wellingtongoose (wellingtongoose) wrote,
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Semantics of Healthcare Part 2 - How we can keep BAMF!John and be Realistic.

It’s been absolutely wonderful to get so many responses to my last meta and after carefully reading the comments I have received I thought it would be best to write a second part to this meta on John Watson’s career as an army doctor.

There is no denying that John is BAMF in every sense of the word. His bravery, dedication and sharp shooting skills are astonishing and worthy of great praise. I cannot help falling in love with his awesomeness (and those oatmeal jumpers) so in this meta:

I have devised some ways in which John can realistic be a fully fledge combatant on the gritty frontlines and also sorted out some nagging questions about inconsistencies in John's backstory.

Please note this meta has been amended to account for spiderinewho pointed out to me that John does say in ASiP that he is was at one stage an army doctor.



I highly recommend everyone who is new to this to read Part 1 first because it sets the premise for everything in part 2.




How do you Join the Army as a Doctor?

All doctors in the army belong to the Royal Army Medical Corps (RAMC). John has a nice mug with the RAMC logo on it in ASiB when he's eating breakfast with Sherlock. All doctors belong to the RAMC and so do most (but not all) of allied health professions such as nurses, paramedics, healthcare assistants and physiotherapists.

Just to reiterate only doctors are Medical Officers: nurses, paramedics, health care assistants are Medical Support Officers. Whilst Medical Officers never fight on the frontline, Medical Support Officer do go on patrols, carry weapons and shoot at insurgents.

Amendment: currently the most well publicised way to join the army as a doctor is through the Medical Cadetship program. You apply to join the army and apply to medical school at the same time. If you are successful in both, the army generously sponsors you throughout your medical school years and then you have to work for the army for a minimum of 7 years.

Amendment: However medical cadetships are very competitive and very limited in number (thank you to the anno. commentor who pointed this out). Therefore the most common way to join the army would be qualifying as a civilian doctor and then under taking the Professionally Qualified officer training course (see next section)


John would have left medical school and been commissioned as a Captain (the reason will be explained later). He would have spent at least the first two years of post-graduate career training in a military hospital inside the UK before specialising as a General Practioner. This training can be done on an army base anywhere in the world under the supervision of a senior GP.

Joining the Army after Qualifying as a Civilian Doctor


People have asked me if John might have joined the army after becoming a qualified doctor?

As I’m currently on placement in a military hospital*, I decided to go ask some real army doctors how they got in the program and why.

(*Side note – the military in the UK have stopped running their own hospitals. Instead they station their doctors in NHS hospitals and then send over wounded servicemen to be treated by military doctors but military doctors also treat civilian patients as well and teach civilian medical students)

Amendment: It is very common to join the army as a doctor after qualifying via the professionally qualified officers training course at any stage after qualifying. However many people prefer either to join before qualifying because of the financial sponsorship or as senior doctors because specialist training posts for doctors joining after graduation are limited.

Most doctors I asked got a Medical Cadetship but there are several doctors who joined the army after qualifying because serving Queen and Country appealed to their sense of duty. These doctors joined as Consultants – i.e. they finished their training and were senior doctors. They have much more autonomy over what they do and even where they are posted to than other RAMC doctors. However they are never allowed to take a combat role because they only receive very basic weapons training (similar to that given to all new recruits). They are commissioned upon entering the army as officers, the rank depends on how long they have been a consultant. They are not automatically commissioned as Captains, one consultant was immediately made a full Colonel.

I think there is logically enough time for John to finish his GP training and then join the army as a senior doctor but his rank as Captain would contradict this. Therefore it is possible that John might have joined up at the beginning of his  specialist training or just before he started.

Amendement: You cannot join the army after qualifying if you are/training to be a specialist in an area of medicine that the army does not need e.g paediatrics, unless you are willing to retrain in a different specialty.




What is a GP?


