The Perfect Consultation

As I sit and write this, two days after this consultation, it still makes me smile.

You know, for many interactions in medicine, there are fault lines which run through them – not enough time, you are tired, the condition is complicated and full of challenges that pressure you, the patient is unhappy with the plan, and so on. This is part and parcel of medicine and of being a doctor – and in fact it is those fault lines which make us learn, adapt and evolve in our practice. After-all if everything was easy we would never get better – the same way that muscle needs to be stressed in order to repair and then develop stronger and more prepared for the next insult.

Of course in all walks of life, we always welcome those instances whereby there is a nice simple event and everyone enters and leaves it happy. I had one of these on Friday.

consultation room

(The above photograph is of my current GP practice consulting room)

The last patient of the day is called into my GP consulting room. My coffee is cold as the last few patients were so challenging that I didn’t even manage the odd stealthy sip! So I am feeling a little tired now but did not expect what came next. In bounce two energetic little girls probably 5 and 9 years respectively – puzzling since I am sure the patient I am expecting is at least 40 years old – though soon rectified as I hear the mother coming up the stairs. The two little ones had clearly gotten a head start on her…and judging by their energy, I doubt that it was the first time.

As they all come through the door, I stick my hand out and shake their hands respectively, introducing myself and getting their names. The look very proper as they shake my hand with their tiny one and giggle, the youngest looking up at me like I was a giant! Then, once mum is in as well, I draw up three chairs and they all sit around me.

“Right, what can I do for you?”

The mother describes her issue with the two little girls kicking their legs away under the chair while at the same time having a fixed gaze with interest at the conversation. Before mum has finished the story, the youngest blurts out:

“I want to be a fairy when I grow up!”

I looked at the girl and said, “Well, have you been to fairy school?”. “Not yet” was the reply. You have to love a child’s imagination! I explained that in order to get into fairy school, you need to pass normal human school really well first – as they only take the cream of the crop. She nodded, taking mental note of this fact.

The consultation goes on and it as it was it turns out that the patient had nothing to be concerned about.

“I want to be a doctor when I grow up!” the older girl suddenly says – with her younger sister looked annoyed at being gazumped! I knew more about this than becoming a fairy, so…

….what followed was such a lovely 10 minutes in which I showed that little girl my stethoscope (after of course it had been thoroughly cleaned), let her listen to her mum’s heart beat with it, and showed her lots of other bits of equipment around the consulting room. This, occasionally interspersed, with conversations about fairy school and that, I had, unfortunately left my fairy wings at home today. The mother looked on with such pride at her children as they confidently chatted with me. I would have done so too if they were my children.

As this was my last patient for the day, I had no time pressures, so let hem ask me questions and explore the room to their hearts content. But when it was time to go, they both said:

“Can we come and see Dr Knight again, please mum?!!! Pleeeeaaase!”

And then on the way out the door both gave me a very unexpected hug.

There is no big medical message this week, just a recollection of a wonderful consultation that, well, melted my heart a little.

Have a great week all.

Dr Nick


The Greener Grass? Life in Primary Care Medicine

As I type this I can only describe a ‘buzz’  about me; physically and mentally I feel pretty good right now. I don’t mean to sound smug when I say that but rather just that I feel I have been on quite a tortuous journey with medicine and how it aligns with my way of life and desires for the future. I am more relaxed, happier, driven and my old self again – after probably 3 or 4 months of losing those aspects a little. Even my family tell me this – and as we are all aware, probably the majority of families know their children best.

So what’s changed?

The short answer is that I have moved out of secondary care medicine (that’s hospital medicine) for 4 months and am now working in primary care (that’s general practice). Life is very different for a doctor in primary care. Now although I am still very wet behind the ears in general practice, being stumped by how to treat Mrs Smith’s achy joints, or little Jimmy’s sore red toe after his swimming lesson – for I am used to patients with severe sepsis, widespread infections, acute heart failure, and massive strokes – I never had to worry too much about the less acute side of medicine.

