When the tail wags the dog . . .

I started my career as a nursing assistant on a care of the elderly psychiatric ward and then moved on to be a healthcare assistant in operating theatres.  My work-life gave me a place in the world.  I did whatever nurses, doctors and operating department practitioners told me to do and followed the training they gave me.  I did anything I thought I could do to make their jobs easier.  At the end of each day I felt like I had done something useful, so my life was worthwhile.  My jobs rarely gave me any dilemmas to lose sleep about.

Times have changed. As a foundation doctor on two occasions while managing unstable patients I have found healthcare assistants unwilling to help me.  Both occurred at night, while I was on my own covering all of the surgical wards in a large teaching hospital.  During the first I was called to see an unstable patient who was septic. On trying to print blood request forms I found the printer was empty. I asked the healthcare assistant sitting at the desk whether she could fill it for me. 

“Why don’t you do it yourself?”

“Because I’m busy?”

“Well I’m busy too” she muttered under her breath.

The second occasion was in an isolation room with a patient with acute cardiovascular instability.  I needed help, so instead of de-gloving I pressed the call bell.  A healthcare assistant came to the door and told me to turn the buzzer off.  I asked her for help and turned it off, but she just went away and nobody came back.  A few minutes later I pressed the bell again.  The healthcare assistant came in, turned the bell off, ignored my repeated requests for help and then walked off again.  I concluded that I was really on my own and would just have to do everything myself.  It was a helpless feeling; not good for patient care.  The next day one of the nurses laughed and told me the healthcare assistant had complained about me.  After I explained to her the clinical nature of the situation, her expression changed.  There is no reasoning with this particular healthcare assistant though.  I wonder what she thinks her job role is.

Neither of the above examples came close to a healthcare assistant with an identity crisis who mistook herself for some kind of manager.  I left a tap running while applying soap to my forearms in A&E and turned to talk to somebody.  The healthcare assistant proceeded to give me a lecture about how leaving the tap running was bad for the environment and how people in Thailand have to pay for their water.  This was within earshot of the patient I was about to suture.  In another job after lending a consultant anaesthetist my tourniquet I soaked it with alcohol-based chlorhexidine spray.  A support worker told me the spray on the floor was a “health and safety” risk and I had better mop it up.  I told her it was going to evaporate, but according to her the basic laws of chemistry and physics were going to be defied that day and it would not, so she repeated her instruction to me to mop it up.  Finally when I stood up to go and get an inco-pad to dry the floor, she repeated herself yet again, telling me I had better mop it up.  I asked her how many times she thought she had to tell me the same thing, she replied “More than once, obviously.”  Needless to say, by the time I had got an inco-pad the alcohol had evaporated.

One of my consultants advised me to just ignore this kind of behaviour, but where is it coming from?  It was unthinkable for me when I was a healthcare assistant.  If I had seen a doctor or nurse make a mess, I would have cleaned it up, and if they asked me to do something, I would have done it.  Everybody is busy.  Perhaps doctors are just not respected anymore in the way they once were.  The knowledge, hours put in and dedication to training is not valued.  One of my registrars explained to me “We are just numbers. We’re not important. They’ll just replace you with another doctor.”  He is right.  Junior doctors are a nomadic population, being moved from team to team, from location to location.  We are only temporary parts of any team; seen as less important than permanent staff and therefore less important than healthcare assistants, some of whom now feel that they can talk down to us.  Healthcare assistants remarkably improve care by supporting professionally trained staff, but demoralising clinical staff can have the opposite effect.  

With the emergence of specialist nurse practitioners, physicians’ associates, surgical first assistants etc one could be forgiven for thinking doctors are now surplus to requirement.  A surgical first assistant seemed to question on Twitter whether anaesthetists should be given so many choices of how to give an anaesthetic!  I think this is a dangerous illusion.  Before becoming a doctor I was trained by the British Army to diagnose and treat primary care and trauma problems, even to the point of independent cricothyroidotomy, thoracentesis and chest-drain insertion.  I administered drugs including opiates independently, checked by nobody but me.  I had to be able to do this, because people depended on me and we were so far away from more qualified medical care.  Looking back on that time I thought I understood what I was doing, but I did not.  I was simply following a series of drills and protocols.  I only really understood what the army had trained me to do after I studied for my MBBS.

Junior doctors may have knowledge, but I do not feel fully empowered to use it.  Sometimes I wonder whether junior doctors are treating their colleagues or their patients.  Multi-source feedback   (MSF) being an integral part of training now means that anybody can stop our career progression.  While that may largely be a good thing, who verifies the validity of that feedback?  Is it going to be based on whether junior doctors follow orders given by healthcare assistants?  A consultant once advised me to just tow the line for an easy life when dealing with non-medically trained staff.  “They all have tea together and talk to each other. If they don’t like you they’ll ruin your career.”  Is this good for patient care?  As a surgical FY1 one of the patients I reviewed daily following laparotomy had advanced dementia.  Whenever I asked her how she was she said “Not too bad” or “Not too good.”  This alternated between days.  Every day I used to check her observations and examine her abdomen.  She had a tender incision site as expected.  Her bloods were improving daily, so we switched to checking bloods on alternate days.  One day I was called by a nurse I had never met before, about 30 minutes after I had examined this patient.  The nurse was not happy that the patient had abdominal pain and demanded that she have a set of bloods and a CT scan.  I was worried, but on re-examination she was no different to how she had been 30 minutes earlier, so I explained to the nurse that these were not indicated.  The nurse then proceeded to shout at me in the middle of the ward that I was being negligent.  The ward sister came and tried to mediate.  “How about we compromise and you just send off a set of bloods.”  I asked what the indication for this was, and as there was no indication I then refused to do it.  I left the ward with the nurse shouting at the top of her voice at me, and told my registrar who then went with my fellow FY1 to resolve the situation.  He came back and told me to “be careful with that nurse.  She can ruin your career.”  He explained that he had ordered a CT scan and my fellow FY1 had taken bloods to diffuse the situation.  As we all expected, the bloods came back showing continuing improvement on the trend, and the CT scan showed nothing unexpected.  A few days later the ward sister told me that particular nurse caused her a lot of stress.  Who was being treated?  The patient, the doctors’ MSFs or the nurse?  Is this the future of fear-based medicine?  Is this good patient care?  

Junior doctors may be under attack from the secretary of state for health.  The last thing we need is concurrent attacks from our colleagues.