Is compassion a luxury?

In January 2013, I started a PhD.  For various reasons, I’ve ended up doing this part-time over 4 years, whilst I continue my clinical training less-than full time.  I’m a 50% clinical trainee, and a 50% PhD student.  I’ve struggled with the idea of being a paediacademiatrician; about missing clinical time; about not being a “real” doctor anymore…

But the sad reality is that I don’t think that I would still be a doctor if I was doing it full time.

This is why.

I started my medical training in 2001; six years later, I’d qualified; in 2008 I started working in paediatrics.

For as long as I can remember, I have wanted to be a paediatrician.  There were brief periods where I wanted to be other things, but they were never real options. (1. Ballet dancer – at 6 years old, I was too old to do that properly; 2. Robopsychologist – realised fairly early on that all that Asimov I’d been reading wasn’t going to materialise quickly enough for that to be a viable career path despite by ambitions to become Susan Calvin; 3. Lawyer – in the brief period after I’d messed up my A-levels and decided that I couldn’t do sciences.)

By the time I’d started my PhD, I wasn’t being a paediatrician the way that I wanted to be.

I was worn out.  Physically, it was fine.  Mentally, not a problem.  After all, this was nothing to what I’d been expecting.  I’d learnt about the NHS and junior doctors by watching things like Cardiac Arrest.  My career trajectory, I’d assumed, would be to work until I dropped and burnt out.  A 48-hour working week, as regulated by the European Working Time Directive, actually seemed mild compared to parts of medical school.  Parts of the rotas I’ve worked involved a 12 day stretch with 7 long days interspersed with “short” days; night shifts come in runs of 3, or 4, or 7. It’s not difficult to clock-up a 90+ hour week without any major events which lead to you staying behind a few extra hours.  Breaks are apparently included in the rules, but they rarely happen.  (How can you have 30 minutes of a break when you’re the only person holding the bleep?)  I know this is nothing compared to junior doctors working hours before, but it matters.

Was I still a good doctor at the end of those weeks?  Competent? Yes. Effective? Probably.  Emotionally? ……..

Compassionate?

Empathetic?

Listening?

As summed up beautifully in this blog by @Adsthepoet‘s mother, empathetic practice is what gives healthcare professionals job satisfaction.  It’s what gets us out of bed in the morning/evening/afternoon; it’s why you can stay 2 or 3 hours late and leave with a smile on your face; why you stop on your way home and just pop in to make sure everything is OK on your ward…

But I was finding this harder and harder to do.  I think that I was retreating further and further behind the mask of professionalism; into my doctor bubble; into that world of different language and rules and social norms.  I think as the workload increases, this becomes more comforting and secure; the short-cuts in terminology and labelling become easier; patients stop being individuals and become “the diabetic in bed 4″… And my response to losing what makes me tick has been to work harder, stay later, try to be better… Eventually, it doesn’t matter how many patients you have waiting to be seen,That’s not a sustainable approach to work.

Discussions this week have led me to question if I’m actually the right kind of person to be a doctor.  I don’t think I’m “tough” enough to work a 90+ hour clinical week on a regular basis.  I love my job because I get to be a part of somebody’s life for a tiny segment, not because I’m sticking drips into them.  Training at 50% certainly hasn’t cut my total working hours (seriously, a PhD in 4 years part-time is not sensible), but it has given me a different perspective on work.  I suspect the same is true if you have a family; run marathons; grow vegetables; travel; go to the theatre, or pole-dance… Whatever it is that gives you another viewpoint on life, and reminds you that it’s OK to be human.

Where will the time to do this come in the new contracts?  Where will the staff come from to ensure that there is still time to tease my patients about the football results; get film recommendations from a 6 year old (Minions is quite funny); get beaten at playing ball by a 22 month old (in my defence, I was wearing high heels!)?  Will I get the time to make sure that I can do all this with them? Because that’s real doctoring: not sticking needles in and writing up inhalers.  It’s listening to who people are when they’re not attached to chemotherapy (and when they are).  It’s recognising being human is important, for all of us; and it’s having the time and space away from work to realise that.

