11 December 2010

Off with their heads

Grumble dreads being on call over those long public holidays we have at around Christmas. It is not necessarily that he minds working when everybody else is merrymaking. There used to be times when he quite enjoyed Christmas in hospital. In Christmas past there was an invigorating camaraderie. On Christmas Day the consultants would come in to carve the turkey properly kitted out with an enormous carving knife and a starched white chef's hat. Consultants would bring their families along and presents were exchanged. Grumble knows because his father would take him on Christmas Day to several hospitals. He saw how pleased the staff were to see him. He saw the joy of hospital life in those days. His memory is of there being masses of nurses everywhere you looked and there seemed to be very little work going on. Very occasionally, but much less commonly, he would see the junior doctors. He can still remember their pristine white coats. Everything was always spotlessly clean and hospitals smelt like hospitals. To this day Dr Grumble does not quite know what that smell was. It's not there any more.

So why does Dr Grumble dread the long holidays so much? Hospitals are no longer the places of merriment they once were over Christmas. Staffing levels don't allow any downtime these days. Turkeys have mutated into twizzlers and the kitchen was separated from the ward aeons ago. That's the modern world. More nose to the grindstone. Less joy. More a contractual relationship. Less duty. Minimal loyalty. Do these things matter? Of course they do. In the Grumble hospital sickness levels are rising. In the past junior doctors were never ever off sick. It's all about the loss of joy, duty and loyalty in the workforce. You can get a lot of work out of people just by stroking them a bit. They just need to feel valued, to love their work and have a sense of duty and loyalty to their patients and colleagues.

These things matter. They matter a lot but they are not the cause of the dread Grumble feels when there is a long public holiday. What worries Grumble about hospitals and holidays is patient care. As luck would have it, Dr Grumble used to work alternate Christmases. One Christmas he remembers an extremely sick man in his early fifties who was transferred from another hospital for Grumble's care. This was now some years ago but the patient's name is still etched in the Grumble mind. The details don't matter except that the patient was very ill and looked as if he would die. His chest radiograph is reproduced below:

OK. It's not the real radiograph but this is what it looked like.

The patient arrived just before the long Christmas and New Year holidays. Dr Grumble knew that there would be a race against time to try and make a diagnosis because, in hospitals, only the front-line workers work over the Christmas break. Any patient reading this might think that it is just a question of having a few scanners working and a single Dr Grumble to interpret the results but hospitals are much more complicated than this. It's people you need not just scanners. It's the expertise to work the scanner and interpret the results that matter.

For those who cannot read chest radiographs, the image above shows appearances consistent with widespread metastases. In other words the patient looked to be riddled with cancer. It would be wrong to go into any details but as Grumble has said the patient was very ill. It would be a struggle to keep him alive. And, if the cancer was essentially untreatable, keeping him alive would not be a kindness. Whatever we did he would probably die anyway.

But it was nearly Christmas. Dr Grumble needed more information. There were all sorts of options for getting this information but none of the expertise he needed was available over the long Christmas break. What should poor old Grumble do? Should he keep the patient alive on the off chance that there would be some treatment for this poor man? Or should he assume that, on the information available, no treatment was going to help? As luck would have it, on Christmas Eve, Grumble managed to get a CT scan carried out. And he was able to discuss the result with the top chest radiologist in the Grumble hospital. She agreed. The patient was riddled with metastases. Nothing else could realistically account for the appearances.

Dr Grumble would have liked a tissue diagnosis. He would have liked to have known that this cancer was not a sort of cancer that might melt away with the right treatment. But none of this was an option over Christmas. He would have to meet with the patient's relatives and he would have to convey all these uncertainties. Patients don't like uncertainly. Relatives certainly don't. Nor does Dr Grumble.

The case was much more complicated than this and Dr Grumble has no intention of giving you the full details of a real case. His purpose here is only to convey the sort of dilemmas that arise over public holidays when patients just cannot get the urgent tests that they need.

And so, Mr Cameron, you have gone down in the Grumble estimation. Because no Prime Minister should announce a new public holiday on the hoof without thinking through the consequences. Patients will die because of your decision to allow us a day off to celebrate a wedding. Did you check which day the wedding would be held on first? Why didn't you lean on those wretched royals and persuade them to hold their wedding at time when it wouldn't damage patient care quite do much? Did you look to check how many Bank Holidays there are then? Have you seen how few working days the hospitals will have that week? Do you know how difficult it will be for Dr Grumble and his colleagues? And do you know how many of Grumble's patients will die as a result of your decision?

Oh. I nearly forgot. Against all the odds Grumble fought tooth and nail to keep his patient alive over the prolonged holiday period. Some thought it would have been kinder to allow him to die. But Grumble had a clinical hunch that the appearances might all be due to infection. And the happy outcome was that the patient miraculously improved and the cannon ball 'metastases' just disappeared. It could so easily have been otherwise.


hyperCRYPTICal said...

It is sad that the sense of camaraderie is dissappearing in hospital settings; tight staffing numbers, nose to the grindstone and a lack of appreciatation leads to low staff moral.

I cannot understand the rationale behind the lack of staffing in some hopital department outside the nine to five, Monday to Friday ideal working times - for disease does not confine itself to work friendly hours.

I can understand your concern re the clutter of public holidays around 'the wedding' - there is a lot!

