Tuesday, 25 October 2011

Supervision on the night shift

This week, I am relaxing with the wife in a beautiful cottage in the countryside, in that hinterland between England and Wales, just outside Hereford. One can get a real sense of the fluctuating identity of this area, that has inevitably led to high tensions over the years - the boundary between England and Wales around here is often indistinct: the names often share common heritage, and it is easy to imagine how neighbours would have tested each other’s resolve by creeping into each others’ territory, stealing, pilfering and generally making a nuisance of themselves. Imagine how tested poor old Offa must have felt to decide to dig a bloody great ditch to stop his Welsh neighbours pinching his sheep. I can only imagine that the presence of the Dyke was viewed as a challenge, rather than a deterrent by many potential sheep rustlers.

In the time and space afforded to me by this week off, I have been reflecting on the night shifts that I did last week, and what kind of experience they were for the people I was working with. In many ways, these shifts were also a new experience for me: for the first time I can remember, we were shadowed by medical students, many of whom actually managed to stay up with us all night. They seemed to enjoy the extra attention that one has the time to offer students during the night, and they seemed to enjoy the buzz of being up at 4 in the morning on a hospital ward. I have to admit that the physical sensation I get these days from being asked to make decisions in the witching hours of the night tend to verge more on physical pain than real excitement, but I remember how thrilling it used to be to have the time and space to make decisions for myself as a house officer on nights.

And this brings me on to my point for today: I am one of those chaps who thinks that the level of supervision and support that house officers gets today is as good as it has ever been, and medical training in the modern age recognises the need for demonstrable progress, graded exposure, and a constant and clear commitment not to let medical education ever undermine the quality of patient care. We do this now better than we have ever done this before, but one of the challenges of supervision is the process of graded responsibility: allowing junior doctors to take on more responsibility when they are able to.

One of the issues is that house officers become so used to having every decision they make checked and ratified, that they can quickly become accustomed to not having any decision-making autonomy. Undoing this mindset can be difficult, painful and scary if they arrive at their F2 or CT1 year with it still in place.

And this is where night shifts come in: I know that in some places, house officers have been taken off the night shift, as some feel that it does not offer a good enough training opportunity. I would however, like to challenge this view and offer the opinion that while house officers on night shifts do not get the level of clinical supervision that they might receive during the day, by virtue of the fact that there are fewer doctors around, what they do receive is the opportunity to learn what it feels like to take responsibility for decisions. In truth, there is always someone around for them to ask should they need support, but for simple, small scale decisions, this is often their first chance to assess patients, decide on the problem and what its solution is completely independently. At first this is terrifying and disconcerting, but even over the course of four shifts, I have seen house officers grow, and more importantly start to experience what it means to be a doctor.

Being a doctor these days is less about being a knowledge expert - all the information is freely available. Among other things, being a doctor is about having good decision-making skills, and also about managing uncertainty. Good doctors manage their own uncertainty well, while excellent doctors manage other people’s.

Night shifts allow house officers to experience uncertainty and to start to learn how to manage it. And it is from helping these doctors learn about that, and from watching them grow as professionals that I gain my enjoyment from those achingly tiring night shifts.

Sunday, 16 October 2011

The tenuous link between sport and neglect.

So the 14 men of Wales lost by one point to the 15 men of France, after Allain Rolland sent off  Sam Warburton for a dangerous tackle - a decision which is a bit like the rugby equivalent of sending Gary Lineker off, such is Sam’s reputation for fair play. Mr Rolland is a referee who rarely offers any sort of apology for his on-field decisions, and I am sure that this time will be no different. Conspiracy theories will no doubt abound: Rolland hails from Ireland (the team Wales beat in the Quarter Finals) and his father is French. I would prefer not to blame the heritage but rather offer the individual time to reflect on the impact he has had. No matter, I may feel rotten now, but I shouldn’t like to be in his shoes next time he goes to Wales: I would advise him against ordering any food or drink in any Welsh-run establishment for the rest of his life - the ingredients may well veer off those stated on the menu.

Perhaps therein lies the only real gain from the whole debacle: Welsh solidarity often seems to rest on a sense of shared injustice. We can be heartened that we now have a real episode of sporting robbery to unite us. For too long our failures as a rugby playing nation have been entirely our own. Having just got off the ‘phone to my brother and my Mum (the proper Welsh person in the family) I can already feel the guilty satisfaction garnered from having something meaty to moan about. Of course, this does not compare to what it would be like to actually have got to the final, but in many ways, talking about failure is our daily bread, so being able to blame it on someone else is like Christmas come early for the chippy Welshman.