I find it difficult to reconcile the NHS that I see developing at the moment with a truly safe and healthy environment for patients.  There is increasing evidence about the importance of compassionate care; avoiding burnout in healthcare professionals; and supportive structures to ensure patient safety.  These issues seem to have been forgotten in the current discussions on pay and working hours and consultant presence.

It’s not just enough to say that there are x number of doctors working x number of hours; the quality of what we do matters to.  Not just to be technically proficient, but to take the time to see people for who they are and learn what matters to them.  After all, that’s what being a doctor should be about.  That shouldn’t be a luxury, but an integral part of their care.

But will that matter?

7 day NHS: part 2 – who?

I’m on holiday at the moment, so I haven’t been part of the #imatworkjeremy selfies that have been going around social media this weekend. I’ve seen the tweets and news reports; and I’ve heard the stories from patients who’ve experienced care this weekend.  I’m incredibly proud to be part of the NHS, especially when I see what my colleagues are giving up this weekend. I’m also incredibly worried about some of the things that I’ve seen and heard this weekend.

My twitter feed is flooded with images of children who won’t be seeing their parents this weekend, because they are working. I can see people who’ve tweeted on their way home because they haven’t had a chance to before this; of colleagues who are several hours late finishing their shifts, travelling home, and then coming back with a few hours rest to do it all over again.  There are consultants who are supposed to be “on-call” for the whole weekend, but who will spend most of that 72 hours in the hospital providing care.  

I’ve also seen the concerns that this level of care isn’t widespread throughout the NHS. Even if it is, I think it’s clear that we need to improve services for acute and ongoing care throughout the week.  I’m lucky that my Trust has worked hard to implement the RCPCH guidelines which mean that new admissions are reviewed by a consultant rapidly (in practice, this means on the ward round or during their time on the admissions unit).  

It’s a good start, but it isn’t enough. With the focus on new admissions, what happens to patients already on the wards who might need a more senior review or ongoing medical input? Watching @adsthepoet and his family asking for help over a weekend; getting increasingly desperate for care in hospital was painful to watch. And I know he wasn’t the only one, because patients and families have also been sharing their stories of when it goes so horribly wrong.   Even a delay of 24 hours in getting results or specialist advice is 24 hours for somebody away from their home, with increased risk of adverse events, and outside of their normal activities (I am paraphrasing @betabetic, but she has the expertise here!!)

So we need better cover in admissions units, and on the wards; specialist advice that’s accessible (again, my local paediatric endocrinology team are fab at this: 24/7 consultant cover throughout the Trent region with discussions about complex patients; I’ve had consultants call throughout the night to check results and make plans, or just to check that the patients on their radar are ok). We need safer care throughout the week.

The question that’s been worrying me this weekend especially is this: who’s going to provide this extra care? There seems to be a thought process that says if the wage bill can be cut, suddenly there will be more man hours available and more doctors caring for patients.  I don’t think that’s true.  What I’ve seen this weekend is a cohort of professionals who don’t have the additional hours to to give. 

More worrying are the numerous examples of people providing additional services in their own time: from the shifts that are regularly worked without a loo break (13 hours without a wee does give you incredible bladder control) and that finish 2 hours late, to the routine clinics held on a Saturday morning without remuneration to keep waiting lists down, I’m seeing a system that doesn’t have any more to give. (These are examples from patients btw).

The obvious answer is to move some “surplus” doctors from the Monday -Friday, 9-5 hours (I presume that is the rationale for changing the definition of unsocial hours). There’s just one problem with this: there isn’t a surplus. Rotas are already struggling to be filled. Every week sees a request for us to work additional shifts in our own department just to provide basic cover out of hours.  Pulling somebody off a day shift to make sure that the night is covered is safer than not having night cover, but it leaves the day team short.  It means that trainees have their learning opportunities cut: attending clinics becomes a luxury; practical procedures end up being done by the same people over and over because they don’t need as much supervision (and then they miss out on other opportunities). It’s a poor investment for health care in the future, and I can’t see that this has benefits for patients in the long-run.

