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This week Professor Simon Carley is giving us an insight into the fast paced world of emergency medicine. A professor of EM in Manchester, an active EM consultant and an associate dean of HENW; Simons somehow also finds the time to be a leading voice of FOAMed and co-founder of StEmlyns and BestBets- essential resources for any aspiring EM doctor. We were lucky enough to grab a few minutes of his time to give us his thoughts on the state of EM training, the future role of FOAMed and whether its worth considering that move to Australia…
Name: Simon Carley
Location: North West
Qualifications: MB.ChB, PgDip, DipIMC (RCS Ed), MPhil, MD, FHEA, FAcadMed, FRCS (Ed), FRCEM
Time in the NHS: 25 years
Thank you so much for your time Simon. Firstly, can you tell us why you wanted to become an EM doctor in the first place?
I started off on a surgical rotation but loved my ED job and started to find surgery too specialized. I really enjoyed the team work and patient contact that you get in emergency medicine. So as a year 3 SHO in surgery I chose to move into emergency medicine. I’ve never regretted the decision. I was also able to combine my EM career with interests in research and education.
What aspects of being an EM doctor have you enjoyed the most?
Emergency medicine is the best 15 minutes of every other speciality. I enjoy most EM work, but especially working in the resus room, making complex time critical and information light decisions. I enjoy the flexibility that the job gives and the ability to switch off at the end of the shift as there are rarely long term worries or patients to intrude on my family and leisure time. Now that we work annualized hours in a shift pattern I have amazing flexibility to pursue activities outside of work.
There must be some difficult parts though?
The flip side is that when we are having a tremendously interesting time, someone else (the patient and their family) are having the worst day of their lives. That, and those days when you experience the really sad or heart-wrenching cases are when it’s a hard job. For example, you never truly get over telling a parent that their child has died, you get better at it, you learn techniques and understand more and more but you never get away from these events being horrible for families and patients. We often share the worst moments of their lives and although that’s tough it’s also a peculiar privilege to try and help guide people through them.
What is the most difficult part of being an EM doctor then?
Tricky. I’m not sure there is a single one. Perhaps working environments and lack of control over workflow are the most challenging as they can interfere with everything else you’re trying to get done in life. Younger docs say it’s shifts, but later in life (when the partying stops) they can be a really good way of working flexibly.
It’s interesting that your perspective on shifts has changed. Many junior doctors in EM worry about getting a life changing decision wrong becuase of the pressure you’re under. What was the worst mistake you made in training? Can you give any reassurances to junior doctors in EM now?
In training? It was making a clinical decision that went horribly wrong. My patient ended up on ITU with an aspiration pneumonia. It was the day before I went on holiday and I remember the fear that they would not survive. I feared for the patient and my career at the time and was a bit of wreck. Although the patient survived I found the realization that our decisions can be life changing in a good or bad way humbling. Back then I was unsupervised in a way that I would hope would be almost impossible today, but many EM docs will be able to tell you similar stories. The uncertainty of EM makes adverse events almost inevitable and we need to be resilient enough to cope. In my opinion we should do more to help our trainees handle these events.
Considering that, do you think there are particular personality traits that junior doctors need for EM?
I don’t think there is an archetype personality. In my department we are very different people, but there are abilities that are consistent. You need to be able to talk to anyone about anything at any time. You need to be interested in patient stories and in solving puzzles. You absolutely be able to manage uncertainty and risk. Finally, in general terms you need to be the sort of person who can lead or work within a team to ‘make things happen’.
Coming back to the theme of shifts, it is something that lots of junior doctors dread. What do you think about them?
It rather depends where you are in life. 60% of my hours as a consultant are out of hours and it’s great. I don’t do much partying these days and any night club would refuse me entry. I have a growing family and the flexibility and ability to get to school pickups and drop offs makes a huge difference. Admittedly, it’s much better as a consultant because of the flexibility, but as a junior shift work can be challenging. However, if you are less interested in beer and more interested in the outdoors and doing things during the day you can organise ED shifts very easily to your advantage. Similarly, the career lends itself well to less than full time training.
With the headlines constantly reminding us about the pressures on A and E what reassurance can you give to junior doctors that the is training still good? How can we protect training as the pressures continue to increase?
In all honesty the quality of training varies a lot, and the experience of EM is very different between departments. Life in a Major Trauma Centre is very different to a small DGH, so you need to think hard about where you want to train. There are undoubtbly some great training programs our there so ask around, some smaller hospitals (e.g. Bangor) deliver fabulous training programs so it’s not about size or configuration. Educational leadership really matters and it’s incumbent on the consultants to ensure that good quality training happens. Apart from anything else training is a patient safety issue and has to take place. Some departments do this really well. Those that don’t need to change or perhaps even lose their trainees.
Other specialties often say that EM doctors are jacks of all trades but masters of none and that all they do is triage. What are your thoughts on this?
That sounds like the sad tribalism that exists across many areas of medicine and in general it’s spouted by those who are unsure of their own credibility. Emergency physicians hold a great set of skills and knowledge that they deliver in the challenging environment of the ED. The speciality is now well established and there is no need to pretend that EM is better or worse than anything else. All our specialities, and co-workers play an important role in the health economy and EM is just one of those vital cogs in the machine. I’d also argue that variety is a good thing for those of us who love EM. It keeps me interested in medicine, learning and teaching and I still love the job.
You’re seen as a pioneer in FOAMEd, how do you see this side of medical education evolving in the next 10 years?
I’ve been called worse! Free Open Access Medical Education (#FOAMed) is a manifestation of the social age of learning and interaction that now exists. As we move beyond simply using technology as a medium to deliver traditional formats (e.g. video lectures) it’s clear that learning takes place through discourse and interaction. #FOAMed is enhancing this traditional teaching and is allowing clinicians to learn on social media platforms in a way that reproduces the face to face learning that has dominated for centuries. We are already seeing traditional educational institutes using social platforms for learning as they try and catch up with those who innovated independently. The big journals and colleges are increasingly keen to get a slice of the social media pie, but there will continue to be the ability to independently innovate teach and learn through digital media. In the next ten years we will see more curation of online material (e.g. Pubmed for blogs/podcasts) and better quality control and assessment to aid learners in navigating the digital classroom.
With the current pressures on the NHS, many junior doctors are considering a change of scenery. Is Emergency Medicine much better abroad?
It’s different. The patients are often pretty similar in places like Australia but they have better weather of course. As with all decisions in life you have to look at the whole package of work, life, travel, families, comfort and costs. EM is one of the best specialities if you are interested in travel as you can take it pretty much anywhere. I’m a huge advocate of trainees travelling (so long as you come back to look after me when I’m older).
Finally, what’s your number one piece of advice to junior doctors who are considering applying for EM training?
Think hard about where you want to train and live. Choose the teams and locations that reflect your own aspirations and of course I would suggest, get online and join other EM trainees around the world using #FOAMed to be the best doctors they can be.
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