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 😦

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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

Academic Training: The Foundation Programme

It’s that time of year again: we’re all thinking about moving to new rotations; graduation ceremonies are happening; e-portfolios are being filled.  Inevitably, this means that my social media feeds are full of people panicking about ARCPs, e-portfolios, and trying to get things finished before the end…  In particular, I’ve had lots of comments about the Academic Foundation Programme (AFP) pop-up.

Maybe it’s because, unlike a lot of our training, the Foundation programme does feel like a separate entity with a definite end-point.  Most people move to different LETBs at this point, so it’s harder to keep connections going.  There’s extra pressure to get audits, projects, research  finished and completed.

And alongside this panic, there’s the retrospectoscope, and the “I wish somebody had told me” and the questions to yourself:

Could I have done it better? (Define better…)

Could I have done it differently? (Always)

And the most common questions coming through are these:

Why did I take this on? 

What was the point? 

 

I’ve seen a lot of the last two questions coming from Academic Foundation trainees over the past few weeks; and I understand why.  That’s exactly how I felt at various points during my FYA (and my ACF, and my PhD…) but I get the feeling that it’s for different reasons.

One of the things that makes me really sad is the feeling that the programme has somehow been a failure if FYAs haven’t completed a piece of research in that time; if they haven’t got a paper accepted for an international conference.

Publications are nice, but focusing on that is to ignore all the other things that the AFP gives you.  I started my academic training thinking that I would have a list of publications by now, and a collection of flight miles accumulated from numerous conferences in exotic locations.  The reality is that I have one published paper which came out of my FYA programme, and was published 3 years after I finished my FYA…

Publications are not what I got out of my FYA project.

 

So, what is the point of the Foundation Programme?

I think you should come out of the AFP knowing if you want to spend more time in academia or not.

It’s that simple.  Academia isn’t for everyone; it isn’t a failure if you decide it’s not for you.

What worries me is that 1) trainees feel that they aren’t suited to academia because they haven’t “achieved anything”, and 2) they have bad experiences because they aren’t properly supported.  You can get your name on a big research paper and not have had any sense of how research in the NHS works because you’ve been a lab monkey for 4 months.  You can spend your 4 months waiting for ethics /R&D approval to come through on a proposal that you drafted in your first week.  That’s not a great experience of research (it might reflect some of the reality, but it’s not all), and it certainly doesn’t feel like enough to make a decision about whether or not you want to pursue academic training.

We do things slightly differently for our trainees locally, largely because we think this is important. It’s not a perfect system by any means, but I think it’s got potential.  And it’s been running for about a decade – we’ve had time to learn what works and what doesn’t.

So, this is what I learnt from my time on the AFP:

1) Be realistic – 4 months is not a lot of time.  My first thought on having a research block was ” I actually get given time to do all this stuff??”  Let’s face it, most of us are used to the extra-curricular aspect of academic life; trying to squeeze it in between clinical commitments, and exams, and the rest of our lives. (Remember that? the rest of our lives??).  Those things don’t suddenly go away. Yes, you will have some dedicated time for reserach that you probably haven’t had before. Yes, this is exciting.  It’s still not a lot of time to get things done

2) Choose your project carefully: find something about it that interests you.  That might not be the topic, it might be the methodology.  Not everything about it will be interesting, and you still only have 4 months to get it done.

3) More important than choosing your project, choose your supervisor carefully.  You are a junior trainee coming into a research group for a short period of time.  The international professor might have a great reputation, but are they used to supporting junior researchers who only have limited time & experience?  Talk to your colleagues, talk to the potential supervisor, have plenty of meetings before you commit.

4) Learn some management skills and appreciate what you’ve learnt.  You’re learning to manage your own time, other people, organise projects… All that is important and relevant and much more useful in the future than a particular technique to count serum rhubarb concentration.

5) Boredom happens.  That’s OK.  Find other people who are in the same position as you (use social media – sometimes it’s easier).  Link up with the people who did the post before you, the people slightly senior to you, anybody who understands the frustration of a coding tree that will not make sense no matter how much you stare at it.

6) Get some training.  FYA trainees are trainees in research.  If nothing else, learn some critical appraisal skills.

Ultimately, see this as your chance to try something different, and make the most of it.

Good Luck!

