Not in my name


A recent coroner’s report caught my attention (highlighted by HSJ’s Shaun Lintern via Twitter). A patient died from a ruptured aortic aneurysm, and during the investigation it was discovered that it had been seen on a CT scan four years earlier. However, the patient never came to hear of it, the GP was not informed, and no follow-up was arranged. The coroner now requires the Trust, through a letter to the Secretary of State for Health, to review its arrangements for flagging up ‘non- cancerous but significant and potentially life-threatening findings’ on scans.

The aspect that worried me was that the consultant, who had read the report and was intending to tell the patient in clinic 5 days later, never saw him. He was seen by a trainee, and the trainee either did not see the scan result or did not understand its significance. This made me think about clinical decisions being made in consultants’ names, but without consultants being aware of them. Does this really happen? Yes.

Consultants lead teams. In some clinics, 30 or 40, even 50 patients will be seen in a consultant’s name, but because the consultant is only able to see perhaps a third of those personally, the rest will be seen by trainees. Those trainees will have some specialist knowledge, but they may be three or four years out of med school. As trainees, they are supervised, but the level of supervision will vary.

During my training, I never saw a clinic where trainees discussed all of their patients with consultants. Rather, consultants relied on trainees to use their judgment and ask questions about challenging cases when they felt it was necessary. Then, as now, many patients were seen, investigated (and perhaps discharged) without the consultant having been directly involved in the decision. This is more common in bigger hospitals, where there are more trainees and larger clinics. It may sound alarming, but just as junior doctors see patients in the emergency department or on the wards, and make important decisions day after day, so they do in clinic too. (In fact, the terms ‘junior’ and ‘trainee’ sit uncomfortably with experienced professionals in their thirties.) Nevertheless, if a trainee misses the point entirely, or overlooks a subtle sign or important result, there is always the possibility that a dangerous conditions could slip through the net.

On the wards, every action and decision is made in a consultant’s name. I remember explaining to relatives, and on one occasion a coroner, why certain clinical decisions were taken by another – perhaps at night when I was not even in the building – but ‘in my name’. When pressed by both whether I thought those decisions were ‘right’, I had to pause. If it had been me on the ward at that time, I might have interpreted the information differently. I might have prescribed a different drug, or referred to another specialist sooner, but… it wasn’t me. It was a trainee, and they did what they thought was best. It wasn’t wrong, but it wasn’t necessarily, in retrospect, as right as it could have been. If there were errors in judgement, short of outright negligence or something amounting to an incident that requires reporting and the duty of candour, it will be dealt with through their educational supervisor. It would seem wrong to allow the full weight of responsibility to lie on the trainee’s shoulders. After all, I have to remember – a few years ago, that trainee could have been me.

So what is the consultant’s responsibility here? Are they truly responsible for the patient’s outcome, even though certain important decisions are not in their control.

Well someone has to be responsible. Consultants stay in one hospital for a whole career (usually), while trainees move on. In the case of the missed aneurysm there was a delay of four years before the error was noted. The trainee who may or may not have seen the result, or who failed to chase up the results of the scan, would have moved on. They are out of the frame. It was the consultant who had to explain what happened to the coroner. In that case, ‘the system’ took the blame (the way in which x-rays were reported and flagged). This is often the case, and in a blame-free culture that encourages reporting of error, it often has to be the case.

The system is often inefficient. The system may have intrinsic gaps which are unsafe. As doctors, we complain about the system all the time, but perhaps this is where our responsibility truly lies. To be open to the possibility that the system we are working is imperfect, and to accept of our role in improving it. That is why consultants must also be continual improvers of quality. It is not enough to moan. If weak areas are identified, we must engage in strengthening them. If we find gaps, we must close them. We must complain, escalate, and help to fix. That is the quality that should be scrutinized, rather than the (superhuman) ability to detect and personally manage every patient who passes through our service.



Curators of compassion

e_radiation_01bb_bm-copy_905Mechanical medic, by Ben Mauro (concept art for the film Elysium)



“When I was hospitalized for multiple cancer surgeries, it was my #nurses who provided the compassion many of my doctors lacked.” – a Tweet I saw this week.


Why is this? Do doctors not care?


