The apprenticeship and training

Junior / Senior

 

Trainee doctors tend to know more about patients than their consultants, though consultants, by virtue of experience, usually know better how to treat them.  Sometimes however, a peripherally involved consultant will parachute in and give an august opinion, but without adequate knowledge of the person or the problem. For instance, in my field, the insertion of a feeding tube to bypass a blockage in the gut, when a few more questions on the ward round would have revealed that the patient had three similar tubes in the past, each of which was pulled out due to intolerance or discomfort. The plan is sound, but will not work for the patient in question.

Consultants grow increasingly didactic over time, a characteristic deserving of its own article. The daily process of absorbing information and providing timely, confidently articulated answers, can lead to decisions based on pattern recognition, and without sufficient focus being paid to all the variables. As a trainee, the challenge is to receive such answers, but to adapt them to the specifics of the patient. Taking the consultant’s opinion at face value, and acting on it straight away, may not be the best thing to do.

When I was a fairly experienced trainee (medical registrar), my strategies for ‘pausing’ before converting instructions into action, included:

 

The deflection – ‘That is one option… but I was reading the other day about ______ procedure… do you think that might be better in this situation?’

The prevarication – ‘Right, yes… shall we see how they do on the current treatment, and review again in three days?’

The bureaucratic delay – ‘…there’s an MDT next Thursday, shall we discuss it then…’

The memory slip (high risk, AKA disobedience) – ‘Sorry, we didn’t get around to requesting that scan… do you think they still need it…’

The second opinion – ‘Dr _____ came around, and said she’d seen this before, and we should do x, y and z… is that alright?’

The direct challenge (for senior-senior trainees only) – ‘Actually I’m not sure that would work for this patient, given her underlying x, y and z…’, or, ‘I don’t think he would want that, his wife was saying just the other day that he’s decided not to…’

 

In fact, all of these are high risk approaches, because when the consultant returns two or three days later and the task has not been pursued, and assuming they remember what they asked for, there could be hell to pay. They are also high risk because they are based on the assumption that the trainee knows best. This is unlikely. But it gets to the essence of the (senior) trainee’s role, that of a coordinator of care, a hub into which results and opinions flow, to be assessed in the light of day-to-day changes that they are best placed to observe. It is not arrogance to presume to challenge a consultant’s opinion, but a necessary part of maturing as a doctor. Don’t accept anything without a critical appraisal of its value. Don’t assume an opinion is right unless it makes sense within the scheme of things. This position is a precarious one, as over-confidence or lack of skill in communication can make you look disrespectful.

So much for trainees. What about consultants? Overnight, you transform from ‘junior’ to ‘boss’. During the early post-transition period you may remain sensitive to the nuances of each patient’s illness. But over time, as you are pulled away from the details and learn to trust your team to micro-manage the bloods and the drugs, the day may come when you formulate and describe a great plan, only for the most senior trainee to pause, look at you quizzically, and say, ‘Yes… that is one option…’

 

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Dodging shadows: the mysterious art of detachment

 

I watched a patient die before Christmas. He was surrounded by the full crash team, which nowadays is a fairly large group. As the attempt was abandoned, and another consultant ‘called it’, I withdrew into the background. There was nothing I could do to help. I walked away to prepare my departure for the week-long break (lucky me, most doctors don’t get that), and couldn’t help but think about him. His death. I wondered how it would affect me as I arrived home. The family were looking forward to seeing me, my return would mark the beginning of the ‘real’ holiday. I wanted to enter the house with a light spirit and smile. Yet, the image barely fading on my retina, and still vivid in my visual memory, was of a dead man.

How to separate the intensity of that memory from life outside the hospital? Detachment. That is the word, the process. An ability to cut the lines of emotion that stretch from the wards though the sliding doors, along the train track or the A-Road or the cycle lane, thin but tenacious like the silk spun by a giant spider of Middle Earth. Pull as hard as you like, they don’t snap. Yet, to avoid darkening our homes, they do need to be cut.

Detachment. This process has received a bad press recently. The surgeon who burned his initials onto a living liver was defended by Henry Marsh, who used ‘detachment’ as a justification. Detachment can impede our ability to sympathise and to emphathise. In this example, it permitted transformation of a patient in an object to be signed. Any detachment we achieve on leaving the hospital or the surgery, has to be reversed when we re-enter the building.

So perhaps it’s not detachment that is required. Perhaps it is management, of bad or upsetting memories. By this I mean the ability to live with them. Compartmentalisation. Reduction. Or temporary blindness. A method by which negative emotion can be pushed to the margins of our minds, while the lives of others who have no knowledge of the patients, and therefore cannot truly ‘care’ except in an abstract sense, proceed uninterrupted. Silence is one option. Yet this requires the healthcare worker to conceal his or her thoughts and behave normally. This means acting, and the dissonance between inner reflections and external actions could, in time, be harmful. I have no reliable answer. My own method, as readers of this blog will know, is to turn a thing over, look at it from several angles, and process it through words. That doesn’t work for everyone (there would be far too many blogs!).

