The Perils of Imperial Research and Development.

A long time ago in a Trust far away, Moff was disappointed with the lack of progress on construction of his new Death Star.  Darth was visiting in a month to check audit results and review progress so it was essential that productivity was increased by then.  Moff thought chocolate cake might increase productivity by improving morale.  The only problem was, he had no evidence to support his hypothesis because the countless people who had used chocolate cake before considered it to be common sense and so had not published their results.  The Empire would not pay the Death Star caterers for time spent making chocolate cake due to the lack of evidence.  Luckily, one of the bakers volunteered his time because he felt enthusiastic about the project. “This should only take a couple of days” Moff thought to himself.  “I’ll get the construction workers to fill out a Quality of Life Questionnaire, give them chocolate cake and then get them to fill out the same questionnaire again the next day.  I can also look to see if the rate of use of construction materials changes between before and after the cake.  I will exclude workers with allergies to the ingredients, diabetes, obesity, tooth cavities or lacking the mental capacity to decide whether to eat chocolate cake or not, and there are no children on the Death Star, so I cannot see any ethical problems with it.”

Fearing the wrath of the Emperor, Moff decided to do it by the book and filled out an Imperial Research Application System (IRAS) form.  This requested the same information to be entered repetitively into different sections of the form and took Moff all day.  He had to send it to the Death Star Research Development (R&D) Team for approval.  Unfortunately, R&D was inundated with more important research requests.  A week later, they got back to him and told him that all of the construction workers eating chocolate cake had to sign several statements on a consent form before they could eat.  Moff’s draft consent form did not match R&D’s standard format, so he was told to re-write it.  The workers would also have to be given at least 24-hours between reading information about the chocolate cake and deciding whether to eat it or not, and Moff would have to personally witness each worker signing the consent form before eating the cake!  

“Surely if they are eating the cake they have consented to it, they have mental capacity after all” he argued to which he was told: 

“You cannot predict how people will behave; just because they eat the cake does not mean they agreed to it.”  

Finally after another week R&D approved of Moff’s documents but would not authorise the Imperial Research Application System form without prior approval from Darth.  Moff started to get the feeling that the system was out of proportion to the intervention he had proposed.  One dose of chocolate cake would be pretty harmless after all.

Darth was a little busy competing with rebels who had gone to far off places or disguised their research as audit to avoid the Imperial Research Application System, but after a week he finished studying the abundant paperwork surrounding the chocolate cake protocol and approved it.  Amazingly the Endor Research Ethics Committee approved the project just two weeks later, on the condition that translation services would be available for Ewoks working on the Death Star.  Moff thought his troubles were over just four weeks behind schedule.  He knew there were no Ewoks working for him.  The workers could eat chocolate cake, productivity would increase, and the Emperor would be satisfied.  The elation was short-lived.  R&D informed Moff the baker and the staff serving the cake would have to undertake Good Catering Practice (GCP) training before they could deliver the chocolate cake.  Moff had done GCP himself and it took half a day.  It was all about catering research.  He wondered why the baker and service staff needed to do it because they had no involvement in the research design and would not be doing anything outside their existing skill set.  Unfortunately this was out of R&D’s hands.  Their fear of the Naysayers of Imperial Hunger Research (NIHR) overwhelmed logic and reason.  The requirement of GCP training doubled the time demands on the baker, so he withdrew from the project.  Similarly the catering staff were overstretched and did not have time for the training either.  R&D also instructed Moff to fill out a Site Specific Form and get it authorised by Darth before any construction workers could be asked whether they would like to try chocolate cake.   Moff tried to recruit another baker and service staff, but alas it was too late.  Darth had arrived to carry out his inspections.

“Why must I fill out a Site Specific Form when my whole research protocol was based on only one site and has all of the relevant information in it?”  asked Moff.  

Darth let out a deep mechanical sigh, and the blackness in his eyes told Moff he had suffered these same pains hundreds of times before.  

“Is this why the rebels are pretending their research is just audit or carrying out their research far, far away from the Naysayers?” asked Moff.  

“I find their lack of faith disturbing” replied Darth “The Emperor is not as forgiving as I.”

Moff quaked in his boots, but he need not have worried.  The Emperor resigned after the Cover-story Quality Checkers (CQC) alleged bullying in his ranks.  There is always a bigger fish.  So there is the story of why the Death Star was never completed; low morale due to lack of chocolate cake.  Where was the beneficence in that?

What the NHS Junior Doctors’ strike means to me as a patient.

The NHS has long been understaffed.  Public consultation for the 2000 NHS Plan revealed that the public wanted “more and better paid staff using new ways of working” and “improvements in local hospitals and surgeries”.¹  The resulting plan included:

• 7,500 more consultants and 2,000 more GPs

• 20,000 extra nurses and 6,500 extra therapists

• 1,000 more medical school places¹

At the time staff nurses and house officer’s were paid about £14,400 (equivalent to £22,320 today) and about £16,710 (equivalent to £25,900 today) respectively.^2,3  My local general hospital had just been closed despite public protests and its A&E department where my life was saved a couple of times, has never been replaced.  A nurse’s starting salary is now about £21,478  while a house officer’s basic salary is £22,636.^4,5  So what happened to the “better paid staff” demanded by the public in response to the NHS Plan consultation? 

