Paul McNamara is a registrar in General practice in the West of Scotland. Prior to entering GP training, he trained in core medicine and emergency medicine. Prior to studying medicine, he did a BSc in Anatomy and graduated with a first-class honour’s degree.
He studied medicine at Glasgow University and qualified with distinction and commendation. In medical school, he received numerous awards from the British Medical Association, The Cross Trust and The Trades House of Glasgow for academic achievement.
Paul has a keen interest in research and teaching. In 2017, he was awarded honorary clinical lecturer by the University of Glasgow for his contribution to teaching. Paul has published articles in the British Medical Journal and Clinical Anatomy journal. Paul has published two medical revision books aimed at medical students and junior doctors. ‘Case-based discussions in medicine’ was published in September 2019 and ‘Mastering medical exams’ was published in April 2020.
He is a mentor for the Reach Foundation which encourages school students from disadvantaged backgrounds to consider tertiary education and gives them access to medical work experience. He loves to read, write, listen to music and swim.
Q1. What inspired you to become involved with medical education?
I have been lucky to have had some excellent teachers and mentors during my time at medical school and throughout my training. I was taught by some incredibly passionate clinicians and this inspired me to get involved with medical education. An enthusiastic mentor can have a profound impact on their trainee’s development.
During my foundation training, I was preparing my application for core medical training, and to pick up ‘teaching points’, I designed a programme for 4th year medical students. Sessions involved bedside teaching followed by a tutorial based on the patient’s condition. We would then go over exam questions related to our discussion as a way of consolidating their learning. The sessions were well received by the students and they gave some lovely feedback. This is where I first had the idea for my ‘Mastering medical exams’ book, but it would be several years before I cultivated it to fruition.
Getting positive feedback from students and junior colleagues is extremely rewarding. It also helps to keep my knowledge and skills up to date. I always try to be enthusiastic, passionate and approachable when teaching, and knowing that you may have a lasting impact on the clinical practice of future doctors and therefore ultimately on patient care, is something that inspires and motivates me.
Q2. How do you manage to work, be involved in medical education and enjoy family life?
Good question! Striking a balance is incredibly important. I guess like most medics, I am good a multi-tasking. Prioritisation is an important skill to develop. In terms of medical education, I think collaboration is key. It’s important to recognise that you can’t do everything yourself.
When I was working as a research fellow in A+E, part of my role was quality improvement. I developed a student selected component with the medical school where I supervised students undertaking research and quality improvement projects. Over the course of 18 months, around 20 students completed projects, all of which were presented at national and international conferences including the European society of emergency medicine in Athens. We formed a synergistic relationship. The workload was greatly reduced, and they got points for future applications (it’s all about the points). The same can be said about my second book, ‘Mastering medical exams’ which greatly benefited from the contributions of Jamie Crawford (FY1) and Nadine Formosa (4th year medic). Recognising the skills and strengths of others to complete a common goal helps to maintain a balance between work and family life.
Medicine can be stressful and demanding, so it is necessary to recognise this and take time out to re-charge your batteries. You must look after yourself so that you can then care properly for patients. We have three children under the age of 6 at home, so things can get rather chaotic. I take time out by reading and listening to music and swimming at least four times per week. Medicine can sometimes feel a little all-consuming and spending time with family and friends is a great way of reminding yourself that life exists outside the hospital and clinic.
Q3. Is there anything you wish you could have told your younger self?
Hindsight is a wonderful thing. I used to worry about lots of things. I suppose I have the same perfectionist streak that other medics do. What if I fail the exam? What if I mess up the presentation? I avoided public speaking like the plague. I wasted a lot of time worrying about things that really do not matter. Over the years, I started using mindfulness and meditation which has greatly helped me to focus my thoughts and live more in the moment. If I could, I would tell my younger self to chill out, breathe, and stop over thinking!
Q4. How was working in A&E compared to working in a GP surgery (the obvious and not to obvious similarities and differences)?
