05 August 2008


Few doctors of the Grumble era can resist talking about how when they were juniors they used to work all day and all night. Dr Grumble regularly used to work eight days non stop. In case anybody is in any doubt that meant eight days and nights or 192 hours. This was then followed by a further 4 days of 'normal' work when at least you wouldn't get called at night. You slept when you could. The patients thought you were going on and off shifts. They didn't realise you were working all the time and that when you weren't with them you were with another patient on another ward. Of course you had to sleep. But you would never know when you would be able to snatch a nap. It was exhausting. Much of the time you felt like a zombie.

Dr Grumble tries not to mention these times to his junior doctors. It is not a good idea to say how tough we were then. You cannot say such things without implying that today's young doctor is mollycoddled. The older generation have always tended to say that things were tougher in their day. There are examples dating back to the literature of Virgil. It's not helpful. And it's often not true.

The job Dr Grumble was describing was a house surgical post in a district general hospital. In the teaching hospitals of the day sometimes you had to stay in the hospital for six months non-stop. But it wasn't generally too busy. One's life revolved around the hospital. One's life was the hospital. You learnt a lot. But if the job was very busy it was cruel and inhumane. Nobody seemed to care about those poor overworked juniors. It didn't seem that it would ever change.

Fast forward to today and things have changed a very great deal. Junior doctors whizz in and out of the hospital on relatively short shifts. Idyllic you might think. And we have Europe and the European Working Time Directive to thank. Dr Grumble always thought that if ever such improvements came they would originate from the other side of the Atlantic but perhaps the American work ethic prevented that. But now they seem to be having the same sort of trouble that we are. In the US it seems that they are no longer allowed to work more than 80 hours per week. And that, believe it or not, is causing trouble.

Here's a description from Dr G:

We continue our rounds and enter the staff room, where an intern, seated at a laptop computer, is feverishly keyboarding a progress note that documents the current status and treatment plans of one of his patients.

A senior resident enters. "What are you doing here?" she asks the intern.

"Finishing up my notes."

"You can't do that. You've got to get out of here."

"But, the notes…"

"I'll do them for you. Make a list."

"I also wanted to check the rash on the kid with Kawasaki disease…"

"You can't. You've got to go home."

Apparently the intern in the staff room is up against the limits of the work rules and has been told to leave the hospital. There's no wiggle room. The ACGME requires training programs to report the actual hours spent in the hospital; it leaves it up to the training programs to figure out how to get the work done in the time allotted. If the intern continues on duty beyond the dictates of the rules, our training program might be cited for noncompliance. The penalty for too many citations: probation for the training program or possibly withdrawing the program's ACGME accreditation. A training program on probation or without accreditation has an extremely hard time attracting excellent resident physicians.

We proceed to the next ward. There we meet another resident who, earlier, had submitted a request for a PID consultation.

"Let's talk about the boy admitted last night with the neck mass," I say to her.

"Yeah…tell me what to do with him," she answers.

"Rather than my telling you what to do, let's think it through together so you'll understand how to do work-ups of kids with cervical lymphadenopathy."

"I don't have time for that.Please, Dr. G, just tell me what to do."

Not this Dr G but a Dr G based in the US. But it could have been Dr Grumble because we have the very same problems. She continues:

The rules, however, are backfiring. Residents no longer are able to observe the timing of a patient's response to an intervention; they can't follow the tempo of a fever or the bloom-and-fade cycles of a rash even when, as responsible physicians would, they sincerely want to. Their heads are crammed with the facts they've learned during medical school, but they can't see firsthand the course of a birth or a gall bladder attack or the phases of recovery from a surgical procedure and then integrate those facts into informed decision making. Instead of producing physicians with high professional standards who see their patients through to the end (of labor, of an operation, of an illness, of a life), the current system is creating a legion of shift-worker physicians who leave when the clock strikes a certain hour rather than when the job has been completed.

Join the club Dr G. Join the club. Doctors at the coal face are not listened to on either side of the Atlantic. Surely there could have been a better way. Surely we could have created a flexible system. A system that would have allowed quality experiential training for our juniors without working them into the ground? Join the club.

With thanks to the Witch Doctor who spotted the original Medscape article.


cramerj said...

So stop trying to teach them everything on earth. That is why specialisation was invented.
I qualified back in the 50s and found the training oddly monastic - so see lots of people, have few acquaintances and fewer friends. This too has an effect on later practice. Make one a bit inhuman I think.
As a now customer of doctors - now in Australia- I'm inclined to think that nurses will do a better job. At least they won't have Velcro bum. They may listen and examine.

Dr Grumble said...

No friends! Just like Dr Grumble. But is that really because of a monastic upbringing? Or is it ingrained curmudgeonliness. Is lack of friends a sacrifice we have made to be dutiful doctors just as a priest is celibate? Is our lack of friends the result of constantly moving from job to job or even from country to country? As for acquaintances, if a doctor is in work he has lots of these - but they revolve entirely around work.

How many close friends does the average person have? When patients are dying in hospital it's usually relatives that appear not close friends. And sometimes the relatives are estranged.

Is deep emotional involvement with patients really a good idea? It's difficult to make good decisions about individuals you get too close to. If you get too close to patients how do you manage when things go wrong for them - especially if it has something to do with a decision or procedure of yours.

The government seems to think that doctors are just in it for the money, are intent on doing as little as possible and need to be bludgeoned into doing a good job. But with a ‘monastic’ upbringing goes a vocational element and a sense of duty. That may be why doctors are so upset about iwantgreatcare.com. Living with adverse comments is not easy if doing a good job is important to you. And if it isn’t you probably aren’t going to care so it damages the wrong people emotionally. It is not like a web site where people criticize products. And if your GP ‘refuses’ to do what you want such as give you antibiotics that is not necessarily being a bad doctor.

Attempts by the GMC to reduce the amount of information being pumped into medical students seem to have had no effect. As for specialization, that is happening apace. But elderly patients rarely have problems in the confines of just one specialty.

As for nurses ‘doing a better job’ they are generally much better at following protocols which can be good for care. But the blind following of protocols by unthinking doctors often turns out to be detrimental. Dr G had a post about that particular problem but took it down because of patient identification concerns (though the patient gave his permission).

When it comes to listening Dr Grumble works alongside nurses. He wonders if this could be a time thing. Dr Grumble sees new patients in the time his nurse sees follow-ups.