Back in Blighty

Coming Home.

Well, we’ve been home roughly 6 weeks now and I’ve finally got round to righting up the final chapter of our USA adventure.

So our first impressions on returning home?

Britain is beautiful and amazingly green. The green is really striking at first glimpse when you’re flying over. It has a real sense of living history – everywhere from the local village pub, to the Royal wedding at Westminster Abbey. Despite it’s reputation, the food is great. Proper sausages, Roast lamb, Yorkshire puddings and gravy, fish and chips with loads of salt and vinegar, proper bacon (and proper bacon sarnies), chicken tikka masala, and the choice of Thai, Chinese, Indian, Malaysian, French, Moroccan, Lebanese, Italian Cuisines. I haven’t had a single burger since we’ve been back. The beer is lovely and warm. Even the weather was great for the first few weeks – probably the best we’ll have all year though. People are more modest, and definitely more reserved.

It’s also very crowded. There is far too much traffic. There are speed cameras and surveillance cameras everywhere. Parking is an issue almost everywhere. Everything seems smaller – the cars, the parking spaces, the houses, the food portions…

Moving back has not been without its drama – nearly missing our flight back, then arriving without any luggage, and a long frustrating search for a home to rent in our new location in the UK. Then taxing and insuring the car, setting up mobile phones and Internet, etc. Moving home 5 times in 5 years has not done the credit rating much good and it’s a real pain filling in the forms. Maybe our memory is short, but it does seem like the move out to the USA was easier than the move back home. I say home, but it’s really hard to define where home is at the moment. Moving house is supposed to be one of the most stressful life events – after a death in the family, and a divorce. Our 5-year-old boy has lived in 5 homes. Now we are in our new home in the UK for at least 6 months before it’s time to move again. We still haven’t unpacked everything yet. In fact I only unpacked my suitcase 5 days ago. It’s taken a month to find somewhere to live, and we still haven’t been able to get our children into a school. We seem to get past one hurdle then find another hurdle of red tape to get past. To find out that nearly all the schools in our region are full and we have no control over which school they are allocated to is frustrating and thoroughly depressing. Moving home has been harder than I ever thought it would be. With retrospect I think I just didn’t plan the return home as well as the trip out to Michigan.

What about going back to work in the NHS? I have been asked many times which is the better healthcare system. I can’t answer that question, because I genuinely can’t decide. The best I can do is to say that both have their pro’s and con’s.

I knew going back to being a trainee after a year working as an instructor in a supervisory role would be tricky and it has been. I’m currently working in a hospital that I never worked in before so I’m completely knew to them, which means I have to give a short potted Curriculum Vitae about 5 times a day. I also have to be constantly mindful that I am not the boss and someone else is often ultimately taking responsibility for my actions. You would think it would be easier going to a job with less responsibility, but it’s not. I still have that responsibility but I also now have the problem of how much responsibility do I take and how much to pass on to the boss. Those who have been in the same position will probably understand. Nearly everyone I have worked with since returning has been genuinely interested in my USA experience, and I have been very happy talking about it. I’m sure I have bored a few people to death about it by now, but I make no apologies for that.

The NHS itself hasn’t changed that much in a year, despite the doom and gloom in the media. It still provides excellent world-class care to whoever walks through the door, completely free, regardless of your position in society. That is still something to be proud of. After returning from a place like the University of Michigan to an NHS hospital it is easy to find things to criticise. The hospitals look old, tired and dirty. I have seen some shockingly poor maintenance issues. I’ve heard of new wards closed for repair months later because corners were cut and the roofs were not sealed properly. Medical equipment is sometimes unavailable because it has broken, and maintenance contracts have not been maintained. Adult patients are being nursed on wards that were meant for paediatric day surgery because the adult wards are full of medical patients. Bed occupancy is constantly at crisis level. The staff in the NHS are generally frustrated and fed up with these recurring chronic problems, and seem powerless to do anything about them. The managers are caught between trying to manage the hospital and constant pressure from the politicians to do more with less money. The politicians of course are only interested in the statistics that they can sell to the public – waiting list times, MRSA rates, 4 hour target achievements in A&E – the headline grabbers. The funding and investment therefore is possibly disproportionately spent on things that give good headlines.