For anyone unfamiliar with healthcare in the UK. GP stands for General Practioner. They are the equivalent of family doctors in the US. They treat common conditions and are the first port of call for anyone who is not actually dying. They are responsible for referring patients to see specialists in hospitals if the patient's condition cannot be managed by the GP.  The system is set up so that hospitals are not swamped with patients who just need some paracetmol and a lie down.

A long time ago before the NHS existed - every doctor could be a full GP as soon as they left medical school. In the last twenty years, standards of practice in General Practice have been tightening. When John graduated about 12-14 years ago, General Practice was already considered a speciality seperate from medicine and surgery. Although in reality GPs have the broadest workload of any doctor, there are many specialist skills that one must acquire in order to be a good GP.

You have to complete a set of really nasty entrance exams before starting your specialist GP training. Therefore you cannot just being work as a GP without having started or completed the GP specialist training.

A GP In training

In Scandal in Belgravia John is introduced as Captain John Watson of the Northumberland Fusiliers. This is slightly odd because all doctors belong to the RAMC – they get posted to different regiments but they don’t belong to that regiment.



I need to point out thanks to arizona's timely reminder that the Northumberland Fusiliers do not exist anymore! They were amalgamated with two other regiments to form the Royal Regiment of Fusiliers in 1968! As omen1x2 has suggested: this is probably just a nice little nod to the ACD books, which give the updated show a much more authentic feel.

John Watson might have started off his medical career on a medical cadetship. I have already explained in Part 1 that John would have been a GP in the army (not a surgeon).

The RAMC prefers recruiting doctors as students because the army only requires doctors who practice certain specialities. For example there are no army dermatologists or paediatricians but they have a much higher proportion of trauma, orthopaedic and plastic surgeons. Doctors who join in the army through a Medical Cadetship are then directed to specialise in a certain area. Thus if John entered the army through this route, he would have been told something along the lines of “we need more GPs – specialise in that”. Of course the military are not entirely heartless – you do apparently get some choice but not very much.

I imagine his first few years in medicine as a House Officer/Senior House Officer* before he had to specialise would have been action packed and fulfilling for John. These junior doctors straight out of medical school often do the night shifts, accident and emergency and general medical/surgical takes. You get into some truly hair raising situations that are worthy of any medical drama.

(*Side note – my mistake in Part 1: when John graduated from medical school the first few years of being a doctor were still called House Officer and Senior House Officer. In modern times they are referred to as Foundation doctors and Core trainees)

Amendment: His GP specialist training would have last 3 years (thank you Kate221b for the source) and all army doctors undergoing specialist training have the rank of Major or above. The rank of Captain is reserved for Core trainees (who used to be called in John's day Senior House Officers). Therefore it is rather startling that at age 35 (or there abouts) John Watson is still only a Captain.


Why did John become a GP?

So why did John decide to specialise as a GP? Well, if he joined the army during medical school they probably forced his hand in that decision but the army needs trauma surgeons too, so why didn’t John apply for that instead?

Amendment: pointed out by spiderine.  John does say he is an army doctor in Study in Pink. Therefore the most likely scenario is that John was presented with a limited number of choices of what to specialise in after finishing his House Officer years. Trauma, orthopaedics and plastic surgery are all very competitive hospital based training schemes with a limited number of posts.

Medical specialitists are also needed but generally not as much as surgical ones. Long term managed of chronic illness (which is what internal medicine is all about) in soldiers is usually carried out using NHS hospitals back in the UK. The army really only need to keep their soldiers alive until they get flown back to the UK for long term treatment. Short term treatable medical issues can be dealt with by GPs actually on site in the army base, therefore they are in great demand. GPs patch up the small problems before they become big ones and keeps the army in fighting fit order.

I believe that John applied and didn't get onto the training schemes for surgery.  I’m not saying he was a bad doctor but, as with any job interview, they offer jobs based on more than just your skills. You have to know the right people, make sure the bosses have a favourable impression of you. Medicine as a career (even in the meritocratic army) is still quite “cliquey”, if John did not come from a medical background it is unlikely he would be as well placed to compete against the offspring of famous surgeons or physicians. Remember there will only be a handful of jobs up for grabs and many many more hopeful applicants.


