The Clinical Incident

Throughout the ages, small pieces of paper have changed the lives of millions of people. Voting slips. Eviction notices. Parking fines.

But these pale in comparison to the sheet of paper that rules the NHS with an iron fist. It's the Mao Tse Tung of the written word. The Joseph Stalin of A4. It's known as "The Clinical Incident Form".

It's supposed to be a routine thing, a little message to the hospital managers when something's gone wrong. It's supposed to help minimise the chances of the same mistake being made twice.

Like any well-intentioned bureaucratic device allowed out into the real world, it's grown into something very different. Nurses now brandish The Clinical Incident Form as a weapon. Forgot to write up fluids? They could end your career with a well-filled out page 1. Did you wash your hands just out of sight of the "Handwashing Audit" team, losing the ward valuable "points? You better get ready to be Formed.

Even though the worst that can happen is a mild-mannered email from Risk Management, getting the Form feels something like getting a sexually-transmitted infection. You don't want either of them, and they both tend to come from a nurse you'd rather not wake up with more than once.

The pen-pushing culture is running riot at the moment. Must be something to do with waking up in the dark and having to wear a proper winter coat in the mornings. We were brutally wrenched from the wards earlier this week, dedicating an entire morning to talking about "diversity in the NHS". This was considered more important - and thus worthy of more teaching time - than something rare and of little clinical use, like how to deal with a heart attack.

Once again, I fear that our superiors haven't quite got the hang of how to say NO to the Department of Health and its bizarre priorities. Surely that should be a Clinical Incident?

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.

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.

Hazing the new guy

No-one's spanked my buttocks. I haven't been forced to eat anything more unsavoury than the usual canteen fare, and my eyebrows remain unshaved.

As far as initiation rituals go, this institution has been surprisingly gentle with me.

But there's no doubt I'm still the new boy. Some of the nurses, with more years on the wards than I've had in medical school, like to pull rank. Sometimes with good reason.

I often ask their advice. Most nurses are happy to give it, and most of the time I agree with them. They've helped me survive my first month as a doctor, and I'm unbelievably grateful to them.

There are exceptions. The Lemon is very similar to the Potato, except that her skin is more sallow, and (ironically) she has a larger chip on her shoulder.

She's already had run-ins with the Giant, who's been unfailingly polite to her. It was my turn today.

Jim was the reason for her fury. He'd been hiding his tablets. To be more precise, alternately hiding them behind his pillow and throwing them away. He didn't like the chalky taste.

I re-assessed whether he needed them, and decided not to re-prescribe them. This did not go down well. Over the phone, in a furious screeching voice, with bile dripping through the telephone wires, the Lemon demanded to know what I thought I was doing. My explanation clearly didn't cut the mustard, because she hung up on me.

One thing they definitely don't teach you at medical school is industrial relations. It's all experience. The Giant can shrug off a thousand minor arguments each day, on the basis that a) it's his job, and b) there's less oxygen up there next to his head, so he needs to save his breath for the important stuff.

The Mountain Goat has a different technique for avoiding the day-to-day hassle of the job. He's a Consultant, so you have to attain quite a high rank before you can take him on. By that point, most people have tired of the petty disagreements, and would rather just treat patients or go home and see their families. Also, by the time you've composed your thoughts enough to start an argument with him, he's halfway up the stairs.

I don't have the experience, or the status, or the stairwell speed, to get round the Lemon. But I do have some sympathy for her. Hospital admissions have increased massively in the last decade, and nurses have borne the brunt of that. They've got too many patients, and I've still got too few.

The old rules of the doctors-and-nurses game are changing. The boundaries are blurring: each year, women dominate medical school intakes, reversing the previous gender imbalance. At the same time, nurses are taking on roles once reserved for doctors - prescribing, management of chronic conditions, specialisation. It's an odd relationship, an experienced nurse and a brand new doctor.

So I'm hoping that we'll sort things out, the Lemon and me. And then my experience of the nursing profession won't be all sour grapes.

I don't need a doctor, I'm having my lunch.

The Potato, a ward Sister who looks exactly like a potato would if it were human, wanted me off the ward.

It was "Patients' Protected Mealtime". This tries to discourage staff and students from unnecessarily bothering patients who are trying to eat.

The fact that I was at a desk, quietly reading through a patient's notes, well away from any other human being, apparently didn't make any difference. Just my presence was upsetting the natural balance of Primrose ward.

Without me there, of course, patients would feel right at home. Dignity would be instantly restored, wounds would close up, and - in the case of one unfortunate lady in bay 1 - bowels would stop opening all over the floor. Doctors are the cause of all of these ills.

I'm not against the idea of giving the patients back some level of control over their lives. They're carted off to their scans, or their operations, without much warning. They're stripped down, then poked and prodded by unkind fingers. This is often worse than whatever disease they came in with. Lots of people put up with occasional nausea and vomiting at home, but how many would let complete strangers come into their bedroom, ask them if they've opened their bowels, then put a finger in their bottom to check?

But I actually find the Protected Mealtime a massive cop-out. Why bother with humane nursing or simple courtesy, when patients have a set time each day to feel like themselves again? Rather than addressing bad medical care that makes people feel less than human, we've created a gimmick that glorifies the pallid slop we make patients eat.

It's a weak, flimsy idea at best, badly misunderstood, poorly implemented and almost useless in practice.

You might as well call it "Dignity Hour".

Which is why I laughed when Potato suggested I move on, and got on with my job instead.