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The Daily Rhino
Sunday, April 20, 2008

Incendiary views
I WAS on the wireless today. It's not the first time - I was on Anita Rani's show on the BBC Asian Network talking all about porn, but that's another story. Today I made it, interviewed by Eddie Mair on iPM. Like most people, I despise hearing my voice, but it could have been worse. I was asked to comment as a piece I wrote for the paper about a year and a half ago was picked up. The topic under discussion was ash cash.

No sooner than one British establishment featured the DR, another did. Now I've
really made it. The great Dr Crippen talked about ash cash too, which is why I thought I'd write this quick note.

The passage quoted on Dr Crippen's and iPM's blogs is tongue-in-cheek and I take any accusation of being insensitive on the chin, for it is deserved. But the passage should be taken in context, so do please read the rest.

Dr Crippen does indeed make the exact same point I did in the extended interview, hospital doctors who deal with death on a daily basis utilise coping strategies that are insensitive. When we talk about getting your ash cash from the ash point, or make jokes about celestial transfers to the big ward in the sky, it is merely a way of distancing ourselves from the fact someone has snuffed it. Crippo's right, we don't develop the same relationships with our patients that a GP might (well, polyclinics will see an end to that).

"I wish I was young again so that it could all be fun and “ash cash”, but I am no longer young. My skin is no longer Rhino-thick for now I understand what I am doing, and how important it is that I do it properly." [Link]

I enjoyed reading some time back that the venerable NHS Blog Doc describes himself as a curmudgeonly git, as this is how most of my friends would refer to me. Whilst I have maturing to do before I reach Crippenesque gravitas, it does not mean that youth eschews pathos.

Sure we joke and pick up our ash cash cheques, but I think we all spend a quiet moment contemplating the elapsed life we are signing off into the flames. In its great early days,
Scrubs occasionally featured some great lines. JD looks at his first dead patient and says "he looked exactly the same, only completely different."

Moments like this, and fumbling awkwardly for a pacemaker across a cold corpse, are the experiences that stay with you and shape your development in medicine. But they're put away and covered by tasteless jokes at the pub. Just the way, I feel, it should be.

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Saturday, April 19, 2008

Scrooge McDoc
Originally published in the April issue of Medical Student Newspaper.

YET
another horrible, horrible month rolls around and curse you Satan, curse you, I'm still alive.

Something's gone terribly awry as I am working a nightshift in A&E...when I don't have to. Yes I have voluntarily taken a locum shift in the hellhole that spat me out four months ago.

In fact this is just one in a line of locum shifts I am making a tradition. One nurse takes great pleasure in teasing me, "ooh look who's back, he who said he would never step foot in here again! You love it really."

How wrong she is. The question is then begged: why am I here? I don't seek to answer this in quite the metaphysical way Aristotle intended, but why am I seeing a perianal abscess at 1am? The only reason people do anything, money.

Once upon a time I used to pride myself on being quite an enlightened soul. Sure sure, this sounds funny NOW but only because you know me as the shallow git I undoubtedly am. However money never used to be high on my life's agenda.

I suppose any doctor would say the same - we're all in the wrong profession if money was our primary concern. But I really was other-worldly in my disinterest with money. I was generous and thought I would work for free as long as I had a roof over my head.

What complete gash. Over the last few months I have become the guy Scrooge McDuck aspired to be, well except for the swimming in your own money thing. That ducker still trumps me there.

I seem to spend my every waking minute thinking about money, whistling Pink Floyd's Money and carrying the FT. Just carrying it, I can’t read it. Now the reason I have subjected myself to additional A&E (along with some medical SHO) locums become clearer. I want money.

I think I can pinpoint where my slide from Buddha-like nirvana to cash-hungry Scotsman happened, and like just about everything in my life, it revolves around jobs.

It was only when I actually got a job that the immense stress on my shoulders became apparent. For months I had deluded myself that I was a chilled out cat, unaffected by job applications and an insecure future. In reality I never realised how much I was suffering.

I'm not alone. Perhaps 50% of my friends are still without employment come August. Feeling insecure about the future is a horrible thing and it had engendered a passion for money I had never experienced before.

With money, I felt I would be able to absorb the blows dealt to me by unemployment, I thought my Benjamins would help me roll with the punches. I spoke to senior colleagues about how much cash I would have to sleep on when I got to their level.

Horror. It turns out I'm earning more than my registrar. Sweet Jesus, several more years of hard graft and my pay will go DOWN.

Not only were my hopes of having a money-mattress dashed, I realised I wouldn't even have enough notes to light cigars with. 'Twas at this point I resolved to turn my efforts towards lining my pockets with the green.

Hence why you find me here, volunteering my time in the place I hate for the sum of £30 an hour. Sounds quite tasty, right? Certainly more than an SHO could expect to make in a permanent post. What if I just worked locum shifts? I calculate I could have an annual salary of £72,000. Not actually that impressive when I consider my best mate, who was at uni half as long as me, is on the same figure plus bonus and his company are buying him an Audi R8. I still drive my Nissan Micra.

As it happens, I know someone that decided to do exactly this, be a lifelong locum. He now owns five properties. The crucial difference is he is a GP. An agency I am registered with lists the following pay rates for hospital doctors: F1 - £21/hour, SHO £30/hour, SpR £34/hour and consultant £46/hour. The rates are the same irrespective of time or day.

For general practitioners, who will now be fully qualified five years out of medical school have slightly different rates: Mon to Fri - £100/hour, weekend - £125/hour and bank holiday - £200/hour.

The positives, let's concentrate on the positives. 20% discount at Nando’s. Back of the net.


Despite my enjoyment at reaping the rewards of locum shifts, they do represent a short-sighted waste of money by the NHS. A recent BMA survey shows that 30% of junior doctors are working on teams with at least one vacancy. My team has three. Hospitals spend money on expensive locums to cover shifts, but most of the time hapless SHOs and SpRs are strong-armed into ‘working a few extra hours’.

These vacant posts, all the more risible when thousands of SHOs are unemployed, are a legacy of MTAS and this year’s unnamed successor.

Consider two systems, both flawed. Years ago the SHO slaved away for three hundred hours a week, slept once a fortnight, knew all the patients and learnt bucketloads. Now I work a shift system, have an astonishing four handovers a day and there is practically no continuity of care for patients. Surely there is a middle ground?

As juniors’ training hours are slashed by the European Working Time Directive, and the time it takes to become a consultant is reduced by the government, we move towards a scenario where tomorrow’s consultants have perhaps a quarter the experience of present-day consultants. Likewise, practical skills suffer.

A renal job should mean getting to do loads of central lines. Sure…provided there is no team of specialist nurses inserting all the lines. They’re good at what they do, they’re cheaper than an SHO and don’t move on every four months, so why would a trust want a doctor doing these procedures? This way the number of expensive and troublesome doctors can be cut.

A superb plan. Except for the fact that I severely doubt the venous access specialist nurses will be around at 2am when a patient has crashing septic shock and needs a central line. But I will.

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