Tuesday, 20 September 2016

Stoicism and hard graft.

Who was not charmed by the sight of Alistair Brownlee giving up his own chance of victory in the World Series Triathlon in Mexico to help his brother Jonny cross the finish line? Jonny hit the kind of athletic wall that would have put you or me into some form of terminal cataplexy. These are tough men - they wonderfully understated, stoical and talented Yorkshire men. They chose to daily inflict on themselves the kind of physical pain that would render me couch-bound for a week, all in the name of sporting excellence.

Jonny Brownlee chose the physical state he found himself in by continuing to push himself when his body was screaming at him to stop. Alistair put it rather more prosaically when he called him a 'flippin idiot' for not pacing it correctly.  Yet, this was an afterthought- his first reaction, instinct, if you prefer, was to help him finish; but it was not instinct that made Alistair gruffly shove his brother over the line ahead of him, in second place. He'd had at least 500m to think about it. That was a choice, and it was borne out of love, and sporting respect. He was rewarding his brother for the race he had run, and the effort he had given.

That brotherly shove encapsulated a great deal: it was a practical solution to the problem of negotiating a limp body over a finish line; it ensured his brother finished by himself (kind of) and ahead of him. It was also a payback for a finishing 500m that Alistair hadn't counted out: presumably he had held enough to get himself over the line but hadn't counted on having to do it for two. He was also making sure they weren't overtaken by the man behind them. It was practical, unfussy and unceremonious. I found it all rather tender. And inspiring. When Alistair Brownlee says that he would have done it for anyone, I believe him.

I have something of a soft spot for understated excellence. I am inspired by success through endeavour, and it often makes me rather emotional to see someone succeed on the back of hours of graft, pain and commitment. I outrageously interpolate unjustifiable conclusions about the type of person a sportsman or woman is from their performance. It's why the outing of Lance Armstrong was so bitter for me. Today, when the provenance of sporting performance is so murky, it is the Brownlees who help me keep my faith.

I want to think that they must have been terrible at school, such was the challenge of persuading them to sit still for long enough to learn something, but that might be my desperation to find a chink in these otherwise amazing athletes. These are not lime-lighters. Every interview with them seems to have the forebearance of someone under obligation. They were recently in an episode of Top Gear, but they seemed to use the challenge as a training exercise.

I suppose we find inspiration in different places. I find mine in sport, and in particular, I find it in sportsmen and women who practice, and train for the chance to win, but without the fear of failure.

I need that inspiration at the moment to counter-balance the clagging tribulations of being a doctor in the NHS right now. Today, it has been announced that the Consultants are to be expected to publish their private earnings (£0 for me - job done) which is one thing. Quite another is the manner of portrayal, as Nick Triggle on the BBC website reports that it is 'certainly not uncommon' for consultants to earn 'in excess of £500,000': this 'fact' can only be explained in 3 ways: it is either a loose representation of reality, a lie, or it is true -in which case my wife will probably tell me to pull my thumb out. Yet it taps into something important: many non-medical acquaintances of mine assume I work short hours for lots of money, with loads of lovely leisure opportunities at a golf course, which I drive to in an expensive car.

In itself, this is a small moment, but death by 1000 paper cuts appears to be looming, as the drip-drip of undermining reporting about doctors eventually makes you ask yourself whether you really are the earnest, hard-working person you try to be. I was bowled so far over by Theresa May suggesting that junior doctors were 'playing politics' that I did wonder whether I'd Rip van Winkled it and woken up in another world. The endless repetition of £10billion of extra investment in the NHS, with the highest number of doctors and nurses in the health services history, and the need for the NHS to be more efficient has been a prevalent, endlessly repeated riposte from the DoH at every marker of NHS crisis, syncophantically repeated by every news outlet that reports on it.

Yet every day, we doctors, nurses, therapists, managers and social workers go to work and know the realities of those pressures. We know that we are not so inefficient that savings will make up the shortfall. We know that we work flat out so much of the time that there is never any time to think about how to do things differently. And we know that no one is really listening, or think we are exaggerating.

Frustrating, isn't it.