Do we go back to working 100-hour weeks to try and deliver this service? I don’t think that’s feasible for two reasons. First, the concerns about patient safety and quality of care delivered by doctors who are exhausted are, in my view, justified. Second, it’s obvious from the posts and patient comments that staff in the NHS are already working significantly beyond their contracted hours and conditions of work. Is there really any more to give? 

I worry that the discussions about 7 day services have focused on money, as though changing salaries will magic up more hours in the day, or that we can clone staff out of thin air.  The recent attempt to increase GP cover through making places for trainees to do a 5 week training course (rather than a trained GP) is even more concerning.  It takes time and effort to train a high quality workforce, and good patient care is about more than just the number of professionals present in a particular building in a Sunday morning.  

Surely 7 day services should first be about improving the quality and safety of care?  What is the vision for a 7 day NHS? And just as importantly, who will be providing it?

Seven day NHS: part 1 – the vision

So, this is my first disclaimer: I’m not a patient. I’m a doctor. 

But I still want a seven day NHS. From reading the papers and a lot of social media over the past 24 hours, I think my seven day services don’t match up with Jeremy Hunt’s ideas. It would be a lot easier to work together to deliver something useful for patients if we could be clear about what that vision was, but the details seem somewhat sparse. In fact, all I can gather, is that it should involve doctors working seven days a week, and as that already happens (despite the media seemingly believing otherwise), I don’t really understand how this is going to benefit patients. I have my own vision for a seven day NHS, and it doesn’t involve having consultants flood the wards on a Sunday evening. (I’ll explain why I don’t think this is feasible in another post, but as we’re talking visions, I’ll stick with my dreams for now).

I want an NHS that can get a child who may have suffered abuse or neglect to a safe place that isn’t a hospital seven days a week. If a baby comes to hospital with some suspicious bruising, they will have a full medical examination carrie out by a registrar or consultant.  In addition, there are a host of medical investigations that need to be carried out. Some of those, like blood tests to look for medical causes of easy bruising, will normally be done and results available within a few hours. Others, like a head scan to look for any evidence of injury, will usually be done “in hours” if the child is well. A baby will often need some sedation to lie still enough for a scan, and will be accompanied by a trained staff member. They’ll also have a series of X-rays to look for old fractures. Once all those results are back, there is a meeting betwee social workers, medical staff, police, and safeguarding staff to discuss the results. A baby who comes in on a Monday or a Wednesday will probably be discharged (if medically safe) within 48 hours. If that baby comes in on a Thursday, they might not get out until the Monday or even Tuesday. None of that process will be speeded up by having more doctors around on a Saturday. It might be if we can get more radiographers, trained social workers, police staff, emergency foster carers…

I want an NHS where I can tell parents if their child has meningitis or a urine infection just as easily at 3am as I can at 3pm.  Both are potentially serious infections in little ones, and the test for both involves a sample of fluid (spinal fluid or wee) being looked at down a microscope by a skilled technician.  During the day, somebody can do that. Out of hours, they will come in from home, which means that they won’t be available during the following day. So there are strict criteria about what I can and can’t request.  Even that will only give us some clues.  The definitive test is to see if that fluid grows any bugs, what the bugs are, and the antibiotics best suited to treating them.  That takes up to 72 hours from the point of preparing the sample in the lab.  In hours, that clock starts as soon as the sample reaches the lab.  Out of hours? If the technician comes in to look at the sample, then they’ll also start growing it. Otherwise, it sits there until the morning.
Doing a lumbar puncture on a child isn’t something we do lightly, and these samples are precious.  (Anyone who’s tried to get a urine sample from their baby will agree that urine is also precious stuff!).  So, the next dilemma is this: do I send it through the pod system where it might end up stuck or lost? Or do I call one of our porters to hand-deliver it to the lab? Ideally, one of our team in the ward would walk it over, but that would mean somebody being off the ward. So, I call a porter.  The same team of porters moving patients to theatre or scan; delivering blood for transfusions; collecting samples from around the hospital… 

I want an NHS where I can get a baby with significant weight loss some breast feeding advice on a Saturday afternoon that doesn’t come from my network of colleagues on social media.  I want the advice that they get to come from a trained professional before they go home, by themselves, over a weekend.  