My final answer is this: doctors and nurses will always bring the memory of death into the home. To leave it on the street is unrealistic. To bury it is harmful. To talk about it incessantly is unfair on those we live with. The only other option, perhaps, is to develop a special facility – to carry the emotional load with as much sadness and respect as death deserves, while simultaneously accepting that the lives lost do not intersect with those who are close to us. The sadness is of a different quality, with a translucence and impermanence that alters us but cannot rob us of normal social reflexes, or the ability to enjoy ourselves.

 

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Reputations: the light and the dark

‘Light in the darkness’ by Pat Cegan

 

A recent thread on Twitter brought up a subject that is really spoken about. Elin Roddy kicked it off with a comment that patients admitted to nursing homes should routinely be engaged in conversation about their preferences towards end of life. With habitual frankness, she later commented that there is a danger that those working in hospitals who are more willing and able to do this, run the risk of gaining a ‘reputation’. Others confirmed that they had indeed become known in their Trusts as being prepared to discuss resuscitation and sign DNACPR forms.

This is something that has bothered me for a long time, being one of the self-acclaimed “willing”. What if a doctor acquires a reputation as being comfortable with the fact that their patients might die? Might that realism be construed as nihilism? Might they come to be regarded less as a saver of life, but rather an usher into the next? Uncomfortable!

Doctors lie on a spectrum. Some cannot bring themselves to consider the possibility of death, and continue to propose active treatment even when the patient does not seem to be responding. Others readily identify signs and symptoms indicating that life expectancy is limited, and are prompted to initiate a (sometimes) difficult discussion about end of life care. Some move across different points on the spectrum, but it is quite possible that they feel at home near one end or other.

If a doctor actively seeks the signs of imminent dying in the belief that they will save patients the burden of futile treatment, there is a theoretical danger that they will fail to recognise opportunities for saving them. A doctor on the other end of the spectrum may identify ‘survivors’, and during their career may be credited with helping to save patients that others would have ‘given up’ on. However, in doing so they will probably push more patients through periods of aggressive and ultimately futile treatment. How many ‘failures’ it takes to justify one ‘success’? This sounds like an overly cold and impersonal way of looking at things, but it is a justifiable metric. In my recent paper on DNACPR decisions, I cited a study by Paniagua et al, who found that ‘29 octogenarian patients with cardiac arrest have to be treated with CPR to net one long-term survivor’. That ratio doesn’t look good.

As a patient, do you want your doctor to be the one who looks for any chance to cure, or who accepts that death is sometimes inevitable and changes their approach swiftly if things are not going well?

Of course, it all depends on clinical context, and on your wishes. However, in the 8th and 9th decades, when physical frailty is significant, comorbidities sometimes numerous, and mental capacity variable, the assessment very much depends on the doctor’s perception. Their instinctive position on the aforementioned spectrum may make a big difference.

They may be influenced by the type of patients they tend to see; their case-mix. A palliative care doctor will spend his or her days looking out for signs of terminal deterioration, and (almost by definition) will not be looking for opportunities to commence heroic new treatments. The elderly care physician will try to balance the burden of curative or preventative treatment against the realistic benefits. In my specialty, hepatology, I see patients in their third and fourth decade who look as though they are going to die in the next week or two (usually from multiple organ failure as a complication of cirrhosis). But, being young, they might pull through if we keep supporting them in the ICU. The reward, survival, seems to justify any cost – long weeks in ICU, months convalescing. But the price (not mine, the patient’s) to pay for failing to recognize that organ support is not working, and carrying on with fingers crossed just in case there’s a ‘turnaround’, is a prolonged death attached to multiple life-support machines.

Negotiating optimism and pessimism in these situations is difficult, and as I described in a recent case report, fluctuations in clinical condition that result in changes of tack on the part of the medical team can result in what looks, in retrospect, like vacillation. This goes to show that few of us are comfortable in diagnosing dying, and, especially in younger patients, will always choose life-prolonging/saving treatment if there is a chance, however small, that it will work.

There are other, perhaps less noble, drivers to continuing with aggressive treatment in the face of apparent futility. Perhaps a patient’s management is being led by another consultant or team, and it does not feel right or comfortable challenging their decision. Perhaps the underlying disease is well outside my expertise, and I do not feel confident commenting on the likely disease trajectory. Perhaps the team treating a patient are known to be therapeutically aggressive, and are bound to take suggestions that they should rationalize treatment badly. Perhaps I have seen too many patients die recently, and just want a good news story…

In my view, as a doctor who is generally comfortable and accustomed to recognizing futility, we must be careful not to lose the ability to see glimmers of hope, even if those glimmers are not apparent until the murky surface presented by illness is scratched away by a period of active, optimistic treatment. As long as we are able to admit defeat when things are going wrong, and brave enough to explain that to our patients or their families, it seems reasonable to sit on the optimistic end of the spectrum most of the time.

In this way we might witness recovery against the odds, feel good about, and use those cases to motivate and enthuse our teams. At the same time, there is no harm in being known as a realist who can identify the signs futility when they begin to accumulate, and who is willing to change direction even if that means pushing against the prevailing wind.