General practice doctors are true generalists – and I envy their knowledge. It is so broad, so encompassing, that they have to know a little about everything – both the chronic conditions, such as Dementias, Parkinson’s Disease, Chronic Heart Failure, Diabetes, and the acute conditions such as recognising meningitis in a sick child. To make this all more challenging – they typically have about 10 minutes per consultation to take the history, examine, diagnose, and make a plan – whether that be for further investigations or management. And they do it all without the support of investigations on their doorstep – you can’t get a ‘quick X-ray’ or ‘blood test’ or’ MRI scan’ to see if they do have a disc prolapse. You have to use your intuition and experience.

This week, as it is still part of my ‘introduction’ phase of my rotation as an FY2 to general practice, I am doing joint sessions with a GP before getting my own patient list next week. This means that we are both in the consultation room, and take it in turns to sit in the ‘hot seat’ and lead the patient consultation with the other watching in the corner. This is great fun! However, what is beginning to wear a little thin is, during the times when it is my turn to sit in the corner and observe, the patient walks in and says “oh, you’ve got a medical student with you”.


I have to just smile, and usually say nothing and bite my lip. My poor lip – it has taken quite the beating this week.

I really enjoy the set up of general practice too – you get a nice big office which, as Louis from X-Factor would say “you can make your own!” and super-comfy chairs. And SO much tea.The training scheme too is more condensed that hospital medicine (though I do appreciate for the ‘patient’ that this may be a less than favourable situation) and so you are qualified much sooner – with a lot more flexibility.

Now I have spent a lot of time reflecting this week about that word – flexibility. I know that I my ambitions are slightly skewed compared with many junior doctors for I not only want to be a good, safe doctor first, but I want to write about health, do some sports and exercise medicine, get more into media work (for the love of talking about it not the public eye status, I should add), and also some expedition medicine. This globally is within the context of having a family – most importantly for which, I have time for. General Practice is the ONLY career path (beyond leaving medicine altogether) that would allow me to do this. I will stand to be corrected on that…

That is food for thought and something that I need to mull over in the lead up to choosing my career route. The deadline for that decision, out of interest, is this November – so not long to go. I feel I know what is the most natural decision to make but I will talk it over with my family first – they are often my voice of reason!

This week I also got a better understanding of what a GPSI is. Now, pronounced “GYPSY” , I never really quite got why all these GPs had such a strong affiliation with the Gypsy community…and then I discovered that is stood for GP with Special Interest. Oh. As my mum would always (and still does in fact) – for someone seemingly smart, I can be very stupid. I cannot disagree. In the practice that I am at currently, we have GPs with special interests in maternity, diabetes, genito-urinary, musculoskeletal, and dermatology. I could be a GP with a special interest in Sports and Exercise Medicine.

I like the sound of that.


Needless to say after a relaxing weekend seeing friends, going to the cinema (Expendables III, oh dear), and some reflective walks through Battersea Park, I feel very good about things. I am looking forward to hitting the GP practice tomorrow for another good week. It’s a busy week too – I have to finish another article for the Independent, and I am doing my final filming session for the Discovery TV show called “What Have I Got” – more on that perhaps another time. All in all, life is good.

Have a great weekend everyone,

Dr Nick


Now, when I looked up the definition of motivation it read something like this, “a reason or reasons for acting or behaving in a particular way.” That seems pretty obvious doesn’t it – we act because look for a result in something –  a person, task or thing. The reason I got thinking about motivation is not some complex, deep-rooted philosophical question that requires all of our combined cerebral white matter. Instead, I was walking back from the gym this morning, having watched people, to varying degrees exhaust themselves on machines and with free weights, some looking happy, some looking sad, and some well, looking like I would definitely cross the road in the street if I saw them and their face all distorted with grimace and grunting. It them continued as I left the gym, having just about motivated myself to complete my workout (but feeling the effects of a processed, synthetic take-away pizza the night before that was not quite in harmony with my gut as of yet), to find the rain pouring down thanks to Hurricane Bertha, and a huge stream of cyclists racing along the Chelsea Embankment as I walked home. They looked wet, tired and showing off far too much in all that lycra.

So the question is not what is motivation but why do some of us feel more motivated than others? Why do I, for example, currently spend a good few hours of my weekend reading up on medical issues encountered in General Practice now that I am on my four month rotation as a GP? Is it fear, low confidence, or more positively a drive to be better, enjoy what I do more if I am armed with knowledge – or perhaps I just have nothing else to do?! Personally it is a combination of all these things I am sure. I could also put my feet up and watch some TV (I am sure I will later) but instead I am sat here typing this blog. Why? What motivates me? Again, I expect it is a multitude of factors but one of the most pressing being that I find it deeply rewarding and enjoy it – two of the best motivators.


