Trust Me I’m a Doctor?

I was sat in a weekly FY2 teaching session the other day when the BMA representative who had come to talk to us referenced the latest data showing how doctors were, once again, voted the most trusted profession by the British public. Not for the first time, this piece of information, and the way it was put forward, did not sit right with me. Is this title really justified and is it something we should be shouting about? As scientists we have an obligation to be sceptical when presented with data, especially if we’re going to use it for self-promotion.

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Jacob Rees Mogg reclines in the House of Commons

According to Ipsos’ 2019 survey, Australia, Belgium, Canada, France, Great Britain, South Africa, Spain and Sweden all put doctors at the top of their respective lists. It seems to have become somewhat of a cliché – with those voting for it susceptible to a heuristic that leads to a self-perpetuating reliability of results, year-on-year from country-to-country. In America, interestingly, the one year in recent memory, according to William Davies’ excellent book ‘Nervous States’, that doctors came in second, was 2001 when they finished behind firefighters. In the light of 9/11, public opinion was at an all-time for firefighters whose bravery had just been broadcast for all to see. But did people really have any new data to evidence the fact that they were ‘trustworthy’?

67% of Britons rated doctors 1 or 2 out of 5 on the scale of trustworthiness – with 1 being the most trustworthy – only 11% did the same for politicians. In truth, it’s a nonsensical metric. It’s an over-simplification of a very broad subject and it does not distinguish between the trustworthiness of the people themselves, the decisions they make in a professional capacity and the profession as a whole. Furthermore, compared to politicians (and advertising executives who propped up the bottom of the table), is it not somewhat simply down to the nature of the work we do? Honesty, confidentiality and impartiality are considered a bare minimum for doctors, compared to those in Westminster who are in the business of opinion, persuasion and ultimately manipulation.

William Davies also talks at length about how the rise of populism has come about in tandem with a mistrust of experts. The opinions of academics are suddenly not warranted in the political sphere and the value of facts seems to have taken a hit. It appears, however, that doctors have thus far remained immune to this swing towards scepticism of the academic elite. People no longer trust ‘facts’ but they still trust us. I wonder if that is at risk, and what our job would look like if we had to make the case to our patients that scientific fact was a valid argument in favour of taking our clinical advice.

A recent spat on Twitter between Professor Sally Davies and Jacob Rees-Mogg MP was triggered by the politician’s ludicrous and crass comparison of Dr David Nicholl and Andrew Wakefield. ‘Doctors are amongst the most trusted people in our country’, the former chief medical officer wrote in defence of her fellow physician, ‘it is worth listening to what they have to say with respect.’ When does the doctor lose that right to have their opinion respected by default and where do qualified doctors that have become MPs themselves rank in terms of trustworthiness? (A subject for a further piece in itself…)

The more doctors foray into politics and wield their power as trusted people, the more they risk being tarnished by the same brush as the countless experts whose claims on the likes of the economic effect of Brexit and the threats of climate change are repeatedly dismissed.

If these polls are to be believed and us doctors are almost universally trusted, what responsibility does it place on us? Should we make our voice heard in political issues that we believe in, as the likes of Dr Nicholl has done regarding the dangers of a No Deal Brexit, given that it is likely our opinion will carry weight? Or rather should we realise our position at the top of the Table of Trustworthiness is precarious, baseless and that one day we could be dismissed as yet another expert sticking their nose in where it is unwanted?

 

Image: https://www.thetimes.co.uk/article/rees-mogg-admits-supine-error-b9sx8hh3w

Blood clots, VAR and the Quest for Perfection

“Perfection is the enemy of good” said the surgeon to one of our patients on a weekend ward-round. It was a phrase I enjoyed and couldn’t help but agree with at the time, but it wasn’t until a further incident the following the week that it really got me thinking.

