Consent

consent

Recently, we had a patient under our care who spoke very little English. We could manage on very basic instructions but because the patient needed an operation, they needed to be consented for it.   Not one of us could speak anything other than fluent English, so we needed an interpreter.

I asked the ward clerk to book one in the patient’s preferred language. When interpreters are booked, they usually come the next day so I was beyond surprised when the ward clerk told me she’d arranged one for midday, little more than an hour away. I let my consultant know the good news.

Here’s where it turned sideways. He wanted me to do it. He wanted me to consent the patient for this operation. That caught me off guard. Consenting isn’t any old task. It’s a multi-layered subject that the GMC* takes very seriously because there’s so much to it. There’s so many aspects that needs to be taken into account: ethics, medical legal issues, capacity etc.

Then there’s the whole issue of F1s taking consent. It’s a grey area. We’re essentially baby doctors running around with a provisional registration. We can take consent for some procedures provided it’s something we’ve seen before. An example would be a colonoscopy (a camera that looks into your bowels). I can do that. I’ve seen several. But this operation I was being asked to consent for, I’d never seen it. I could hardly even pronounce it.

Obviously, all of this didn’t come to me at the time. I just held the phone to my ear for several seconds, trying to comprehend exactly what I was being asked to do. I started off with ‘O…..kay….’ Followed by ‘I don’t think I can’. Note the conviction in my wording. The consultant was urging me, saying I wasn’t really taking consent, I was just reading the form out to the patient and then the interpreter could sign the consent form. Still, it didn’t sit right. I was stuttering, falling over my words until eventually, I agreed.

But I was uneasy.

I walked back onto the ward heavy footed, wondering: why me? I kept going over it in my head.

Luckily, I bumped into another F1 and quickly ran over what happened. She gave me a definitive no, it wasn’t a good idea.

And really, it’s what I needed to hear. Intuitively, I knew it wasn’t a good idea. I wouldn’t be able to explain it to someone succinctly. Yes, I could read off a piece of paper, but that isn’t what consenting is about. I always find it difficult to say no, but I called the consultant back to let him know.

I managed to find someone else more versed in this procedure than me to explain it. He drew a diagram, he explained it clearly, he answered questions. Only a person with actual experience with the operation, could go into the amount of detail he did.

It made me realise how unfair it was for the consultant to put me in that position. Chances are, the operation would have gone smoothly. Yet even so, what if something bad did happen. It’s hard not to think of worse case scenario when there’s that constant reminder that you need to watch your back; we’re living in an increasingly litigious society.

Most importantly, it wasn’t fair on the patient. That patient needed to know exactly what was going to happen with their body. If they had questions, I definitely wouldn’t have been able to answer them. I knew what the aim of the procedure was, but how they were going to approach it, where they would make an incision or what exactly would happen would have been guess work. The patient deserves way more than that.

I’m really glad I made the right decision in the end. But I was so so close to making the wrong one. If I hadn’t talked it through with someone else, I genuinely think I might have done it. And it would have been a mistake. But in that moment, I felt pressure beyond belief. The consultant questioning why I couldn’t do it, telling me how busy the team were just made me feel more guilty.

It reminds me of the SJT**, the exam where you have to rank how you’d behave in different situations from the most appropriate to the least appropriate. It’s really easy to read a scenario on paper and say what you would do, but in reality, the situation can be very different. Rational thinking fails you, and your left to make quick judgement calls under a lot of pressure.

Let me know what you think. Has anyone else been in something similar? What happened? It would be good to know how I could have handled it differently.

 

*General Medical Council
**Situational Judgement Test

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Some Good Things

Some Good Things

Even when I feel down, there is always something to be grateful for. I try to make it a habit to look for the smallest things, just to keep me going and keep me motivated. Here are some examples of a few silver linings that have happened recently:

  1. When another F1 sent me a stinging message on a group WhatsApp, it left me confused. I couldn’t decipher the tone. Was it a question, covered in humour, or was I being told off? I’m not particularly close to this person so it was hard to tell. I replied as diplomatic as I could because I wanted to get the balance right so that 1) I addressed the issue, 2) I didn’t go overkill and have the other person tell me later they were joking and 3) have an all out argument on a group WhatsApp. No one wants to be told off by a colleague and I didn’t like that they felt they could embarrass/shame me in that way. If there was an issue, a private message would have been way more appropriate. I was really surprised and touched when the other F1s messaged me in private to support me. They were probably more ruffled than I was. It warmed me up a bit that other people took the time to try make me feel better.
  2. Even though I’m mid placement, I’ve already had my end of placement feedback for my ARCP. (Don’t ask why, the powers that be have decreed that it needs to be done two months before the actual end of the placement). My supervisor put the nicest things down, which took me aback a bit. It’s unusual to get really positive feedback in this game, it really is. You sort of just plod along and do the job. Maybe it’s because everyone expects you to be hardworking, that’s how we all got here. But as a newbie all you want to know, at least all I want to know, is that I’m doing OK. So imagine my heartache when it gets to the point we submit the form and the system decides to malfunction, deleting every nice thing that had been written. Luckily, my supervisor rewrote it all. I really needed to hear something positive, because my last placement had knocked my confidence, read here and here.
  3. My current placement has another F1 who is awesome. What’s annoying is that we don’t get to work together often because of our on call schedules. We’ve probably overlapped by four days so far. BUT, it looks like we’ll probably be working together more in June/July. We get on really well and we have a laugh, which makes the job much more bearable.

