Communication, communication, communication

For once my formal training & the real world in hospital have coincided.  And it’s all about communication.  According to the lovely gentleman from an organisation that provides medical indemnity, most complaints against doctors are about communication.  Which I thought we all knew…

And then I walked straight into a communication disaster with a mother on the ward.  Did I commit a communication “sin”? No, I don’t think so.  I took a nurse; said “hello my name is”; asked her to start with her concerns… and fell straight through the communication black hole that I could not find my way out of.  Let’s just say it did not go well.  Basically, I was having one conversation and she was having a different one; it didn’t even feel that we were talking about the same baby at one point.

 

I love talking to people.  One of the highlights about doing nights on the neonatal unit was the chance to catch up with parents outside the business of the day-shift.  I love the chats about siblings & getting back to school; remembering what pets people have; where their families come from and is it a long drive…

One of the things that’s changing is that increasingly, I have to tell patients & parents things.  And if it gets difficult or I haven’t got the message across, then there’s a limited number of people I can pass it on to.  Sometimes, it’s quite straightforward transfer of information for people who are looking for answers.  Sometimes, it’s not so easy, and none of the things I was taught in communication skills sessions at medical school seem to make any difference.

I’m looking at definitions again.

Communication: the imparting or exchanging of information.

Exchanging.  How much of our communication in hospital is about exchanging information; having information pass both ways?

One of the big challenges is that the exchange of information has to be received by both sides. And that means that both groups have to be ready to have the same conversation.  If I’m telling parents that I agree that their child is sick, that we need to do some tests & start antibiotics, then we’re usually having the same conversation.  Parents have brought their child because they’re worried about them; they want answers; an action plan; they’re waiting for the information that I’m giving them.  It’s never easy telling families that you’re worried about their child too, but at least you’re having the same conversation.

Sometimes, there’s just a huge gap and I don’t know how to bridge it.  Sometimes, there’s such a difference in expectations & wishes & priorities that we might as well be speaking different languages.  And I don’t know how to do it.  How does a doctor communicate with a family that their newborn, beautiful child isn’t a “quiet baby” but seriously ill? How does that family get across that what really matters to them is that their child has their first breastfeed that they’ve spent 9 months waiting for, or wears the cardigan that their grandmother poured her love & care into making?

How do we do it? Because when we get it wrong, and if we can’t at least have the same conversation, then it all goes horribly & badly wrong 😦

EWTD & the 48 hour myth

Apparently, the solution to the problems caused by the EWTD is to encourage junior doctors to “complete training projects outside of their normal working hours”  I’m still formulating a sensible thought process to this, but it comes back to “what do they think we do now??”

It’s taken me a while to respond to this suggestion that junior doctors should “do a bit extra” in their spare time because I’ve been busy. (I know: I can see the irony here).  I know I’m the academic trainee and so a lot of my “spare time” work is self-inflicted so I’ve tried not to go off my own experiences here.

We don’t accurately measure or record how much work junior doctors currently do in their assigned working day, never mind outside of those hours.  Working hours are monitored, but what happens to that data? The response to a breach in working pattern is to repeat the monitoring exercise, or to investigate the junior to make sure that they are telling the truth. (I love how nobody ever suggests investigating a monitoring report where I leave work precisely on time and have a 30 minute uninterrupted break every day for a fortnight. Because that’s such a realistic situation).  And, well, by the time it’s been repeated, it’s time for a new cohort to start…

Yesterday, as I went home, three SHOs sat in the office ploughing through old notes for an audit. It ‘has’ to get done, and there’s no time to do it during the day.  I’ve had a chat with some (non-academic) colleagues recently, and as a bare minimum, these are the things that they do in their “spare time”.

1. Exam preparation
2. Clinic attendance
3. Audit
4. Preparing teaching sessions
5. Attending mandatory courses

None of this will get counted in the EWTD hours; none of it is recognised or acknowledged.  Because if it was counted, then we would have to realise that junior doctors already work well in excess of the 48 hour average.  And that is the bare minimum: that doesn’t count those of us with special interests; attending conferences; going to meetings; developing resources…

Confining us to a 48 hour week has implications for training & patient care.  But to refuse to acknowledge the huge amount of work & time that trainees already put in outside of working hours seems a little unrealistic.  It’s not a 48 hour week, and we need to be honest about that.

Because I can always fit another project into my “spare time”…

Sure. Why not? Sleep is over-rated anyway

Caring and the EWTD

There’s been a lot of talk recently about the European Working Time Directive and the detrimental effect that it’s had on training; particularly in the “craft” specialities.  (EWTD limits the amount of time that junior doctors can work to an “average” 48 hour week, and places some other restrictions on working patterns.  You can still work 100 hours/week as long as the average is <48).  There seem to be increasing attempts to subvert the EWTD, either by trainees who stay late for “educational” purposes (I know, I’m one of them) or by official bodies.

Generally, the view seems to be:

1. EWTD is a bad thing for medical care
2. It’s bad for trainees as it prolongs training/reduces experience
3. We should all complain about it

I trained in a fairly old-fashioned medical school, and I was shocked when I started working as an FY1 to see how much my hours had been cut.  I grew up watching “Cardiac Arrest”: I was going to be Dr Claire Maitland  (although possibly without the complicated social life).  And so I’ve been very anti-EWTD.

Gradually, I’ve come around to the idea that maybe it’s a good idea for patient safety if healthcare workers aren’t exhausted all the time.  I hadn’t really thought about the other aspects of being tired until this week.

I have just finished 5 night shifts so I may be feeling slightly jaded.

They weren’t easy nights in many ways (and I won’t go into details); but what always amazes me is how much the team cares about the families.  Sometimes, they’re people that we’ve known for a while; some are acute admissions with no previous contact with health services.  But I work with a great network of nurses and HCAs who listen & laugh & joke & cry with these families.  And doing that takes energy and commitment.

It’s exhausting, but it’s such a vital part of our job.  And it gets harder and harder to do well when we are tired & run-down & hungry & haven’t slept for 48 hours.  Every time I’ve seen a colleague breakdown at work, it’s been at the end of a run of long-shifts.  Every time I’ve had to slide into the treatment room for a minute to take some deep breaths, I’ve been working a long-day.

Being compassionate is tiring; caring is tiring; doing this job properly is tiring.

I know when I’m tired, I have to really think about what I’m saying; to take time & be patient feels harder.  It gets harder to do the “little things” that matter.  And they do matter, because if I can’t be bothered to get you a blanket or a cup of tea, then why would you think I was bothered enough to look after your child?

So maybe the EWTD is cutting training opportunities; maybe it is reducing patient contact time.  Does that really matter?

I don’t really care if my training gets extended.  I do care if I’m so exhausted that I’m not doing my job properly.

Being a doctor is about more than technical skills & being a diagnostician: this is supposed to be a caring profession.  Limiting the hours that I work doesn’t decrease my training opportunities, but maybe it does change them away from the purely technical and towards the human factors side of medicine.

Should we keep the EWTD? Yes. Not just because it’s safer for patients & staff, but because it allows us to do our job properly; it allows us time & energy to care. And really, that is the job