***

 

In my day

Reading about the situation at Derriford hospital, where two doctors found themselves responsible for over 400 people, I thought about my own training in the 1990s. Before you slap the computer shut or throw down the phone, I should say that although there is a fair amount of ‘in my day’ reflection here, it is not my intention to promote a ‘just get on with it’ attitude.

Back in the 90’s few if any junior doctors thought about challenging potentially dangerous staffing levels. If we turned up to the hospital on a Saturday morning to find that we were one doctor down, we steeled ourselves for a nightmare and hit the wards determined to fight the fires as they arose. If people died, we attributed their demise to disease, not to a paucity of doctors. Overnight, in the large hospital where I started work, two JHO’s and one SHO* managed all the medical wards and all medical admissions after seven o’clock. The Registrar went home at ten. The consultant was not seen until the 8AM post-take round. That was just how things were. It seemed hard, it felt threadbare, but we did not complain.

Our perspective was centred on our own experience, not that of the patients. As the sun rose to brighten the night-blackened windows after a non-stop night, and the nurses handed over to the early shift, we congratulated ourselves for having responded to the many calls, requests and emergencies that had arisen. The euphoria of finishing the shift counteracted any misgivings we may have had about sailing too close to the wind at times. We felt like heroes. In the pub, we spoke about working in ‘warzones’.  We weren’t happy with it, and the hours before a series of weekend on-call shifts could become heavy with foreboding, but we managed.

If a patient deteriorates during a period of sub-optimal staffing, it is very hard to link their outcome with the number of doctors available. The sick get sick, that is why they are in hospital. Doctors are good at focusing their time and energy on those who need it most, so of those 400 and more patients in Derriford, perhaps twenty will have required urgent medical assessment and a new management decision over an eight or twelve-hour period. The stable majority were looked after by nurses, who could alert the doctors to any signs of deterioration if they developed. It is rare for two or three patients to get acutely ill simultaneously, such that a doctor cannot physically be with a patient during an emergency.

But what if that does happen? A doctor might have to run away from one patient before he or she has sorted them out, to see another one who was just deteriorated. If there are only two doctors, and six simultaneously sick patients, it would appear that a difficult choice has to be made, and the least deserving will go neglected. This is extremely rare. When the alarm goes up, other colleagues (anaesthetists, outreach teams, even orthopods) emerge from the ether. The system stretches. The need is met. So at the end of the day, nobody seems to suffer. There are no ‘serious incidents in which the root cause is felt to be under-staffing. And the patients… they would have had no idea the team was a doctor or two down. So what exactly is the problem?

Well, there was risk. There was probably delay in seeing patients, and perhaps some associated morbidity – but none that could be measured or proven. And the doctors, for all their coping ability, were strung out, and felt vulnerable. The price to pay for a system running at full stretch is the potential for disaster, stress, a poor learning environment, disillusionment and ultimately burnout. Yet many of us saw this during our training, and said nothing. We were in the problem so deeply, we didn’t see it as a problem. Or perhaps we didn’t have the ability a look up and gain a broader perspective.

Today junior doctors are more vociferous, and, in certain circumstances, more militant. The industrial action that took place last year was the clear example of this. Unsatisfactory staffing levels and training opportunities are now challenged. They do not regard those difficult shifts as a heroic challenge, but as failures of the system which they, the doctors, have a responsibility to highlight. This involves informing management and pressing for locum cover, providing feedback freely and without fear through GMC surveys and empowering their BMA representatives.

Why the change? I think junior doctors are more mature nowadays. Many have competed degrees before entering medicine, or have pursued different careers. They may be more independently minded. As a 24-year old in my first teaching hospital, I was grateful to have been selected for a ‘good’ post. I saw the challenges ahead in terms of my ability to meet them, to avoid failure however steep the learning curve… not to question the organisation itself, or the wider political environment. Therefore, during those years when I worked to the limits of my ability in understaffed areas, I did not complain. I did not seek to improve patient safety by making a fuss. I was, in a way, complicit.

Old attitudes don’t fall away easily. When I hear about an understaffed shift now I worry, and I sympathise, but a hard part of me thinks, ‘They’ll manage. They always manage…You know, back in the 90’s…” etc., etc,, yawn, yawn.

The future requires doctors like me, who appear to have grown older and perhaps a little cantankerous, to recognize that what was once acceptable is no more, and that without fuss, there is no change.

*JHO, junior house officer – first year post-qualificiation; SHO – senior house officer – 2nd or 3rd year post qualification

 

The dead of night

Doctor fatigue has featured heavily in the media this week. There are tragic stories of fatal car accidents, and a survey of anaesthetists has revealed that half have had accidents or near misses after night shifts.

As a consultant who works at night rarely now, I look back at the long nights and deep fatigue with a sense of achievement – I got through them without harming anyone, or myself. But the challenge, both physical and mental, was great. I will share some memories.

