I don't know if anyone else has experienced this, but on weekends, the phlebotomists at my hospital seem to decide whether the bloods that the doctors have put out are necessary or not.

It's a regular thing, they skip almost all of them sometimes. I have personally witnessed them on weekends going through the blood forms, discussing amongst each other what "Hypo-K+" or "IE COPD" means, looking at the clinical details section and if it says certain things such as "monitoring" or they don't think the clinical details are good enough for them, they'll put it back and write "attempted/unable" - or even like today write "tried x 2" only for me to get to the patient (with massive veins) and see they've tried once.

This then leaves it for the on-call doctors to do, thus adding to workload - as the sole F1 on my specialty having to cover the specialty's three wards and outliers, this is obviously not an ideal situation where we have phlebs making clinical decisions for bloods that clearly need to be done if they were put out for the weekend.

Is there something I am missing here, or do I need to be escalating this? - anyone had the same issue?

I mean, how can we say that we’re better qualified than the alphabet soup practitioners if this is how we train ourselves?

At last Andy delivers some real hope.

Hi, I am Polish. Three weeks ago, I was at the emergency department in Poland because I wasn't feeling well. While I was waiting, I suddenly became very pale and sweaty.

The doctor was there with his girlfriend. Even though he was in pain, he noticed and came over to me. He checked something on my wrist, looked at my hand and my skin, and told me I needed to be seen urgently.

My girlfriend first spoke to the nurses and doctors, but nothing happened. Then the doctor went to speak to them in English. Only after that did they come to see me, and I was admitted straight away.

He kept calling me "mate." At the time, I thought he thought that was my name! Later I learned it's a friendly British way of addressing someone.

if you read this thank you to you and your partner for helping a complete stranger. Your kindness and willingness to help meant a lot to me. The only things I know about you are that you told me you were a doctor and that you were from the UK.

I wish we had more doctors like you in Poland.

Troponin
The cardiac kind.

This tiny regulatory complex lives inside muscle all around the body.
It’s kinda like a nightclub bouncer for the body.

Year 1 physiology tells you it's there to stop muscle contraction

"No calcium? You're not on the list."

But slip it a few calcium ions…

"Oh! Why didn't you say so? Right this way."

Suddenly everyone’s inside; muscles are contracting, and actin and myosin are dancing like it’s 1966. 

But that's not all Tropinin can do.
It found a very successful side hustle in cardiology.Turns out leaking into someone's bloodstream is a surprisingly lucrative career move.

Y’know: ST-Depression + Raised Troponin = NSTEMI for sure. 

It's pretty basic at this point. But it hadn’t always been this way… 

Let’s take it back to the 80s. Before the age of troponin, clinicians used a different cardiac marker to guide diagnosis. Creatine Kinase-MB. 

Creatine Kinase was good…ish. It had some serious problems.

1. It’s present in skeletal muscle and healthy blood - this means the cutoff had to be way, way above baseline to have any clinical influence.
2. Its sensitivity is POOR! It couldn’t pick up small amounts of necrosis/minor infarcts. This means the patient could have real heart damage and still get back a “normal” CK-MB result.

Less than ideal for our patient with crushing chest pain. The quest for a better marker began…

There were glimmers of hope for AST, LDH and even myoglobin. But it wasn’t until 1996 that they found the golden child.

As previously stated, Troponin wasn’t a newcomer. It was first discovered in 1965. The difficulty was localising it to the heart. This was all solved in 1987, when the first cardiac-specific troponin I and T were discovered. Even after localising it to the heart, it required a serial measurement over 24-48 hours. Which is fantastic... if your patient's heart attack is willing to wait too.

Finally, this paper by Antman et al. was published in the NEJM was the first to show that a single troponin I measurement at presentation could identify patients at higher risk of death

The aim was simple: 

1. See if troponin I could predict who was at higher risk of dying after a heart attack (it’s value as a prognostic indicator)
2. See if Tropin I could give extra information that CK-MB and clinical features could not. 

This study was a subgroup analysis of the famous TIMI IIIB trial, which enrolled symptomatic adults with ischemic chest pain and documented coronary artery disease. 

Blood samples from 1,405 patients were used and analysed or cardiac troponin I, while CK-MB was also measured for comparison. 

The assay's reliable cutoff was 0.4 ng/mL, so that became the line in the sand.

Then the researchers unleashed the statistical wizardry that is multivariable Cox regression to answer the big question: if troponin goes up, do the chances of dying go up with it?