 

Why a desk is more important than my training

Last week I bought a desk from a well known high street retailer (I’m not going to give them a plug, but let’s just say that I’m a doctor in the Midlands and it’s a national brand. There aren’t that many options really)

One small problem: this desk arrived neatly packaged up in its box without any fixtures or fittings (I have never understood what the difference is, but the things that hold it together and stop it collapsing).

I made one phone call, and explained the problem. Within 12 hours, I’d had contact from the manufacturers in Denmark to confirm what I needed, and within 48 hours a package arrived on my doormat containing the missing parts.

That’s all it took. One phone call to report a problem, and there was a solution within 48 hours. The shop actually offered to collect the existing desk, and replace it with a completely new one, but I said no. (I couldn’t face waiting for another delivery!)

So there you go: one problem, and a solution that was discussed with me and adapted to what I need. A brilliant example of how to do customer service. And that’s just a desk. In the grand scheme of things, it’s really not that important.

I don’t usually like comparisons between the NHS and commercial organisations (for many, many reasons) but this experience came at the same time I was trying to give some feedback on my medical training, and the two encounters could not have been more different.

Nobody suggested that I was responsible for the fixings not having been delivered; it wasn’t my fault that something wasn’t perfect. The retailer & manufacturer were just concerned with finding a solution to the problem that I had reported. They weren’t trying to investigate my behaviour; there was no discussion of an inquiry into what happened. Just a genuine interest and attempt to help.

It’s just a desk. It’s not the future of the clinicians employed by the NHS.

You would think that medical training was worth more than a desk; that those responsible would relish the chance to improve the experience of their trainees; that feedback would be welcomed.

I’ve come to realise just how naive that is.

We’ve heard a lot recently about how the NHS needs to listen more to patient & carer feedback; the friends & family test is one way of picking up on this. Rather than waiting for complaints, there’s a move to seeking the whole picture from patients, families, staff. It’s a way of pre-empting problems (hopefully); of finding systems problems before they develop into errors and spark complaints.

Why is it so hard to see that could be useful for medical training? Keogh was right: trainees are the front-line of the NHS, and have useful insights into what’s going on with patient care. Funnily enough, we also have a bit of insight into what’s happening with our training. When it isn’t working, and when it is. Feedback should be welcomed & encouraged, not repressed. Raising concerns shouldn’t be seen as a reason to blame trainees for not receiving training, but rather a reason to look into why this has happened.

Maybe it’s just time to let my idealism die a little

Doctors don’t care

The conference speaker has just finished her presentation.  There’s silence in the room.  Then, a hand goes up and the inevitable question is asked:

“Do you think it’s possible to train doctors to care about their patients? If you showed them case studies like this?”

In the audience, I’m so stunned, I can’t think of a sensible comment to make.  I don’t know what I’m more astounded by: the assumption that doctors don’t “care” as a default position; or the belief that listening to a 10-minute case study can give you any idea of what it’s like to be a person who’s a patient.

It’s not an unusual belief though.  A quick look at the headlines tells you that doctors don’t care.  We perpetuate this myth in research too: projects that look at studies of care in hospitals only look at non-medical staff; studies of interaction between nurses & patients are focused on care, those about doctors are sparse to say the least.  Especially in my field of paediatrics, the idea of a doctor as someone who develops a relationship with a child is hardly acknowledged.  Studies talk about the importance of including everyone who cares for a child in planning services, and then leave out medics (they often leave out the child too, but that’s a whole other issue.  I will talk for ever about that if I get started).  I was so shocked to read this about debrief, because it actually included doctors as people who cared.

But how much do you really want me to care?  When I started in paediatrics, I found taking blood from children really difficult.  Even with the best preparation & support, sometimes it’s just a horrible experience for the family & child.  I found myself getting upset; angry with myself that I was putting people through all this.  It’s not a helpful emotion.  If anything, it feels self-indulgent.

I felt terrible about telling parents that their new baby might have sepsis; that they needed a lumbar puncture; that I had made them cry.

Here’s the reality:

My job is to be able to suspend emotion because otherwise I can’t function.  Part of the skill set I have to develop is to separate my emotions from the patient in front of me.  How can I possibly justify getting emotional about something that doesn’t really affect me? How can I allow myself to feel something that potentially impacts on how I do my job?  I step away from one patient, and on to another, and another, and another.  It’s not fair to one child if I’m still upset about something that happened 5 minutes ago; I go from sharing bad news to telling someone else they can go home  to being shouted at for not having results back to apologising for keeping you waiting.  I smile and play and laugh.

