How can I cope with redeployment?
BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m1228 (Published 30 March 2020) Cite this as: BMJ 2020;368:m1228Read our latest coverage of the coronavirus outbreak
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Dear Editor
Across the country doctors, nurses, allied health professionals and academics have answered the call of duty, leaving their comfort zone within their daily professional activities. This has evoked feelings of anxiety, fear and uncertainty. The extensive redeployment includes experienced consultants in outpatient-based specialties returning to conduct medical ward rounds, senior surgical trainees looking after medical inpatients and research nurses returning to full clinical duties after several years.
It is not easy to work in an unfamiliar role. Given the recent trend towards sub-specialisation, more experienced, senior doctors may find it particularly challenging to work in a specialty and environment they have not encountered for more than a decade. This applies not only to the clinical aspects of the re-assigned role, but also to interpersonal relationships and team structure. Delegation, supervision and handover all need to be carefully considered in the context of the diverse backgrounds and specific skill-mix of the wider team.
Some redeployments are more challenging than others. For example, an experienced anaesthetist may be moved to the intensive care unit. While they may not have worked on an ICU for several years, they have multiple transferrable skills and they are familiar with much of the terminology and equipment. In contrast, an experienced dermatologist or surgeon redeployed to an acute medical unit is likely to find the new role much further removed from their day-to-day practice.
Redeployed doctors may also find themselves supervised by colleagues who, in the conventional hierarchy, might be considered their juniors.
This is where reverse mentoring can be a useful approach. This is a concept that originated in the technology industry, where junior employees could keep their more experienced colleagues up to date with the latest developments. However, it can be applied to the medical field too; previously this has been task- or situation-specific such as learning to use electronic patient records. However, the Covid-19 pandemic emergency response has resulted in a much broader need for updating, educating and supporting colleagues.
Traditional mentoring is a process where the experienced mentor, guides the inexperienced mentee in developing knowledge and skills, supporting their professional development. Reverse mentoring flips this and has been aptly described as “a reciprocal and temporally stable relationship between a less experienced mentor providing specific expert knowledge and a more experienced mentee who wants to gain this knowledge”. [1] Importantly, this breaks down traditional hierarchies and is a two-way process of shared learning. For example, a neurology consultant may seek advice from a respiratory or acute medical registrar regarding the treatment of patients on the front line. However, while deferring to the greater clinical expertise of junior colleagues in this specific area, the senior may still bring valuable attributes to the team (such as leadership, communication and influencing skills gained through years of experience), and this can be an inspiration to the juniors.
This working relationship relies on mutual respect, and each member of the team should value the unique experience and expertise of their colleagues. It is also vital to recognise one’s own limitations as well as those of others. This is necessary to maintain team confidence and morale as well as patient safety.
The world will almost certainly be a different place once this pandemic is over. Within our own sphere of work, maybe we too will see lasting change. An improved team ethos with greater emphasis on staff physical and mental well-being might improve staff morale and result in a more motivated workforce. With a permanent softening of the hierarchy, perhaps we will move towards addressing all our colleagues by their first names. A more open culture also encourages innovation and makes it easier to raise concerns. Coming out of our silos and better understanding our colleagues promotes better collaboration between professionals, which ultimately translates to improved patient care. This crisis has brought us hardship and tragedy aplenty. Reverse mentorship could give us the tools not only to survive, but to build a better system once it is over.
[1] Clarke AJ, Burgess A, van Diggele C, Mellis C. The role of reverse mentoring in medical education: current insights. Adv Med Educ Pract. 2019;10:693-701
https://doi.org/10.2147/AMEP.S179303
Competing interests: No competing interests
Dear Editor,
I am a General Surgical FY1 at a district general hospital in London. When COVID–19 hit the UK, my colleagues and I knew we would need to step up and adapt to prepare for this global pandemic. When I graduated medical school, never did I think that within seven months of becoming a doctor, I would be working in such a climate. These past two weeks, I have witnessed difficult decisions being made and difficult conversations being had. I have heard doctors telling families over the phone that their loved ones, who they have not been able to see because of risk of exposure, were dying and that they did not have long left to live. The four pillars of medical ethics were drilled into us at medical school, but now more than ever do we as healthcare professionals find ourselves thinking about it more and more to ensure that we do right by our patients to maintain their autonomy in these trying times.