Those of my more dedicated readers will remember a certain Mr Bunce from a previous post. This notorious frequent flyer has now surpassed the impressive milestone of 200 hospital attendances. On number 208, he came in with the typical story of breathing difficulties, unkemptness and the desire for some attention. When patients come in with breathlessness, the list of possible causes is long and ranges from the benign to the life threatening. In the case of Mr Bunce, this is a typical presenting complaint and it is almost always just an exacerbation of his COPD, or ‘smokers’ lung’. Picked up with a simple chest X-ray and bloods, these episodes are easily managed with some antibiotics and steroids and Mr Bunce is sent on his way – until next time sir. However, this time, the 208th, the story was slightly different; the onset of symptoms slightly abrupter, the pain in his chest slightly sharper.

What he was describing was sufficiently suspicious of a blood clot on the lungs to warrant a CT scan. Low and behold, the scan showed multiple clots and Mr Bunce was treated with blood thinners. There was disbelief and wry smiles amongst my colleagues.

I felt this had been an important lesson, but perhaps not how you might think. The take-away could easily be that we should never assume someone is not unwell and doesn’t require thorough investigations for all possible ailments. But, in fact, I think it highlights quite the opposite. There are plenty of reasons why it would not be best practice to CT every patient that comes in with breathlessness, in spite of the fact that it would mean we would never miss blood clots. Firstly, a CT scan is about 1000 chest x-rays’ worth of radiation, but they also carry a far greater expense and burden of time than a standard x-ray. Furthermore, in the case of some patients who are frequent attendees – perhaps due to health anxieties or malingering – putting them through a full battery of investigations is only going to worsen the problem and encourage them to return. Thankfully, this time the history was significantly different to usual, and my colleague was skilful, thorough and judicious enough to ascertain that and hence organised a CT. However sometimes the symptoms will be atypical, and sometimes a patient falsely crying wolf, will in fact have a wolf lurking behind them. In this case, the story was different, and a CT was the right thing to do, however if Mr Bunce had simply complained of the exact same issue as normal, we might have, understandably, not scanned him, and missed the blood clot. We have to come to terms with this risk of diagnostic imperfection.

The Women’s World Cup this summer was a wonderful spectacle, in spite of the new technology. The parallel with medicine is that football, with the implementation of video assistant referees (VAR), has embarked on a dangerous quest for perfection. No matter how many camera angles you have of a sports event, there will always be contentions and ambiguities. Since the introduction of VAR, there have been more bitter arguments and discontent than ever before.

VAR.jpg

Whether it’s enjoyment of sport, or a sustainable health service and a doctor’s ability to sleep at night, the capacity to settle for ‘good’ and not be distracted by the unachievable ‘perfect’ is vital. Referees and doctors alike do a very good job, but they’re only human, and like all humans, they cannot be afraid of imperfections.

 

*Not patient’s real name

Image: https://www.wired.co.uk/article/var-football-world-cup

Do No Harm

It is often reasoned that making mistakes is an unavoidable facet of mankind and that we should merely see them as opportunities to learn. Oscar Wilde went as far as saying that ‘the only things one never regrets are one’s mistakes.’ Whilst it’s nice to feel like that is the case – that we can proceed fearlessly in all our endeavours, even those we feel ill-equipped and underprepared for, for every mistake we make will be a bonus – is it really wise? Is this win-win philosophy actually practical and applicable in the real world – is it applicable to medicine?

For me, the single worst thing about this job is that feeling I get, almost daily, of having made a mistake. It might manifest as guilt, or frustration at myself, or panic and sometimes it even makes me feel like packing the whole thing in. You feel like what you did was unacceptable, that you are a bad doctor and, most dangerously, that no-one can find out. You start to make excuses in your head, find ways of shifting the blame and try to explain why what went wrong is actually nothing to do you. The default position is that we must appear infallible to patients, to colleagues and to ourselves.

In his excellent TED Talk (1), Dr Brian Goldman talks about the ‘unhealthy shame’ that doctors feel when they make mistakes. As he describes, instinctively it is not what you did that was bad but that you were bad.

I’ve not worked in other professions, but my hypothesis is that this is more aposite in medicine than elsewhere.  And I think it comes down to two reasons. Firstly, it is a product of what is at stake. When it comes to people’s lives and wellbeing, it is so hard to come to terms with having potentially caused harm to the very person you are employed to help. The second reason is perhaps less obvious but equally pertinent, and that is that the type of people that end up as doctors tend to be perfectionists who set high standards for themselves and are naturally competitive. They don’t easily expose themselves as capable of getting things wrong, failing to succeed or being worse than their fellow doctor.