So ask yourself this: what would the Brownlees do? Tapping into my habit of detailed character profiling from minimal robust psychological information, I have decided they would:

  1. Keep working as hard as ever, to do the best with what they have. 
  2. Not complain, but plough on
  3. Wait until someone asks them for help sorting the mess out
  4. When they do get asked, they would have a list of practical, sensible measures ready to implement.
So, from watching a brother help his hobbling brother finish a race, I have decided that I can finish this race by continuing to work on the things I do best (being a doctor) and spending time with my teams working on how we can continue to provide good care for our patients with what we have. We will be honest about what we can't do, and then just get on with it. Right now, no one wants to hear anything different, so we'll have to wait for someone that does.

If, in the meantime, you need cheering up, then perhaps you can watch the clip of Alistair and Jonny. Or perhaps you could watch this one, or this one, or even this one. 

Tuesday, 6 September 2016

Timeline melancholy

My Twitter time line is a forlorn place right now. The dominant theme is the Junior Doctor's strike, and there are three prevalent themes:

  1. Junior doctors are striking because of their concerns about patient safety
  2. Junior doctors are striking and are threatening patient safety.
  3. This person says Junior Doctors shouldn't strike, and this is why they are wrong. 
In the last couple of weeks, David Oliver (@mancunianmedic) has been asking doctors close to CCT how they will behave when they are consultants (#whenimaconsultant), and he sparked my current train of thought. 

I struggled emotionally through registrar training, and my overall synopsis of those 5 years could be presented in the motif  'I was a happy geriatrics registrar and miserable med reg.' Too much of my time was spent worrying about why I was finding the role difficult. I spent way too little time articulating to myself and others what made the role unnecessarily hard, and what could be done to improve it. I spent a lot of time feeling bad about feeling bad. I felt guilty that it mattered to me that I felt unsupported, over-worked and stressed. 

I would go to talks about leadership and hear platitudes about embracing the leadership potential of junior doctors, and about improving training. In the end, there were two things that made all the difference to me. The first was taking a year out to do a leadership programme that taught me all about reflective practice, and the habits of personal sustainability. The second was working for a consultant who offered all of his registrars the opportunity to help him develop his service and develop beyond the delivery of clinical services. He was fun, energetic, kind and restored my faith. 

A great many consultants I worked with over my junior doctor career were guided by the ethos of 'telling not asking', and 'bollocking not understanding,' and for them it was easy pickings: the entire focus of my junior doctor training, until I wrestled some control back, was entirely focused on clinical skills. None of the other essential skills of stress management, team working, team building, reflection, or understanding behaviours featured on my curriculum. 

Junior doctors now, as then, find out their rotas the day they start a job. Contracts never appear, pay not confirmed until you are actually paid. I once presented myself at induction, only to be told to go home as I was starting nights that evening. One hospital tried to be organised, and demanded that I take a day off work before I started there to visit their HR department. I refused. The consultant I was working for told me not to make trouble and to go along. 

There is something very akin to bad schooling about how we treat junior doctors. Publicly, we encourage them to question, to enquire, to be open about mistakes and feedback, but in private, our behaviours scream the exact opposite: we expect them to do as instructed, to mask their independence and intelligence until they are consultants, because until then, they are someone else's responsibility, and cannot be trusted to use all of their clinical skills, common sense and social skills effectively. I found it infuriating then - it still is now. 

Too little trust and autonomy is placed in these capable, effective men and women who staff our wards and clinics. Too little time is spent on helping them develop the habits and skills that will help them navigate stressful and demanding jobs with happiness and satisfaction. 

Twitter is currently reminding me of how toxic this kind of culture can be. The GMC has escalated the rhetoric about the risks junior doctors run by striking; the Association of Medical Royal Colleges has decided to discount the value judgement behind the decision to strike. Everyone seems to have an opinion about the justification of strike action, or the risk to patients, but with each comment we mark ourselves as dissociated and out of touch with the very doctors we are supposed to be mentoring. The debate around the strikes has turned into conversations with them, advice given to them, instruction given to them. No one would know we are all part of the same professional family. 

