Why I’m not a doctor (yet)

Realisation of the weekend… I’m not a doctor.

Now if you’ve met me; read this blog; read my Tweets, you would be justified in thinking I was having one of my self-doubt “I can’t do this” moments.  Of course I’m a “doctor”: I go to work in a hospital; I treat children.  This week, I’ve seen ear infections, gastroenteritis, tonsillitis, gastroenteritis, bronchiolitis, more gastroenteritis, seizures… And did I mention the gastroenteritis?

I’ve prescribed antibiotics, fluids, and anti-epileptics; I’ve been coughed on, vomited on, sneezed on, and bled on (I love paediatrics); I’ve put in cannulas, felt bumps, looked at spots…

It sounds like doctoring, doesn’t it?

The ‘official’ definition of a doctor is “someone who is qualified to treat those who are ill”.  Which sounds great: I have a medical degree (MBBS); I have a shiny certificate that says that I’ve passed my membership exam in my chosen speciality (MRCPCH); I have regular appraisals, and an e-portfolio that I (kind of) keep updated.  Does that make me a doctor?

And then I found this definition too “a person… trained in the healing arts”

That sounds more like it.  That’s what I want to do. Not just treat the illness, but help with healing; support health.

Sounds great, doesn’t it?

And yet… I’m not a doctor.  I go into hospital or clinic and I work for the first of those definitions.  I treat illnesses; I don’t help people heal.

On top of my list of things I’ve done at work, I’ve also done these things:

I’ve not listened to parent’s concerns because I was “treating” their child for an illness, instead of paying attention to what they were worried about in the first place.

I’ve taken some time to talk to parents about their child… whilst standing over them as they lay on the bed with their child, and then wondered why they sounded a bit annoyed…

That’s not doctoring.  That’s not healing, or supporting health, or any of the great things I want to think that I’m doing at work.

NHS Change Day has provoked a lot of comments over the past week or so, and a number of blogs about the types of pledges that are being made.  I want to pledge that I’m going to try and be a doctor, but I think that’s going to provoke the kind of response “well, shouldn’t you be doing that anyway”*

Yes: I should be doing all these things, but if I’m honest, then I’m not.

So what now? Do I stop, and realise that actually I’m terrible at this doctoring thing?  Sometimes, it feels like that.  But I’m taking some comfort from the realisation that I’m paying more attention to these things, which is surely the first step towards making them better?

Doctoring is a skill that develops, and we keep learning.  That’s well recognised from the “treating illness” side of things – that’s the point of appraisal, and assessments, and reviews, and CPD.  Learning how to be a doctor is an ongoing process too, but there isn’t a course that’s going to teach me how to do that.

I want to be a doctor… and I’m not. But I hope I might get to be one day.  What NHS Change Day is doing is teaching me how I can get there.

* Plus, it’s vague and not terribly useful to me or anyone else; I need a manual of how to do it, not a grandiose statement.

Why it’s the little things that matter

This is going to get a bit ranty at points, & I’m finding it really hard to write for some reason, so I will try and remain coherent…

It’s a year since the Francis Inquiry published.  If 2013 was the year of the big 3 reports into NHS failings (Francis/Keogh/Berwick), the details in the Public Inquiry into failings at Mid-Staffs (Francis) was probably the most harrowing as far as personal stories were concerned.  Unsurprisingly, this has generated a lot of interest at the one year anniversary: how do we move on, take the lessons from Francis (and the others), and make the NHS better?

Yesterday I went to a conference on Implementing the recommendations to The Francis Inquiry.

It was a brilliant line-up, including people I’d always wanted to hear in public like Julie Bailey & Ann Clwyd MP.

I work in the NHS and I find some things just appalling.

Why on earth does an organisation that’s responsible for the care of millions of people make it so hard to complain?

Why is it only in the past year that there’s been legal protection for healthcare professionals who blow the whistle on persistent failings?

