Doctors (Part 2)

Surgeons

There are more surgical specialties than you can shake a scalpel at. In order of decreasing IQ, they include:

Neurosurgeons, aka brain surgeons

Every young and ambitious schoolboy and schoolgirl dreams of becoming a neurosurgeon. It kind of makes sense that this group of doctors is the most intelligent, at least among the surgeons. They work on other people’s brains day in, day out, so it stands to reason they get to know what makes a really good brain tick and therefore how best to use their own. Plus, I wouldn’t be surprised if neurosurgeons didn’t occasionally augment their own processing capacity by surreptitiously slicing off the best bits of some of their patients’ brains and surgically splicing them onto their own.

Ophthalmologists, aka eye doctors

I’ve put this bunch in second place because it takes real intelligence (intelligence that I was sadly lacking in) to realise right at the very beginning of your medical training that ophthalmology consultants rarely, if ever, get called back into the hospital out-of-hours and have a lucrative private practice, to boot. They also have the least to learn. The eye is very small, after all, with only so many bits and pieces inside it. Ophthalmologists only know how to do three operations: removal of cataract, trabeculectomy (an operation for glaucoma, high blood pressure of the eye; you can go blind if it’s left untreated) and surgical extraction of a fly trapped underneath your eyelid.

Urologists, aka willy doctors

In a well-deserved third place, urologists don’t get called back into the hospital much either. They don’t just operate on willies, though. Bladders, urethras, ureters, kidneys and prostates (note, not prostrates) are all included in their remit. A friendly bunch, some of my favourite surgeons were urologists.

Otolaryngologists, aka ear, nose and throat (ENT) doctors

They operate almost exclusively on perpetually snotty-nosed kids with permanent sore throats or deaf kids with smelly pus coming out of their ears.

Cardiothoracic surgeons, aka heart doctors

The epitome of NHS heroes, this lot save lives on a daily basis. They would be higher up my list if it weren’t for the fact that they are often called back into the hospital at all hours to perform heart and lung transplants. Sharing the glory with them are the kidney and liver transplant surgeons.

General surgeons

When I was training, being a general surgeon was really a thing. They operated on gullets, stomachs, small bowels, colons, rectums, livers, pancreases, gallbladders, thyroids, arteries and breasts. They whipped off lumps and bumps from just about anywhere. They became extinct somewhere along the line, I’m not sure when exactly, to be replaced by a family of subspecialists including upper GI surgeons, colorectal surgeons, hepatobiliary surgeons, vascular surgeons and breast surgeons. A good thing, too, I suppose, because while being a jack of all trades and a master of none might be satisfying for a surgeon, you, the patient, would probably prefer to be operated on by somebody who does tons of whatever it is you’re under the knife for.

Obstetricians and gynaecologists, aka doctors dealing with women’s bits.

Very womb-centric and so only relevant to roughly half the population, these surgeons divide their time between the delivery suite and the operating theatre. In the former, they facilitate the safe arrival of new babies into the world by performing forceps deliveries and Caesarean sections. In the latter, they essentially do the opposite by performing hysterectomies and laparoscopic sterilisations.

Maxillofacial surgeons, aka max-fax.

Gluttons for punishment, these surgeons have to be doubly-qualified in medicine and dentistry, which means that by the time they’ve completed all their training, it’s nearly time to retire. I only ever anesthetised their patients when they were having their wisdom teeth extracted, so I rarely got to see them practising their obviously prodigious surgical talents on bigger stuff. If you inadvertently refer to them as dentists, prepare to have your lights punched out.

Plastic surgeons, aka cosmetic surgeons.

They make loads of dosh doing private nose jobs, face lifts and Botox injections for the rich and famous. To be fair, they also do a grand job in their NHS practice of reconstructing and repairing the victims of severe burn injuries and trauma. I should really have put them much higher up the list. I didn’t because I hated them all the years I was an anaesthetic registrar. It is a resident plastic surgeon’s job to re-implant fingers that have been accidentally torn off (it happens a lot more often than you might think). Sadly, it was my job to anaesthetise those patients. Watching somebody painstakingly operating on blood vessels and nerves I could barely see (the surgeon wore loupes, operating magnifying glasses) for hour after hour after hour throughout the entire night makes watching paint dry and grass grow palpitatingly exciting in comparison.