Imagine you are part of a rugby team, and you are planning a foreign tour somewhere, but your forwards don't want to go because of the poor human rights record of the country you are planning to visit. Do you tell them not to be silly, that they are putting in jeopardy the whole tour, upsetting the sponsors, and anyway, all the tickets have been booked? Would you go without them and try to beat a 15 man team with your 7 man team? Or would you listen to them?

In Bowling for Columbine, Marilyn Manson was asked what he would say to the children from the school, and marking himself out as something of a sage for our times, he replied 'I wouldn't say a word to them. I would listen to them.' Who knew that occasionally you need to consult a Shock Rocker to get any sense of a situation? What he realised about Columbine is that rock music wasn't the problem, it was a symptom, and that when kids feel like they're shouting and no one is listening, the shout louder, and more violently. 

Our junior doctors are shouting loudly, and instead of listening to them, we keep bollocking them. They are shouting loudly because no one seems to be listening properly, and those that do come up with childish put-downs which clearly misunderstand the point being made. Junior doctors are people who articulate complex problems for a living. They interpret a raft of symptoms into neat, precise sentences. They have analytical skills, deductive and inductive insights, and they have the verbal fluency. They are telling us there is a problem. That means there is a problem. 

Remember, junior doctors all learn when to ask for help. Good ones take the problem they are dealing with as far as they can, then call their consultant. These juniors have called their consultants, and now it our job to help them find a solution. It is our duty because they are part of our professional family, because they are crying out for support, and because they clearly recognise that they cannot fix this current impasse by themselves. They are doing all the things we have taught them to do. 

Perhaps with this round of industrial action we can do more than either support them or criticise them. Perhaps we can engage with the discussion both at our own trusts and more broadly about how we move forwards. Perhaps we can demonstrate to our junior colleagues that times have changed, and not only do we trust them, but we also believe them, and we value them. 

That was what I promised to do when I became a consultant. 

Tuesday, 16 August 2016

Tilting: the absence of effective team functioning.

I suffer from recurrent earworms. It's an affliction I've had for a long time. I once had to watch Adele's performance of Someone Like You on Jools Holland about 100 times before I could move on. The problem has flared up again recently with Christine and the Queens' 'Tilted'. The traditional management strategy is either to feed it relentlessly until it burns out, or pass it on to someone else. Usually, I have resorted to the former, but more recently, I have tried to share it with my 4 year old daughter. She loves music videos - her favourite is Michael Jackson's 'Beat It'. I don't think she is entirely convinced by Michael's ability to heal gangland rifts through the power of dance, but she does find it terribly amusing. 

For the last week, therefore, I have been exposing her to repeated viewings of Christine and the Queens' 'Tilted', both in video and live performance versions; she particularly enjoys two aspects: the man who walks on his hands and the line 'I am doing my face with magic marker.' 'That's silly, Daddy', she says. She is right, which only leads me to wonder whether a magic marker is the same as a permanent marker, and how worried I should be that she will become a music-lyric-copycat, and be left with ink stains on her face that remain until she grows new skin. She's due to start school in a few weeks - it's a real concern.....

Tilted is a song that first appeared in French. Heloise Letisser (Christine is her alter ego) speaks English with the kind of thought and consideration that allowed Nabokov and Conrad to write beautiful English prose in non-native languages. Tilted in English, is, I suspect, purposefully ambiguous, and contains the delicious line 'I am actually good, I can't help it if we're tilted.'

You make of that what you will, but to me, it invited comparisons with what it is like to work in healthcare. Over my career, there have been moments when I was unable to be the conscientious, well-meaning young man that decided to be a doctor. There have been moments when I found it impossible to be as compassionate as I wanted to be, to be a considerate as I needed to be, or as patient as my patients needed me to be. 

I am not alone in having set out in medicine to be expert, caring and good under pressure. I am not alone in having failed to live up to these objections. I am not alone in having felt the shame of having fallen short. Today, I wonder sometimes how I made it through my time as a medical registrar. 

Feelings of inadequacy in a hospital can be insidious, and undermining. You look around at all the people who manage to be nice all the time, who seem to breeze through the day, while you wrestle with the anguish of feeling inadequate. You exhort yourself to try harder, to be better, because, well, that is how you manage problems in the NHS. 

