Overtime?

The O-word has been cropping up a lot in the discussions about the junior doctor contract recently.

Overtime: 1. time spent working at your job that is in addition to your normal working hours; 2. the money paid for work that is done in addition to your normal working hours

One of the problems is the way in which the term is used, and what it means to different people.  For the employers in this dispute (whoever they are, Trusts, HEE, NHS England… have we worked that out yet??), the overtime is all about money.  That makes sense: it’s easier to quantify within a huge system.

But for the staff working in those organisations, overtime gets a bit more complex than that.  And that gets frustrating when we’re told that there’s a financial incentive to work unsafe hours.  (Apart from the belief that we have some kind of choice over the hours that we work – we don’t.  We get issued with a rota)  And yes, if you do a locum shift because there is yet another rota gap that hasn’t been filled, then most people will claim for that.

That’s not what overtime looks like for junior doctors.

Overtime is spending hours after a night shift trawling through patient notes, collecting data to complete audits.

It’s going in to work on your day off to teach and mentor and support your juniors; to present the audit; to write a guideline.

It’s giving witness statements and writing safeguarding reports and completing child protection paperwork.

It’s taking annual leave and using that to catch up on clinic letters.

It’s trying to get your mandatory training done while your partner watches films in bed and wonders why you never, ever seem to stop working.

All in our own time.  

On our days off.  

Unpaid.

Just to get the job done.

i-do-not-think-it-means-what-you-think-it-means

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It’s (a bit) about the money

So.

Here’s the thing.

Last year, I spent more on clinical training than I did on my mortgage.

Last year was a quiet year.  (I’ve been trying to concentrate on the PhD).  It was about 1/3 less than 2014 where I got a bit carried away and thought that I could do a PhD and spend the time learning medicine.

It definitely wasn’t as expensive as the 2009 – 2012  period when I was preparing for exams, buying revision books, and paying for online and face-to-face courses just so that I could progress to the next level of training. (Total cost = around £5000.  I was lucky)  Oh, and paying for the MSc (£10,000).  Plus all the usual costs of training and courses.

It’s a rough ball-park, but even if I use my “quiet” year as a guide, I’ve spent at least £44,000 on post-graduate education.

You could argue that it’s my choice to do this.  And it is.  Nobody made me do a MSc (it’s just kind of important before you attempt a PhD).  Nobody made me do post-graduate exams (except that Membership of a Royal College is a pre-requisite for progression to being a registrar).

Learning about the neuro-psychological impact of cancer treatment isn’t in my mandatory training (unlike learning that fires really, really like oxygen) – but I think it’s kind of important to understand so that I know what questions to ask families when they come back to late-effects clinic.  It’s apparently not essential that I learn about end of life care (although it bloody should be), but what kind of service would I provide to families if I didn’t?

I love my job. And I don’t think that I will walk away from it.  (Last week I got given a Starburst by a patient and I was told to eat it.  My job is fantastic)

But I am starting to think if I am going to continue to invest in my job rather than my life.  I’m wondering if it’s really more important to constantly try and improve my practice, or if maybe I can stay in something more upmarket than a Travelodge occasionally.  If perhaps it would be nice if I had the kind of house where two people could fit in the kitchen at once.

I spent more on my training than I did on my mortgage.

 

 

Reflecting on/in language

My partner will quite happily tell you that I am very, very good at seeing nuance in the words that people use.  On a really bad day, I’m quite capable of turning “hello” into an existential crisis (and all before he’s had a chance to drink his tea…).

The language that we use matters.  This is one of the things that I’ve taken from the fab work that #MatExp have been doing – all those phrases and terms that we use as healthcare professionals without thinking – and the impact they have on the people hearing them.

I keep thinking about how much I’ve learnt from doing this PhD.  All the opportunities that I’ve had to talk to people that I just don’t have when I’m at work.  (And lets be honest, it’s the talking that I really love about my job).  And how much of a culture shock it’s been.

And maybe I’ve got just a little bit complacent.

Because now I’m writing up results. In formal, PhD-acceptable, academic language.  And as I’m writing, all those things that I thought I’d learnt about are flying out the window.  I find myself using words like “compliance” to talk about the decisions that families make.  I’m writing more approvingly if the families and professionals agree about issues.  I’m writing about how “difficult” it is for professionals if families dare to disagree with them…

One of the reasons that I like the e-portfolio emphasis on reflection is that it makes me write.  And as I write, it helps me think.  Hopefully, thinking will help me change what I do.

PhD writing is making me realise how much more there is to change.

Starting with an epic re-write of my current chapter… #hownottogetaPhD

Calling all paediacademiatricians…

The one thing I’ve realised as an academic trainee over the past 8 years (that went quickly) is that it’s very easy to become quite isolated.  I think this is something that all trainees experience: we rotate around every 4 – 6 months; you rarely meet your peers apart from at occasional training days; and you’re not even on-call with other people from your speciality.  Apparently there’s something called a “doctor’s mess” in our hospital, but it’s over on the adult side and I’ve never been able to get there.

Add in the academic side of training, and things can get much worse.  For one thing, we’re even more scattered (I work with colleagues in the same department, but in different buildings on campus); and we work even more bizarre shift patterns because of trying to combine the academic and clinical commitments.  This either means that you have blocks of time where you only see your research team; blocks of time where you only see your clinical team; or entire years where you don’t really get to know anybody properly because you split your time between two completely different spheres.

It leads to problems.  It can lead to isolation and a general feeling that you have no idea what you’re doing.  It leads to more practical issues, like not knowing when the application dates close for College exams or what your status is with the junior doctor contracts.  It means that you miss out on learning opportunities and experiences, just because you can’t find people in a similar situation.

