Guilty cubicles

I’ve recently cut down to working 4 days a week. I found out i’d been working 8 hours of voluntary over time a week since i started the job. I get paid for it. I just don’t want to do it. So I don’t.

Anyhow. Best decision I made – days off in the middle of the week are immense.

I think i’ve realised how stressed i get in work. I used to think that i never got stressed in work – i presumed stress meant that you made lots of mistakes and cried all the time and hated the job. Which is not what I mean.

What I mean is the continual frustration I find with the busyness of the place, with the compromises in care that I make because of the pressures of time and work load. And most obviously (to me at least) is how grumpy I get with the staff.

Ask me to do too many things at once and I start to get a bit short and snappy with people.  With people I love about things that are important. That can’t be a good thing.

As odd as this sounds – i find myself most relaxed and on form when it comes to the sickies – the people needing resuscitation and emergency treatment (alas making up probably less than 10% of my work). It’s the list of comparatively well chest pains and tummy pains and kiddies with temperatures demanding attention that stress me.

Having a day off a week helps me with that. I sleep better. It is in many ways an acknowledgement of weakness – that I do not cope as well with the job as perhaps i once did. Doctors are a fairly high-performing bunch of people –  it seems to attract that type, and perhaps emergency medicine as much as any. I still love the job as much as ever – i just find it harder.

The other thing I’ve come to understand is why I lie awake thinking about the patients I send home, or the patients who I’m not so clear about what’s going on with.

I’ve heard it called anticipatory guilt by the wonderful Jerry Hoffman on EMA.

He’s one of the anti-test brigade. The idea that we order far too many unneccessary and stupid tests on people who don’t need them. Which gives the impression to the patient of being a thorough and wonderful doctor when actually you’re just a bad doctor making up for bad judgement by ordering too many tests. I’m with him on that.

As an example:

A pulmonary embolism (PE) is a clot in the lung and a potentially fatal diagnosis that thankfully we can treat quite successfully once we know it’s there.

Most of the time people with PE look pretty sick and have quite significant symptoms and signs.

A small proportion will look very well and are easily missed.

We define them into low, medium and high risk groups depending on what else is wrong with them (ie having cancer or just giving birth makes you much higher at risk for PE).

When this risk idea was initially thought up about 10% of the low risk patients who we suspected had PE turned out (after tests) to have PE. Today less than 1% of who we call low risk and who we investigate turn out to have PE. We investigate a far greater number of these patients than we used to.

The implication is that we’re investigating a far greater number of people with no real success. We are also testing far too many. A 1% miss rate is considered acceptable for most conditions –  for example we miss about 2% of heart attacks and that number has remained constant over 30 years despite the huge amount of extra testing we do and the huge increase in spending.

What the numbers about PE suggest is that people who are low-risk are effectively no-risk patients these days.

So why do we keep testing them?

Is it a fear that the well looking patient with a mild cough and a bit of pain in the right side of the chest will come back dead?

Yes and no.

Yes that there’s a fear that the patient will come back dead but no because it’s not really the patient you’re worried about. It’s yourself.

We anticipate the guilt we’ll feel if we miss the diagnosis and it’s that that makes us order the unnecessary test.

The guilt will have some relation to the poor dead person’s family but most of it (and for this i can only speak personally) the guilt is how i will feel for professionally missing something important. For the feeling i have when I know that my peers know that i missed the diagnosis.

This is where the rational reasoning of what we know to be scientifically true meets the emotional fear of personal responsibility. The burden of decisions making (which is effectively what i get paid for, even though i’m not sure i’ve had that much training in it) is what we carry – and it seems all the numbers and science in the world won’t change that.

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2 Responses to “Guilty cubicles”


  1. 1 Roads November 4, 2009 at 9:17 pm

    This is fascinating stuff, Andy. Honestly, you should write a book to share all these insights. I’d even pay a tenner just to read them.

  2. 2 Nelly And I November 5, 2009 at 12:05 am

    Cheers Roads. I presume the cheque is in the post?…


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