We have been fostered in an environment that talks about 'no-blame cultures', but which, through every action it actually takes, cements the perception that you are OK as long as you don't mess up. Targets are met through constant cajoling, pushing and exertion. Each day is a full throttle effort to keep up, leaving no time for colleagues to sit down and ask of each other 'Are you OK?'. There is no space to reflect, to learn, to plan different ways of working, or simply to make sense of what has happened. 

It is in this environment of working that staff start to wonder whether they have the stamina to survive. Each day in an acute hospital is run as if it is a crisis. Yet a crisis response is only sustainable if you know that the crisis will end; that one day soon, you will be able to take your foot of the peddle, slow down, catch up, tidy up and recover. 

The recovery time in medicine has disappeared. Recovery used to take place in the mess, in the pub, in the quiet moments of the day. The old way of team building through having the whole firm working together all the time wasn't ideal - machismo and practising on patients are no way to do healthcare, but at least there was solidarity. Now the hours have changed, but nothing has replaced the team structure. Modern working schedules do not allow firm team structures to exist in the way they used to. Without them, however, junior doctors have lost the support networks they used to have, and they have not been replaced with anything. One would have thought that with doctors switching teams so often, that the NHS would be the world leaders in team development strategies. Perhaps we might be, except that the current culture of healthcare seems to view team-building as non-essential. For confirmation, look at the number of junior doctors who started posts this August who still don't have contracts, know what they will earn and didn't get their rotas until a few days before starting. 

I have been musing over this, to the tune of Christine, and various online articles that have caught my eye (here and here, for example). The comments section of the 2nd article is illuminating, including the remark 'You're already a good doctor, and you'll get better.' A revealing insight into the perception that you learn by doing, and by coping. I would hope for more than that. 

The moment of expressed crisis in a colleague is not the moment to reflect deeply on what they are doing wrong. It is the moment to reflect on what you as a team are doing wrong. The moment a colleague makes a mistake is not the moment to enquire only on whether they are competent to do their job, but to enquire whether your team is functioning as effectively as it could be. Crises and mistakes are the moments when teams should huddle together in collective responsibility and openly outline the problems, and earnestly offer the solutions they can try. 

Fostering a team environment in which mistakes and crises are taken as opportunities to reflect genuinely on how they can operate better need not be hard. It requires only two commitments: to treat mistakes and crises as the whole team's responsibility, and commit to open, safe discussion of the causes and solutions as a group. 

I am glad I survived registrar training, because I have ended up working in with teams with whom I think I could take on the world. More importantly, I have ended up with teams with whom I feel I can be fragile and vulnerable. I know they will help me, and I wouldn't swap them for anyone. We may be out in West Dorset, but together we are working really hard to offer our patients services that we are proud of; and we are doing this by making sure we have time in our schedules to discuss what is going well, what isn't and what we want to try next. 

Next time someone looks like they're struggling, or they make a mistake, sing yourself the song, and remember, 'They're actually good, but can't help it if they're tilted'. 

Monday, 1 August 2016

Domiciliary admissions

On Friday, a GP phoned the integrated care hub in the community hospital I work in to request an admission for a lady bed bound at home, and in need of medical attention. We took her details, made sure the ward was ready for her and organised transport to bring her in.

Ordinarily, a team would wait for her to arrive and assess her when she was in her bed. Ordinarily, she would be brought on to the ward, sometimes after an interminable delay waiting for transport, and then be assessed by a nurse, then a doctor, and then acclimatise herself to the unfamiliar environment she found herself in.

Ordinary is boring. I wanted to do something a little different. Instead of waiting for her to arrive, I picked up my computer, my bag, and a drug chart, and I drove round to her house. I clerked her in her bedroom. I assessed her medical needs, I had a quick look around her house, and I met her husband. The ambulance arrived while I was still there, and I was able to talk to the crew about her needs. I spoke with her about what I thought was going on, and outlined to her how we would try to help when she arrived in hospital.

