Is being a doctor just a job?

You hear this phrase a lot; being a doctor is “just a job”, but funnily enough in widely different contexts. On the one hand, the “higher calling” of medicine is derided by some, who insist it’s “just a job” like any other. On the other, doctors under extreme pressure need to know sometimes that their work is “a job”, it should stay compartmentalised and allow them a life outside the hospital or surgery, to balance their own mental health against their working lives. 

Which is it?
I don’t think anyone who has working in any emergency setting with human beings would accept the derogatory label of “just a job”, whether that job is doctor, nurse, physiotherapist, pharmacist, fireman, policeman, or paramedic. The normal course of a human life is long periods of normality and stability, punctuated by “Life” with a capital L; births, deaths, marriages, divorces, comedy and tragedy. There’s only so much of that a human mind can take, few of us can stand constant turmoil and upheaval. That’s why the mental health of those in extreme situations suffers: refugees, long-term domestic abuse, and homelessness amongst others. 

Being in an emergency job such as medicine means you are party to a constant stream of Life events: births, deaths, monumental illnesses. All the things that intrude into our bubble of stability to rudely remind us of what we already know but wilfully forget: life is random, and hard, and cruel, and important, and wonderful. 

So medicine isn’t “just a job” in that sense: it’s an enormous privilege to bear witness and to help human beings through the hardest and most real times in their lives. 

But if you let that tragedy in too much, you expose too much of yourself to that constant stream of suffering, you run the risk of your own mental health, exceeding your mind’s capacity to process capital L Life events.

That’s why it’s important to know in a positive sense that medicine is “just a job” too.

Knowing it’s “just a job” means you know you can walk away, which validates and empowers that unconscious choice to walk back in again. 

We all chose to do something important with our lives, but we should all recognise that that was a “choice”, and take heart in that. 

We should always recognise that we chose to help others, and that no one has an infinite individual capacity to do so; that’s why we work in teams, that’s why we do go home, that’s why we should remember to look after ourselves so we can look after others properly.

So yes, medicine is “just a job”; you have the freedom to walk away at any time, and, I hope, be empowered to choose to come back again. It’s a job, yes, but it’s a job like few others; it’s an enormous privilege and it is honestly one of the best jobs in the world.
juniordoctorblog.com

Junior doctors are left with few options, none good. What now?

Today the independent judicial review into the junior doctor contract imposition legality, put forth by the five junior doctors who make up Justice 4 Health, closed.

Justice Greene found in favour of the government, upholding their peculiar defence that Jeremy Hunt never actually imposed a contract, leaving it up to local hospitals to decide if they want the new contract or not. This, despite the fact that Jeremy Hunt has repeatedly hit the ‘nuclear button’ of imposition in TV interviews, parliament and speeches. Here is a quick video with some obvious examples;

As ludicrous as it seems, legally we have told all of this was an ‘irrelevance’ and although the judge suggested Jeremy Hunt could’ve been less ‘ambiguous’, the High Court rules that the contract was never imposed in the first place. News to 54,000 doctors, and no doubt many patients who were adversely affected by strike action against imposition. This final legal clarity prompted the question; if Jeremy isn’t imposing, who is? Well it would seem hospital trusts are imposing , and therefore can we now negotiate directly with them?

NHS Providers quickly tweeted to crush this speculation – they want a nationally agreed contract, and suggest there will be no local negotiations.

This of course follows in the same week that the BMA JDC have decided to suspend further strikes, and instead are now calling a symposium to which they have extended Jeremy Hunt an invite- whether he will turn up or not remains to be seen. Seeing as how he hasn’t turned up  to any of SEVEN crisis meetings in the last year at his OWN organisation I’m not holding my breath.

So junior doctors are left with few options. None of them good.

The first question is – do you accept the contract or not?

 

If doctors accept working under this contract, that still disadvantages women and LTFT workers and still is worryingly untested, then they must actively engage to make it work. This means forming local doctor forum, helping develop easy apps to exception report and challenging behaviour anywhere in the hospital that doesn’t meet the terms of this contract. If things go south, as these early rotas from obstetrics and gynaecology and emergency medicine anecdotally suggest, doctors must be vocal, and the BMA must back it’s members, although their powers may be severely limited.

If you don’t accept thev contract;

You essentially have few options. A lot will depend on how well organised doctors are from this point forward – with the BMA in full retreat this seems unlikely.