Health and how we look after ourselves is also driven by motivation. Some feel motivated to look after the one body they have – they choose to eat well, exercise, get plenty of sleep, and to not abuse their body too much with all the vices that flow through modern living. Others on the other hand either fail to be motivated to do this or are motivated to other aspects of life such as sitting and playing video games, alcohol, late nights with friends, and so on. Now I realise that the majority of people do fall somewhere in the middle, and as I have said before, there are such a huge multitude of factors that effect motivation that we could be sat here all day. This blog entry is merely a ‘pause for thought’ on the topic, I suppose.

Now in general practice, my motivation has changed. This is largely thanks to more sleep, less stress, and the pressured feeling that I was having in my last rotation now being off – at least for now. Now, as a result, I feel much more motivated and driven, my mind clearer on my goals such as working hard on this rotation, revising for the next exam in January (because I forgot to submit my request to sit the exam in September and the deadline has now passed! Dropped the ball there, Nick), get into writing more for the Independent (which I am still on cloud-nine about), and see what other adventures and opportunities open up. It is also interesting in General Practice to see what motivates patients to come into the practice – often it is the result of something they have seen on TV, the start of a new relationship and they want that bit of acne magically removed, or they just want to chat. I suppose my point is, it is not necessarily driven by a desire to improve their health but to make them feel better. That’s fine as we can sort them both out at the same time hopefully.

So going back to motivation, yes, it is a complex beast. It may have its roots in physical, psychological, social or culture factors, or be driven my a general desire to optimise wellbeing and total health. Perhaps, on the other hand, it is driven by a specific desire or goal such as to get that better job or better image you crave. Now the theories of motivation are in the dozens, and I am sure you don’t want to hear about every one of them. But let me just tell you about the simplest way to thing about motivation:

Intrinsic Motivation:

This is driven by an interest or enjoyment in the task itself, and exists within you rather than relying on external pressures or the search for reward.

Extrinsic Motivation:

This is driven by the attainment of an outcome, and not whether or not there is intrinsic motivation. Positive extrinsic motivation includes rewards or showing the desired behaviour, whereas negative extrinsic motivation is the threat of punishment if the task is not met.

Sadly nowadays there is a lot of negative extrinsic motivation – especially within the workplace with nearly every market becoming so competitive and peoples jobs resting on a hair-pin. I know personally that my intrinsic motivation is a double-edged sword for in drives me immensely in some aspects such as the pleasure of practical medical procedures or treating an acutely unwell patient; in other aspects however I am negatively intrinsically driven by my own internal barometer of how well I should be doing – and if it isn’t met, then I blame myself. As for extrinsic motivation – for me, I tend to do what I do because I enjoy it – I don’t feel a need to please the powers that be just so they can pat me on the head…

So there we go, something to think about for a while. Motivate yourself and more importantly (as it will come full circle to you) motivate others. Let’s keep it positive as well, no good really comes from motivation through fear – it certainly has no longevity to it.

Oh, and last time I’ll do this, as if you follow me on Twitter, you’ll have seen this re-tweeted to death but I am over the moon the have my first ever media article published in the Independent online – it even made the front page! I have put the link below in case you have an interest to read it. Now, that is a great external motivator to compliment my internally motivated love of writing them!

Have a great week all.

Dr Nick

The Changing of The NHS Guards

At the strike of midnight last night, that was that – I was no longer a Foundation Year 1 (FY1) junior doctor. My time as the junior guardian of the NHS trenches, carrier and organiser of mountains of paperwork, scan-result chaser extraordinaire, absorber of all blame, and patient vampire (for the endless blood tests required) has come to an end.