Orthopaedic surgeons, aka orthopods, aka bone doctors.

Although some of my best friends were, and remain, orthopaedic surgeons, all my fellow anaesthetists will agree with me that they rightly take their place at the foot of the surgical IQ league table. Orthopods are basically surgically-qualified DIYers. Forget the loupes, the small retractors, the delicate 8-0 sutures. Just give them a power drill and a hammer. No, not that one – the big one. Crash, bang, wallop! Sorted. Only an orthopod would declare in the middle of an operation that wasn’t going so well, ‘This hammer doesn’t work, get me another one.’

Like general surgeons, orthopaedic surgeons have sub-specialised. Now we have knee surgeons and hip surgeons; foot surgeons and hand surgeons; shoulder surgeons and back surgeons. The back surgeons have specialised even further into neck surgeons and lower back surgeons. If you’re ever involved in a serious road traffic collision and sustain multiple injuries, you can rest easy in your anaesthetised slumber while an entire regiment of orthopaedic surgeons put you back together again. In the fullness of time, I fully expect there to be different orthopaedic surgeons specialising in the thumb, ring finger and little pinkie.

The Service Specialties, aka ‘I didn’t know they were proper doctors’ doctors.

The hallmark of these specialists, apart from the fact that people often don’t realise, or care, that they are medically qualified, is that their patients don’t officially belong to them but are instead registered under another consultant’s name, usually a physician or surgeon.

Anaesthetists, aka sleep doctors.

The claim to fame of this group of doctors, apart from having a name nobody can spell correctly, is that they are the largest of all the medical specialties. Anaesthetists can be found in the operating theatre giving anaesthetics, on ICUs directing the medical management of critically ill patients, on the delivery suite providing labouring women with pain-relieving epidurals, running chronic pain clinics, leading cardiac arrest and other emergency resuscitation teams, as well as teaching other doctors, nurses and paramedics the principles of resuscitation. There is almost nowhere in a hospital where you won’t find an anaesthetist, and fully 70% of all hospital inpatients will encounter an anaesthetist at some point during their admission.

Most people have only the vaguest idea about what an anaesthetist does. What they do know has usually been acquired by watching TV medical dramas. An intravenous injection of a sleep draught and a whiff of gas to send the patient off, an injection of antidote and turn the gas off again to wake the patient up at the end of surgery, with nothing much else to do in between time except complete The Telegraph crossword. Surveys regularly show that nearly half of the general population does not know that anaesthetists are medically qualified. A patient once asked me what it was like to be an anaesthetist. I was delighted she was so interested and enthusiastically gave her chapter and verse about what a fascinating and professionally challenging job it was. My bubble burst when she said, ‘I think that’s something my son would like to do. He didn’t get the grades to get into university, so becoming an anaesthetist would suit him down to the ground. Can you study it at night school?’

Radiologists, aka X-ray doctors.

Never confuse the term radiologist with radiographer if you are in the X-ray department for an X-ray or scan (ultrasound, CT, MR, PET, radionuclide investigation, etc). Radiologists are doctors. Radiographers are highly qualified medical technicians, but they are not medically qualified. Radiologists, like anaesthetists, are a trifle miffed when their patients don’t realise this, particularly if they ask, ‘When will I be seeing a doctor?’

Radiologists used to spend pretty much all their time closeted in their cubbyhole, windowless offices, reporting on said X-rays and scans. However, they have reinvented themselves during my working lifetime as interventional medical practitioners, performing complex, invasive diagnostic investigations and therapeutic procedures such as coronary and cerebral angiography, balloon angioplasty, coronary stent insertion, biliary stent insertion and percutaneous nephrostomy, to name but a few.

Pathologists, aka lab doctors.