I want an NHS where I don’t have to order intravenous feeds three days in advance and hope that the salt levels stay steady enough over the weekend. I want pharmacy cover in case a bag of TPN breaks and my patient needs a replacement. (TPN – total parenteral nutrition is used for babies and children who aren’t able to take enough nutrition orally. It’s a complicated mixture of sugars, fats, fluids, salts and trace elements.  Making it up is a highly skilled process).

I want an NHS where I can call an experienced pharmacist on Saturday afternoon to ask about a possible reaction to chemotherapy.  I’ll have access to my pharmacist during the week, the one who knows childhood cancer drugs inside out, but on the weekend I might get the one interested in gastroenterology or rheumatology instead. 

I want more than all of this though.

I want a hospital that families can get to on a weekend because the public transport system actually works beyond 4pm on a Sunday. (We’re in the middle of town, not out in a suburb or outskirts.)  

I want a canteen or a hospital shop so that families can get a meal if they need to stay for a few hours.  And no, if you’ve just been told that your child has a wee infection and not meningitis; if you’ve not eaten all day and not slept for three days; then a half frozen cheese sandwich from a vending machine isn’t good enough.

I want a play specialist 24 hours a day, seven days a week. Doing bloods in the middle of the night is upsetting enough; not having somebody trained to distract and support the child through that makes it worse. 

I want a housekeeper and a laundry service so that I can get a pillow and a blanket for someone who hasn’t slept.  I want a decent supply of tea and toast.  

I want access to notes on a Sunday. I want GP records so I can work out what dose of medication somebody’s on. I want to know that IT will come and fix the printer on a Saturday (or any day – that at least doesn’t seem to happen whether it’s Monday or Sunday) so that I can send a family home with a letter explaining what happened to their child.

I know what I want because as a doctor, I’m there with my colleagues on the weekends; we are there after 10pm on a Sunday getting the “medical” bits done. 

Seven day medical services already happen in our NHS. And really, we’re not that important.  We’re just a part of the whole. And if we want a truly seven day service, we need to get some of the essential staff in there too. 

Having it all

The past few weeks have been confusing. After a lot of persuading by various people, I’m starting to realise that I might be able to do this whole academic/research thing as a career. (I mean, always assuming that there are things like academia, research, and careers in the future. Having seen the budget, I’m not convinced.)  Having the chance to do research has always felt like a lucky break until now; a hiatus from my “real” job. I’ve tended to see the academic jobs I’ve had as something temporary and finite. It’s not been in the career plan (I mean it has been on paper and when I talk to people; that’s not the same as believing it in my head)

So, the first confusing thing has been making that mental shift from seeing research as a phase in my life to something integral to my future (see above for caveats on there being a future).  (If you’ve read some of my other posts, then you would be right in thinking that I seem to keep making this mental shift and that it always confuses me. All I can say is that it’s an ongoing process)

But the second confusing thing is that I’ve started to think of my PhD as my real job. Not even a part-time, 50:50 split with clinical work job. But a real job. Something that’s worth doing in its own right and not as an adjunct to my clinical work. I want to work on my PhD more than I want to go to the hospital.  Not just for on-call days when I can’t do oncology; but even sometimes my ward work. 

A paradigm shift is fine, but this one has gone too far! Yes, there are the usual annoyances with training and staffing etc etc, but this felt different.  It’s an extension of “I don’t have to be a Dr” because now I can be something else instead. 

Mind. Blown

I can be something else.

Maybe I want to be a researcher. Maybe I don’t want to be a doctor. (Please bear with me: I’ve been ill and very tired for the past few weeks. I’m fairly confident it affected my thinking.)

And today I went in to work (I am on holiday, I promise. Just sorting out a few bits). As I walked through the entrance to the hospital, I recognised a parent and waved hello. They looked like they wanted a chat, so I went over. 

He did want a chat. He wanted to give me an update about his child. He wanted to share that with me, somebody he’s only ever met in this horrible place where bad things happen, and I got to be a part of his life. Not because it was my job and I was working, but because he invited me to be a part of that. 

I know when the relief hits, sometimes you just need to share it, and a familiar face will do. 

Even so, that’s still pretty awesome. 

I like doctoring