After I finished at her house, I popped round to a couple of other patients at home, and by the time I arrived back at the hospital, she was there, at her bed, looking both relaxed and relieved.

Seeing her at home might seem like a small thing. It might seem like a massively inconvenient thing, But it was also very useful. For some time already, I have given up out-patients clinics and only see patients at home. I find it is more relaxing for them, and useful for me. When you see someone in their own home, you instantly get a feel for how they are actually managing. In the same way, by assessing this lady at home, I could instantly get a feel for what she needed from me. It was also, surprising and reassuring for her to meet one of the doctors who would be looking after her in hospital, before she arrived.

I'm not saying that all patients could be assessed at home prior to admission, but I am saying that introducing  new ways of working that are designed around the needs of the patients you are trying to help can have a big impact on their experience and comfort with health services. I also suspect that it allows us to help them more effectively.

Monday, 11 July 2016

What CGA means to me

It worries me when someone talks about 'doing a CGA.' I shy away from CGA evangelism, but comprehensive geriatric assessment is the cornerstone of geriatric practice. Put as simply as I can manage, CGA is the holistic assessment of a patient, to capture all the issues that may be affecting a patient. Done well, it should cover medical, psychological, social and functional domains, creating a detailed picture which helps to explain the presentation of the patient at that moment.

Simple to understand, difficult to implement.

One of the tricks of geriatric medicine is to make sensible treatment decisions for the patient you are dealing. Achieving 'sensible' relies on having a clear picture of what that person is like when they are not ill, and not in hospital.

Admission to hospital is a cognitive stress-test, which usually takes place in the context of the physiological stress-test of acute illness. Often, the patient in front of you is far from the person they usually are. Imagining your way to that person in their routine is like foraging through a thick forest, looking for clues. The risk is significant: underestimate their usual level of function and deny them treatment that might be effective because we think they are too frail; overestimate them, and subject them to futile, disorientating care that offers them little utility.

I wrestle with the challenge of knowing my patients. I also wrestle with the concept of a CGA done in an acute crisis. It yields important information, but it yields it too late, and often incompletely. Too often it tells me too little about the recent narrative of that patient's life, the trajectory they have been on, and if offers them too little opportunity to take part in planning their care.

Serving a frail, elderly patient well asks that you involve them in their care, that your practice is influenced by their preferences, their style and their goals. These all vary hugely, and practicing geriatrics only one way means expecting your patients to all fit in with your judgments, preferences and biases. This is a certain way of ensuring that you partially serve most of your patients.

In the world of community geriatrics that I circulate in, we have been building services that aim to manage patients holistically, gently and responsively over time. The cornerstone of our adapted services has been the recognition that almost all of our frail, elderly patients are known well to at least one community service. Over time, these services, and key people within them understand in some detail what that patient deals with, what they are looking to achieve, and what they want to achieve from future care as they become more frail.

We base our conversations about how we help patients through periods of crisis or deterioration on the information provided by the person who knows them best. We develop our input around what we have learned about them from their previous care. It is an approach that requires carefully nurtured team cultures that encourage participation from staff of all roles, and it is an approach that demands significant investment of time, to allow for conversations that often swirl and circulate before you are able to focus in on the key issues that have been identified.

What we have yet to achieve is a system in which every routine assessment contributes to a centrally collated CGA, built up over time, and from every healthcare interaction, to which any relevant health professional can refer when they meet a patient. Some people call these care plans - I like to think of it in the narrative sense.

I am working towards a world in which CGAs are not done, but continuously honed. I look forward to a world in which every interaction with an elderly patient is treated as an opportunity to contribute to care when they get sicker or frailer; in which a crisis is just another chapter in the process of caring for frail, elderly patients. We should be able to leverage the opportunity offered by electronic records to collate this information automatically.

The goal is this: whenever a patient presents with an acute illness or crisis, their admission should be underpinned by an holistic care plan, built up over time, honed at every opportunity and able to support critical decision-making at any time.

My great frustration with acute geriatrics before I moved to the community was that I would spend time helping patients recover from their illnesses, understand how their diseases responded to treatment, and then have nothing to do with them until they became sick again.