First night shift as a house officer in Bristol; I lay down in all my clothes, anticipating the first bleep with a mixture of excitement and fear. I thought I would never go to sleep. But nature insisted, I drifted off, and an hour later the bleep shrilled. It was 2.30AM. And oh the nausea! I leaned over, wondering whether to vomit onto the carpet tiles, suppressed the urge, gulped some water, then headed out to the wards. Ten minutes later I felt absolutely fine. I was wide awake, and ready. The first of so many awakenings.

For some it wasn’t that easy.

An SHO colleague went to do a blood gas. This involves passing a needle into the radial artery, watching the column of oxygen-rich haem rise into the syringe, then pressing down with some gauze to prevent a haematoma forming. As you press, you make conversation, or, if the patient is too ill to talk, you think of other things. This SHO fell asleep. She was found kneeling by the bed, as though in prayer, with one hand draped across the insentient patient’s abdomen, her head resting on its side by his hand.

Although we were not expected to sleep, and no provision was made for it, I quickly made the observation that as little as 45 minutes of shut-eye helped to make the next day a whole lot better. So I grabbed sleep where I could: on endoscopy trolleys (causing three months of neck pain), on couches in waiting rooms (too narrow, I fell onto the hard floor) and most controversially, on mattresses taken from unoccupied beds. Having lain down to sleep on the dusty floor of the doctors’ ward office only to come eye to eye with a cockroach, I stormed into an empty bay and dragged the thick, rubber-coated brick of foam off the bedframe.

“But that’s the MRSA bay!” called a nurse, “You can’t do that!”

“Watch me!”

During a spell in Sydney, where I worked 7 nights in a row on the ICU, I experienced strange personality changes. Generally placid, I found that fatigue led to disinhibition. In Circular Quay, waiting for a ferry to take me back to Neutral Bay after a long and sleepless night, I picked a magazine up from a kiosk and began to read it. It was 8AM. The owner of the kiosk walked around and said, “It’s not a bloody library.” His tone lit a fuse that had been dramatically shortened by the night, and I threw the magazine back at him, saying “Have it then!” That really wasn’t like me. The other personality change I noticed was emotional lability, leading to uncharacteristic crying during sentimental films; Finding Nemo, for instance.

To get through the deep trough that comes at 4AM, the time when our bodies crave sleep and threaten to shut down, I drank coffee, of course. In each hospital, I found the places where free drinks were available (hot water dispensers with large signs saying ‘PATIENTS ONLY’). As the night deepened, so did the layer of bargain granules in the plastic cups. By 4AM the ratio was close to 50:50. Once or twice, in a hurry and desperate for something to make me more alert on the way to an emergency, I poured dry granules straight into my mouth. Bitter.

The effect fatigue had on me during skilled tasks was interesting. Somehow, the importance of the situation beat the tiredness. I remember, during a long weekend (Saturday morning to Monday morning straight through, no protected sleep… followed by a routine Monday with ward round and clinic) how the corridor started to sway as I walked along it. The fluorescent tubes on the ceiling doubled up and shifted. I leaned against the wall and slapped my own cheek. It was important to be in control of my ocular muscles, because the task that awaited me was a central line insertion. This involved passing a thick needle into the vein that lies next to the carotid artery. By the time I held the needle in my latex covered fingers, sweating in the surgical gown, with a bright light shining down on the iodine-stained skin, I was all there.

The terrible stories of doctors dying in car accidents are not surprising. My methods of staying awake in the car were typical. Driving back from Kent to London, along the dreary A2, I played music at maximum volume, I bit the back of my hand until it hurt enough to squeeze adrenaline from my glands, and I hung my head out of the window, forcing my face into wind and rain like an unintelligent dog. I was lucky.

Back in my flat, the last vestiges of coordination left me, and I could be relied on to break dishes or drop glasses in the kitchen. A costly habit.

However practiced you are at jumping out of sleep into action, or pushing through the 4AM barrier, it is never easy. The body hates it, and rebels. The brain lags behind, and your true personality becomes obscured. Unfortunately, disease does not wear a watch. But however bad or long the night, the sun will rise, the windows will brighten, and your friends will appear, ready to take the problems from you.  

[Advice on fatigue from Association of Anaesthetists of Great Britain and Ireland here]

 

 

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The unknown quantity

What determines if and when patients ‘turn the corner’? I have never understood.

In my world of acute-on-chronic disease, where patients suffer sudden and life threatening reverses, there are numerous stories of unexpected turnarounds. Our efforts to prognosticate accurately have led to many scoring systems, all of which have been ‘validated’, but when applied to individual patients who surprise you with twists and turns, their relevance appears diminished. However bad the numbers, we treat, we support, we try to save… unless the presentation comes at the end of a long and well recognised decline, and we (the patient, the family, the team) are thoroughly ‘signed up’ to palliation. That circumstance remains a rare one, despite the increasing value we give to conversations about death.

So we are guided by experience – that fickle teacher.

