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  From a psychological viewpoint, probably the most significant effect of the reduction in working hours has been its impact on the so-called ‘firm’. This is the old-style hierarchical working arrangement in which fledgling doctors belonged to a distinct clinical unit headed up by a consultant and supported by a number of other trainees of varying levels of seniority. Of course this arrangement wasn’t perfect; if you had a bullying or unpleasant consultant or senior registrar, your life could be made a misery. But at its best, it provided a degree of consistent psychological support for the most junior members of the team. As psychiatrist Gwen Adshead has noted, the particular language used to describe these systems31 – referring to them as ‘attachments’ or ‘firms’ – reminds us of their potential for providing psychological support.

  Unfortunately, the move to a revolving shift system (prompted by the working hours’ reduction) has disrupted the continuity of the firm. Juniors are now supervised by a changing raft of senior doctors, rather than being members of a stable team. In addition, the introduction in 2005 of three placements each of four months (as opposed to two placements of six months) has made it harder for foundation doctors; instead of having to find their place in two teams each year, they now have to settle into three.

  *

  In 1984 a young woman named Libby Zion was admitted to a hospital in New York City complaining of a fever and earache. Six hours after admission she was dead, due to a rare interaction between drugs she had taken prior to admission, and drugs that were administered in the hospital. Following Libby’s death, her father, who was a New York Times journalist, campaigned for a full investigation into what had happened. The Grand Jury brought no criminal charges against the two junior doctors concerned32 – instead they indicted a medical education system that had allowed the error to occur.

  It took nineteen years, in the States, from Libby Zion’s death, for any limits on residents’ duty hours to be brought into effect33. Finally in 2003, a weekly limit of eighty hours was imposed. Further limits were implemented in 2011, restricting first year residents to working no more than sixteen hours in one day.

  In Denmark a normal week for trainee doctors is thirty-seven hours. That’s less than half the hours that trainees work in the US, after the restrictions were put into place in 2003. A systematic review of 135 studies on the impact on surgical trainees in the US of this so-called ‘reduction’ (so-called, because eighty hours per week still seems an excessive number of hours to me) found that levels of depression and burnout decreased34. However, no comparable benefit was found when the daily maximum was reduced to sixteen hours. In fact there is some evidence that the sixteen-hour restrictions may have increased the rates of post-surgical complications in patients. Counter-intuitive as it at first seems, this finding can be accounted for by the fact that when doctors work shorter hours, the frequency of patient ‘handover’ increases.

  There’s an almost poetic parallel here. At the point when a medical student becomes a fledgling doctor they are transferred (handed over) from the medical school to the hospital. When this transfer happens, uncertainty, confusion and difficulties can arise on the part of the junior doctor. And so it is with patients. Doctors working shorter hours means that the care of an individual patient has to be ‘handed over’ more frequently between different clinical teams; that’s the weak point in the system, the point at which error can creep in.

  Transitions, it seems, cause trouble.

  2

  Finding the Middle

  COTTON IS NOT known for its soundproofing qualities. But that’s all that separates one patient from their neighbour, on some hospital wards. Just a flimsy cotton curtain.

  I’ve heard terrible things discussed on the other side of the curtain. It’s a bit like toddlers playing hide-and-seek who believe that if they cover their eyes and can’t see you, then you can’t see them. Some doctors on a ward round who can’t see the patient (because they are on the other side of a drawn curtain) act as if the patient can’t hear them, or is oblivious to their presence. In reality, the patient and their family members on the other side, together with any other nearby patients, all get to hear much of the clinical team’s discussion.

  I can remember an elderly gentleman well into his nineties, who looked as if he was standing to attention next to his bed in a geriatrics ward. I was puzzled by the formality of what he was wearing: crisply ironed shirt, tie, sports jacket with neatly folded handkerchief in his breast pocket and smart trousers. It was almost as if he was heading off to work. The consultant asked him a couple of questions about how he had been over the previous day and night, then the team left the bedside, closed the curtain, and waited for the consultant to speak.