  1. Leave training – the imposition of the new contract is for trainees – going out of programme, into locum work, into research, or even abroad will mean you continue working as a doctor, but you aren’t subject to the terms of the imposed contract. For those at the end of training, finishing up and then moving abroad is a sensible option.
  2. Try to negotiate locally- whether individually or en masse doctors could offer to stay on the current contract, or organise a mass resignation against rota and contract conditions. Despite the bluster of NHS Providers it seems unlikely that hospitals will force a new, ‘cost-neutral’ contract at the expense of all their doctors. That is contingent of course on Health Education England, the training body of doctors, not imposing the contract by the back door and pulling funding for trainees who do not comply with the new contract.
  3. Offer your own contract. This isn’t as mad as it sounds – making a counter offer is a standard employment arrangement in most industries, just unheard of in the NHS. A contract that doesn’t discriminate against women, pays for study and has fair and safe rota arrangements isn’t too much to ask. But it seems unlikely.
  4. Bide your time. The contract is scheduled for review in 2018 – rumour has it Jeremy Hunt will be gone by then, and this may no longer be such a contentious political issue. With sufficient evidence of poor patient care and unsafe rotas, a renegotiation may be viable.

However, consider the context of the NHS. Over the past three years by every indicator the NHS has fallen into decline – waiting times, deficits, and now even hospital department closures, due to lack of staff. A new Autumn Statement might bring more money to the NHS, but having been through it’s most austere decade in it’s history, it’s even-odds whether there will even be an NHS at all come 2020.

For me, I left full-time training in August and have no plans to return. This contract dispute highlighted a multitude of problems with training to start with – but the utter contempt our NHS leaders, our government and their solicitors, and even some of our own seniors have held their trainees in appalls me. It has become a toxic environment for training and working. As a flexible worker I feel appreciated and needed, train and study when I need to, and most importantly, see and look after my family.

It’s up to the individual doctor what they do from here. If you can live with the contract, live with it. If you can’t, then find some way to find someplace you can. I fear too many will find that place outside of the NHS. With a collapsing union, a rejected judicial challenge, a toxic training environment and a complete lack of political will to shore up the health system, can you blame them?

 

juniordoctorblog.com

 

 

The NHS is collapsing. Part 2: if the NHS were a patient, I’d be pulling the emergency alarm

It’s my job as a doctor to interpret trends and analyse hodgepodge information to predict an outcome. I look at the NHS and see a single direction of travel: collapse without rapid and drastic intervention.
In a series of posts we will look at exactly why and how this is happening. This is what I see- you can decide yourself what you see.

In the first post here, we looked at why the NHS budget must rise 3-4% per year just to stand still.

In this post we will see exactly how this isn’t happening and what effect it’s having.

Imagine the NHS is a person- and it is very sick.

When I first see a patient we are trained to go about their assessment systematically. We first check their airway is clear of obstruction and they can breathe.

What do health systems breathe? Money. Everything has a cost, even in a free at the point of service system like the NHS.

So let’s look at our patient’s charts- as demand has risen the NHS has suffocated without proper oxygen to feed it.

Already an alarm is flashing; hospitals went from £0.6 billion surplus in 2010, to the worst deficit in NHS history- £2.3 billion in the red. 


If I saw this nosedive in the hospital I would pull the emergency buzzer. We have second and third opinions here too- The Kings Fund called this

the most austere decade in NHS history.

Professor Don Berwick, patient safety tsar, said

 “I know no nation that is seeking to provide [modern] healthcare at … 8% of GDP let alone 7% or 6.7%, that may be impossible “

The government spun this crisis as hospital ‘overspending‘- but that’s the equivalent of telling a gasping patient that they are ‘overbreathing’. It’s estimated the NHS needs £30 billion to keep afloat by 2020- the ‘extra’ £10 billion promised by government hasn’t appeared, is actually just £4.5 billion and is nowhere near enough. A deflated armband for a drowning man.

Next we look at the circulation, which is how the blood flows through the body and delivers life to the vital organs. What is the lifeblood of the NHS? The staff.

And we are haemorrhaging out. Just like our real blood the NHS system is made up of lots of essential components; doctors, junior and consultant and GP, nurses, midwives, paramedics, pharmacists, health visitors, radiographers, physio and occupational therapists, clerical and secretarial staff, cleaners, security. The list goes on. Every single staff group is suffering.

In the last two years the number of vacant posts for doctors has increased 60%, the number of gaps in nurse’s posts 50%. GPs are contemplating mass resignation, community pharmacies face mass closure, and the cuts to student nursing bursaries mean fewer nurses will be enticed into training. And junior doctors? Alongside most NHS staff junior doctors have already taken a 25% paycut in real terms since 2008, and certificates to leave the country are on the rise.