This hodgepodge of doctors can be found lurking in the mysterious clinical sciences buildings, within which the hospital mortuary is usually housed. They include chemical pathologists, microbiologists, haematologists and histopathologists.

Chemical pathologists run hospital biochemistry laboratories that analyse samples of body fluids, such as blood and urine. They advise physicians and surgeons regarding the diagnosis and treatment of patients with abnormal test results.

Microbiologists run the hospital’s microbiology and virology laboratories, which analyse samples of body fluids and tissues for bacteria and viruses to diagnose the cause of infections and determine which antibiotics and antiviral agents the organisms are sensitive to.

Haematologists run hospital haematology laboratories, the blood bank (which provides blood and blood products such as platelets, clotting factors, plasma and suspended white blood cells), and the anticoagulation clinic. Their job is to diagnose and treat disorders of the blood and bone marrow such as anaemia, haemophilia, leukaemia and lymphoma. Unlike chemical pathologists and microbiologists, who don’t get out much, haematologists like to escape the confines of their laboratories whenever they can to assess actual patients on the wards and in outpatient clinics.

Histopathologists are the doctors most people think of as pathologists. As well as examining biopsy tissue samples under the microscope for evidence of disease such as cancer, they examine whole patients, usually dead ones, in the hospital mortuary. Forensic pathology, the criminal investigation branch of histopathology, has become sexy in recent years thanks to TV programmes such as Silent Witness, Waking the Dead, and the CSI franchise, and many universities now offer BSc degree courses on criminology and forensic science. Aspiring forensic pathologists should be warned, however, that the only route to realising their dream in the UK is to spend five or six years studying at medical school, followed by ten years training as a junior doctor before finally becoming a consultant. Choosing a career as a histopathologist is a good choice if your communication skills and bedside manner are lacking. Practitioners of the dark art also have the enviable reputation of never receiving complaints from their patients or being sued by them.

Occupational Health doctors, aka Sick Leave police.

Their patients are the staff of the company or organisation they work for. Fortunately, I didn’t have much to do with ours, apart from when I had three months off work with back trouble. I wasn’t swinging the lead, either, because I ended up having a two-level discectomy and lumbar decompression/stabilisation. I suspect I would have seen a lot more of our occupational health doc towards the end of my career had I not diagnosed myself with burnout and decided to take early retirement.

Hospital Doctor Grades

If you thought the nomenclature of hospital specialists was bad enough, the grading system used to denote the seniority and status of hospital doctors is even more arcane and confusing. Terms abound, including house officers, senior house officers (SHOs), registrars, senior registrars (SRs), specialist registrars (SpRs), specialty registrars (StRs), consultants, staff grades, specialist and associate specialists (SAS doctors), specialty trainees, foundation doctors, junior doctors, trainees, core trainees, residents, locally employed doctors (LEDs) ­­– the list is endless. Phew!

Consultants

Consultants sit at the apex of the medical pyramid. I speak from experience when I say it’s not easy to become one. First, you have to get into medical school. That’s far from a walk in the park when approaching 30,000 budding doctors apply each year for fewer than 10,000 places, never forgetting that to join the ranks of those 30,000 hopefuls, you should be expecting to achieve a minimum of three A grades at A Level, with top-tier universities also demanding at least one A* grade. Five or six years of hard slog later, you graduate with your medical degree, which is only marginally more valuable than the parchment it’s printed on as a marker of how ready you are to assume the mantle of junior doctor (oops, I mean resident doctor – see later).

If you thought it was tough thus far, the really hard work only now begins in earnest, as over the next ten years, you work long and stressful hours learning how to be a doctor, making life and death decisions regularly along the way, while simultaneously applying for, and succeeding in getting, the next job up the greasy pole. In addition, there’s studying for postgraduate examinations with a broader curriculum than most university degrees in the spare time you don’t have, paying for them, and passing them (the pass rate for most postgraduate exams is less than 50%). Shoe-horned in between all that is your private life. Work-life balance? Forget it.