There are lots of areas of the NHS that have suffered from underinvestment over time, but the thing that stares out at me as a huge difference between the NHS and my experience in the USA is in the use of technology. Patient records consist of piles of paper notes in folders that are often falling apart, and the first hour of my day consists of running around the hospital running from ward to ward trying to find my patients for the day, then trying to find the notes somewhere on the ward, then trying to find the information I need somewhere in the 4 folders of notes. Consequently I’m often not ready to start the lists on time. However, there aren’t enough theatre porters to get the patients to theatre on time so I’m still ready before we have a patient. Lists often start late. It’s also difficult to contact members of the theatre team or be contacted about changes in the list or to relay some vital information about the patient. Even communication between myself and the consultant I’m working with is difficult and often relies on the hope that we’ll both turn up on the same ward at the same time. We don’t carry any bleep or paging system, and mobile phone signals are very variable. Switchboard is still completely unautomated and it can take 10 minutes just for them to pick the phone up. In a specialty and an industry where poor communication has been known for years to be the leading cause of medical errors, it is still remarkably difficult to communicate with your team members unless you are in the same room as them.

These things are not new. They have been the same problems to a greater or lesser extent I have seen in every hospital I have worked at in the UK (8 in total) or been a student at (another 7) over the last 16 years. 16 years ago (1995) was around the time it feels to me like the world we live in started to change in a major way. In 1995 few people had mobiles or e-mail or laptops. Some had desktop computers, but no-one had the internet. There were no smartphones, satnavs, WiFi , Automated phone menus. There was also no such thing as automatic check in, call centres, online banking, e-billing. No touch screens and electronic form filling. No Wifi cafes; No Google; No online data storage. You may think that not all of these changes have been for the better, but it would be hard to imagine a world now without any of these things. As the technology has been invented, companies have invested in them to keep ahead of the game. Those that have not kept up with the game have perished. How many people would open a bank account now that did not offer online or telephone banking, and worked on paper records for your account? How many businesses would not provide any method of mobile communication to it’s employees? In short – the world has changed, we have changed, but the NHS has not. Whilst private companies were investing millions into technology, and the University of Michigan was investing millions in it’s electronic records systems, the NHS received some of its biggest ever increase in budget (during the early years of New Labour from 1997 onwards). Rather than using this money to invest in new technologies that would improve efficiency, productivity and safety, it was spent on meeting the headline grabbing targets. Now the money has dried up the waiting lists are growing again, and the efficiency, productivity and clinical outcomes are lagging behind. The governments response is of course to blame the staff, rather than blame themselves for such short sightedness. To see how important technology is for patient safety at the University of Michigan anesthesiology department you can read this excellent article by the chair of the department Dr Kevin Tremper, who also gave a lecture on the subject at the ASA conference in San Diego.

This link should take you to the publication in April’s Anesthesiology. I highly recommend it, especially if you are an anaesthetist or have an interest in patient safety. In the article, Dr Tremper describes the change in anaesthetic monitoring in relation with changes in the cockpit of aircraft. Both industries with a keen interest in safety. (Picture is from the article published in Anesthesiology)

Of course there are other issues. The geography of the UK has resulted in lots of hospitals offering the same services with a small geographical area. All of these hospitals require a certain minimum number of staff to keep them running. The EWTD (European Working Time Directive) has had a huge effect on working hours and on-call rotas in particular. This has 2 effects. First – it is difficult for smaller hospitals to staff the on-call rotas. Second – it means that the staff do more shift work, and less Monday to Friday 9-5 work. This is bad news if you are in a training post. The current generation of trainee doctors are suffering from less experience and on the job training than previous generations. Despite this though, it is my opinion that training here is very high quality – though it is more spread out than the American training, which is shorter and more intense. After all - my training allowed me to go to the USA, work in a very different health care system, work as an attending, and manage some difficult cases on some complicated patients.

The unions also have a powerful grip over the NHS and in my opinion are responsible for a certain element of resistance to change. Whilst the NHS is kept in such a tight grip of government and union control, and politicians work on 4 year cycles I think it will always suffer from poor long term investment, and it will ultimately fall behind the rest of the world in terms of efficiency and patient safety. I hope this doesn’t happen, because I still believe in the NHS. It is ultimately a more efficient way to deliver healthcare – without the costs involved with insurance and billing. It needs to keep up with the times though. It needs good leadership with an eye on the long term plan, without the inevitable bias and baggage that comes with politics. Otherwise it will be run to failure, then privatization.

