On Outliers.

Due to bed shortages, about half of the vascular patients are not on the vascular surgery ward but are "outlier patients" distributed across 5-10 different wards all over the hospital. This makes the simplest of tasks infuriatingly slow, the (true) worked example below is illustrative of common occurrences.

Consultant:

“Do you mind re-doing this patient’s bloods ready for the ward round tomorrow?”

“ I’d absolutely love to!”

Step one: Find a spare few minutes in the afternoon(?!)
Walk to the opposite side of the hospital (approx 10 miles)
Try and find a free computer to request blood tests
Attempt one:  software doesn’t work for some reason
Attempt two:  this one isn’t connected to a printer
Attempt three: Great! This one works. Press print.
No paper.
                “excuse me , sorry, where do you keep your pathology paper on this ward?”
Fill printer, press print.

Answer bleep: “unwell patient at opposite side of hospital, please attend immediately”

.....

Return to ward.
                “excuse me, sorry,  where do you keep your venepuncture equipment on this ward?”
                “excuse me, sorry,  do you know the code for the treatment room?”
                “excuse me, sorry, there doesn’t seem to be any tourniquets/syringes/needles in the
                treatment room, do you know where I can find some?”
Eventually collect correct kit. Locate correct patient. Wash hands.

Answer bleep: “unwell patient at opposite side of hospital, please attend immediately”

Go directly to ward. Do not pass go.

..... 

 Return to ward.
                “Hello Mrs Patient I’m one of the vascular doctors, is it okay if I take a quick blood sample?”
                “Sure if you can! The last person tried six times!”

(Sigh loudly.)

Attempt three failed.
I’ll just take an arterial sample instead.
Need to get more kit.

                “excuse me, sorry, could you tell me the code for the treatment room again?”
 Obtain blood sample, blood everywhere. Make token effort to clean up. Need to send sample to the lab.
                “excuse me, sorry, do you know where the pathology bags are kept on this ward?”
Answer bleep: “please return to other side of hospital to do several outstanding jobs”

.....

Return to ward. Better  find a free computer to check the blood results and write them in the notes for the ward round tomorrow.
Attempt one: the software doesn’t work for some reason. Try again.

                “excuse me, sorry, do you know where Mrs Patient’s medical notes are? No? Ok thanks anyway I’ll keep looking then” 

.....

The following day:
                “Good morning Dr Consultant, I did the blood tests you asked for and...”
                “Yeah, er thanks, whatever.  Plan: Discharge today”

Do you want this done quickly or do you want it done well?

Neither. You can have neither.

I have now completed 11 full days as a junior doctor and it is tiring. In common with the thousands of other new doctors I have experienced a whole spectrum of new feelings in my first few weeks. I’d quite like to document every single thought and feeling I’ve had because I’ve had a lot of them, but I won't because more than ever before I am seriously lacking in spare time to do so, and I am making a small effort to be less tedious.

A quick summary:

A normal day on the vascular ward involves arriving at the doctor’s office at about 7.30 and updating the list of patients ready for the day. There’re about 15 on the ward and 10 or so scattered around the rest of the hospital and it’s important to have an up-to date list of their names, locations and problems. Then we try and find all of the illegible clinical notes to put into a trolley ready to take around on the ward round. This sounds like quite a simple task but it’s nearly impossible to find all of the information as the patients randomly move beds several times a day, I seem to spend most of my day looking for notes because there is a chaotic and inconsistent system of organising and storing the notes that in no way keeps up with the Brownian motion of the patients through the hospital. 

Within seconds of printing out the handover list I usually find out that it is mostly inaccurate because I failed to predict all of the new admissions or changes or discharges that occurred overnight. This happens every morning and it is most annoying.

From 8 o’clock (when my working day begins) we go round the ward and hospital checking up on the patients, usually under the supervision of a senior doctor/surgeon. This takes the form of an intense memory challenge to remember what has been happening to each of the patients (most of which has not been recorded in the clinical notes that I couldn’t find), and/or an intense balancing challenge involving several folders and scraps of paper to scribble on frantically whilst the consultant speed-raps a completely new management plan. My general coordination impairment means I drop a folder and explode its contents onto the floor at least once a day. The ward round is usually led by a different doctor each day so the management plan is different each day too.

We usually finish the rounds in the early afternoon and then set about doing the jobs that have been generated, concurrently with the infinity of day to day paperwork and the routine or symptomatic management of any problems with the patients. So far I’d say that >50% of the job has been infuriatingly inefficient and often pointless administrative work. A large portion of the rest of the time is spent phoning a bunch of different people to ask how to do literally every little thing that it is assumed we already know, and then trying to correct all of the things that we did wrong the previous day. Due to the nature of the problems managed by the vascular team there are frequently huge burdens of disease, complicated patients with poor outcomes and occasional medical emergencies that often end in true tragedy. Here especially the feelings of not being up to the challenge can reappear.

A common game among doctors, and especially new doctors, is the “my job is harder than your job” contest: everyone wants to be a martyr, or a moaner at least. The truth is the job of any junior doctor is quite a lot harder than being a medical student, and it’s not quite the dream job many of us had been hoping for. The funding and staffing shortages in the NHS are very real and unfortunately there isn’t nearly as much senior support as we thought we’d have. The hours are universally longer than in our “contracts”, the breaks non-existent, the computer systems and protocols maddening, and the decision making is more difficult and much more significant than answering MCQs – which you can simply guess blindly, get half wrong, and still call yourself Dr.

But occasionally there are glimmers of job satisfaction. A lot of the time the only doctors on the ward are FY1s, and often there is only one. Through trial and error my feelings of inadequacy are slowly reducing and the occasions when I know the correct thing to do are becoming more frequent. It is quite ridiculous that when patients wish to speak to a doctor they often prefer to trust the very most junior doctor over some of the vastly more knowledgeable other members of the team to explain their situation. This is a privileged position of trust that I aim to live up to.

This weekend will be my first weekend of night shifts and I’m actually quite looking forward to it, despite the inevitable feelings of being new, exhausted, overwhelmed and inadequate all over again.