The apprenticeship

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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Click image to explore all the author’s writing projects.

 

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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New collection – click image to explore on Amazon

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…

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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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The place of blame

The importance of a ‘no blame’ culture in the NHS has become axiomatic. It is accepted that the chain of learning that connects adverse healthcare events to improvements in safety is fatally interrupted when incidents are not reported. If people fear blame and censure, they will not report. Berwick focussed on this in his 2013 post-Francis report, ‘A promise to learn – a commitment to act Improving the Safety of Patients in England’. It says,

Patient safety problems exist throughout the NHS as with every other health care system in the world.

NHS staff are not to blame – in the vast majority of cases it is the systems, procedures, conditions, environment and constraints they face that lead to patient safety problems.

Fear is toxic to both safety and improvement.

 and recommends,

To address these issues the system must: 

– Recognise with clarity and courage the need for wide systemic change.

– Abandon blame as a tool and trust the goodwill and good intentions of the staff.

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As a doctor who is involved in mortality and morbidity meetings, I often think about the role of blame in learning lessons. At my level medicine consists of numerous interactions between just two or three kinds of people; patients and doctors/nurses. If a mistake is reported an assessment is undertaken as to whether that mistake was due to a fault in the system (eg. poor process, unclear guidelines, bad IT, poor labelling) or a restricted error on behalf of the health care worker. The latter might include mistakes due to a lack of knowledge, or due to a lack of concentration.  But what if the lack of concentration is the result of unintelligent rota design, or distraction due to an over-burdened system? The spectrum of potential accountability is wide, but whenever an error is identified it is necessary to see at what point on that spectrum the underlying cause lies. Or the blame.

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Example: a junior doctor gives a patient an antibiotic that she is allergic to, the doctor having failed to recognise that the trade name (let’s say Tazocin) disguises the fact that it contains penicillin. The patient has an anaphylactic reaction and spends a week on intensive care.

The focus of accountability could reasonably fall on one of several points. It could be the doctor not being aware that the antibiotic contained penicillin, or for not checking that the patient was allergic. For not bloody thinking, his exasperated supervising consultant might say to herself, immediately succumbing to the emotional retort that is ‘blame’.  Or, could it be the doctor’s educators who have not emphasised that fact in his training? Or the drug firm for releasing a medication which does not make its crucial ingredient plain? Or the Trust for not being responsive to the fact that this doctor is routinely over-pressurised at night, and making decisions in a hurried way. Or the Department of Health for capping central funding, or David Cameron for supporting a policy of austerity…  or mortgage lenders in America for contributing to the 2007 financial crisis.

This begins to sound sounds absurd, but the point I’m trying to make is that the chain of blame could be a long one. And when you make a mistake, it is natural to look up and around for mitigating circumstances.

Now imagine that the junior doctor is brought into his educational supervisor’s office. It is explained that the patient came to harm because the doctor prescribed the drug to which the patient was known to be allergic. It’s my fault, is how the doctor will feel. But the educational supervisor will be quick to soften the criticism by explaining that there will be a review of systems, more nurse education so that injections are not actually  given if it says penicillin allergy on a drug chart, and the Trust will arrange some extra pharmacology teaching for House Officers. Use of the misleading trade name will be banned. The system has learned. It’s not your fault.

Immediately the sense of blame rises from the shoulders of the junior doctor and it becomes clear to him that it is not just his problem. Should that doctor walk out of the room with no sense to blame? Well, I can recall most of the mistakes that I have made in my career, and the intense sense of blame and guilt that accompanied them. Whether it was mismanaging Gentamicin and causing renal failure, missing a cord compression or making a late diagnosis on data that I should have interpreted correctly. It is blame, the sense of personal responsibility, that nagged at my mind and made sure I never made the same mistake again. For this reason I think individual blame does have a role. And I am not alone. A National Patient Safety Agency presentation from 2004 includes these slides:

blamejustculture

blamegraph1

 

At least 90% of error can be attributed to system problems or ‘honest’ errors, while only a small percentage are deemed ‘culpable’. This data is largely derived from the aviation industry, where many parallels with healthcare have been identified. But even this presents problems. The ‘honest error’ is still an error. Just because it is honest (ie. not intentional or negligent, an error that quite would probably have been committed by a peer in the same combination of circumstances) there is still something to be learned by the individual.

The psychologist James Reason describes person and system approaches. The former attributes unsafe acts to,

aberrant mental processes such as forgetfulness, inattention, poor motivation, carelessness, negligence, and recklessness.

 Whereas a system approach accepts that,

 humans are fallible and errors are to be expected, even in the best organisations. Errors are seen as consequences rather than causes, having their origins not so much in the perversity of human nature as in “upstream” systemic factors.