Suddenly, from today, August 6th 2014, I was a Foundation Year Two Doctor, aka Senior House Officer (SHO) or “Senior-Ho” (an informal title that I was perhaps less happy about, with its endless opportunity for misinterpretation). This has a meaning attached to it that I may be yet to understand – hence my happy and most likely naïve reaction to leaving my FY1 post. For with this SHO post comes hidden traps – more responsibility, more accountability, more expectation and most likely the first person that the FY1 on my team may look to for advice on how to treat the patient. I however relish this – an opportunity to stretch my wings a smidge more, focus that little bit more on the medicine, rather than whether I have the 30 sets of clinical patient notes organised and ready for the ward round, while simultaneously taking bloods from 3 patients, answering the bleep, and trying to call that random consultant from another hospital with half a story about a patient at your consultant’s request (all in the painful knowledge that you know they will most likely bite your head off)….all duties of an FY1.

If you also read my blog entry before this, you may have felt it had a slightly negative (‘sad’, as my mum put it) undertone to it, layered between the printed words. You would have been right – I was stretched to an inch of my ability in my last job and drained both physically and emotionally – making me question everything about the job. This saddened me in two ways – one in that any job should do this to a person but probably more impacting on my mood was that I realised perhaps I wasn’t up to it – that it has beaten me. I hate to lose. I still have my doubts, and still step into the forthcoming year with caution and my wits about me but I must say I feel a huge sense of relief; I have after-all survived the year (and that very hard final rotation) with most of my faculties intact (still single though, much to my disgruntlement), and feel that tight suffocation lesson its grip a little.

For all the new FY1s out there starting I would give one personal message and one from someone much wiser than I. From me I would say, don’t ever let people tell you that you are worthless, or that you are incompetent, and never ever let that bring you down for more than a heartbeat or question yourself as you lay in bed in the dead of night – you have worked so incredibly hard to get to where you are – so be proud and keep that bloody chin up. And from the man himself, Winston Churchill, “Never give in–never, never, never, never, in nothing great or small, large or petty, never give in except to convictions of honor and good sense. Never yield to force; never yield to the apparently overwhelming might of the enemy.”

In this case, the ‘enemy’ is your own self doubt when people try to make you question yourself.

On a final note, this made me smile – it came up on my phone this morning at 8am. I had obviously set a reminder to myself…..I’m not sure why I set it…it wasn’t like I would forget!


To another year in the NHS….

Dr Nick

12 Months a Doctor: My Reflection

Twelve months can go by in the blink of an eye or a painful minute by minute slow-mo. We have all experienced those years that cement our lives, define who we are, or are simply packed with some of the best – or some of the worst memories we have stored. I am 2 days away from finishing my junior year as a doctor in London. Looking back and re-reading some of my old blogs from July and August 2013 makes me realise how so much has changed, and how much has remained unmoved. With a year as a doctor now over, I wanted to reflect with you….


We all start out as eager pups when it comes to medicine, drunk on the knowledge and drama of episodes of House and ER, keen to become the best, most knowledgeable doctor that we can be. When I first started out, I quietly wanted to achieve this, for with knowledge comes confidence, and with confidence comes a lower level of stress! My greatest fear about medicine was being confronted with a situation or emergency crisis that I simply did not know how to handle. Many sleepless nights were had, particularly just before an on-call (where the chances of isolated emergency crises may arise with more probability), with visions of patients dying because I simply didn’t have the knowledge. Thankfully this never materialised and maybe it is one of those never events – because deep down you can always do SOMETHING to make the situation better. I still love medicine as a subject. I love the human body, human physiology and the science behind how we work. Perhaps though, I am more cognisant that there is so much more to learn. This frustrates me as there is just not enough time – I want to know more about how we, as a complex biological system, work every day, but I am always just too exhausted or simply still at work. I think that my love of medicine has evolved slightly as well. The more I see of medicine, healthcare, and the people and patients within hospital, the more I realise my passion rests in their wellbeing. This is a global measure of a person and focuses on aspects like good nutrition, stress, physical activity, sleep and so on – not rather the complexities of a patient’s glomerulonephritis and their anti-GBM antibody profile. There is a lot of work to be done in the area of health and wellbeing and its one I find myself increasingly drawn to it.