I know that some places have regular get-togethers for their clinical academics, but I still don’t think that’s enough.  We work in increasingly specialised fields – the people having similar challenges to you might not be in the same University or even Deanery – but I’m sure they’re out there.  If you’re in a small unit, then the people around you may also be your supervisors and mentors… Not always an easy situation to discuss ideas or have a mini-panic in.

So, I suggest that we set-up a network of paediacademiatricians (something similar to our local group).  I don’t know what it looks like yet, but it has to be more accessible than face-to-face.  Meetings are lovely, but they can’t be the only option for trainees with complex rotas based all around the country with night shifts!

What would work? A website for basic information (conferences; exams; contact details for peer support)?? Regular twitter chats? (with a shorter hashtag than #paediacademiatrician)

Please help. Let me know what you want it to look like.

And then watch this space 🙂

Equality in thought and deed?

Last week I got to go to the Royal Society’s annual “Diversity” event.  I admit that I went into this meeting with a certain amount of cynicism (just for a change).  Visible differences are much easier to address than hidden ones.  Much of the focus was (predictably) on promoting ethnic and gender diversity.  I’m not usually classed as an ethnic minority (half Welsh and half Latina – see what I mean about visible differences?)

I am however a woman: an easily recognised minority in science, especially in the higher rungs.  But I’m not aware of having experienced any gender discrimination in my science career.  I’m lucky: I work in a research field that is largely dominated by female researchers; my research group is almost entirely female.  I’ve never felt that it’s an issue.

This is very different to my experiences in the NHS.  Again, I work in a field that has a slightly higher number of female trainees than others, but the expectations of me as a woman are completely different.

“When are you getting married?” might seem innocuous, but it reinforces the message that I’m expected to see this as a goal in my life.  It’s often followed by “when are you having a baby?”.  It’s not “if” but “when” – again, as though this is something that I should be doing.  

This is just social chat amongst peers.  Much more damaging are the statemetns by my seniors:

“you’ll never be any good as a paediatrician until you’re a mother” still haunts me.

Being told that “doing a PhD is not an acceptable reason to work part-time; you should be raising a family” was easier to shrug off – at least it was an open acknowledgement of something rarely acknowledged: regardless how many other aspects to your life, a woman is seen primarily as a potential mate and mother.  Not a Professor or a Clinical director or a Chief Exec.

Universities have put a huge amount of working into ensuring “family friendly” working environments; funding bodies emphasise their family leave allowances; institutions have diversity officers… What about the NHS?

If we’re going to recruit the best people to research, then we need to make sure that these kind of attitudes aren’t allowed to stifle ambition.  We need to stop defining women as proto-mothers above all else. And we need to focus our attention away from the universitites to the wider environment, including the NHS.

I am not a mother in waiting; I am not an incomplete wife.

I am a PhD candidate and paediatric trainee. I am a baker of breads and cakes.  I am a cat owner (or owned).  I am a pole dancer and occasional aerial hooper. 

Define me by the thoughts in my mind and the works of my hands and my body; not by what my colleagues think I should be doing with my womb.

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 notfairnotsafe.com 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?

Multiple ways to F@*k up in the virtual world

My usual response to Twitter goes something like this:

  1. See interesting point/comment
  2. Get involved in interesting discussion (usually medical; sometimes political; occasionally cat-related)
  3. Trundle along quite happily
  4. Get completely thrown by comment (usually re: doctors or the NHS)
  5. Realise that I have (yet again) fallen into the trap of believing that I’m a half-way decent person who is open-minded and doesn’t live in the bubble… except that I do
  6. Slink away to try and re-set my brain and process the new information
  7. Reconnect with social media
  8. Start the cycle from #1 all over again.  And repeat.  And repeat

The comments that I struggle with are always ones that attack (?) something that I think is important.  I’m getting better at dealing with the ones that are political (although I cannot comprehend the logic that says that some children are more deserving of food, warmth, and life than others because they happen to be born in a particular part of the world.  Still struggling with that one. Not going to get my head around that any time soon. Or the thought process that states that the more guns are available, the less likely you are to get shot.  I’m shaking a little just trying to fathom exactly how that one works).

The comments that make me turn and hide are the ones that are personal; the ones that challenge my values.  The discussions about “you lot” as though by being a doctor I’ve made a choice to detach myself from the rest of humanity  (Why  is it considered socially acceptable to refer to healthcare professionals as “you people”? It happens to lots of groups… but I hadn’t realised that it was acceptable to do so.)  The comments that don’t let me pontificate in my head about how it’s all about patient care; how healthcare professionals always work for the best for their patients; how “we” do things differently…

Oh yeah… “we”

I struggle with social media because it’s challenging.

And it’s a lot easier to rationalise in my head that:

  1. The real world isn’t like that (“Of course I don’t see myself as different”)
  2. I/we would never act like that (“I don’t talk about patients like that”  Except of course, I’ve just referred to “patients” as a single homogenous group who can be “talked about”…)

Every so often, usually when I’m engrossed in some Twitter discussion or fuming about a particular comment my partner will suggest that I block or mute people.  It’s tempting. And sometimes I do delete my apps and sign-out of all my social media stuff (apart from Instagram – because that’s mainly cats and pole-dancers) and sit in my own head for a bit.

And then I start to wonder how far in my bubble I’m living… So I come back

I don’t have any neat profundities to sum this up.  Except that I’ll keep running through the social media cycle.  I’ll take Twitter-holidays when I need to, but I’ll be back when I have the resilience to be challenged again.  And I’ll keep f@*king it up.

Bear with me?