Medical Specialties - GUM (6 Nov 2024)

SPEAKER_03 0:13

Hello everyone and welcome to another episode of Career Conversations brought to you by the Royal College of Physicians of Edinburgh Training and Members Committee. My name is Dr. Marilena Gianudi and I am the co-chair of the committee, and today I'm delighted to be joined by Dr. Sarah Schumann, who is a gum consultant at Leeds Teaching Hospitals, and also the co-chair of the GUM SAC, and Dr. Michael Ewins, who is a gum and internal medicine consultant at Leeds Teaching Hospitals. And in case that introduction hasn't painted the scene for what we will be discussing, we will be discussing a career in gum medicine, so genito-urinary medicine. So hello both. Thank you so much for joining me. So my first question on this podcast is always why did you go into your intended career? And I think we're incredibly lucky to have both of you joining us today to paint the scene of what gum medicine involves. So if we start with you, Sarah, do you mind telling us a bit about your path into gum?

SPEAKER_02 1:15

Yes, absolutely. Going right back, I grew up in Southern Africa, so I had quite exposure at quite an early age in relation to the HIV pandemic and the impact it had on communities in resource-poor settings. I knew I wanted to do medicine very early on, and I knew I definitely wanted to do medicine rather than surgery or anaesthetics. I trained at Newcastle Medical School and then did the rest of my medical training in Leeds. I did my normal postgraduate training in relation to medicine and lots of different medical rotations. I really enjoyed renal medicine, I really enjoyed diabetes and endocrinology, I really enjoyed dermatology, and I was really struggling to know which specialty I wanted to go into. And it just happened that when I came back from maternity leave, there was an opportunity for me to do a locum post in sexual health in GU medicine, and I joined and I never left because it ticked so many boxes for me in relation to the medicine across the board within one specialty from the HIV service perspective, and being able to build up a relationship with those individuals living with HIV over a long period of time and the links into hospital medicine in relation to those individuals, but plus the beauty of the outpatient working in relation to sexual health, a young, diverse, generally population, but always really, really interesting, and never have one day at work that is the same. And you really feel in the Sexual Health Service that you are very privileged to be working there, really speaking to people about their sexual health needs. And also it's nice to be able to be hands-on, take history, take samples, have a look under microscope in the lab, potentially make a diagnosis in clinic on that day, give them treatment, talk to them about partner treatment. And it feels like a very hands-on specialty that you're able to offer individuals a lot in a very short space of time. And in addition to that, not just the patients, the team that we work with within sexual health is just amazing. It's a really friendly, it's a small specialty, really friendly, really supportive. And as a registrar, I never felt that I was in a competition with anybody. It just felt that everybody was supporting each other from consultant level completely downwards. And those are the main things I think that attracted me to the specialty.

SPEAKER_03 3:25

And Mikey, was it something similar for you or something slightly different?

SPEAKER_01 3:30

Yeah, so I did my undergraduate degree in Lancaster and I got very little exposure actually to sexual health and HIV there. And the predominance of my training in sexual health at that point was in a GP block. And as a male, you didn't really get exposure very much in primary care to those sorts of presenting symptoms I certainly didn't in when I did my undergraduate training. I then finished and started F1 and F2 in West Yorkshire and was lucky enough to do a sexual health job in my first rotation in Bradford and instantly fell in love actually with the specialty straight away. Absolutely loved the team. It was the first time I actually joined a team and was like, wow, this is where I'm supposed to be. Everyone just working really cohesively in a great multidisciplinary team in one centre. Really getting to know our patients well, you know, we're really privileged in the fact that people tell us the their deepest secrets, share, you know, some really personal information and stories that actually have shaped their whole life, and sometimes their partners aren't even aware of some of this information. And I think for me, I I just got a real sense of developing the communication skills with people like that. I was like, I d I don't want to stop doing this. I wanna I want to really continue to try and help people who have either STIs who've suffered from sexual violence in the past, are at risk of other things. And I I think one of the most interesting parts of our training is that we see not only the sexual health side of things, we can shape sort of more public health aspects in terms of partner education and getting partners in for treatment, but also we're really responsive teams. The MPOX situation didn't tell us anything last year. You know, we really are at the forefront of public health and and sexual health medicine. After I got that experience in Bradford and finished my core medicine training, I was really torn. I didn't go straight into sexual health. I did enjoy the rotation, but I thought I wanted to do respiratory medicine for a little bit. But actually, after I finished my MRCP, I did a staff great job for a year and I thought actually I'm just gonna go into GU medicine because it just ticks so many of those things that I've mentioned before. And then did my training in West Yorkshire, so I did a year in York and then the rest of my training in Leeds, which was incredible. Things, training programmes change a lot, and I was really privileged in the fact that my department really helped myself and a colleague through a a changing training programme that became a group one specialty. We were doing lots of general medicine as part of our HIV outpatient work, and actually we were able to uh take an OOP and extend our training and be supported during our dual accreditation on the new curriculum as soon as it was live back in August 22, was it? August August 22? August 23? August 22, yeah. 22, yeah, sorry.

