What doctors don’t want you to know… (Day -200)

What doctors do not want you to know

Growing up I always believed in doctors knowing everything. Actually it was more like doctors were not human being only doctors and living in the hospital and that was all they did. For me this applied the same to dentists. One time going to the dentist for a morning appointment, and the dentist arriving in their street clothes looking normal actually made me nervous about my treatment that day.

How could someone that looked so normal carry out treatment on my teeth?

I was thinking about this today whilst I was visiting the doctor at the human hospital for my rabies booster.

By thinking of doctors like this it is possible to remove the fear from the visit as doctors knowing everything would prevent anything going wrong. Actually I started to realise that it wasn’t just thinking of them as doctors, we start to elevate them to gods and miracle workers. We need that hope to protect us from the fear of what is going to happen as when we go to hospital we are vulnerable and not in control.

We need that doctor to be in control – and to do this we need to elevate them to a superhuman status. Where we will be safe under their care, where they will not make a mistake, where they will fix any problem.  We need to do this to trust them with our life, especially when it comes to surgery where we are absolutely helpless.

I then realised the same thing happened when I put on my scrubs and step into clinic. Especially when things go wrong – people look at you and expect you to have an answer.

Even when you don’t have an answer you have the responsibility of finding one. Sometimes it is logic, sometimes it is common sense, a lot of the time it is having support there from others and then sometimes it’s a combination of all three.

I remember the first time I was in this position was a couple of years ago. It was lunchtime and I was alone in recovery with a patient that had just come out of surgery, and there was the patient from the previous surgery whose owner was sitting with them whilst they recovered. The next thing I know the owner is saying something (I didn’t understand Slovak back then) however looking at the dog I see the eyes are flicking side to side.

I’ve no clue why however the first thing I do is check the breathing and heart. I see there are no muscle tremors. I’d read about nystagmus which is the random movement of eyes side to side, I thought this may be nystagmus, however I did not know why this dog had just started showing this. However I didn’t think that the dog was going die in the next few moments and my recovering anaesthesia patient was stable so I decided I had time to run to the staff room to get a doctor.

It was only a few minutes, however it felt like eternity. I had no clue what I was dealing with, I was not sure if it was even nystagmus. It turned out that it was positional nystagmus from the anaesthesia drugs that only happened because the dog was laid on its side. Knowing that my book knowledge was a little bit correct didn’t take away the feeling that I had got really lucky.

It was the first time that I felt like an imposter. Since then I’ve learnt that it is not just me that feels like this. Apparently it is a very common feeling that doesn’t completely go. No matter how much you learn, there is always more to keep learning. The really scary thing here is when you have something that you try to find out more about to only learn that there is no answer.

This is where you just start to realise just how human doctors really are. That no one has all the answers. Then you start to realise that doctors can make mistakes.

Then you realise that they really are no different to you, they are only human, people. Maybe they have studied a lot, maybe they have worked for many years…

The white coat or scrubs is almost a protective barrier to remove the human element. Remove this and they really are just another person.

Why did the doctors go on strike?

junior-doctor-strike

I came across this and had to share – it is written by Dr Ravi Jayaram

I have kept quiet on here until now about the junior doctor’s strike but the time has come to stand up and say what needs to be said. Apologies in advance for the long essay, I will try to keep it simple. This is aimed at those of you who are not medical; those who are will know exactly what I am talking about.

If you simply believe what is said in the media, you might think that this is all about Saturday pay or even that junior doctors don’t want to work at nights or weekends. It is depressing to overhear people express these views but hardly surprising given the public coverage of the issue.

So what exactly is going on? A junior doctor is any doctor who is not a GP or consultant who is in training to be one of those two. Most doctors spend 8-9 years as a junior but many stay as juniors for longer, especially female doctors who may take time out for families, academics who take time out to do research and doctors in specialities where training in two specialties is needed such as paediatric intensive care. I myself spent 14 years as a junior doctor so was still one aged 37. Junior doctors are the doctors you will see first when you go to A&E or get admitted to a ward and will be responsible for delivering your day to day care when you are in hospital. Junior doctors are covering the hospital 24/7, 365 days a year and always have done. And contrary to what you might believe from the papers, they don’t have any choice in the matter, their contracts say they have no choice in working evenings, nights and weekends.

So what is all the fuss about? Well it is about being able to be safe. When I was a JD, I used to work ridiculous hours. In one job in my 1st year, every 3rd weekend I would go to work at 9am on a Saturday and leave at 5pm on a Tuesday. That was 80 hours in a row with sleep grabbed when the chances arose. It was dangerous and dehumanising and the even crazier thing was that I was actually paid at a lower rate for the unsocial hours than basic pay (1/3 of basic in fact).