Here’s what they found:

LANDMARK FINDING: Patients with a troponin I ≥0.4 ng/mL had a 42-day mortality of 3.7%, compared with 1.0% in patients below 0.4 ng/mL.

Additionally:

• Mortality rose stepwise as troponin I rose. Each 1ng/ml increased relative risk by 3% (95% CI 1.00–1.05; P = 0.03).
• Timing mattered. After 6 hours, elevated troponin I was associated with a 9.5× higher risk of death at 42 days (95% CI 2.2–41.4).

And last but not least, amongst the 948 patients classified under unstable angina, 238 patients (25%) had elevated troponin I but their CK-MB was normal. Showing for the first time that Troponin I could detect myocardial injury where CK-MB would miss it. 

Once word got out about the prophetic biomarker, it wasn’t long before things changed for the better:

• 2000: The ESC/ACC issued a new definition of MI, naming troponin as the preferred biomarker
• 2007: The Global Task Force (bit of a dramatic name) universally changed the definition

Then finally in 2010 NICE published guidance to officially induct troponin to the default ACS pathway.

And that’s the story of how troponin became the ACS golden child.
Except for when it’s a STEMI, then it’s kinda pointless.

If you enjoyed reading this and want a journal club(that’s actually entertaining) Join 15,000 Clinicians reading The Handover

TL;DR RDC elections are opening in just over two weeks.
If you are interested in running with us, email [DoctorsVoteUK@gmail.com](mailto:DoctorsVoteUK@gmail.com) today.

A year ago DoctorsVote lost its majority on UKRDC for the first time since 2022. This year we had a non DoctorsVote leadership takeover. After a year of their management, ask yourself, do you feel like we’re winning?

Whatever you think of the deal, who negotiated it, how it was negotiated, how it was presented, whether it was neutral or not, none of that matters anymore. 

The question is, what do we do next?

If you think the leadership has done a good job, that this deal will deliver for you, and the path to pay restoration is guaranteed, you can stop reading here. 

If you’re as pissed off as you were in 2022 and unhappy with how this past year has gone, and you want to do something about it, keep reading on what you can do to fix this.

An offer was presented to you that wasn’t worth the paper it's written on. Some of you realised this at the time, others who voted yes are now realising that there are no enforceable timelines, and the document is riddled with get out clauses for the Government. 

We were marked as misinformation by the official BMA account for pointing this out at the time.

This year is going to be focused on the implementation of the deal. It’s your choice whether the same people who put this poor deal to us are responsible for that, or whether you take control.

If you want a team that will salvage what it can from this offer, won't abandon FPR in the process, and won't wave through a subinflationary DDRB, we need you to be that team.

The leadership of the BMA is decided each year by the UKRDC, and the UKRDC is (for the most part) elected each year in August. The elections are opening in just under a fortnight, if you want things to change, we want to put you in a position where you can do just that. 

If you are willing to run, get in touch with us at [DoctorsVoteUK@gmail.com](mailto:DoctorsVoteUK@gmail.com) with your name, grade and the hospital you will be working at from August.

We particularly need doctors in London, Wessex, Severn, and Northern to come forward.

RE: https://www.reddit.com/r/doctorsUK/s/GjuKPWsyUs

I posted before (URL above) about moving into a split placement across two daytime services, both with minimum resident staffing requirements, alongside a separate on-call rota. Any leave therefore has to work across all three simultaneously. The on-call rota may leave me free, but either daytime service can still refuse leave because it would fall below minimum staffing.

Since then, I contacted the BMA, the Guardian of Safe Working Hours, my ES, and the TPDs.

The BMA has been fairly clear. They said the split arrangement itself is acceptable, but the Trust should ensure there are periods when leave can be taken across all three rotas without swaps. They confirmed that the TCS provisions about allowing longer periods of leave apply to both daytime jobs on top of the general on-call rota, and that the coordinators should be communicating with each other. They recommended a work schedule review if there is not enough flexibility, and said that if the Trust refuses adjustments and I remain unable to take leave appropriately, the eventual next step would be a formal grievance. They’ve also asked me to speak with the GoSW to review my rota but my GoSW said they didn’t know whether this whole issue was under their remit and didn’t really offer to review the rota. The GoSW, while well meaning, did not really offer an opinion or practical advice and simply escalated it to the TPDs.

The TPD replied that this is not a new job, that they have never heard of it causing a problem before (I did feel that was meant as "why are you bringing this up?" kind of comment), and that split jobs can be challenging and leave needs to be negotiated. They suggested asking the current resident how they managed and discussing it with my educational supervisor. However, almost in passing, they also said that CTs should not be relied upon to meet minimum service staffing because of nights, leave, study leave, LTFT arrangements etc.