In the mean time I’m going to start looking for a consultant post in the NHS, and try to do my bit to use what I have seen and learnt from this experience in my practice here. It has been an amazing experience. One that I am very grateful to have been allowed to do. I can’t recommend a year abroad highly enough, and I can thoroughly recommend a year at the University of Michigan. I hope to return there one day and I look forward to seeing friends and colleagues again. As for my blog, this is Dr Ramoray signing out. Thank you for sharing our journey. I hope you have enjoyed the ramblings, and I hope it has inspired some of you to go and explore, broaden your horizons and see different ways of working and living. If you do please share your experiences!

For the last time,

Take care,

Drake.

Dreams come true...

It's done then.

Our year in the US of A has come to an end. For the new bunch of rotators the adventure is just beginning, and we were just a tad jealous meeting them last week.

Last week I finished work, said some very sad goodbyes, cleared out my office desk, packed up and left. The last few months seem to have gone by quicker than any others. Possibly because I've been pretty busy. As always there is never any let up or easing off at work. I was busy right up to the end, as was my very patient wife. On top of our usual day jobs we also had to plan our trip home (including a nice holiday in Florida en route), organise shipping of some of our stuff, pack up the rest, fill out paperwork for leaving, fill out paperwork for starting my new job in the UK, try and find somewhere to live in the UK - (still working on that one), pack our bags, clean up and go. It's been a pretty stressful month. It seems moving home has been more stressful than the move out here. All is good now though. Nothing a bit of sun, sea and sugar coated Disney can't fix.

So the final tally for our year in the States (non-medical readers feel free to skip this bit):

I was the recorded attending anesthesiologist for 1100 cases. About 350 cases were Head and Neck - my chosen speciality here. I learned how to manage an array of difficult airway problems using techniques I'd never used before, as well as brushing up on a few skills I already had. I managed some interesting surgical cases that I'd never seen before - radical head and neck dissections with free flaps; robotic surgery for anything from prostatectomy, cystectomy, even a tonsil tumour - ectomy; bariatric surgery, liver resections, craniotomies for deep brain stimulator insertions to name a few. I've learned to modify my techniques to allow different neurophysiological monitoring like MEPs & SSEPs. I've learnt that you can give an anaesthetic that consists of Propofol, Remifentanil, Isoflurane, Nitrous Oxide and Ketamine all at the same time. I've learned to use new drugs such as Sufentanil, Dexmedetomidine, and used other drugs such as Ketamine a lot more than I had ever used before. I've managed much sicker patients than ever before, with the majority of patients ASA 3 and 4 with multiple medical problems, and a huge list of medicines (and allergies) Everyone in the States seems to be allergic to Sulfa. To this day I'm still not sure what drugs that's relevant for but there you go. I've learned that you can anaesthetise pretty much anyone as long as you're careful. I've also had good experience with managing the larger patient. My highest recorded BMI was 67. I got off lightly though - one of my colleagues had a patient with a BMI of 78.

I've learned to supervise two rooms at once (although I don't think I ever mastered this). It's good though to see different ways of working. I have had plenty of opportunity to teach the residents - some of whom are very intelligent, keen and a joy to work with, others who seem disinterested or think they know it all already. I have found that often residents use confidence to hide gaping holes in their knowledge, and it doesn't take long to work out who knows what they are doing and who needs closer watching. The majority though have been excellent. Intelligent, hard working and good fun to work with. I also interviewed candidates for the residency programme which was a new and interesting experience.

As well as teaching up to two residents a day I've had plenty of other teaching opportunities. I've lectured the medical students (I had a standard lecture on cardiovascular physiology) who are much brighter and much keener than I ever was as a student. I've helped with starting a Simulation course to teach Human Factors to the residents, including programming a scenario in to the Meti Simulator. I gave a lecture and taught on an Airway course arranged by the department. I also supervised some of the residents core teaching sessions and journal clubs.

I've also had some great research experience, including transforming an idea in to a formal research proposal, then collecting and analysing data, and writing up our findings, though it's still some way from being submitted. Hopefully I'll get the opportunity to present it at this years ASA conference in Chicago.