As foundation year trainees, we were meant to move onto the next rotation on the 1st of April 2020. With increased demands of doctors needed to be covering the wards, Health Education England decided that we would not receive adequate induction and we should remain in our current placement till informed otherwise.
Daily routine
Pre–COVID pandemic, a General Surgery on–call would amass on average around forty inpatients over four days. However, the last two on–calls, we have only admitted on average ten patients. I think this is because patients understandably do not want to present to hospital as they fear becoming infected by COVID. Nevertheless, the incidences of common surgical presentations, such as appendicitis and abscesses has decreased. This brings the issue of patients in the coming weeks being admitted with delayed presentations, leading to worse outcomes. With the reduced patient load, as surgical juniors, we are more available to help our medical colleagues. What I have appreciated most in these unprecedented times, is how we have banded together to deal with this emergency. It is heart-warming to see radiologists, haematologists and ophthalmologists and many more volunteer themselves to come back and work on the wards as juniors to help ease the pressure on our medical counterparts.
To ensure our staff are working effectively, the department leads have acted quickly to devise an emergency COVID rota. The surgical team has now reduced to a skeletal team, which covers the on-call and existing inpatients. The remaining surgical staff are deployed to the critical care team to staff the supplementary ICU. I worked my first weekend shift on the ICU on 28th - 29th of March. Initially, I was anxious as I would be working in a new environment with critically ill COVID patients, hooked up to machines I was unfamiliar with. However, I quickly eased into the role as my team were extremely supportive. There were two anaesthetic consultants leading the team who were appreciative of having extra bodies and were fully understanding of my inexperience in this setting. They took their time to show me where I could find appropriate PPE and emphasised the importance of proper safety procedures. During this shift was the first time that I had worn full PPE for an extended period of time. The ward round only lasted about forty-five minutes but wearing the respirator mask for this long was challenging. It was difficult for us to communicate with each other as our voices were muffled by the mask. At the end of the shift, I found myself more tired than usual. Donning and doffing full PPE is necessary and important but also exhausting. It makes simple clinical skills such as a catheter change more laborious. I came to have a far greater appreciation for ICU nurses. I found it challenging simply wearing full PPE for 30 minutes, yet they would spend the majority of their shift in the full PPE caring for the patient.
COVID-19 has been frightening. The future is uncertain and we as healthcare professionals have stepped out of our comfort zones. Despite all of this, from what I have seen, we have absolutely risen to the occasion. I am grateful for how well Trusts are dealing with this pandemic - not only in looking after patients but also in looking after its staff. The public have been very generous in their donations to organisations such as ‘Meals for the NHS’, who are providing us with a constant supply of hot and delicious food. Though our service is being stretched, from my first-hand experience, I can wholly say that we are successfully persevering in upholding NHS’ core value of delivering the best patient centred care we can.
Competing interests: No competing interests
Dear Editor
Thank you for the insightful and supportive article.
The fear of redeployment is real but I do believe as doctors we are able and want to rise to this challenge.
As you mentioned 'For junior trainees, rotating into different specialties is the norm' [1] . As a GP trainee, our training expects us to rotate through different sub specialities every three or six months. This can cause great turmoil in our personal and professional life. For example, we may have to move home, start afresh in a new work environment, meet new colleagues and learn about a new sub speciality at a rapid pace. This again is true when we are redeployed to the frontlines. However, such training, creates well rounded, strong minded and competent doctors to face potential insurmountable challenges, such as Covid 19.
This current pandemic is the greatest challenge that we as medics face in more than a generation. It is normal for us to feel fear and anxiety at all levels from junior to senior doctors. Fear is our brains safety valve to warn us of danger but it does not take away our choice of how we react. Victor Frankl eloquently highlights this 'Everything can be taken from a man but one thing: the last of the human freedoms—to choose one’s attitude in any given set of circumstances, to choose one’s own way' [2].