Therefore his other option was to become a GP. When John graduated (probably around 12-14 years ago) the GP training program that we have today hadn’t been established. You still needed to do some training but it was shorter than the 5 years of training that is required today to become a full GP. Therefore it is conceivable that within 4-5 years of finishing medical school John could already be a fully qualified GP.


(My personal headcanon: John went through the civilian route and when it came to applying for a speciality he didn’t get into any of the highly competitive hospital based specialities so he decided to train as a GP, got horrendously bored and went off to join the army. As he has university degree he would have been encourage to go to Sandhurst and become a commissioned officer.

This was the premise of my original post but I have amended to it fit with the theory that John admits to being an army doctor in ASiP. There might be a plot bunny in there somewhere.)

If John remained a GP how can he possibly be having nightmares about fighting in Afghanistan?

I have concluded the only way he can possibly be fighting is if John is actually a career soldier not a career army doctor. This scenario also answers many of the questions people have:

1.Why is John such a sharp shooter?

2.Why does Sarah think he’s overqualified?

3.Why invalid a doctor out of the army with limp?



-

Becoming the Career Soldier


My personal view is that he found GP training utterly dull. Being a GP is definitely not the most exciting career in medicine and for an adrenaline junkie like John, he wouldn’t have lasted very long before his brain started to die in despair. I believe the reality of being a GP even in the army was just not John's thing, he wanted excitement and adventure so he applied to the Royal Military Academy Sandhurst once his contract with the army had expired (i.e after 7 years) to become a career military officer.

As one doctor once said to me - you can only do this job for so long before you just need to go out and shoot something.

Sandhurst


Sandhurst is the only Army Officers’ academy in the UK; all successful applicants must go through a gruelling 44 week training program after which they become commissioned officers. These are the officers who lead troops into battle, who fight on the frontlines, who lay their lives down with their men. All army doctors undergo a short officer course at Sandhurst but I believe the second time John joined up to be a soldier not a doctor so he would have done the whole thirty months.

Here is a great BBC documentary series about life at Sandhurst.

I highly recommend anyone who wants to write a realistic portrayal of John’s army days to watch this.

In addition to leadership skills, strategy and tactics, cadets at Sandhurst are also expected to have a high competency with weapons of all kinds. This could explain why John is such an amazing sharp shooter. He probably excelled at marksmanship in his time at Sandhurst. The academy also has a rugby team so I guess John would be tearing his way through that as well.

Like all officers who “pass-out” of Sandhurst, John would then be properly assigned to a regiment. He would also be given the commissioned rank of Second Lieutenant.




(Passing Out - the equivalent of graduating not fainting)

(Side note - Why Doctors become Officers - it's not just to confuse you!

The reason why doctors are commissioned as high level officers is mostly financial. They expect a certain pay grade and for administrative purposes they get a military rank corresponding to that pay grade. It also oils the wheels of doctor-patient relationships. Soldiers are much more likely to obey your instructions if you’re an officer. However it is important to remember that doctors never command soldiers in the field of battle or on any other military excursion (they are simply not trained to do so). If, in the unlikely event they become the most senior officer in the base, they are required to delegate command to someone more junior who actually knows something about fighting!)


Why John is Still Only a Captain

Amendment: I assume that John would loose the rank he previously attained as doctor in the RAMC. This is because that rank is purely administrative - John might well have reached Major by the time he left the RAMC but he doesn't have the military skill to command a large group of men. He would have to start his combat career off as a Second Lieutenant.

Going to Sandhurst would explain why at age 35 (or slightly more) John is still a Captain. If he graduated from medical school and then trained and worked as an army GP for 7 years before entering Sandhurst – he would be at least 30 or more by the time he gets commissioned as an military officer. He then has about 5 or 6 years serving in Afghanistan (as a full combatant) to attain two promotions from Second Lieutenant to Lieutenant and then to Captain.

