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.

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