How can we stay resilient in difficult work times?

This piece has been circling round in my head for a bit now. I’ve been trying to think of ways to make it accessible without sounding like a self help article, yet keep the salient points in there, and remain true to the original course that it came from.

When we chose medicine as our career we didn’t choose it because we wanted a nice calm 9-5 job. We knew it would be stressful, we knew it would take over our lives, we knew there would be times it drained our psychological energy. Were we prepared for quite how much our energy would be drained? At times I don’t think so. The stress of having to be in three places at once, flip-flopping our circadian rhythm from night to day, rotating from job to job every three months, being new all the time and yet being empathic and attentive to our patients no matter how we feel inside.
Are we trained for this? Should there be sessions at medical school on building resilience?
The NHS has resilience built into it. We can cope with a few fallow years with stretched budgets, reduced investment, delay to equipment replacement, but after a while the strain starts to show. We have now had more than five fallow years. I find it immensely frustrating – a small investment or increase in budget would make our service so much better. The imposition of the new junior doctor contract was the last straw for many, crushing their remaining enthusiasm and draining their last drop of psychological energy. 
At a recent rather excellent session on building resilience we discussed strategies for remaining positive and effective in a difficult work environment. Staying positive and enjoying your job at a time when there is a complete refusal to engage by government despite the protestations of the vast majority of the medical and nursing profession is hard, but essential. At this point I’m not just referring to the junior doctors dispute but the treatment of the NHS as a whole.
How do we avoid being drained? How do we remain happy and effective when our work environment is against us?
I think first and foremost we must build and vehemently protect our social support network. Working as a part of a supportive team, having people around you who build you up, who are positive and enhance your life, and who recharge your psychological energy pot. This includes us supporting others. Staying positive, building up others, avoiding draining their psychological energy.

As a part of world sleep day last month, my friend and sleep expert Mike Farquar (@thefourthcraw) filled his timeline with gems on how to optimise sleep, protect your rest times and deal with the constant jet lag of shift work. A well rested person has so much more to give to others, so much more reserve for difficult days.
There is so much more here to talk about – probably worthy of a couple of more blog posts, or even a series of its own. I think my take home message from this post is that we have to stay positive and keep ourselves in the optimum condition not only for doing our job but for keeping our personal lives happy and successful. We must actively protect our time, our relationships, and our reserves.

I want to acknowledge Ruth Roberts (@execstrength) for her ideas here. Thank you! I’d also like to throw this open to others. Please post ideas in the comments section or tweet using the hashtag #NHSresilience to collate them. 


Junior doctors in anaesthesia – the canary in the coal mine?

From February we have at least 12 vacancies on senior anaesthetic trainee rotas across my home trust. I know this is repeated around my region and around the country.  Some of these vacancies have occurred at the last minute and we have no hope of filling them by last minute recruitment into the gaps and I have a rising feeling of panic when I try to think how on earth we are going to cover the shifts affected.  

Contrary to the belief of some commentators in the media, anaesthesia is an acute 24/7 specialty. Emergency operations occur in the middle of the night, every epidural for labour in the small hours is inserted by us, trauma, resuscitation, pain relief, critical care – all are covered by anaesthetists.  The new junior doctor contract, which proposes to cut the pay for out-of-hours work, will therefore affect anaesthetists much more than many other specialties.

I work in North West London, and we are lucky that our anaesthetic training schemes are sought after and popular. Even here though, the number of doctors that are leaving the rotation is increasing, and has now reached crisis point. The hospitals involved have well organised training, generally perform well in the GMC survey of training posts, and yet doctors are leaving. Talking to my training leads many reasons are cited, but the most common are burnout, leaving the country for better pay and conditions abroad, leaving medicine altogether, and women choosing family life over a career in an emergency specialty.  Some have chose better paid jobs covering intensive care units in the private sector. Most also cite low morale and feeling undervalued by the NHS as a major contributory factor.

The doctors in charge of the training schemes routinely have junior doctors in tears in their offices saying they just can’t carry on in the current climate. They are highly intelligent, motivated, hard working individuals who could all earn an awful lot more in industry or in the City than the NHS pays them. There is also no allowance for the resignation rate in the training numbers recruited.  At least we are still able to fill those posts in NW London, other regions in the UK struggle to recruit more than half the doctors they require to maintain their anaesthetic service. 