After three years working in the community, I am much closer to understanding how holistic geriatric care could work effectively in the modern health system. And it's not as far away as you might think it is. 

Tuesday, 5 July 2016

Modern rituals.

Life has a lot of rituals. From the way we organise child-birth, to the day we die, our lives are marked in the stage-posts of periodic rituals. My little girl is due to start school in September, and even that has the hallmarks of a ritual. From the care-free playful days of her first four years, she will embark on a routine that starts to embed in her an understanding of the way that our world works. She will make friends (hopefully), she will learn to read and write. She will take exams - one of my favourite rituals of all.

Perhaps I am being too liberal with the word 'ritual'. Our lives are not governed in the way they once were by religion. That is not true everywhere, but here in the UK, religious practice is a matter of personal choice, rather than compulsory observation. Ritual has become secularised, which is not without its pitfalls.

I see evidence of secular ritualism all over the place, from humanist naming ceremonies, to football matches, summer festivals, graduation, even Christmas. Who can still argue that Christmas remains a primarily religious celebration?

I like rituals. They give us context, grounding and perspective. But primarily, they must have purpose. A good ritual allows us to appreciate where we stand in the world, where we have come from, and where we are going. It is a piece of community history, that encapsulates the learning of the past for the benefit of future generations.

Baptisms introduce a new child into their families and communities. Weddings celebrate the bonding of a couple. Funerals organise the grief over a lost friend or relative. It is always good to forge one's own path, but it is also important to understand from whence you came.

Yet, the ebbing away of religious practice from wider communities has left a big gap in how we deal with death. Today, over half of people die in hospital, yet only 8% want to. The majority would prefer to die at home.

At first glance this appears to be a fundamental failure of the health service to adapt appropriately to the needs of the people it serves; but hold your counsel for just a moment. How many of those people who were asked were actively dying at the time they were asked? I suspect not many.

I have supported a great many people in their final days, and done well, it can be a serene and valuable experience. Many of my patients were ready to die, and tired of life. Yet many were understandably scared and lonely. I try to advise families not to keep vigil, but to keep loving in those final days and hours. To talk, to hold hands, to give space and quiet. I have encouraged them to enjoy final lucid moments, to look out for signs of distress that we can help with, but more importantly to talk openly, honestly and candidly about what is happening, and to take a final chance to say the things they won't ever have a chance to say again.

And sometimes, to me, it feels a little absurd that it is I, a physician in his 30s, who is giving advice to families about how to deal with the process of seeing a loved one die. I never really thought I would become an expert in dying, even as a geriatrician, but then again, who else has the chance to become expert?

Patients often come into one of my community hospitals for palliative care, and we are glad to have them. We are pleased to be able to help. The nurses I work with offer the kind of care I wish everyone could have. With a calm, compassionate simplicity, they tend these patients compassionately, and allow the patients and their families to focus on the things that are important to them.

Many of these patients arrive having had a fraught time at home. Often they are desperate to be at home, and their relatives are desperate to support them. But the challenge of meeting the care needs of some very frail relative, often in pain, or with other symptoms can be overwhelming and incredibly stressful. It is also entirely unfamiliar. What is normal when someone is dying? How do you know what to expect?

Many of us, I suspect have never seen someone die, or even seen a dead person. I remember clearly the first time I was present at the very moment of death. You can tell instantly, and you start to understand why we used to believe in a spirit leaving a body, because that is exactly what it looks like.

It used to be the case that many people died young, or the elderly died at home. It used to happen all the time. Within communities, it was something that most people had experienced.
Vestiges of the past still live on through our hospital chaplains, who minister our patients with grace, calm and compassion. It is through our local vicars that some of this community expertise lives on. The double-edge of the success of modern medicine is that these routine occurrences have passed out of the collective experience. End of life care has been outsourced to hospitals, which means that when it does happen at home, it can be a scary experience for all involved, because there is too little access to people who know how it all works.

Much of the comfort that patients and relatives get from dying in one of my community hospitals is from being surrounded by staff who can help them know what to expect; people who will tend to routine care that is important, so that they can enjoy some tender last moments, without the pressure of attending to basic needs.

