Working weekends

Here’s the thing: I hate working weekends.  Not because of the loss of time with other, non-healthcare people.  I’m quite capable of feeling up every “free” weekend with conferences or meetings anyway, so that doesn’t make much difference.  And I don’t mind working night shifts over the weekend either.  But I dread working Saturday and Sunday day shifts.

I hate it because despite the fact that junior doctors have a #7dayNHS the truth is that patients don’t.  We don’t have the same staffing levels or the same access to services at 10am on a Saturday as we do on a Tuesday, and so the care that we provide on a weekend is different to the care that I can (usually? hopefully? aspire to???) provide during the week.

Especially at this time of year, there’s a lot of pressure to be a certain type of doctor.  The tasks of medicine seem to take precedence over the art.  A ward round is encouraged to be a “business round” to get things done; get through the tasks; move on and on and on…

It’s not my kind of doctoring.  It makes me uncomfortable; it makes me worried; and (I think) it makes me a worse doctor.  I suspect it even makes me less efficient in the long-run as I reach emotional exhaustion much sooner.  A grumpy penguin is not one that you want in your team.  I really, really doubt that you want one as your doctor.

So, last weekend, I did something different.  I thought what would happen if I came home every night after my shift and could go through my day with someone that I trusted, and who would understand things from the patient’s side.  How would I feel telling them about my day?  Would I feel happy about what I’d done? Or would I feel ashamed about the way that I’d acted and the care that I’d given.

I don’t really buy into the whole concept of “What would X do?”.  It’s far too easily manipulated to what we ourselves want to happen, particularly if the person in question is a historical figure, 2000 years old with patchy fragments of oral history to form an idea of.  But I know a little more about what I’m like, and how I feel.  I know what I’d be happy to share, and what I would want to hide from the people that I respect and trust.

Eight months ago, I lost one of those people. And now I can’t go back and tell him about my day and which bits I cocked up.  But I can think if that was a shift that I would have wanted to tell him about; if he would have understood the decisions I made, or if he would have gently (but quite firmly) told me off…

It was a much better weekend.  Maybe I did take a bit longer with each patient; maybe it wasn’t (on the surface) the most time-efficient ward round I’ve ever done.  But it’s the first weekend in years that I’ve come home and not felt disappointed in myself.  It’s the first weekend in a long time that I haven’t felt cross or frustrated; I had fun with my patients – there was paint and Lego and proper paediatrics involved.  And I think it’s a weekend that I would love to have shared.





Monitoring: the end?

I have just completed my diary card for the week.

This may be the last time that I can.  And despite my love-hate relationship with “monitoring” and my concerns about its utility, losing this is one of my primary reasons for voting #yesyes to strike action.

If you’re not familiar with it, “monitoring” is a way of checking that the hours worked by junior doctors match up with those that they’re rostered to work.  It’s supposed to provide a check on excessive hours by imposing financial penalties on Trusts who repeatedly breach these contracted hours (e.g. if there are too few staff for the workload, or if people have left without adequate cover being provided).  If you draw an analogy with driving offences, monitoring is the equivalent of a speed camera.

It’s a patient safety mechanism.

But it’s more than that: it’s a realisation that there is a gulf between the work outlined in our contracts and job descriptions, and the work that actually happens on the floor.  It’s a recognition that we work in a service where demand is variable and that healthcare professionals will meet those demands.  It is an acknowledgement that we don’t work “to rule”, and that our professional code is such that we don’t just “clock off” on time.

It’s useful for other reasons: it asks you to record if you’ve had a natural break – for years, I thought this was a polite way of asking if you’d had a chance to pee during shift.  Recently, the form has been updated to explain that this is the 30 minute break we’re supposed to get. (The answer is usually no to both questions).  It’s a useful check for me sometimes to realise that I don’t actually work every day of the week, and that maybe I need some days off.  There is an option for “day off”, but there isn’t an option that says “Yes, I know it’s my day off but when else am I supposed to write my clinic letters?”

It is by no means perfect.  The Trust have to collect the data, but the responsibility lies with the individual to defend the hours that they have worked.  Experiences such as being called in to see the Clinical Director to explain why you stayed late are not uncommon; Trainee Encounter forms (usually used to pick up trainees who are struggling) have been used to report individuals for having poor time management if they complete their monitoring accurately.  It can be “explained” to trainees that a post which consistently breaches the hours agreed will result in those posts being withdrawn, leaving their colleagues without a job…

I never thought I’d be sad to see it go. But the thought that this may be my last monitoring exercise makes me deeply, deeply worried for the future.


The Wotsit test

There is a piece of medical equipment that you cannot buy in Foyles or Blackwells; I would be surprised if it existed in the elegant medical supply shops on Harley Street; I have never seen it on the medical suppliers websites (although I’m sure that it is available online).

A packet of Wotsits is an essential piece of my toolkit. 

Performing the Wotsit test is very simple: observe the child in the playroom; watch their reaction when offered a bag of luminous orange snacks (or better still, when someone else starts eating “their” bag of Wotsits); observe when the parent tries to remove the bag to clean their hands or to “go and see the doctor”.  

It’s a reassurance for my gut feeling that a child is well or unwell. A child that demands a bag of their personal treats (or reacts when somebody else eats their  treats) 

Parents have their own version of the Wotsit test which they use all the time. They tell us about things that aren’t quite right; that makes their child “different” from their normal. 

