Sunday, 30 September 2007

Name and Shame

Introducing myself never used to be difficult. I had a name, I used it, the conversation moved on.

Pretending to be a responsible professional makes things much more difficult. I don't know whether to introduce as Dr {Worm}, or rely on a more user-friendly first name.

The end result: total tongue-tying. A mumbled conglomerate of first name and surname. This leaves the indelible impression that, far from knowing the ins-and-outs of acute medicine, I'm not even sure who I am.

Not the look I've been striving for.

The trouble is, every patient seems to need a different doctor. Some patients prefer the white coat and distant manner, whilst others - usually the ones with Facebook accounts - would rather have a chat with their medical team. Not for them the formulaic introductions and formality of a bygone age.

The UK's pioneering a "Choose-and-Book" system, allowing patients to choose their hospital specialist. GPs are supposed to be able to point their patients towards the specialist who will "suit" them.

But family doctors have a responsibility to send their patients to the most competent specialist, not one who introduces him/herself by their first name. When I'm sick, I don't care if my surgeon's manners are a little old-fashioned. He can demand that I wear a top hat and tails, as long as his surgical technique's up-to-date and he gets the job done better than anyone else.

The new style of medical training is pushing through doctors with impeccable manners, first-name introductions and delightful bedside etiquette. As a nation, we haven't decided whether that's acceptable compensation for a lack of technical expertise.

We need to make up our minds before the decision's made for us. I respectfully suggest that maybe a little professional formality isn't so out of touch after all.

Monday, 24 September 2007

The Royal We

I've started talking in the plural.

"We've decided to do this test", I hear myself explaining loudly. "We should try this drug". "We need to get you to pass wind".

I'm not entirely sure how this started. Nor am I clear who's included in this fictional group, or why I need their support.

My subconscious seems to have assessed my medical knowledge, and found it inadequate. Subconscious Worm decided that no sensible medical governing body would licence me to take potentially life-changing decisions on my own.

Ipso facto, X-factor, all my decisions need to be group ones. Safety in consensus.

The Royal We is comforting, for me and the patient. It says there's accumulated wisdom behind my seemingly random choices, method in my madness. Multiple physicians agree with my diagnoses; they're just busy doing other things at the moment, so you can't see them.

Sometimes I wish there was more of a real group dynamic with my patients. Having to talk to people - or still worse, get near them - on my own can be truly horrifying. Tom, an A&E regular, was not a pleasant one-on-one interaction. He smelled so bad, I actually retched as I tried to take his blood. When he finally told me, "f**k off, I need to sleep off my hangover", it was a relief.

At other times, having someone else there makes a bad situation worse.

On call, I was asked to insert a catheter for a guy who couldn't pass urine.When I put in some local anaesthetic so that the catheter wouldn't be painful, his nether regions responded to the cold gel, like a toddler in a swimming pool. Instant wee, all over my (gloved) hands. Having his wife there, as well as another doctor, wasn't quite the mental group hug I was looking for.

Ultimately, you stand alone with your medical decisions. No-one else can take responsibility for the prescriptions I write, the tests I order or what I tell my patients. But I'm getting more comfortable with that - maybe I won't need the Royal We much longer.

I'm even getting ready to hold my hands up in the air and admit it when I make mistakes. Let me just clean the wee off them first.

Saturday, 22 September 2007

Mad angry

Rich, a male Filipino nurse, is clearly insane. Despite plenty of evidence to the contrary, he's chosen me, basically a medical student with a staff discount in the canteen, as his personal icon of clinical excellence. A ward-based Dr Quinn Medicine Woman or Karl Kennedy.

He's also got a touching faith in our drugs' ability to cure any medical complaint. Sometimes his enthusiasm for the chemical cosh oversteps the mark. Take Mr Harris, a middle-aged firebrand who was getting frustrated that he didn't feel any better despite the improvements in his blood tests. When Mr Harris got cross with one of the nurses serving him lunch, Rich asked me to prescribe an anti-psychotic.

With a hopeful look in his eyes, Rich handed me a syringe he'd already prepared, with the immortal words: "Haloperidol, doctor?"

I looked at Mr Harris, by this point fiercely attacking his mashed potatoes, and decided that a powerful sedative may not be necessary.

Making sense of emotions like anger and fear - mundane events in the real world - is actually quite difficult in hospital. Arguments can come from personality clashes, but can also be the first sign of an acute delirium. It's the same with new symptoms: aches and pains that most people don't bother to mention to the GP take on a new, possibly frightening significance when they're already in hospital for something else.

I left Mr Harris to enjoy the rest of his lunch in peace. Even if he did have something serious going on, it certainly wasn't spoiling his appetite. It wasn't a trouble-free decision though: I think I may not be Rich's number 1 medic any more. He asked another junior doctor to prescribe the teatime sedatives.