I hide in the treatment room for 2 minutes to let myself breathe; I go out and smile & talk & apologise & take histories & examine & play.  I can’t care. Not then, not there.  How do I give everybody else my full attention if I’m so engrossed in one terrible situation?

This is the other reality:

It’s the part of your brain that won’t let you go home until the test results are back.  It’s the calling up a ward in the middle of the night to see how things are, or just wandering past on your day off to see what the scan showed.  It’s remembering the look in their eyes when you tell them, and knowing that you can’t go back and intrude, that they probably never want to see you again.

It’s hoping that if I’ve done my job properly, they won’t remember me because I should just be part of the service that smooths them through the worst parts of their lives.

It’s lying in bed telling yourself to stop thinking about it; to not go back in just to make sure they’re OK: because tomorrow morning, you have to go back and do it all over again with somebody else.

But what would I know? I’m a doctor: I don’t care

 

In praise of e-portfolio

My name is Carmen, and I like e-portfolio….

There. I’ve said it. Confession made.

I’ve confessed to a few things in my time (I’m a pole dancer in my spare time, and I really never have seen all of Star Wars), but this is likely to be the most controversial.

But I do. I think e-portfolio is amazing. Genuinely.

And I know I’m not supposed to think that.  If there’s a social taboo amongst junior (senior?) doctors, it’s admitting that there are any benefits to the current assessment systems.

If there’s one thing that units orthopods, anaesthetists, and microbiologists, it’s a shared loathing for the e-portfolio.

But I quite like it.  I didn’t use to.  I used to agree with the prevailing thought that it was an instrument of torture devised by ARCP assessors to stop us enjoying the summer.

And I no longer think like that.

 

Here are my reasons for liking e-portfolio

Storage

It’s my career development in one neatly organised place.  I normally keep records of conferences I’ve attended and meetings I’ve gone to in a box that I keep meaning to sort out.  Every so often, the pile of papers escape into a second box which is often non-existent, and then start taking over my bed.  I keep meaning to sort it out, but I rarely do.  The last time I opened the box, there were papers in there from 2010. I dread to think what’s on the bottom, but I think it may come to life if it reaches sunlight.

Organised storage

Trying to write a summary of things I’d achieved over the past year (academic ARCP reviews – lovely things) used to be a total nightmare, and would normally involve wrestling THE BOX into submission and trying to find a diary of some sort.  Now, it’s all in one place.  Finding my research development evidence for my upgrade meeting took 10 minutes because it was all in e-portfolio

It’s a way of showing the work that I actually do

I hadn’t realised this until recently, but some people go home after work and switch off.  I spend Sunday mornings dragging my friends out of bed so we can talk about a website whilst consuming far too much caffeine; I run away from barbecues so that I can spend the evenings doing journal clubs and trying to get Tweetdeck to work at a reasonable speed.  E-portfolio is a way of recording all of that, and it genuinely takes a minute of my time.  If I’ve spent an hour at journal club, why not spend 60 seconds inputting that?

It helps me learn

I don’t have an encyclopaedic memory.  I’m a paediatrics trainee for goodness sake, not an anaesthetist.  I don’t remember exactly what the Centor criteria are; or when to scan in UTI.  I don’t really want to trawl through Google every time I have a minor clinical point that I’m sure I’ve considered before.  What I need is one place that stores the answers; a universal notebook (even if it isn’t very pretty)

It stops me exploding

I like the reflective entries.  I think they’re difficult to write, and sometimes they can be very traumatic.  But looking back at some of the entries, I can remember how I’ve dealt with situations in the past.  More than that, sometimes I need to remember that I have survived, and that I can manage.  It can be cathartic writing about difficult things, and I find it helps me.

It’s MY record

It’s a space for me to share my concerns and worries about my training.  Yes, I discuss them with my educational supervisors; my TPDs are aware of my concerns, but that doesn’t mean that they are recorded anywhere or that anything is being done about them.  Part of me feels that I’m clawing back a tiny bit of control by creating a record of my training that isn’t controlled by an official view (or at least, not too much)

 

Ultimately, my e-portfolio is just that: mine.  I don’t use it to comply with the ARCP requirements or my educational supervisor’s demands (to be fair, I’m not convinced my ed sup can access it).  I use it for me, and as my training record.

And yes I will stand up and say, my name is Carmen, and I like e-portfolio.