 

For those of us dealing with error on a day to day basis, an approach that tackles individual blame while paying heed to system-wide lessons must be taken. For reporting to be encouraged, blame must not apportioned in public… for that is where shame develops, and its lethal consequence – inhibition. But in private, as we look at near misses and significant errors, we will sometimes accept that it really was a silly thing to do. And we will not hide our concern, nor conceal our disappointment if the error appears to indicate a worrying gap in knowledge, method or attitude. If this is the case a way must be found to lighten the sense of personal blame by looking up at systemic factors (if present), but without allaying personal discomfort entirely. In this way we (for it will happen to all of us at some point) will remain alert, and perhaps even a little paranoid, when we enter a similar clinical scenario in the future.

 

oOo

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Sick enough? Doctors, illness and the scaffold

Some time ago, during a weekend on call, a young doctor called me to say that she was ill and probably needed to go home. When I went up to see her she was leaving the sluice, having just vomited. She had felt awful since waking up in the middle of the night. There was of course no question – “Go!” I said. She left, but reluctantly. There were tears in her eyes. She was embarrassed and ashamed. For being ill!

“But what about the jobs?” she asked. The list of tasks and patient reviews that she had picked up in the morning was enormous.

“Don’t worry, we’ll deal with it.” I said. But I knew we wouldn’t deal with it very well. There is rarely enough slack in a hospital, especially at the weekend, to easily accommodate the transfer of one person’s entire workload. As I watched her leave, encouraging her when she hesitated at the door, I thought oh dear, this is going to be a bad day. And it was, for everybody. There is no doubt that patients on the ward waited longer for the medical care that they needed that day, although I am equally sure that no-one came to harm.

I wondered what went through her mind when she woke up that morning? Perhaps…

‘I’ll manage…’

‘However bad I feel, the only thing that will really stop me is if I’m actually vomiting…’

‘Because I can’t not go in… I saw the handover list last night, there are 30 patients to see…’

‘… and they are worse off than me…’

‘You don’t call in, nobody does’

‘But what if I’m contagious – only if I’m vomiting… and I’ll be careful…’

‘They say we shouldn’t go in if we’re unwell, but they want us to, really…’

‘…because the work has to be done…the policy doesn’t account for that!’

‘I know how annoyed I feel when a colleague calls in sick… some just do it…’

‘I’m going in… I’ll see how it goes…’

 

In this post I am going to explore the decision to call in sick. Much has been written about the rather profound insights that doctors’ behaviour when ill provides, and I would strongly recommend Jonathon Tomlinson’s January 2014 blog post ‘When doctors become patients’ on the subject (of which a little more later). Here though, I wish to examine the milder end of the sickness spectrum, and specifically the apparent rise in short term junior doctor sickness.

 

Paradox

Why was it that the thought of going home made that doctor distressed? It is not usual for people in other walks of life to feel so upset when they have to take time off. Was it the thought of letting her patients down? I don’t think so. More likely it was a lack of confidence that the hospital would easily adjust to her absence, and a concern that chaos would ensue. Patients were at the centre of her thoughts, not as people, but as incomplete tasks that would create stress for her colleagues. Whatever the reasons, sickness was something that this doctor had clearly tried to stave off, until the inevitable viral emesis overtook her. Typical doctor!

Or perhaps I have got this all wrong – this doctor was actually atypical, because there is evidence to show that doctors are now taking more time off. According to a study performed in a single NHS Trust before and after the introduction of a 48 hour working week,

 

Taking into account the increase in trainee numbers, the proportion of junior doctors taking sick leave increased by 90% (p = 0.001), and the total episodes taken by 170% in the year following the implementation of EWTD-compliant rotas

During the study period, episodes of sick leave among junior doctors more than doubled with just over 1 in 3 taking leave in the year to August 2007 and nearly 3 in 4 the following year. The number of days taken and the number of repeated episodes of leave increased.

 

There appears to be a paradox here. On the one hand we know that doctors find it hard ‘be ill’ – Jonathon Tomlinson’s illuminating post (regarding chronic or more serious illness, including mental illness) describes internal blocks to accepting illness such as dissolution of the medical identity as healer, stigmatisation and shame. In the case of life changing illness there are even more subtle psychological factors at play, including loneliness and the insiders fear of modern medicine’s fallibility. Some of these probably apply to minor illness, albeit disruptive ailments that impair young doctors for 1 -3 days, but there is no denying that the threshold has dropped. Trainees are, in general, more comfortable picking up the phone to call in sick. What is the answer?