Tuesday, 18 September 2007

Chris Ak-abuse-i

Many people frown on racism. Not the Worm's team. For at least one of our patients, racism is actually a very positive sign. As far as Mr Bradshaw is concerned, the more racist the better.

Other patients have their blood pressure and pulse monitored every 4 hours. Mr Bradshaw gets asked how he feels about immigration.

He was a devoted racist before he came into hospital. Since he was admitted, any weakening of his belief system has correlated pretty well with him getting sicker. Racist abuse is the best barometer we way have for him: any sign of a "live and let live" attitude is pretty worrying. We want to get him back to his pre-hospital best, which means aiming for some truly objectionable opinions.

It's usually the other way round - as patients get more confused, they get more abusive. Abuse of medical staff can itself be a worrying symptom. I for one was extremely worried when a small elderly woman in the canteen today threatened me with a plate of carrots and tried to eject me from the area. Most worryingly of all, bystanders were more concerned by the threat of carrot spillage than any potential bodily harm on my part.

A lot of routine abuse is aimed at the nursing staff, who bear the brunt of patients' frustration. Relatives also head their way: 2 nursing students burst into tears earlier, after being screamed at by an angry son. It was interesting to see him apologise afterwards to other patients, who he thought he might have disturbed with his outburst, but not to the two girls he'd reduced to tears.

I found some respite from this evening storm at the nurses' station by slinking off to do some small jobs. When you're covering other people's patients it's easy to see them as one-off jobs: bloods, cannula, Xray. Tonight was different - it was an absolute pleasure to have a proper conversation at normal volume with someone who wasn't racist or confused, or both. I actually paid attention to the patient I was sticking needles into, and it paid off. He was a professor of politics who talked me through the break-up of the USSR, because we both felt like being real people for a few minutes.

The doctor-patient partnership is like any other abusive relationship. There's an infectious sense of optimism when things go well. When things take a turn for the worse, both partners promise to try harder, and to watch out for the warning signs of impending conflict. I for one know to look out for the racism and the carrots.

Friday, 14 September 2007

Fatality mentality

Mr Sumner is not a well man. 97 years old and just 4 days after major surgery, he initially stunned us with the speed of his recovery. Then, ten minutes after lunch, he suddenly slumped back into bed, cold and unresponsive.

I broke into a cold sweat of my own - none of my patients have died yet, and this was too close for comfort. I actually felt nauseous. Somehow the rising tide of bile stayed down just long enough for me to do the basic blood tests and call for help.

Even when you haven't made a glaring error - as far as you can know - the pressure when patients become acutely unwell is immense. It really does feel like your entire career, not to mention your mental stability, is riding on every change in the patient's blood pressure, every cough or hiccup.

Maybe this sensation (or something like it) stays with you, regardless of how senior you become. But I doubt it. Noone would stay in the job. So when do you lose it? Does the terror of catastrophe recede after the first patient death? Since I haven't yet had to certify any deaths, I can't stop thinking the first one must be just around the corner. At any moment, my patients could start dying all over the place. And I really don't know how I'll cope with that.

Excuse the abrupt end to the post, but I need to get some fresh air. I feel a bit sick.

Tuesday, 11 September 2007

Vote for Pedro

Our new patient Napoleon is hard to read. More Napoleon Bonaparte than Napoleon Dynamite. Asking him for intimate personal information - like, for example, whether he feels thirsty - is more taxing than you'd think. He gives out these details piecemeal, like a serial killer toying with the police. Finding out when his bowels last opened takes the entire day, and usually ends up with me negotiating with the nurses to get him a double helping of dessert. He's a master, and gives away nothing for free.

He's pretty clear on one thing though: he's smarter than I am. He peppers our conversations with references to the times he's Googled his condition, and the self-help groups he's been to.

As far as he's concerned, a medical degree doesn't count for much if you don't actually have the disease. We've disagreed on so many aspects of his treatment that I've honestly considered telling him that I too have a complex intestinal disorder, just so he'll hear me out.

I can't fault him: his rules apply to everyone. Consultants get the same disdain as entry-level graduates. Studies in major journals are rejected: the authors don't have the symptoms, so they don't know what they're talking about. Napoleon's logic is impeccable.

This Frenchman's a tough nut to crack. Short of acquiring his disease, which may or may not necessitate a bizarre infectious agent, I'm not going to win this argument. I'm not even on a level playing field. This could well be my Waterloo.

Saturday, 8 September 2007

Someone ate my chocolates

Contrary to what you've heard in the papers, there are loads of jobs for doctors. LOADS. I was lucky enough to see the job allocation process in the flesh. In the canteen.