Why #NHSChangeDay (almost) made me late for work…

Last Wednesday I was the woman doing the comedy half-walk, half-scurry into work.  I’d left on time (OK, early because I hate being late for work); I’d checked my bag (twice, because I hate not having stuff), and I was still clattering my way into work.

And it was all the fault of NHS Change Day.

It was all their fault because when I’d carefully packed my bag, I’d forgotten an essential piece of kit.  Stethoscope; dictaphone; 4 black pens; NHS ID badge; NHS SmartCard… All the things that I usually take.

And I’d forgotten the stickers.

I don’t normally take stickers to work.  Maybe that makes me a bad paediatrician, but it’s not something I got into the habit of doing. (I’ve never seen my seniors give out stickers either, so maybe it’s not just me)

And then I saw a pledge on the NHS Change Day pledge wall; pledging to have stickers at all times for the children we look after.

So I joined.  Because it’s such a small thing to do, isn’t it? To give a child a sticker for being brave in a situation when they are ill & terrified & in a strange environment.  (Actually, I sometimes think it’s worse if they don’t feel ill, because why are you going to see the doctor if you’re not poorly or having injections??)

And I’d already forgotten the stickers. So, back I went on Wednesday morning; dug out a pack of stickers; and scurried my way into work.*

And I offered each child I saw in clinic that morning a sticker, and said “thank you for coming to see me today”.

And that’s it; that’s one of my pledges for NHS Change Day done.  Box ticked; self-congratulatory mode engaged; happy patients, happy parents = happy me.  Except it wasn’t and isn’t that simple.  Because my patients weren’t just pleased to have a sticker: they all looked surprised that I was bothering to thank them for coming, for missing school, for being asked personal questions about how difficult things could be for them.  Having a Dr who recognised that coming to clinic isn’t a simple or easy thing was a surprise to them.

I like to think that I talk to my patients.  It really annoys me when colleagues ignore the patient, and talk to their parents instead.  It’s something that I think about quite a lot.

Giving out stickers and taking that extra moment to say “thank you” made me realise how long a way I have to go before I even come close to being good at that side of my job (sometimes, I really do not appreciate having insight.  It’s incredibly annoying).  So no, not a happy me.

 

Why bother pledging?

Some of the criticism levelled at NHS Change Day is that the pledges made are just things that we should be doing as part of our job; that if we need reminding to do this, then maybe we shouldn’t be doing this job at all.

I can see where the sceptics are coming from in some cases: maybe we should just be “doing the job”.  (Maybe if I need reminding to talk to my patients, then I shouldn’t be doing this at all)

And then I’ve read the pledges.

And I’ve started to wonder what exactly “doing the job” means, because when you’re working in the NHS, then it is so easy to feel that “doing the job” is completing tasks.  Fill in blood forms, take bloods, examine patient, explain management plan, supervise juniors, call the wards to make sure they’re happy, try and scurry around a quick 6am ward round to pick up any problems… For a long time, I thought that was doing my job.

Gradually, I’m realising that isn’t all.  And seeing the pledges from NHS Change Day have helped me think about my practice, and what I can improve.

These aren’t pledges from people with massive resources in the most part; they’re individuals who want to make things better for the people we work for & with.

What’s amazed me about reading the pledges is how practical they are, and how wide-ranging.  Bringing in treats for the night shift just makes things tick along a little easier (it’s also sanity-saving if you haven’t had a “break” all night) – that’s not in anyone’s “job description”***

Reviewing documentation & forms to make them more user-friendly: potentially time-savingfor clinicians, and safer for patients.  Not one of the tasks that comes into the “job description”.  (Someone is going to quibble that we should be doing audits and QI – trying to negotiate a quality improvement project past your supervisors without also having to do an audit that the department needs completing is an interesting task)

 

So, what is the point of NHS Change Day?

For me, it’s been a great opportunity to think about my practice and the kind of Dr that I want to be.

It’s given me so much additional support because I’ve been able to use the pledge wall as a practical tips section for improving how I work.

Most importantly, it’s been a massive catalyst for communicating ideas and enthusiasm from everyone else who’s involved.  We’ve discussed ideas (I’ve lurked on some fantastic discussions).  I’ve heard real experiences from people like me, who can change things in their daily lives, that make a difference.

I’ve realised that it isn’t a failure if I don’t change the entire NHS.