Now thanks to a toxic contract dispute they are leaving training in England; first choice applications to Scotland and Wales jumped 30-40% vs 2015, and first year training was under recruited in England for the first time in history.

The NHS needs a rapid and skilled workforce transfusion, and to stop bleeding staff burnt out by demoralising leaders and working environments.

The next step in a real patient is to assess their brain- so who are the brains? Well, Jeremy Hunt is still Secretary of State for Health, a man who looked at the above gasping and bleeding patient and declared “the NHS needs to go on a ten-year diet“. I think we need a brain transplant.

Then we assess the vital organs. What are the vital organs of the NHS? A&E, GP and cancer care. Let’s look at some test results. A&E is crashing- wait times over 4 hours just hit the highest in history, with just 81% of patients seen in target time compared to 98% just 8 years ago.


A&Es are closing and downgrading due to lack of staff and funding and no plan to cope with demand when other local departments close.

GPs are closing at record rates– and some being sold privately for more money, and for the last two years we are consistently missing cancer targets.

And let’s not forget the huge problems in social care funding. Even if we resuscitate our dying patient, we can’t forget that their house is caving in as well.
In the midst of all of this the government want to launch a ‘seven day service’, and deny there are any problems at all. Some NHS leads are even starting to leave reality altogether and claim ‘we don’t need safe staffing levels’.
Imagine a crowd of very concerned doctors and nurses around a very sick patient, tubes and wires and monitors blaring, and in jumps Mr Hunt, trying to shoo attention away and declaring “He’s just overbreathing and needs a good diet is all!”. As a doctor I would be within my rights to have him thrown out of the hospital. I can’t seem to get him thrown out of government though.

And as our leaders withhold the vital oxygen our patient NHS needs, as they fail to address the profuse haemorrhaging and the multi-organ failure, we have to ask why? Why would a responsible government be so wilfully ignorant of such catastrophe? And can we hope to resuscitate?
Find out in our final instalment;

The NHS is Collapsing Part 3: The collapse is a choice, not a necessity. 

Juniordoctorblog.com


Read the other parts in this series: The NHS is Collapsing.

Part 1: A Life in a Day of the NHS

Part 2: If the NHS were a patient, I’d be pulling the emergency alarm

Part 3: The collapse is a choice, not a necessity.

How To Sell Off The NHS: A Users Guide

So you want to sell off the NHS? A 65-year old behemoth, part of a raft of reforms that radically improved the quality of life of working people for nearly a century? It won’t be easy, but with this handy step by step guide you too can privatise your health service.

Step One
Know your enemy. In 2010 a Kings Fund poll put NHS satisfaction at above 70% [1]- the highest ever recorded approval rating. The United Kingdom has low child mortality outcomes globally; 5 per 1000 live births, (compared with world number 1 – Iceland at 2 per 1000 and the U.S. At 8 per 1000), long average life expectancy (male); 79 (compared with world number 1 Iceland at 82 and the U.S. at 76) and for maternal mortality the UK has an estimated 8 deaths per 100,000 pregnancies (compared with 1 per 100,000 in Belarus and 28 per 100,000 in the US). As a system the UK was ranked the best in the world for health access, efficiency, effective, safe and coordinated care (Commonwealth fund, Mirror,Mirror 2014). However, it currently spends only 9.1% GDP on healthcare or US$3,598 per person, which is free at the point of service. [2] The US spends over twice as much (17.1% of GDP or US$9,146) and was ranked dead last in the same Commonwealth Fund study. [3]
So, to sum up, you’re faced with a well-liked, efficient, life saving machine. So you won’t be able to try a head-on approach, public opinion will need to be swayed first.

Step Two
Misinformation: the great thing about the NHS is most voters at any given election will not have a vast deal of deep experience of its services. To many people the NHS is for shoulder physiotherapy and antibiotics for a chest infection and maybe the odd stitched wound at A&E. This is to your advantage! Start early on by pervading a helpful message of ‘improvement’ and ‘efficiency’. Steer every news piece towards this same message, regardless of context. Be consistent with this message and quickly this will become the ‘norm’. You will need some national newspapers on side to keep this reinforced. Before you know it the NHS will be percieved as ‘failing’. But that won’t be enough!

Step Three
Divide and conquer! It doesn’t matter what you campaigned on- once you’re elected you only have to apologise occasionally and you can do whatever you want! Push through some major reorganisation as early as you can- use words like ‘transform’, ‘power’ and ‘into the hands’. These will keep everyone in service on the back foot trying to respond. Make sure any change is extremely complex- this has two advantages; A) it makes it difficult for opposition campaigners to create ‘headline’ zingers against you and b) this is your opportunity to lay some legal horcruxes to build your platform!*

Step Four
Wash your hands early! If you want to sell off a national institution you have to make sure it’ll slide away easy. When no one is looking, make sure the government no longer has a legal duty to provide the NHS. But don’t stop there! Now is your chance to plan ahead!