How will we cover? The hospitals will advertise them as extra shifts, and consultants will cover the shifts that they can’t fill. The anaesthetic service has to cover the shifts to protect our patients, but the ability to cover routine work will invariably suffer. This is the consequence of unfair treatment of the workforce.  

This will harm patients much, much more than any strike. The NHS is not a bucket shop zero-hours-contracts employer. Highly trained, highly qualified doctors have other options – inside and outside medicine – and will follow those opportunities.  Maybe the NHS should simply be taken over by the private sector, then everything will be better won’t it? The NHS trains almost all the doctors that work in the private sector, it is a leader in quality improvement and the private sector frequently follows where the NHS leads.  A recruitment and retention crisis for junior doctors will hurt the private sector too.  The private sector cannot and should not replace the NHS. 

I ask the government please to treat our junior doctors fairly, come to a swift mutually acceptable agreement, and to start tackling recruitment and retention. They are harming patients by driving doctors out of medicine and particularly out of the emergency specialties.

…but they’re CHILDREN!

Does the total separation of paediatrics from adult services cause more harm than good?

Many years ago when I was training I was working on an adult trauma intensive care unit and we had an adult sized patient admitted with multiple injuries.  Everyone assumed she was in her late teens or early twenties, she received good care and after initial resuscitation and operation was brought to the intensive care unit. She continued to receive excellent care by nurses and doctors experienced in dealing with trauma patients and although still unstable was showing signs of improvement and the outlook was good.
Then her identity was established and it turned out she was 15 years old. Although her care didn’t change at all, suddenly the senior management became involved, the atmosphere changed, everyone became nervous, and there were rumours that she should be transferred to a paediatric intensive care unit. Many of us felt it made no sense to subject a critically ill patient to a transfer to a unit that doesn’t deal with trauma just because she was a few months away from official adulthood. She was adult sized, had an adult disease process, and was doing adult things when the accident happened.

Despite our protests she did get transferred. The transfer was thankfully uneventful and she continued to improve. No harm was done, but I have never forgotten how protocol and policies were victorious over common sense and the best interests of the patient.

Over the last twenty years paediatrics has separated in the main from adult services.  I have no problem with that in general, children mostly get an excellent service from the NHS and so much is done to make their hospital visit as pleasant as possible.  

In emergency care, however – particularly surgery and trauma – I feel that separating the care of children from adults can lead to increased risk and delays. Trauma is extremely rare in children, and most of the expertise in trauma care lies in the adult units.  That fact that they are “paediatric” is often prioritised over the fact that they have a time-critical illness that needs urgent surgical care.  Conditions that come to mind also include appendicitis, testicular torsion, head injuries and acute bleeding. 

Making the clinical decision that it is in the child’s best interest to be treated immediately rather than following policy and transferring is a difficult  but crucial one. Paediatric services are already outstanding in the UK, blurring the borders a little would make them even better. 

Please wipe the phrase ‘nil-by-mouth from midnight’ from your vocabulary.

One of the most common complaints relating to anaesthesia is being left without food and drink for extended periods of time waiting for surgery.  Being left without food or drink became one of the issues on the medical wards in the Mid Staffs scandal and it makes people miserable.  I know if I miss lunch I start non-specifically hating everyone and generally getting irritable, so I can see why our patients get upset.  

In the UK, despite much guidance for 6hrs for solids and 2hrs fasting for clear fluid, the phrase ‘nil by mouth from midnight’ is routinely used as a safe default , even when their surgery might not be until later in the morning, or even late afternoon. Our patients themselves have also become so used to this principle that they are often too frightened to follow the (up to date) fasting instructions we give them and still make themselves NBMFM, or even way before, just to be extra safe.

Why do we fast our patients before an operation? At the start of anaesthesia we give opiates, general anaesthetic drugs and medication that paralyses the muscles in your body. With a full stomach, the likelihood of acidic content regurgitating and being inhaled into the lungs increases when we abolish the body’s own defensive reflexes. The average person’s stomach is usually empty six hours after a normal sized meal (although when I have a large curry I know for a fact my stomach is still full the next morning, particularly when beer is also involved). Clear fluid is usually absorbed much more rapidly.

The European Society of Anaesthesia has produced some really sensible and excellent guidelines on preoperative fasting recently. You can view them here: ESA fasting guidelines. All the evidence I quote here is referenced from there.

