Month: July 2015

Phoning it in

phoning it in

All this talk of 24/7 working set me thinking about the strange arrangement we have in medicine – that of being on-call from home. It makes sense for senior doctors to be contactable and available to come in if needed, but so much of medicine relies on the visual, tactile and overall impression gained by being with patients, it is questionable how valid those ‘over the phone’ decisions are. It is generally accepted that the NHS cannot afford to have consultants on site 24 hours a day, as that would require massive recruitment and investment, so the model of giving advice over the phone will remain for the foreseeable future. Is it safe? Is it useful? Or is it just a form of reassurance to the person making the call?

As a trainee I tried not to call consultants too often. To make the call seemed to me a kind of failure. This was not just a case of exaggerated pride, but the result of a realisation over time that whenever I asked a question, the answer I got seemed obvious! I just had to be led to it, and I soon learned to lead myself to the answer without touching base. That’s how you learn medicine.

Some questions were ethical rather than technical, and the reason I asked was because I didn’t feel I had the authority to make the big call. It might be a decision not to escalate care in a young patient with severe comorbidities, or a tricky resuscitation judgment. I would describe the case, give the details, and often the answer would be, ‘Well, Phil, you’re there and you can see what she looks like, and based on what you say the plan sounds very reasonable.’ Sometimes the consultant would say, ‘Do you want me to come in and eyeball him?’ To which I would say no, I’ve got it covered, I’m happy. Rarely, never in fact, did the consultant say, ‘Actually, I’m not sure about that, have you thought about this…. No, don’t do that, do this… I’m glad you called, you’re clearly out of your depth…’ But I felt better, and I was able to write in the notes ‘discussed with Dr-‘ It had the stamp of seniority, and it was defensible, even though the decision depended entirely on information and interpretations that I had provided.

Now, as a consultant, I take those calls. I feel uncomfortable with them. They are big decisions and they have to be made with data and impressions that may or may not be trustworthy. The safety of over the phone consultations relies on the consultant’s ability to glimpse the holes in the narrative and sense the anomalies. If it doesn’t sound quite right you must press the caller for more details, and send them back to the patient for more data if necessary. Sometimes the caller will not have reached far enough into their own stores of experience or deductive logic. Patiently, kindly (more difficult at three in the morning) you might say, ‘OK, so what do you think that result means? Yes, precisely, so given that, what do you think you should do next? Yes, exactly, get a scan, then let me know the result…’ That’s fine, it serves to teach the caller, who, if at all typical, will have turned the decision to call over and over in their mind before picking up the phone and shattering the consultant’s sleep cycle.

Readers of a non-hierarchical nature may be astounded that there can be any block at all to trainees calling up their consultants. It goes against all sense of patient-centred care. However, if a senior opinion is available but not present, it is natural to hesitate. The junior colleague wants to own the problems they are presented with to as great a degree as possible. In running the shop on their own they learn how to shoulder responsibility, manage, delegate and lead. Registrars and Specialist Trainees are, after all, experienced doctors in their own right. The long and burdensome nights are important steps, as long as there is no dithering over important decisions in life threatening situations. Safety trumps all other considerations, and the criticism for not calling is more acute than that for having too low a threshold. The irony is that those time critical, life threatening scenarios are not well suited to consultants with sleep-jaded faculties giving advice in the darkness of their spare bedroom, advice based on detached information and breathless descriptions delivered from the hubbub of the resuscitation bay. Better, surely, for consultants to be there all the time. What am I saying? Is that what I want? No, but the (controversial) mortality data currently feeding the 7 day working debate will surely be applied, in time, to the day-night discrepancy.

Very few specialties provide 24 hour in-house consultant cover, though larger centres have built rotas to sustain just that in selected areas (there is lots of local variation). This article in BMJ careers describes the pros and cons of a 24 hour paediatric service at the Royal Free Hospital. To maintain the rota 15 consultants are employed, but as it says, the cost can probably be justified over time. Of course, consultants elsewhere are poised to attend in order to perform specific tasks, like emergency surgery, interventional radiology, coronary angioplasty or endoscopy. But before coming in they must decide if the case meets the criteria required to justify an out-of-hours procedure. Sometimes it’s obvious (heart attack, ruptured aneurysm), sometimes it’s clearly not necessary (the 19 year old who has binged on ten pints and throws up a little bit of blood), but sometimes the information provided is not enough. You have to see the patient, feel their skin, meet the relatives and hear the story recounted first hand.