The question was brought into focus by two things recently. A nurse consultant reminded me, after a talk I had given on the difficulties in finding time to understand the personal histories of alcohol dependent patients, that it’s not all about the doctors. Their job, if they are personally unable to sit down and explore what makes people tick, is to ensure that others do. They need to manage the service such that qualified and skilled people are around, like specialist nurses. This seems self-evident, but it reveals a truth. Doctors, especially consultants, are not necessarily best placed to act as the conduit of compassion or understanding. They are there to make the right medical decisions, to prioritise aspects of care (according to the patient’s needs and goals, obviously), and to help keep the whole team functioning. But, frequently, it is not they who are the face of kindness.


The second reminder I had was a very lovely thank you letter from a patient who needed an operation, and who was in pain every day, but did not tick the usual boxes for jumping up the waiting list. I helped to nudge and negotiate the bureaucracy such that her operation was brought forward, although it was by no means a single handed effort. Once on the ward I barely saw her. Her daily struggles were dealt with by trainees and nurses. Yet, when it was all done and she felt better, she wrote to me praising the whole team for our caring attitude. Some of this warmth reflected onto me, as the senior clinician. Yet I know I did not have the opportunity to show compassion, personally. All I did was organise stuff. That contributed to the positive outcome, and the perception of compassion.


As a consultant, you must get used to not being on the ward to demonstrate those human qualities that helped drive you to become a doctor in the first place. Depending on the job structure, you might go round the wards every day for a week, and have the opportunity to develop a rapport with patients. But then, when connections has been established, you disappear, into the land of clinics or other duties. The patients, who grew to know you and recognise your face, must now establish new connections. Or, you may do ward rounds in a more old fashioned model, making executive decisions, giving direction to the team, but only twice a week (a vanishing arrangement!). In that model your window for demonstrating compassion is very brief. You might try to pack all of your caring and empathic instincts into an interview with the patient, trying to achieve a good understanding of what needs to be done (especially important, say, a dying patient), but then… you are gone. You delegate the implementation and ongoing communication of the plan to the team. If there are problems, they will negotiate the hurdles and come back to you if they are insurmountable. That is delegation, a necessary art.


You may go off to do some other things, of no less value – perhaps administrative, managerial, educational or academic, but not ‘patient-facing’. Overall, that non-clinical work will contribute to better care, perhaps even a more compassionate system (the result say, of making a business case for more trainees), but it must be accepted that seniority is likely, over time, to reduce your role as a direct conduit of compassion.


So, if patients being discharged reflect that they ‘barely ever saw’ their consultant, it is worth remembering that their care was supervised and overseen by them, and that the (haughty? – never) individual who floated through the ward once or twice was once, possibly, quite good at sitting by the bedside and making the time to understand. Possibly.




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ABCDE…X – hierarchy and lost opportunities

The accumulated knowledge within a typical medical ‘firm’ is great, but the way a typical firm functions may not allow much of that knowledge to see the light of day. If all the decisions made by that peculiar monster originate from its ‘head’  – the consultant – opportunities can be lost.

The situations described below are based on examples that I have observed or been part of. The contrast between them serves as a lesson.

I have described the symptoms and signs in generic terms such as A, B and C, with a diagnosis X, because I do not wish to describe the specifics. The educational value of the piece might be greater if I had stuck to reality, but in this case I wished to avoid giving medical details.


The patient presented on day 1 with symptom A. The admitting doctors didn’t have a clue what the diagnosis was. The patient was transferred to my ward. I saw her on day 2, and an investigation showed abnormality B. A and B did not connect in my mind – the diagnosis was still not clear. I dictated a broad differential diagnosis centred on common and not so common conditions, and I gave instructions that various investigations should be arranged to narrow it down. Time was short; we moved on.

On day 3 I was told that the patient was reporting symptom C, and that the patient was worse. I went to see her, and detected sign D.

A, B, C and D. It still didn’t make sense. A strange collection of symptoms, signs and findings. The Foundation Year doctor I was with looked worried, because the family had been asking why their mother was not improving. The SHO came onto the ward. I asked about the results of the investigations that had been requested, and rather embarrassedly the two trainees told me that only three of them had been completed. Others were ‘in the system’.

We had a conversation about how to prioritise tests and persuade radiologists…we talked about getting the most out of the system. We didn’t talk about the patient. The differential diagnosis remained unmodified. The juniors set off to do their best.

On day 4 I saw her again. She had deteriorated further. We waited for some more results. Overnight she was seen by the on-call team, as she had suddenly begun to display a florid example of sign E. The new, crucial development completed the picture and led to a new diagnosis. A specialist opinion was requested first thing, and when I saw that specialist in the corridor during the day she told me about the ‘classic features’ of disease X. But it was probably too late now. The patient was on the way to intensive care.