I am pleased that your patient recovered and that your hunch proved correct.

Dr Grumble said...

When Dr Grumble was a youngster Sundays were sacred. You couldn't buy a damned thing. Hospitals were one of the few places that were open day and night.

As we have moved more towards a 24/7 society what you can do for patients has increased along with the range of expertise you require. Providing all this around the clock is a challenge.

Most emergencies occur outside business hours so we do need to address this problem. It is not going to go away and the data will continue to show that holidays kill people.

E said...

Wards at christmas are quite grim these days I agree, though when I was off over xmas last year from placement I went back and from what I hear they had a jolly good time. I think the more "McDonaldization" occurs the more damaging it has been in the NHS over the years. Where are all the managers that pull the puppet strings, particually at a Nursing level on xmas day? All at home and the wards are left to fend for themselves without all the services they need; physio, rabid lab results, pharmacy, radiology. Some years I think wards hope and pray it goes smoothly and that nobody becomes more acute than they are and some years I suppose it goes all about tits up for some wards and it becomes a miserable and dangerous experience for everyone involved. The people who then get the iron rod for that are the frontline staff, nurses and doctors.

Though I have to admit, I worked christmas day in 2008, the evening shift at my local A&E and I had a wicked time. More fun than I did at home, though some would argue my idea of fun. Lots of cooking injuries and kids running around all hyper and I'd say about 99% of all the patients have had at least one drink so they were generally quite pleasent and amusing. All the staff brought something in for a mini buffet in the sisters office (she was off!) It was fun and I think we were more productive because our spirits were up, it was busy but it was good.

Anonymous said...

At our place, our Trust has agreed to pay anyone who will work extra hours over the bank holidays for Christmas and New Year, to help patient safety. All 6 consultants have volunteered to keep do their usual ward rounds (which will extend past the time we will be paid for. Out of almost 20 juniors, 2 have volunteered. A generational change?

Dr Grumble said...

I agree. There has been a generational change. But it is the fault of modern management and not the individuals. We were brought up with a sense of duty to our patients, our colleagues and the service. Our juniors have been told to go home at 5 on the dot and to work for money according to a contract.

Interestingly the system is getting less for more from these changes. For example, the new consultant contract led to better pay for, on paper, less work. The new GP contract was the same. They thought doctors only worked for money. And now, sadly, it seems they do.

This political and managerial interference has destroyed our once great profession.

Sam said...

"Our juniors have been told to go home at 5 on the dot and to work for money according to a contract."

I know loads of juniors and all speak the same, they do way above the hours they are contracted for without the pay to follow. And they do have a very strong sense of duty to their patients regardless too. Indeed, they are passionate about what they do and love doing it too! Only they rightly feel they are not being treated fairly pay wise, and I agree. Because if you compare your earnings when you were, say, 30 years old and what you could get for your money then to a 30 year old doc of nowadays and what s/he can get for their money, you will see that you probably were earning double what they get now in real terms. Of course, compassionate as you may be, you still need to eat and have a roof over your head and maybe have or are thinking of starting your own family too, and how many 30 year old doctors can do that unaided by parents nowadaysj? Or evust en get your own 1 bed flat, on a mortgage, somewhere around central London just to have your own space? We're talking a minimum of 400k here, and that's not in the best parts of London either! Your wage multiples if you are a 30 year old doc now won't get you half this flat, while you could easily do it when you were 30, and so can the nowadays lawyers, accountants, media presenters ... etc, etc, let alone the bankers, because it is Kensington SW7 for them!

Is a doctor considered less of a professional than these now? Hence, deserve a basic pay way well below the national average as is the case?

Single Female Doc said...

From my own point of view, I welcomed the extra holday. As a new single handed GP in 2005 I never received the MPIG bung other GPs had so can seldom afford to pay £450 a day for a locums. I had a full week off in 2009 for the first time in 5 years (didn;t manage this year).
The wedding has meant I can get 11 consecutive days off for just the cost of 3 locum days.
Last time I did that I had broken both my arms! Going to be weird having 11 days without doing any medicine.

britishmedicaljobs said...


Hope you don't mind but I've posted your blog onto our FB site britishmedicaljobs.com :D

Unknown said...
This comment has been removed by the author.
Unknown said...

Dear Dr Grumble

Our editorial team loves your engaging and informative blog on the status of the NHS, and have decided to nominate it for the Best British Health Blog 2010 Award.

We have been on the hunt for great blogs that make for intelligent and unique reading in the healthcare space, and we thought Dr Grumble was up there with the very best.

Feel free to check out the 9 other contenders in your category -

We run a health care comparison website called cliniccompare.co.uk, dedicated to providing users with the best service for their healthcare needs.

We will be offering the blog with the most votes on the 1st February 2011 the coveted award and a crate of Virgin wine. Bang goes the New Year’s resolutions!

Best regards and Good luck

The Clinic Compare Editorial Team
Ps. If you want a widget to encourage your readership to vote, then shout and we can send you the code.

Anonymous said...

Its the same in GP land -nose to the grindstone, constant pressure and little joy.
At least though we can choose whether to work bank holidays (for now)

Anonymous said...

I think it is a downward spiral. Disillusionment has lead to increased sickness and missed work days among juniors - hospitals won't cover their hours with locums and the existing juniors have to cross-cover and work harder longer hours. Which leads to disillusionment.