I loved A+E. It is a fantastic job and I think every doctor should work there at some stage. I worked in the same department as a clinical research fellow for 2 years before entering training to ST3 level. It was my absolute privilege to work alongside some incredible colleagues, including nurses, doctors, HCAs, porters, paramedics and radiologists. It is a truly multi-disciplinary team and the camaraderie that develops when you are faced with horrendous life and death situations is second to none. I made wonderful friends. I have encountered some remarkable things. Foreign bodies in unmentionable places (a toy car in a 43-year-old man’s anus stands out). A thoracotomy on a 63-year-old lady who was stabbed in the heart by her daughter (for sleeping with her boyfriend). A couple of premature babies born down the toilet. And many, many more. A+E is a stage in which the entire human condition is played out. I loved it! I loved the drama, the team, the patients, the excitement, and the urgency. Life and death scenarios played out in cubicles that were only separated by thin paper curtains. But shift work in your mid-30s with a young family is difficult. It is not impossible and I wouldn’t want to put anyone off! However, I was working 80-hour weeks (mostly nightshifts) and the ‘work-life’ scales were heavily skewed towards lots of work and not much family life, so I decided to apply for GP. I’ll be honest and say when I applied it was mostly for life-style reasons. I had poor learning experiences during my medical school GP blocks, and I was anxious that I wouldn’t enjoy it. However, I have just finished my GP rotation and it was fantastic! There are a lot of similarities to A+E. There is huge variety and you never know what clinical problems are going to come through the door. You need good diagnostic and problem-solving skills and be able to think on your feet. One of the things I disliked about A+E was not following up on the patient. You never really knew what happened to them after they left the department. In GP, I really get to know my patients and their families, and this is hugely rewarding. William Osler was right when he said, ‘just listen to your patient, he is telling you the diagnosis.’ In A+E, your diagnosis is supported by a barrage of investigations such as bloods, ECG and CXR. In GP, I think there is more clinical uncertainty and risk and you rely heavily on clinical skills to reach a diagnosis. Being the responsible physician for an individual at the beginning off their patient journey and supporting them through investigations and treatment is incredibly satisfying. I left work every day feeling that I had made a real difference to peoples lives. After probably being a bit burnt out in A+E, it reminded me why I got into medicine in the first place.
Q5. Was there anything that influenced your decisions on your medical journey with regards to specialities?
My slightly meandering career requires some explanation. So, bear with me. At medical school, I enjoyed most subjects and I wasn’t sure which path to take. I enjoyed medicine, paediatrics and emergency medicine. For foundation, I chose rotations that would allow me to experience these specialities. In FY1 I did paediatric surgery, medicine and general surgery. In FY2 I did paediatric medicine/neonates, medicine, and emergency medicine. I really enjoyed all the rotations which made choosing a speciality especially difficult. When I was applying for speciality training in 2012, the vast majority of FY2s went straight into higher training. This contrasts with now where the majority take some ‘time out’ after FY2. I ultimately decided to apply to core medical training (CMT) and gained a position in Glasgow. I enjoyed CMT but with hindsight, I should have probably taken some time out to ensure I was making the right decision. Choosing a speciality is a huge decision and one not to be rushed. It’s ok to not know which path to take. In the ‘old days’ trainees would do a number of SHO years and then apply for speciality training. Now you need to decide only 18months after qualifying. This is too early in my opinion.
CMT was a steep learning experience! As a CT2 at a large city centre hospital, I was asked by management to ‘step up’ onto the senior rota. This meant I would be the most senior doctor on call for all the medical inpatients and those presenting to A+E overnight and at weekends. CT2 is still quite junior and I found the prospect rather terrifying, but the rota was slightly better than the junior rota and I didn’t want to disappoint my consultants, so I agreed. I remember turning up to my first night shift as the ‘med reg’ and feeling absolutely petrified! I thought I was the only one who felt like this, but it turns out everyone feels the same! Everyone is winging it! I learned a huge amount in this post. One-night sticks out. At 1am, I was paged by the coronary care unit to assess a 56-year-old man who was having severe chest pain. As I arrived, he was grey, sweating, gasping for breath and vomiting. I got to work quickly assessing ABCDE, putting in cannulas, giving morphine and oxygen. His ECG confirmed STEMI and I organised for him to be transported via ambulance for PCI. As I was arranging transfer on the telephone, a female patient across the bay went into acute respiratory failure. Rapidly assessing her revealed severe type 2 respiratory failure so I commenced non-invasive ventilation. Just as she was stabilising, a nurse from the opposite ward came running in saying ‘there’s a lady seizing next door!’ Sprinting to the next ward, I was informed that the female patient in her 70’s writhing on the bed had been seizing ‘for ages!’ I gave her a dose of IV benzodiazepine and thankfully she stopped seizing, but she also stopped breathing! As the other ST1 ventilated with a bag-valve-mask, I reviewed the notes and it transpired that the patient wasn’t for escalation to ITU! The ST1 had to hand ventilate the patient for the rest of our shift until the benzos wore off. Thankfully the patient woke up before the morning ward round! Lesson learned. Don’t give big doses of benzodiazepines to old ladies!
