New Year, New Variant

Great Dixter, July 2020

It's been an unsocial yet comfortable time at Lola Towers over the Feast Days - I allowed myself quite a lot of chocolate and ended up feeling slightly sick, which is a first. When all the plans made for this time period had to be called off and I wasn't at work I reverted to hibernation mode, broken only by phone and Zoom calls with friends and family. I even made the effort to get dressed, just for these highlights.

Given the long stretch of nothing over several days, I managed to tackle a job that has been waiting literally for years - my Lasting Powers of Attorney for both health and finance. While not all that difficult to create given that the Government website sets it all out in a very straightforward way, the main barrier is with the 'Certificate Provider' (who agrees that I'm sane and not being put under pressure) and the witnessing arrangements, given that we're not supposed to meet indoors and I don't want to involve anyone at work.

Then I got ambitious and embarked upon another long-postponed task - the Advance Decision (or Living Will) which outlines my wishes should I lose mental capacity but need life-prolonging treatment. Alongside that lives the Advance Statement, which gives all my preferences should I reach that state of loss of capacity, so why not do that at the same time? And, since my divorce was finalised in November, why not look at my Will as well?

Since nothing else was going on I knuckled down and printed all the paperwork ready for signing. 

On Monday I'd been so bold as to arrange a socially distanced walk. Surely that couldn't be called off? and no, it wasn't. Three of us wrapped up warm - snow flurries were forecast. A whole lot of other people had the same idea, the paths were two inches deep in mud, and there was quite a lot of dodging around puddles and people and avoiding getting pebbledashed with mud from all the loose dogs. My two companions were also kind enough to sign and witness all the legal documentation, which was no trivial task. And it felt good to go outside even though my knee started to complain towards the end of the walk.

I had been feeling bad from not moving enough - both my body and my mind start to complain when I've been sitting down too much. I've mentioned before that my knee was playing up and I couldn't run any more, so I had the great idea to do a bit of skipping, with the bonus that it can be indoors. It seemed to go well and the knee didn't hurt at all, but it turned out that I was using muscles that hadn't seen much action since badminton stopped ten months ago. I was crippled for nearly a week afterwards.

So that's the end of a pretty bad year, when isolation and solitude (usually my good friends) conspire to turn me into a recluse, relieved only by going to work, seeing mum and dad, and Zoom calls with friends, family and Buddhists. There has certainly never been another year like it, but we will have to wait and see how soon the vaccination programme will make a difference, and what that difference will be.

Marmalade does not count as a portion of fruit

Botanic Garden, Rio de Janeiro, April 2019

I suffered for 10 days with a cold I caught from a Doctor; that's the last time I help him out with a challenging patient. Not really, he's the Doctor I chose to keep when I reduced my working hours. But he could have kept his cold to himself.

Luckily illness didn't stop me from accompanying mum and dad to the last wedding I'm likely to be invited to - both nephews now done and the niece declaring she's not getting married. All involved seem to have escaped without catching anything from me. As weddings go it was a good one - a Humanist ceremony in a field out in the open, so a good thing the weather was fine. Afterwards there was a tent for food and dancing, but as the sun went down it got really cold, and obviously the main players were a generation younger than me so the music wasn't from my era. They had laid on a whole lot of attractions though - props for photographs, pick and mix sweets, a bar making burgers and bacon sandwiches, a fire pit with marshmallows to toast, the wedding cake, a mountain of cheese, more doughnuts than you can imagine and probably more that I've forgotten. It was nice. Mum and dad stayed for the ceremony and some nibbles afterwards but headed off in a taxi before the partying started.

The tax return is done! Also Eurostar booked for ski trip #2 after a whole lot of hassle with logging in and passwords. I'm not convinced the Eurostar website will ever work for me again so I've printed tickets and emailed them to myself just to be sure. Ski trip #1 is all arranged by someone else so I don't need to do anything much. Next job will be booking the bus to the resort from the train station and then it's ski hire and I'll be ready.

The planning and arrangements for all these ski trips and another visit to the Christmas Market in Munich and a week-long retreat in October have been disrupted by my changed working hours. Annual leave in the NHS is incredibly complicated: it is calculated on an hourly basis and you have to include Bank Holidays in the allowance. So if you work 10 hours on a Monday and 1 hour per day for the rest of the week, you have to book 10 hours off when a Bank Holiday falls on a Monday, but conversely if a Bank Holiday falls on a day that you don't work you can use those hours for leave on another day. Swings and roundabouts.

The hours allocated for leave are also calculated pro-rata for weekly hours worked, and the year for which leave is calculated runs from April to March. I halved my working hours at the end of July, which is only a third of the way through the year, so in the second two-thirds of the year I was given half as many leave hours compared with my allowance in the first third of the year. My problem was that I took an awful lot of my year's allowance in the first third of the year, what with the trip to Brazil and the music festivals. When the allowance was calculated for me (there was no chance of me being able to work it out for myself) in August I was presented with a remaining allowance of 1.75 hours up to the end of the year, whilst having committed to two ski holidays requiring 27 hours off. And I was fortunate that Christmas and New Year holidays are not on Monday or Tuesday this year, otherwise I would have ended up in negative balance. Luckily I've been allowed to juggle my working days and take the days off that I need by working extra days in December, January and February.

I have started to use my days off for leisure pursuits as well as all the admin and household tasks that are still needed. Last Friday I took myself off to Birmingham. One of the reasons was that I needed to exchange a defective pan at John Lewis, but then I had lunch at my favourite Cafe Soya, and afterwards I went to the Museum and Art Gallery for the first time in the nearly 20 years I've been living and working here. I didn't have time to see all that much, which leaves scope for another exciting visit, but I did see the Staffordshire Hoard, which is both more and less impressive than I was expecting. Less impressive because all the pieces on display were smaller than I expected, but more impressive due to the sheer quantity of tiny fragments that were retrieved from a ploughed field., totalling 5 kg of gold and 1.4 kg of silver. Now I have looked at the excellent website (link here) I have to say that the information provided at the exhibition itself isn't great.

Another new responsibility for me this year is to be Captain of the first mixed team for badminton club 2. The main tasks are to assemble a team for each match, collect match fees from each player, and register the score if we win. Which sounds straightforward but is usually quite a lot of hassle - I can't play in our first match, and all the men are proving remarkably unreliable so early in the season. But anyway, Mr M, I iz a Captain now, and therefore fully qualified to adjudicate on fruit portions in marmalade and other conserves.