Last year a very sick patient came in. He struggled, we struggled; he responded to intensive care support, we felt satisfied that our decision to advocate for aggressive treatment was the right one. He deteriorated, we isolated the infection. We talked the family through it, and suggested that not give up yet. He fluctuated, weakening a little with each reverse, until… weeks later, he died. All that hope. All that work. The ‘numbers’, at one stage, had looked better. But that is the nature of the disease. Unexpected complications. Hidden infections. Sudden ruptures.

The grim picture joined the file of failures that I, and all doctors, compile in their memories from day 1. It is called experience. But the way such memories absorb the light colours our view of the present. That is the whole point of experience, of course; to change the way we approach similar circumstances in the future.

The shapes and lines of that patient’s clinical course remained etched in my mind when, months later, I recognised an almost identical scenario. Her liver function looked the same during the first week. Her slide into an intensive care bed occurred over similar interval. I was ‘guarded’ in my prognosis, but I knew what was going to happen here. I knew. The road home presented too many traps and potholes for her body to negotiate, given the advanced nature of her disease. Any and each of them could kill her in a few hours. As time passed, her clinical course described the usual sinusoidal curve. The downslopes were not catastrophic enough to justify withdrawal, and the upward gradients were not sufficiently sustained to launch a bid for convalescence.

We reacted to each complication with urgency. Our policy was unchanged – treat, support, save. But my heart was not really in it. I did not have hope. I know I communicated that to trainees. Those muttered opinions as we walked out of intensive care. But at no point did we hesitate or withhold. And time passed.

Until… she returned to the ward. She turned the corner. She had climbed far enough up the hill for the swirling, sucking mists of death to no longer have a hold on her. Then she went home.

A trainee asked, “You know _____? I thought you said the chances of her surviving were…” I stopped her there, and turned the case into a occasion to teach on the subject of uncertainty. 

Is it a ‘survival gene’? Poor science. Then what? We do not know. Probably, luck is involved. When such large unknowns are involved, when the rules that underlie our attempted predictions appear unfixed, pattern recognition can lead to erroneous conclusions. Sometimes it’s better just to treat, support, stand back, and try not to outthink the disease… hoping that they turn the corner.

 

See also, Patterns and pride: diary of a medical anecdote

 

 

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So superior… – making judgements on medical care

 

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The Amber Spyglass (or what a retrospectoscope might look like)

 

Patients may see many doctors during the assessment and treatment of a particular illness. In the transition from primary to secondary care, medical opinion becomes more specialised, and the knowledge of the doctor facing the patient deepens in that particular area. Doctors become more confident in their opinion, and in the light of information are able to judge the quality of the decisions taken earlier on. This means that the specialist must, either privately or openly, pass judgement on what has gone before. Usually there is no controversy, because nothing incorrect was done. But sometimes, looking back, it becomes apparent that clues were missed. Things may have been done ‘sub-optimally’… according to the specialist’s very particular expectations.

The decision then has to be made – do you, as the specialist, tell the patient what you are thinking, or not?

The answer to this would seem simple. If by omission or commission the patient has been harmed, there is a responsibility to be open about it. However, harm is difficult to define, and the grey zone between delay and harm is broad. An abnormal blood test performed fifteen months ago might, if interpreted correctly, have led to an earlier diagnosis – but who can measure by what degree the patient’s life has been affected?

For the patient, finding out that two years ago a scan showed some early signs of liver damage, or that an abnormal vitamin level went unnoticed and uncorrected (contributing to months of fatigue), the conclusion is bound to be that things were not done well. The question of blame arises. The patient may ask  – what do you think should have been done? What do you think about the quality of the care I received? Patients, in fact all people who receive a service from a professional, like to benchmark. It is natural.

It isn’t just at the transition between primary and secondary care that judgements on the quality of care may me made. On the wards, once a patient is established under the care of a specialist team, questions may be asked about the time it took to reach a diagnosis, or about the appropriateness of initial treatment. If the wrong diagnosis was reached (say, heart failure rather than chest infection), was the error acceptable? Was it just the way medicine works, with the correct diagnosis emerging over time, as pennies dropped and more experienced people made their assessment – or was it just bad medicine?

The temptation for doctors is to close ranks, and to present the hospital, or the health service as a whole, as a seamless unit where information comes in and decisions are made, by individuals yes, but by professionals who are part of a larger machine. Individuals shouldn’t be criticised; rather, blame the system.

I remember once, as a registrar, the family of a deteriorating patient asking me the name of the doctor they saw in casualty, who they felt did not diagnose the illness quickly enough. In the relatives’ room they pressed me hard, and demanded details. I felt that the presentation was complex, and that the quality of initial assessment had been satisfactory, if not genius. So I refused to give a name. I talked about the ‘team’. In my wisdom I felt that it could not help the situation to offer up an anxious SHO, and that the request reflected the family’s grief and uncertainty. The family needed a focus on which to direct their anger with the situation. Was I right or wrong?