Perhaps this was a ritual that we used to have the community expertise to do at home. Perhaps it's something that we still have the expertise to do at home. What I know is that for some patients, being cared for in a calm, expert environment that isn't their home, is often the right thing to do.

Sunday, 22 May 2016

Calm under fire.

I'm a little baffled by the new contract proposal. I don't understand how you can mentor someone who has been on maternity leave to make up the time spent as a mother and not a doctor: equality doesn't mean that to me. Only women can deliver babies - they shouldn't be disadvantaged by that reality. I also don't understand why night shifts that start at 7.30pm don't attract the same pay uplift as shifts that start at 8pm (it is entirely possible I have missed something), and I don't understand why the same contract discussion is still taking place when it has been well demonstrated that not only does this contract not solve the problem the government is trying to fix, but that the problem itself is not a problem. Surely, we do not still linger on the misconception that radical working changes are required to improve survival expectations of patients admitted at the weekends.

Guessing what lies beneath the contract chicanery is a fool's game: we can tell you what the evidence suggests to us - that the NHS is being teed up for greater private provider involvement, but the current political oversight of the NHS is something of an evidence-free zone. Who can reason out the illogical reasoning behind our current situation?

And this is the knuckle-gnawingly frustrating thing about the whole situation. Logic doesn't prevail. Evidence doesn't talk. It reminds me of what it is like trying to explain to my three year old why she can't have more ice cream, while she is having a hissy-fit about not having more ice cream. Nothing gets through.

I can't count the number of people who have shaken their heads patronisingly at me, and said that junior doctors are being naive, that this is politics. The implication is that politics goes by different rules, and we should be OK with that. We should be OK with a world in which reason, evidence and grown-up dialogue are usurped by the diaphanous concept of 'winning'.

Where the sad reality leaves us that is that there is no clean way out of this. Jeremy Hunt talked, the morning after a proposed contract was agreed, about this not being about who won, but how long will that last. Can junior doctors trust him not to go crowing about winning the day after they agree what has been proposed? Could they stomach what would come after if they rejected the new contract?

The Department of Health keeps reminding us that this is about providing a 7 day service to patients. I suspect many are not convinced about their real understanding of what this means. But we do. We all know the areas of our service that we want to improve, we all understand the limitations to achieving what it is that we want to achieve; yet I imagine many of us still have plans for what we are going to do next.

In this crazy world of doctors having to play politics, understand the nuances of PR and social media, we are all still going to work, delivering the best we can for our patients today, and thinking about making our future services better still. There are elements of the service we work in that we have no control over. We can't predict what the current Health secretary wants to do next, and we can't predict how the next one will want to make his or her impact. What we do know is that they will want to do something, because when was the last time a Health Secretary trusted the people who run and deliver healthcare services to know what the best thing to do next might be?

And it was ever thus. We have been tinkered with, reorganised, and in some cases catastrophically buggered around with, all in the name of improving what we do now, since the NHS began. And yet we have continued to deliver better healthcare. The care we deliver now is not perfect, but our outcomes are better now than they ever have been.

There is also a silver lining. When was the last time that consultants and junior doctors felt so connected? The sense of solidarity pervades the NHS. Consultants now have a better grasp not only on what the problems of being trainee are, but what the day to day frustrations they experience are. They may only have walked a few days in the shoes of their juniors, but it has been enough to erase the rose tint from their own memories of being a junior, and focus on the reality of that life today, in the current NHS.

So we have solidarity, but we still have the threat of imposed change. Of course we do - and it won't go away. But in reality, it doesn't change very much. We always operate within the limitations of our current framework, yet great change is always possible.

The system may be telling junior doctors that they aren't appreciated, but we don't need to toe that line. Consultants, nurses and therapists are all capable of creating teams that any junior doctor would want to work in, and of delivering better services together.

It's not much, I know, but perhaps we would do well to remember that any framework creates opportunities, and however down-trodden we feel right now, we can still hang on to the prospect of creating something better for our patients.

While the metaphorical mortar shells are flying overhead, we must keep calm under fire, and do what it is that we have always sought to do: put the patient first.