"I love you this much"

Team meeting and Festival

Festival campsite, August 2018

At work we had a team meeting for the Diabetes Dietitians where the Dietetic Manager came to tell us all about the Outpatient Project that she's in charge of implementing. I like the DM a lot - for example she introduced patients Bob, Bobina and Bobetta to illustrate various points. Anyway, this Outpatient Project involves reviewing and re-classifying every one of our many outpatient clinics in order to be able to assess our capacity and understand exactly who we are seeing, how long they wait for an appointment, how long their appointments are, how many times we see them, what we do if they don't attend, and much more. There are a few niggles that still need sorting out which are a bit too technical and boring to describe here.

The rest of the meeting without the DM was just as complicated, as our new Team Leader tries very hard to understand how things have ended up as they have, and impose some sort of discipline and order onto the amorphous mess. It is even possible, if she is tenacious enough, that she may get to the bottom of the conundrum about how my post is funded and how exactly I should handle various complex administrative situations. Again, too technical and boring to go into here.

The day before the meeting, as is traditional, I checked the previous meeting's minutes to see if I had been given anything to do. I noticed that I had been asked to find out whether the doctors where I work have any official referral criteria to describe who they will and won't see. I asked the most amenable of the four doctors who work here, and he said that he didn't, but if he were to write some then his guidance to GPs would be "No stupid referrals." When pressed, he elaborated that a referred patient should have diabetes, and that the GP should have done something about it before referring them. Good enough for me. I wasn't asked for this information at the meeting, thankfully.

Then came the Bank Holiday weekend in which I went to the Shrewsbury Folk Festival. This was my second year there, and I have to admit it wasn't as good as the first, but that was down to a) the wet and windy weather, b) no Oysterband this year, and c) my failure to pack any bedding. After I'd arrived and put up the tent I realised that I'd brought no sleep mat, sleeping bag or duvet. So I went home again and fetched them.

This ruined my plan for a lazy Friday to include a walk into Shrewsbury for lunch at the sushi place I found last year, but actually only postponed the plan until Saturday, when the weather was fairly nice. The rain came with a vengeance on Sunday, but with a watertight tent and all the sound stages under cover it wasn't much of a problem. Highlights this year were all the female singers - The Fitzgeralds, Gretchen Peters, Edwina Hayes, Miranda Sykes with Show of Hands and Maddy Prior with Steeleye Span. What voices they have! I was too tired to see the end of the Steeleye Span set, but lying down in my tent I could hear the strains of the classic "All Around My Hat" with full audience participation.

Back home after the festival weekend and Ilf arrived at his usual crack of dawn next day to make a start on the decoration of the Screening Room. There is still no sign of a screen for the screening room - my TV woes continue, and the second scheduled delivery of a replacement television was also cancelled by the selling company. They refused to speak on the phone and were only willing to converse by email, so I lost confidence in them, withdrew my order and am now awaiting my full refund. Shortly afterwards I set up a profile on the Shpock platform with a view to selling the old sofabed mattress, but then on a whim I bought a temporary replacement TV for £20 so at least I can watch DVDs. When I have the strength, I will go back to the large TV project. And sell the mattress.

On the subject of selling, regular readers may remember that I was all enthusiastic after checking out my local car boot sale. You may also have noticed that the summer is over and I haven't done anything more about it.

Morris Dancers in Shrewsbury - and no, I have no idea why

Seize the moment to blog

Garden rose, June 2015

It's no use trying to compose careful prose and produce a well-crafted blog post about some aspect of my work or leisure that has made me think of something clever or interesting. There's no time. I have a mountain of paperwork, a backlog from my holiday - I knew there was a reason that I only go away for a week at a time. Then I was away for another two days on a course (that I want to write about) and then my week was stupidly busy and I was away for another weekend. So I'll just bang out some words about anything that occurs to me and have done with it.

We have a problem with our plumbing at Lola Towers. Mr A told me last week that the hot water had stopped running, but then it started again. We put it down to polystyrene balls - a very long time ago, one set of incompetent plumbers allowed polystyrene balls to get into the water system. On reflection, we haven't had any trouble for quite a while, so when the hot water failed again when I got back from my weekend away, I sought the advice of a friend who had that very weekend suffered something similar. Following his advice we ventured up into the loft, where the header tank for the hot water turned out to be empty. That was Sunday night, and I wasn't about to call for an emergency plumber seeing as the cold water was running fine and it was an intermittent fault - by Monday morning the tank had filled again.

I am an organised person, and I have many lists that remind me of things that need to be done. I find it impossible, however, to manage to simultaneously do the things on the list that I find difficult; I can just about manage them one at a time - partly because of the difficulty, but also because I have very little time to myself at work due to multiple patients and full clinics and delivering training off-site, and because there is no mobile phone signal in my office. To make a mobile phone call I have to leave the building and stand outside the door, and then it's difficult to write things down, and I can't refer to my online diary because the computer's inside, and if there's no answer I can't leave my number for them to call back because there's no signal when I go back into my office...

So I try to achieve one difficult task a day, and there are many tasks waiting. On Monday it was a call to a solicitor, and today I managed to call the plumber. (There is also the problem of when to arrange for him to visit, as Mr A and I are both working full time at the moment). Tomorrow I need to call the accommodation we have booked for New Year, on Thursday I need to send a letter of mild complaint to the accommodation I stayed in on Saturday night (Lola II is helping to draft it), and you would not believe how dirty the shower is. And there's that huge pile of paperwork that needs sorting out or else my car will not have a parking permit in August, among other slightly less urgent issues.

Then on Thursday there's the second week of our current carb counting course, so I have to cook some carbs for them to count. That means baking a potato and cooking measured amounts of pasta and rice on Wednesday evening to take to work on Thursday. This is a) to demonstrate the change in weight of raw vs cooked food (rice and pasta increase in weight, baked potato decreases in weight but carbs are unchanged for both) and b) to encourage the participants to weigh/measure these hard-to-estimate starchy carbohydrate foods, so that they will know for example how many carbs are in a standard tray of takeaway rice.

And of course I want to keep up the running, and my elbow is pretty much better so I'd like to go back to badminton, and there's the clarinet choir which is staging a concert in a couple of weeks. And I need to buy a new car, and new trainers, and waste paper baskets, and a bedside lamp, and put the charcoal picture that I drew at Mr M's birthday event into a frame, and re-pot and rejuvenate my house plants, and now the 15-foot rose bush and the enormous wisteria need pruning. I've used weedkiller on the patio weeds, but they need to be cleared, and all the rubbish littering the garden taken to the dump. My email inbox is bulging with messages that aren't important enough to be dealt with straight away but not unimportant enough to be deleted, and I am well behind on reading my blog subscriptions.

At work I have a similar number of issues. I was determined with this change of career that I would try and avoid the frustration of being unable to change the world by keeping my head down and letting the world sort itself out. It turns out that I can't seem to do that. Before I went away to America, I wrote a very apologetic note to my manager, detailing three pages of projects that I have taken on but are being thwarted by various barriers: procedural, technical and human.