It isn’t a failure of NHS Change Day if we don’t solve the budget deficit; cut waiting times; keep local hospitals open…

What I can do is make things better in my way.   After all, change begins with me 🙂

 

* I wasn’t late, by the way.  I just wasn’t as early as I like to be.**
**No patients were delayed in the making of this pledge
***Job descriptions are a bit like contracts sometimes – mythical beings that are rumoured of, but rarely seen

My Pledges

“I will remember to say “Thank you” to the colleagues I work with for doing an exceptional job everyday (not just when they’ve done a superhuman one)”  If this sounds like just part of my job, then you should know that I feel spectacularly uncomfortable when somebody thanks me for doing my job.  I didn’t realise that other people don’t feel like this until I did a Myers-Brigg session with an amazing facilitator.  Ooops

“To treat the children I work for with respect; explaining what I’m doing & why; and sharing decisions as much as is possible”  No patient should feel that they need a contract like this. This blog breaks my heart.  And again, I’m a paediatrics registrar, and I should be doing this anyway because that’s how paediatrics works, right? Wrong: this paper is a brilliant observation of just how children are treated, and how we all seem to accept this as normal.  This is the speciality that still publishes phrases like “the terms patient, parent, and patient-parent set are used interchangeably”

“I pledge to ask my paediatric patients what I can do next time to make their visit to hospital better; and to listen to, and respect their ideas”  Children are still marginalised in paediatrics – sounds silly, but it’s true. We ask parents to fill in satisfaction surveys, talk to parents about management plans, and ask parents about their worries. Parents are important, but they’re not the patient. It’s far too easy to forget that there’s a “real” child lying in that bed, with worries & fears of their own. Inspired by http://www.justbringthechocolate.com

Why I’m not a doctor (yet)

Realisation of the weekend… I’m not a doctor.

Now if you’ve met me; read this blog; read my Tweets, you would be justified in thinking I was having one of my self-doubt “I can’t do this” moments.  Of course I’m a “doctor”: I go to work in a hospital; I treat children.  This week, I’ve seen ear infections, gastroenteritis, tonsillitis, gastroenteritis, bronchiolitis, more gastroenteritis, seizures… And did I mention the gastroenteritis?

I’ve prescribed antibiotics, fluids, and anti-epileptics; I’ve been coughed on, vomited on, sneezed on, and bled on (I love paediatrics); I’ve put in cannulas, felt bumps, looked at spots…

It sounds like doctoring, doesn’t it?

The ‘official’ definition of a doctor is “someone who is qualified to treat those who are ill”.  Which sounds great: I have a medical degree (MBBS); I have a shiny certificate that says that I’ve passed my membership exam in my chosen speciality (MRCPCH); I have regular appraisals, and an e-portfolio that I (kind of) keep updated.  Does that make me a doctor?

And then I found this definition too “a person… trained in the healing arts”

That sounds more like it.  That’s what I want to do. Not just treat the illness, but help with healing; support health.

Sounds great, doesn’t it?

And yet… I’m not a doctor.  I go into hospital or clinic and I work for the first of those definitions.  I treat illnesses; I don’t help people heal.

On top of my list of things I’ve done at work, I’ve also done these things:

I’ve not listened to parent’s concerns because I was “treating” their child for an illness, instead of paying attention to what they were worried about in the first place.

I’ve taken some time to talk to parents about their child… whilst standing over them as they lay on the bed with their child, and then wondered why they sounded a bit annoyed…

That’s not doctoring.  That’s not healing, or supporting health, or any of the great things I want to think that I’m doing at work.

NHS Change Day has provoked a lot of comments over the past week or so, and a number of blogs about the types of pledges that are being made.  I want to pledge that I’m going to try and be a doctor, but I think that’s going to provoke the kind of response “well, shouldn’t you be doing that anyway”*

Yes: I should be doing all these things, but if I’m honest, then I’m not.

So what now? Do I stop, and realise that actually I’m terrible at this doctoring thing?  Sometimes, it feels like that.  But I’m taking some comfort from the realisation that I’m paying more attention to these things, which is surely the first step towards making them better?

Doctoring is a skill that develops, and we keep learning.  That’s well recognised from the “treating illness” side of things – that’s the point of appraisal, and assessments, and reviews, and CPD.  Learning how to be a doctor is an ongoing process too, but there isn’t a course that’s going to teach me how to do that.