SPEAKER_03 6:39

There's a couple of things that I want to touch on, but seeing as we've spoken about the fact that it's now a group one specialty, it's perhaps the best thing to talk about that first. So what does it actually mean for doctors wanting or thinking about going into the specialty? The fact that it is now a group one specialty, how does that affect training?

SPEAKER_02 7:01

It's a medical specialty. So trainees need to do IMT stage one training. So that's now three years of IMT stage one training, so one, two, and three. And then in the third year, they would then apply to whichever medical specialty they want to train in, if that's one of the group one specialties. So at that point, they would then apply and move into genitor urinary medicine and GIM, which is now a dual training programme. So across the four years of training, they would be doing three years in total of genitor urinary medicine training and one year in total of GIM training. But that one year of GIM training is usually split across the four years. And the guidance is that they try and have some GIM blocks through each year of training. For example, it could be three months blocks through each year of training, or it might be two six months blocks. But the training curriculum requires at least three months of GIM in the final year of training. So different training units or programs might structure those GIM blocks in a slightly different way, depending on what works best for the trainee or what works best for the service and the setup of the GIM rotor and the team. But essentially it's four years of training, one of which is a GIM 12 months in total over the four years and three years of GUM training. So that's sexual health and HIV.

SPEAKER_03 8:27

Does that mean that once you successfully CCT in booth, that you are now required to work as a consultant in booth, or will that be deanery and hospital specific?

SPEAKER_02 8:39

So yes, absolutely. That would be deanery, hospital specific or service specific, because some sexual health services are commissioned and provided by non-NHS providers. So sometimes we have colleagues working across non-HS providers and NHS providers. It doesn't mean because you're dual accredited as a consultant, you would either start or finish doing general medicine. Mikey can explain a bit about his appointment and how that's worked from a leads perspective, but it would depend on what jobs were available and not all of the consultant jobs that are being advertised currently include a GIM component necessarily. The reason this has happened is to do with the shape of training and medicine as a whole, and it's not just ourselves. There are other specialties that have moved into group one specialty recently, along with us in 2022, so that includes neurology and palliative care, and the other big group one specialties, I'm not going to name them all, but are cardiology, respiratory, diabetes and endocrinology, for example. And we are very much a medical, physicianally specialty, and there's so many advantages to having that GIM training embedded within your GU medicine training. So I'll let Mikey just uh describe some of his experiences in relation to his consultant post.