So all in all, I think I have surpassed my objectives for coming here. It is unlikely I could have done all of the above had I stayed in the UK for the last year. I probably could have done most of the above in the UK, but it would probably have taken a couple of years. It's felt like I've had 2 years of training crammed into a year. The reasons are complicated, but the European Working Time Directive and the New Deal have affected working patterns, reducing our clinical experience. There is also a big service commitment to our job, which means lots of night shifts, lots of time covering intensive care or labour wards. I am not saying that this is bad. In fact one other thing I have learnt in the last year is that our training is actually excellent. I was able to come and work in a big academic department in another country at an attending level (the equivalent here of a junior consultant). If I had stayed at home I'm sure I would have had excellent training. But it would have just been more of the same. By going abroad, and in particular the USA I have experienced a whole load of different things. Of course one of my main reasons to come to the USA was for none of the above, but to travel and see more of this great nation.

The places we wanted to visit but didn't include New York City, California, Yellowstone National Park, Hawaii, Oregon and Alaska. We have no regrets about this though, because I'm sure we'll be back. America is too big to visit in a year. Most Americans don't see it all in a lifetime. We've done pretty well though.

We saw a lot of Michigan obviously, and I really think it has a lot to offer. It's a beautiful state with lovely parks and beaches. Detroit is a fascinating city - Sadly much of it derelict, but I'm sure it will be back on it's feet soon. The Henry Ford museum is a must if you ever go there. The beaches on lake Michigan, Sleeping Bear Dunes, Glen Arbor, Petoskey, Mackinac, Taiquonamen Falls, Kensington and Pinckney Parks were our favourite places in Michigan. And Ann Arbor itself of course. Ann Arbor is a great place to live - A city with a town feel, and so much to do there. We also went to the following states:

Ohio, New York, Pennsylvania, West Virginia, Virginia, Washington DC, North Carolina, Tennessee, Kentucky, Indiana, Illinois, Colorado and now Florida. Only 36 states we didn't go to!

It is fitting in a way that we have chosen to end our year at Disneyworld Florida. It is in some ways a small concentrated extreme version of America. Somewhere that you can love or hate, or sometimes both at the same time. A cynical person will tell you all the things to hate about it - it's brash, fake, over commercialised; everything is designed to extract as much money from you as possible; everything is sugar coated (not just the food); it brings out the worst in people - greed and selfishness; it's busy and crowded unless you can afford the VIP treatment. I can't really disagree with any of these arguments. But it's also such a positive place. Efficient and professional yet warm and friendly. Vast and crowded yet with great little places to get away from it all. It brings out the best in people - a sense of community and shared happiness. It is magical and inspirational. A place where "Dream's come true" - (as long as you can afford them). Love it or hate it - it is what it is. I for one hope it never changes. There are things I'd like to change about America, but if I did it wouldn't be America.

I think the American within me has come out a bit more in the last year. I haven't become American, I've always been one at heart. A friend of mine once said that we are all Americans now, we just can't vote there! He has a point. What ever happens in America affects the whole world - just look at the affect of some Americans defaulting on their home mortgages! We look to America to bring the rest of the world out of bad economic times. We rely on America for military security - whether we like it or not. We seem to need reassurance from America more and more. We've grown up watching American TV shows and films and our culture has become more and more American. Whether you like it or not, Britain today is more like America than Britain of two generations ago. If I could bring one more bit of America home with me it would be the optimism and "Can do" attitude to everything. Rather than whinge about a problem, wouldn't it be great if people just went out there to fix it.

What I've come to realise is that politically I am actually more American than I thought too. I don't mean we should legalise guns and abandon the NHS. What I mean is there should be rewards for working hard. People should never be in a position where they are better off not working, thereby staying on state benefits for years and years. Work is good for people and good for society, and to encourage people to work you have to make it worth their while. It shouldn't matter where you are from or what class you are, or what your family did. All that should matter is what you can do. Of course there should be a safety net for those who can't work or who have been unfortunate, but it should be just that - a safety net to help people get back on the show. People should be more responsible for themselves - if you don't like the situation you are in, get out there and fix it. If this sounds obvious to you then maybe you're American too.

My advice to anyone coming here - whether it is to work or to play - is leave any preconceptions and prejudices at immigration (they have plenty here already) and just explore and experience as much as possible. Take it all in, and embrace the American life. I'm sure you won't like everything here, but I'm also sure there is something for everyone here.



So... Will we be back?



Of course! - but most likely just for holidays. To come back to work would mean having to sit the USMLE exams, and jobs and visa are hard to come by. It's not beyond the realms of possibility though, and in true American fashion, If we really wanted to we could probably do it - with hard work.