 

Personally, I am working on overriding this instinctive attitude. First of all, we are human and to strive for perfection is to set an unachievable goal and destine ourselves for failure. Additionally, with each mistake that I have made, I have learned that the system is well designed to ensure that it will get noticed and corrected before serious harm is done. Of course, there are exceptions but on the whole, as a junior doctor we operate with a reliable safety net below to catch us if we fall off the tight-rope. But most importantly, I have come to believe in the importance of trying to be honest when we do make mistakes. We have an obligation to have probity as doctors and that includes admitting when we have done something wrong. But also, we have an obligation to put our competitive, perfectionist tendency aside and be honest when it happens, for the sake of enabling ourselves, those around us and the system as a whole to learn from it and ultimately improve. Sometimes that will manifest as an honest word with ourselves, and having the courage to not make excuses, and sometimes we will have to outwardly discuss it with colleagues. Any fellow doctor that does not make you feel like you can be honest with them about mistakes you have made, is doing far more to harm patients that you ever will do through the inevitable lapses in judgement that we are all destined to make.

 

  1. https://www.ted.com/talks/brian_goldman_doctors_make_mistakes_can_we_talk_about_that#t-1136932

 

Doctor Coming Through!

The train ride back to the south coast from London on a Sunday evening is usually a two-hour period I enjoy. Inevitably delayed, terribly insulated and not especially comfortable, the Southern Rail service is hardly premium, but it does offer a time to be by myself, read my book in peace, and, most importantly, enjoy not being at work.

Sleep on train

Last weekend, however, a few stops outside of Chichester, the ticket-inspect made the following announcement over the P.A. system:

“Excuse me ladies and gentlemen. There is a passenger who I am unable to wake up. If anyone is a doctor, or policeman, could they please offer some assistance in carriage 2 and confirm whether or not said passenger is in fact alive.” What first struck me was the nonchalance in his voice. I was made to wonder whether this particular rail network employee was a strange, possibly sadistic man, or whether in fact he knew full well the passenger was not in fact dead.

If I’m honest, I was initially irritated he had disturbed my peace, but realised that on the off chance that this passenger was actually unresponsive, they could probably do with some help. As I arrived in carriage 2, there were already two people tending to the alleged corpse. One of whom spun around to tell me to stand-down, as he was in fact, unsurprisingly, just pretending to be asleep to dodge the fare (we’ve all done it). To my surprise, the woman who had turned to face me, was a colleague of mine and the third attendee at the ‘scene’ was also an F1 doctor I work with.

The incident reminded me of the time my parents were flying to Hong Kong and the cabin crew had asked if there was a doctor on board to assist with an unwell passenger. My dad, averse to public attention, and a psychiatrist with rusty knowledge of acute medical emergency management*, kept quiet initially before realising no-one else was sticking their head above the parapet. Ultimately, dad did help, perhaps spotting a potential opportunity. The passenger was predictably absolutely fine, but dad advised she be moved to first-class for the remainder of the journey none-the-less. And of course, he and my mum better move with her – you know, just in case…

Following our drama on the train, I was surprised, not just that we all happened to be on the same train, but also that we had all chosen to respond to the call for help. Given that the likelihood that this was a true ‘emergency’ was very small, and it was even less likely that no-one else would be there to help. I would bet that the three of us weren’t even the most qualified people on that particular train. Furthermore, there is no legal obligation for UK doctors to attend to a medical emergency outside of work. (That being said, the Medical Defence Union considers there to be an ‘ethical obligation’ to help in scenarios such as this (1), whilst the General Medical Council guidance states that we ‘must offer help if emergencies arise in the community’ (2).) But is it really that surprising that we did all answer the call for help?