SPEAKER_01 10:00

Thanks, Sarah. So my job plan, sorry, and my colleague and Kyle Piu were the first sort of duly appointed GIM, GUM posts that were successfully taken to advert and appointed to in Leeds. My average working week is probably easier to say my specialty week. So usually I on a Monday I would have in the morning my HIV clinic. I do that usually three weeks in ball. And in the afternoon I have a sexual health clinic over at our integrated sexual health service. Within that I am usually the senior GU consultant on the shop floor on that day, giving advice to more junior members of the team, to our health advisors and to our nursing colleagues. Within that is the young person's clinic. Quite often seeing people that are at risk of sexual exploitation, need some good health promotion advice, and feed into our safeguarding MDT. So that's a really interesting day, quite clinically heavy, but really enjoyable. On Tuesdays, I usually have a mixture of MDTs in the morning, so I do HIV inpatient MDT one week in two. And I also input into our HIV virology MDT one week in two, which antiretroviral therapy is most appropriate for people living with HIV, usually based on their comorbidities, their HIV treatment history and resistance, and also a commissioning guidance. So again, that's really good. MDT's really benefited from having some general medical input because we've got a more broader medical knowledge, so it's reassuring that sometimes we we're saying actually we don't think this is related to this person's antiretroviral medication, for example, and actually this patient may benefit from a gastroenterology opinion, or we would recommend these investigations while they're seeing gastroenterology outpatients and sort of liaising with our colleagues how best to arrange those investigations. So that's really good. Overall, that's quite good for the integrated care system because it means there's less appointments being done overall and it's better patient experience in my opinion. Tuesday afternoons I tend to do some educational supervision, so I do a supervised learning event clinic for junior doctors who can book in and have some feedback based on either a GU case or an internal medicine case at the hospital, and I'll offer that from FY1 to SD7, which is really very interesting clinic to do. And then Wednesdays I work in acute medicine in the acute trust. So I work in a variety of settings there. I can work in 7-day emergency care. I can do a post-take wardround, I could be front door clinician, so I could be the point of contact for primary care or the emergency department. It's really enjoyable. It's hard work, but again, it's very good, and I actually see quite a lot of my own specialty within that work. We are well placed to teach other trainings about screening for STIs and how to do that within the acute setting and how to refer into lead sexual health if that person's needing treatment. On Thursdays, I have some SPA time and development time, and I have a sexual health clinic. And Fridays are my day off, which is good. And then every so often, one week in seven, I do a Gemed rotation. So I'm a supervising consultant in the Teaching Hospital Trust. And I go and offer senior clinical input into the general medicine department, and that can be a mixture of ward-round, supervising senior clinical fellows, and don't currently have an patient clinic, but it may be something that they look at developing in the future. I think all of these things have really stood me in good stead to then develop a complex prep service. And what I mean by that is novel may not be the first or best treatment for a patient, and we can investigate and manage appropriately and get them access to second-line HIV prevention methods. So a really exciting job plan. I'm sure it will evolve as time goes on. My job plan involves medicine, it involves sexual health medicine, it involves HIV medicine, it involves virology, microbiology, public health, um, hepatology, renal medicine. And I think it's really good to have that broad medical overview to then really offer, I think, patients the best care that they can have at a single point of access, whether or not that is the HIV service, sexual health service, or in the acute medical department.

SPEAKER_03 14:46

That does sound really quite varied. I assume that you wouldn't have the kind of acute medicine GIM element to your job role. So perhaps you could maybe tell our listeners some of the other things that you may do as part of GU medicine on a typical week. Yep, absolutely.