 

Presenteeism and indispensability

An Audit Commission report into medical staff sickness (2010) stated,

Another cost, closely associated with sickness absence but much harder to quantify, is ‘presenteeism’.

Presenteeism is the loss in productivity that occurs when employees come to work but function at less than full capacity because of ill-health. The cost of presenteeism could be as high as one and a half times that of sickness absence. This cost increases when the cost of staff turnover due to ill-health is considered.

The Boorman review interim report found that ’presenteeism is greater in those who work long hours and experience managerial pressure to return to work’. There is little available data on presenteeism but Boorman found that 71 per cent of qualified nurses and midwives in the 21-30 age group report presenteeism compared with 45 per cent of staff in the same age group in corporate services.

 

In my experience presenteeism (which I have interpreted as the tendency to come to work when ill, rather than the ‘cost’ of such behaviour) is driven not by external pressure, but by an internal sense of indispensability. Because healthcare workers are always busy and pressurised, this perception seems unavoidable. How can we not regard our presence as absolutely vital to the service?

Another illustration: although I minimised the concern for the experience of individual patients earlier, there are times when this does play on one’s mind. These are when the clinical commitment is a ‘one man/woman show’ with no prospect of internal cover. I remember arriving back from holiday a couple of years ago with a resolving, though still rather scary looking dose of conjunctivitis (picked up from a dodgy hotel swimming pool I think). The chance of getting a replacement at such short notice was zero, but the impact, of sending 16 or 17 patients away, was going to be huge. I visualised their expressions, and the difficulties they would face in rebooking within an over-pressed system. I decided, on their behalf, that they would rather have a hands-free consultation than be cancelled on the day. This was a classic case of perceived indispensability, in the context of a contagious illness for which occupational health would have had me quarantined!

If indispensability does feed presenteeism, could it be that trainees feel less indispensible now than before? I’m not convinced. Although shifts are shorter, they are probably busier. There is more to do on the ward, there are more frail and deteriorating patients, and the expectations of both patients and relatives are higher. Each team member is just a vital as before. This argument does not scan very well… but it does bring us to the idea of the ‘team’?

 

Team cohesiveness

The pre/post European Working Time Directive study comments,

Both shift work and reduced working hours may contribute to a loss of the ‘group cohesiveness’ provided by the traditional medical team.

This is conjecture, but it does chime with people’s general feelings. A vivid memory, for me, is the sense of team working that pertained during the early years of my training. At the end of attachments I pledged to stay in touch with various colleagues, strong bonds having been formed over several months in the forge of long hours, silly levels of fatigue and vital inter-dependency. Life has moved too fast to maintain all those relationships, of course, but the sense of fellowship at the time was real. Indeed, when I was a junior house officer my registrar said one day, ‘Take tomorrow off – we’re on top of things here. Take a Mental Health Day’. And how I enjoyed it! I would love to offer the same to my present day juniors now and again, but the idea of being ‘on top of things’ is laughable. Back then the team was fast… however, I’m not sure if this made me more or less likely to call in sick. If you know colleagues well, and they trust you in return, you may be more comfortable picking up the phone and excusing yourself. If you are part of a larger but more ephemeral team – brought together just for the weekend for instance – there may be less of an expectation that colleagues with whom you have an easy relationship will cross-cover without question or reproach. The ‘team’ in this case indicates a collection of individuals whom a rota has thrown together, not a group of mutually supportive colleagues. The leader of that team, the consultant, may not know who is on the team, so dispersed are modern shifts and responsibilities. Yes, there is less cohesion, but the link between that and a greater willingness to call in sick is not clear in my mind.

 

The scaffold

So far I have presented the internal debate that precedes the decision to call in sick as a battle of pro’s and con’s, but this neglects the person’s general state of mind. No enquiry into the subject of medical staff sickness can ignore mental wellbeing, and it is this (largely unspoken) issue that may provide the link. The rising problem of anxiety and depression among junior doctors has been described recently (in the BMJ)-

 

Head of the Practitioner Health Programme in London Clare Gerada has found that since the service began, an increasing number of doctors have presented with mental health problems — 195 in 2008/09, compared to 242 in 2012/13.

Significantly, Dr Gerada found that more than half — 55 per cent — of the patients presenting to the service in 2012 and 2013 were 25- to 35-years-old, while only 22 per cent were 46 or over.

‘It may be that job stress, rather than personality, pre-existing mental health problems or factors at medical school, are behind the mental health problems seen in newly qualified doctors.’

 

These small numbers represent a tiny proportion of the workforce, and do not explain sickness behaviour overall. But if it can be safely assumed that beneath those with manifest, admitted mental health symptoms there are hundreds and thousands more with sub-clinical or contained anxiety or depression, we can begin to understand how an individual’s threshold for calling in sick might fall.

