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]