Monday, May 08, 2006

you're a lightweight. you're fired.

dr D&C was skiving on friday.

that's not strictly true. i'm going to be unemployed in august and so i said to the house officers that i would be in at 9.30am because i wanted to hand in a job application at another hospital. i also said to them bleep me if there are any problem because yes ladies and gentlemen my pager not only works in the hospital, it also works at home, it works at my friends' houses, it probably works abroad and when i have left this corporeal existence and ascended to a higher plane of consciousness/the afterlife, i am sure that it'll still be putting through the crash calls at 3am.

anyway i left my friend the bleep/pager switched on and sure enough at about 9.15am it went off. i called the phone number displayed and to my suprise it was the voice of the clinical director that answered.

being called by the clinical director is a rarity. it is also quite frightening. you feel a bit like the generals in that scene on the death star in Star Wars when darth vader announces that the emperor will shortly be arriving. "the emperor is coming here?" reply the assembled generals, terrified faces, poop in their pants.

actually our leader is quite a nice guy. he tutored me as a student and i quite liked him. what on earth could he want though? i briefly scanned my mind of the medical activities i'd been involved in over the past few months. no, i couldn't think of any obvious malpractice.

he asked me if i had a minute. i was buying a coffee so i guess i did. he proceeded to ask me of my thoughts on a radical shake up of the way the hospital works. yes he was asking me about hospital at night.

i won't go into HaN in detail as i have ranted at length about it here. also refer to Dr Crippen for more details. in short the idea is that you only need a skeleton crew to run a hospital overnight and at the moment there are too many doctors doing far too little work.

the wonderful thing about HaN is that it is marketed (in the labour spin world) as something to help us doctors have a smoother time on call. bollocks i say! it is about cost cutting and meeting working time targets. that is what it's about.

at present in my hospital we have two junior doctors covering the wards, splitting the hospital geographically down the middle. what the clinical director was asking was why not get rid of one of the doctors and provide an advanced nurse practitioner with advanced skills (he said advanced twice) instead.

what are advanced skills? i'm not sure really.

bow hunting skills? computer hacking skills?

anyway i said i'd let him know on monday because delight of delights i was to be night shifting across the weekend. and off i scampered into work that night.

the weekend was fine as it happens. people weren't very sick and the stuff i had to do was quite basic... for me. initially i thought about writing back to mr clinical director with "bring on the nurse practitioners and screw you guys i'm going home."

but then in retrospect i thought about the activities i'd got up to overnight. for example prescribing fluids. this is relatively easy but then after three years of medicine i can very quickly assess someone's hydration status, their requirements, factor in their cardiac/renal status, correlate this with their electrolyte results and give them the right fluid at the right speed so that their organs get adequate perfusion and they don't drown in fluid. though it has taken me a long time to get to that level.

so i am a little perturbed at a nurse practitioner rocking up and ploughing 3 litres of gelofusin into a tiny man whose heart has the equivalent pumping function of a small clementine. that could be a disaster.

similarly i had lots of people with chest pain. again you have to worry about the heart. even if you take a careful history and look for (what can be subtle) changes on the ECG it can be a very difficult call. do we want nurse practitioners with no cardiac training to be doing this? i'm not sure (though having said that the CCU nurses i worked with were superb.)

anyway i sent my email back to the big boss saying that i didn't think that we were ready for this scheme. if the nurses had years of medical training and experience (ie were doctors) it would be fine. knowing my hospital they'd do it on the cheap and employ someone who was all talk and no ability.

did he reply? yes he did.

"thanks for the email. take care."

who says i don't make a difference?

[i am listening to the specials]


Vegas said...

What a nob. I guess one day he will have an MI and be admitted in the middle of the night and see what a mess his hospital is really in. Do they have Nurse Practitioners with bow-hunting skills on the private wards?

Dazed & Confused said...

i think they ONLY have nurses with nunchuk skills on the private wards. apparently if you go private you're solely under the care of the consultant - ie no junior input.


Clare said...

Smile -- you're in Health Service Journal! Good blog -- very dark and disturbing.

Kate said...

You know you're way too caught up in your dissertation (public executions in Tudor England) when your first thought is... "what about nurse executioners... if you're going to be neglecting patients anyway.... They could have advanced skills in drawing and quartering..."

I need a life.

Anonymous said...