We'll be spending our last night watching the fireworks at the Magic Kingdom with a few cocktails. We arrive back in the UK on Wednesday 6th April (new tax year). I have 12 days before starting back at work. Looking forward to seeing y'all again real soon and keep checking in - I intend to do at least one more blog after we return.


Hope all your dreams come true!

Drake.

The home straight

Time is flying here. Winter seemed to reach it's peak last week. We had a couple of weeks of really cold mornings - down to -25C on a couple of mornings and -30 with wind chill factored in. At that temperature the cycle to work becomes a race to get there before your nose and fingers drop off.

The snow is now melting, and it's warming up. We had a couple of feet of snow altogether. The boys are very disappointed we didn't get to build a snowman. It's too cold - When it's cold here there is no moisture in the air - and the snow seems really dry like powder, so the snow doesn't stick together. We had to buy a humidifier for the house - I was getting nosebleeds overnight because of the dry air. We'll miss the snow - it's been fun - sledding with the boys, cross country skiing, and skiing in Brighton - just 30 minutes drive North of Ann Arbor.

We also had a holiday in Breckenridge, Colorado. We hired a condo there via VRBO.com - a great website for finding private holiday lets. Breckenridge was awesome. We had a fantastic week, and we will definitely be heading back there. A lot of Brits skiing there said to us they would never go back to Europe after skiing in the USA. I highly recommend it for any skiers. Fly to Denver, hire a car. 2 hour drive from the airport. Rent a condo from VRBO.com or Homeaway.com. Rent ski's from Blueriversports.com. See Breckenridge.com for lessons, passes, etc.


It's unbelievable a whole year has nearly gone. They are planning the annual Rotator leaving party (aka "Go back to your own country" party). A year ago we were frantically making arrangements to come out, and we had already had our leaving party. We are less frantic about the move back to Britain. That's not to say we haven't got a lot to organise. At the time of writing we still do not have anywhere to live sorted out in the UK. The move back to the UK is exciting in some respects, and sad in many others. None of us really want this year to end because it's been such a great experience. It's been intense - like a couple of years worth of experiences squashed into one year. We've worked hard, played hard - it's a cliche, but it's true.

All the rotators here know it won't be the same when we go home. In our time here we've had holidays / breaks to Chicago twice, Las Vegas, Niagara, Washington DC, Colorado, North Carolina & Tennessee, 2 holidays in Northern Michigan and one long weekend on Lake Michigan. We're also having another holiday in Florida before we return to Blighty. As well as the frequent holidays, we've got a taste of the good life in general. Big house, big car, nice city to live in. We've got used to eating out 2-3 times a week, and have got used to big portions and service with a smile (and always having to tip..) . We've got used to beautiful parks and clean streets. Good coffee and crap chocolate. Most of all we've all made very good friends - who no doubt we will keep in touch with, but we will be sad to say goodbye.

In work we have got used to more responsibility, and also more respect. We are not treated like children, but like professionals. In return we're expected to act like professionals. It's not uncommon for us to be working later than our official hours here to make sure that all the lists get finished (Cases never ever get cancelled because we ran out of time). In return we are paid well for our extra hours, and we get fed (Usually 30 pizzas from the local takeaway). We get fed a lot here at work. Bagels or yoghurts from breakfast every day, Fruit and danish pastries every Thursday morning with the M&M meeting. There is often a free lunch, and pizza or mexican in the evenings if you're here late. And of course there is Starbucks filter coffee on tap all day long. We have a nice on-call room for our on-calls. The residents have on-call rooms too. They realise the importance here that even on a night shift, a short sleep and a break helps you function.

I'm worried that because we've had such a good year I will have to come back down to reality with a thump. It's not just me - it's a sentiment shared by all the rotators. A fear of going back to normality - back to "life before". Back to a small house, small car, eating out less, fewer holidays, nights shifts, no on-call rooms, less responsibility, less respect, less money, and all the latest pointless tick boxing exercises forced upon us by the government.

In a way I think the differences illustrate the difference in how the US and UK societies value their doctors and healthcare in general. In the US people pay a lot for healthcare. They pay huge insurance bills, then often have to pay co-payments on top of that. They know it is expensive. Perhaps because of that they value it more. The doctors earn a lot from healthcare. They justify this because of the amount of personal money and time they have had to invest to become doctors. The doctors here get a lot of respect from the public in general because people know they have worked hard to get to their position.

