rheumatological diseases together with being on the ward, on-call and so on, but in the case of uncommon ones such as PMR that may not mean very much.

Finally they receive a Certificate of Completion of Training, meaning they’re qualified to apply for Consultant posts. If they’re completely brilliant they may be asked to stay on but not everyone actually wants to remain in the hothouse of academic medicine, at the cutting-edge of research.

Having trained under Professor Fantastic World Expert (thinking of David Isenberg, actually) does not mean they have by a process of osmosis acquired all Prof’s knowledge.

So then they’re out in the hard cold world of the DGH and are your rheumy.

S/he may be a single-handed Consultant, which means what it says: is the sole Consultant Rheumatologist magically expected to be omniscient concerning everything from tennis elbow to systemic sclerosis and of course is not. If a nice sensible person s/he looks up things, consults colleagues. If not nice and sensible s/he remembers s/he saw a PMR patient at the Whittington four years ago and that has endowed him or her with all he or she needs to know about PMR.

All doctors are supposed to be in continued training.

Key parts of the GMC guidance on good practice of which certain doctors described in this forum are in clear breach are:

b provide effective treatments based on the best available evidence

c take all possible steps to alleviate pain and distress whether or not a cure may be possible1

8 You must keep your professional knowledge and skills up to date.

9 You must regularly take part in activities that maintain and develop your competence and performance.

Good medical practice-english (gmc-uk.org)

In short a doctor who insists a PMR patient suffer pain and distress through insufficient Prednisolone hasn’t got a leg to stand on.

[Rachmaninov2]

Thanks very much for this Mayadill, enlightening and extremely interesting.

[PMRpro Ambassador]

Or SHOULDN'T have a leg to stand on - but occasionally gets to borrow one or two from the collegues watching their back ...

[Mayadill in reply to PMRpro]

Ah, the medical centipede

[SheffieldJane]

To be fair I have experienced great wisdom and knowledge from very young doctors over the years. An open mindedness that can be absent in the unconscious incompetence of the seasoned consultant. One doctor in particular stands out, he looked about 16, he knew about GCA and lined up appropriate tests in A&E. With the urgency that was warranted.

[Mayadill in reply to SheffieldJane]

Yes, absolutely. It's a lottery.

[PMRpro Ambassador in reply to SheffieldJane]

My guy looks about 16! He is gaining in gravitas as he is now going grey ...

[piglette]

The trouble is a doctor who insists a PMR patient suffer pain and distress through insufficient Prednisolone leaves his patient without a leg to stand on too as they are left supine!!

[Mayadill in reply to piglette]

I suppose one could crawl pitifully into the PALS office and say, "Alas, I two months ago i stood tall and strong. I am reduced to this state by the instructions of Dr X." Not quite sure what would happen - arriving at a Buck House garden-party in a bikini occurs to me - though the only person I knew in PALS was no sycophant, and you might just get one person fit and will and ready to fight your corner.

[piglette in reply to Mayadill]

😁😁😁

[Suffererc in reply to Mayadill]

they would gang up and ask you to leave the practice 😊

[Bcol]

Interesting read, thank you.

[SnazzyD]

I have seen swathes of medical students come through my workplaces and we have had to ‘train’ them in that particular area. I would say the majority were unsuited to dealing with people. I think it was partly to do with the particular university they were from though. Occasionally we would see a rare gem, a person with humility, a thirst to know for the patient’s benefit not just for the academic rigour and passing exams, smart, possessing of ability and wish to listen to anyone. The rarest gift was also being a creative and critical thinker and not mainly a person who can just regurgitate information. The issue was also they were being taught by the old guard so the same old attitudes were being recycled. In all my years in the health field I have never come across such poor practice as in Rheumatology. For one reason and another I had avoided this field until I became a patient within it and came on this forum and boy was it a shocker!

[Mayadill in reply to SnazzyD]

Indeed yes those with a people problem are not best suited to medicine. There is an excellent institution down the road, Doctor. It's called the Royal Veterinary College. There you may be assured your patients will not answer back. There was one little honeypot of a student in one department I worked in, temping basically, earning a little extra doing admin/IT. He actually described himself as a people person. I hope he went far. There is a distinct element of intellectual delusion. The top A Levels give some to think they are a reincarnation of Einstein but a top grade in A Level Chemistry does not indicate a capacity to question, to 'think outside the box' as the jargon puts it. which is what the great ones do.

[Suffererc in reply to Mayadill]

or to be people friendly. Some approach as tho they actually find the patients tedious.

[PPop]

I must say that I do get a bit weary of the doctor bashing on this forum. I thought the initial post was quite informative ( until the last sentence!) and perfectly illustrated why it’s difficult for a general rheumatologist to be an expert in all fields. However, I suppose that’s the nature of these type of forums, as helpful as they can be, they do tend to attract patients who are having difficulties, both with the disease and the relationship with their health professionals.

[Mayadill in reply to PPop]

We are talking about the deliberate infliction of needless suffering. I do not think we need to be nice about it. Personally I have had excellent doctors. It only takes one to destroy quality of life. Since my PMR goes straight to my hips, if anyone had messed with my dosing I'd be in a wheelchair.

