Rainstorm

umbrella

He had sat through the starter and the main course, each morsel sticking in his dry gullet. Opportunities had come and gone, but he had failed to take them, paralysed by cowardice. Nevertheless, his mind was made up and nothing was going to change his course. His mother seemed to sense that something was wrong; the conversation faltered, he declined to have his wine glass refilled.

“What’s wrong love?”

“I’m giving up medicine.”

oOo

A month earlier.

He parked his car and turned off the radio. — ‘…doctors will be criminalised if found guilty of wilful negligence…’ — was the sentence echoing in his mind as he entered the hospital through a side door. He was on-call today, but he hoped to see some of his own patients before things began to heat up. His first patient had been diagnosed with inoperable lung cancer, and their relatives were on the ward waiting to talk to him. David took them into a private room. As he closed the door behind them the patient’s daughter pre-empted him, asking,

“Who are you?”

“I’m David Clark, the SHO.”

She opened a spiral bound note book and began to take notes.

“…before you go on doctor, can you tell me when you found the lump?”

“Well…soon after he came in, when he had the scan…”

“Wasn’t it on the x-ray he had on the day he came to casualty?”

“Well yes, but we, the doctors looking after him them, were concentrating on the infection, but now a scan proved it…”

“That was two weeks ago. I don’t understand why there has been a delay.”

David controlled himself. His plan, the careful steps he rehearsed in order to take the family along an explanatory path of diagnosis, treatment options, arrangements, support…had been blown to bits. Flustered, he continued. Everything was being written down. A phrase from the cop shows rattled in his head as tried to focus on the words, ‘…will be used against you in a court of law…

The day got busier. While he was inserting a urinary catheter he was fast bleeped to another ward. He couldn’t move, committed to the task that he had begun. He hurried it, didn’t do it quite as carefully as he normally would, anxious to leave the patient and rush to the emergency. When he got to the other ward a charge nurse informed him that he had no choice but to fill an incident form. Only the most junior member of the team had responded to the urgent call, and she hadn’t been able to deal with the emergency.

“But I was tied up, I couldn’t come…’

“I know doctor. But we have to do these forms. Otherwise nothing changes, does it…?’

He imagined his name in the text, the focus of culpability. In the Acute Medical Unit ward he received a call; the bed manager had been trying to find him. There was a patient on an outlying ward under his team’s care who had not been reviewed for four days. Although David was mired in emergency admissions by now (enjoying the rapid throughput of fresh cases, stimulated by the need to make fast decisions, arrange investigations and take responsibility for the treatment plans), he dragged himself away to visit the lost patient. She was very elderly, evidently succumbing to pneumonia on a background of heart disease. In fact the admitting team had done a very thorough job. They had spoken to the family, discussed resuscitation, introduced the idea of palliative care, but then…nothing. For four days. No doctors. The odd on-call visit to prescribe fluids, but nothing substantive. It shouldn’t happen, but it can and it does. And now her son was here, visibly upset. David introduced himself. The son retorted,

“I want an explanation!”

“I’m sorry, there must have been a mix up, and then over the weekend…”

“I don’t care. No-one has seen her, she’s been ignored. Who is this?” He pointed to the consultant’s name written in blue marker on the white sign above the bed, “Is he the consultant?”

“She. Yes she is. But your mother has only just come under her care.”

“No she hasn’t, that name has been up there every day. But you didn’t see her on Monday or Tuesday. It’s neglect. What chance she did have has been lost.”

“The nurses tell me she has been comfortable.”

“Yes, she has. But…

David entered the final hours of his difficult day. He made many accurate diagnoses and many good decisions. The consultant seemed happy with his clerking but David was down. He kept thinking back to the old lady’s son, his sharp words. ‘Wilful…’ ‘Ignored…’ ‘Neglected…’ David’s usual spark had been extinguished. His shift was over. As he walked into the doctors’ room to pick up his coat the bleep went off one last time. He called the number.