John as a career military officer would have been fighting on the frontlines right beside the troops he commanded.

I imagine the army would also have made use of his medical knowledge by strapping an extra first aid kit to his back but he would not have been the Medical Support Officer (military paramedic) of his squad as that requires special training. He's probably help out when someone was wounded and when he gets back to base he may even be drafted in to run some GP clinics for people with running noses and sunstroke.

This theory would explain why Sarah took one look at his CV and said “you’re a bit over qualified for this job”. She wasn’t talking about his medical credentials, she was talking about John having excelled at Sandhurst and being a proper military officer.




Why Invalid a Doctor out of the Army for a Limp?

This scenario also fits with why John was invalided out of the army. Army doctors who get injured on the frontlines do not usually get invalided out of the army because their physical fitness requirements are not the same as full combat soldiers. You can still treat patients with a psychosomatic limp but you can’t lead soldiers into battle.

Amendment: If you like the idea that John is still in the RAMC at the time of his discharge the army must have either thought he was an immediate danger to his patients due to his psychological condition or possibly not going to recover mentally in a workable timeframe. Army doctors are a very valuable commodity. The army does not spend hundreds of thousands of pounds training a doctor only to discharge him for a gunshot wound that would heal up (and we have seen that John doesn't have mobility problems with his shoulder).

Wounds can be slow to heal but the army would be loosing far too much  if they discharged a doctor because they didn't want to give him long enough sick leave for his arm to heal. Generally the RAMC doctors after their contract ends. They get many benefits such as free accomodation on site, bonuses and scholarships for their children to private schools.


I think it is more likely that John might have made it back to work after the gunshot wound and then had some kind of a nervous breakdown or did something untowards to one of his patients. Basically John couldn't function as doctor because of his mental not his physcial health.

Alternatively his discharge may have been due to cost cutting measures being implemented by the army. They may not have a surplus of GPs but the military accountants probably thought they could survive with less. Therefore the first doctors to be discharged are the ones that the military can easily discharge for technical reasons. John's limp and possible PTSD are valid reasons for him to invalided out of the army at least on paper.

So with one gunshot wound, John’s military career came to an end but he has a trade to fall back on – being a GP. It’s terribly dull but it pays his bills and always him the flexibility of running around after Sherlock.


I personally think that John was an army doctor and a career soldier, his distinguished military service covers both spheres because he's just that awesome.



Side Note - John's legal right to practice medicine

Several people have asked how John could possibly go back to being a doctor if he's spent years training to become a soldier and then fighting in Afghanistan for even longer.

In the UK in order to legally practice medicine you must be registered with the General Medical Council (GMC). All doctors after completing their first two years as junior doctors are fully registered with the GMC. The registration never expires - no matter how long you stop practicing medicine for - you just have to pay the annual registration fee on time.

However as John hasn't practiced medicine for a few years - he must prove his professional competency. He doesn't have to retake his GP specialist exams (they are called the MRCGP and they are pretty nasty) but he does have to demonstrate to the Primary Care Trust (the NHS organisation that run all the healthcare services within the region) and the surgery where he works that he is a safe and competent doctor.

Therefore his first job at Sarah's surgery is in fact a probational post. They are observing him to see if John is fit to practice. Sadly, falling asleep during clinic is considered very unprofessional and I don't think we see John going back to work at the surgery again. If any one can find evidence that John wasn't fired for being unprofessional - it would make me very happy!



More Side Notes:

I have decided to move this section to part 3, mainly because it doesn't actually belong here.


Part 1 - Exploring Dr Watson's Army Career
Part 3 - Guide to making John a Realistic Army Surgeon


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Comments, thoughts, feelings, thanks, hate mail are always very welcome!

Tags: meta: john watson
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