Archive for September 28th, 2008

You can do better than me

If you talk to me about work (and i advise that you don’t) you will be quickly hit with a mix of enthusiasm, passion and frustration. Most of you have realised this by now and therefore stopped talking to me about it altogether. Ultimately only i find it this interesting. But occasionally some poor naive soul asks about my work and all of a sudden they’re pinned down under a wall of health policy, stories of dying people and how, to be honest, we often don’t really do that great a job of looking after people. By the end of the first pint, most people are moving swiftly toward the corner and onto the weather or the footy results. I don’t blame them, it is perhaps natural that only i am as enthusiastic about it all. This is not to say – as you might presume – that i think what i do is more important than what you do. I just know what i do is pretty important.

But there are a few people who talk about what they do with the same degree of enthusiasm and passion. And i don’t mean what you find most medics talking about – bitching and moaning about things that other people do wrong.

What i’m talking about is more like confession. Owning up to each other that we do not always do well. That in fact we quite frequently do badly and that we’d like to a whole lot better. These are our dirty secrets, fit only to be aired with a cup of coffee in confidence in the staff room.

So why are we so scared of admitting that we are failing our patients? Given that it’s something we do daily.

Part of it can be explained by the natural competitiveness in medicine. Say, for example you have a 12 year old cyclist hit by a car, with head and chest injuries. Waiting for him in the emergency department (apparently that’s what we call it these days, it used to be A&E. An ED seems to be different in that it sees more patients with less staff and gives them a worse deal…) will be at least 4 doctors (more likely 6 or 7) and a few actually useful people like nurses. The doctors will be of varying grades, varying specialities and with varying experience. In most cases (especially after a recent changeover of staff) most of the doctors will not know each other’s backgrounds and levels of experience (which is frequently different from seniority).

The astute observer can observe a bizarre performance. Like the pheasant’s tail in action. There is posturing and great fan fare and internal politics and people finding their place in the milieu of doctors. I know this because i have done this. I have spent evenings in resus rooms, trying to present the most obscure and complicated diagnosis to most impress the on lookers. If someone else mentions an equally obscure diagnosis that i have never heard of, i do everything not to let my ignorance show. I remember an ED consultant in Hawke’s Bay interrupting one of these such sessions of self-aggrandisement with a rather rude though salient comment that “aren’t we all having a nice wank…”

Simply talking the loudest and the most and leading the resuscitation does not ensure your place at the top of the professional pile. Consultants especially are notorious for not listening to what other parts of the team are doing – eg one consultant will say mid-resus “don’t give him more fluid” and within 20 seconds another will say “give him more fluid”. What is a junior to do…

Part of this reign of confusion can be assuaged by having people who know and talk to each other and perhaps, dare i say it, have a degree of respect for each other. This tends to eliminate a lot of the showing off and place finding.

The tangible arrogance that seeps out of doctors is difficult to deal with. From a human level, no one wants to admit they’re wrong, or the potential that they may be. At least certainly not in front of a colleague. On a professional level, self-confidence in decision making is encouraged. Unfortunately, too often this leads to the delusion that you’re somehow special, that unlike everyone else, you don’t get things wrong, you don’t miss things, you never make the wrong decision. This is a very dangerous place for you and your patient to find yourself.

We are perhaps victims of our own (or rather our medical ancestors) success. Penicillin, vaccination, transplants… There is an idea that the medical professional has the answer, however unsure we are about what the question is. While we are becoming largely distrustful of statements that people make – politicians, lawyers, criminals, moisturiser adverts… – there is still great credence given to ‘the doctor’. If the doctor says you’re OK, then you’re OK. The statement the doctor makes is often given more credit than it is actually due.

The problem lies in that people believe that medicine is an exact science. Which popular culture (and no doubt the medical profession itself) has tried to foster. It is however a big stinking lie. Medicine is not an exact science. It is merely educated guesswork. Sometimes the guesswork is more educated than others. People think this uncertainty applies to only the ‘clinical medicine’ of asking the patient questions and examining them, and that therefore scans and tests hold the key to concrete facts. This is also a lie. The scans and tests only contribute to the education of the guess.

Now this is not to devalue medical knowledge altogether, it is perhaps the best we have. However imperfect. But you must know – it is most definitely an imperfect science.

Which means we need to do better. In every single aspect. Something that seems to be getting lost in hitting targets and not eating or peeing over a 12 hour shift. There is not a tangible culture of excellence. Maybe there is, but it seems well hidden below the endless patients and targets and complaints. We are getting by yes. But getting by is hardly good enough.

I think it was done better when i was in New Zealand. That was partly resource driven. There were simply more resources, therefore we could do better. It was also driven from the top-down. The bosses expected a certain standard of care, and a culture of no mistakes. How else do you get better?

The desire, i think, is there. The desire to do better. The circumstances and structures are perhaps not there.

Efficiency does not imply excellence or quality of care. These are variables that are very difficult to measure and therefore very difficult to win an election with.

I have no easy answer to fix this. i have not the slightest desire to have any role in dealing with health policy and sit in meetings and argue over budgets. I suspect i don’t have the talent for it either. It’s as i tend to say, an important job, i’m just glad it’s not me that has to do it. In fact it would be easier to blame our failings on “the system” something institutional and anonymous and can be blamed on “the suits” in Whitehall.

But that’s probably a tad dishonest. Yes we are failing on an institutional and policy level, but we are also failing on a personal level. An overworked, demoralised, uninspired work force finds it all too easy to blame the system and is averse to admitting any personal failings. That perhaps they don’t advocate as vigorously as they should for their patients. There is a lack of personal responsibility for patients care. The expected level of care seems to be only a medico-legal one, not a moral one.

And this is where, i suppose, the responsibility is mine alone.


September 2008