A less visible factor, and one that is harder to explain, is the effect on other patients. Most on-call arrangements require the consultant to do a full day’s work after the night in question. For the patient being seen in clinic at 5PM following a complex emergency procedure or assessment at 2AM, that’s not so great. So consultants need to ration themselves a little. That might explain why some are less warm on the phone than others.

The skill of being on call is knowing when you can safely stay away, and when you must attend. It is a skill in itself, but one for which there is little training. It’s a skill that will be needed by most consultants for a long time to come. However strange the system may seem to patients, it seems to work just fine most of the time.

 

[Here is a recent discussion thread on the subject in BMJ Forums]

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A final act

This post is about the difference between responsibility and accountability. If you are a doctor it is likely that at some point you will be asked to attend the coroner’s court. It is a nerve-wracking and intimidating experience. The relatives of the deceased patient may be just a couple of metres away from you. Sometimes there are reporters from local newspapers. You may take the stand as the patient’s consultant or GP, even if you were not present when certain actions and omissions occurred. You will explain your own thought processes, the ways of the system, and you will defend, to an extent, what went on. You may even have to explain the actions of others. The inquest is an exercise in information gathering, its aim is to allow a confident judgment as to the cause of death. It is not primarily about blame, but the penetrating questions and forensic approach may make it feel that way. The coroner may be hard on you, and their conclusions may be harsh.

You will be asked to go because you were responsible for the patient. That sense of responsibility is something you have to learn to live with as a senior doctor. But a visit to the coroner’s reinforces how heavy the burden of responsibility can be. How can you carry on with life outside the hospital if responsibility continues even after you leave the building? How can you ever relax?

One way to deal with it is to understand that responsibility does not equal accountability. What’s the difference? The two words are largely synonymous, but the difference probably revolves around the place of blame and the likelihood of being asked to pay a penalty. A doctor can function if they accept that they are responsible, in charge, directing the therapeutic strategy… but not if they are fearful that the blame for success or failure (assuming that treatment is undertaken in good faith and with appropriate expertise) will arrive at their door. And not if all actions taken in their name, as the consultant whose name is ‘over the end of the bed’ are attributed to them.

There is a balance, certainly. One cannot take on a senior position in any organisation or service and be entirely immune to blame, but fear of blame cannot infect every interaction. Yet, for all the personal indemnity that working in the NHS offers, you will still feel vulnerable as the doctor in the spotlight.

The four paragraphs above seem to lead nowhere; the sentences circle back to the state of mind of the poor, overburdened doctor… because they are written from the point of view of the doctor. Perhaps this is the error. Thinking in this way, there appears no escape from the blinding storm of pressure. It is not possible to compartmentalise the burden of responsibility unless another approach is adopted.

The lesson I learned from my day at the coroner’s court is that the need for a named, responsible person as a focus if inquiry is incontrovertible, because relatives of the dead have a right to answers and the record must show how or why people died. If not you – as consultant (or GP) in charge – who else will provide those answers? That is the responsibility, to stand up and explain events that would otherwise remain opaque. However, you cannot expect to be blamed for everything that happened in a complex system that is the hospital. Blame, if apportioned, will be directed at the organisation for which you work. So, bruised and sensitised by the experience, I came out of it is realising that it wasn’t about me. It was about the patient and those who have been left behind. I was a source of information, and had to be professional enough to give a clear narrative without becoming personally defensive. It was the least I could do.

Doctors will have to attend inquests at least once during their careers unless they are extraordinarily lucky or working in a specialty that does not take in patients who are at risk of dying. Surgeons, general physicians, GPs, they will probably find themselves standing up and taking responsibility at some point. Handling the hard questions is a role that must be played in the final, posthumous act of their patients’ lives.