SPEAKER_02 15:12

Obviously, Mikey's job plan is very packed and very varied, and he's working across general medicine and sexual health, as he's explained, and HIV services. My job plan, as you said, doesn't include general medicine because I didn't dual accredit. That wasn't the training pathway at the time that I was in training, and so it was a single accrediting specialty programme that I did. So I became a consultant in 2010. My job plan has evolved since then, as everybody's consultant job plans do over time, depending on personal interests but also service requirements and other colleagues' interests as well. So I currently juggle several different roles. So I'm the lead clinician for the HIV outpatient service at Leeds Teaching Hospitals Trust. So in my job plan week, I have some time for that kind of management role, which includes clinical governance and quality forum reviewing service incidents and day techs and complaints if we get many, but we don't get many, which is good. And then obviously I do clinical work as well. So I do a clinic within Leeds, HIV clinic every other week, and then I do a weekly clinic in Wakefield because we do a bit of a hub and spoke model in Leeds. Every HIV service is slightly different. I have a day on a Tuesday that I spend within the sexual health clinic doing a morning and then afternoon-evening clinic, which again is very varied, but I have got a special interest in genital dermatology. And as I said before, I was interested in dermatology when I first was doing my training rotation. So for me, that's been able to bring my interest in dermatology into my genitor urinary medicine consultant role. So I have a specialist genital dermatology clinic every other week. I'm not a dermatologist, so there's a lot of referring backwards and forwards between our two specialties. I also have very close links with gynecology in relation to sexual health patients. We have close links with urology and colorectal surgery, for example. And then I also do training roles. So I'm an educational supervisor, I'm a training programme director, and recently taken on the co-chair of the GUM Specialty Advisory Committee as well. So that's a national role. And then I'm also involved in various national roles and regional roles in relation to HIV across the region and across the UK, across England as well. So I do some work with NHS England. I've got an interest in research, so we do a bit of research as well in my working week, but it's not necessarily within my job plan, but it's something that I'm doing within the clinic setting, which is kind of complementary in relation to kind of the HIV side of things. There's lots that goes on within a working week, and it's just really nice as a specialty to be able to tap into those opportunities because we're a fairly small specialty, but there are so many opportunities to get involved in so many different aspects of sexual health and HIV medicine, both locally, regionally and nationally. And everybody that we work with, as we've said before, is so hugely supportive. Whenever you step up to these roles, you feel a bit anxious because you're not sure whether you're the right person to be doing them. But it's always team effort and there's always people able to give you lots of help and advice. And that's one of the things that I absolutely love about specialty. As I've said before, I never feel completely overwhelmed because there's always other colleagues who are there prepared to give you some help and advice if needed.

SPEAKER_03 18:16

One of the big questions I think that doctors in training think about when they're choosing their specialty is their lifestyle as both as a registrar, but I guess more importantly as a consultant, because you kind of know that the registrar years have to end at some point. So what are your on calls like if you do have on calls? And I know that's very person-dependent and job plan dependent, but if we take an average GU consultant, are there on calls? And if so, what are they like?

SPEAKER_02 18:50

So if I start just from a kind of consultants that are just single accredited and it will vary across the country. In Leeds, we don't any longer do any on-calls. We do some out-of-hours work in we do some evening clinic sessions. Every month or so we do a Saturday clinic, but we don't do out-of-hours on-call rotor work anymore. We used to feed into on-calls with our ID colleagues and covering the HIV inpatient work, and that does happen at several other centres and HIV services across the country. Everybody is slightly different. There are a lot of single accredited geo consultants that don't do on calls, but equally there are quite a few that do, but mainly the on-calls are HIV inpatient-based on-calls. Some of our consultants now are also doing some general medicine, not necessarily of dual accredited, but maybe looking at going down the C is a route because again, within their trust and within their service, that's worked really well for them, especially it evolved from the COVID pandemic. So it is very individual, potentially kind of what your interests are, but also the requirements of the service that you're working with and how the on-call rotors are set up. And Mikey, yourself?

SPEAKER_01 19:59

In my child plan, I share a slot within acute medicine on call. So I was contributing about one weekend in 16. I don't do any out-of-hours work during the week um for any general or acute medicine. So that contribution to Q medicine is actually relatively small and it it's actually reducing soon to be one in 20. So actually, from an overall lifestyle and point of view, it's it's not too onerous and actually it can be really nice working with other teams as well, sort of you know, with the other departments. In terms of my general medicine component of the job, I do do some planned clinical care at weekends. Again, this is sort of evolutionary within our trust in a brand new general medicine department within Leeds. So I contribute roughly once every couple of months to a very short ward round. I I sort of do sort of three hours on a Saturday and a Sunday. And again, this is something that is going to evolve over time as more and more people enter jeweled training posts within the trust. So easily manageable, works really well with my lifestyle. I usually work over four days a week, the vast majority of the time, able to take my leave as and when I need to. You know, the different departments that I work with are fantastic and accommodating and recognize actually the pressures are really in every department and actually supporting each other and working in in teams that are great.

