Its 07:25 on a cold, crisp Winter morning. I’ve just pulled into the hospital car park (£25 per month for the privilege, I might add). A beautiful dawn breaks over the M25, the highlight of my hour long commute.
I’m a Urology registrar halfway through a five-year training programme. The Trusts in the deanery cover a large geographical area and moving hospitals every year means sucking up a long commute or moving home annually.
I’ve got a theatre list this morning (which is the reason I’m in so early, along with avoiding the worst of the morning traffic) and an outpatient clinic in the afternoon.
On the average week I have four theatre sessions and sometimes five. I have 2-3 clinics, one admin session, a full morning of MDT and a half day off after a weekly non-resident on call.
I went through today’s operating list last week, checked all outpatient letters and investigations and generally prepared for the morning. I arrive this morning to find out the list was changed completely on Friday, with an urgent cancer case bumping someone else off and a couple of cancellations due to other medical reasons.
One patient is having a bladder tumour resected, another having his prostate trimmed back and a diagnostic cystoscopy for the last.
I go to theatre, change into scrubs and show my face. It will be another 20 mins before we have a morning huddle with the rest of the team so I go and make more coffee and sign off a few patient letters.
Back in theatre we all introduce ourselves and talk through the day’s operating, confirming the order, equipment, antibiotics, anaesthetic issues and anything else that comes up.
I’ve got a few minutes before the patient is anaesthetized so I find a seat in theatre, run through the operation in my mind a few times, check my emails and scroll through Instagram.
I’m at a stage where I can do most of the core operating myself. Endoscopic operating is a solo sport anyway, not like open surgery, only one person can hold the scope at a time. My consultant will be in and out of theatre to check in from time to time and I can always call them if I’m worried. This is great for training and I enjoy being in charge of my own list – the responsibility does focus my mind.
The tumour is on the lateral wall of the bladder, increasing the risk of an obturator kick (a strong contraction of the thigh adductor muscles caused by the diathermy current stimulating the obturator nerve, running along the inside of the pelvis) very close to where I’m operating.
I use all the methods of reducing the risk, asking the anaesthetist to paralyze the patient, short bursts of diathermy with the loop kept close to my scope and with the bladder not too distended.
Most perforations can be left to heal over with a catheter in for a week or so, but some need an open incision to close and would lead to a longer recovery. A perforation would also mean the patient couldn’t receive mitomycin, an intra-vesicle chemotherapy agent that is given immediately post-op to reduce the risk of tumour recurrence.
Thankfully there is no perforation and I manage to resect the entire tumour safely. The patient should be able to go home later with follow up in a few weeks.
I have a 10 minute breather after writing the op note, histology forms and electronic discharge.
I absolutely love operating and get such a feeling of satisfaction from it. It can be challenging and sometimes stressful and tiring, but I feel a great sense of achievement when I carry out a good operation and I see my patients after (and they’re still alive).
Back in people clothes and in clinic. It’s a two-week-wait cancer clinic. I see patients referred in on a fast track pathway with haematuria or a high PSA, testicular lump. It’s essentially a paint by numbers exercise sending patients for MRI scans and biopsies, cystoscopies and ultrasounds.
There’s a mix of the people who really need to be in these clinics, young men with testicular tumours, middle ages men with a high PSA, men and women with blood in their urine who need bladder cancer ruling out.
I also see referrals for raised PSAs in 90 year old men or men with urinary tract infections which are not appropriate 2WW referrals and should be seen in a routine clinic.
This year I’ve decided to take my time in consultations. Getting someone out of your clinic room within 10 minutes and seeing 20 patients a clinic is not necessarily the mark of a good doctor.
Taking time to explain and educate, talk through all options and answer questions leads to a much more satisfying consultation for me, and more importantly, I hope to the patients too.
I’m convinced that if outpatient appointment slots were increased from 10 to 20 minutes the number of follow up appointments, extra phone calls and letters too and from patients would be reduced. Isn’t this what get it right first time is about?
End of the Day
I finish off the clinic, sending one more patient for an MRI and prostate biopsy with information sheets and about five different forms to take to various places and then escape for the evening. I’ve got a clinic and theatre list at a hospital 10 miles down the road tomorrow and I’m on call overnight too.
It’s a non-resident on call, meaning I don’t have to be onsite, just available on the phone to give advice and come in if needed, but as I live over an hour away I’ll stay on site anyway.
As it happens there are always patients to review after 17:00 and urology on-calls are getting busier with more sick patients and as other specialities become less comfortable putting catheters in. Thankfully the on-call accommodation is clean, warm, comfortable and free. I certainly wouldn’t want to swap back to 12 hour day/night shifts.
I love being a urologist and I love operating and on the whole, I love the patients too. The system we work in is flawed and that’s where the frustrations come from.
Urology is an incredibly rewarding speciality that medical students sadly do not get enough exposure to. Currently there are plenty of consultant jobs available too, so there is definitely a light at the end of the training tunnel.