The Never-Ending Patient Journey

How some patients remind us of medicine’s persistent attempts to fix the unfixable

The usual sounds of a Friday night in the emergency department don’t stop you from tackling the usual backlog of patients. You stroll over to the EPIC to be dealt a familiar name. She’s back again, is she? At this point, she has become a friend of the department, a permanent fixture of your ED. As you walk in, you are met with the same exhausted expression on the faces of all parties involved, her slow decline best measured in millimetres rather than miles.

The culprit for her presentation seems to be a similar one and a look back at her notes would show you five previous presentations with exacerbations of her COPD symptoms. All of this worsened by her failing heart and faltering kidneys. With each passing month, her willpower weakens.

For her, her doctors, and her family, this situation represents a familiar paradox: the patients we know we can never cure, but equally cannot abandon. Patients who are too sick to get better, but yet too well to die. These patients sit in an area of medicine that we call Liminal Medicine, which is the part of medicine that exists on the threshold between life and death, health and illness.

The Myth of Progress

We are given the impression that medicine is a story of progress. A story of cures and triumphs. We often promise resolution through diagnosis, treatments, and cure.

But most of our daily work, particularly in areas that face significant social deprivation, is not one of triumph. For many liminal patients whom we simply ‘maintain’, this linear pathway of improvement is far from reality. The definition of a successful outcome, and our role in these patients may require reframing. Holding them at bay against the inevitable is often a more accurate description for these patients.

This can be compared to the story of the ancient Greek king Sisyphus, who was eternally punished for his trickery by being forced to roll an enormous boulder up a hill, only for it to roll back down again before he reached the summit. Albert Camus used the story of Sisyphus to explore the inherent meaninglessness of the world. We can reframe the story of Sisyphus to represent something else in medicine, where we return each shift to see the same familiar faces, carry the same pathologies, and the same incomplete cures.

Can We Find Meaning In a NeverEnding Story?

Prolonging life can be viewed as a triumph, it gives these patients more time, but deep inside us, there is a quiet despair in trying to heal those who will not heal. We become so busy trying to patch and manage the inevitable that we often become quite numb to reality.

Camus famously ended his Myth of Sisyphus by asking us to “imagine Sisyphus happy”. So perhaps meaning and success in medicine shouldn’t be viewed solely as a cure. We are filled with despair when managing these patients if we measure meaning by cure.

Tomorrow she may come again, and we will begin again, rolling the metaphorical bolder up Sisyphus’ hill. We do this not because we necessarily expect to reach the summit, but because for some patients the act of pushing is what it means to be a doctor. Our profession isn’t defined solely by curing, but also caring - over and over again.

The Homophily Effect: Who Do You Sit With in the Canteen?

Glance around any NHS canteen, and what do you notice? You’ll see doctors managing to find some time away from clinical duties to tuck into whatever the canteen is serving. But beyond that, you’ll see the hospital’s social architecture on display. Sometimes it may be hard to discern a pattern, but for the most part, hospital friendships obey Lazarsfeld and Merton’s 1954 phenomenon of homophily.

Cardiologists gather to debrief on the world of balloons and catheters; consultants share tables with fellow consultants; and overseas doctors may sit together, united by shared language or cultural experience. In NHS hospitals, this reflects both status homophily (connection through role or seniority) and value homophily, the comfort of shared understanding.

Research shows that these patterns persist in healthcare: physicians are more likely to communicate and collaborate with colleagues of similar background or specialty. Such networks can provide belonging and psychological safety in a demanding system, but they may also reinforce professional divisions: consultants with consultants, juniors with juniors, reducing the informal exchange of ideas that we all know brings great value to each individual involved.

Isn’t it amazing that something as simple as the NHS canteen can often reveal a subtle map of the NHS’s social dynamics?

The Road to Consultancy: CCT vs CESR

The rise of the portfolio pathway and the reinvention of UK Specialist training

What do we really know about the state of medical training in the UK? In short, it’s crowded and competitive with bottlenecks at every level, from foundation placements to specialty recruitment.