“Dr Clark. Hi, it’s Mary on Chestnut ward. Mr Threlfall, the man we put out a fast bleep for earlier, he’s died. No, it was expected, your registrar came to see him and made him not for resuscitation. It’s just, because of that incident form earlier, I’m going to send the notes on to the morbidity and mortality meeting for review. As a formality, you know.’

As he closed the door of the office behind him a colleague ran past him in the corridor; breathlessly he shouted,

“Crash call. Some guy who had a catheter inserted this morning, on Warfarin, he’s bleeding out…”

David opened his car door, sat heavily in the seat, and turned on the radio. —‘Police have confirmed a second criminal investigation into a potentially avoidable death in Mid Staffordshire, five years after…’— He turned it off, put his palms on the steering wheel and his forehead on the backs of his hands, and muttered, “I can’t do this anymore.”

oOo

David sat in his consultant’s office. She had locked the door and asked that they not to be disturbed. She had heard about his decision, and started by asking him to hear her out. Then she explored what it was that had made up his mind. He described his shift from hell. She said,

“I’ll tell you what I think. We’ve got to help you adapt to these…stresses. The scrutiny, the incident reporting…”

“You mean just ignore it?”

“In a way, yes. They should not dictate how you function as a doctor. Because they are more visible – after Mid Staffs, after the Francis Report – and because they have imposed themselves on you, you have come to react to them rather than the instincts that drew you into this vocation in the first place. They are important, yes, they are there to protect patients, yes, but from those doctors who might be harmful. You are not one of those doctors. You are good. You should be able to function without bring fearful of running into these electric fences and getting hurt all the time. From what I’ve seen of the way you practice medicine, you will find a path goes nowhere near the edges of reasonable, sensible practice.”

“Yet I seem to have run into those fences time and again. I described it to my girlfriend as living in a continuous rainstorm, where each raindrop is a new patient and a potential clinical incident or mistake that I must protect myself from. Usually I can, using my knowledge and experience, or luck, but sometimes one of those raindrop gets through, and explodes. And I never know which one it’s going to be…”

“What happens to patients isn’t always down to you or your decisions. Some get sick despite everything. You can’t necessarily stop that, so you can’t take the blame. Looking back, did you actually do anything wrong during that day on call?”

“I felt like I did. Incident forms, threats of ‘wilful negligence’! And the catheter. That was my fault.”

“Didn’t you hear? He had a bladder tumour, that’s why he bled! Forget that. And ‘wilful negligence’…please don’t be scared by that term. The relative who used it wasn’t criticising you, he didn’t know who you were. He was frustrated with the situation. Wouldn’t you be? That term, whatever it means, wasn’t designed to be applied to isolated mistakes.”

“But she was neglected.”

“Yes, by our system. And we’ve tried to close that gap. But not by you. You were never in danger. Did you really think you could go to jail? Really?”

“No. Yes. I don’t know. I just kept hearing it…”

“I know. And the incident form…well, they are important, and are used to alert us – the doctors who will be working here for years! – about what needs to be fixed. That wasn’t personal either.”

“I appreciate what you’re saying, I really do. But I can’t work in this atmosphere of…negativity.”

“But it’s just that. An atmosphere. We have to learn to breathe it without taking it personally, without a sense of suffocation..”

“So it’s my fault – this crisis. I’ve got it out of perspective?”

“A bit. That’s why we’re talking. I want to help you understand how a good doctor must accept that they will be subject to what seems like criticism now and again. You seem to be aware of your limitations. In fact you may be too aware, because you’ve grown nervous of them. The warnings and safety nets that have become so much more visible recently are not there to punish you. If you, as one of the great majority of trainee doctors who are good, intelligent and conscientious, are picked out and quoted in some incident form, or referred to anonymously in a mortality meeting, it’s more likely to be a reflection of how stressed the service is, or how fallible a particular system is. It’s not a judgment on you.”

“But if I am a good doctor why am I being reminded about these systems all the time? Threatened by them.”

