My partner is an archaeologist. I think it’s fair to say that I get paid significantly more than he does; but it’s also fair that our jobs have very different expectations. Archaeologists (as far as I can tell) don’t tend to ring up the site at 3am just to check how things are, or call work when they’re on holiday to make sure that an excavation went OK. Nor do they have to face accusations from the media & public like we’ve seen this week. Just from one article and the response to it, doctors (all of us) are instantly branded: arrogant, threatening, inhuman, viewing parents as the enemy, torturers of families; we think we’re gods, that we own people. Some commentators made explicit links to paedophilia, racial abuse, and Nazism… And yes, this is all from the public response to one article (a fairly measured one at that).
Is that really what I am? Is choosing to be a doctor and a paediatrician also making the choice to be all of those things that the public feel able to call me? Is that accepting that part of our social media society, or is it something specific to some jobs?Because last time I checked, being an archaeologist didn’t mean that the public instantly thought that they could denigrate you in this way (although, to be fair, we live in Leicester, so sometimes that does happen to archaeologists too…)
My job is changing the longer I spend in training. What I find really frustrating is that the things that I think are the important parts of my job aren’t really in the (unspecified) job description. I went through medical school and the early part of my medical training being trained as a diagnostician and therapist: take a history, do some tests, find an answer, give some treatment, review. That’s the technical side; relatively speaking, that’s easy. (No, I don’t get it right all the time!) The other stuff: oh, that is hard. And that’s OK, because that’s what I get paid for. Not the diagnostician part, but everything else. The listening & explaining; the balance between interfering in somebody’s personal space and finding out what it is that’s not right about the treatment I’ve suggested; trying to find out exactly what it is that’s worrying them; trying to get across what it is that’s worrying me. Knowing when to step away, when to keep asking; trying to manage everything else so that I can do that and not have to walk away and see somebody else just after I’ve delved into their life. It’s trying to judge who wants facts & an action plan; who wants time to come to terms with the first thing I’ve said (whilst still getting the plans in place to treat the child safely); who wants each step discussing & explaining why I’ve suggested what I have… That’s just the job.
And sometimes, as we’ve seen this week, it goes horribly wrong. It goes wrong because it’s difficult and complicated; because it involves people & emotions. It goes wrong because people care, and because we can’t offer certainties or promises or guarantees. Can you imagine just how easy medicine would be if all you had to do was input a list of symptoms, some blood results, and a blood pressure, and suddenly there was a simple, one-size fits all treatment with a guaranteed outcome? If all we “knew” what was best, automatically?
The “uncertainty” conversation that I have most often with parents is about neonatal sepsis, and it usually goes like this:
“Your baby has a temperature and we need to look for why that is. I think we need to do some tests to look for what’s making her poorly, and start her on some antibiotics while we get all those results back. We do a lot of these tests in little babies, and often we don’t find anything worrying. But I can’t tell from looking at her if this is a serious infection or not”
What I’m really saying is this:
Your baby (your precious, precious few days old child who has only been home with you in a time period that you still count in hours & minutes; who you watch when she’s asleep to make sure that she’s breathing; who you’ve waited and waited months to arrive; who looked at you properly in the face when she was just a few minutes old) has a temperature (which is why you brought her here in the first place, and because you were worried and I’m not reassuring you because I’m worried too) and we need to look for why that is (I don’t know where it is; is it meningitis or a urine infection? is it a blood sepsis?). I think we need to do some tests (bloods, urine, lumbar puncture: how worried am I? Do the bloods help change my decision making process? probably not, but we need to take a blood culture that won’t come back for 36 hours. Do I wait for a urine on the off-chance and risk getting a dodgy sample that we have to repeat? Do I put a catheter in to get a clean sample? Will I get microscopy on the urine? Do I just go ahead and do the lumbar puncture now? Probably, because I don’t want to wait before I start her antibiotics for tests that may not really change my decision making) to look for what’s making her poorly (she just looks poorly; her temperature is settling but her heart rate is still rocketing away and I think her perfusion is worse than when we started talking), and start her on some antibiotics (is now the time to tell them about gentamicin monitoring? Or that if her cannula tissues we’ll have to put a new one in which is going to be distressing for everyone? She’s going to have a cannula and be attached to a drip) while we get all those results back (we might not get everything back for a few days; I might get some results that give me clues but no answers). We do a lot of these tests in little babies, and often we don’t find anything worrying. But I can’t tell from looking at her if this is a serious infection or not (so I’m going to treat your precious little girl as though she has, because I don’t know. Because I’m not taking the risk of having her die of sepsis or meningitis or a horribly nasty urine infection. Because I don’t know, and even if it’s a 1/100 chance that she has one of those and I don’t treat it, she could get so much more unwell. Because waiting for her to do that isn’t an option, and I don’t know what will happen).
And that’s my perspective on something relatively straightforward: who know what the parents are thinking, what they go on to think while they’re waiting for results that may or may not give them answers?
Dealing with uncertainty and negotiating that is part of the job; it’s in the skill set that I’m (hopefully) learning. But it is definitely not easy. And part of the reason that I get paid is, I think, developing those kinds of skills to do my job properly.
It’s hard, and it’s complicated, and it’s essential. But when it goes wrong and things don’t work out, I don’t think we should be abused for it. Just a thought