Fortunately my generation of juniors was amongst the last to have to do that and things slowly changed. Now junior doctors get paid at a higher rate than basic for unsocial hours, that rate determined by the intensity of work in that specialty e.g. emergency room work would be a higher rate than dermatology. Standard hours are defined as 7am-7pm Monday to Friday (which are not exactly standard working hours for most people) and there are rules on the maximum number of hours per week and consecutive hours that can be worked. There are also safeguards in place so that if employers are consistently making juniors work beyond these rules, they can be fined; hence there is a disincentive for employers to overwork junior doctors, therefore they are not tired and dangerous 1990-style.

But work done outside standard hours is NOT overtime. These hours are contracted hours and have to be worked and, quite rightly, are paid at a higher rate than basic pay. In specialties where there is not a lot of emergency work, the majority of work is in routine hours, but areas like A&E, paediatrics, intensive care have a lot of work done in unsocial hours and attract a higher rate of pay for those hours. I stress again that this is not overtime; overtime is work done in addition to contracted hours. All doctors and nurses do overtime – staying late to complete work and ensure patient safety and very rarely if ever does anyone claim for these overtime hours.

But Jeremy Hunt wants to change the contract for junior doctors, his logic being that doing this will help to deliver the “7-day NHS”. Nobody is really sure what exactly this means. It may mean that he wants routine services such as outpatient clinics and planned surgery or scans for non-urgent problems to take place on Saturdays and Sundays, not just Monday to Friday. If this is the case then changing the juniors’ contract is not going to make this happen as without doing the same for (deep breath) consultants, nurses, porters, receptionists, pharmacists, operating department assistants, radiographers, physiotherapists and many other staff these things won’t be able to happen at weekends.

The 7-day NHS may refer to emergency work. If this is the case then it already exists. Junior doctors are already there at night and at weekends. The proposed contract changes are not going to change the numbers who are there as there is no plan to increase the total number of junior doctors. What is proposed is that the definition of normal time changes from 7am-7pm to 7am-10pm Monday to Friday and from 7am to somewhere between 5pm and 10pm on Saturday. This means that employers could make junior doctors work more unsocial hours as they have redefined as standard hours. It is true that the basic rate of pay for standard hours will be increased by 13%, which sounds great doesn’t it? Except that for the emergency specialties as above that routinely have a lot of evening, night and weekend work, what is currently paid at an enhanced rate will be paid at standard rate; even at 13% higher for standard rate, total pay for junior doctors in these specialties will drop considerably, maybe by as much 30% for some. Doesn’t sound so good now really.

And, of course, there will be the same number of doctors but spread over 7 days rather than 5 so there will be weekdays where there will be fewer juniors than there are now. A great analogy I heard was to imagine that you have a 10-inch pizza cut into 5 slices. You decide that 5 slices isn’t going to fill you up so your mum cuts the same pizza into 7 slices and tells you that you’ll be full with that. But she won’t get you a bigger pizza.

So same number of junior doctors spread more thinly is going to reduce cover on weekdays as compared to now. And weekdays are when not only emergency work but also routine planned work that also needs input from junior doctors takes place so this will have a detrimental effect on waiting lists for clinics and operations as well.

Junior doctors with children will be hit particularly hard, especially those who have junior doctors spouses, as more unsocial hours will be worked. Childcare is generally difficult to get hold of outside of 8-5 on weekdays; the department of health have actually said (with no hint of irony) that in this situation, family members who are non-medical and don’t work evenings or weekends should be asked to provide child care to get over this problem! It is very likely that couples could go several days without actually seeing each other or their families if rotas do not coincide.

But what about the increased deaths at weekends we have been hearing about? Actually, the statistics have been completely misrepresented and even the authors of the research paper that gets quoted regularly have pointed this out. The statistic was that if you are admitted to hospital on a weekend, your risk of dying within 30 days of that admission was higher than if admitted midweek. Your risk of dying is very low anyway and that very low risk is marginally higher (but still very low) if admitted on weekends. This is probably because admissions to hospital in the week consist of not only sick people but also well people coming in for routine things, whereas at weekends you would tend to avoid hospital unless you were desperately unwell and most likely would leave things as long as possible and so be sicker when you got there. Interestingly they also showed that if you were already in hospital on a weekend, having been admitted in the week, your risk of death within 30 days was lower than it would have been. Either way, there is no evidence of cause and effect in terms of numbers of junior doctors around at weekends. The so-called weekend effect has also been seen in the USA and Australia too so it isn’t peculiar to state-funded health as opposed to private insurance-based systems.