On other occasions, in clinic, I have had to explain as best I can the decisions made by a doctor – often a GP – whom I have never met. I may end up saying things like, “Well, based on the information that was available eighteen months ago, it wasn’t unreasonable to monitor the situation…” Or, “Perhaps another doctor might have referred you six months earlier, if they had a special interest in this disease, but yet another might have waited a year. There is no right answer.” Or, if the patient asks me up-front whether I think their GP is any good, based on what has happened before, “It is not fair for me to pass judgement… I see patients with your problem nearly every day, and I come to this with a very specific expertise. Your GP has to decide when to refer… and it’s perfectly reasonable to monitor things for a while first.” I may say this even I think, privately, that they can’t have been that up to date with modern medical thinking on the topic in question. But who am I to criticise? What do I know about psychiatry or gynaecology?

So what drives this instinct to obfuscate? Is there a justification? Surely, in an era of transparency, the patient should know exactly what I am thinking.

It may be a desire to nip a potential complaint in the bud, even when I think a complaint (formal or informal) might be unjustified? If so, am I right to forestall what a more objective person might regard as a necessary corrective?

It may be loyalty to the larger medical community – an instinctive reflex to shield colleagues from criticism, just like in the relatives room on the ward all those years ago.

Or perhaps it is based on my acceptance that the practise of medicine will always involve variation in knowledge and in quality. Not every biochemical clue will result in the same decision. Each doctor will have developed their own store of knowledge, a unique bank of experiences and memories on which to base their decisions. As long as the decision was not clearly negligent, or so stupid as to warrant immediate correction, we are bound to let borderline or ‘sub-optimal’ decisions go without making a song and dance. We might hint in a letter back to the GP, or in a comment to a trainee’s supervisor, that next time a different decision should be made, and perhaps in that way we reassure ourselves that we have tried to improve the quality of the system as a whole. But patients are excluded from this feedback loop. They may go home entirely ignorant of the fact that things could have been done better, and may not read between the lines of the letter that they are copied into.

In modern medicine patient involvement is key, and transparency is a central pillar. We have a duty of candour which applies to identifiable errors of a certain gravity, and no doctor will overlook a pattern of behaviour that clearly puts patients at risk.  But no such duty exists for reporting back on the grey cases where some educational improvement can be made. Is it reasonable not to inform patients in these circumstances? Would it help them? Or would it just cause confusion, and a loss of faith?

Over time I have become more honest about the non-scientific nature of medicine. Sometimes I begin a discussion with the patient with the papers spread out in front of me, or the blood results on the screen, and talk through what may or may not have been going on in their body over the last few years. If I think a spike in a liver enzyme might have been an early signal, which in retrospect was missed, I will tell them, but without loading it with an opinion. It’s just a fact. The ‘retrospectoscope’ can provide a false image of the circumstances that existed years before. Now you are here, let’s sort it out. There is no point in opining from the security of the specialist’s chair. Misdiagnoses are made there too.

In this way patients can begin to understand that the narrative of illness may follow numerous detours and diversions before the destination – a firm prognosis, a treatment plan – comes into view. Care is not homogenous, and variability, while sometimes permitting the occasional detour, is an inevitable result of human involvement.

 

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The corrections

 

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I can number on the fingers of one hand the times I have been explicitly corrected during my medical career. There was the time I treated a patient all night for septic shock when in fact he had cardiogenic shock – the fluid nearly drowned him. There was the time I performed a lumbar puncture on an obese patient, and put the needle three inches away from the correct inter-spinous space. There was the time I failed to check a gentamicin level before the weekend, and came back on Monday to find the patient in renal failure. And during higher training, the course where my endoscopic technique was picked apart against a list of errors that the assessor held in his hand; he described three issues, but I glimpsed the piece of paper and the list was at least ten items long. There are others, some of which are littered across this blog.

Each time I felt embarrassed and defensive. I reacted by rationalizing. The reasons, or excuses, were various, and included the way I had been trained, the pressure of time, the load of patients, the need to balance speed and vigilance, and plain bad luck. But each time the fact that I had been criticised ate away at me. I was not used to it. Few of us are.

Medical students tend to come from the highest strata of achievement in secondary education, where their performance requires very little correction. Most float through training in the middle of the pack, periodically struggling to stay above the flood of knowledge, neither excelling nor failing. They require little in the way of feedback, just the odd nudge back on track. They become competent in the early years on the job and deliver medicine safely. Errors occur, many due to weaknesses in the system rather than personal fallibility. Corrections happen, but they are infrequent. And then, before you know it… they are practising more or less independently. They are part of a team, but they are essentially ‘complete’. They habituate to many forms of stress, but one that they are not accustomed to is ‘constructive’ feedback. When it comes, if it comes, it hurts.

How else do we improve once we have arrived at our natural ceiling of seniority? Continuing professional education is mandatory, we do it, and our knowledge is augmented, but weaknesses are not identified by passive absorption. Appraisal? Somewhat routine, and focused more on our perception of ourselves than feedback. Revalidation – mmmm… we’ll see. So how do our weaknesses get identified? The answer is, by our peers – those whom we work with day in and day out. The difficulty with this is that they are the last people who wish to engage us on our deficiencies. They are colleagues and friends.