I want to have a Internet-enabled data projector in our education room. I want to create a website to support our very low carb lifestyle group. I want to be able to show web content to our patients that is blocked by the Trust, including social media and videos. I want to support a new 'transition' clinic for young people moving from the paediatric to the adult diabetes service. I want to be able to offer patients the option of very low calorie 'diabetes reversal' diets that include meal replacement products. All of these need someone else to do something or agree to something, but instead of getting these things that I want, I have been asked to cover an extra clinic in the community on a Tuesday afternoon, and - the horror! - three half-days of ante-natal clinic over the summer (one of my colleagues has left and there is a gap before her replacement starts). And I have stupidly followed up a very good idea from one of my colleagues which needs me to do even more organising and coordinating.

I appreciate that these are problems that some people would be happy to have in place of the real and serious problems that they are having to deal with, but we all would like an easy life, wouldn't we?

Quality

National Botanic Garden of Wales, May 2013

Tuesday was a real throwback to my university studying. It's officially my day off but I've agreed to write an article about gastroparesis for a professional journal. I had thought the deadline was the end of May and had been procrastinating wildly, but decided it was time to start. When I checked the previous correspondence, I found that the original deadline I'd been given was 21st March...

Anyway, I settled down to get started on writing last week, and found all manner of distractions at home. Then I was told about a meeting on Tuesday. The Quality people (this is shorthand for all manner of administrators whose job it is to make sure that health professionals and associated personnel provide the best service possible to the public) recommended that the Diabetes Service in this Trust should have a multi-disciplinary meeting. Despite being another potentially tedious and time-wasting get-together, I actually think that this is a necessary evil, as change and improvement is very challenging when you don't know who the decision-makers are in your own service. It helps that a couple of new consultants have joined the team, who are young and dynamic and seem to be open to new ideas.

So the meeting was on Tuesday, my day off, in the main hospital of the Trust (not where I work), and I needed to get some work done away from the distractions at home. It made sense to work in the library at the hospital, which would give me the opportunity to go to the meeting too. I set my alarm for 'early', because my Couch to 5k run schedule usually includes a Tuesday morning.

The only problem was that I'd signed up for a badminton competition that took place last Sunday. It started at noon so I'd made some sandwiches, and then left them on the kitchen table. The teams were divided into groups, and we'd played everyone in our group by half past two, been soundly beaten by all but one team, and I was getting very hungry, so I was looking forward to going home without waiting to see the semi-final and final at the end of the competition (played by the top team in each group). Then they announced that we would be playing everyone in our group for a second time...

Needless to say we were beaten all over again (even by the team who had lost to us in the first round), and it was four o'clock and I was starving. I found out when I went to club night on Monday that the only team we had beaten were the eventual winners of the tournament, which was annoying. Having played six hours of badminton over the previous two days, it should have been no surprise that I decided not to respond immediately to my 'early' alarm heralding a 25-minute run on Tuesday morning.

An hour later I managed to get up and head off for the library, except that I had a couple of jobs to do first. One was straightforward, involving a signature on a form applying for a memory stick that is encrypted so that it can be used in Trust computers - obviously the risk of downloading and exposing confidential patient information means that ordinary memory sticks are not allowed. The Diabetes team in the hospital where I work is not particularly interested in technology, so we don't have a laptop or computer projector, and the old-style overhead projector with acetates is still used extensively. A laptop/projector combination can be borrowed from the Learning Centre, which I have done on a couple of occasions, but came up against the problem of transferring the file containing my presentation to the non-networked laptop.

The other job I had to do was around verifying my previous NHS service, which was a two year stretch in the 1990's. The only reason to bother with this is because length of service is one factor that determines how much annual leave you get, and those two extra years should give me an extra two days (or is it an extra five days? I can't remember any more). I had managed to extract a letter from the NHS Trust where I had worked, confirming the correct start date, but for some reason my record showed that I had worked there until 2006, which was clearly not true. Unfortunately, my contact in the HR department was still insisting that I get confirmation of the correct dates, and suggested that I use pension records (I didn't pay into the NHS pension in the 1990's) or tax records. I thought I would take the opportunity to visit the HR department in person, and see whether they could be brought round.

It was an interesting meeting - my HR contact had never personally dealt with the tax people, but seemed to accept my view that this was not going to be a desirable line of enquiry. It then transpired that a) she had thought we were talking about my previous employer rather than something that had happened two decades ago, and b) she hadn't realised I was asking for fewer years to be taken into account than were stated in my letter, rather than more. She is going to think again, and I hope that common sense will prevail.

So after all of this, I reached the library mid-morning, then found out that I couldn't access any work information from the library (again because of concerns that patient information might be left somewhere electronically insecure), then worked out (with assistance) how to get my laptop to access the Interwebs, and then, instead of knuckling down to work, I thought I'd do a bit of blogging. Just like my old student days.

The MDT meeting was a bit of an ordeal, all about how we can collect data to show whether we meet the 13 Quality Standards set out by NICE. Obviously it is important to provide patients with a service that includes all the things that contribute to high quality patient care. It is, however, an immense amount of work to record and then collate data to prove that we offered people structured education, foot clinics, retinopathy screenings and blood and urine tests even if they don't turn up for their appointments or provide samples and we can't actually deliver the structured education within current resourcing levels. Apparently, the Diabetes team in the community has a waiting list of 560 people for their structured education programme, which isn't actually being delivered due to lack of staff, or funding, or both.

We also have Quality Standards for clinical results like blood pressure and cholesterol levels as well as average blood glucose (HbA1c). Although I don't quibble with the targets, which are set at levels that ought to reduce patients' risk of cardiovascular disease, stroke and microvascular damage, I don't think the service should be held to account if patients don't achieve the targets - there's only so much that medications and health professionals can do. At the end of the day, if patients want to eat pies and burgers and drink Lucozade then the targets won't be met even if their doctors have dosed them up with as much medication as they dare, and done their best to let them know they're not doing themselves any favours.

I managed to do the run on Wednesday morning instead.

Commissioning diabetes services

Cotswold Falconry Centre, April 2013

At this very moment, right now this instant, I should be getting on with my admin. After a triumph last weekend when I finally, FINALLY managed to switch energy companies, I thought I would keep up the momentum and finish the deal with sorting all the bits of paper heaped up in an enormous pile.

So far this weekend, I have been obliged to go to two, count 'em, TWO Christmas dinners, as well as having my hair cut and going to the greengrocer and making two cakes. Because I am leaving work and there is only one weekend left before my leaving 'party' and I want to stuff vine leaves next weekend and that takes ages. So cakes must be baked this weekend, but I can't do another one because I have run out of cinnamon, so I have to do my admin. Except for the small matter of blogging.