Once you’ve been appointed as a hospital consultant, you’ve made it. Well done, you! Time to buy that new set of golf clubs and work out the quickest route to the private hospital where you’ll now be spending most of your time (only kidding).

I mentioned it briefly in the last blog, but it seems a good idea to clarify why some hospital doctors are referred to as ‘mister’ rather than ‘doctor’. Many people are confused on this point or simply assume that all consultants are misters. Here’s the reason.

Medical students work their bollocks off to gain the coveted title of ‘doctor’. They’re not proper doctors in the academic sense, of course. The only route to becoming a ‘real’ doctor is to undertake a PhD at university (a doctorate of philosophy degree). For example, my chemistry teacher at secondary school, Dr Slater, was a real doctor. Despite the exacting entry requirements and the long years of study, the qualification you come out of medical school with is a bog-standard Bachelor of Science degree. Your title of doctor is, therefore, honorific.

You would have thought that after sacrificing so much and working so tirelessly to be awarded the title of doctor, the last thing you would do is immediately set forth on a course of study, the end result of which would be the removal of that title. However, that is precisely what happens with surgeons. Once they pass their fellowship of the Royal College of Surgeons examination, they revert to being called plain old Mr again (or Mrs or Miss). In effect, they spend five or six years in medical school to become doctors, and then spend the next five or six years relinquishing the title. Work that one out.

Professors

A special type of hospital consultant is the professor. Starting off as a common or garden doctor, you generally get to become a professor by conducting scientific research as a university senior lecturer into a particular area of clinical interest. Over years of intense academic study, your focus of enquiry intensifies and narrows, and you come to know more and more about less and less until finally, knowing absolutely all there is to know about absolutely nothing, you are made a professor. One anaesthesia professor I worked with certainly fitted the bill. He might have been a whizz with a test tube in the lab, but he was a bloody liability in the anaesthetic room. Even as a lowly registrar, I always used to try to persuade him to catch up on his university admin in the coffee room while I got on with the job of safely looking after his patients before he killed them.

Nurse consultants

Another special type of hospital consultant is a nurse and not a doctor. Confused? So am I.

Junior doctors, residents and SAS doctors

There is a bewildering array of hospital doctors who are not consultants. Some of them are training to become consultants (trainees), others are no longer in training and work in permanent posts at other grades. It will give you a headache trying to make sense of who’s who. It’s given me a headache just thinking about what I need to say. However, I will do my best to make some sense of it.

The Firm

Back in the day, junior hospital doctors worked together in a team called ‘The Firm’. A firm comprised, in order of decreasing seniority, a consultant, senior registrar (SR), registrar, senior house officer (SHO) and house officer. Not all firms had all five ranks, though they all had a consultant and a house officer. You saw patients as a team. You had sleepless nights as a team. You lost patients as a team. You saved patients’ lives against all the odds as a team. You stressed out as a team. You consoled and supported each other when the going got tough, as a team. A firm provided a structured mentorship and apprenticeship. Being a member of a firm was key to surviving and thriving as a junior doctor. Your firm was almost like an adoptive family.

The system worked really well. Sadly, Health Secretaries, NHS managers and senior medical academics adopted a ‘If it ain’t broke, damn well fix it’ philosophy. A system which served doctors and patients well was chopped and changed so much over the years since I trained that it’s now almost unrecognisable. Here’s what we have now:

Foundation Year 1 trainees (FY1)

Basically, house officers in their first year of medical practice.

Foundation Year 2 trainees (FY2)

These would have been first-year SHOs in my day. All newly qualified doctors must follow a structured training curriculum during their two foundation years. They must demonstrate core competencies and be signed off before they are allowed to continue their medical training.

Core Trainees

After foundation training, doctors enter a core training programme to gain deeper experience in a specific field of medicine or surgery for two or three years. Such doctors are designated CT1, CT2 and CT3. FY2 doctors and core trainees together constitute old-fashioned SHOs.