Junior doctor strikes have been planned for 1/12/2015, 8/12/2015 and 16/12/2015 because the government expects junior doctors to work more anti-social hours without financial compensation in an organisation where they already voluntarily work extra unpaid hours to plug holes due to dangerous understaffing.⁶   What does this mean to me as a patient whose life has already been saved by the NHS on more than one occasion?

I do not want to be a patient during the junior doctors’ strikes, but who plans to be a patient?  When  I travel on motorways I have faith that should there be a motor-vehicle pile-up that I survive, I will be evacuated by (overworked underpaid) paramedics to the nearest A&E department or trauma centre.  When I cross a road, I look both ways first, but if a speeding driver or motorcyclist comes around a corner I have some faith that the NHS will provide for me.  The same applies when I go out at night at the risk of being mugged, or go to pubs or clubs where drunken violence is a real risk.  We never really know when we are going to get ill, and though consultants will be providing medical care the quality of care with reduced staffing levels will obviously be worse.  I am not going to take the same risks I have been doing on a weekly basis my whole adult life, because though the probability of things going wrong is very small, the potential consequences are going to be a lot worse.  If I had elective surgery between now and 17/12/2015 I would cancel it, because I would not want to risk still being in hospital during the junior doctors’ strikes in the event of unexpected complications of surgery.  

Hopefully though, the strike action will lead to a wake-up call for the government regarding underfunding of the NHS.  I hope other NHS staff organise strikes too, until they all get a fair deal and a future, publicly owned NHS has been secured.

1. http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_118523.pdf

2. http://news.bbc.co.uk/1/hi/special_report/1999/01/99/nhs_in_crisis/252610.stm

3. http://www.thisismoney.co.uk/money/bills/article-1633409/Historic-inflation-calculator-value-money-changed-1900.html

4. https://www.rcn.org.uk/support/pay_and_conditions/pay_rates_2014-15

5. https://twitter.com/VenthanMailoo/status/660727815717961728

6. http://bjgp.org/content/64/623/295

NHS Junior Doctors are obviously out of order for complaining about their pay.

Dear Samie,

Thank you very much for your questions. This is exactly the kind of dialogue required to shatter public misperceptions about what junior doctors do. Members of the public get fleeting glimpses of hospital doctors because we are so busy, and that can be misleading. My mum and dad worked in an ice-cream factory. I have also eaten ice-cream. I still do not feel qualified to comment on the relative workloads of different ice-cream factory workers. I appreciate your mum has done 3 healthcare jobs and you may have been a patient, so you have a perspective of what doctors do. I have been a patient and also had direct experience of several healthcare jobs so if as you say your mum has only worked in 3 roles, my experience has been more diverse than hers. I can tell you from experience that healthcare workers in general are overworked and underpaid, but I can also tell you that NHS doctors are being pushed to breaking point at the moment.

You asked how many patients I dress/undress: Countless when I was a healthcare assistant. Since then I have rehabilitated disabled people to be able to undress and dress themselves as an occupational therapy assistant and occupational therapist.

You asked how many IVs do I attach and unattach: I have set up drips for collapsed soldiers and hung the bags in trees. Attaching and disconnecting drips is not physically demanding or time-consuming though it must be done properly using aseptic technique. Try cannulating an obese patient, or somebody who is in shock. Try doing it at night with poor lighting. These tasks are completed multiple times per shift by junior doctors and are far more difficult than connecting a drip. Admittedly nurses (not doctors) usually prepare IV antibiotics and that is time-consuming, but in my current job I prepare IV antibiotics and give drugs myself.

“How many aggresive patients do you deal with?”: Patients often get aggressive due to the frustrations of how long they have to wait to see a doctor. That is because there are not enough of us, and as they see nurses first, nurses deal with the brunt of the aggression. After checking for and treating medical or surgical causes of aggression, such as lack of oxygen, low blood sugar, poisoning or intoxication, infections, metabolic diseases, head injury or cancers, if patients are unreasonably aggressive I let the security staff deal with them.

How many patients' buzzers do I answer at night? Unlike a ward nurse, a junior doctor covers multiple wards at night and usually gets bleeped relentlessly. On one occasion I had to deal with two patients with acute chest pain, at the same time, at different ends of a hospital, and on another I was called to simultaneously deal with a possible transfusion reaction on one ward and sepsis on another. At night, doctors may not have time to sit down, let alone eat or drink and after some night shifts I was barely fit enough to walk home and would have been unsafe to drive. The nurses know this and try to look after us, but often we do not have time to be looked after. How many nurses have you heard of falling asleep at the wheel or being unable to concentrate and crashing their cars on the way home due to exhaustion?

http://www.edp24.co.uk/news/health/staff_at_norfolk_norwich_hospital_pay_tribute_to_promising_doctor_killed_in_car_crash_1_4181293

http://www.heraldscotland.com/news/13166072.Hospital_working_hours_cut_after_death_of_junior_doctor/