  ‘That patient used to be a local GP – Dr Williams. I think he has become somewhat confused. Nurse said that he had been incontinent of urine during the night, but he didn’t seem to have any memory of that at all.’

  All the ward could hear this discussion.

  I wasn’t convinced that Dr Williams was confused. Having witnessed the conversation, my overriding sense was that the last thing in the world Dr Williams wanted to talk about, in the hearing of the rest of the ward, was his urinary incontinence. This poor man had found himself admitted to the local hospital where once he would have referred his own patients. His dress and demeanour spoke of a desperate attempt to hang on to the last vestiges of dignity. And unless he was far deafer than he seemed to be when talking to the consultant, he would have heard much of what the team said about him on the other side of the curtain.

  One of my main aims when I observed these sorts of ward rounds was to encourage consultants to have a pre-ward round meeting outside the actual ward. There were so many advantages with beginning in this way: sensitive issues could be discussed out of the earshot of patients or family members, consultants could test medical students’ and junior doctors’ knowledge without running the risk of undermining them in front of patients, and juniors could ask questions without making patients feel that the doctors looking after them (who tend to be junior team members) didn’t know what they were doing. Following this pre-meeting, the team could then go to the patient’s bedside, if necessary examine the patient, and then focus on answering any questions that the patient or their relatives had about current or future clinical plans.

  Over the decade that I observed doctors on ward rounds there was a gradual shift towards keeping the discussions round the bed to a minimum, coupled with greater awareness of the need to avoid sensitive conversations in places where the team could be overheard. People began to realise that the curtain round the bed was just a curtain.

  One morning I turned up to do my first observation of a consultant paediatrician in another district general hospital. The team was assembled in a side room where they were holding their pre-meeting, prior to going on to the ward and seeing the actual patients. The purpose of this pre-meeting was for the junior paediatricians to discuss how each of the patients had been progressing since the consultant had last seen them, the previous day. In addition to the lead consultant, Ellen, there were three other members of the team: Suzy, a senior registrar, who was a couple of years away from completing her training in paediatrics; Ben, a senior house officer (SHO) who had two or three years’ post-medical-school experience, and Vartika, a trust grade doctor, who had recently arrived in the UK from India. The crucial difference between Vartika and the two other junior team members was that her trust grade post wouldn’t enable her to progress up the training ladder. Trust grade doctors are there to deliver a clinical service, and there is minimal opportunity for training built into the post. In terms of the clinical hierarchy, doctors in trust grade posts are at the bottom of the pile.

  ‘Let’s get cracking,’ Ellen said. ‘We’ll begin reviewing whoever is in the first bay on Dolphin Ward.’

  With notes in front of him, Ben started to describe Kirsty, an eight-year-old patient with diabetes who had been admitted a couple of nights previously sufferi
ng from diabetic ketoacidosis (DKA). For patients with diabetes, DKA occurs when, due to a severe lack of insulin, glucose cannot be transported from the bloodstream into the cells of the body. In the absence of glucose, these body cells start to use fat as an alternative energy source, and ketones (which alter the pH of the blood) are a by-product of this process. DKA can be life-threatening, and it happens particularly fast in children. Prompt treatment is needed, with a closely monitored mixture of insulin, glucose and intravenous fluids. When Kirsty was admitted she was unconscious, but three days later her blood glucose levels had been stabilised and she was well enough to be discharged.

  ‘Good,’ said the consultant. ‘That’s pretty straightforward. Who’s next?’

  Ben opened a second set of notes, and started summarising the clinical history of Jack, a six-month-old baby, who had been in hospital for a couple of days with severe breathing difficulties. Jack had been diagnosed as suffering from bronchiolitis, an acute inflammation of the small airways in the lungs. Three days ago his frantic parents had called an ambulance when it looked to them as if their baby was stopping breathing entirely. The ambulance took him to A & E and he was admitted on to the paediatric ward very quickly. In the couple of days prior to this hospital admission he had seemed very miserable with a hacking cough, a severely blocked-up nose, and difficulty feeding.