Speaking from personal experience, Kate, I don't think you can have a life AND a dissertation...
One or the other, not both. :-(
I've got less than a month to go, though - how about you?

Kate said...

Hand a first draft in at the end of July. The whole thing, bound and finished, needs to be in Sept. 22.

Anonymous said...

Hate to trash your delusions about NPs but patients in the US, wgenerally prefer NPs over physicians; a number of studies have demononstrated that the quality of primary care services rendered by NPs is equal to or better than care rendered by MDs; as for the years of medical training and experince, would you like to know how many emergency and family physicians are sued each year over missed diagnosis of AMI, usually because they fail to recognize the symptoms and/or couldn't correctly read the EKG?

Dazed & Confused said...

and which delusions are those then?

i can't comment on the US where *everything* is better with life in general so i would be led to believe.

however if you read the post then you might have come across the crucial line "nurse practitioners with no cardiac training" with regard to diagnosing acute MI. i repeat emphasis on practitioners with *no cardiac training* reading ECGs.

i'm not really interested in how many doctors get sued for missing MIs in the US because everyone gets sued in the US for everything. "i'm too fat. i have health problems. it can't possibly anything to do with me. i shall sue all restaurants." or "i fell over because i was drunk. the people who built the road should compensate me for not making adequate provision in their sidewalk design for drunk people" etc etc.

i would however be interested in seeing any stats you have on how many "nurse practitioners with no cardiac training" misdiagnose acute coronary syndromes. if you have data similiar to that which you refer to (but do not cite) about NPs delivering better care than physicians for the above i would be very surprised. in fact i would urge my hospital to employ my cat who also has no cardiac training and cannot read ECGs (or so i assume) as i'm sure the Uk public would rather be seen by a sweet animal than a horrible insensitive poorly trained incompetent doctor.

as for primary care if so many people in the US cannot stand being treated doctors, surely you should get rid of all these useless US doctors and replace them with NPs. maybe give the NPs a few more years training, broaden their knowledge base and allow them to develop a wider range of clinical skills and acumen. oh but that would be a medical degree and that would make them doctors. but who would do the nursing then? i guess that good basic nursing care is not important to you. i often find it is essential. but i am deluded.

Mekon said...

last week, cecause of our surgery has advanced access, and I rang a nanosecond after the GP surgery opened, I wasn't able to get an appt. with a GP for my son, who had previously had blood in his stools. We got palmed off onto an NP. My missus was impressed, as she was friendly, used accessible lingo, and was seemed to have a plausible account for the symptoms we'd observed. Good enough? What played on my mind was that earlier in the week, I'd been around my prof's house, and her husband mentioned when he'd once correctly diagnosed bubonic plague.

It's all well and good having a protocol that lets NPs diagnose the most likely explanation, but what about when it's not the most likely explanation? Do they know what the don't know? I hold on to the hope that in primary care, the chances are that there will always be time get another crack at the advanced access lottery, but in acute care?

Dazed & Confused said...

common things are common as the adage goes but you're right the tenth patient with a chest infection may not have something so simple after all and yes it does take a lot of experience seeing a variety of cases before the ability to distinguish subtle nuances develops. and again even if one doesn't know the full differential the skill also lies in recognising when all is not as simple or as clear cut as it should be and acting appropriately.

i'm glad your son got a decent consultation. it really shouldn't be any different WHOEVER is seeing a patient.

however more often than not people hold a good consulting manner (which is OF COURSE important) as equal to good diagnostic ability as you say. the two are not the same. i would certainly prefer to have a terse slightly colder surgeon with excellent skills rather than a really chummy friendly matey one who doesn't know his small from his large bowel.

Kristina said...

I'm not in the medical field, so sorry this comment is not a medical one, but I stumbled on this site because of the darth vader implication here and read on because I think your writing is exceptional. Anyway, my comment is that I'm American and I cringe every time a foreigner says something sarcastic along the lines of everything being better in America, as though we all sit over here scoffing at the world for its grave inabilities and inadequacies.

Maybe the two percent of the upper crust, but the rest of us are very peaceable people who don't poo poo the rest of the world and are confused as to why the world sees us as snobbish. I'm not even touching politics or war here, I'm speaking on behalf of the average person. We don't think we're better. On your turf and ours there have been snobbish visitors from abroad that would leave us to form a national impression.

The media is brilliant at helping portray us in a negative light, though, I'll say that. Propaganda, anyone?