Monday, 5 December 2011

Witching Hour Wariness


Fresh from a night shift, it is always interesting to reflect on the range of behaviours that one sees on display. There is something about the conversation or crisis at 3am that amplifies our reactions and emotions, that lays them bare at our feet as some kind of reflection on the person you are. The hospital at night may be empty of the legions of staff who turn up for the day shifts, but this means that there are fewer places to hide; whatever you may think you have learned from ‘Scrubs’, it is not cupboards that we hide in when we get scared, but behind other people.

The pressure of having to state your opinion and plan of action, all in the midst of sleep deprivation can be a heady mixture. It can also be suffocating - decisions you make in the middle of night rarely look the same in the morning.. Much of this is due to the consensus-basis of clinical decision-making: the post-take ward round is a social construct, in which the practice of validating or undermining others is seen as often as clinical expertise. The nature of the ward round is a spectrum - at one end there is the tendency to support decisions made by the on-call team, regardless of how valid they, and at the other end, there is the tendency to reverse decisions, as some gesture of authority. In the middle, in that Goldilocks zone is the practice of making the right decision, based on what is best for the patient. As obvious as it sounds, achieving these professionals heights is rarer than one might think. The skill of being a consultant running an effective post-take ward round is difficult: the challenge is to balance the needs of the junior doctors, their efforts, their inexperience, and the cognitive effects of being up all night; one also has to make sure that there is scope to change decisions when evidence supports another course of action, and there is also the pressure to remain objective, and not play up to the cameras: these ward rounds often have an element of theatre, consisting of a multitude of junior doctors, medical students, nursing staff and pharmacists; remaining cool with this kind of audience can be difficult.

What then of my midnight learning? The purpose of the paragraph before is to set the scene for the decisions we are asked to make at night: there are fewer people to ask for advice from, achieving the same intellectuals heights at 3am is much harder than at 3pm, and one also knows that in the morning he has to stand in front of the assembled gaggle and justify the actions one took.

There are different ways that one can approach this problem. I have always tried to be confident about acknowledging my uncertainty when it exists, about working on the basis that as long as I am not guilty of slothfulness or sloppiness while working, then what inevitably results is the best that I can offer. I am variably successful in this endeavour: total success relies on the absence of self-doubt about one’s clinical skills and attitudes, and I do not possess either. This inevitably  means that anxiety sneaks through, and what I think I noticed was a form of anxiety peaking through in every other registrar that I dealt with on my night shifts; this anxiety does not seem to exist during the day, as it is borne out of the sense of exposure one feels from being much more alone that usual - let’s call it Witching Hour Wariness.

My own particular foible is to become pointed and direct - not the softest and warmest form of interaction possible. I would have previously argued that this is borne out of my perception that being the on-call Med Reg has a broad remit, and being able to avoid taking on unnecessary work is a good thing, and swerving some of the hassle that swings my way involves being able to say no in a direct and unambiguous way. This is partly true, but a revised truth must acknowledge that this behaviour is also precipitated by the WHW. How does your WHW play out?
I was offered an insight into this by the registrar who had been doing the day shifts this weekend, who fed back to me that she wasn’t sure what I’d done, but one the registrars we had both been dealing with wouldn’t be bothering us unnecessarily in future. It turns out that in the course of one simple phone call, during which I had explained that the extent to which I was prepared to help her was not the same as the extent to which she wanted me to help her. I felt I made a reasonable point, and perhaps I did. What, however, is important is that she came away from the conversation with the feeling that she had definitely been Riazed. That is not always a good place to be, and was certainly not where I either intended or wanted her to be.

So what am I mulling over right now? Well, I am reminding myself that we are responsible for the perception of ourselves that we create in other people, and that often that perception is way off what we either feel or intended; for example, if you accuse someone of being arrogant, they will often retort that they are merely confident. They are wrong - the perception is real, and cannot be refuted. The only course of action is to reflect on how that perception was created.

So perhaps, if instead of outlining the manner in which I was not going to do what she had asked, I had said something along the lines of ‘Actually, I’m pretty busy, and if I’m honest, a little stressed right now - this can be such a hectic job at times, is there another way to solve this problem?’, would I have had such a negative impact?

The trick, however, is to know how to access this kind of insight when you find yourself in the grip, and this is still very much a work in progress.

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