  ‘How’s he been overnight?’ Ellen asked.

  ‘Much better, his oxygen sats are now fine.’

  ‘Well, let’s take him off the oxygen and see how he does. With a bit of luck he should be home in a couple of days. Anybody else we need to discuss?’

  Ben described a ten-year-old patient, Jasmine, who had been admitted overnight with a high fever. Swabs had been sent off to the pathology lab but the results weren’t ready yet, so the source of infection hadn’t been established.

  ‘I wonder if it’s tonsillitis,’ Ellen commented.

  ‘We tried to look at her throat in A & E, but Jasmine didn’t want to play ball.’

  ‘OK, we’ll take a look now.’

  And so the pre-meeting went on for the next quarter of an hour. Ben reviewed the notes of the other children on the ward and the consultant briefly commented on how she thought the patients were progressing, other clinical investigations that needed to be carried out, and when it might be safe for the children to be discharged. An unmemorable pre-meeting, in an equally unmemorable small district general hospital. Nothing prepared me for what happened next.

  As soon as Ben had worked his way through all the notes, Ellen informed the team that the ambulance service had been called to a house in the local town at five o’clock that morning. A couple had put their four-month-old baby son to bed at ten o’clock the previous night. When he failed to wake for his regular early morning feed the mother went into his bedroom, and couldn’t rouse him. The ambulance quickly arrived on the scene – but tragically the baby was pronounced dead. The parents, together with the body of their baby, were brought into hospital. Nursing staff were with the parents, and the chaplain had been called. But somebody from the paediatric team needed to go and formally certify the death.

  Ellen turned to Suzy, who immediately responded by saying that she wasn’t on call for emergencies. They both then turned towards Ben who was the next most experienced doctor in the pecking order.

  ‘It’s not my turn either, to be on call.’

  All three then stared at the only remaining person in the room – Vartika. The bottom of the medical pile.

  ‘I don’t know how to certify a baby’s death,’ Vartika responded. ‘I’ve never done that before in the UK and I’ve only been in the country a few weeks.’

  As quickly as this task had been passed down the chain of command (from consultant, to registrar, to SHO, to trust doctor), it went back up again. None of the others seemed to have heard what Vartika had said, and instead were quick to give reassurance.

  ‘There’s a protocol in the file,’ said Ben.

  ‘The files are at the nurses’ station,’ said Suzy.

  ‘It’s quite straightforward,’ said Ellen.

  ‘I’m really not sure how this is done,’ Vartika repeated. ‘Death certification might be completely different here, from how I did it in India.’

  Once again, the same reassurance was passed down the food chain, with the other three doctors reiterating that it really wasn’t difficult and anyway, all the instructions were in the file.

  ‘If you’ve got any queries, ring the ward,’ Ellen said. ‘It won’t take you too long. When you are finished, come and join us.’

  And with that Ellen, Suzy and Ben left. Vartika remained standing in the middle of the room, barely moving, with a terrified look on her face. I noted this down on my observation sheet, attempted to give her a reassuring smile and then followed the rest of the team as they walked round the corner to the paediatric ward.

  First stop on the ward round was Kirsty, the eight-year-old girl who had been admitted a couple of days previously with diabetic ketoacidosis. She was sitting up in bed playing an electronic game and didn’t seem at all perturbed when the three doctors walked in.

  ‘How are you feeling today?’ Ellen asked.

  With reluctance Kirsty looked up from the screen. ‘I’m a bit bored. Can I go home now?’

  ‘I just need a word with your mum first,’ Ellen replied, ‘and then you’ll be good to go.’