“Off her feeds”

“He’s just quiet”

“She won’t even watch Peppa Pig” (this sets all my alarm bells ringing)

For some reason, the Wotsit test has to be translated into medicalese before doctors take it seriously.  We try and quantify feed volumes and write our notes to describe lethargy and malaise. We’re not so good at just accepting that “not right” or “different” is a valid concern in itself. 

The problem with the Wotsit test is that it works brilliantly for children who eat Wotsits. It’s not so good for children who don’t. 

I was thinking about this more today as we talked about children with complex needs and the care that they receive.  Most families that I meet with extensive experience of hospitals have an organised way of sharing information with healthcare professionals. I quite often get handed a printout with a summary of diagnoses, operations, and medications. It’s incredibly useful, but it’s not all the information I want. 

I want the non-medical stuff too. I want to know what makes families worried and why they think their child is different. I want to know if they’re ignoring me because they don’t like being in hospital or because they’re not well. I want to know if they hate bubbles or not; if their feed usually makes them tickle; if having hugs and cuddles are things that they only want when they feel ill. 

I want to know your Wotsit test. And I will try to listen. 

If I don’t, please feel free to throw a packet of Wotsits at me. 

Do NHS Employers understand the NHS?

I continually wonder if the people in charge have any idea how the NHS works.  And I don’t just mean Jeremy Hunt.

What really bothers me about the junior doctor contract offer released by NHS Employers today is that it bears little reality to how the NHS functions.  There are two options for why the wording of the new contract is so inept: 1) that it’s deliberately worded to be inflammatory, or 2) there is a genuine lack of understanding of how NHS staff work.  I find the second option deeply concerning as I strongly suspect that it’s more likely to be accurate.

Why?  It’s because of comments like this from the “Junior doctors’ contract offer: main points” policy paper from the Department of Health today.

“automatic pay increase” I don’t get an automatic increase. I jump through an ARCP hoop every year and have to get signed off that I’ve reached a certain level of training every year.  There’s nothing “automatic” about the ARCP process.

“high flying junior doctors supervising colleagues who are paid at a higher rate because they have progressed more slowly”  Speeding through your training does not equal “high-flying”.  I’m going to take longer to complete my training than my colleagues because I’m taking time to do a PhD. Apparently that means I’m not a “high-flyer”. I’ve had the option in the past to progress more quickly through my training and I’ve chosen not to.  Why? Because I happen to think that experience is important when it comes to healthcare; that there are some things that you need to experience to learn effectively; and that I’d rather spend a bit longer as a junior doctor than steam through and become a consultant with less experience.  That doesn’t mean that I’m not a “high-flyer” – it means that I think that thorough training is more important than a consultant title.  Suggesting otherwise is insulting to those trainees who’ve chosen to seek experience elsewhere than enhances the care that they can give patients in the future.

“Junior doctors will be paid for all hours worked”  I would LOVE this to be true.  A quick look at will show how unrealistic this is.  Am I really going to get paid for every hour that I spend completing audits? Filling in my eportfolio? For every clinic that I attend in my annual leave?  If I stop in to check on a patient after my shift finishes? If a parent wants an update on their child, but can’t get to the hospital until after 6pm?  Am I really going to be paid for that?  No. Because that’s not how the NHS works.  But the simple fact that the Department of Health can release a statement like this just epitomises how little they understand about the service they oversee.

“junior doctors who take time off for academic research…” It’s not bloody time off.  Time off (as I understand from my partner who isn’t a medic) means that you don’t carry your sodding laptop with you all the time; it means that you sleep after you finish nights rather than going in for a supervision meeting; it means that you don’t plan your annual leave around when you can get to the British Library (hello December!); or that you don’t duck out of a very dear friend’s wedding reception to glance over a paper.

“unrelated degree” so who’s going to decide what an “unrelated degree” is then? Personally, I’m not sure that an MBA is going to lead to improvements in patient care in the NHS, but looking at the rest of the plans for the health service, maybe we’ll all need one to navigate through the new business models.  Is sociology a “related degree”? Psychology? Not to mention that it’s incredibly tough to get approval to take time Out of programme anyway – and already has to meet certain criteria… But, you would have to have some understanding of the NHS and junior doctor training to know that.

“financial incentives that encourage junior doctors to work unsafe hours” I am not encouraged to work unsafe hours.  I get given a rota that is determined by HR and that tries to meet the demands of the service in which I work with the limited number of staff available.  I applied for a job in Deanery (what is now the LETB) that covers my training within a fixed geographical area. And that’s it.  That’s about as much control as I get over the hours that I’m rota’d to work. (I work less than full-time because of the PhD thing, but that doesn’t change what the full-time rota would be – just the percentage of it that I work).  If I get sent to a hospital where the rota involves 24-hour shifts or longer days or more nights than I am currently scheduled to work – tough. If the system changes so that rota patterns change (e.g. to provide more cover in busy periods or because the service delivery is changing) – tough. If I get allocated to a placement which doesn’t have an out-of-hours component (wishful thinking), resulting in a significant pay cut – tough.  This is not under my control.  I don’t choose my hours or design the rota or select which days or shifts I can work.  It’s not an incentive because I DON’T CONTROL IT.

So I’m left wondering how it’s possible to write something that has no resemblance to my reality. Thoughts?