[123-go in reply to PPop]

I have to say that I don’t feel that critical comments about those responsible for managing our diseases can justifiably be called, ‘doctor bashing’ (I must admit I have once felt literally moved to do that). This forum was set up as a safe place to come when problems arise and where members can express their concerns, talk things over and receive support and advice based on sound knowledge and personal experience. 🙂

[Rachmaninov2 in reply to 123-go]

Well said 123-go, I totally agree. 👍

[Suffererc in reply to PPop]

don’t think anyone is Dr bashing just tired of their disbelief of the pain we are suffering

[PMRpro Ambassador in reply to PPop]

Doctor-bashing is not allowed - no names in public at all. But it is only reasonable to allow patients to tell us about how they have been managed and the result - since that is how we can appraise a situation and suggest ways of getting around it. Patients have been totally misdiagnosed for years because of poor medical care

healthunlocked.com/pmrgcauk...

and we actually picked it up when the patient originally posted years ago.

Some patients have lost their sight as a result of poor - even downright negligent - care, Try telling a formerly active and engaged patient in their 50s that they shouldn't "doctor bash" as you put it as they are now blind and dependent on others.

[Mayadill in reply to PMRpro]

As you'll have gathered negligent is a word I should use. But on this issue we always deal in fact and indeed reproducible fact. Someone's doing fine on 12.5 mg. Doc says drop to 10 mg after one week. Result misery. We note instances - is that detached and academic enough! - where medical professionals flout the GMC, flout NICE, flout the BSR, flout everything medicine itself upholds as good care. Silence would be intolerable.

There is perhaps sometimes another element, which we can't talk about because we have no evidence but which crops up with too much regularity in the news -- mum of three sent home with Paracetamol and turns out to have bowel cancer: the trivializing of women's pain. Add to that that few of us are what could be called young and isn't it a lovely thick stew.

[DorsetLady PMRGCAuk volunteer in reply to PPop]

Further to 123-go reply -

Many patients feel they don't have a voice in the wider world...friends/family aren't always interested, neither are some GPs...won't say all, because some are very good. So better to get it off their chest here than fester about it and cause more stress...thus exacerbating their illness.

[123-go in reply to DorsetLady]

I couldn’t agree more.

[Longtimer in reply to PPop]

If l ike me you had over the years seen all types of Rheumatologi sts you would agree with post becau se of it's honesty. My first Rheumatologist said don't ask questions just follow this lowering on this printout and you will be fine.....I got worse.... .second one said the same, also said if you have pain it's not PMR!....I askef what is it then.....he didn,t bother to answer.....Third one....brilliant, he listens, he discusses everything and asks if I have any questions!......that is all a patient wants.......

[Greenthought]

Belated thank you for an excellent overview of how medical training works. I didn't know much about this. There are lots of parallels in the more general education field, too.

[Mayadill in reply to Greenthought]

Thank you. Yes, everywhere there's a ladder to be climbed indicating hopefully increased knowledge and competence.

[PMR2011]

I’m okay with and understand there is a learning and experience curve. It’s when they take the attitude of knowing all and not listening that I lose patience. I’ve had both young freshly minted and ancient with cobwebs docs who have learned from me (and I have learned from them). That is the best scenario. A partnership to wellness!

[PMRpro Ambassador in reply to PMR2011]

My rheumy is a world name in the field and he says he learns something about PMR from me every time he sees me.

[123-go in reply to PMRpro]

I hope he mentions you in his research papers 😁.

[PMRpro Ambassador in reply to 123-go]

Sarah Mackie has had my name on a paper.

[Mayadill in reply to PMRpro]

I'm one of the authors on two papers in the British Journal of Rheumatology. Epidemiology stuff, I did the legwork, data gathering, plotting where patients lived, clustering of scleroderma round Gatwick and Heathrow, and the other one basically just required the ability to read. How many pts have this that or the other - abnormal FEV1/FVC ratio and so on.

[123-go in reply to PMRpro]

Well, there you go! ⭐️

[Mayadill in reply to PMR2011]

When it comes down to it I guess it's basically a question of Normal Human, open mind or closed. You can find the same thing talking to a stranger at a party, this person is not listening, not absorbing what you say, running totally on what's inside his head which is impervious to penetration. it's just that strangers at parties don't have the entire quality of your life in their hands.

[orangemax]

Well THAT totally explains a few things!! Thank you!!

[Gimme]

I have thought for a while that the younger newly qualified docs are so often more flexible and creative in the way they think about a patient's problem, less likely to stick to old rigid ideas and pre-conceptions, plus more likely to be up to date on latest advances. Just my perception. The GP who diagnosed my PMR is very young, he did a really thorough exam, and seemed to have a good idea what was wrong as soon as I started to explain. I get the impression that he does have a specific interest in PMR though. He looked very smug and pleased with himself when I told him about my response to pred. But above all else, as has been pointed out, He was kind and he listened and did not try to invalidate my experience. That was worth a lot and made me feel that I was in safe hands.

[Mayadill in reply to Gimme]

Unspoiled. To be encouraged and cultivated. Some kids choose to study medicine for reasons that aren't exactly wrong, but not people-centred. Some really want to help people and make our lives better.