I looked up disease X on the computer and saw how, in this condition that I had not personally encountered before (but one I had read about during my studied) symptom A – accompanied by abnormality B – proceeds to symptom C, followed a day or two later by sign D, and in latter stages evolves into sign E… by which time the disease has often progressed too far to be salvaged.

Another day, another way…

The patient presented with symptom A. The admitting team did not know what cause was, but they had a few ideas. On the next ward round an abnormality in laboratory parameter B was noted, but it still didn’t add up to anything in particular. Various tests were requested, and a referral made to specialist M (mainly because they were used to seeing patients with multi-system, i.e. frequently baffling, disorders).

The patient did not do well on the initial treatment regimen, and on day 3 was seen again by the consultant. This time the patient described symptom C. The junior doctors stood at the end of the bed looking worried, still uncomfortable when faced with deteriorating patients due to unexplained disease. Time was pressing, there are many more patients to see. Further investigations came to mind, but they were not guided by an idea. It was diagnosis by ‘shotgun’  – multiple simultaneous tests arranged in the hope that one of them hit something.

The consultant worried that he didn’t know what was going on, but reassured himself that all of the sensible things were being done. The team moved away from the bed. Then the consultant turned around, and took them to one side.

“What do you think?” he asked of them.

“What do you mean?”

“Well what do you make of these symptoms, these abnormalities. Do they ring any bells with you?”

“Er…not really.”

“Well have you seen a patient with anything like this before? Anything similar? Anything!?”

“A couple, but nothing that really looks like this. There was one case…”

“Tell me about it!”

“He didn’t behave like this. The patient was much younger. But they went on to develop symptom E, and I remember they went to intensive care. I was a student then. It was, I can’t remember the diagnosis, something to do with…system Y.”

The consultant paused. That category of disease had not crossed his mind. Could it be that? Could it be?

He went to the computer. A bell began to ring faintly in his mind. Something from the early days of his training. He googled (everbody does) the system mentioned, and added symptom A. He clicked on a link to Pubmed. And there it was. Disease X, a severe manifestation of system Y dysfunction. It starts with symptom A, is associated with abnormalities in parameter B, often leads to symptom C, usually progresses to display sign D, and at that stage you have to give treatment Z before sign E kicks in. Could it be that?

“Let’s get the specialist. It’s a small chance, but if it is that she needs treatment today.”


On the face of it these examples demonstrate something simple. If you spend time reflecting on a difficult diagnosis and keep an open mind to new data you might happen upon something that pushes you in the right direction. Don’t commit yourself to the initial plan, don’t be wedded to the first thought. That’s just good medicine.

But there is also a lesson about leadership on the ward.

As one progresses through a medical career one’s breadth of view contracts. Most hospital consultants are also specialists in something, and the demands of the specialty can leave little room for refreshing one’s knowledge of the rare and exotic. However,  the temptation to allow the consultant to embody the entire experience and expertise of the team is great. Junior doctors are meek, especially early on in the training, and will not readily challenge the differential diagnoses or management plans put forward by the consultant. Often (always!) they will be having independent thoughts as to what might be going on with the patient, but only a proportion of those thoughts will be voiced. Bits of knowledge, recollections, ringing bells from their own experience are ignored or put to one side as the momentum of the consultant’s diagnosis generating, management planning juggernaut rolls on. If they are clearly in a hurry, they are even less likely to be slowed down or interrupted by a trainee.

Sometimes the hierarchy needs to be flattened, albeit temporarily, to allow the views of each team member to be aired and enlarged upon. It’s not a revolutionary concept, but in hospital medicine, which remains hierarchical by virtue of the need to remain highly efficient in a continuously pressurised environment, the luxury of slowing down and allowing new ideas to germinate can be lost.


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Interactive Ward Ethics 3: Obedient

Having survived the challenges presented to her in Collusion and Dangerous, Nina must now negotiate her way through another nightmare week, in Obedient. Here she finds herself questioning a consultant’s decision to set limits of care on a young patient with a life threatening problem. What should she do – obey, question, or seek alternative opinions? Each choice has its risks….and who is to say that she is right and her consultant is wrong?

As usual, you make the choices in this interactive blog. You can move backwards with the back arrow to escape from any cul-de-sacs. In the Summing Up, I explore the various issues faced by trainees in the still somewhat (necessarily?) hierarchical world of hospital medicine.

Click here to enter Obedient!