Specialty Registrars (ST3-ST8)

The registrars and senior registrars (SRs) I grew up with were first amalgamated into a unified grade designated as specialist registrars (SpR). Don’t ask me why. I’m damned if I can remember, and I can’t be arsed to look it up. Some time later, the powers that be decided another tweak was needed, and SpRs became StRs (I think this stood for specialist training registrar, but once again, I haven’t the foggiest what the point of the rebranding was. Finally, we arrive at where we are now with the new, super-improved specialty registrar grade (ST1, ST2, etc, the number indicates years of seniority).

SAS doctors (Specialists, Associate Specialists)

This group of doctors is not in training. The only difference between the two designations is historical. SAS posts are taken up by individuals who, for one reason or another, do not intend to become consultants. Some of the best anaesthetists I worked with were SAS doctors.

Locally Employed Doctors (LEDs)

These doctors are also not in training. The posts are often temporary stepping stones to a training post or SAS position.

Junior doctors versus resident doctors

I never minded being called a junior doctor ten years into my training and fully sixteen years after first arriving at medical school, and I don’t recall it ever being an issue with any of my colleagues. However, times change and referring to doctors with years of experience under their belt was deemed (by the BMA, the British Medical Association, the doctors’ trade union) to be demeaning, giving the impression to the general public that junior doctors were somehow inferior and underqualified. As a result of a rebranding exercise, 50,000 junior doctors became resident doctors on 18 September 2024. On a point of order, SAS doctors were never junior doctors and are not residents.

Of course, patients don’t give a toss what moniker a doctor goes by. All they care about is whether their doctor is safe, knowledgeable, and can make them better. None of it would matter if The Firm were still there to safely manage patients and serve as both an apprenticeship-teaching model and a mutual support mechanism for the doctors. Sadly, though, not only have the titles on the hospital name badges changed, but so too has the operation of The Firm. There are too few resident doctors on duty at any one time to look after the number of acutely ill inpatients on the wards, so The Firm cannot function as it once did when I was roaming the wards.

There are several reasons for this. Back in the day, many hospital inpatients were either convalescing or were only moderately unwell. Nowadays, you virtually have to be at death’s door to merit a scarce hospital bed. Demand for hospital beds has increased almost exponentially over the years, while the availability of resident doctors has decreased following the implementation of the European Working Time Directive (EWTD). The upshot is that The Firm is a luxury the NHS can no longer afford. Instead, disparate groups of residents are thrown together almost at random to cover hospitals at night and over weekends. There is no sense of team. No mutual support mechanism. No sense of belonging. I know I sound like an old fart – correction, I am an old fart – but that’s my view, and I’m sticking to it.

Medical Students

The chances are that if you’re a hospital inpatient or outpatient, you will come across medical students eager to find something interesting in your medical history or, even better, on physical examination. As an aside, there’s an old saying known only to doctors: never be an interesting patient. If a doctor ever tells you you’re an interesting case, it’s time to make your last will and testament, if you haven’t already. You’ve either got an incredibly rare syndrome, or they haven’t a clue what’s wrong with you, despite you undergoing every test in the book. Whichever it is, the condition is invariably fatal.

Medical students are a fascinating bunch. They go through five or six years at medical school, being taught a load of stuff that may be of academic interest but doesn’t really prepare them for day one on the wards as an actual doctor. That was true for me forty-odd years ago, and I’m sure it’s even truer today. They often hunt their unsuspecting prey in packs of up to ten, taking turns to poke and prod you. It pays to clench all your sphincters tightly when the medical students are in town.

Third-year medical students are more afraid of you than you are of them, but by final year, the tables have turned. The need to examine every possible pathology in preparation for Finals supersedes all other considerations, and even if you are only visiting your Great Aunt Maud, be prepared to find yourself on the receiving end of a finger up your arse, examining your prostate gland, or your breasts being palpated in the optimistic hunt for a hitherto undiagnosed malignancy.

After qualification, the tables turn again as house officers are terrified of every patient under their care now that it’s their personal responsibility to ensure you don’t peg it.