Re: New evidence of worse outcomes for weekend patients reignites call for seven day hospital services - Good men, doing nothing.
20 June 2012
The response of hospital managers to the results of this study are regrettably all too predictable. But as doctors we know that the only proper solution is to employ more doctors and we should not be afraid to say so, and actively resist alternatives.
There is a ticking time-bomb in hospital training which, if we fail to remedy, threatens to destroy the profession from the inside. It is a situation which has been allowed, often encouraged, to develop by senior clinicians and actively trumpeted by managers. We ignore it at our peril.
The training of junior doctors and the integrity of their role has been progressively eroded by the introduction of Nurse Specialists of ever more various hues, who are increasingly relied upon to conduct the so-called ‘routine’ work of junior doctors. Their roles are often ill-defined, enabling the mission creep to which the past decade has borne witness. At first they were intended principally to provide senior support to nursing colleagues; now they threaten to remove what little training remains in what we still laughingly refer to as teaching hospitals. In my hospital, Advanced Nurse Practitioners (a name which inadvertently exactly identifies the blurring of roles) are very heavily relied upon. They run the hospital at night. They accept referrals from GPs. They review sick patients on the wards. They specialise in specific practical procedures and clerk new patients, removing these critical skills from trainees. They prescribe. Elsewhere they conduct ward rounds and are deans of medical schools! They review minor cases in A&E. And a brand new group has recently been introduced exclusively to see A&E major cases – if these patients should not be the primary responsibility of clinicians, then it is difficult to conceive which should. And they resent being asked to restrict their roles to nursing responsibilities so that the lone junior doctor covering the wards out-of-hours has a chance to manage the acutely unwell, because they of course are also keen to emphasise their distinction from the nursing staff from which they evolved, and doing what the doctors do makes them feel different. But they are not medically trained and they are not doctors.
By allowing the continued blurring of the boundaries between doctor and nurse we destroy morale, disenfranchise junior doctors, undermine training and threaten the very structure of the hospital environment – this exists not to allow each group to feel exclusive but because it works and it’s important. It enables the safe management of patient care by a satisfied and productive workforce, each conscious of their unique and critical role. In allowing its erosion we fail nurses, fail doctors and cheat patients.
We have witnessed this development and done nothing. And why? Because - as is endemic in health service management - no-one considered it necessary to ask those who do the job what they thought; afraid perhaps that they would not like the response. Junior doctors feel, and genuinely are, powerless and do not wish to threaten their future careers. Senior doctors also lack power in the face of an overbearing managerial oligarchy, but also seem apparently to have forgotten that they have reached their positions of seniority only through the training that life as a junior doctor afforded. A nurse practitioner is reliable and consistent and constant; and hence preferable to junior doctors who will be with the team only for four months (six months should be an absolute minimum). But professional integrity and loyalty to the training of junior doctors should make us resist this seductively simple solution. The erosion of the team structure has led to a switch of senior loyalty from team and training to a focus on the provision of service – the raison d'être of the hospital manager. But we are clinicians.
This must stop and in my view, be reversed. Junior doctors have already faced the humiliation of having their training reduced to the travesty that is the ePortfolio - at best a reflection of competence with no room and apparently no desire anymore for excellence. The ePortfolio was intended to act as a reflection of training but is now largely its replacement. This is not good enough. I implore senior clinicians and those responsible for medical training to acknowledge openly what is happening and provide forums to listen to the views of their trainees. And then, collectively, do something about it. Edmund Burke once noted in a different context that “All that is necessary for the triumph of evil is that good men do nothing”. He was right - and we are good people, but doing nothing.
Despite all evidence to the contrary, the future health service needs us and if our role is not protected and nurtured then, like the others that have left in their droves, we will be forced to go elsewhere. We are willing to work harder, to adapt, to face disruption in achieving such change – but this goodwill is running out fast and unless, with your support, we can regain our pride and satisfaction in what we have strived so hard to achieve and at times still love, the profession will inevitably implode and we will all be the poorer for it – patients, doctors and nurses alike.
Competing interests: None declared
Medical Trainee, Cardiff
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