Christmas dinners: one was on Friday night in a local pub/restaurant with my home badminton club that I haven't played with for six months, and the other was on Saturday night in a posh hotel with the Dietitians from the hospital where I used to work a year ago. On balance I probably liked the second one better, because there was a live band and lots of dancing. But the first was very good too.

Cakes: one spiced with fruit, one lemon drizzle.

My leaving 'party': this is taking place after work in a couple of weeks, when a modest buffet will celebrate two people leaving and one going on maternity leave.

Work is a bit strange because I will be leaving in less than a month, so I have much less patience for all the annoying things that happen on a daily basis. Colleagues are constantly complaining about all sorts of things, some of which are genuinely troublesome, but a lot of which are just giving them the pleasurable sensation of feeling put upon. Nothing much has changed in my world, except that I have at last finished the Carbohydrate Reference Tables and sent them for approval by the Trust communications police via the approved route, and have heard nothing at all for two weeks.

The main complaint at the moment concerns a plan by the Clinical Commissioning Group (CCG) to improve the service given to people with stable Type 1 diabetes who are registered with City GPs. The CCG is the official body now authorised to commission services and spend the NHS's money, and it wishes to discharge these patients from care within the city hospitals to be seen in an 'intermediate' service in the community instead. The advantage to the patients is that clinics should be easier to get to and there will be some evening and weekend appointments. There is no change planned for patients who live further afield in the catchment area served by the Trust. People with Type 2 diabetes under the care of the City CCG have already been discharged in this way, but they are back under the care of their GPs rather than being seen in a specialist diabetes service.

In itself, this plan is a good thing. The difficulty lies with the bitter internecine conflict between staff in the Diabetes service based in the two hospitals within the Trust. I may have written long ago about the attempts being made to bring the two locations together somehow, but we have not only remained as two separate units, but the divisions between the two seem to have increased. All this is helped not at all by feuding Consultants and an extreme lack of nurses that is due to become worse when three nurses reduce their hours and one goes on maternity leave in January. Despite the lack of consensus and the lack of staffing, the CCG continues to press forward with the plan.

Some of the difficulty was brought into the open recently because we offer two completely different types of Structured Education, which NICE says should be offered to people diagnosed with diabetes soon after diagnosis. Quite a lot of information, knowledge and skill is needed to manage diabetes in the best possible way, and there are many courses available, some of which are based on a national curriculum and others developed locally. Suitable courses must be evidence-based, and must demonstrate that participants have better outcomes in their diabetes management after they have been on the course.

The two hospitals in the Trust currently offer different Structured Education packages, one developed locally and one licensed nationally. The CCG wishes to offer just one type of Structured Education in the new service, and it is proving difficult and divisive to decide which one this will be. Emotions are running high, as various people have a deep commitment to one or other of the courses, and not only seem unable to decide which to choose, but also seem unable to settle upon a method by which the choice should be made.

The decision to discharge these patients into the intermediate service has also been made seemingly without adequate consideration of the practicalities. How will appointments be made, and by whom? Who exactly will be seeing the patients, and what level of qualifications should they have? Where will they be seeing the patients? What data will need to be recorded, and where and how will it be kept and made available to people who need to see it? How will patients contact the key doctors, nurses and dietitians? A date has been circulated for when the new service will start, without any reassurance that these questions have been considered.

The more forcefully that the new service is pushed, the more resistance is developing, and where I sit and have my lunch all goodwill has evaporated towards the instigators and supporters of the scheme. It is unusual for a day to go by without someone starting up some sort of complaint about the whole situation, and all and sundry chime in, and my pleasant relaxing lunch break is over.

I am very much looking forward to the new job, and it was very useful chatting at the Dietitians' Christmas do. A colleague asked how many days I would be working, and I was able to turn to the manager (who was sitting next to me) and ask, "How many days a week will I be working?" Her answer was "At least four," so that's a bit clearer now. I'm not exactly sure what I will be doing, but another colleague said that she had trained my predecessor for a renal clinic (kidney damage is one of the complications of poorly-controlled diabetes). I was also told that the Diabetes Dietitians in the Trust who are based in a couple of other locations have regular meetings as a team, so I should be able to draw on the expertise of more experienced colleagues for support and for clinical supervision.

Stop Press: my Carbohydrate Reference Tables have been returned by the official people who approve such publications, and who now want us to get written feedback from five service users before approval will be given. And so it goes on...

An account of the past week or two

National Botanic Garden of Wales, May 2013

Let's start with some good news. Here are some bad things that haven't happened: the boiler hasn't broken down. The car hasn't needed any attention for nearly a week. There have been no work-related disasters.

My list of everyday tasks expands and contracts but never goes away. There has been progress of sorts - we have a date for installation of a new boiler, I have a certificate to prove I am not a criminal, and I have even managed to get proof of previous employment in the NHS back in the 1990's. This is useful because the amount of annual leave that one is entitled to depends on duration of employment, and it doesn't matter when that employment took place, so I should get a few more days holiday as a result.

On the down side, I haven't had any firm offer of employment so I haven't been able to give my notice in, and it is now looking as though I will therefore have to work through Christmas; I am nowhere near dealing with the Will or the Power of Attorney that I have been determined to set up for several years now, and there are some other jobs that look like they will be pushed further and further into the future. Income tax self-assessment form? Forget it.

The employment situation becomes ever more complicated. Why is it never straightforward? I got a call last thing on Friday as I was driving home last week, saying that there were more hours available to add to the 20 hours in one of the prospective new jobs, and then the voicemail message was cut off. An exciting prospect - perhaps this would be enough to make up a full time job together with the one day I've been offered by the other employer?

I had to wait until Monday to get more details. It took nearly a whole day of phoning and leaving a message, followed by not being able to answer the phone when it rang, then leaving another message, then being with a patient again when the return call came through, and so on throughout the day. Eventually we managed to find a time when both of us could speak, and of course the extra hours turned out to be on the same day as I had been offered for the one-day job.

Pros: four days with one employer is better than three with one and one with another, and it would cut out all the travel. Cons: the one day job would be doing education for people with Type 2 diabetes which is something a bit different that I'd actually like to do; I've said I'll take the one day job and don't like to mess people around; the extra hours tacked on to the 20-hour job would have to be taken on trust because that offer can't be put in writing. Watch this space.

