A whole bunch of people work in NHS hospitals: doctors, nurses, physiotherapists, occupational therapists, radiographers, phlebotomists, cardiology and respiratory technicians, cleaners, porters and hospital managers. I debated whether to include the managers on my list. Do they do anything that could reasonably be described as work? I decided to include them in the end for completeness. They do, after all, outnumber all the other groups put together. (That statement may not be strictly accurate, but it often feels that way.)

As a patient or hospital visitor, it used to be fairly easy to tell who was who by what they were wearing. Male consultant doctors would be immaculately attired in a tailored three-piece suit, with shiny black shoes and a Rolex wristwatch. Female consultants would be wearing a smart dress or skirt, kitten heels, and tights or stockings. Junior doctors would be kitted out in something similar to their more senior colleagues, albeit less expensively, with the addition of that universally recognised sartorial totem of junior doctors the world over – the hallowed white coat.

When I first started training, nurses all wore a standard uniform, which had changed relatively little over the years. Their smart yet functional dresses were colour-coded to indicate their rank as matron, sister, staff nurse, student nurse or healthcare assistant. Nurses wore a cap, that instantly recognisable symbol of the caring profession, first introduced by Florence Nightingale. Members of all the other groups also wore characteristic uniforms, except for the managers, who would compete with the doctors for the accolade of most fashionable man or woman about town.

Nowadays, it’s Mission Impossible to work out who’s who solely from their appearance. Pretty much everybody has been forced to ditch what they used to wear by the Infection Control Police and dress in theatre scrubs instead. Is the person standing before you the consultant surgeon who’s going to be operating on your gallbladder this afternoon or the plumber who’s on the ward to unblock the ward toilet?

A cross between pyjamas and martial arts kit, theatre scrubs give the appearance that the person wearing them overslept, was in a rush and couldn’t be arsed to get changed for work. Or that the wearer is about to karate-chop their patient back into good health. When I say everybody working in your local hospital has to wear theatre scrubs, I naturally do not include hospital managers. They have retained the right to wear smart, professional-looking clothing. Conspiracy theorists would claim that the scrubs-for-all policy has nothing to do with infection control and everything to do with keeping doctors, nurses and all the other minions in their place.

Doctors (Part 1)

I’ve placed doctors at the top of the pecking order in my Who’s Who list, not only because I was one, but also because, as an erstwhile and perspicacious consultant colleague of mine often pointed out to our managers (it will come as no surprise that it was Ross Logan from my books), a hospital without doctors is a nursing home.

Hospital doctors can be broadly divided into three groups: physicians, surgeons and service providers. In this post, I’ll be talking mainly about the physicians. You’ll have to wait for the next exciting installment to find out what I have to say about the surgeons and service providers.

The cleverest doctors become physicians. It is sometimes said that physicians know everything but do nothing. This is a bit harsh, but there is a grain of truth in the old saying. You do have to be well-endowed with cortical neurones to remember the 1001 symptoms and signs of Rocky Mountain spotted fever or the almost limitless number of potential interactions between the ten different drugs a typical patient might be taking. But what’s the point when most medical diseases are relentlessly progressive, can’t be cured, and will end up killing you anyway?

Not so clever doctors become surgeons. It is sometimes said that surgeons know nothing but do everything. Well, how hard can it be to whip out someone’s inflamed appendix or cobble together your granny’s broken hip with a hammer, a few screws and a metal rod? When a trainee surgeon passes all their exams to become a fellow of the Royal College of Surgeons, they relinquish their title of ‘Doctor’ and revert to being plain old Mr, Mrs or Miss, again. It’s got something to do with bygone times when only prospective physicians went to university to become learned gentlemen. In contrast, any Tom, Dick or Harry could hack off someone’s gammy leg or drain a putrid boil poking out of someone’s rectum. Most surgeons back in the day were barbers, carpenters or butchers by trade. Not much has changed, really.

Service provider doctors are a group that includes anaesthetists, radiologists and pathologists. Not clever enough to remember the names of all those obscure diseases and which drugs won’t cure them, but far too cerebral to wield a scalpel or hammer, they spend their time helping the physicians and surgeons to look after their patients.