Step Five
Open market! Everyone knows they get a better deal when one supermarket opens next to another one! Despite there being absolutely no evidence this applies in any way to healthcare provision! Use that knowledge to your advantage! Use words like ‘competition’ and ‘drive up performance’ – the more you can paint the NHS like a car the better- people like to sell their cars. Meanwhile once the law has changed,  open up the NHS to private contracts bit by bit. This will mean if anyone kicks up a fuss you can say ‘come on! It’s only 4%! It’s only 8%! Etc’. When the numbers start to get bigger use the relative percentages ‘It’s only increased by 15%!’. Useful phrases here are ‘can we please focus on the bigger picture?’. But then what about the staff on the inside?

Step Six
You do have a problem here: much of the NHS staff will see what’s happening, and people will listen to them if you don’t do something about it! Politicians are the least trusted individuals in the country, while doctors are the most; start early on with subtle denigration of the perception of all NHS staff. Take any news report about A&E or midwives or doctors or nurses and make sure someone high profile gets on a box and sticks it to them. Appoint a health secretary who will regularly inflame the situation- this will create distraction from the sell off! Frequently offer empty re-organisations that both fail to address and belittle any problems. Then get down to business.

Step Seven
The money! Cut it, and cut it hard. People use A&E and the GP the most- keep these areas stripped of cash and drive up demand by demanding people go at any time of day- encourage your health secretary to do exactly this! Once these areas go too far under they’ll sink by themselves- locum agency costs to cover staff gaps will cripple failing departments, and smaller GP closures will domino into bigger ones. Obviously don’t be seen to be thrifty- use words like ‘efficiency savings’ and ‘reform’, and above all ‘austerity! But do cut services away- the more gaps you can create the easier it will be for private companies to fill them! Put pressure on the very front services by cutting departments like a and e and maternity, and sell off the backend like microbiology and biochemistry, because no one really understands this stuff anyway.
Make sure you use this opportunity to crush the spirit of the staff- cut their pay, at least in as boring way as possible, e.g by pay freezes and under inflation changes. In the meantime try to award yourself a huge pay rise- this sell off is hard work you know! Doctors and nurses will leave, temporary agency staff will come, the service will worsen and the People will suffer! Now it’s time!

Step Eight
It’s showtime! If you’ve followed the above steps then this last will be a doddle. You’ve got a demoralised and depleted workforce, an unhappy electorate and you aren’t even spending very much on it all! You’ll need to do some hand-wringing, some lamenting, some explaining away. You will find these phrases useful; It’s ‘an ageing generation’, 21st century demand is too much, and ‘the burden to the taxpayer’. And then roll them in- hopefully by this time you should’ve got private companies into at least 20% of services.

Step Nine
Sit back and relax! All your hard work no doubt has been a lot of stress. And those long hours of drinking and smoking and missing the gym have really taken their toll. You deserve some time off! Don’t worry about the newspaper backlash- it’ll come eventually, and there won’t be a hint of apology as the same papers that supported you will hypocritically tear you down. And don’t worry about that chest pain you’ve been having! You’re insured right? Oh you lost your job? But what about the end game- the cushy seat on the board of the health companies? Oh, you’re politically toxic now and all those backroom offers disappeared? And you didn’t save anything?

Oh.

Goodbye.

Re-printed with kind permission @ juniordoctorblog.wordpress.com

*if you have to bridge an election with this still hanging over you just apologise for it! Say it was a big mistake. Then once you’re re-elected you don’t have to do anything about it!
[1] http://www.kingsfund.org.uk/projects/bsa-survey-2013
[2] http://data.worldbank.org/indicator/SH.DYN.MORT?order=wbapi_data_value_2013+wbapi_data_value+wbapi_data_value-last&sort=asc
[3] http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror

Let’s change the tone

How long can we be angry? Is it just me or does anyone increasingly pick up the paper and cannot believe the non-partisan, agenda-based drivel on the front page? The tragedy surrounding the victims of Victorina Chua in the last few weeks has created a predictable torrent of media-based attention. Is that attention on the rigours of qualification checking? On the staffing shortage of nurses in this country? On the fact that nursing has become increasingly ill-paid, increasingly harder work and increasingly despised? No, it is, of course, focused entirely on the fact that Victorina Chua is Filipino.