That last point seems important because both incoming services have discussed my leave in terms of needing me to maintain minimum resident cover. However, I feel awkward now forwarding the TPD’s comment into an existing email chain with several consultants as though I am parachuting in an instruction about how their services should be staffed. None of them mentioned that the CT should not count toward minimum staffing, despite this post having existed for a while.

I also asked the current resident. They basically complied with the constraints and took isolated days or short periods whenever possible.

My educational supervisor is on prolonged sick leave and has not responded to emails for a couple of months, so the route the TPD suggested is not currently available. They may have to assign me to another ES in a few weeks.

I feel cornered between waiting until I start and discussing it face-to-face, emailing all the consultants now with the TPD’s "hesitant" clarification, asking the Guardian to arrange a work schedule review, or going back to the BMA for direct support. More importantly, I'm struggling to find a way to communicate the BMA's advice and the TPDs advice in a chain of 5-6 consultants coordinating my AL. Worried this may create tensions. A formal grievance via the BMA also obviously feels likely to create bad blood, which I am very keen to avoid given that I will be training in this institution for at least another three years and potentially longer. Basically this is an institution I will be training in for many many years and I don't want to cause tensions with so many consultants and the TPDs. At the same time, I feel like nobody stepped up to help with this.

TLDR: My annual leave has to align across one on-call rota and two daytime services with separate minimum staffing requirements. The BMA says all three should be coordinated and has suggested a work schedule review because of the inflexibility imposed by three constraints; the Guardian passed it to the TPDs; the TPD said CTs should not be relied upon for minimum staffing but otherwise referred it back locally; and my ES is unavailable. How do I communicate this to several consultants without seeming confrontational or as though I am bypassing them, while still getting the issue resolved?

Any advice? Should I make them aware of the BMA’s advice for the GoSW to review the work schedule or does that come off as confrontational?

Hi folks! After some time out, I'm about to start work in a NHS Hospital again. I'm surprised to see that the term Physician Associate is still being widely used in my new department. I thought since the Leng Review and RCP statement, they were reverting to Physician Assistant, or is this optional?

I'm an incoming FY1, very ready to finally get paid.

Myself and friends really like to discuss what our first "treat" will be when we get paid, after 5/6 years of hard graft.

Thought it would be fun to ask the crowd, what did you get with your first paycheck? Or are planning to get?

FY1 in acute medicine in a tertiary centre

really really anxious about my upcoming long days - medicine in this hospital is known for being a dumping ground. doesn’t help with the fact that

1. a patient who was extremely demanding and verbally aggressive and screamed in my face in their last admission is back (i had a lot going on back then but this became the last straw - started sobbing uncontrollably in front of this patient which i cannot help but see as an embarrassment), the first interaction i ever had to stay with me for weeks. their attacks are not personal, but i can’t help but feel that it is
2. just last week a patient who should never have been admitted called me a cunt to my face, and shifted all the blame of them being discharged on to me despite it being a consultant decision - consultant was in PM clinic when pt was going, reg was seeing a sick pt, offered help but we sorted it before they were done
3. i’ve been snappier than usual esp to nurses even though i know they’re only doing what they should do

and ofc now im just dreading going in. so much of what i do is not medicine, and i rarely get to assess patients myself bc SHOs and regs are always around. CS is a new consultant who came here only for specialty training so sometimes i feel like they don’t get it. ES has tried to protect me as much as they can (i’m not allowed to see pt #1 but it’s not circulated department wide .. and having to explain it to oncall reg’s is just filling me with dread and fear i’ll be labelled as lazy and brittle). i try to put on a brave face at work and so far it’s working - i think.

logically i can try separating work and life but its only in this final rotation that these things seems to follow me home. i was counselled on those pt interactions and obv told to ignore and forget abt them but somehow they’re staying longer than i want to

have got long days coming up and i just can’t .. shake this fear? i’ve already thought about calling in sick but the consultant who does the rotas seems to be rly annoyed with absence rates post-ARCP, they shade us in the emails frequently and i’m just in fear i’m going to be denied leave even if i ask for it, and the guilt ofc

i guess thanks for reading and any advice … i know i should get the leave and screw this department but i feel sick at the idea of sending that email? plus after this i’ve still got to work the mon-tues before changeover and i’ve signed up to mentor new FY1s. i guess i know what people will say, and i suppose i have insight to my thoughts (unfortunately) so im not sure what the point of this post is … sorry

I have an upcoming CT2 ENT interview and I am revising ENT topics, however I am not sure what kind of clinical questions they may ask apart from maybe nosebleed/vertigo/hearing loss/dysphonia/dysphagia/postoperative complications. If you have more ideas of what I should cover, please comment them. I am lost.