The way clear fluid is managed preoperatively is my biggest bugbear. Our patients arrive in theatre very nervous, with a dry mouth and cold peripheries. Their previously beautiful veins shrivel to mere capillaries, and being dehydrated only makes this state worse. The evidence quoted in the fasting guidelines above suggest that in most instances a moderate amount of clear fluid is absorbed from the stomach in about 30minutes. In addition, the stomach itself produces an appreciable volume of acidic fluid continually, and being allowed to drink clear fluid reduces the acidity of the stomach content. Chewing gum has little effect on gastric volume, and neither does eating boiled sweets – they get rapidly dissolved into sugar solution and absorbed in the same way as clear fluid.

So, even if you anaesthetise a patient who an hour ago had a carton of Ribena, their stomach content is likely to be the same volume, and less acidic than someone who didn’t.  In addition, they are likely to be less miserable than someone who’s been fasted for 8 hours or more, and they are less likely to do acid damage to their lungs if they inhale their vomit.

Preoperative carbohydrate loading has become one of the pillars of enhanced recovery, and it looks like patients do better if we give them some calories before operating on them. Minimising fasting time preoperatively and starting food soon after an operation changes the body’s physiology from a catabolic fasting state, where the body’s reserves are being broken down for energy, to a more anabolic state. There is now reasonably good evidence for the overall enhanced recovery principles not only being better for our patients, but also reducing length of stay in hospital, making it more cost effective too.

Many people (me included) find it difficult to face a new day without their morning coffee. The good news is that coffee and tea count as clear fluid as long as you don’t add milk.  The European guideline committee wanted to add coffee/tea with a little milk as an allowable drink, but this was vetoed by a single member of the working party. Again evidence shows that if milk is added to a clear drink so it makes up less than 1/5th of the volume it acts as a clear fluid and gets absorbed quickly. When it forms a larger proportion it curdles and gets handled by the stomach as a solid. So a latte gets handled as a solid, but an americano with a dash of milk is a liquid.  I suppose the guidelines err on the side of caution, and to avoid confusion it might be better to avoid milk altogether.

Allowing your patients to drink clear fluids up to two hours before surgery is not only safe, but probably safer than starving them excessively. We currently generally say patients ‘may’ have a drink of clear fluid two hours before surgery, but I think we should change this to ‘should’. Patients are still frightened to do so and need encouragement that it’s not only right, but better.  Interestingly the surgical division at Mid Staffs has been doing this for years, and I’m really proud of our orthopaedic/trauma wards who are now actively giving our patients apple juice at 0630 on their day of surgery rather than hanging up the NBM sign.

Does it get better?

Recently @parthaskar and I asked senior doctors on Twitter if they would choose medicine if they had their time again. I realise Twitter may not be a representative sample, but the overwhelming response was yes, they would.

It would be a rare doctor who never questioned their career choice – usually at 4am when doing something entirely unglamorous with a negative team and ungrateful patient. During our discussion yesterday I was reminded of the #itgetsbetter campaign aimed to reduce suicide in gay teenagers who can see no way out of their misery growing up to homophobic parents and friends.

Should we set up a similar reminder for junior doctors that for most of their working lives they’ll be in positions with better hours and more recognition than the jobs they’re in right now? Also, should we remind senior doctors of how big an impact negative criticism and lack of recognition has on their junior colleagues?

I realise that my junior doctor years are a couple of years (!) behind me but they’re still very fresh in my mind. I was lucky to have missed the truly terrible 1:2 and 1:3 rotas. Most of mine were 1:4 and as I started anaesthetic training 1:6 where your shift started at 5pm and you went through to the morning. This is still my preferred shift pattern, and I think the full shift systems that our current juniors have to deal with are worse, and much more disruptive to their circadian rhythm. The long days are also more socially disruptive.

I realise the above is UK specific, and if you’re reading this as an Irish junior doc you’re still working the sort of hours that leave you no time to maintain a decent family life, and give very little psychological headspace for you to treat your patients with the care and empathy they deserve.

What are the factors that make junior doctors question their career choice?

Let’s start with being new all the time. The average British employee finds it stressful changing jobs – new teams, new practices, having to prove you’re not rubbish, establishing rapport with a load of new people. Many of our trainees rotate jobs every three months, and so just as they’re beginning to get the hang of the place they’re in they move on. They are new all the time.