In some places nurses are understaffed, particularly at night, and personally I think this is dangerous, but doctors are understaffed too. You asked: “How many hours do you spend with each individual patient?” Exactly! Doctors spend minutes with each patient, because we are spread too thinly and have too many patients. We do not get the quality patient contact that would increase our job satisfaction. I had more job satisfaction from patient contact when I was a porter and healthcare assistant. Patients and relatives often get annoyed by how difficult it is to see a hospital doctor. Even nurses can get annoyed and shout at us when we do not come to talk to their patients’ relatives quickly enough because they do not realise how busy we are when we are on wards other than their own. That is because there are too few of us. When it is a choice between spending time giving vital medical care to keep somebody alive, or talking to patients and relatives, the vital medical care takes priority; that does not mean we would not rather be talking to our patients. In A&E when patients are queueing in corridors waiting for beds, the reason they are not being seen by doctors is because the doctors are busy, seeing one patient after another. You stated that “doctors do not undertake the physical workload” and that is mostly true, but our work is intellectually, emotionally and physically testing, especially if we forget to eat or drink. I would recommend our job to anybody who wishes to lose weight, because as a junior doctor you will lose weight, not only due to having limited time to eat, but also due to the number of miles you walk each day walking from ward to ward, from patient to patient, the glucose consumption of your brain and the increased metabolic rate provoked by anxieties about patient care. At the start of my medical career I used to worry about my patients when I should have been sleeping at night, but as time goes on, I have got used to that stress. You stated: “You should just appreciate that you get to do a job you love which has a good wage.” Yes. I love my job, but it is like chocolate. In reasonable doses it is great, but too much chocolate on any one day will make you ill, and too much chocolate over a cumulative period will have serious health consequences, just like working as a doctor. “Antisocial working hours and poor work–life balance have been linked to stress, anxiety, depression, cardiovascular risk, gastrointestinal disorders, obesity in men, and workplace accidents possibly due to sleep and circadian rhythm disturbances, social marginalisation and poorer dietary habits. Excessive working hours have also been linked to increased alcohol consumption by women, lack of sleep and increased smoking for both sexes, and lack of exercise for men. Medical careers are a risk factor for substance misuse and suicide.”: http://bjgp.org/content/64/623/295 The wage is good, but if you include the unpaid hours we do, the hourly rate is often not good. In one of my surgical jobs I was working on average two extra unpaid hours per day; that is the same as working 6 days per week but only being paid for 5. If all we cared about was work, doctors would only be complaining about risks to patient care, but guess what, we would like to have lives too, and as it stands, a career in medicine in the NHS will ruin your life. When our Saturdays are considered a ‘normal working day’ it will be even worse.

“You say you should be compensated for studying through your life, what do you think us mere mortals have to do if we are teachers/ pharmacy assistants/emts etc.” I was not always a doctor. I was an army 'medic, physiotherapist and occupational therapist. I had two previous degrees before I started medical school. Trust me on this one. The ongoing personal study I had to do as a physiotherapist or occupational therapist is so insignificant compared to the ongoing study required for a medical career, that any comparison is laughable. My other half is a nurse. She sees how much work I do and I am 100% positive that she would agree with me on this one. The amount of study I have to do strains our relationship.

You said: “be thankful for obviously being academically minded enough and having a decent education to provide you with opportunity” Eduction is not handed to us on a plate and neither are opportunities. We get into medical school through dedication and hard work. When our friends were watching Sky TV, playing on their Playstations and going out, we were studying. I am dyslexic and got poor A-level grades. Due to that and another unseen disability I had to do two other degrees just to meet the entry requirements for medical school. None of that was ‘provided’ to me; I worked for it. I remember while I was in medical school I heard on the radio on my way to a hospital placement a discussion with people complaining that they think doctors get paid too much and I thought to myself ‘Anybody who thinks doctors are getting paid too much should try medical school, to see what we are being paid for’. If you pay us any less, students will give up when they hit walls in medical school, because they will quite rightly recognise that the personal sacrifice is not worth it.

“If you want to orchestrate change focus on the issues which matter, being paid upto £22 an hour is not one of them.” A NHS doctor has to work for 11 years and pass post-graduate exams to be able to earn a basic rate over £22 per hour. You seem to have missed the £10.85 starting wage, which is after dedication at school and 5 years of hard graft at medical school. This does not account for the unpaid hours we do because the NHS is short-staffed. Not having the best people in medicine will matter. But by the time you realise that, it will be too late.

“And if you even have to ask why you should be a doctor other than for financial compensation, then maybe you shouldn't be.” You may be absolutely right on this one. The entry interviews for UK medical schools should have the following screening questions:

1. Would you like to spend time with your family?

2. Would you like to choose where in the country you are going to live?

3. Do you have any leisure activities you would like to continue regularly?

4. Do you value your own health?

5. Do you like getting a good night’s sleep?

6. Would you want to be compensated if any of the above were taken away from you?

7. Would you be upset by having to move house every 6-months to a year, or commute long distances between cities to work?

If anybody answering “yes” to any of the above questions was automatically denied entry to medical school, perhaps you would get the future doctors you are looking for.