SPEAKER_03 21:31

I found it really interesting that you both, I don't want to stay stumbled upon GU medicine, but fate kind of took you there because you happen to have a rotation in it and enjoyed it so much. And I think it's one of the rotations that we don't have a lot of exposure in medical school. I know I certainly didn't. And unless you do have a rotation, I think it's quite difficult to get that exposure with the way training is at the moment. And it may be a specialty that's not necessarily on. People's radars because we just don't know enough about it. Obviously, just the fact that we are trying to get resources like this out there for doctors in training, such as this podcast, can help. What would you advise doctors who are interested in the specialty or doctors who think, oh, it might be for me, but I'm not 100% sure. How should they go about learning more about the specialty and if it's the right fit for them or not?

SPEAKER_02 22:30

That's a very good question. And I think we do feel that some of the reasons why we do struggle to recruit trainees to the specialty. There are multiple reasons, but one of the reasons may be a lack of exposure. And we are trying to tackle that in various different ways. And this is one example. If trainees are interested in the specialty, there's our Specialist Society for Sexual Health. That's the British Association of Sexual Health and HIV Medicine, so Bash. On there, there is a training page, and trainees can go on there and they've got the details for myself and Andy Williams, who are chairs of the SAC. So we can be emailed directly if people are interested in the specialty. We can arrange training days locally. We have got a network of training programme directors across the country who are very keen and very accommodating for people who want to spend a bit of time in the specialty. So doing taster days, so we arrange those very quickly and are able to do that. So happy for people to contact us directly. There is also Stash, which is the Student and Trainee Association for Sexual Health and HIV. So they've got a Facebook page, they've got an email address as well, they do mentoring, they've got various projects, they do some careers, events, education, they've got monthly webinars, they've got a podcast as well. So that's a really fantastic organization to kind of link in with. We've also got British HIV Association, the HIV Specialty Society. Bash and Beaver for medical students have given free membership. And for undergraduates, the membership is a very reasonable price, so people can come along to conferences as well. We have a national training GUM Taste Today, which usually happens within the first week or two of October. It's advertised on the Bash website, but in various other places as well. That's online and is usually very well attended. So people can sign up for that. It's a free event and hear about sexual health and the specialty in a little bit more detail that way as well. So lots of different opportunities through the specialist societies, through Stash, through local Taster Days that we can arrange very quickly for people, and through National Taster Day that we run online as well each October. We have just launched in June a new website. So it's called LoveGum. So if you just Google LoveGUM, there's a fantastic website with lots of resources available and links to how you can get more experience of the specialty, what the training pathway looks like. And there's a few video clips on there as well from consultants and from trainees. It's a good website anyway, just have a quick look at, even if you're not interested in GUM but you want to know a bit more about the specialty. But yes, lovegum, hashtag lovegum.

SPEAKER_03 25:06

I'll make sure that all of those are referenced in our footnotes. So for any listeners who might be interested, please visit the footnotes and then you'll have the direct links to the sites.

SPEAKER_01 25:15

Over and above from what Sarah said, there are some other organisations that you can get involved with. One is the HIV Trainee Association, which is a training organisation run by GU, HIV and IG trainees actually, um focused around HIV training and that can either be treatment, prevention, opportunistic infections, viral hepatitis, public health, research, all of these arms to our training program. They are free. They organise training days twice a year and they're open to all internal medicine trainees as well. So people in IM stage one can register on their website and they can join those days for free as well. So lots of ways to gain more exposure other than stepping onto the clinic floor. There's also British Infection Association, they sometimes do some HIV and opportunistic infection training, and they can be quite cheap educational days and workshops, again, giving people a flavour of HIV medicine. And I think also just highlighting that locally going to your deaneries research days, quite often GU and HIV have departments have quite active research teams and they often present at local and regional and national training and research meetings. So trying to see your local research leads are quite important because obviously research is a big part of our specialty as well.

