On not striking

Today I went to work. I do this most days, but my arrival today was unexpected because this day I had planned to participate in a strike that the vast majority of junior doctors in England had voted for.

It was made clear by the BMA that this industrial action was a last resort. Doctors have never wanted to strike but we have been backed into a corner by a destructive health secretary unilaterally imposing a cruel and damaging contract on the medical workforce. The BMA balloted its members for industrial action and obtained phenomenal support from doctors collectively appalled at the decisions of central government. 

98% of those who voted (76% of those eligible, so 74.5% overall) said they would support strike action, a massive mandate for change and a clear sign, from those who know, that the government should re-examine their actions. The accusation that the BMA is merely a small band of "militant doctors" has been soundly disproved - essentially all doctors are willing to strike to prevent further erosion to doctor's conditions, ultimately to defend the NHS as we know it.

Compare this mandate with that of our government who received 36.9% of the vote, of 66.1% of the electorate: only 24.4% of the electorate gave their consent for the conservatives to vandalise our health service.

At the last moment the day before the strike Jeremy Hunt agreed to the BMA's conditions; lifting (temporarily) the threat of imposing a new contract and returning to meaningful negotiations via Acas. This was needlessly late in the day as there have been many, many occasions for the government to listen to the legitimate concerns of nearly all doctors.

I disagree with some of my colleagues who feel let down by the BMA. Some are angrily cancelling their memberships and have accused the BMA of weakness. Striking after receiving a reasonable truce would have been counter-productive in the extreme, leaving doctors open to accusations of greed and callousness. Striking is not our goal, it is our last resort tool in the struggle for a fair contract - its misuse would be very damaging to the public's perception of the profession and to our cause overall.  Right now I think we retain both the upper hand and the moral high ground. We're winning, and Jeremy Hunt knows it - so he continues to cast doctors as villains, openly lies and attempts to divide us to weaken our resolve. Not going on strike is a good outcome at this point. Not least because we save our innocent colleagues and patients from some inevitable and regrettable hardship and inconvenience.

Of course I would have enjoyed the novelty of standing at a picket line rather than enduring the often tedious and menial tasks I perform on the ward. I wanted to express the righteous indignation and fully demonstrate my depth of feeling for the profession and for the NHS.

And of course I still think Jeremy Hunt is a dishonest, smug, odious tosser and I don't trust his treacherous grinning weasel face with any aspect of managing the nation's health. 

But there's a much bigger picture: Doctors (and the health service and public sector as a whole) must remain united, dedicated and utterly professional in the struggle for fair treatment and the continued existence of the NHS. We have been gracious enough to give Hunt's first offer of conciliation the benefit of the doubt but if his arrogance continues we have the legal and moral mandate to strike in January.

Doctors feel attacked and denigrated, they have united to express this view and the secretary of state has been made to listen. The threat of imposing the new contract has been lifted for now, yet we maintain our mandate for industrial action should talks break downs. The most effective strike is one we don't have to do (yet).

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.

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.

ex-med-student

Since passing my finals I've received four or five emails addressing me as Dr.

All of them are junk e-mails but I still get a small warm zap of egoism each time. And although I haven't yet seen any patients or participated in the hat ceremony my identity as medical student is steadily and undeniably drifting away from me.

The most significant manifestation is the expiration of my student card which runs out at the end of the month. I am deeply saddened at the prospect of paying actual money to acquire that daily shameful extra cheeseburger from the McDonalds down the road from the hospital.

This all means that my rubbish unoriginal blog title and url need updating too. "medstudentwords" was boring but descriptive but now its not even accurate. So, until I outgrow it or change it, the new title for my home on the digital will be "juniorblogtor".   I am aware that this is an extremely poor title, but my alternatives were even worse:

cyberjonny
technolojonny
drblog
procrastimedicine
bowelsoftheweb
juniordoctorwords
crashcall
blogtoroctopus
drblogtopus
droctoblog
weak-foundations
diarrhoeaideas
jonnyology
blogacetamolqds

sheesh.