In the UK society has become used to free healthcare. Very few people understand the true costs of their treatments. Fewer and fewer people appreciate what they get from the NHS. Those that do value the NHS are often those old enough to remember the days before the NHS. Everything is expected to be provided for free. Perhaps because everything is free it is undervalued. Doctors have invested just as much time (although admittedly less money till now) to get to their position, but earn substantially less. Doctors in the UK are still relatively well paid, but when you compare doctors earnings in the UK with other professionals, and doctors earnings in other countries against other professionals it appears that in the UK we are relatively undervalued. I'm not just talking about doctors, but healthcare in general. And it's not just about the money either. We put up with worse and worse working conditions and are powerless to complain about it. We don't even get tea or coffee or milk provided anymore. No hot food after 8 in the evening. No on-call rooms. Over crowded office space. Small, cramped and dirty changing facilities.

Of course going home is not all that bad and every cloud has a silver lining - and I can't wait to go to a nice pub and drink a nice warm beer, eat a big roast dinner with yorkshire puddings, watch some rugby, go walking in the welsh mountains, see the sea, drive on proper roads. In work - I'm looking forward to doing my own cases again, and doing my own procedures rather than supervising most of them. I'm looking forward to doing my paediatric module, finishing my training and getting my CCT. And of course I'm looking forward to catching up with all my friends, family and work colleagues.

It's not over yet of course - and we're determined to make the most of our last 6 weeks or so. I'll be working for most of it - I've got my research project to finish off and write up. I'm hoping to present it at this years ASA conference in Chicago. We've got 10 days in Florida before we return to the UK though which will be a great way to end the year.

That's all for now - Keep checking in -

Drake.

Happy New Year!

Apologies to all my blog readers for the lack of blogwork over the last month or so - hope you had a great Christmas and Happy New Year. I've been keeping busy - as I'm sure you have. December was a great month. Quite possibly my best yet!

Since my last entry we had a fantastic Thanksgiving Day party hosted by one of the other rotator families, we've had not one but two trips to Chicago (courtesy of a bargain on hotels with priceline.com), we've been sledging and cross country skiing, we had an awesome Christmas hosted by another rotator family, we also had a lovely 4 course fondue meal on New Years Eve, and a New Years Eve party hosted by yet another rotator family. We've also had quiet nights in front of the log fire with a bottle of Napa Valley's finest and occasionally I've been to work.

"The Holidays" are a great time to be here. America does holidays well, especially Christmas. Decorations and lights, Santa Clauses and Grottos, Candy canes and Gingerbread houses, Egg Nog and Gingerbread Lattes (and my personal favourite - peppermint mochas. Yum!), Turkey and trimmings, Log fires and Gigantic Christmas trees... Just like the movies.

For those, like me, who love their home comforts it is possible

to find proper Christmas pudding and mince meat for mince pies - though they are not easy to come by. Christmas TV wasn't quite the same, although if you are moderately technologically minded it is quite easy to set up a VPN (Virtual Private Network) on your home computer that will allow you to watch BBC iPlayer from the USA (normally it blocks foreign access).

On the plus side of course, there is snow - an essential ingredient for the perfect Christmas. Lots of it - although not as much this year as there was in Wales - typical! We were very excited about it and couldn't get enough of it, after growing up with grey drizzly winters for most of my life. It's made the 12 minute cycle to work a bit more interesting. Previous rotators have developed a guide to cycling to work through the winter, as most rotators with families don't buy a second car here, it is the only choice. It's really not too bad as long as you're prepared. Essentially you want to make sure every inch of skin is covered. So far the coldest it has reached since I've been here is -15 Centigrade. It has been known to get down to - 28. That's frost bite territory! The wind chill can also really make it much colder too. I've been told to cover up or risk losing bits of body...

There is a list of essential equipment to buy that includes:

Snow tyres for your bike (metal studded tyres) - As well as the cold, there is also the risk of slipping and breaking some bones of course. They're great in the snow, but not so great on black ice as I found out,

Thermal underwear - best $$ I've spent since arriving!

Good thermal breathable tops,

Waterproof breathable jacket and trousers,

Balaclava / Woolly hat, neck warmer,

Snowmobile goggles (like ski goggles but not tinted - as it's dark on the way to work and usually on the way home too)

Really good thermal, waterproof gloves or mittens,

Good thermal socks (some people say not just for the feet, but I haven't had to do that yet),

Snow boots - thermal and good grip.