SPEAKER_02 26:44

And just adding to that as well, Mikey, I mean, you're welcome to contact Andy and myself from an SAC chair's perspective, but you could also just get in touch with your local sexual health clinic, find out, you know, who the lead consultant is and email them. If you don't get anywhere, then feel free to come directly to Andy and myself if you don't do that first. As we've said, the specialty itself is very friendly and people are happy to be approached and very keen to arrange opportunities for people to have some time within our specialty because we know it can be difficult to have specific placements.

SPEAKER_03 27:14

I'll add to that, even though I'm not within your specialty, but based on previous discussions that we've had, that it might be worthwhile for any potential listeners to look at the GRCTB website, which I will also link, to have a look at the GU curriculum to see just how vast a curriculum it is, and just how many different things one can get involved in or different opportunities to work within different teams. And that can also maybe help signpost people within your local deanery to approach if you're particularly interested in one area of it or not. So that's great. Thank you both so much for that. The next question which fits in nicely is are there any particular skills that you think a doctor must have to excel in GU medicine?

SPEAKER_02 28:02

As a specialty, we are extremely inclusive and we are very supportive of people working less than full-time and lots of other commitments outside of their work environment. And so from that perspective, anybody could do GU medicine. I think the most important thing is that you are and we help with this in the training programme, but that you're open so that people can feel they can have an open conversation with you, that you're non-judgmental in clinical settings, that you have very good communication skills, that you can have sometimes difficult conversations with patients breaking bad news, but that's not different from a lot of other medical specialties. Confidentiality is really, really important as Mikey has described, but that puts us in a very privileged position. We see our service users are a very diverse population, so being able to adapt your consultation skills very quickly within one clinic session. So you might be seeing a very young person, and then you might be seeing an 80-year-old, heterosexuals, you know, men who have sex with men, trans community. We also provide services for them as well. And so you have to be very adaptive, but at the same time, that makes it a really interesting environment to work in. A lot of the skills that we have are general medical skills that are important for most of medicine, but there are some very sensitive conversations that we have to have, and those additional communication skills are additionally important. Mikey, I'll hand over to you.

SPEAKER_01 29:25

I'd echo communication skills, empathy, compassion are all really key actually to our specialty. Some of the other key skills that people should have don't quite often can be developed are a keen interest in potentially academia because of the evolving nature of our specialty, particularly with HIV treatment and prevention and the research that's going on in the field of sexually transmitted infections at the minute. Great teamworking skills. We work in quite often small teams but uh a large number of teams across many specialties. So I could give you an example that on one of my days I could work within the sexual health MDT and Safeguarding MDT, which comprises of GU and CSRH consultants, but also has a myriad of health advisors, clinical nurse specialists, safeguarding specialists, and other external providers of care, so people that coordinate care in the community, such as the Joanna Project, which looks after women at risk of sexual violence or sex working. We also have Mesmac involved, sometimes looking after our youth LGBT community. In terms of wider other MDTs, we've got virology colleagues, we have infectious disease colleagues, microbiology colleagues, public health doctors and nurses as well. So we quite often work in these huge environments and actually taking our communication skills as well into these MDTs are really good in order that we provide the best patient care that we can.

SPEAKER_03 31:05

And how important do you think things like doing an audit or a quick within GU Medicine is or, you know, poster presentations? We've already highlighted it can be quite difficult to show commitment to specialty if you don't have a rotation of which there are very few in training. Do you think that it's something very important, or do you think that as long as you can show transferable skills that actually it's about knowing that you enjoy the specialty as opposed to having something on your CV to say, look, I've done a HIV project, Sarah?