Additionally, each year, the number of international medical graduates (IMGs) applying to practise in the UK continues to climb. The result is a growing cohort of doctors looking for alternative routes to consultancy…

Enter the newly rebranded Certificate of Eligibility for Specialist Registration (CESR), now known as the Portfolio Pathway as of 2023.

The Portfolio Pathway

The Portfolio Pathway allows doctors who have not completed a UK-approved specialty training programme (and therefore without a Certificate of Completion of Training (CCT)) to join the GMC’s Specialist Register.

This makes them eligible to apply for substantive consultant posts in the UK. It exists in recognition that an experienced Consultant Hepatologist in India doesn’t need to start UK specialty training from scratch. Instead, they can present evidence of their clinical practice, teaching, leadership and research to demonstrate that they have the same knowledge, skills and experience expected of a UK-trained consultant.

Applicants compile an extensive portfolio of evidence, collecting page and page of clinical work, audits, teaching, leadership, amongst other materials. These submissions are reviewed by assessors (which vary by royal college), who then make a recommendation to the GMC.

CCT vs CESR

Research commissioned by the GMC found that, across the profession, there was still a perception that CCTs were more “recognised” or “prestigious” than CESR certificates, even though both confer equal legal standing.

Doctors embarking upon the CESR route often end up staying at one trust throughout their training rather than rotating regionally, which can limit exposure to different systems. If one trust has a set way of doing things, you may never experience the alternatives. This may sound like a clear drawback, but in a climate where rotational training is pulling and straining the lives of trainees across the country, some doctors may not be too concerned at the prospect of staying at one trust their whole careers.

It must be noted that the formal CCT route brings much more stability to one’s training, meaning that the formalised and structured nature of the programme should create less room for variance across the country. This is certainly the case compared to the CESR route, which can be far more variable and dependent on individual experience.

Dr Beatrix Langara is an example of an acute medicine consultant who decided, after her MRCP exams, that rotational training was not compatible with having a young, busy family. Following a conversation with her supervisor, she pursued the CESR route. She recalls being told that it was not going to be a shortcut or an easy ride, but that it would be better for work-life balance.

Relieving Bottleneck Pressure

Some also argue that the presence of the portfolio route may relieve pressure on the bottlenecks and free up capacity in training posts, indirectly benefitting trainees. The reality is that many doctors who pursue the portfolio pathway have significant experience in their specialities and would be able to put forward significantly more impressive CVs than their counterparts who are applying at ST1 or ST3 level.

Thus in this regard, UK trainees, may do better to focus on what they gain from the presence of the CESR route: advantages related their ‘brand’ of training (CCT) and structured progression through their resident doctor career. At the same time, the GMC needs to do the hard work to ensure that this ‘alternative lane’ remains high quality. We cannot have a loosening of standards in the hope of expediting the filling of posts.

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Some things to review when you’re off the ward…

One of the longest studies ever conducted on human happiness was titled The Harvard Study of Adult Development and what they found was that relationship satisfaction (and not wealth or fame) was the single strongest predictor of long-term health and happiness.

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Evidence and Entry: How Acute Medicine Changed The Game

Acute Internal Medicine (AIM) arose in the optimistic times of the early 1990s, when the Berlin Wall had just fallen and the ED still had some spare beds.

It became apparent to the minds of the time that the traditional model of medical patients being admitted from the ED to ward beds was unsustainable in the face of an evergrowing demand. The proposed solution was AIM and the idea was that it would allow patients with acute medical illnesses to be given the best quality care, in the right environment.

Since its adoption, researchers have looked at the evidence behind its adoption, and showed a significant reduction in the length of stay of patients solely admitted and treated in AMU. However, what about those who start their journey in the AMU and then are transferred to a ward? Their stay actually ends up about a day longer on average. This should be a reminder to all NHS policy makers and doctors that the initial admission decision really matters. Where these patients go after being seen front of house can have significant ramifications on their stay.

Mortality data is also on the side of AMU, with most studies reporting a decrease in overall mortality of patients admitted to the unit. So the data speaks clearly, when we can get patients to where they need to be, AIM trims hospital stay and reduces mortality.