I have been given the extension to the deadline for my Masters module that I asked for, and spent the whole of last weekend working on it. Really and truly, the whole weekend, except for a couple of hours watching La Vie En Rose, a biopic of the life of Edith Piaf, and a trip to the shops for provisions. I was able to do this due to the absence of Mr A, who is on a Bulgarian Biking Bonanza for a week. He returns very soon, and I await the thrilling tales of excitement and adventure. As far as I know, he hasn't broken anything, but I doubt that he would mention it if he had - he would just return home in plaster as a lovely surprise.

There is more to do for the stupid Masters module, which is taking up a disproportionate amount of leisure time, to the extent that I have decided to use work time to do it as well. Studying as a full time student was wonderful; combining it with a full time job is not so much fun. Just a couple more weeks of pain and it will be over - I do wonder whether I can be bothered to put myself through this for all the other modules necessary for the degree, but I imagine when the memory of this module has faded I shall miss the learning experience.

I am doing a fair bit of learning through everyday work, because I always want to make sure I'm on top of the game. A chance remark by one of the nurses set me thinking about the effect of caffeine on control of blood sugars in diabetes, and I chanced upon a recent paper which investigated just that. In case you're interested, it concludes that caffeine is bad for blood glucose control in Type 2 diabetes, and probably also in Type 1 and gestational diabetes. I'm not sure whether the paper is freely available because I accessed it through my university account, but if you're interested then look for "Whitehead N. & White H. (2013) Systematic review of randomised controlled trials of the effects of caffeine or caffeinated drinks on blood glucose concentrations and insulin sensitivity in people with diabetes mellitus. J Hum Nutr Diet." Or ask me, and I'll email it to you.

Speaking of gestational diabetes, those ladies keep on coming. I have had to deal with a glut of interpreters recently, some of whom have been truly awful, along with some very difficult patients who have been struggling both to understand what is being asked of them and to put it into practice. But some good news to finish with: at the end of today's clinic there was a lovely smiley lady whose interpreter hadn't arrived, but whose blood sugar record was near perfect and who indicated (with the help of family present) that she actually felt much better having made the recommended changes to her diet. That hardly ever happens, but so nice when it does!

Writing letters

Basilica of Esztergom, Hungary, October 2012

I have a half-finished post written about gestational diabetes, but in my obsessive way I have facts to check before I can publish it, and I'm not getting round to it at the moment. It is quite busy at work and at home, and very soon Mr A and I will go on holiday for a week, which I expect will get in the way of blogging.

There has been nothing exceptional in the last week. I have seen some patients, and started writing letters. It appears that no letters have been written following dietetic patient consultations for quite a long time, so this is more exciting than it sounds. I think that letters should have been written, at least for the first consultation following a referral, and for any significant change of treatment or discharge. I am now familiar enough with the department to be confident that my opinion that letters should have been written is correct; therefore, I am now going to have to write some.

Of course, there is no 'writing' involved in writing letters. There are two options: one is a word processing system whereby I call up an appropriate template and type the thing myself, then print copies for file, referrer, GP and patient, and attempt to ensure that all copies go to the correct destination. This is the option I have been using for my first few attempts at letters, because I don't really know what I'm going to say when I start, and the alternative is a dictation system. I've never done dictation before, and am not looking forward to it. Eventually I shall move to dictation, because then all the formatting and printing and filing and envelope-stuffing and posting will be done by the admin staff rather than me, and this will make up for the amount of time it is likely to take me to dictate a letter in an effective way.

However, it has not gone unnoticed by the admin staff that the Dietitians who previously were not writing letters are now writing letters, and this suggests an increase in the volume of work that they will have to do. There appears to be some ambiguity about the status of Dietitians in the Diabetes administrative setup, which accepts Doctors and Nurses as entitled to dictate letters, but is not sure about Dietitians. So we will see how many dictated letters it will take before there is a revolt, and the Managers are invoked, and Dietitians will temporarily have to return to the word processing template system while people argue about budgets.

Meanwhile, the cell that RSB and I share by way of an office has suddenly become a sauna. We have no window or air conditioning, so there is nothing we can do except turn on the fan on the filing cabinet and blow hot air around. At home I wear jumpers and fleeces and Mr A and I sit on the sofa under a duvet, and at work I wear thin tops, anti-perspirant, and look forward to my clinics (where it is not so hot). The important meeting to decide the future location of the Diabetes service has taken place, and unsurprisingly, no decision was made, although the process by which a decision might be made was laid out. So I don't anticipate that we might have a more habitable office any time soon.

I start to find out how much I don't know

Sissinghurst, June 2012

It is a nightmare. I Have No Time At All. This evening (the second one I have spent at home since last Thursday) I have managed to contact a friend whom we will be visiting next week, ordered some Euros for that visit, and 'helped' Mr A sort out parking at the airport by generally answering either "I don't know" or "I can't remember" whenever he asked me a question. The only answer I got right was "Terminal 5". I have about 20 emails that need attention, I need to help dad upgrade his computer, most of my savings accounts and utilities are now uneconomical and need switching, and I'm nearly a week behind with blog reading, let alone writing.

I am crazy tired, and it is my own fault. I continue to try and play badminton twice a week for two hours, and this eliminates two evenings from the week. I am challenged by simple tasks like arranging a service and MOT for the car, because I need to drive the car to work, so will have to arrange everything in a city I don't know at all, at a garage that allows me to drop the car off and pick it up without impinging on the working day. The job makes me late home quite a lot, although this ought to change in April when the schedule of clinics will change, and I will have my own clinics with my name on and everything.

Work is interesting and stressful and difficult but full of promise. I have been keeping a list of 'things to write about on the blog' that I thought I would get round to, but (see paragraphs above) I may as well summarise now because that's as much as I can manage.

Things I have learned about diabetes: all about different sorts of insulins, rules for days when you are sick if you use an insulin pump, how to manage exercise and alcohol if you take insulin, how to manage someone who has just been diagnosed with Gestational Diabetes and keeps bursting into tears, what carbohydrate counting really involves.

Things I have been taught that are not about diabetes: how to use at least four different computer systems, how to apply for study leave, where to find at least 100 policies and procedures, what the Very Low Calorie Diet is for, how to wash my hands and not contaminate food.

I would like to write much more about most of these things, except for handwashing and food safety.

One of the most annoying things at the moment is needing to remember at least five different combinations of user names and passwords. I am told that all of the passwords have to be changed regularly, and don't allow you to just change a number e.g. password01 to password02. This policy does not improve security; all it does is force you to write your user names and passwords down. As long as I can remember the password that gets me access to the document with my passwords in it, I should be OK.