I do believe that we as medics can rely on our training. We can choose to react, adapt and implement what we have been trained to do and rise to this current pandemic challenge.
1. Abi Rimmer. How can I cope with redeployment? BMJ 2020;368:m1228
2. Frankl, Viktor E. Man's Search for Meaning: An Introduction to Logotherapy. New York: Simon & Schuster, 1984. Print.
Competing interests: No competing interests
Covid-19: Perspective from a dermatologist
Dear Editor
As Covid-19 invaded the NHS, we all got ready, we acted on our clinical instincts and the united force of the NHS kicked in. Dermatology and the rest of the non-acute medical specialties prepared to be redeployed to the wards. The dermatology registrars were recruited first and then consultants, albeit a little nervously. We dusted off our stethoscopes and boned up on acute medical pathways and ECGs. We wanted to support our frontline friends and colleagues in any way we could. I have never had more respect for my frontline friends in blues, who took on the pressure and marched into their shifts, as Covid-19 cases flooded into hospitals. Many of my dermatologist friends were called upon to be second consultant on call, buddied with an acute consultant or were happy to play the role of a junior and be an extra pair of sensible hands on medical wards.
Dermatology has always embraced visual technology and many departments have systems in place to adjust to a brave new world of virtual clinics. We had a headstart on many other specialties, who have had to use this new way of conducting outpatient clinics. We continued to manage urgent skin cancer patients face to face in PPE, but we all had to adjust to video conferencing and using clinical photos and a referral letter to diagnose and manage skin rashes and lesions. Virtual dermatology clinics for new patients can be like having 70% of the pieces of a puzzle and relies on clinical acumen to reach a final skin picture/ diagnosis. One positive outcome from this crisis, is that mountains have been moved within days between managers and clinicians and innovative ways of working will change the way we practice medicine and dermatology forever in the NHS.
The skin wellbeing clinic for staff was one practical way we could help. Colleagues came in exhausted, with hand dermatitis and war wounds from PPE, seeking solace in emollients and the peace of outpatients. The pharmaceutical and cosmeceutical industries came to our rescue producing hand sanitisers and donating free emollients for NHS staff. Staff left the clinic a little lighter mentally and heavier with creams.
The skin is often a window into internal disease and we are seeing an array of skin presentations with Covid19. The most characteristic presentation appears to be the ‘Covid toes’, or non-blanching erythema, chilblain like lesions at acral sites, particularly on the toes and sometimes fingers. This presentation appears to be more common in children but can be seen in adults at any stage of the disease. [1]
The underlying pathophysiology is not fully understood but maybe a result of a vasculopathy due to the pro-thrombotic state of Covid19 patients, although further clinicopathological correlation is needed. Classically this presentation is self-limiting. Other cutaneous presentations are less specific and include maculopapular, vesicular, urticarial and livedoid rashes. [2] Although, one also has to consider other diagnoses in patients with Covid-19 such as drug eruptions, or acro-ischaemia due to inotropes. The Italian group have found 20% of Covid19 patients have skin rashes [1], although in China this figure appears to be much lower 0.2%. [3] As dermatology publishes and collates databases internationally, a clearer picture should emerge regarding the association of skin disease and Covid19.
Skin examination should be part of the consultation in a patient with suspected Covid19 and may help identify patients.
Dermatology and all specialties have a role to play in the fight against Covid19. The collaborations, camaraderie and unfailing work ethic are some of the success stories within the NHS.
References
1. Recalcati S. Cutaneous manifestations in COVID-19: a first perspective. J Eur Acad Dermatol Venereol. 2020 Mar 26. doi: 10.1111/jdv.16387.
2. Galvan Casas C, Catania A, Carratero Hernandez G et al. Classification of the cutaneous manifestations of COVID-19: a rapid prospective nationwide consensus study in Spain with 375 cases. Br J Dermatol 2020 Apr 29. doi: 10.1111/bjd.19163. [Epub ahead of print]
3. Guan WJ , Ni ZY , Hu Y , et al; China Medical Treatment Expert Group for Covid-19. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. Published online February 28, 2020. doi:10.1056/NEJMoa2002032
Competing interests: No competing interests