“There is a temptation to use them as levers, to get you to see patients more urgently than you, as the doctor, might feel is appropriate. Remember, you are the doctor, your opinion is valuable .If you are asked to see someone who is deteriorating, you have the right, by virtue of your experience and understanding of clinical priorities, to decide how soon they should be seen. But if somebody else thinks they should be seen sooner, and they are able to wield a stick, it’s natural for them to do this to motivate you to hurry up. They want their patient seen first – that’s natural. But in doing so they ensure that you are driven by a negative motivation rather a positive one. You fear the situation rather than embrace it. And look where it has brought you.”

“So I just say no, sorry, I’ll come when I want to.”

“If you are juggling what appear to be equally important priorities, yes. But you must explain why, help the person you are talking to understand and, if possible, agree. And you must follow through, see that patient, hold your course, finish each task that you begin, and leave the ward confident that you have dealt with the problem in hand…”

“And when I get called away to see an even sicker patient…”

“Ask, build a picture, make your own mind up. Things don’t happen that fast. The sicker patient will have been deteriorating all night, they can usually wait another ten minutes. If they are arresting you will find out, there will be a crash call. It’s all about accommodating the continuous stream of emergencies, catching the raindrops, without being caught up and carried away in the flow. If you do you will become disorientated. You are the one who needs to keep calm, maintain perspective. It’s you they’re looking to for reassurance. Remember that David.”

“I hadn’t thought about it like that. I’ve just felt…so junior…all the time.”

“Junior in some ways, but senior in so many others…at three in the morning you are the most accessible doctor on the wards. First contact. It’s a massive responsibility. With that responsibility comes respect.”

“Really. I don’t feel it.”

“It comes.”

“If there was respect they wouldn’t have done an incident form.”

“No. You’re taking it the wrong way, personally. The incident form is irrelevant. It wasn’t a judgment on you, it was an observation that when a fast bleep was put out the doctor couldn’t come because he was doing something else. So what? If you can accept that now and again, purely by virtue of the fact that you see so many patients, you are bound to be involved in a complaint or an incident form, you will be able to work naturally, learn, and progress. If you can accept that you work within a network of continuous feedback, but without having your outlook obscured by it, you will achieve whatever you want to achieve.”

“You make it sound almost cosy. It isn’t. In the middle of the night I get shouted at if I don’t come. And relatives write down what I’m saying as though everything is a statement.”

“Well…so might you when you have a relative in hospital. Are you coming back to work next week?”

“ I haven’t decided.”

“That’s OK, take your time.”

______

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4 comments

  1. Great blog Phil.
    We will need to support our juniors especially, but also our senior colleagues. I had great support from consultants when I went through a period of self doubt years ago as a houseman.Still remember the comments made to me now-helped me to stay on track.
    Kind regards,
    Richard.

    Like

  2. It is very simple. Drs are not given enough time with the patients to practice what they know and what they could and should do. That is all that happened here.

    It is Russian roulette medicine based on probabilities and crossed fingers. Here is a case that was not missed not by one doctor but dozens who did not have time to take a proper history or examine the patient fully http://clinicalarts.blogspot.mx/2013/11/a-tragedy-of-time-limited-medicine.html

    The fault lies with the politicians, the administration, the beancounters and the system. They dictate the time doctors have to spend with patients and limit doctors from fulfilling their potential in objective patient care. They force doctors to play Russian roulette with patients’ lives and then it is the doctor who is liable and in the worst case scenarion above, criminally pursed the the police!

    No it is not the doctor’s fault. This is a societal criminal act against doctors and patient health and care.

    Like

  3. We’ve all been there. Or know someone who has.
    Great wisdom from the consultant – she sees the bigger picture, and how we as supposed professionals are just cogs in a wheel – given a different ‘illusion of autonomy’. But we have the power to – and should strive to – change the system

    Like

  4. Thanks so much for this. It has seriously made me reconsider my words when “chasing” doctors on the phone and asking them for things within the department. I suppose we all have our own responsibilities and our own agendas and it is hard to see the bigger picture, but I would be mortified to think that I had played a part in anyone feeling like you described, particularly when I know my medical colleagues work so hard in difficult conditions anyway.

    Like

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