All the most annoying things so far involve administrative systems. The induction process has been shocking. My scheduled day for induction is two months after starting my nine month contract, and seems to be a series of presentations about the Values and Vision of the Trust - the mandatory training I was expecting will be at a future date that I won't be told about until induction day. Just as I think I've done everything administrative that needs to be done, I find out about more - I have to email evidence of mandatory training to a random email address. Food Safety and CPR training is arranged by someone who works in Catering. I have to complete a document for my Personal Development Review that I didn't know about on a date I haven't been notified about. I have to book any annual leave at least six weeks in advance, using a form I haven't been given yet, without knowing how many days I'm entitled to. Today I found out that a filing cabinet drawer in the main office contains copies of referral letters for me - nobody had thought to mention it before. And don't get me started about Tracking... I may muster the strength to write about Tracking another time. And clinic procedures: what to do if a patient doesn't attend, or changes their appointment, or does attend, or I am asked to see them by someone else, or I want them to be seen by someone else.

There are some very good aspects of this job, though. Professional development seems to be built into the job, rather than an expensive luxury available only to the lucky few who have to pay for it themselves. This means that I am already booked onto a postgraduate module about diabetes taking place over four days at the university, and there seems to be little resistance to other opportunities that come my way. I have already learned a great deal about diabetes, and have reached the uncomfortable stage of being much more aware of how much I don't know, but I do occasionally have flashes of insight allowing me to feel good about some of the things I do know.

There is so much to write about work that it has almost squeezed out any mention of the fun that has been happening at weekends. Lola II and Mr M staged a film festival, and Lola II and I went to Liverpool for the weekend, and there was much hilarity at both these events. I would love to write blog posts full of amusing anecdotes and illustrated by YouTube clips and photos, but perhaps Lola II will volunteer to document these occasions on my behalf. She is pretty busy most of the time as well.

A few steps forward

Brixham, August 2012

Into week two I go, forging ahead with getting more of the policies under my belt (Arson Prevention Policy, anyone?) and still observing other people at work rather than doing any proper work myself. I spend a happy couple of hours walking around the hospital with floor plans, discovering a deserted Cyber Cafe, the ID office, the car parking and security office, and registering with the medical library. I can nearly find my way to most of the important places now.

My parking pass arrives, and mystifies me by being entirely paper with a small hologram, and no accompanying explanation. Given that the car parks are 'pay to exit' with barriers, I can't understand how it would work. I pay a visit to the car parking and security office, which I now know how to find, and they explain that some of the car parks would now accept my swipe cards, while others operated by numberplate recognition. Having made sure to clean my numberplate, I am recognised successfully this morning.

I have decided to call my Room-Share Buddy 'RSB', which can equally represent 'Really Supportive Bloke'. He is proving a delight to work with, and although I am not moving forward towards independent working as fast as I would like, he is reassuring about my progress. We have discussed which clinics I will cover, and agreed a start date of 11 March, when I will be on my own. It is unfortunate that this date is my first day back after a week's holiday that I have planned with Mr A, and is the start of two weeks when RSB won't be around. So I really will be on my own, except for the DSNs, who I'm sure will help if I need it.

On Friday, by coincidence, RSB was scheduled to deliver a talk to Dietitians from the main department, so I joined the merry throng. We were split into three groups and given tasks to complete: one group was looking at medications for Type 2 diabetes, I was in the group categorising different types of insulin, and the third group was sorting out various hypo treatments. We made a dog's dinner of the insulins, highlighting again that I still have much to learn. I have found a checklist designed to ensure that different types of patients are given all the information they need, but it will prove useful for me to indicate how much I don't know.

I attended another CPD session led by the specialist obesity Dietitian, all about obesity in pregnancy - how much weight a pregnant woman might gain, healthy eating advice in pregnancy and whether weight loss should be encouraged for obese women who get pregnant. It was very interesting although not very relevant, as I won't be covering the ante-natal diabetes clinic unless I am called upon due to unforeseen circumstances. More relevant was a session delivered by a rep from one of the companies that sell insulin - more on this in another post, I think, along with a report on the 'structured education' that I have been attending, aimed at people with Type 1 diabetes and delivered one day a week for four weeks.

I had a long discussion with a very congenial chap from IT, and we took about a quarter of an hour to find suitable times for training on three essential systems, after which I still had to move my Occupational Health appointment (again) and send apologies for a meeting that I can no longer attend. I'm sure that computer systems will feature again on these pages before long. I have many strong opinions already about the state of the IT to which I have so far been given access.

Part of the difficulty of scheduling the IT training is the number of meetings that have been deemed appropriate for me to attend. Being part of two separate teams (Diabetes and Dietetics) doubles the number of team meetings, and the Diabetes team seems to have a lot of other meetings, including education and updates from reps aimed mainly at the medical team, and sponsored by pharmaceutical companies. I've been to two of these, but they were rather dry and focused on the presentation of lots of clinical data to support the prescription of their products, and the speakers were soundly heckled by the doctors, seemingly as a form of sport. It does mean a free lunch one day a week (although of course there is no such thing as a free lunch).

We have a large and important Diabetes meeting tomorrow, which all ranks and grades and specialties are required to attend, and which will 'debate' the future convergence of the Diabetes service, potentially onto one site rather than over the current two sites where it is presently located. I am not looking forward to this meeting one bit - it will be highly political, I won't know any of the background and locations and services and personnel, and while I would prefer the future location to be Hospital A because that is easier for me to get to, I have no relevant arguments to support this in terms of quality of service outcomes. The meeting is also scheduled to end more than an hour after the end of my work day, so I will be trying quite hard to sit near the door and leave as inconspicuously as possible.

Specialist Diabetes Dietitian

Sissinghurst, June 2012

Are your fingernails bitten to the quick? Is your breath bated? At last, I have more than two minutes to sit down and waste time on this blog, rather than running about like a mad thing. I have to admit that I didn't help myself by agreeing (having my arm twisted) to play in a badminton match on Tuesday, so that I didn't have more than ten minutes at home and awake and not in the shower between Sunday night and Wednesday evening on my first week in a new job.

So the new job started bright and early on Monday morning, when I reported for duty at Hospital B. The new employer is an NHS Trust which was formed from the amalgamation of two Trusts several years ago, and contains two large hospitals which I shall call Hospital A and Hospital B. My main place of work is Hospital A, but my direct line manager and her manager are both based at Hospital B, which is why I started there.

The first few days and weeks of a new job are always difficult, confusing, alternately crazy busy and tediously dull. Because you don't know anyone, are perpetually lost both literally and figuratively, constantly depending on other people for instruction/direction/advice/signatures on forms, there is very little that can be done independently. What I can do independently is deathly, and consists of reading about a million policies. And when I say 'reading', I mean 'skimming in the most cursory way imaginable'.

So far, then, subjects of particular interest are, in no particular order: commuting, parking, hospital navigation, and administrative paperwork.

