Layla's space

With all its sham, drudgery and broken dreams it is still a beautiful world.

Tuesday, May 12, 2009


At the risk of sounding like some crusty old fart saying 'in my day...', WTF is happening to house officers and SHOs these days?

There seem to be a lot more incompetent/lazy/unprofessional/downright SHIT ones working at the moment. Is it MTAS? Is it the EWTD? Is it just a general change of attitude and loss of professionalism on the part of doctors in general?

In Oncology, for example, the ward SHOs should generally be expected to have done a reasonable amount of general medicine so that they can deal with medical problems which (frequently) affect Oncology patients. I am not on the ward very often - I spend most of my time in Outpatient clinics, often in other hospitals. I need competent SHOs to deal with the ward patients most of the time, with telephone advice from me whenever it is needed. I expect them to know all the patients, to know what's happening with their schedule of investigations, what their blood tests are doing, what their vital signs are doing, and what the plan is regarding their treatment and eventual discharge. I also expect them to get the important jobs done - and this means that if it comes to 5 o'clock and the important jobs are not done, they fucking well stay until they are done, or they hand over to the SHO on call who should get them done. I did that job less than a year ago - I know these are perfectly reasonable expectations that are relatively simple to fulfil.

One of my SHOs is fantastic. He doesn't know very much about Oncology - that is fine, that's my job. But he is a good general medic and he is safe. He gives a shit too, which is becoming increasingly uncommon. The other one, less so. I came to the ward the other day around 5pm (yes, late, but clinic finished at 5) and asked this SHO to sit down and quickly run through the patients with me before I saw them (I wasn't going to make him stay late and go round them, I just wanted to talk over each one briefly). He just sat there, all attitude, blatantly pissed off that he was having to stay one second beyond 5pm. Told me complete bollocks about the patients, e.g.

Me: 'Was her renal function any better today?'

Him: 'Yeah, fine'

Me: checking result on computer 'Actually, it hasn't been done and she was in renal failure yesterday'

Him: shrugs

I eventually got fed up and told him to go home. I then spent 2 hours seeing everyone and correcting his fuck-ups. For example, a lady with an electrolyte imbalance who was losing calcium, potassium and magnesium by the bucketload and needed constant topping up via a drip. She had a 12-hourly bag of plain saline (no additives) running, was dry as a crisp and also had carpopetal spasm and a positive Chvostek's sign - suggesting a dangerously low calcium level. Her bloods showed very low calcium, potassium and magnesium levels. He hadn't fucking checked them. He hadn't written up any fluids or additives to replace her electrolytes.

Having a very low potassium can kill you. This is something medical students know. Writing up intravenous fluids and replacing electrolytes is something the lowliest, greenest house officer in their first week on the job should know how to do. It isn't fucking rocket science - and that's the point. It's not that he wouldn't have known how to sort out this patient's electrolyte balance. He just didn't care.

When I was an SHO (here we go...yes I know it was only a year ago), I would have been mortified if my registrar had to go round writing up fluids for my patients. I would be almost insulted if they checked the bloods on a ward patient - that was my job.

I had a call from an A+E SHO the other day:

SHO: 'I have a man here in A+E. He was diagnosed with skin cancer in March. He's 63. He came in because he's not very well. He's acidotic and I've given him oxygen and some fluids and I think he should be transferred to the Oncology ward.'

Me: 'What kind of skin cancer does he have?' (Thinking, perhaps metastatic melanoma, post-chemotherapy, neutropenic sepsis perhaps...)

SHO: 'I don't know.'

Me: 'Well, has he had any Oncology treatment? You know, like radiotherapy or chemotherapy?'

SHO: 'I don't know.'

Me: 'OK...what's your working diagnosis? Do you think he's septic? Or could he have had a pulmonary embolism maybe? Has he had a chest x-ray?'

SHO: 'Er...he doesn't look like he's had a PE, but I'm waiting for the bloods to come back. I haven't ordered a chest x-ray. But he has cancer and he's going to breach soon [ie about to hit the 4-hour limit in A+E] so he should really go to the Oncology ward.'

Me: beginning to lose it slightly 'Hang you have this guy, you don't know what's wrong with him, you think it must be related to his cancer or his cancer treatment because you're referring him to me, but you don't know what kind of cancer he has or if he's had any treatment for it, and you want me to sort him out for you?'

SHO: 'Er, yes.'

Me: sounding a wee bit terse now 'Get your registrar to look at him, get a working diagnosis, find out some information about his Oncology history, and call me back.' Click.


I mean, WTF?? You make a referral to someone, you get the relevant information and have it in front of you and get your fucking story straight before you pick up the fucking phone! Our letters are on a computer system - even if the patient was confused and had no relatives with him his clinic letters would all be there at the click of a mouse. And at least have an idea about what might be wrong with the fucking person before you try and send them to me to sort out.

For the record, I spoke to the A+E registrar later. He was apologetic. The patient had pneumonia and was admitted under the respiratory team. His cancer diagnosis? He had had a BCC (very slow-growing, usually innocuous skin cancer) removed from his forehead by a dermatologist in March. Never been seen by an oncologist - did not need to see one.

I know, these could be isolated cases of someone who is just shit and someone who just doesn't care. But I have seen the same kind of stuff again and again. My colleagues tell me similar stories (and much, much worse). The over-riding impression I get is 1) junior docs are less competent these days and 2) they don't give a shit.

Are we losing our professionalism? Have we as a profession decided that we're sick of thinking of medicine as a 'calling', sick of papering over the cracks in the system by staying late without being paid to and by sacrificing our personal lives? Do we just want to do a 9-5 job? Perhaps, and perhaps enough is enough for some of us. But that doesn't explain the shitty attitude of doctors who have barely been qualified for five minutes. Surely they haven't had time to become that jaded. Who knows?

I know the system is far from perfect. I know that to deliver the care that patients expect and deserve in today's NHS, you often have to sacrifice your personal life. You have to stay late, go in early, bust a gut. And actually, why should we? How is the system going to improve if we keep 'covering' for it? Fine, so we fire-fight. We make sure we are safe, that we are not negligent, that patients get treated and of course 'first, do no harm'. But we do not go the extra mile to make things perfect. I can understand that approach.

But I'm sorry, there is no excuse for being fucking shit.


Anonymous Anonymous said...

you know i agree with your post! i have also come across some arrogant surgeons/consultants who dont give a toss

May 13, 2009 1:58 PM  
Blogger Grumpy, M.D. said...

Absolutely agree.

Here we have hospitalists taking over inpatient work.

Many are good, but a frightening number are only doing it because they weren't good enough to get a regular doctor job, or got fired for stupidity and/or incompetence.

And, as a specialist, I have to help pick up the pieces.

May 21, 2009 2:57 AM  

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