Leadership – the immediacy of example

Leadership, I am sure, takes many forms, but explicit exposure to the theories and approaches that might have helped develop doctors of my generation was lacking. The leadership that I was conscious of, as a trainee, was the example set by my seniors. Thus, as a consultant myself, the most direct route to leadership that I have identified is the example I give. This may be one-dimensional, and I hope that over the years other ways will reveal themselves.

The trouble with leading by example is that we are, as fallible people, inconsistent. In medicine inconsistency is risky. After several years on the wards it is possible to recognise how the example one sets can translate, directly, into the care that is delivered. In this post I try to relate how that translation can occur with a short account. It is not a sophisticated scenario, but one that shows how healthcare, more than other profession perhaps, can excel or fail due to the behaviour and attitudes of those in charge.


A busy ward round – Monday. The consultant, Dr Blackburn, paces himself. He intends to see all the patients, but there are a handful whom he especially needs to ‘get my head round’. They are complex and potentially unstable. It will take an hour and a half to achieve that aim, and in the remaining two and half hours the spectrum of acuity and severity that he meets will be wide. Some of the patients will be medically fit, just waiting for a package of care. He tends, not unreasonably, to see them at the end of the round. But he will see them. They are his patients.

At twenty to one he looks down the list. There are still four patients to see. He has a regular meeting at one o’clock. He was late for it last time, and does not want to be late again. He asks for a précis of the patients’ problems, and they are pretty much stable. One was admitted overnight, but the word is that they failed an occupational therapy assessment at the front door, and if not for that they would have been discharged immediately. ‘Could you take a quick look?’ he asks his registrar, Emma. ‘Let me know if there are any real issues…medical issues.’ He leaves the team. In truth, he left them half an hour ago. His attention began to slip, he began to ask the same question twice. The intellectual meat of the morning had been chewed and digested hours ago. He was now using reserves of enthusiasm that only professionalism drove him to access. But the team has done well. The week should proceed safely enough, now that they have the measure of their charges.

Emma and the rest of the team need to eat. She will see the new patient later, as promised. Did she promise? Well, she was asked and did not say no. That’s the way it works. She has a clinic though, and it does not go as smoothly as she had hoped it would. At 4.50PM she bleeps the FY1, Luke, and asks him to make sure the new patient has been reviewed. He speaks his mind, does Luke, and he is just coming to terms with the requirements of the job – that is the ability to accommodate last minute requests and fit them into the sequence of the day. His job feels truly Sisyphean. Just as he is beginning to feel that he is getting on top of his list of tasks, another is added. ‘I thought you…’ he stops himself. ‘OK, but if there’s a problem, what should I hand over, the lumbar puncture or the new patient.’ Emma replies quickly, ‘Neither. But make sure the LP is done, please, that’s crucial.’

Luke circles the name of the new patient at the bottom of his list. But he concentrates on the LP. He’s done several, but cannot undertake them unsupervised. Emma would have looked on, but she remains tied up in clinic. His second option, Lucy, an experienced SHO on another firm, offered her time after lunch, but she is probably getting ready to go by now. He sees her, and sighs in relief when she makes the offer again. By 6.30PM they have done it. The samples are on their way. His day is almost over. Except for the new patient review.

A review. Just a review. But a new patient. That’s the catch. To do it properly requires a ‘from scratch’ assessment of the presenting complaint and past medical history, and a physical examination. It’s a 30 minute job, at least. He wants to do it. No, he wants to have done it. But now, at a quarter to seven, the task’s magnitude has become inflated. What if it’s complicated? What if the drug chart needs re-writing? It is unlikely. No-one has bleeped him about her during the afternoon. They must be truly stable – off legs at worst. Isn’t that what they said on the ward round? – failed OT assessment, no ‘medical’ issues. Dr Blackburn wasn’t interested. Luke recalled his far-away gaze, the evident lack of enthusiasm, ‘Let me know…’ he said, ‘if there are any real issues…’ Even consultants, with all their knowledge and experience, cannot achieve 100% of their work. Luke decides to take it on trust. The chances of that patient coming to mischief are minimal. Luke is not going to cut himself up about this one lapse. He’s done so much today.

At three in the morning the on-call FY1 is called to see the patient. She finds him confused and septic, with clear signs of pneumonia. She is surprised such basic diagnosis could have been missed, and puts the fact that his chest x-ray and his blood tests have not been scrutinised down to the circumstances – the decision to admit was made late in the evening, and they must have been arranged just before he went to the ward. But she would have thought the results of those investigations (which include grossly elevated inflammatory markers) would have been seen on the ward round that day. Strange, she was sure Dr Blackburn himself went round on Mondays.