Saturday 7 February 2015

A Comparison of Practices

Hello from UK!

Just as a quick introduction, I'm Indy, and I'm a young doctor fairly new to the world of Emergency Medicine. Definitely new to the world of Emergency Medicine in the UK. I've been in the field since late 2013, and had the opportunity to work under some wonderful mentor-ship in Mumbai, India, and now in good ole UK.

I contemplated a fair bit about the title of this post. You see, I've only been here for a month as of today. The points mentioned in this post are basically a few of my observations so far. In fact, I'm sure I've noticed more, but it's difficult to pen down the smallest of differences. These are the ones that stood out to me.


Now, personally I was fortunate enough to be under the guidance of Emergency Physicians from the get go. But, not all of India has them. What I mean, is that though there are physicians from various faculties coming together to comprehensively train the future Indian EP of tomorrow, there aren't many places with trained EPs to begin with. The reason for this is that Emergency Medicine has only been recognized as a separate branch of Medicine in India recently, and so it is a growing field, still in its infant stages. In the UK, there are already a bunch of Emergency Medicine Consultants, and sometimes that makes things a little easier by not going in-depth into the various associated specialties, and instead staying focused on the Emergent aspect of the cases.

Teaching Environment

Our training is based largely, like any other medical practice, on the shop floor - learning as we go with each patient, each case. But we do also have scheduled lectures. So the junior doctors get a chance to assemble, and focus together on a certain topic presented by the consultants, and with a good deal of interaction going on. Though the lectures are in themselves very useful, I find the system useful in helping us develop and maintain a discipline. Each week at the same time, we have a lecture. We're expected to show up, and we always do. You end up making a habit of it. And a habit of learning is always a good one.

Work-based Assessments

Exams are important. Passing exams - even more important. But studying with the intent to just pass the exam, isn't very good. The system here is good in that way because they take two components into review. One is of course, exams. But those alone don't get you very far if you're lacking in the other element. Work-based Assessments. There are different ways of doing these - Mini system based exams focused on any particular system, Procedures, Communication skills, Case-based discussions, Feedback, CMEs, Workshops. All these help to build a strong portfolio. More importantly, they ensure a systematic learning process.

No one is expected to be an expert at every aspect on their first attempt - or even second. What they do expect is growth from every experience - and that's made much easier when you know your strengths and weaknesses. This sort of stratified, systematic, and guided learning is one of the highlights for me here. You aren't passing to the next level because you've finished a requisite amount of time - you're passing because you've spent a requisite amount of effort. Personally, I think that's brilliant.


At any given point, there is always a registrar on duty. When the consultant is not around, a registrar is capable enough of handling the department (with some exceptions obviously). That means the more junior doctors such as myself, have someone to turn to when we get stuck or when we need some good advice. Now this doesn't mean that you go and talk about every single case with them, but should the time come when you're overwhelmed, or feel like something is out of scope, there is someone who has more experience, more knowledge and practical wisdom to turn to for aid.

Another thing I like about the system here, is that they are happy to help, happy to teach. From the overall department point of view, the top priority is the patient. But from the training point of view, the priority is that the growing doctors learn. Whenever we seek advice from seniors, whether it be a case review, or knowing local hospital protocols, they are happy to help. They want you to learn. It benefits you, them, the system and the patient. When reviewing cases related issues, they don't tell you the answers. On my first day working here, I showed one of my consultants an ECG, and asked him what it is. His eyebrows shot up, and he said to me, 'It matters what you think it is.' So he asked me first to give my interpretation and then he would tell me his. It's a good thought-provoking way of learning.

The System

How it works here is that the GP is the main point of contact for patients. Unless it's an emergency, they don't show up to the A&E very often - they do, just not every patient ends up at the A&E as their first point of contact. The patients go to their GPs who assess them, treat them and arrange for referrals. It's unusual that absolute emergencies would go to the GP first; those do come to us.

Now in India, we have the system of the patient contacting the hospital or doctor directly and taking available appointments of their choice with whatever relevant (sometimes even irrelevant) specialties. Here, it is the GP who determines if a specialist consult is required, if so, which, when and so forth. Hence I said, they are the patient's primary contact. The record keeping here is quite tremendous and meticulous, so the GPs have all their patients' records.

And after a patient has been to the A&E it is a practice for us to let the GPs know the important and relevant parts about the visits. I won't go into the details of how - it's an elaborate internalized, computerized system. Wonderful how useful technology can be, eh?

It may not be a fully closed loop, but it is certainly useful.

Record Keeping

Segueing into record-keeping, as I said, it is meticulous. Again, I was fortunate to have worked at a hospital under an experienced EP who knew how important records are/can be. And so I haven't been having too bad a time adjusting to that aspect. They are even more important in cases which can/may go to court - but since you can't always predict which cases those will be, good record keeping is a key practice for every case.
With the general population developing more awareness of their rights, I would say it is important world-over. Those who till now, have not paid much attention to their patient notes, I'd say now is a good time to start. It helps the patients, it helps the doctors involved, the institution. Good records are a reflection of good practice.

Continuous learning

When you're in a (healthy) competitive environment, you end up really motivated. That is the case here. I feel in awe of a lot of my peers. They are so knowledgeable and up-to-date. It makes you want to be like that too. Since coming here, I have been reading articles on medical forums like medscape and similar, doing online CMEs, reading Journal articles. And of course, there are always books.
It's invigorating to progress - not for progress sake - but to actually be able to improve your knowledge and practice.

Basic Skills

I've certainly been revising a lot of skills that I haven't much practiced since internship - cannulations, ABGs, blood collections etc etc. It's not that I've forgotten how, but when you're out of practice, it shows. It is an art - especially the difficult lines - let me tell you, relearning all of it seemed daunting for the first couple of weeks. But I feel a lot more confident now that I've gotten back into the groove. Besides, there is always someone to help should help be needed. That in itself lends you the confidence to begin a job.


Something that everyone from overseas takes a bit of time and effort to adapt to over here is the communication aspect of good medical practice. Bed side manners are important here. You always ask for permission. You always maintain a calm, even tone. It is important for everyone concerned to not be judgmental. And this has to be done for every patient, every time. Sometimes it can get a bit hard, but with enough practice it becomes habit. Communication is important anywhere in the world, but it is different in different places. It is important to conform yourself to local practices. You cannot be rigid in your way. It's all about a achieving a good balance, with the ultimate goal of helping the patient, and the patient being made aware of that in the proper manner.

That is pretty much all I can think for now. I'm sure there are more things, but they seem to have gone to a secluded part of my conscious thoughts. If I can think of more, I'll be sure to let you know. It is interesting to know the various practices from different parts of the globe. For me it is a great opportunity and a wonderful learning experience. If and when you get the opportunity to work abroad, don't pass it by without due consideration. And with that preachy bit, I bid you goodbye until next time!

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