I have one vivid memory of medical school: being taught basic sciences by people who were neither teachers nor doctors. I vaguely remember being taught about the Frank-Starling curve in the first year. We stimulated a real myocyte at various lengths and measured its contraction. In fact, we did lots of rather bizarre experiments, but no one mentioned what relevance they might have to real life. I threw all my physiology notes away triumphantly after passing the 2nd MB (preclinical exams).

STEVIE GRAND/SPL

Later at medical school, I was taught to take a history, perform an examination, and then make a diagnosis. But no one mentioned that this would be inappropriate when faced with a critically ill patient. In fact, no one even told me that tests do not make a diagnosis. I do not recall ever being taught about oxygen (except that it's dangerous), arterial blood gases, different fluids and fluid balance in illness, how inotropes work, and all the physiology I would need to know as a house officer and a senior house officer (SHO) in medicine.

No one even told me that tests do not make a diagnosis

As an SHO in medicine I did not know what I did not know, so I carried on in blissful ignorance, administering what is now known as suboptimal care to unsuspecting patients. And because most of my seniors probably did the same, I carried on. I studied hard for the membership exam and learnt all about southern blotting and nitrous oxide, outpatient medicine, syndromes, and how to investigate people who are essentially well-there was no time to read about what I spent most of my time dealing with.

Then one morning, after three years on a popular medical rotation, I was finishing a night shift and starting my handover to the day SHO. We were on the coronary care unit and I had been looking after one of the many patients I had treated for cardiogenic shock. I had inserted lines (in the septic technique I had been taught) and had cranked up the dobutamine to a good dose, but the blood pressure remained 70/50 mm Hg and there was hardly any urine output. The day SHO looked at me: "Of course," he said, "dobutamine doesn't raise blood pressure." This confused me because I had used dobutamine to raise blood pressure ever since I was a house officer. He started to talk about alpha receptors and beta receptors in the circulation. I cannot remember the rest because I was lost. "Where can I find this in a book?" I asked him. He shrugged and said, "Any anaesthetic textbook." He was one of a few anaesthetic SHOs on our medical rotation. I had noticed that they seemed to be the only specialty in the entire hospital who were trained in physiology as applied to real life. This encounter started me on a journey. I decided I could not possibly become a medical registrar without knowing such basic facts about acute medicine.

A year's training in anaesthesia and intensive care medicine later, I now spend my time helping medical and surgical SHOs learn "what you really need to know but no one told you." This is because good acute care is simple, and it makes a huge difference to patient outcome. I still marvel at the fact that it is possible to experience several years' training as a medical or surgical SHO, gain membership, and still not have the ability nor a sense of urgency in managing the generic altered physiology that accompanies acute illness. With a growing number of courses available things are slowly changing, but why isn't this taught at medical school?

There was no time to read about what I spent most of my time dealing with

A little while ago, some colleagues and I were debating what makes a good junior doctor. We decided that learning is a lifelong experience, but that five attributes are essential from day one:

Common sense (which I define as the ability to put two and two together and make four)

Organisation/prioritisation

The ability to communicate well with patients, relatives, and colleagues (including note keeping)

A knowledge of medicine, especially prescribing

How to recognise critical illness and do something about it.

All my non-medical friends say they would prefer a competent doctor to a "nice" doctor in an emergency. There is only one thing that you never have time to look up in a book, and that is how to spot when someone is really ill, how to understand and treat abnormal physiology, and when to call for help.

I have worked in several hospitals, and every time I ask an SHO a question about oxygen, why PaCO2 really rises, fluid balance in illness, how to interpret the central venous pressure (I could go on), I am faced with blank looks. They know lots of good medicine and surgery, but junior doctors are the coal face doctors; they really need to know this stuff. Are we producing "fit for purpose" doctors?

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