Physicians

Being so clever, physicians do a lot of thinking. Well, they have to do something when they’re at work. Physicians don’t operate. They don’t put people to sleep. They don’t report on X-rays and scans. There are lots of them in most hospitals, looking after patients with heart and breathing problems, diabetes, strokes, epilepsy, arthritis, over-active and under-active thyroids, and a whole host of other diseases and medical conditions that nobody but them has ever heard of – except for the poor sods who actually suffer with those diseases and medical conditions. Physicians come in more varieties than Heinz, so the following list is far from exhaustive.

General physicians.

These now rare beasts roamed the plains of the medical wards in massive herds when I was a medical student and house officer. However, they’ve since become almost extinct because they were unable to compete for hospital territory with newly evolved specialist physicians. It’s a shame, because general physicians were holistic doctors who treated the whole patient rather than just one disease or medical condition in isolation.

Cardiologists, aka heart doctors.

These are the ones to see if you’re having a heart attack or your blood pressure is through the roof. They are the experts at diagnosing heart murmurs through their stethoscopes that nobody else can even hear. That might sound impressive, but a scientific study years ago demonstrated that consultant cardiologists were no better than medical students at diagnosing valvular heart disease using only a stethoscope. Fearing for their professional reputations, cardiologists successfully reinvented themselves to become interventional cardiologists, who insert stents into the blocked coronary arteries of heart attack victims under X-ray control. Great news for patients, who avoid having to undergo major open heart surgery; less great news for cardiac surgeons.

Respiratory physicians, aka chest doctors.

They mainly look after patients with asthma and chronic obstructive airways disease. If your GP refers you to one for a flexible fibreoptic examination of your upper airways (bronchoscopy) because of a persistent cough, you might want to make sure all your affairs are in order.

Neurologists, aka nerve doctors.

You’ll find yourself under one of these if you’ve got epilepsy, Parkinson’s disease or any of a myriad number of weird and not so wonderful degenerative neurological conditions like motor neurone disease, muscular dystrophy and multiple sclerosis. Amongst the cleverest of the physicians, their talent is largely wasted because there isn’t an effective curative treatment for many of the conditions they manage. They end up spending a lot of their time reassuring battalions of worried-well patients complaining of recurrent headaches that their scans are normal and that there really is nothing wrong with them.

Endocrinologists, aka diabetologists.

They do treat other conditions apart from diabetes, but the vast majority of their patients do have a blood sugar concentration higher than a can of Coke.

Rheumatologists, aka arthritis doctors.

Every rheumatologist I ever encountered during the course of my career impressed me with their stellar intellect, encyclopaedic knowledge and quietly spoken manner. They look after people with rheumatoid arthritis and other chronic inflammatory systemic conditions. They’re the only group of doctors who routinely treat their patients with 24-carat gold. They send all their failures to the orthopaedic surgeons (see later).

Oncologists, aka cancer chemotherapy doctors.

Although definitely not the group of doctors you ever want to be professionally acquainted with, oncologists have transformed the prognosis of so many patients suffering from advanced leukaemia, lymphoma and many other cancers from being the virtual death sentence they were at the start of my training to being entirely curable in many instances.

Geriatricians, aka Department of Medicine for Older People (DMOP) doctors.

The terms geriatric patient and geriatrician are apparently no longer PC for reasons I don’t really understand, and have been replaced by ‘older patient’ and ‘physician for older people’. Given that a 30-year-old is older than an infant, does that make the 30-year-old geriatric? I digress. When I was at medical school, a professor of geriatrics (that was what he was, then) lectured us. We were amazed when he told us that, soon, a majority of hospital inpatients would be over the age of sixty-five, the threshold at the time for being labelled geriatric. It couldn’t be true, we thought. Hospitals, full to the rafters with old fogeys. He was just bigging his part, surely. But he was dead right. These unsung heroes do a fantastic job in difficult circumstances.

Paediatricians, aka kids’ doctors.

Working at the other end of the age spectrum, as a parent, you’d rather be seeing an oncologist about yourself than taking one of your children to see a paediatrician. A subset of paediatricians (neonatologists) think a 2-year-old is verging on the geriatric (apologies, I mean verging on being an older child), and limit themselves to looking after poorly newborns on the special care baby unit (SCBU).

Psychiatrists, aka mental health doctors.

As mad as the patients they treat, it’s impossible to tell the two groups apart. When I was a fourth-year medical student, I was asked by the registrar on my first day of psychiatry to assess one of the inpatients, a 52-year-old man called Colin, who had been sectioned under the Mental Health Act. I went to his room, only to find it empty. I looked in the day room, but he wasn’t there either. ‘He’s in the smoking room,’ piped up a dishevelled, ancient woman in desperate need of a shower, breaking off from watching the TV and pointing over to her left.

