Nobody likes a complainer

Nobody likes a complainer, so I feel real sympathy for my friends and family who have listened to me moan about my job with astonishing regularity and passion over the past couple of months.

There are dozens of things that irk me about my job, and since it feels like I am at my job most of the time I feel irked most of the time, in dozens of ways.

What is difficult is that despite all of my complaining, most of my friends and family don’t really understand why I am so angry all of the time. So I can only conclude that 1) I am not at all good at articulating my gripes and 2) I am an unusually grumpy and furious sort of person.

There is good evidence for both 1) and 2), but I don’t think we can exclude the third possibility being true at the same time: 3) there are several problems with the job at present that are only acutely apparent to an fy1 in my position. So with that in mind I’ll power on ahead with some more complaining about a particular aspect of my job, mercifully in a highly ignorable way.

A broad category of irritation is prescribing; managing patient’s drug therapy is an important part of the role of junior doctors.

On my most recent night shift I got talking to a pleasant patient who refused to relinquish his usual tablets to the nurses for safekeeping. I was unable to convince him because I privately agreed that this was a pointless thing to do.

A patient in hospital is expected to hand over all of their regular medications to the nursing staff so they can lock them in a safe. A junior doctor is then asked to copy all of the drugs and doses onto a hospital drug card which instructs the nurses when, if and how to give each drug.

A pharmacist then checks that this has been done correctly, and alerts the junior doctor to any mistakes so he or she then can return to correct them. This is common because very junior doctors have only a small fraction of the drug expertise as the pharmacists, but only doctors can prescribe.

Even if a patient previously had complete control over when to take each drug, in hospital it is the nurses that administer the medication. The gentleman I was talking to protested that quite often on his previous admission he was left for long periods of time before being allowed his pain medication as the nurses were unable to attend to him immediately, because they have millions of other things to do.

When the space on the drug card runs out the junior doctor is then asked to copy out the drugs once again onto a fresh drug card. These re-writes would not be necessary if we adopted electronic prescribing.

http://www.polyp.org.uk/index.html

When a patient is well enough to be discharged from hospital the junior doctor must take the dug card to a computer and type them into a specific and ancient piece of user-hostile software in order to produce a printout of the patient’s list of drugs (the same drugs as on the drug card) to give to a pharmacist, who will check the list and dispense the drugs.

A pharmacist then checks that this has been done correctly, and alerts the junior doctor to any mistakes so he or she then can return to correct them. This is common because very junior doctors have only a small fraction of the drug expertise as the pharmacists, but only doctors can prescribe.

This prescribing process is required for every patient in hospital, even when their drugs are exactly the same before, during and after their hospital stay. It creates delays for patients receiving their drugs, requires the input of and communication between at least three different professionals and delays discharge from hospital, further contributing to the already pressing hospital-wide bed shortage.

A patient cannot be discharged until a doctor writes their discharge summary, and their medications are “prescribed” by a doctor. It falls to the junior doctor to write this summary even if they have never before met the patient. The doctor must also prescribe their drugs without expert knowledge of their condition, or management plan, or why they are even on the drugs, so often they are prescribing drugs simply because they were on them before admission. Such time-consuming paperwork never takes priority over more urgent jobs for unwell patients and so very often discharges are delayed, at great cost to the NHS. Some trusts employ “discharge locums”, doctors who are paid simply to ensure all of this paperwork is done and all these boxes are ticked to allow beds to be freed up. This isn’t an entirely satisfying solution but may be a pragmatic solution to the issue in the short term: on the same nightshift I was bleeped repeatedly to do some of these TTOs  (“to take out” medicines) left over from the day before, and I ended up doing the discharges when I had a spare minute away from more urgent tasks- at 8am the next morning.

Let me quickly insert dozens of caveats; I am not questioning any of the following:

I can see that there is value in having a clear record of a patient’s drug therapy before and during a hospital stay.

I can see that there is value in allowing nurses to control medications, especially when there are issues with a patient’s capacity to safely administer them himself. I can see that it might be important to store controlled drugs away securely to prevent them getting into the wrong hands.

I can see that experience in prescribing is an essential part of the training of doctors.

I can see that having a clear summary of what happened in hospital is important, and I can see why having an up-to-date list of medications and any changes is important for record keeping and to inform future management decisions.

But I am questioning all of the following:

I am questioning whether it is appropriate for a junior doctor (on-call or otherwise) to complete discharge paperwork for patients they’ve never met.

I am questioning whether it is a good use of resources to mandate that nurses dispense routine medications to competent patients.

I am questioning why it is necessary for the doctor to perform tasks that are then repeated and improved by a pharmacist.

I am questioning whether it is safe for junior doctors to write discharge summaries without clear instructions from senior doctors regarding future management or follow up.

I am questioning whether it is reasonable to expect discharge summaries to be completed between 2pm (end of ward round) and 5pm (closure of pharmacies) when there are a multitude of more important things to be done.

I am questioning the sense of using a paper based prescription system that is simply translated to an electronic one (via hideous software) upon discharge.

Of course, none of these problems would be quite so irksome had we either sufficient time or staff to perform the tasks to a satisfactory level without feeling rushed.