Wednesday, 31 August 2011

Sick Doctors

In June this year an article published in the British Medical Journal reported that in a period of four weeks a third of doctors and nurses have worked when they should have taken sick leave. The authors claimed that, on average, working when sick “nearly halves their working capacity”.
The e-link to an abstract of this article can be found Here
I believe that many of those working in the National Health Service will readily identify with this state of affairs. Why do doctors and nurses do this?
My own experience as a general practitioner is that there is, first and foremost, a desire "not to let the side down" and, of course, a reluctance to inconvenience their patients - or even to attract complaints. For more than once, when I have seen patients of behalf of a sick colleague their comments have been less than sympathetic.
I have myself been fortunate with my health. In more than 40 years of practice I think I have taken no more than seven days off sick. But that is not to say that for considerably more than that I worked when I was feeling more or less wretched. And I saw my colleagues doing the same. Of course, were they having to go to the toilet to vomit between consultations - yes, that has happened - they have been sent home quickly enough. And usually another colleague was called in from her or his half day off to see the abandoned patients.
It may not generally be known that NHS GPs are expected to arrange their own cover for their own absence - be it for sickness, bereavement or any other cause.
But perhaps most concerning is that the doctor who is ill, stressed or grieving is a potentially dangerous doctor. Nevertheless, serious medical errors as a consequence of these episodes are thankfully rare. Yet if they happen, the unfortunate doctor can expect to have the book thrown at him by the General Medical Council (the doctors' professional regulator) and may even be successfully sued. Being unfit for practice for reason of illness, stress, bereavement or fatigue is not considered a mitigating factor.
The General Medical Council (GMC) and successive governments have been at pains to address concerns about "patient safety" and in particular when it is a consequence of a doctor not coming up to the mark, for whatever reason. They have seen the way forward to be the introduction of revalidation, or reaccredidation for doctors at 5 yearly intervals. It is anticipated that this may identify in the region of 2% of doctors who may present a risk to patients.
What I would propose, however, is that doctors attempting to work fatigue and short term illness present a far greater risk to patients than any of the factors that may - or may not - be identified by the revalidation process. Yet this far greater cause for concern has attracted scant attention from those who purport to have the interests of patients at heart. The views of the GMC and the politicians remains that the consequences remain the responsibility of the individual doctor. The sick doctor who makes a mistake can expect not support from them, but censure.

Reference: Dew K, Pressure to work through periods of short term sickness. BMJ 2011;343:218-219 d3446

Monday, 29 August 2011

Public Platforms, “Experts” and Error

BBC Radio 4 is generally thought to be the transmitter of “quality” broadcasting, and its weekly “Any Questions” programme is considered worthy of serious attention. OK, so the opinions of some of the celebrities on the panel might be taken with a pinch of salt, but those of the experienced politicians, journalists, academics and scientists who feature on every edition may not readily be dismissed.

            It was all the more shocking, then, that an eminent scientist, Dame Wendy Hall, Professor of Computer Science at the University of Southampton, should have made such a crass and inaccurate statement with regard to the way general practitioners consult with patients presenting with hypertension (high blood pressure).

            The question concerned the increasing prevalence of obesity in the population, and whether an appropriate way to address it might be to put into practice the proposal that “junk” foods should be taxed.

            Professor Hall chose, in her response, to offer the opinion that a part of the problem lay in the way she claimed that general practitioners handle the presentation of high blood pressure. “You’ve got to think of this holistically,” she said, “But you go to see a doctor for high blood pressure, you get a pill for high blood pressure.” Her implication was that doctors do not look at the wider issues of lifestyle – do not look on situations in a “holistic” context (to use a hackneyed and discredited term).

            This is a terrible misrepresentation of the facts. All the more surprising because a scientist should concern herself with facts – not speculation, hearsay, sources of information that go unchallenged or whatever.

            GPs have always looked at the problems patients present to them in the context of them as people, a part of a family or community, they way they live and what they do to maintain their health or to compromise it. OK, so their efforts to do this are constrained somewhat by the all too brief allocation of time to do it in. The demand for their time sets the appointment length pretty universally at ten minutes (when I started in practice, it was six minutes).

            What she said was insulting to the legions of doctors who follow conscientiously the guidelines given to them - guidelines that have been painstakingly drawn up on a well researched evidence base.

            Professor Hall should have known better. More than that – she should be ashamed of herself for so portraying the dedicated men and women in the medical profession who do their damnedest to give their best against very considerable odds.

            For just a few moments she spoke, not as a true scientist basing her statements on accepted truths, but more like a person who, with staggering credulity, had blindly accepted the mouthing off of a sensation seeking journalist writing in a cheap magazine.