The guiding hand

guiding hand1

M.C. Escher – Hand with reflecting sphere

 

It’s a common enough feeling but one that is rarely expressed. This patient did express it – or at least her husband did for her.

The patient had undergone multiple investigations and several procedures during three stays in hospital. Her GP had referred her for a review on account of weight loss and worsening debility in the hope that something could be done to improve her condition. Her anxious family described how she had gone downhill despite all that had been done. I nodded, unsurprised. That’s what illness, infection and hospitalisation do. Then her husband said,

“And during all this time, nobody has really treated her as a whole person.”

I paused. Rather than letting the comment slip by I asked him what he meant by that. Because everything that happened seemed logical and correct to me. Her condition has been a serious one, but the underlying pathology had been recognised and treated. Nature had determined that during this time energy was drained from her. It was not a result of neglect or mismanagement. But I knew what he was getting at. Her course had been punctuated by episodes of acute deterioration, and procedures had been done on an urgent basis. Several consultants had been involved, several teams, comprising what, twenty doctors? Onward plans had been made as she was discharged from each episode. Her general practitioner, kept up to date with cryptic discharge summaries, had observed with a careful but non-interventional eye.

I told them the story of her illness, as I understood it. A nine month saga. To catch up, to provide a sense of continuity in respect of the whole person, required careful explanation. As I explained what had led to what and why, the patient’s expression lightened and reminded me of the pupil who suddenly begins to understand a principle of mathematics or chemistry. It all began to make sense.

She left the room looking and sounding better. I had done nothing physically significant.

The reason I asked – or challenged – her husband as to what he meant about a ‘whole person’ was because I thought her treatment had been good. It was thorough, timely and appropriate. Yet for some reason it has not been satisfactory. True, she was not as well as she or her family expected her to be at this point, but the future was bound to see a gradual improvement. What more could have been done?

It struck me that what this patient and her family needed was not a minute assessment of each symptom, nor more frequent clinical reviews, but a degree of confidence that there was a guiding hand behind the arrangements that had been made. She felt like a pinball, shunted this way and that by unplanned events and opaque decisions. I knew, having read the correspondence with a better understanding of why each step had been taken, that there was a sensible guiding hand. Yet that hand was invisible to the patient, despite the name of the primary consultant being clearly visible on documents and procedure notes. The presence of a central pivot and controlling mind had not been made manifest through clear and measured communication.

What she actually needed, I concluded, was a more confident perception of where she and her body stood in the natural history of the disease that had afflicted her. If she could visualise better how her symptoms related to the diagnosis on her papers, she would feel less of a wanderer in the unfamiliar territory of illness.

Is it a luxury, to be told in plain terms what is going on? It would seem so, judging by the number of patients who appear bewildered in the maelstrom of events. I can understand why it happens. For doctors dealing with rapidly developing conditions or emergency situations the priorities are clear – make a diagnosis, make a decision, and treat. It is medically correct. Then, when the treatment has been completed and the anticipated response has been confirmed, the pressure is off. This would be the time to sit down and describe what has happened. But this recap often does not take place. New and more pressing cases have arrived in the hospital. Sometimes it is the most junior member of team who is left to tell the story and they may not understand all of its elements. They will certainly be unsure how to frame the future. The patient is discharged ‘better’, safe, but relatively disorientated.

So, my conclusion from this reflection is that a ‘holistic’ approach to medicine is actually quite easy to deliver. It does not require the specialist to delve into every symptom or system outside their comfort zones. It does not require them to be the patient’s GP (specialists are notoriously quick to deflect non-specialised problems back to primary care without so much as hearing patients out). It may be enough just to explain what is happening and why, where the patient sits in the network of involved teams and processes, and how the guiding hand that is rarely visible does actually exist. This hand is not omnipresent or dedicated solely to one patient. It does not promise to sense and respond to every little change. The guiding hand must make decisions and then pull away for a while to get on with other tasks. While it is away the patient may need to guide themselves. This is possible, but only if patients have a clear perception of where they stand in the story of their illness.

 

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