But if you’re getting as far as making a formal complaint, or whistleblowing, then there’s already a big problem.  More importantly, if as an organisation all you’re paying attention to are the formal complaints, then you’re only listening to the people who have the time and energy to put forward a complaint.  Because we know that getting your voice heard in the NHS to raise your concerns isn’t easy, whether it’s as a patient or as a member of staff.

One of the phrases that keeps coming up again, and again, and again is the need for a culture change.  In the words of Julie Bailey (Cure the NHS) “…we are reliant now on those that work in the NHS to change the culture and to make it safer for us all”

The problem with that is the comment from the Chair for the morning session, Sir Richard Thompson (RCP, London) that started off the morning.  As you can probably tell, this did annoy me a little bit…

Interesting take on #francisinquiry from RCP. Placing responsibility for not speaking out on trainees shoulders?? We "gave up" apparently

— CarmenSoto (@gourmetpenguin) February 5, 2014

Why was I so annoyed? There are the obvious reasons: it’s a hard realisation that actually, despite my pontificating on this blog, that “giving up” on reporting your concerns is a real danger. And that probably affects the response to Francis if we’re honest

I don’t want to think of myself like that, but the reality is that that could be me.

But the other reason is that it doesn’t solve anything.

Now, I take the point that we can’t keep blaming “the system”

Systems are all well good, but it’s how we implement and respond to what they tell us that matters.People implement systems #FrancisInquiry

— CarmenSoto (@gourmetpenguin) February 5, 2014

But where you have a consistent problem with reporting, then maybe we need to accept these failings, and make the system better.  And that means making it easier for everyone to raise their concerns in the NHS.

“Feedback is vital management information” @AnnClwyd We need to be facilitating and supporting patients to do this #FrancisInquiry

— CarmenSoto (@gourmetpenguin) February 5, 2014

What Francis showed is that there were warning signs, and they were ignored.  Nobody wants to get to the state where there’s another Mid-Staffs.  Things are going to happen; if we’re honest we have to accept that the NHS can & will fail patients.

For me, that means that when the warning signs start, we have to pay attention, and pay attention early.

So I think we need to focus on the little things.  

Responding to patient complaints, and protecting whistleblowers; these things are important but they’re just the tip of the iceberg. They’re what happens once there are consistent and repeated failings in the NHS.  What are we doing about the systems that are supposed to act as early warnings?

Data are useful, but @martinfarrier explains that it’s just the start of the story; it’s what that data means that matters #FrancisInquiry

— CarmenSoto (@gourmetpenguin) February 5, 2014

In my naive brain, here’s how the system is supposed to work:

1. Healthcare professional reports adverse incident (missed drug administration)
2. Incident is investigated
3. Possible underlying causes are identified
4. Monitoring of other, related incidents is initiated
5. Feedback to the reporting healthcare professional
6. Education & development to reduce the modifiable risks

Incident reporting is one example: as doctors, I think we’re terrible at reporting clinical incidents & near-misses.  The process is inconsistent, and we don’t really accept why it’s important.

My personal experience of incident reporting is variable: sometimes I get a clear response of what the investigation has found and what the next steps are.  (These actually do make a difference – like the blood culture samples that disappear because the processing system doesn’t work = new computer system!)

Sometimes the form disappears into a black hole with a polite, noncommittal e-mail telling me that “my time is appreciated”.

And nothing else.

As professionals, if we can’t see the benefits of reporting near-misses/medication errors/under-staffing before they become major problems, then that’s a problem.

It’s a problem for professionals because they are excluded from the system that is part of their professional duty of care.

It’s a problem for Trusts & Boards because they don’t know what’s happening on the floor and can’t react to issues at the “smoke alert” stage

And most importantly, it’s a problem for patients because the systems are there for alerting potential problems but we’re not focusing on the warnings.

So how are we supposed to stop another Mid-Staffs if we’re not concentrating on the small things?