SPEAKER_02 31:37

Yeah. I mean, at the moment, are you talking about people wanting to apply for the specialty and making sure that they've got the kind of the right things on their application form? At the moment, we are unfortunately an under-recruited specialty. That's for various different reasons, but some of them we have touched on in relation to exposure. We've had a change in our training programme that for some people has been a reason that they've wanted to kind of wait and see how that would develop and pan out. But we do think it is a really positive move. We've also had sexual health services move into a different commissioning environment, so local authority commissioning, which has had some impact in relation to how sexual health services are tendered, and that has created a bit of uncertainty within the specialty, but that's been going on for a few years. So all of these things have impacted on our recruitment figures, we think. So at the moment, we are significantly under-recruited and really, really keen to shout about our specialty, to tell everyone how brilliant it is. And so actually, those people who are applying currently probably don't have to reach as high a bar as other specialties where they are over-recruited. That's not to say we would at least expect some evidence of interest in the specialty, for example, trying to arrange a taste a day or going to the National Taste Today online, being aware of stash and maybe having signed up to some of these trainee association organizations. But it's never a bad thing to be involved in a small audit project within specialty beforehand. It gives you extra points and extra things that you can talk about during your interview, so you probably feel more confident. And again, that's something if you can make contact with the local sexual health service, see if you can arrange a taste today, but you could also ask, you know, is there any audit work that you could get involved in? We always have loads of audit projects or quick projects that we're wanting to do and very keen to have other individuals involved with those. So definitely a good thing to do, but not an absolute requirement to be able to be successful in an application process at the moment.

SPEAKER_03 33:34

My last question for you, because I think you've done an excellent job at chatting about your specialty, and I'm kind of upset that I didn't have the exposure that I perhaps could have done to it. If you can, whilst abiding by patient confidentiality, obviously, is maybe describe a really interesting case that you've been involved in, which can possibly I know we've spoken about all the different aspects of the specialty, but that could possibly highlight that.

SPEAKER_01 34:01

So interestingly, working in a mixture of settings, I see quite a lot more systemic presentations of STIs than I traditionally would have in sexual health, actually, which is really interesting. You know, we had a young chat in his twenties that was heterosexually identifying in acute medicine with joint pain and swelling, and was seen in our acute medicine department and was labelled as having an acute muscular injury from falling into the river. But actually, on further history and examination by GE physician in the department, we then highlighted some of the risk factors for other conditions and he ended up having what we thought was a potential reactive arthritis. We got our rheumatology colleagues involved and did a sexual health screen, and actually, subsequently later on down the line, found out that he had a disseminated gonococcal infection, which is where gonorrhea infection goes through the bloodstream, primarily affecting the joints. And subsequently, the patient went to trauma and orthopedics where he had a joint washout. So, again, further specialities involved in this patient's care. We were able to go up to the ward and offer him addective treatment for his disseminated gonorrhea. But unfortunately, due to lifestyle pressures for this individual, he ended up self-discharging from hospital before completing treatment. And actually, with our sexual health service, we were able to keep a track of the patient and try and get him back in and be engaged in care with our sexual health colleagues. But unfortunately, again, he couldn't because of other lifestyle pressures, and he then ended up being in the prison service. He was able to articulate to his prison health care service that he hadn't completed treatment and actually was able to re-engage with sexual health care. So just to highlight him really that some of our clients have extreme lifestyle pressures and challenges that mean that they're unable to keep and complete treatment, so therefore allowing for that and making reasonable adjustments and making sure that we're accessible to everyone's really important. And again, making sure that we're non-judgmental and that we're able to really explain in language that a patient understands the ramifications of them not completing treatment, both for their own health, but also that of the wider community as well. So for me, that's been one of the more interesting, more complex cases that I've been involved with over the last few months.

SPEAKER_03 36:35

And I think it it's really interesting that you mentioned that at each stage of that patient disengaging, there was someone there to trying to get him to re-engage with the service and with treatment. And I think that's something that isn't necessarily seen in other specialties. I know in some of the specialties that I've worked in, Humis, in our patient appointment, you're discharged. It's up to the GP to sort that out. And I guess that's really important and really rewarding if you end up getting to the point that that patient completes their treatment, because you've you've had to put a lot of effort into it to make sure that that happens.

SPEAKER_01 37:11

Yeah, it's it's it's really rewarding and actually, you know, making sure that they know that we're approachable, friendly, that they know how to access care when they need to, and actually, if they can't come back to our service, how can we network them into a service closer to where they are at that point in time? And I think that's one of the other amazing things about our specialty is that we've got such great networks with other sexual health services all across the country that actually we work the best we can for the patient at that time. It can be really rewarding, and actually we can go on and strike long-term relationships with these patients. So this particular individual has then decided to go on to oral HIV prevention tablets so that we're able to continue to provide him safe and effective HIV prevention in the future.