In the run up to this match, I felt unprepared for the concept of a truly gifted, performing Welsh side: we have spent so long talking about past achievements that it has become ingrained that such performances and successes can no longer be expected from current and future Welsh teams. What we have learned over the last few weeks is that high performance can be earned, and that the past does not necessarily indicate how the future will look.

And this brings me on to my main point for today: Wales losing a rugby match because of a cheating, biased referee is only a sporting event - it has resonance for many reasons, including collective identity and heritage, but playing and watching sport are pastimes, and they only reflect the real fabric of society, and never truly replace them. These matches sometimes feel so important that it can be easy to forget that they are not. One of the reasons that Wales have been playing so well is that they seem to get this: they recognise that playing sport is important for the national sense of well-being, but that the position in society of what they do is brought into sharp relief by miners dying in pit accidents, or mass unemployment back home. They see their performances in the World Cup as a salve for the real world going on back home, and this really shows.

How then should we react to the news that we continue to abuse and neglect our elderly patients in hospital? This is a theme that crops up with regularity, and it is the same issues every time. Ann Abrahams published the excellent report ‘Care and Compassion’ earlier on in the year, and who was surprised to find out this week that in many hospitals, the same issues are still there?

Radio 4 wheels on individuals to relate what happened to their vulnerable relative, and we shake our heads, wring our hands, and talk about staffing levels, attitudes to caring, the qualifications of nursing staff and health care assistants. We talk about how we need to do better, and yet I go to work every day and pretend it’s not happening on my patch,

And here’s the rub - I am prepared to get exercised about the questionable call of a well-meaning referee when I see it, but do I roll up my sleeves in the same way when I see the abuse and neglect of elderly patients. I happen to work on wards where the care my patients receive from nursing staff is superb, but I still see patients admitted to hospital bearing the scars of sub-standard care every week. We always initiate the relevant reviews and safe guards, but it is my perception that neglect particularly of the elderly is so endemic, that we are less sensitive to it.  

Mistreatment of the elderly has relevance to me because I work with them; for others, the conversation strikes a chord because of their experiences with their own relatives. What we are lacking is for the elderly to have relevance in the wider society, and for them to be integrated in to the daily workings of their communities. Many elderly folk do not have the physical robustness they used to have, but they have experience, acquired emotional intelligence, and a perspective on life for which there is no short cut. The reality for many pensioners is social isolation and isolation.

The treatment that we afford them in hospital is a function of this bigger picture. The treatment that our elderly receive when they are ill is the best that our society has decided they deserve. We should be careful of criticising the standards of service that are offered to them by statutory services that are paid for by a society that clearly feels that the elderly are not that important.

The solution to their mistreatment in hospital lies partly in addressing staff training and attitudes, but it also lies in addressing societal attitudes. I fear that our elders will continue to experience poor standards of care until we as a society value them, both for what they have done in the past, and for what they continue to offer.

So next time you read a story about the poor treatment of the elderly in hospital, as yourself whether you individually contribute to the solution, or whether you are part of the problem.

Monday, 10 October 2011

Teamwork and the revolving doctors.

There is of course only one thing to talk about this week - the Welsh rugby team are in the semi finals of the rugby world cup. As you may recall, Mama Dharamshi is in fact Welsh, and she got in there early with my sporting education, and I have been watching Wales mostly lose for as long as I can remember.

The range of emotions I have been through watching Wales play have ranged from ecstasy and exhilaration (I have twice seen them win the Grand Slam in the Millennium Stadium) to despair (virtually every year they haven’t won the Grand Slam).

I learnt about disappointment watching Wales, and I learnt what it means to really invest emotionally in something, only to find oneself disappointed. Therefore, the experience of seeing Wales win, and win well, is doubly good - they haven’t just won, they have won by playing with skill and with enjoyment.

This contrasts starkly with the England rugby team, who have spent the last month playing badly, behaving badly, and failing to reflect honestly on the way they have performed. That bunch of lads have clearly forgotten how to enjoy playing the game.

Now I know that many of you will be switching off and tuning out, but bear with me - it has been a few months since I used a sporting analogy, and this one does work.

What we have seen from the Wales team that we haven’t seen from the England team is a sense of collective - they respect each other professionally, they enjoy each other’s company socially, and it clearly matters to them all how they as a team are perceived.

Tuckman describes the stages of team work with the terms ‘forming, storming, norming and performing’. Any new team that comes together has to go through a formation process, where they learn about each other, behave well with each other and avoid conflict. Guess what happens when teams start storming? This can be a rough ride, and this is where a lot of the behaviours play out.