Learning is exhausting. If you’re working within your experience most of the time the tiredness you feel at the end of the day is usually much less than if you’re learning something new. The vigilance you need is much higher and it takes more concentration to perform the same tasks that an expert could achieve with only a fraction of the brainpower.

Being continually jet lagged from turning your day around every couple of weeks takes its toll. I know everyone is different, but I found the second night to be the most difficult. I was never able to sleep terribly well in the daytime and so much preferred doing one solitary night, then just staying awake and collapsing in bed about 9pm the following evening, circadian rhythm intact.

For these reasons I don’t think the seniors of my generation have a particularly valid point when they say the juniors of today have an easier job than 20 years ago. In addition the training is more bureaucratic and prescriptive, and the pressures of having to prove yourself while learning just as high as previously.

Becoming a “senior” doctor generally leads to less night work, a stable job, better salary and more recognition. It saddens me how much more polite people were to me after my ID badge changed to having consultant written on it.

Yes senior docs have more responsibility, more dealings with management, and it’s not necessarily always brilliant, but in general it’s a lot better. If you’re a senior doctor reading this please remember that the things that come easily to you now were a struggle at the start. Just because you were treated badly when you were a junior doc doesn’t mean you should treat your juniors the same.

As a junior please remember the trainee years are only a fraction of your career, and if you never doubted yourself you wouldn’t be a good doctor. Medicine does get better.


Confessions of an anaesthetist – wrong drug, wrong route.

Many years ago when I was still a trainee I was on night shifts. I always found multiple night shifts difficult as I’m a very diurnal person and find it hard to sleep in the daytime. It was always the second night shift I found hardest, not the first.

At the end of one of them I was exhausted – it had been really busy and I hadn’t stopped. I was putting a major case on the table and all was going well. I was very much looking forward to 8am when I could hand over to a fresh pair of hands and crawl into my bed.

8am came and no one had shown up. The person taking over from me had a reputation for taking an extra 20 minutes or so to be punctual and on this day she lived up to her reputation. This irritated me.

At 0820 she finally arrived and stood in the doorway of the anaesthetic room talking at me for the next ten minutes. I continued working, was trying to listen and also suppressing the temptation to sharpen my voice, tell her to stop talking, go get changed and start work.

While this was going on I gave what I thought was diamorphine down the patient’s epidural. It wasn’t. It was metoprolol, which should go intravenously, not down an epidural. It was properly labelled, and I have no other excuse than being tired, distracted and irritated.

I realised what I had done immediately. I felt so ashamed, so guilty. I had bonded very well with the patient and the thought of doing them harm made me feel terrible. I felt angry with myself and at that point thought I was the worst doctor in the world.

I got onto the Internet as soon as I could and luckily it seems metoprolol doesn’t cause any neurotoxicity. The patient was absolutely fine and grateful for my care and attention. This made me feel even more guilty.

I published this on Twitter yesterday and there followed a lot of discussion about what factors make us make mistakes and why we don’t report our mistakes.

I never reported mine (well, maybe I have now). Much of the discussion about why we don’t report mistakes revolves around fear of repercussions and punishment. I do think this is true, but the main reason I didn’t was shame and embarrassment. Such a schoolboy error, but as no harm was done and no one else noticed it was much easier to stuff it into a dark corner of my soul rather than come clean.

Would I have reported this through an anonymous online tool where I wouldn’t have been identified? Probably. I think there are learning points from this incident, particularly how you should modify your behaviour when you’ve identified yourself at risk of making a mistake. HALT stands for hungry, angry, late and tired. I was at least three of those, and I’m sure my supply of Haribo brain food had run out by then.

The most important way of modifying your behaviour is to recognise you’re at risk of making a mistake. Slow down, tell someone, vocalise what you’re doing. Even if you’re a surgeon in the middle of an operation find a safe moment to stand back, look up, walk away from the field and take five minutes to gather your thoughts.

What did I learn from this? First of all to recognise when I’m at risk of making mistakes, and secondly now the last thought that goes through my head when I’m giving someone a drug is “is this the drug I think I’m giving, and is the patient allergic to what I’m about to give”. I ask myself it almost out loud. I’m still trying to learn how not to get distracted. I’m getting better.

Anaesthesia for the medical student.

A guide to the student standing terrified in the corner on how to get the most of your short time in the anaesthetic department even if you never plan to do anaesthesia or anything acute as a career.