Interestingly the misrepresentation of this study has led to ill people actually avoiding hospitals on weekends and delaying presenting till Monday with potentially devastating consequences. Have a look online for the ‪#‎hunteffect‬. Scary.

Another worrying thing about the proposed new contract is that it takes away the safeguards against juniors being made to work ridiculously long hours. Whereas currently there is a mechanism that makes it in the interests of an employer to ensure the hours are not exceeded, the new contract removes these safeguards. It does suggest that each hospital trust has a “guardian” to whom junior doctors can flag up concerns about their hours but this “guardian” will also be a senior member of the trust who has no obligation to actually do anything about these concerns. I think back to my days as an exhausted junior doctor and it scares me to think that such unsafe and dangerous hours could make a return.

The pay scales are also changing. There has been automatic pay progression as you gain experience and seniority until now. The new system means that there are fewer points where pay is raised. This is not necessarily a bad thing as it can be argued that you shouldn’t get a pay rise unless you deserve it. But remember that over 10 years can be spent as a junior doctor in which time you are likely to acquire husbands, wives, children and mortgages; many existing junior doctors have made their financial plans for the next few years based on the expectation that there will be pay progression. One part-time junior doctor who has worked with me told me that if the new contract came in she would no longer be able to pay her mortgage and would have to sell her home. Bear in mind that these are young people who have spent at least 5 years at university accruing debts from both student loans for living expenses and now also £45000 in tuition fees before even starting work. The new pay scales do not reflect the levels of responsibility taken by junior doctors at different stages of their training at all which makes no sense whatsoever. For female doctors who are likely to take time out to have children and then return to work part-time, the consequences on their income will be huge. The department of health actually acknowledged that women would be hit unfairly but suggested that this had to be accepted as an unfortunate consequence.

The BMA junior doctors committee walked out of talks with the department of health because the DH’s definition of negotiation was that they would reserve the right to do what they wanted if they didn’t agree with what the committee was suggested. In other words, they did not want to negotiate so there was not point in the BMA trying. This is why industrial action was proposed because there was no other way to try to get Jeremy Hunt to talk. Sadly, even when negotiations restarted, he could not see that without a bigger pizza nothing was going to improve patient care and in fact things would be worse and so talks stopped. He has now said he is imposing the contract and that is that, he won’t talk anymore. When a strike ballot (of, let’s face it, intelligent reasonable and educated people) has a 75% turnout and 98% vote in favour, it is clear that there is a serious problem with the DH’s thought processes and they need to listen. It is highly improbable that a small bunch of radical lefties have brainwashed 50000 intelligent doctors who have been trained to analyse information and draw conclusions, much as the press like that idea.

If you have read this far, please take it on board and share with your friends. I’ve tried to keep it simple (even though it may not seem that way!) The public is not getting the full story from the TV and newspapers and if this contract is imposed then we will all be on the receiving end of the consequences eventually.

A bull in the room…

Collection of bull semen

Today’s Diary Entry is sponsored by Best Pet Hair Remover

One of the things here that is a little strange is that a lot of the lecturers also have private clinics in the local area. Whilst this lowers the number of patients being seen at the university it does mean that it is possible to see several different styles of medicine being practiced.

This week has been pretty hectic for me and I managed to go all week(well since Monday) without seeing a single surgery. For me it’s almost like withdrawal, i start to get cravings as it just feels like real medicine and a reminder of why i am here. During andrology our doctor mentioned that he had a mammary gland tumor resection and i was like a fish on a hook.

Before we go there lets talk about todays andrology class, as I’ve said andrology is all about the male reproductive organs. So today was all about the collection and examination of semen from a bull. This is pretty interesting as when a bull mounts a cow they ejaculate pretty quickly. Our lesson actually started with us watching this happen; sometimes i am still amazed when walking into classrooms with massive animals in. For this class there are metal pillars set into the floor for us to stand behind, in the UK at least not many places keep bulls because they are so dangerous, and apparently as a young inexperienced bull even more so i really was glad of this little bit of protection.

After the collection of the sample (apparently enough to inseminate 100+ cows) we moved to the lab where we performed the examination which included staining to distinguish between the live and dead.

After class i then met with the doctor to go to his private clinic for his surgery. I was impressed as it looked pretty recently constructed, and though being a relatively small space still had a lot fitted in. Within the university a lot of relatively simple stuff takes a long time with so many students so it was a breath of fresh air to see so many patients so quickly and effectively. This continued with the surgery using a basic triple combo anesthetic, good monitoring, and the patient recovering uneventfully.

Today i finished my day by having food with some friends. Though it was not such a crazy day this was the first food I managed to have today so was very well recieved!