SPEAKER_03 38:02

Thank you for that. Any interesting stories or anything that you tend to see regularly? It doesn't have to be, you know, case study publication worthy, Sarah.

SPEAKER_02 38:12

Yes, there's so many different cases. I worry if I pick one then I forget to kind of mention all the other stuff what we particularly are trying to make a difference in, like Mikey has said, is making sure that we are diagnosing people with sexually transmitted infections and HIV at as an early stage as possible, so we avoid these systemic and further complications and also onward transmission. There's a lot of late diagnoses of HIV in the UK, and we see that quite a lot within our region. And these are individuals that have been to multiple different appointments, either with their GP often, or they've been in and out of AE, or they potentially have seen other specialists referred for their thrombocytopenia or their renal function's gone off, or they've got lymph adenopathy, they've got respiratory problems. And so often we do end up then eventually making those diagnoses. And these individuals have had so many potentially unnecessary investigations, waste of hospital appointments. Eventually, for the ones that we see, their HIV has been diagnosed. And to be involved in that journey, although it's often a shock for those individuals, they're often relieved as well that they've got a diagnosis, that somebody knows what's going on, that we can very quickly get them started on treatment. We know what other infections we need to be looking out for, that the treatment is so effective, not only improving their own health, but also with U equals U. If people are on treatment and they're undetectable with HIV, they can't pass the infection on. It's a really life-changing diagnosis to get, but so much more positive way than it was back in the 80s when we had all these scary adverts in relation to AIDS and death. So it's a real privilege to be involved in those cases and they present in so many different ways that it's just fascinating. Most of the cases that we see, especially the late diagnosis cases, are really interesting and rewarding to be involved with. From a sexual health perspective, Mikey alluded to the recent monkey pox pandemic. That was something that we really hadn't seen before, and it was a new infection as far as we were concerned across the UK. And for us as sexual health physicians to be leading on that and making sure that we're vaccinating those most at risk, that we are identifying those with very different presentations often, that whole time was fascinating as well. So our specialty is extremely flexible, adaptive, fast-moving, responsive, and so diverse from a medicine perspective. So I think it's so difficult to just think of one case, which is why I'm struggling.

SPEAKER_03 40:36

But I hope that's given a bit of a flavor anyway. It definitely has. And I think the one thing that I will say to our listeners is that you won't be able to see them, but I can. Both Sarah and Mikey cannot stop smiling when they talk about how amazing GU medicine is. So if you're in doubt about, you know, where your career is taking you and what the right specialty for you is, then you have to consider GU medicine because they look like very happy people. And I can tell you there's a lot of doctors out there that aren't that happy. So if that's not a plug, I don't know what is. From my point of view, all I can do is thank you so much for your time and for explaining everything in such depth. And I don't know if you have any lasting comments before we bring this podcast to an end.

SPEAKER_02 41:25

If you're even thinking that it might be something you're interested, please do get in touch. We'd love to hear from you. And there's lots of ways of doing that, as we've already explained. And thank you for your time, Marlena, and the opportunity to have this conversation.

SPEAKER_01 41:37

I would echo what Sarah said. Yeah, thank you very much, Marlene. And if there's one thing that I would recommend to all early medicine trainees, is I'm sure you've probably seen syphilis at some point. You've just not diagnosed it. So I'll leave it there.

SPEAKER_03 41:53

Well, that's a nice end. Great way to finish, Mikey. Yeah. Yeah. Dramatic. Um, it was lovely to see you, and I'm hoping we start getting more GU consultants too. If you enjoy listening to Career Conversations, why not become a member of the Royal College of Physicians of Edinburgh? Our membership provides you with access to the RCPE educational portal, the live evening medical updates, and you have options to view the symposia both in person or online. If you would like to learn more about this, please go to the Royal College of Physicians of Edinburgh website.