Near the end of CMT, my wife and I found out we were expecting identical twins. Unfortunately, twin pregnancies are fraught with complications. Our twins had a condition called selective intrauterine growth restriction, which meant placental blood flow was poor and the twins weren’t growing properly. We were referred to foetal medicine and it was strange to be on the receiving end of ‘breaking bad news’. We were told that there was a high chance of foetal demise, but if they survived, they would likely be very premature and possibly brain damaged. This turned our world upside down. At the time, I couldn’t envisage a career in hospital medicine with two disabled premature babies, so I decided to leave training to support my wife. At the same time I was doing CMT, I was also locuming during my ‘free’ weekends in the A+E department where I did FY2. They were very good to me and offered a full time locum position which would mean I could work as much as I needed (we were renovating an old house) whilst allowing me to take any time off I would need whilst the twins were in neonatal intensive care. Our twins, Emily and Freya, were born 8 weeks early, and apart from requiring a bit of respiratory support, they did really well. They turned 5 last week and they are happy and healthy little girls.
I then commenced training in emergency medicine and loved it. Unfortunately, I was diagnosed with seronegative spondyloarthropathy and I was commenced on Adalumibab which is an immunosuppressant. The long shifts were no longer compatible, and I was picking up a lot of infections. This is when I decided to apply to GP. I don’t regret my colourful career path and I have no doubt that the experiences I have gained will make me a better GP.
Q6. Could you tell us a little more about your books ‘Mastering Medical Exams’ and ‘Case-Based Discussions in Medicine’?
Case-based learning is a fundamental part of teaching at medical school because it links theory to practice. ‘Case-Based Discussions in Medicine’ is designed to help prepare students for clinical practice by working through authentic cases.
All cases are presented in a consistent style, and cover:
- History of presenting complaint
- Examination and interpretation
- Differential diagnoses
- Diagnosis and management
Each case concludes with background information covering the pathophysiology, diagnostic criteria and clinical guidelines.
The book is a study companion for medical students and foundation doctors and will help the reader to:
- become proficient at writing up a patient’s history and examination findings
- improve clinical decision-making and patient management
- build clinical knowledge
From back pain and breathlessness to post-partum psychosis, via abdominal pain and jaundice, placenta praevia, and alcoholic liver disease, the book guides you through common cases in medicine, surgery, obstetrics and gynaecology, paediatrics and psychiatry.
‘Mastering medical exams’ is designed to prepare students for exams and equip them with the knowledge required for clinical practice. Practice questions are an essential part of medical school exam preparation. They allow you to practice answering common questions and identify recurring themes. They are a vital resource for medical school success.
Preparing for your medical school examinations is a daunting and anxiety provoking experience. But this book will help you to detect recurring topics and themes and will take you through a system-based approach to common exam questions. Answers are presented in a way that will consolidate your knowledge. Answers are short, succinct and to the point! They are not meant to be exhaustive and are displayed in a way that will help you remember the pertinent points for exam success and for answering questions on ward rounds and in clinics. Practice questions allow you to test your knowledge, but they are also beneficial for boosting exam technique and perfecting time management and will prepare you for success on the day!
Q7. Do you have any tips for current medical students and junior doctors who are interested in being involved in medical education?
Most medical schools now have peer-led learning. If you are interested in medical education try to get involved with teaching your fellow students whilst at medical school. Some medical schools also have student selected components with a medical education element. Be keen and enthusiastic. Approach doctors on your placements and ask if there are any projects that you can get involved with. Doctors are usually delighted to have a helping hand. Audits and quality improvement projects are a great way to get future application points and if you present them at conferences then this looks great on your CV. Personally, I wouldn’t get involved with large research projects that requires a lot of time and commitment as you want to make sure you complete it, write it up and present it. Small projects that allow you to close the audit loop are what are required at this stage. I’m a big fan of collaboration. Team up with your friends and spread the workload! Joining clubs and societies (such as ASME – Association for The Study Of Medical Education) are also a useful resource.
Q8. How has the role of the GP changed during your time as a GP registrar?
Due to Covid, a lot of consultations are now taking place via telemedicine and video calls. I think digital innovation will be the future of general practice.
Q9. What is the best thing about being a doctor?
Raymond Tallis said that ‘scientific medicine is one of the greatest triumphs of humankind’. It is a great privilege being a doctor. Patients give us access to their lives at their most vulnerable. Interacting with patients is the best thing about being a doctor.
Q10. What is the worst thing about being a doctor?
Getting sent pictures of body parts from friends asking for a spot diagnosis for their ‘rash’!
I would like to thank Dr. Paul McNamara immensely for taking the time to be interviewed – this short blog will have a lasting impact on so many budding medical students/doctors!!