I spent about $650 on thermal clothes. They work though. The only problem is when you arrive at your (heated) destination you have to strip as quickly as possible before you overheat. They will also come in very handy for future skiing holidays.

Speaking of which - the Ramoray household is very excited about another vacation in a few weeks. We're going on our first ever skiing holiday - to Breckenridge, Colorado. Flights from Detroit are about $220 return, and we have found a bargain condo to rent online. There are some Ski resorts in Michigan which are apparently quite good. We were originally planning to go there instead. The two main resorts are Boyne Highlands and Crystal Mountain - both roughly 4-5 hours drive away, so close enough for a long weekend trip. In the end though it worked out only slightly more expensive to go to Colorado for a week.

It's funny how every time it snows in the UK the news is of catastrophe. The country has come to a halt. Airports are closed. Travellers are stranded. Roads are blocked. Councils have run out of grit. Etc. Then someone always pipes in and says how shameful it is when other countries manage perfectly well every year it snows. Well, it's true - no catastrophe here. But not because of the government that's for certain. The council here doesn't run out of grit probably because it doesn't seem to bother with grit. For weeks after it snowed all the roads in Ann Arbor still had a thin layer of super slippy compacted ice. I was amazed that the roads weren't gritted or cleared at all. Not even the main interstate between Chicago and Detroit which was a bit of an ice rink on our more recent drive back. I had to walk instead of cycle to work for 2 weeks when the roads got really bad. Yet there was no news of disaster, no despair or panic. I'm not sure why, but I suspect the difference is purely down to the population here go through it every year, so they make much less fuss about it. It snows, the roads

are treacherous, so just be careful! No big deal. Oh, and most people seem to have a 4WD which probably helps a bit. We love our big 4 WD. It's a gas guzzling beast, but if I could afford to fill the tank in the UK I would seriously consider shipping it home.

It has also struck me this last few weeks that my time here is getting near the end. 2010 went so quickly. It's been a great year in and out of work. I've seen a lot of America, and I've had the chance to see some amazing Medicine in work. You really feel at the cutting edge of health care (so to speak) when you're here. Robotic surgery is a big thing here, and is the next big thing after laparoscopic (key hole) surgery. For more details take a look at www.davincisurgery.com

At home keyhole surgery is limited to Gallbladders, diagnostic procedures, appendicectomies, sometimes colon surgery and a few other things. In the last month I saw patients having their tonsillar tumour and also a thyroid gland removed by robotic key hole surgery. The thyroidectomy was particularly interesting as the incision point was via the arm pit. Now I know what you're thinking... WHY??? Well - that's what I was thinking anyway. The thing is, in a competitive private healthcare system, you always have to offer something above the competition. One of the problems with a thyroidectomy is a scar at the front of your neck where everyone can see (unless you wear turtle neck jumpers for the rest of your life - which is probably worse). Now you can have your thyroid removed with no visible scar. If your insurance will pay for it - why not? People probably questioned laparoscopic cholecystectomies (Keyhole gallbladder removal) when they first started doing them. Now they are doing them endoscopically in some centres - so no scar at all. It really is fascinating, and feels great to be part of. It's more expensive of course, but that's not a problem if someone will pay for it. How long before someone declares it a travesty of justice that robotic laparoscopic thyroidectomies aren't available on the NHS? Of course if I was employed by the company that sold the robotic equipment, I'd be outraged that anyone would consider any other type of surgery.

Thats the thing about healthcare. Everyone always wants the very best, but it would be impossible to pay for everyone to have the very best. It would be like all travellers going first class, or all hotels being five star. If that were the case then 5 star hotels and first class travel would have to be more like economy class and 3 start hotels. I know this is a statement of the obvious, but nothing annoys me more than people complaining about drugs or operations that are unavailable on the NHS. The NHS is great because what it manages to provide for everyone is actually a very good standard. There will always be those who can afford it who will search for bigger and better though. Of course if politicians had any balls they would just state clearly what the NHS will and won't pay for. Then if you want something that's not on the list you pay for it yourself or you pay for extra insurance. Unfortunately politicians like to perpetuate the myth that everyone can travel first class and stay in five star hotels.

The reality is most people are quite content with economy flights (and bargain condos booked online). And are still very grateful for it. After all, they still get you there!

My other mission this month is to try and find a pub in Ann Arbor that will show the 6 nations. I will let you know how I get on with that and with the skiing.

Thanks for listening,

Till next time, Drake.