In my institution the medical student attachment for anaesthesia lasts two weeks, and is part of the junior surgical firm. Other medical schools have one week, and some none at all. This is a great shame in my (biased) opinion:

anaesthetists form the largest in-hospital specialty and an appreciable proportion of the students will eventually become anaesthetists (often via other specialties, maybe a direct result of the lack of anaesthetic presence in undergraduate curriculums)

Every student can learn stacks during their anaesthetic attachment – even if they want to do the most community-based non-acute specialty imaginable.

I’ve put together a few words on how to get the most of your time with us anaesthetists.

Before you start
Do a little bit of reading. Not much, just a bit. Revise your physiology and pharmacology a little. Particularly analgesics and fluid therapy. Think about the relationship between heart rate, blood pressure and blood flow. Know a little about how we deliver oxygen to the tissues. It should all be there somewhere in the first and second year notes, it just didn’t mean much then, but now you’re going to see all this physiology and pharmacology in action.
Do a bit of background work: find out where you’re supposed to turn up, ask the students who’ve just finished the attachment for some tips. Particularly find out which anaesthetists are interested in teaching and go for those lists.

Learning objectives
Your objectives during your time with us is not to learn how to give an anaesthetic. If you want to do anaesthesia as a career there’s plenty of time for this later, and if you don’t it’s an entirely useless skill. Your objectives are threefold: practical skills, acute care, and safety/teamwork/non-technical skills.

Practical skills
Cannulation is probably the most useful of these. Anaesthetists cannulate all the time and we’re generally quite good at it. Did you know that for every successful cannulation by a junior doctor on the wards 2.4 cannulas get used? This translates to a first time hit rate of about 40%. I realise I may offend some people here, but the technique most junior doctors employ isn’t very good and sets them up to fail. Learning cannulation on plastic arms with veins that don’t move about and thick skin that you don’t need to tether doesn’t help with real people.

Other really useful practical skills include setting up monitoring, drawing up drugs, opening glass ampoules without shredding your thumb to pieces and running through IV fluids. All of these skills make you useful in emergencies. You don’t want to be the junior doctor who stands back barking orders at the overloaded nurse because the doctor doesn’t know how to draw up antibiotics.

Acute care
We render our patients unconscious and hypotensive with the drugs we give them. The way we support their physiology isn’t very different to how you would deal with an acutely unwell patients, and seeing it in a controlled elective environment allows you to gain great insight into how a patient’s physiology responds to insult and the treatment we initiate. The anaesthetic attachment is a fantastic opportunity to revise (learn) your physiology and pharmacology.

Safety and communication
Anaesthesia has become so safe through advances both in technology and safety behaviour that most people take it for granted. Observe how we communicate as a team, how we can gain a patient’s trust when they’re terrified of being anaesthetised, how the WHO time out is done and how surgeon and anaesthetist and theatre staff communicate during the operation.

Before the operating list starts
Introduce yourself to the patient. You’re part of the team and it can be immensely comforting for the patient to have someone else around when they’re being anaesthetised. However, don’t delay the admission staff from getting the patient ready, as this may delay the theatre list. Remember running an operating theatre costs more than £500 per hour, so even a small delay has large financial consequences.
Have a look at the other operating lists running. The patients may have some great surgical signs, and they will often be bored waiting around a bit for their turn, so happy to assist students.

In theatre
Become part of the team. By all means help out, particularly transferring patients on and off the operating table. If you hang back and cower in the corner everyone will forget you’re there.

Don’t touch or have your nose in the sterile field.

Engage with the theatre nurses and the anaesthetic assistant/ODP. They will teach you a lot. Learn from them especially how to scrub, draw up drugs, and how to run a bag of fluid through a giving set. Basic stuff that many doctors seem utterly incapable of doing.

Get your balance of questions vs silence right. The silent student will get forgotten about, the one that fires constant questions becomes irritating and can actually impair safety by distracting me at crucial moments.
Give me time to write my anaesthetic documentation.

There are probably a lot of things I’ve forgotten about – I’m sure some of my anaesthetic twitter colleagues will add to this and I’ll post it underneath. Please enjoy your anaesthetic attachment, don’t be intimidated by the operating theatre environment and take part in the team working. We enjoy teaching you, particularly when we get interested and keen students.