On reflection, I realised that I was always going to go and help. I’m sure the enthusiasm to put yourself forward as a doctor in a public setting wears off with time, but we were three bright eyed and bushy-tailed first-year doctors, and this made us all the more likely to stroll up to ‘save the day’, perhaps with a slight dose of misplaced swagger. For now at least, we are proud of what we do and the skills we have, and so what if we want to show off a bit?! As cheesy as it sounds, we do actually want to help people, as all upstanding members of society do. Ultimately medicine is a vocation, as opposed to a job, and as a consequence, you are never quite 100% ‘not at work’.

 

*sorry Dad

 

  1. https://www.themdu.com/guidance-and-advice/guides/good-samaritan-acts
  2. https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/good-medical-practice/domain-2—-safety-and-quality

Image: https://www.stuff.co.nz/travel/travel-troubles/80927139/man-falls-asleep-on-train-wakes-up-alone-and-in-darkness

Needle Stick

Blood test, blood samples on a laboratory form

https://www.health.harvard.edu/blog/blood-test-results-not-quite-normal-201606029718

The desire to finish work on time, especially on a Friday afternoon, is about more than spending the bare minimum amount of time in the hospital beyond what we’re paid to do. It’s about pushing back against ‘the system’ and refusing to be gobbled up by your job. In truth, the rota of an F1 is relatively fair, but we don’t have to look far to see senior colleagues who have surrendered any semblance of a social life to the juggernaut of the NHS. As a consequence, on a Friday 5pm, we are prone to rushing our work and therefore, coupled with inevitable fatigue, are prone to mistakes.

Last week, for these reasons, with the added element of my own complacency, I gave myself a ‘needle stick’. In laymen’s terms, I took blood from a patient and then stabbed myself in the finger with the same needle. As I watched a small speck of my own blood appear on my finger, indicating that I had in fact pierced my own skin, my initial reaction was one of frustration. ‘How could I be so clumsy?’ And in an instant I knew I would not be leaving on time after all. I went straight to the phone to call Occupational Health, as procedure dictates. No answer. I looked at the clock; 17:01 – they were shut.

The protocol for ‘out of hours’ needle sticks is to go to A&E and wait in line for a blood test. I marched in there, pissed-off with myself, and tried to book myself in and take my own blood test (surprising hard to do!) before one of the consultants told me to stop being an idiot and to wait for a nurse to see to me. So there I was, 17:30 on a Friday, still in the hospital, but now as a patient and not even able to claim for over-time.

 

Thankfully the blood results for the lady from whom I’d received the needle stick, came back the following day giving my housemates only a 24-hour window in which to tease me about the prospect of having contracted HIV or hepatitis (not to belittle the significance of these lifelong illnesses, but sometimes you have to be able to laugh to stay sane). Luckily, she tested negative, meaning I was in the clear, assuming she hadn’t contract one of these bloodborne viruses in the last 3 weeks. I felt relatively assured that she hadn’t partaken in any risky activities such as anal sex or the injection of recreational drugs during this time period – all of which she’d spent in hospital, unfortunately too demented to get out of bed.

The lesson I was reminded of was of the risks to the patients but also to ourselves, associated with rushing and that it’s unlikely to get you home any earlier anyway. This lesson was reinforced just the other day when I was observing a procedure where a senior doctor had to drain some fluid from a patient’s lung. Before doing so, he put some relaxing classical music on in the background. I commented on what I assumed was a technique to help relax the patient, to which he replied;

“It’s for me as much as for them,” he said. “I’m a big believer in ‘go slow to go fast’”.

 

So, what had I learned?

  1. Less haste means more speed, plus better care for patients and fewer trips to A&E for me.
  2. The hospital will let you leave when it is ready.
  3. And for God’s sake wear gloves!

What is your time worth?

 

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Enter a caption

As flu seasons hits hospital staff, as well as patients, rota gaps appear. The hospital throw money at the problem and the gaps are plugged by doctors who are supposed to have time off but are paid extra to come in instead as a ‘locum’ – at short notice. Last Sunday, having had a relaxing weekend off, I received a message at 4pm asking to help cover for the evening. I agreed to 5 hours work, at 3 times my usual pay, and I am satisfied it was definitely worth it, but it got me thinking about how we value our time. What factors are taken in to consideration? And how logical and well-reasoned are our thought processes?