Most error is self detected and self corrected. Although I listed only a handful of occasions where mistakes were fed back to me, there are hundreds (well, let’s say ‘tens’) of similarly significant mistakes which I identified myself, and reflected on. Nobody came to tell me that such and such happened because I missed a clinical clue or performed a procedure incorrectly – there is no ubiquitous or all-seeing observer to perform this function. The continuous feedback loop of self-improvement requires attention to consequence, and the ability to accept that something bad has happened because of what you did or omitted to do. Without a willingness to seek the consequences of our decisions we will blunder on regardless. However, a safe culture cannot be expected to rely solely on such of subjective system.

Receiving  feedback as a junior doctor in training is hard enough, but it is standard and expected. You rely on it. The discomfort that comes with receiving negative feedback from a colleague of equal seniority, at consultant or GP level, is even more acute. The same rationalisations occur, recourse to the same ‘excuses’ – the pressures, the pace, the reaction to diffuse responsibility that appears to have unjustly landed on your head just because your name was over the patient’s bed. So much for receiving; how about giving? It’s even worse. But becoming comfortable with discomfort seems an absolute requirement for a safe medical culture. It is easily described, but not so easily undertaken.

Soon after becoming a consultant I took on the task of reviewing the notes of patients who had suffered ‘hospital acquired’ venous thromboembolism (ie. DVT or PE). It sounded easy, and quite interesting. I flicked through the charts, identified possible lapses in prescriptions of anti-coagulant, and marked them as avoidable or unavoidable. The catch was… I had to interview the consultant in charge of patients deemed to have suffered avoidable events. I sent out emails, arranged convenient times to meet, and found myself addressing equally experienced or more established consultants. It was not easy. The key to converting it from a repeatedly painful and nerve-wracking exercise was this – I too had been called up to justify a similar lapse, months earlier. The discomfort, the access of humility, the acceptance that yes, it could have been done better, we (I) should have been more vigilant, served as a brief lesson in correction. That was the angle when it came to phrasing my own feedback:

‘It happens to all of us at some point, it’s bound to. Happened to me last year. And it worked. If I hadn’t been asked to attend the meeting I wouldn’t have known that so and so had a big PE three weeks after they went home from my ward. It worked. It made be think twice about checking it on ward rounds, brought it home. It’s not about criticism, it’s about focusing minds on the things that are easy to let slip through your fingers…’

You get the gist. Correction shouldn’t be exceptional; it’s inevitable.

If hospitals and surgeries are to witness more of those ‘difficult conversations’ we keep hearing about, in order to promote a safe culture, each of us has to find a way to get comfortable with starting those conversations. The best way – in my limited experience – is to bracket them in the context of our own fallibility, for none of us are perfect, and we are all bouncing from error to error as we move forward in our careers. That’s medicine.

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There do not seem to be many articles on how to deal with the discomfort of giving negative feedback, but I did find these two in the BMJ and the Hospitalist (US).

 

New booklet, click picture to explore…

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Intrusion

 

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Two students arrive on the ward, as per the arrangement that has slipped my mind. I see them loitering by the nurses station. They are eager to see and hear signs – that’s all I wanted when I was at their stage. Unprepared, I scan the names on the white boards at the end of each bed bay. There! An elderly patient with florid aortic stenosis, a slow rising pulse, oedema in the lungs and in the skin… but she is frail, she is ‘end stage’. Some days she is bright and talkative, some days she is withdrawn. Today she is in between. Her clinical signs are classic, and it would be a shame if the students did not have the opportunity to examine her.

 

I remember similar encounters from my own training – the first murmur, the first example of bronchial breathing; they stuck in my mind, and advanced my knowledge. So, I am decided… I will ask the patient for permission to be examined by the students. Before doing so I flick through the notes to catch up on any developments. I see the coloured A4 sheet used by the palliative care team. They have been asked to see her for symptom control, and to help arrange her discharge. They came this morning, just two hours ago. And prior to that entry is a short note from the registrar saying that she has spoken to the patient and her middle aged son to explain that there is now nothing more that can be done to optimise her breathing or oedema. She has progressed from ‘end stage’ to ‘end of life’. It is not obvious to the passing observer. She is the same woman.

 

The students are looking at me in expectation. Should I ask her? It will not benefit her. It will probably tire her. It will not be in her best interests. But neither is it positively harmful. And the signs… so precious, educationally. No, I’ll leave it. It’s not fair. I approach the students and explain that in the absence of any other obvious patients we will tour the acute medical unit and find something there. Then I glance back to the patient and watch her. She is sitting out, and looking out across the ward. I reconsider. I approach.

“Mrs ______,” I say (gabble actually), “I wondered… if you wouldn’t mind… please say No if you are too tired… if two students came to ask you some questions and examine your heart?”