The goal of course is performing, which is the team that results when the individuals have a clear grasp of what each person brings to the group: everyone is motivated, capable and autonomous. This frankly is where the Welsh rugby team is, and why they have exceeded the expectations of even their most ardent fans. They have developed a trust in each other, by sharing some pretty painful experiences together (there was a famous training camp in Poland, where they all stood in freezers after training sessions to help with the recovery and thus allow them to do more training), and spending a lot of time together.

But I work in a system that almost precludes ‘performing’ teams by virtue of the fact that some of its members rotate every 3-4 months. It can be disheartening and exhausting to start again with new house officers and SHOs so often, and I have often wondered whether such frequent rotations undermine the level of performance of the team as a whole.

It’s a difficult question to answer but what I have noticed is that when there are highly performing teams in a hospital, that level of performance is usually a function of the more senior doctors working well with the nursing staff and therapists. A far more common experience, however, is to work in poorly performing teams, where the communication between members is either absent or unhelpful, and where team members do not value the contribution of their colleagues.

I have no doubt that my most productive and effective periods have been made possible by the people around me. The question I constantly ask myself is whether I have returned the favour. We each have a responsibility to do what we can to help our colleagues reach higher, and in turn, we can reasonably expect a leg up in return. It does not take long for new comers to a team to recognise when they are working in an environment in which individual contributions are valued. So when I think about how to incorporate new junior doctors in to the team, I think about what my relationships are like with the nurses and therapists are like. If I have paid enough attention to these relationships, then my new house officer will have no trouble settling in, because a conducive team environment will have already been created.

But rather like following the Welsh rugby team, one’s fortunes can turn in an instance: these relationships need constant nurture, and there is no such thing as completed work in maintaining the performance of a team.

Monday, 3 October 2011

I wasn't listening before, but I promise I am now.

Last week, I was having a chat with my consultant. Forgetting that this is the chap that I may someday need a reference from, I took the opportunity of his monologue to check some emails on my phone, and fire off some quick replies. ‘Don’t stop,’ I said to him, ‘I’m still listening.’

‘No you’re not.’ he replied

I mumbled some platitude about being one of those blokes who could actually multitask, but he was right - I had decided that I didn’t need to listen too closely because I already knew what he was going to say.  

The following day, I gave a talk, and experienced the satisfaction of knowing that it had gone down pretty well. After the end of the session, one lady came up to me and told me that she had enjoyed my presentation thoroughly, and that she knew that everyone else had too, ‘Because you could feel it.’

I know what she means - there is a certain feeling you experience when you are talking to a room of people who are paying attention, but I have always thought that it is more of a sound: you hear it rather than feel it. I think it has something to do with the fact that attentive crowds fidget less, cough less, tap on their phones less, and consequently achieve a silence that one rarely hears. The point, however, is that it is a very nice experience. And one, apparently, that I am not prepared to extend to my boss.

This realisation has got me thinking about what it means to be heard, and what it means to listen. I have been struck by the number of bad habits that I seem to have developed. For example, when I am on-call (this is a euphemism for being busy) I often use the time that the patient is talking to think about how I am going to investigate and treat them, which patient I am going to see next, what I might have for dinner, how I might try to win my next squash match and so on. It was disheartening to realise that I use very little of that time to actually listen to the patient and give them my full attention.

A medical maxim is that the diagnosis is always in the history and rarely in the examination. This is true, but in my case, the diagnosis is often in another doctor’s history, which they then tell me.

The way we work in medicine means that there is often a lot of duplication of effort. Let me explain - I send a house officer or SHO off to see a patient, and they come back and tell me what has happened and run over what the plan should be. Sometimes I will have to go over certain aspects of the history with the patient myself, and partially repeat the process that the other doctor has already gone through. My consultant will then repeat this process with me. Even when I see the patient from the beginning myself, that patient has already been seen by a doctor in A and E or their GP - those are the entry criteria for the attention of the on-call medical registrar, so it must seem like Groundhog day for them.

Between presenting to a doctor with a problem and being treated for the problem, a patient can expect to be seen by upwards of 4 doctors, often all asking the same questions. This must be insufferable.
We all know the importance of asking opening questions, and it can be a particular skill to resist the temptation to ask more specific, closed questions when one is busy, but I guess that it doesn’t matter what kind of question that one asks if one is not actually listening properly. Speaking to a patient doesn’t only have to involve finding answers, or monitoring progress - there is therapy in the conversation itself, and there is reassurance in the being heard.

Doctors in general, and this one in particular, have a habit of being goal-orientated, and trying to ensure that each particular experience achieves an outcome. What I have realised is that a goal in itself is allowing people to know that they have been heard. It does not matter if nothing they tell you has a material difference on what you do for them, the experience of knowing that you have been listened to is a powerful and important one.

This week, therefore, I am planning to shut up and listen. Even on Thursday, when I am on-call.