 

Ultimately there are numerous factors involved in the decision-making process, the most significant of which I believe are:

  1. How much will I enjoy (or not enjoy) the shift?
  2. How badly do I need the money?
  3. How many hours am I working this week?
  4. How else would I use my time otherwise?

For me the answer to the first question sits somewhere around neutral, on average. The second depends on your individual situation.

The third question is an interesting one. It is true that there are certain guidelines in place that should in theory prevent us from working ‘unsafe’ hours in a given week, but these are always bendable. It also brings to light the fact that there comes a point at which no amount of money would entice us through the hospital doors. You have to sleep at some point.

From my own experience and from talking to others, this is the first thing we consider. Before we think about the money and what we would do with it, we look at what the week ahead has in store and evaluate how shattered we are from the previous week. Only then will we decide we are willing to go to work and subsequently will evaluate if the money on offer is worth it. This heuristic is a good one for our own well-being and the safety of our patients.

The issue of how we would otherwise use our time is one that really sheds light on the transition we make from medical student to doctor. On the whole, medical students have a variety of hobbies and co-curricular interests – ‘work hard, play hard’ and all that. Personally, I value the opportunity to continue that busy and varied life outside of work very highly. If, by picking up a locum shift, I am not sacrificing the opportunity to play football, or go for a drink with a friend, and the money I earn can be used to fund these hobbies, then it is worthwhile. But otherwise, what’s the point in having money but no time to spend it? And likewise, what’s the point in having all the time and none of the means to enjoy it?

Clearly, I am over simplifying. The potential learning opportunities that work provides is one key factor that also needs to be considered. As does the fact that a lot of what we enjoy outside of work; reading a book, socialising with friend for example, is essentially free. And, ultimately, we will always be guided by our instincts when deciding whether to go for that shift or not. But stepping back to look at how we make these instinctive decisions is worth it once in a while.

Beware of the Mentals

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Idris Elba as DCI Luther (https://www.netflix.com/title/70175633)

I recently watched Bird Box and Luther – probably the two most talked about small-screen productions of late – and enjoyed them both. In fact they had a lot in common; a gripping and scary storyline, with great actors playing the lead roles. In the case of the former, Sandra Bullock stars in a Netflix film based on the book by Josh Malerman about an apocalyptic world in which demon-like ‘creatures’ provoke instant suicide in all they encounter, whilst Idris Elba is brilliant as a gritty London policeman, taking on the city’s most violent criminals.

There was one further element in common, that was less admirable. Both these productions, and countless others in the genre, used mental illness as a source of horror. Tom Hollander’s character enters the fray half-way through Bird Box as a quivering wreck, allegedly shaken by a narrow escape at the hands of ‘these psychos from a mental institution’. As if the concept of fantastical monsters that were so terrifying that even looking at them caused the victim to violently kill themselves wasn’t sufficiently scary, the writers felt the need to sprinkle in a vague mention of the mentally ill to dial up the fear-factor.

Meanwhile, DCI Luther’s latest nemesis is a man receiving treatment from a psychiatrist for his ‘paraphilia’ which drives him to violently murder people. It is this same psychiatrist who betrays doctor-patient confidentiality, in the interest of protecting those in danger, by informing the police about him and his illness.

I like to think that the vast majority of viewers are well aware that in reality, people with a mental illness are the vulnerable ones, not the ones to fear. (As it happens, we would have to detain 35 000 high risk schizophrenia patients in order to prevent one stranger homicide (1).) But it is hard to argue that this kind of storyline doesn’t have at least some impact, though it may only be subconscious, on the way people view the mentally ill and further fuel the problem of stigma. My experience of patients with mental illness is that they themselves are the ones feeling scared, vulnerable and threatened – much like the way their victims are portrayed in film.

We all know it’s just fiction and creators of TV and film can put whatever they want in to their stories, but can we not at least make the case that it is unnecessary and unimaginative? I don’t believe it is unreasonable to suggest that there are more than enough alternative sources of horror, both real and imaginary, that those suffering from a mental illness can be left well and truly out of it.

 

  1. https://www.tandfonline.com/doi/abs/10.3109/10673229.2011.549770