Member profile: Sarah Fox and her year in Edinburgh
Sarah Fox was a consultant at Prince Charles Hospital in Brisbane before she took leave in 2022 and moved to Edinburgh for a year-long placement at the Royal Infirmary of Edinburgh. Now back in Brisbane, Sarah reflects on her experience and learnings from a memorable and rewarding year.
Last year, I worked as a geriatrician in Edinburgh. I received an offer in mid-2021 and after clarifying that no, we would not be allowed to live at the Castle, we boarded a plan the following January anyway.
Like a lot of doctors in previous generations, I was keen to experience work as a geriatrician in a different country. Often asked what prompted me to go, I have usually replied that I was looking for a bit of an adventure. And while this is partly true, I was also keen to know whether what I learnt during my Australian training still ‘worked’ in a whole new health system. I wanted to challenge myself in a new environment, hoping it might make me more self-aware and self-critical in my own clinical practice.
We are lucky that as Australian-trained physicians, we can work as (locum) consultants in the UK without needing to formally register on the specialist register (which by all accounts sounds like a painful and arduous process). The UK government also offers readily available visas to Australian doctors.
Leaving Brisbane in the middle of summer to arrive in an Edinburgh winter required some adaptation. But once the children got used to the more obvious differences (“Do we really need to wear a coat to walk to school?” and “Why can’t I bring a snowball inside?”), we settled in for life as usual, and I was able to start at the Royal Infirmary.
I was the recipient of a lot of kindness that made the year a happy one. Many people went out of their way to make us feel welcome, and it’s that demonstration of kindness that I hope to extend to those making the opposite journey in the future.
One colleague, who was to become a close friend, was entrusted with my orientation, patiently answering questions from this so-called geriatrician from Australia – what’s a POC? A package of care. And a PF? The procurator fiscal (…and what’s that?). How could I do my job if I didn’t grasp this basic know-how? But of course, I learnt, and people were happy to answer my questions with only a small amount of ribbing on the side.
To be better understood by my patients, I made small adjustments to my Australian drawl. Bowels soon became ‘bow-wells’ (I am a geriatrician after all…) and world ‘wi-deld’. But the skillset was of course the same – communicate clearly, make sensible decisions that centre around patient needs and values, work as a team. In this way geriatric medicine was the same in Edinburgh as it is in Brisbane. This was the biggest relief of the year.
In Edinburgh, I worked a combination of acute geriatrics, as well as orthogeriatrics. The established position of geriatric medicine in Scotland, in which patients are admitted directly from the emergency department to MoE wards (‘Medicine of the Elderly’ has not been renamed) is something I found extremely beneficial in terms of proactively commencing comprehensive geriatric assessment at the front door and then continuing this during the hospital admission.
The NHS is under pressure. I witnessed an incredible amount of dedication from everyone working in the hospital. No nursing ratios mean that beds don’t close. This took some adjusting. There were times on the acute geriatric ward, admitting patients straight from ED, where we had three nurses for 36 patients. Palliative care and early mobilisation are both equally hard in that setting.
From a medical perspective, I do think the clinical load I managed in Edinburgh is higher than back home, but the requirement for departments to create structured job plans mean that the workload is spread evenly, which I felt improved efficiency and made things clear and achievable. Doctors get paid significantly less in Scotland than in Australia but the professional standards they work to are the same. Wage differences between different medical specialties don’t exist. The financial motivation for a career in medicine is somewhat less powerful over there. The doctors I worked with were passionate about excellent patient care.
Working in a different setting makes you think about how you practice and why. Different prescribing practices demand an open and inquisitive mind. Gentamicin is king in Edinburgh, a fact that coming from the northside of Brisbane I found hard to digest. Conversely, the hand that prescribes augmentin or (gasp!) ceftriaxone in Scotland is much maligned. (I think this is partly due to an earlier mandate by the Scottish government to reduce rates of clostridium difficile infection). Other similar, and relatively small, local differences required some adjustments during the year.
Home care packages in Scotland appear more generous and available than in Australia. Maxing out at two carers visiting four times during the day plus once overnight, living at home in the later stages of frailty seemed more achievable there than it does at home. Despite concerns about the ‘long waits’ for home care packages in Scotland, these seem to pale against what we have come to accept in Australia. As such, people will wait in hospital for the POC (that’s a package of care) to become available, in a way that we would never be able to entertain in the Australian system.
I had the impression of more geriatricians having higher research degrees in Edinburgh. Junior doctors have the opportunity, as residents or registrars, to do dedicated research (PhD) time, whilst being paid a wage equivalent to a doctor working clinically, and without losing a spot on the training pathway. This means that two of the big barriers to pursuing a higher research degrees – money and loss of clinical opportunities, are removed. This translates down the line to more consultants who are also researchers.
Another positive observation in Edinburgh was the established position of nurse practitioners within the department. This highly professional group provided a constant, stable workforce that did not come and go in the way that junior doctors must. They could keep the unit cohesive, keep things ticking over, provide consistency at points of medical workforce transition, and provide oversight and insight during quality improvement initiatives.
The practicalities of moving our family to Scotland seemed large but achievable. Some things helped, like finding a lovely flat while still in Australia and having our children welcomed wholeheartedly into the local school. The challenge of moving back was more unexpected, as we hadn’t reckoned with leaving a piece of our hearts in Edinburgh.
Why don’t more doctors go now? I am not sure. Maybe the quality of our training in Australia feels more than adequate (I think it is), maybe it’s the scare of the news reports about the state of the NHS (in Edinburgh it was busy but not in a harrowing way). I think few experiences can make you reflect on your practice as clearly as a year abroad. As a new consultant, I’m so grateful I was able to do it, and what better place than Edinburgh.
Image Courtesy: Sarah Fox
Sarah with her children outside a castle in Edinburgh