A survey by the BMA (the 7th report of the ongoing cohort study) in 2013 found that 44% of 368 doctors thought that stress levels were ‘worse or much worse’ than they had been a year before, and one in five reported ‘unacceptable’ levels. 40% said that morale had worsened. The BMA said in response that working patterns had resulted in a ‘trial of endurance’. The stress that surveys like this elicit is hard to define. It is not necessarily a pathological thing, more an overtone, an absence of well-being, a reaction to never-met demand, or bewilderment at the Sisyphean nature of the task.

When you are sick, physically, the inclination to work depends on a more general sense of positivity towards the workplace, and a feeling that one’s efforts will be appreciated. If the individual feels unsupported, rarely acknowledged, an isolated cog in a huge automated machine, the likelihood of fighting what might be quite trivial or transient physical symptoms, and pushing them to one side, is likely to be smaller. If the supporting mental and emotional scaffold is weakened, the fortitude required to ‘push on through’ cannot be mustered. Perhaps this is the link between ‘team cohesiveness’ and the observed increase in sickness absence. There is mental disquiet, but it is rarely described in words – only absence.

 

Empowerment

Or, there is a more prosaic explanation… younger doctors have got over the traditional, undesirable trait of ‘illness-martyrdom’, of equating the acceptance of illness to moral weakness, and have instead been empowered to develop a more mature and assertive approach – I am ill, therefore I do not work. This suggestion is not backed up with evidence, but may be part and parcel of the generally welcome changes in medical culture that have flattened the hierarchy (a little), and made it easier for trainees to speak up and challenge their seniors. Training needs are vocalised. There is less awe and fear on the wards. Perhaps the thoughts of that (atypical?) young doctor should have been…

‘Face it, I’m ill… we all get ill.’

‘And if I don’t go in today, what will happen? Will anybody die? No.’

‘I’ve covered others, they will have to cover me – that’s life.’

‘I will feel guilty… perhaps that is just another part of being ill. It will pass.’

‘They know me. They know I wouldn’t do this if I didn’t feel absolutely awful…’

‘And if something happens, if the work is not done, and someone complains, then I’m sorry…perhaps it’s needed to demonstrate that we need more people, rather than working at maximum intensity all the time…’

‘You know I’m over-thinking this… where’s my mobile…’

‘Hello, Sam, sorry, it’s me Esther…I can’t come in today, I’m ill…’

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.

oOo

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.”

oOo

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.

oOo

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Introduction to ‘A face to meet the faces’

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This is the third collection of blog posts to be published since I started writing regularly in August 2012.  The title of this book, A Face to Meet The Faces, represents a change of focus. I am interested in describing the workings of the medical mind – all the ticks, clicks, springs and processes that are engaged before the first word is spoken to a patient. I do not suggest that the face we present is insincere, but it is professional, and it will not express our every thought. Occasionally, as Dev finds in ‘The good in him’, those processes result in an entirely wrong impression being given to those whom a busy doctor is trying to help. At other times our usual natures and inhibitions are challenged by special situations, and we find ourselves ‘Making deals’ (with patients who wish to self-discharge), or dancing along the fine line between treatment and bodily assault (‘A rare and unpleasant duty:  involuntary treatment and the deprivation of liberty’). Those normal natures can render us susceptible to pride (‘Diary of a medical anecdote’,Hollow Heroes’),  expediency (‘The perils of reassurance’) or paralyzing timidity (‘Being comfortable with uncertainty).

 

Elsewhere, subjects have grabbed my attention randomly (the Hurricane Katrina healthcare catastrophe for instance), or I have reacted to observations in the media (‘Bed X), or to important policy developments (such as changes in organ donation). The core preoccupations that fuelled the first two collections – end of life care, autonomy, resuscitation decisions, the Liverpool Care Pathway, medical futility – are still represented (Replacing the LCP, Notes on a judgment).

 

A new feature is the ‘ethical adventure’ or Interactive Ward Ethics section – a role playing, decision making exercise inspired by the Fighting Fantasy books I read as a child. The reader is asked to decide, on behalf of the well-meaning and conscientious young doctor Nina, what to do in a variety of challenging situations. There are three in this volume, and the idea is to roam vicariously through the actions of a sometimes luckless substitute!

 

It can do no harm to illustrate how we sometimes struggle to accommodate the emotional dissonances encountered in healthcare, although I do not pretend to set out solutions. The first and most important step, it seems to me, is identifying the challenges. I hope this collection of articles serves that purpose.

 

 

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