She looks around slowly. I think she heard and understood. But I have to ask again. She nods, which I interpret as consent. I beckon the students over, and watch as they perform the examination. I then demonstrate the signs, before getting them to examine again, until they are satisfied that they have heard and absorbed the features of the disease. We leave. It has taken twenty-five minutes, with feedback given along the way. The patient sits passively. It has tired her, as I thought it would. The look in the eyes of the students is priceless. Descriptive words on a page in a book have evolved into physical, memorable reality.

 

They thank the patient and they thank me. Their morning was well spent. My morning was well spent. Her morning was devoted to the education of two students who had nothing to do with her, and the convenience of a doctor, an educator, who offered nothing in the way of medical care. But that’s what happens in hospital. When there are students, or doctors studying for exams, the question will always be asked. Sometimes it feels uncomfortable, and the path of least resistance appears attractive (‘Sorry guys, I don’t want to trouble her today…’). However that path does not lead to the best educational experience – the palpable liver, full of metastases, nystagmus secondary to a disabling cerebellar stroke, the petechial rash due to acute leukaemia.

 

Patients can say No of course, but in my experience they rarely do. The thing that is asked of them sits outside the usual therapeutic transaction. Consent, when asked, relates not to an intervention, but to what amounts to a ‘favour’ – their time, their inconvenience, in exchange for knowing that they have contributed to a general good. Often the reply is not so much a ‘Yes, of course…’ but a ‘Well they’ve got to learn haven’t they!’ That phrase contains an imperative – an expectation. I have very rarely heard a patient say ‘No, no thanks, not today,’ although I have read as much in their look of pained exasperation, or the unfocussed gaze that betrays distraction, by unresolved concerns – questions, prognosis, a scan result, disability, mortality. It is easier when you know the patient, but sometimes a colleague will have tipped you off about a valuable examination before a teaching session. Then you must introduce yourself, explain the purpose of your visit and ask permission all in one go – the fast track. It feels intrusive. It is intrusive. But it is necessary.

 

See also ‘Signs’

 

oOo

 

New booklet, click picture to explore…

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Glide

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A now traditional Christmas Carol-esque cautionary tale for busy doctors, which also owes something to another, less esteemed cultural influence…

oOo

Jim, a thirty-something medical registrar, stared out of an eighth floor window into the lifting darkness. With dawn came the prospect of home, and the end of his fourth night on call. He thought about going to the pub on his way back, but decided against it. Beer, at 9.30AM! What a mess.

A patient called out to him. Jim averted his gaze, the time-worn method of avoiding engagement with those who might distract him from more urgent tasks. But he was doing nothing, just staring at the city’s transition below, so he answered.

“Can I help you Sir?”

“Here, here.” growled the old man. Jim liked the look of him; there was humour in his eyes, a spark of cynicism.

“Yes?”

“Come here lad. I’ve got something to tell you.”

“Go ahead. I might get bleeped away though.”

“No, you won’t.” The tone was oddly prophetic. With a thin arm he directed Jim to make himself comfortable on the bed. Then he began…

I was a doctor you know? I was. I don’t tell people when I come into hospital… at 85 I know very little that would help, medically. But I know how people should be treated. I’ve been studying you… Jim, isn’t it. You’re at the top of your game aren’t you. Slick. I’ve seen you field questions, referrals, crises. You know a hell of a lot, and you think clearly. You’re fast too. I was fast. I could get round a huge ward of patients in a couple of hours, I could see twenty-five in a clinic. At your age. Then… I changed. I slowed down. I annoyed those in charge of the hospital, I caused a backlog, but I had to, you see. Want to hear why?”

“Yes.”

“I was doing a ward round. A man grabbed my hand, a bony hand it was – just as I grabbed your attention a moment ago. He pulled me down so that his mouth was at my ear, and he said – young man, you’re gliding, you’re gliding. Like you Jim. You glide. You’re fast and you’re smooth but you never touch down. What did he mean? He meant… I wasn’t connecting, wasn’t engaging. I wasn’t leaving anything behind. I was fast yes, I made the right decisions, mainly, but after I had left the patients they could barely recall the interaction. Do you remember seeing me yesterday Jim? Vaguely? You were in and out in a flash, focussed entirely on the medical facts. I was impressed, you made the right diagnosis and changed my treatment for the better, but I wanted to talk to you… about something else. I started, but you were already turning away. Teflon. Smooth. You didn’t realise I had something to say, because you were not open to the possibility of anything obstructing your serene progress through the ward. Leaving nothing behind…”

“How can you leave something behind with every patient? You’d be eaten away.”

“Nice image! Like piranhas eh? No, no. It’s exhausting, it has to be. If it’s not exhausting you’re not doing it right. It’s called empathy, and it costs, in the short term. And to do it you have slow to down, and touch the ground.”

Jim nodded, not exactly in agreement, but too stunned to object.

“Anyway, just a little bit of feedback! Off you go Jim. Get home.”

Jim stood up, ashen faced. He murmured his thanks and walked away. When he arrived at the nurses’ station he turned to look at the old man, the gnarled old physician with bright eyes. The bed was empty.

“Talking to yourself were you? Bit tired?” asked a nurse.

“Possibly. Possibly.”

And he walked home, slowly.

oOo

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