  Ellen explained that she had asked the specialist diabetic nurse to come and see Kirsty before she was discharged, and the nurse would also give them a date for an outpatient appointment.

  ‘Bye, Kirsty,’ the three doctors chorused, and they then moved on.

  The trio had just drawn back the curtain and were about to walk into the bay with the next patient, when they were interrupted by the ward sister.

  ‘An Indian-sounding doctor is on the phone and wants to talk to you urgently,’ the nurse told Ellen.

  ‘Wait here, and I’ll be back in a moment,’ Ellen said as she followed the nurse out to the telephone.

  A couple of minutes later Ellen returned, muttering under her breath.

  ‘OK, shall we continue?’

  The next patient was more complicated. Jack was the six-month-old baby who had been admitted a couple of days previously with breathing difficulties. Perhaps the memory of the dead baby was in everybody’s mind, but for whatever reason, Jack was examined carefully from top to toe. Finally the group checked the most recent oxygen saturations in the notes at the end of his cot and it seemed as if Jack was on the mend.

  ‘Let’s try him off the oxygen,’ Ellen said to Jack’s mother. ‘We’ll see how he gets on. But I want to keep a close eye on him today, before we think of letting him home. How’s he been feeding?’

  ‘Much better,’ the mother replied. ‘He seems a bit more like his usual self.’

  Ellen smiled. ‘Let’s see how his breathing is today, and we’ll think about a discharge tomorrow.’

  Ben and Suzy peered down into the cot and waved goodbye to Jack. Slowly he broke into a shy smile.

  The third patient, Jasmine, was the ten-year-old girl who had been admitted overnight with a high fever. The group were huddled around Jasmine’s bed, and the consultant was about to start examining her when the same nurse reappeared.

  ‘Vartika on the phone for you. Again,’ said the nurse.

  Raising her eyes to the ceiling in a look of irritation, the consultant asked the registrar to continue the ward round.

  ‘I’m not sure when I’ll be back, but clearly Vartika can’t be left on her own.’

  Suzy straightened her posture and seemed pleased to be deputising for the consultant. The reduced team of two turned their attention back to Jasmine. Following the discussion in the pre-ward round meeting, Suzy knew that she needed to look inside Jasmine’s mouth to examine her throat. She pulled out a tongue depressor from her pocket – an instrument that looks a bit like an overgrown ice-lolly stick. It’s not particularly pleasant to have one’s to
ngue pressed down by it, and both children and adults dislike the procedure. Paediatricians are taught to examine the throat last so that if the child is going to become distressed they can immediately be comforted, rather than having to carry on with examining another part of the body.

  Suzy did everything in the correct order, leaving the throat examination till last. However, she didn’t ask Jasmine’s mum to hold her daughter in a firm cuddle when she introduced the tongue depressor into her mouth, and instead pushed it in with some force. Jasmine clenched her jaw around the instrument with all the strength she could muster.

  ‘Come on, Jasmine, help me out here and open your mouth,’ Suzy instructed.

  Jasmine’s jaw didn’t relax a millimetre.

  ‘I need to look at your throat. We need to find out why you are feeling poorly.’

  Jasmine’s mouth remained fixed. She stared at Suzy.

  Perhaps unfairly, I’d taken something of a dislike to this registrar. She hadn’t offered to support Vartika, and she hadn’t been particularly gentle with Jasmine. I could tell that she was unhappy that Jasmine hadn’t complied with her instructions, and she had been made to look less than competent in front of a patient, the patient’s mother, a more junior doctor. And of course, in front of me.

  For a moment I thought that Suzy was going to use brute force to get Jasmine to open her mouth. She then had second thoughts, and withdrew the instrument entirely.

  ‘We’ll come by a bit later, and try again,’ she said.

  And with that, all three of us left the ward.

  My job was to observe how the consultant trained her juniors, so in the absence of the consultant, I was left without a clear role. The two juniors went off to see patients on another ward, and I waited for Ellen to return.