I wandered over in that direction and peered into the acrid cloud of smoke billowing from inside the doorway. I could vaguely make out two silhouettes sitting opposite each other, one male and the other female. ‘Could I speak to you?’ I asked the man. ‘Sure,’ he replied, stubbing out his cigarette. He followed me into the seminar room, and I got straight down to business. Half an hour later, I could well see why he had been sectioned. I had made a diagnosis of paranoid schizophrenia, complicated by manic-depression and sociopathic personality disorder. I finished my note-taking with a flourish of my pen and said, ‘Thank you very much for your time, Colin.’

‘Oh, I’m not Colin,’ he replied, ‘I’m Dr Derrington, one of the consultant psychiatrists.’

Community Medicine doctors and epidemiologists, aka your guess is as good as mine.

I’m not sure what this lot gets up to. Nobody does. Something to do with making national health policy. Their motto is: prevention is better than cure. With the UK’s spiralling prevalence of obesity, diabetes, hyperlipidaemia, hypertension, alcoholic liver disease, cancer and dementia, to name but a few conditions, there is clearly still work for them to do.

Emergency Medicine doctors, aka A&E doctors.

These doctors really are generalists extraordinaire. Working in what used to be known as Casualty, the Accident and Emergency Department, or simply A&E, but is now the Emergency Department (ED), they have to take all-comers from the victims of major trauma to timewasters with a sprained ankle; from patients with perforated appendixes and bowels to those with simple indigestion a couple of Rennies would settle; from patients who have collapsed after a brain haemorrhage to idiots complaining about the tension headache they’ve had for the past ten years and have only now decided to present to the ED with because there is nothing on the telly tonight.

You have to feel sorry for ED doctors. I know I do. They are tasked with managing an exponentially increasing number of patients while the primary healthcare and social care sectors collapse around them, often working in dilapidated buildings designed for a fraction of the number of patients flooding through the front door, with an even smaller fraction of the required number of trained staff to safely treat those patients in a timely fashion. I can see most ED doctors and nurses burning out or taking early retirement to avoid burnout, which will do nothing to help the staffing crisis.

Acute physicians, aka Medical Assessment Unit doctors.

The newest kids on the block, this specialty didn’t even exist when I started out. As long as your admission diagnosis is medical rather than surgical, acute physicians will look after you for the first 24-48 hours after you’ve finally made it through the back door of the ED into the one empty medical bed in the entire hospital (which will still be warm from the previous occupant and possibly a bit smelly if the nurses haven’t had time to change the sheets). The medical assessment ward is one level down from a High Dependency Unit, and you stay there while your acute medical condition is treated and stabilised before moving onto the cardiology ward, respiratory ward, diabetic ward, stroke unit, etc.

Intensivists, aka critical care doctors.

I’ve saved the best till last. I worked as an intensivist, spending roughly half my time caring for the sickest patients in the hospital, in the Intensive Care Unit (ICU) and the High Dependency Unit (HDU). The other half of my day job as a consultant anaesthetist was gassing patients in the operating theatre, of course. That critical care is an important part of many anaesthetists’ job descriptions is not well appreciated. A minority of the general population is aware that anaesthetists have any role in the running of ICUs, let alone that the majority of intensivists are anaesthetists.

From a patient’s perspective, needing to see me in my professional capacity as an intensivist is even worse than having to see an oncologist. Although the chances are you won’t be conscious when you meet me because you’ll be at death’s door in a medically-induced coma on full life support. It will be down to your nearest and dearest to have a few cosy chats in the Relatives’ Room with me about your chances of survival. Intensivists are right up there with the ED doctors in terms of their risk of burnout from decades of working long hours without a break, cumulative sleep deprivation and the constant stress of having to make life-or-death decisions.

Any junior doctor who decides to become an intensivist is making a really bad choice. They are always being called back into the hospital out of hours and have a curriculum of required knowledge that encompasses everything all the other medical and surgical specialities need to know plus their own Intensive Care stuff. Loads of their patient die despite their best efforts. A word of advice - become a dermatologist or an ophthalmic surgeon.  Virtually no out-of-hours work and tons of private practice. Marvellous.