The drive to and from work is taking a very long time indeed. Hospital A is nearer than Hospital B, but parking is more challenging, so I have been advised to try the (free of charge) Park and Ride service, which adds about 20 minutes to the journey time (including the bus trip to the hospital). Sometimes I have to travel between hospitals, which takes about 45 minutes on the (free of charge) shuttle bus, but may mean finishing the day at the wrong hospital, in which case it takes up to an hour to get back to the Park and Ride car park, followed by that long commute home. So I have applied for an on-site parking permit, which is reasonably priced but doesn't actually guarantee a parking place.

Hospital B is where I had my interview, and is an old site comprising buildings from ancient times that might have been workhouses, through to modern convention centres, with every era in between represented, and plenty of traditional lino-floored corridors. For just a moment one day, I caught an evocative whiff of that 'old hospital' smell of disinfectant and floor polish, transporting me back to the time when dad once took sister D and me to spend the day in Westminster Hospital while he worked there. The site containing Hospital B is huge, and the Diabetes department is in a separate building at the opposite end of the site from the main Dietetics department where the rest of the Dietitians live. It is probably a ten minute walk between the two.

In contrast, Hospital A is a purpose-built concrete monstrosity. I had to go there a few times for courses as a student, and found it confusing then, but now that I am expected to work there I am finding it almost impossible to navigate. Coming from my previous situation in a modern hospital with a completely logical layout and consistent ward numbering, this is a rabbit warren that makes no sense at all and has me utterly lost as soon as I turn a corner. I have learned just two routes so far: from the front entrance and from the nearest bus stop to the department, and even these are fairly flaky. If I go anywhere else, I have to be accompanied, like an idiot child or a convicted felon.

I am based in the Diabetes department, which is a different area from where the other Dietitians live. I share a room with the Dietitian who got the full time permanent job that I applied for, which is only fair as he had already been working there on the temporary contract that I now have. Our room is only just big enough for two, has no windows, and opens onto one of the main corridors. All around are corridors containing doors to rooms housing Diabetes consultants, registrars, their secretaries, Diabetes Specialist Nurses (hereafter abbreviated to DSNs), and the office containing two admin staff, a load of files and the kitchen/eating area. I have been introduced to a LOT of people.

I'm starting to see the end of the administrative paperwork phase. Apart from the contract and the payroll information, which I am obviously very keen on, there have been forms for the parking permit, the ID badge which doubles as a swipe card for getting through security doors, annual leave authorisation, occupational health forms, local induction, Trust policies and procedures, and - my favourite - my competency has been assessed and verified by signature of my line manager in the use of weighing scales and stadiometers (height measuring devices). Trust induction has been delayed, however, because there is no space for me to attend in February and the dates haven't been fixed for March. Let's hope I'm not involved in a cardiac arrest or have to lift anything heavy in the meantime, because I'm sure I wouldn't know what to do.

So far, so good. People are friendly, I can even remember some of their names, the other three diabetes Dietitians are lovely, and my room-share buddy (I'll have to think of a way to refer to him) even baked some delicious cookies and brought them to a meeting. I haven't even mentioned the job itself, but I'm looking forward to getting on with it with great relish.

Electronic referrals

Sissinghurst, June 2012

We have a new computerised referral system. The old referral system involved the telephone and pieces of paper with words written on them. Nurses on the wards would phone our office, and the admin team would write some scanty and usually misleading details about the referral, on paper forms kept in a file. When each of us had seen a referral intended for us, we would tick the form to show we were dealing with it, and go off and deal with it. This involved the admin team in answering the phone quite a lot, but on the plus side, they would do some basic triage and reject inappropriate referrals or bleep us if they thought we needed to know about a referral straight away.

The new referral system has been added to one of the many hospital systems that exist. The most surprising things about the introduction of this system were a) that we were told on the Friday that it would start on the following Tuesday, and b) we were given no information about how it would work or what we should do to pick up referrals or manage them once we had them. You can imagine that it has been a pretty steep learning curve, both for us and for the nurses on the wards. The main people to benefit have been the admin staff, who no longer have to write anything on the referral forms, but do still have to tell the nurses who continue to call the office that we don't accept telephone referrals any longer.

It has been an interesting experience, working with a new computer system that has not been designed or adapted for our use. I am still ignorant of the purpose of the change - why ditch a paper system that worked perfectly well for a computerised system that seems to work no better? It is possible that some numbers can be extracted more easily from the computer than from reams of paper forms, but which numbers are they, and what do they mean? If numbers were at the bottom of the change, then surely we would be given some instruction on how the system should be used, so that the numbers extracted would mean what they were intended to mean.

As an example, the nurses on a ward complete one section of the online referral form, and we then open the entry and can see what they have written. The referral has three options for status: when it is created it is 'Open', then it can be 'Under Review', where it sits on a viewable list, or 'Closed' when it still exists and can be viewed and edited, but is no longer on the special list, which only shows referrals that are Open or Under Review.

So we can assume that 'Open' means the referral is a new one. The next thing that used to happen was that we would tick the referral form and do a bit of background research before seeing the patient. We might see the patient several times, before they either died, left the hospital, or didn't need our input any more. At which point should we change the status to Under Review, or Closed?

The system has been in use for nearly two weeks, and the consensus about this has shifted several times. The latest informal discussion concluded that ticking the form in the book corresponds to changing the status to Under Review and typing our initials as the first entry. Actually seeing the patient prompts a change to a status of 'Closed', even though we may continue to see the patient many more times. And now, each time we see a patient, we are supposed to write something on the electronic record as well as writing on the record card.

I imagine that someone will gather the numbers about how many of these referrals are made, and perhaps the time between the various changes of status. That 'someone' will have little information about what these numbers or times mean, otherwise they might have specified what they wanted and told us how to operate the system in advance of going live.

The overall effect of this new system, after nearly two weeks of operation, is that the admin staff have considerably less to do now that phone referrals have almost stopped, but there has been an equivalent increase in workload for nurses and doctors who are now making the referrals online, and we Dietitians having to make additional notes where we didn't before. And our head of service is getting some data that she didn't have before.

There is a positive side to this, however. In time, we will be able to see whether a patient has had previous contact with a Dietitian on a ward, which is very useful information that we don't have at present. We might also be able to see details of what was done on that previous occasion without having to track down a physical card that might be archived in a warehouse somewhere. The electronic referrals also have scope for the nurses to provide a good deal more relevant detail about a patient than they used to on the phone.

The negative aspects, apart from those outlined above, also include the fact that access to computers on the wards is very limited - the doctors are usually using them to look up blood results, scans and x-rays and results of investigations. This has made it quite difficult for nurses to actually do the referrals online.