Big boss consultant: "So, you're working here next month?"
Junior doctor: "No, I'm a locum"
Big boss: "No-one passed on the message that we wanted you to apply for the permanent post? You were a shoe-in."
Junior: {silence}
Big boss: "So do you have any friends that might be interested in the job?"
Junior: {dark clouds of despair make response inaudible}

This kind of thing isn't good for morale. I almost lost my appetite at the sight of a doctor's career being derailed next to the coffee shop. I had to keep eating, though, because the junior doctor's body needs near-constant energy intake. The perpetual stress of not being very good at your job burns up calories surprisingly fast. So when a patient brings in a box of Quality Street to say thank you, it's not a meaningless gesture. It's literally a lifesaver.

The Big boss making job offers in the cafeteria thinks otherwise - he says we need gratitude in writing, to the chief executive, thanking the hospital for the good care the team's provided. This "balances out the complaints". Is there a complex equation, or does one thank-you letter cancel out one complaint? We must be told.

I admit it's nice reading the letters on the ward noticeboard. You don't often get a pat on the back for doing your job, just a sharp telling off when you forget something. But it does make you realise how patients value totally different things to doctors.

No-one's written "Thank you for the inventive antibiotic regimen that saved my life despite my multiple allergies." That's the kind of thing that would make my colleagues glow with pride. What people actually write ("Thank you for your kindness") actually reflects more on the nursing care, and makes doctors feel small because it's something that requires 0 years of medical training.

So, whilst I wait for the first compliment on a job well done, I'm going to the canteen. For a coffee and a job interview.

Tuesday, 4 September 2007

Living for the weekend

Covering the wards over the weekend is like travelling to a family wedding in Norfolk. People seem familiar, but they all turn out to be far more bizarre than you'd ever imagined. And the food is disappointing.

You meet a lot of patients whose charming eccentricities as smiling faces in the hallway suddenly become downright freaky. Take Alan. A normal pudgy teenager during the week, somewhat reluctant to get out of bed, turned into a growling Rottweiler.

He wouldn't stop asking whether the operation had ruined his chances of becoming a professional bodybuilder. Given that he refused to stretch his legs even when warned he was heading for a DVT, I thought it unlikely he'd be a regular enough visitor to the gym to get himself a prize-winning six pack.

I quite like the idea of going to his post-op Gun Show though.

Mr Jackson was quite the opposite - a real wanderer. He roamed the corridors with zeal, telling anyone who would listen that his doctors were doing nothing for his diarrhoea. In our defence, it was difficult to do anything for him. Every time we came to see him, he'd locked himself in the toilets, smoking.

Unusually for someone with diarrhoea, he had difficulty providing a good stool sample. I explained that it had to be as sterile a sample as possible, so his suggestion of scraping it from the inside of his pyjamas - whilst inventive and showing an admirable ability to think outside the box - wouldn't actually work.

Nor would the lab accept the sample on the toilet paper that he waved in front of my face.

These people seemed so normal during the week. It almost makes me worry about seeing the other doctors socially - if patients can be this different outside of office hours, what on earth are my workmates hiding? The mind boggles.

Next weekend, I'm staying in.

The Meaning of Pain

I have awarded Jenny a Pain ASBO. She is no longer permitted to complain about pain within a 1-mile radius of the hospital.

Before the PASBO, Jenny claimed it was agony each time I took her blood - despite my getting it first time, with a tiny needle, no digging around, in and out in 30 seconds. She found the experience excruciating, despite receiving the "Magic Cream".

The "Magic Cream" is a local anaesthetic that you can rub into the skin, deadening the nerve endings. It's used mainly in paediatrics, mostly because children like the idea of magic.

We all smiled when Jenny requested the cream - especially when she earnestly referred to it as "The Magic Cream". Jenny's a 60 year old lady, and you could hear the capitalised letters in her voice. We stopped smiling when we realised she was serious, and wasn't prepared to have any blood tests without it.

It's easy to envisage a world where hers would be a perfectly normal request. As people emphasise the importance of customer service in medicine, and patients become 'clients', the idea of leaving a customer in any pain at all sounds increasingly ridiculous. The hospital's Pain Team - a nurse-led conglomerate of specialised nurses and anaesthetists - even talks about the human right to be free from pain.

But pain, just like blood pressure and temperature, is a really useful indicator of how things are going. When the pain of the next blood test is the worst thing on the horizon - not the pain of the disease that brought you into hospital - things are actually looking up: you're probably getting better. So, whilst you're cringing at the thought of that needle, the doctor's cringing at the thought of the discharge paperwork.

I don't think being in hospital can ever be a totally comfortable experience.
If you really wanted a relaxing couple of days with a good-looking man in a white uniform, you'd book yourself into a spa, not somewhere that looks like Wormwood Scrubs. Still, it needn't be agony. A quick chat with the medical team about how reassuring it is to fear the odd blood test should make things less painful all round.