First off, let me just say I work daily with nursing staff looking after some of the sickest patients in the hospital- and they are nearly universally brilliant, dedicated, caring professionals. And yes, while you were wondering, a good proportion in the hospitals I have worked in are Filipino. For the record, these nurses in my experience are nearly always the best in the hospital. But that is meaningless.

For some comparison- look to the Daily Mail reporting of Andrew Hutchinson, convicted of raping and spying on unconscious patients at John Radcliffe Hospital in Oxford earlier this year. He was reported as “29, nurse” or even ‘male-nurse’. Nowhere was it mentioned ‘white nurse’, ‘Caucasian Nurse’, ‘British Nurse’, and nowhere to be found was the headline ‘The NHS is STILL hiring British/male nurses?!’, as there is sadly, in today’s copy of the Daily Mail in regards to Filipino nurses. And did anyone ever see a headline that read “Harold Shipman, white, qualified doctor?”.

But is anyone really surprised? All of us underestimate the effect that these newspapers have on our own thoughts and opinions. There’s an interesting cognitive effect called ‘anchoring’- it is well documented and very easy to prove with simple numbers. Put in simple terms- if I asked one hundred people to estimate the height of my house – I would most likely get a range of numbers centred around the true value (e.g. some people would be way under or over, but most people would approximate roughly the right height). BUT, if I asked the same one hundred people two questions: the first – ‘do you think this house is over or under 100 metres tall?’ And then: ‘How tall do you think this house is?’ – most people would vastly overestimate the height of the house, by 50-60% greater than the average if I hadn’t mentioned the value of 100 meters question. You can repeat this with the question “Do you think this house is over or under 2 metres?” and get an underestimate of the same proportion. Despite knowing how absurd a house 100m tall is, this information still drastically alters their estimation, and participants always avidly deny this.*

Now take this information in mind when analysing thoughts and attitudes towards the NHS. If you read on the front page of the Daily Mail how ‘foreign’ nurses are killing patients, and ‘Filipino’ nurses are STILL being hired- you, as a rational human being, will know that this applies to a single, unqualified criminal, and has no bearing on the vast, qualified, workforce of nurses from outside the EU that are the utter bedrock of the day-to-day NHS. But actually, when this information keeps getting re-presented to you, apparently supported by ‘NHS Doctors’ such as Max Pemberton, the ‘anchoring’ effect is very real. The next time you encounter a ‘foreign’ nurse, maybe when you or a family member are admitted to hospital, and everyone is very scared and anxious, you will find you have already pre-judged that nurse’s ability, second-guessed their intentions and competence, and you will no doubt, probably not on purpose, be rude to them because of it. And that, I’m sorry to say, IS racist.

But that’s not the point, and that’s not the argument. Something terrible happened- yes, and the victims of the criminal Victorina Chua and their family’s deserve our utmost sympathy, and our utmost ability to prevent unqualified, unsupervised professionals working in the NHS. But, when emotive, horrifying things happen, the ‘anchoring’ effect is all the greater. And you have to recognise that newspapers such as the Daily Mail twist these events to pander to a certain world-view, that propagates itself through it’s readership, which reassure themselves their world-view is correct by what they read in the papers.

So let’s change the tone. This is the truth: the newspapers do not report events to the public, they sell events to the public. And because of this, every newspaper has to add their ‘take’ on it, one that will appeal to their readership, so they can sell newspapers. It’s infantile, in the 21st century, to take everything you read in the newspaper at face-value, and most of it is not worth reading at all. Here is this event reported factually;

“Victorina Chua, 49 years old, is convicted of murder by means of injecting insulin into patients while posing as a nurse at Stepping-Hill hospital, resulting in at least two fatalities.”

And similarly the actual issues raised:

“This raises the issue of qualification-checking in NHS hospitals. This also raises the issue of clinical supervision in NHS hospitals.”**

And that, boring as it is, is it. But the world needs more sanity, it needs more boring. People are safer, happier, and more content when they are not constantly battered by fear-mongering bulls**t. But as long as you are buying the newspaper, or even clicking the links***, money is rolling in, and this drivel is floating out. Money doesn’t buy happiness, but it buys fear by the bucket-load. So let’s change the tone; re-write every article you read, with just the facts, and see how different your world-view is thereafter.

juniordoctorblog.wordpress.com

 

*If you are interested please read the fascinating “Thinking Fast and Slow” by Daniel Kahneman

** I will call my new, no-frills, objective news reporting newspaper simply ‘Things That’ve Happened- Daily”.

***Which is why you shouldn’t share social media links to articles you are criticising- it merely increases the hit-count for their website and increases the revenue.