Being a doctor is hard. I must confess that I nearly quit medicine every year while at medical school. My poor family have been up and down with the decisions I have made or threatened to make (such as quitting medical school). The job demands you to disregard other aspects of your life and despite the glory and drama shown on televisions, the reality is very different. The pressure can be immense, the work load punishing, and the thanks for the sacrifice, well, obsolete. I hate the attitude of ‘well it was hard for me so it should be hard for you’ since while I agree on the right of passage to earn your spurs, we should always be striving to make the system better, work less demanding and more efficient and harness a team ethos. For a team ethos to work you need a team. Over the year I worked with brilliant teams in intensive care and anaesthetics and not so great teams elsewhere. This is not necessarily because the individuals were not team orientated but because they just were not there. The best example that I can give of this is in the general medical job that I am just finishing up, I am the only ward doctor 90% of the time – all decisions rest largely on my shoulders – and while it has made me stronger, it has emotionally exhausted me – and I feeling that at present. If I was being honest, the job as a doctor is not what I thought it would be and it has indeed left me with questions about the future and where I should be directing my career – is it in medicine or outside of it? If I am honest it is leaning to the latter. This saddens me somewhat but then excites me at the possibility of venturing out into the health and wellbeing sector on my own and using all of my energy, enthusiasm and passion to make a different. You should always follow your passions. Plus, I do like the idea of being my own boss!


I won’t lie – it hasn’t been great. I am yet to meet anyone and it is something that increasingly bothers me. I was optimistic at the start of my junior doctor year coming into medicine, being in London, and getting out there to meet ‘the one’ – but it just hasn’t happened that way. When I look back at the year and ask myself “why?” I do have a number of reasons that include being too exhausted to even want to go out on a date, not being able to get back from work much before 8pm to even get to meet a date by 9pm, having the weekends to sleep and just enjoy some peace and quiet and things I know I will enjoy – rather than trek out to meet someone I may not like. Haha, yes I know, I know, writing this I do sound a little sorry for myself and well, I guess I am a little. Still, nobody likes a moaner so I will persist and hope that someone is around the corner and all these feelings will change. Rather amusingly I have been on a few dates where the girls have said “it won’t work as doctors live for their jobs”…it was hard to deny. Now that’s sad! Let’s not mention the girl I nearly had to get prophylactic cover for after we went on a date and then I found out the next day I was potentially exposed to a dangerous airborne pathogen in intensive care…!


Thanks to my amazing family, I am stubborn, hard working, and driven. This means that I don’t like to leave a job unfinished. Now while this is great in many spheres of life and I thank my lucky stars every day for having such a wonderful family – the downside is that I do stay late at work and I do the extra bit of work, or finish up the last discharge summary or missed set of bloods. This means personally I loose out on my time at home or resting. Over the year this has worn me down. And it is my own fault and people often say “oh, just leave – it’ll get done eventually” – that isn’t my ethos. My family have also made me kind – and because of that I will stay and talk to patients, don’t stone-wall their relatives and try to make time for the things that people may often say “that’s not a doctor’s job”. Well I would argue that sometimes we all just need to muck in and help out and sometimes that means doing the things you may not be meant to – in healthcare nothing should be above your station. I would also like to think that I have a lot of patience, rarely loose my temper and make people feel uncomfortable. Much to my disappointment, I have lost my temper at other people (staff not patients), raised my voice and made people feel uncomfortable. These instances (the most recent being last Thursday) have usually been at the end of a day in which there was chaos on the wards, no support and I was feeling the pressure. I must say I always cleared the air and apologised and we have continued working together (as are the highs and lows of any relationship or team). Worryingly for me this is a quality that medicine and working as a doctor has drawn out of me – I was not like this before. I don’t like it and it does concern me that this has surfaced after only a year in the job. This is not the sort of person I wish to become and so if need be would walk away from medicine to preserve this.


I smile at the thought of this section because it is very much like a yo-yo. Some weeks I’m up, some weeks I’m down – and it is, in all honesty very difficult to decide which one predominates. Currently it is down as I have had a very tough few weeks on the wards and this may be reflected in the tone of this blog (don’t worry, I am sure I’ll bounce back to hyperactive Nick shortlty!). The frustrations, stress and pressure of being a doctor in combination with my personality traits of wanting to do well, hating to make mistakes, and always wanting to be better and more effective at what I do, act as a pestle and mortar slowly grinding away my mood. You see, medicine doesn’t allow you to progress at the rate YOU want – it is a slow insidious process that happens at ITS pace rather than the one you set. I am inherently a positive, aspiring, a massive dreamer and a happy person – all the qualities my family instilled in me (I know I keep harping back to them but they made me who I am and I am so grateful for that!) – And medicine does not seem to have promoted these but instead demote them. This to me is utterly unacceptable. Maybe this will change as I progress into my Senior house officer (SHO) year. If it doesn’t, I will take further action – he says dramatically…!