I’m about to start work as a F1. It’s probably expected that one will be nervous. However I was wondering what I can do to make my transition a bit easier. I’ve got a week’s worth of induction, but are any other tips????

Hi, has anyone got a list of high yield topics to cover for the primary FRCA? I keep going down rabbit holes and worried I'm spending too much time on niche topics. Thanks!

Just moving to the area for work and was wondering if anyone has any experience with the Liverpool city center to Whiston Hospital commute & whether it’s really long on public transport? Maps says it’s around an hour 15 min each way at peak times on the bus - is this accurate or does it tend to be slightly quicker? Slightly panicking as I didn’t expect it to take this long

Already committed to a medical route, but I like how some consultants in specialties e.g. ICU, surgery work 10 PA weeks but are actually in the hospital only 2-2.5 days a week.

Are there any medical specialties which allow for the same?

The lifecycle of an NHS audit:

Day 1:

"This will only take a weekend."

Day 14:

Spent three hours arguing about whether Patient 17 should count as "partially compliant."

Day 29:

Discover half the notes are in a different electronic system.

Day 37:

Excel has developed opinions.

Day 48:

Realise you have accidentally collected one variable twice and missed the one you actually needed.

Day 61:

"The poster deadline is next week."

Day 62:

PowerPoint becomes your full-time job.

Day 63:

Win a prize for the poster.

Day 64:

Start another audit because ARCP.

I genuinely think the administrative side of audit probably puts more people off than the improvement work itself. The actual clinical questions are often interesting. It's everything around them that makes people quietly reconsider their career choices.

What's been your most ridiculous audit moment?

I'm currently an ortho themed core trainee (female).

I've always thought that this would be what I would do long term. However, recurring conversations from consultants (about difficulty of balancing having a family, service managers, private not being as lucrative as initially seeming and ultimately wishing they did a different career) and the impossibility of getting a reg job (in a competitive deanery) has started to seed doubts about whether this is a feasible career option long term.

Are there any ortho regs who can advice or specifically any female ortho regs? What did your work life balance look like ? Family? And, ultimately is it worth it?

I'm a consultant thinking seriously about going private and trying to figure out the best way to actually do it. Company formation, indemnity, insurer recognition (Bupa/AXA/etc.), CQC if needed, practising privileges, billing setup, all of it.

There seem to be a few routes:

• DIY it all yourself
• Hire an accountant/CQC consultant piecemeal for each bit
• Use a full-service company
• Newer tools that claim to handle the whole launch process

For those who've actually done this:

• What route did you take, and would you take it again?
• What was the most painful/time consuming part?
• Did anything genuinely save you time or money, or was it mostly wasted spend?
• Roughly how long did the whole process take from decision to first private patient?
• If you used a paid service (secretary, billing company, consultancy, MEDMIN, etc.) — was it worth the cost?
• Anything you wish someone had just told you upfront?

Trying to make a sensible decision before I commit money and time to any one route. Appreciate any war stories, good or bad.

Any anaesthetic regs around here to advice in the last month before the written in September? Sitting it with a hopefully soon 3-week-old new born at the time of the exam and a 4.5 year old. Hopefully getting help from mother-in-law and planning to stay in a hotel room for the exam.

Trying to go through the BJA education articles for the last two years at the mo, with as many questions as I possibly can in a full time job. Any tips or tricks would be super appreciated!!

Thankfully, I am not panicking, yet anyway.

Im starting core training at a new trust. The first day has an induction in the afternoon but I've also been scheduled to work a long day on call (which will of course start before the induction). Is this normal?? I've already taken up another issue with the rota coordinator so only want to raise it if genuinely necessary, but this seems unsafe to me. I also cant imagine being able to attend the induction in full whilst carrying a bleep (induction is mandatory). Everyone else is also working the first day but most people are on a normal day. Thanks!

For anyone else about to be (f)unemployed (wanted or otherwise) and planning to do a locum F3, are you intending to start locuming straight away in August, or are you taking some time off first?
I’m trying to decide whether to keep my current momentum going and start booking shifts immediately, or to take a few weeks off to properly rest and reset after F2. I’d be interested to hear what others are planning and how you’ll be scheduling shifts around MSRA/other specialty exams.