If you have read this far, you either know me personally and imagine that this blog entry will get more interesting by the end, or sufficiently obsessive not to be able to stop reading until you have finished. Or, in the case of Lola II, you will have skipped the majority of the boring bits and reached here to finish off, which is not a criticism of Lola II, but in this case a very sensible way to deal with a fairly tedious text. Well done for getting here! Next time, perhaps there will be something more interesting. Unfortunately, the most interesting bits are about patients, and what makes them interesting is precisely what makes them impossible to write about.

Jobs and birthdays

Sissinghurst, June 2012

Another long, difficult week, with two colleagues still away and the added bonus of having a student with me for much of the time on the wards. A good student, which is so much better than a bad one, but still, it's a little bit of added pressure. Last week we made the considered decision that I would not be able to do a clinic while two of my colleagues were on leave, and there was only one patient left in that clinic by Tuesday who was seen by the Dietetic Manager. I have no idea why we did not make a similar decision this week given that the same constraints applied, and instead of one there were five patients that I had to see. But I am not complaining, oh no, I have a good job and some lovely colleagues and I cannot afford to get cross with it because I must continue to turn up for work every day for the foreseeable future. The unforeseeable future - now, that's a different story.

On  Wednesday I did another job application and didn't go to badminton, which always makes me slightly less cheerful. The interview for the first job I've applied for is looming, and I have to get my interview presentation ready for Thursday when it has to be emailed to the recruitment panel. I have very foolishly volunteered to do a CPD presentation to my colleagues all about how a new lot of equations are now favoured over the old lot of equations for estimating energy requirements, and it's on Wednesday and I haven't even started looking at the equations, let alone the evidence behind their use. I have no idea when I'll have time for this, let alone my tax return and various other important items of home-based administration.

On the other hand, Mr A and I celebrated our birthdays on Thursday with dinner at Queans, the local restaurant that gained such a great review from a celebrated newspaper restaurant critic. But directly before dinner I went to donate blood again, and after pricking one finger and finding my iron level was borderline they had to draw some blood to evaluate it a different way, and then said I was OK to donate. So I turned up at the restaurant with plasters everywhere, and then halfway through dinner I had a funny turn and had to put my head between my knees. Despite all this I thought it was a delightful dinner, and my duck breast was cooked to perfection. I'd definitely love to go there again, but Mr A was less impressed, perhaps because his expectations were higher and partly because he had to choose a vegetarian starter (I always underestimate his desire for animal flesh). I'm wondering whether it's worth carrying on donating blood, but perhaps will do so in future only when no other activities are planned for the hours to follow.

It seems incredibly dense, but I have only just realised why it has been difficult to maintain the frequency of my blog posting. When I started the first, student blog, I had already left work to do the degree. It is only since starting this blog that I have been working full time. Naturally there are fewer hours for leisure now that I am occupied all through the day. I don't know why it's taken me this long to cotton on.

Outpatient clinic

Lakeside, May 2011

Outpatient clinics are stressful, from my point of view, anyway. I don't know whether the patients find them quite so difficult, since all they experience is the frustration of almost always being seen later than their appointment time. Although parking at the hospital is enough to make anyone feel cross when they finally reach their clinic waiting room.

My clinic runs from 9.00 a.m. to 12.30 p.m., at least in theory. New patients get half an hour, follow ups only fifteen minutes. Four minutes late and you might have lost a quarter of your appointment time, except I'll probably have to run late because there's no way I can complete any sort of sensible consultation in eleven minutes. Four minutes early and you're probably going to wait for half an hour because the people before you were late or were particularly chatty or had complex conditions that needed some extra time.

I sit in my clinic room with the patients' cards and the computer showing the clinic list. I have reviewed the cards in advance so I have an idea of what I'm going to encounter, and have a chance to research any conditions I haven't come across before (this is starting to seem pointless; see below). Every minute or so, I press the 'Refresh' button, which re-loads the list and shows if anyone has checked in at the reception desk.

It is 9.18, and it seems my 9.00 patient has DNA'd (Did Not Attend) and my 9.15 is late. I click 'Refresh'. The updated screen shows that at 9.17, the 9.00, 9.15 and 9.30 patients all turned up together. Oh boy. What a great start to the morning.

Or, it is 8.58 and my first patient is at 9.15. I click 'Refresh'. The updated screen shows that the 9.30 patient has already arrived, so I can see him at 9.00 and get ahead. What a great start to the morning!

Here are some examples of consultations, which have been changed from the real ones, but are close enough to give you an idea.

The referral states that the patient has IBS (Irritable Bowel Syndrome) with symptoms of diarrhoea. I'm a bit shaky on the guidelines, so I make sure I have copies ready for us to go through. The patient arrives: IBS is old hat, the latest diagnosis is colitis, which is what the subject of the consultation will be. And we discover that I don't know what you actually do with golden linseeds.

The referral asks me to advise on a diet that will help a type 2 diabetic reduce blood sugars. A typical day's diet history is faultless in terms of sugar, saturated fat and complex carbohydrate intake, and when I check the results on the computer the last tests were done in 2010 and show all blood results within the desired range. Both of us are confused.

The referral states the patient has a Syndrome that I've never heard of. I do a fair amount of research in advance into what it is - it turns out to be a relatively rare endocrine condition marked by excessive hormone production - and I fail to find any relevant dietary guidelines. We will have to work it out together. The patient DNA's.

The card shows that a very overweight patient wants to lose weight, having tried for ages without success. The patient arrives and announces that thanks to a support group, 5 kg has already been lost, and motivation remains to lose more. All I have to do is say thank you for taking the trouble to come and let me know! And write to the GP.

The card shows that the patient needs in-depth dietary advice, and only speaks Urdu. It is 30 minutes before the patient's appointment at the start of the clinic, and I have no idea whether an interpreter has been arranged, or what to do if there hasn't. The admin team arrives and saves the day, showing me how the system shows that an interpreter has been booked. We manage very well, although some concepts don't translate well - I was very confused about 'fish fingers' until it became clear it wasn't the conventional sort.

After the clinic, I have to make sure that all the notes are written up on the cards, and each patient is 'outcomed' on the computer (a nice example of verbing of nouns) so that follow-up appointments can be arranged. Letters are written to the referrers of new patients, if there has been a change in treatment and a new prescription is needed from the GP, or if the patient has been discharged. This week's ambitious target was to try to get all of this admin done on the same day as the clinic, and I managed it!

The manager of the department is very supportive, and encourages using pro forma letters. She didn't exactly say that we didn't have to write when a patient is discharged, but gave the strongest impression that it wouldn't be considered unacceptable. I am still suffering from having to take days off as Annual Leave or forfeit them altogether, meaning that I have to squeeze five days of work into just four, but I'm still writing discharge letters; I think it's the right thing to do.