After a year of medicine, there isn’t a cannula I can’t get in, a blood sample I can’t get or an arterial blood gas that can’t be acquired…I am a true blood-hound! The same goes for putting in urinary catheters (though big prostates always prove a little trickier), nasogastric tubes and, although a little harder, even the odd central line! Perhaps I have a procedure fetish? – I love that aspect of medicine – and it is perhaps why anaesthetics and intensive care was such an enjoyable rotation for me. The other aspect that has improved, that I noticed compared to starting as a doctor, is the ability to assess an unwell patient. Over the year I have written numerous blogs about how I assessed sick patients either on-call, on the ward, in A&E or even intensive care, from those with severe sepsis to those who were having a cardiac-arrest. The confidence in me to assess someone unwell has moved on leaps and bounds – a very comforting process. Of course there is still an awful long way to go and lots of learn about managing the acutely unwell patient but when asked to review a ‘sick patient’, it no longer fills me with the fear and dread that I had with my first few months as a doctor.


Now despite everything I have said, I am a calmer doctor than I was a year ago. When my bleep rings off I don’t flinch with fear, as mentioned above, when I asked to review a sick patient, I don’t panic, and when all hell is unfolding at the rate of knots on the ward, I am less panicked. There are three reasons that I can put this down to; firstly as I have gained my experiences, my knowledge bank has improved and so I am more comfortable with managing the situations (as, most likely I have experienced similar ‘nightmare’ days – and survived them); secondly I have realised that you cannot control everything, that some chaos does just happen and that you have to learn to let go and not hold onto control so strongly as it can be counter-productive and ineffective; thirdly, and this goes particularly for my last rotation job, I have to be ‘seen’ to be in control – for the nurses, healthcare assistants, patients and relatives will most likely turn to me as the doctor for the answers and re-assertion of control. Thus if I am running around panicked, this will just fuel the fire. I should also add, mind you, that we have some amazingly experienced nurses and health care professionals in the NHS who would equally and more capable of managing these situations – it is just a sad fact that there is still this perceived (and misplaced, in my opinion) hierarchy in the NHS – with doctors higher up.


As I am typing this blog on a sunny summer Sunday morning, I am in agony, just about able to lift my arms up off the table. You see I have started back at the gym yesterday (I bought new trainers to motivate myself!) after 10 months of very little deliberate gym or fitness work. Life as a junior doctor is very poorly compatible with exercising three or four times a week – well for me at least. I mean by the time I have got up at 5.30am, worked all day, got home at 8pm, eaten, I am already thinking about bed in an effort to salvage the 6 hours of sleep I may be able to muster! That said, I bet that I must cover a good 5km running up and down on the hospital wards – and that, plus all the countless missed lunches, would account for my 5kg weight loss this year. That is going to change, I will no longer, I have decided, stand by and let this happen. Hence – new gym membership. New attitude.


My year as a junior doctor has been challenging, exciting at times, and difficult. It has brought with it untold emotional and psychological questions for me about what I want from life and whether medicine can deliver it. Physically I don’t think that I am better off but I do have no doubt that I am mentally more robust having experienced first hand people go through loss, suffering, stress, pain and anguish – but I have also seen joy, relief, healing and happiness. I have seen good nature and bad nature but over-all I feel comforted by the knowledge that kindness is out there in a world that the media often makes us feel is just out for itself. I feel that I have come some way as a doctor, cut my teeth in my junior year and survived it. I have only however just tickled the surface. I don’t feel like I have made any inroads at all to having a family of my own and this is something that must change in the forthcoming year – which I guess starts with meeting the right person – or at least getting myself out there. If you are reading this and thinking, that this blog was more about me as ‘Nick’ rather than me as ‘Dr Nick’, well that true and it is for good reason; you see medicine is just my job – not who I am – I still have dreams and aspirations of my own to be healthy, fit, happy, settled and secure, and life as a doctor effects the ability to achieve those. We will see what the next year brings but I am determined to make it a 12 months to remember – and I do hope you will continue to read and enjoy my blogs into the forthcoming year.

Best wishes to you all.