I want to be a doctor… and I’m not. But I hope I might get to be one day.  What NHS Change Day is doing is teaching me how I can get there.

* Plus, it’s vague and not terribly useful to me or anyone else; I need a manual of how to do it, not a grandiose statement.

Why it’s the little things that matter

This is going to get a bit ranty at points, & I’m finding it really hard to write for some reason, so I will try and remain coherent…

It’s a year since the Francis Inquiry published.  If 2013 was the year of the big 3 reports into NHS failings (Francis/Keogh/Berwick), the details in the Public Inquiry into failings at Mid-Staffs (Francis) was probably the most harrowing as far as personal stories were concerned.  Unsurprisingly, this has generated a lot of interest at the one year anniversary: how do we move on, take the lessons from Francis (and the others), and make the NHS better?

Yesterday I went to a conference on Implementing the recommendations to The Francis Inquiry.

It was a brilliant line-up, including people I’d always wanted to hear in public like Julie Bailey & Ann Clwyd MP.

I work in the NHS and I find some things just appalling.

Why on earth does an organisation that’s responsible for the care of millions of people make it so hard to complain?

Why is it only in the past year that there’s been legal protection for healthcare professionals who blow the whistle on persistent failings?

But if you’re getting as far as making a formal complaint, or whistleblowing, then there’s already a big problem.  More importantly, if as an organisation all you’re paying attention to are the formal complaints, then you’re only listening to the people who have the time and energy to put forward a complaint.  Because we know that getting your voice heard in the NHS to raise your concerns isn’t easy, whether it’s as a patient or as a member of staff.

One of the phrases that keeps coming up again, and again, and again is the need for a culture change.  In the words of Julie Bailey (Cure the NHS) “…we are reliant now on those that work in the NHS to change the culture and to make it safer for us all”

The problem with that is the comment from the Chair for the morning session, Sir Richard Thompson (RCP, London) that started off the morning.  As you can probably tell, this did annoy me a little bit…

Why was I so annoyed? There are the obvious reasons: it’s a hard realisation that actually, despite my pontificating on this blog, that “giving up” on reporting your concerns is a real danger. And that probably affects the response to Francis if we’re honest

I don’t want to think of myself like that, but the reality is that that could be me.

But the other reason is that it doesn’t solve anything.

Now, I take the point that we can’t keep blaming “the system”

But where you have a consistent problem with reporting, then maybe we need to accept these failings, and make the system better.  And that means making it easier for everyone to raise their concerns in the NHS.

What Francis showed is that there were warning signs, and they were ignored.  Nobody wants to get to the state where there’s another Mid-Staffs.  Things are going to happen; if we’re honest we have to accept that the NHS can & will fail patients.

For me, that means that when the warning signs start, we have to pay attention, and pay attention early.

So I think we need to focus on the little things.  

Responding to patient complaints, and protecting whistleblowers; these things are important but they’re just the tip of the iceberg. They’re what happens once there are consistent and repeated failings in the NHS.  What are we doing about the systems that are supposed to act as early warnings?

In my naive brain, here’s how the system is supposed to work:

  1. Healthcare professional reports adverse incident (missed drug administration)
  2. Incident is investigated
  3. Possible underlying causes are identified
  4. Monitoring of other, related incidents is initiated
  5. Feedback to the reporting healthcare professional
  6. Education & development to reduce the modifiable risks

Incident reporting is one example: as doctors, I think we’re terrible at reporting clinical incidents & near-misses.  The process is inconsistent, and we don’t really accept why it’s important.

My personal experience of incident reporting is variable: sometimes I get a clear response of what the investigation has found and what the next steps are.  (These actually do make a difference – like the blood culture samples that disappear because the processing system doesn’t work = new computer system!)

Sometimes the form disappears into a black hole with a polite, noncommittal e-mail telling me that “my time is appreciated”.

And nothing else.

As professionals, if we can’t see the benefits of reporting near-misses/medication errors/under-staffing before they become major problems, then that’s a problem.

It’s a problem for professionals because they are excluded from the system that is part of their professional duty of care.

It’s a problem for Trusts & Boards because they don’t know what’s happening on the floor and can’t react to issues at the “smoke alert” stage

And most importantly, it’s a problem for patients because the systems are there for alerting potential problems but we’re not focusing on the warnings.

So how are we supposed to stop another Mid-Staffs if we’re not concentrating on the small things?