Just some of the good things that have taken me aback recently. I’m trying to remind myself of the good things and not allow myself to be weighed so heavily by the bad. Reading through comments is another thing that I look forward to. Even when I’m ranting, it’s really interesting to see your opinions and your take on a situation, so a big thank you for anyone who has left me a comment.

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Dear Paediatric Registrar

letter

Sorry that I don’t know your name. I’m writing this letter knowing that you won’t ever read it. I’m hoping by the virtue of me describing what happened this Saturday afternoon, it’ll serve to at least bring me closure and stop the angry rewinding and replaying in my mind.

At 3:30, I was bleeped by a nurse to do a discharge letter and discharge medication for a child. I let her know that I would do the letter as soon as I could.

Then you called a moment later.

I’m not sure what kind of day you had or what the situation was on your end, but equally you could say the same to me. So, when you said I needed to make this child a priority, I thought that was unfair and unnecessary. Every discharge letter that gets thrown my way is pushed on me because it’s urgent. It’s a Saturday and pharmacy closes before 4 (essentially giving me less than a half an hour window). When I’m waist deep in tasks, it’s unhelpful to tell me to leave what I’m doing, to do what you deem a priority. You had no idea what my workload was like, you failed to see beyond what needed to be ticked off your list.

You were unkind for telling me off for asking the nurse to look in the BNF for the antibiotic dose. I didn’t ask her to. She offered. And when she offered, I said she could. I don’t see where I went wrong. I didn’t ask her to prescribe it or to give a prescription. A nurse is more than capable to look in a book. But I didn’t argue with you. I got the sense that there would be no point. You clearly had a bone to pick.

I came up to the ward, leaving behind a stack of unfinished tasks and finished the letter. You bleeped me again: I had prescribed the formulation that the ward didn’t stock. And you wanted me to come back and prescribe on the bottle.

You were relentless.

Part of me wants to think it’s because you cared so much for the child at the end of all this. But I don’t think that explains everything. Because if it was truly that, if you really wanted to get that little girl home you could have prescribed the right antibiotic formulation, something you’d have done a thousand times. You could have written the prescription on the bottle, it would have taken you less than a minute. If that child was your priority you wouldn’t have instead dialled my bleep, countless times, to try to get me to leave everything, again, to come back up to your ward to jot a few words down. If you just did it yourself, you would have saved you and me a lot of time. I’m not sure why you needed to pick on every single thing.

I would understand more if it had come from a nurse. They get their own pressure from bed managers. But from a doctor who has been in the position I was in, who has been a junior doctor carrying the load several doctors normally would, I would have expected you to get it. To get that I’m one person and I can’t do everything at once.

At a time when everyone’s feeling the stress, you rely on your colleagues more to motivate and encourage you. But you gave me a metaphorical kick in the teeth. You were demanding and unfair. Again, I don’t know what type of day you had and I probably couldn’t imagine the stress that comes with being a paediatric registrar. But I hope that when those stress inducing situations arise, that you’re treated with more compassion and respect than you showed me.

Sincerely,
Zed

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Halfway

halfway

I’m halfway through my last placement as an F1 and I’m literally counting down the days to the end of July when I go away for a family holiday. It’s also really close to when we swap over, so coincidentally I’m also counting down the days till I never have to do surgery again.

I know surgery isn’t for me. I knew it halfway through medical school after a brief stint on the general surgical ward. I’m not keen to go to theatre. I’m not keen to stitch. I don’t really like seeing organs spilling out of the cavities they belong in. It just doesn’t stir any interest in me whatsoever.

The 2 year foundation programme should have a good balance of the different specialties which means there definitely should be a surgical rotation in there somewhere. Lucky for me, I got two. I’ve already completed one rotation so this is my last one. (!) I’m not very keen on my current surgical rotation. It’s a whole host of issues. Plus, the way F1s are treated on surgery isn’t fun. Imagine a garbage truck at a landfill. We’re the landfill.

Surgery is very top heavy, so all the decisions come from up top. Daily consultant led ward rounds (which is good). In comparison to my first placement when it was a team of 4 junior doctors, we often had to lead our own rounds. I resented this in the beginning but now I’ve come to appreciate it. It meant I knew each patient, I knew their history and I knew where we were heading. I felt comfortable having discussions with patients and their relatives. It felt cohesive. Patients felt like they were my patients. I was making decisions and acting on them. Whilst on surgery, I don’t feel that same familiarity. The ward rounds happen so fast, it’s a bonus if I can catch a glimpse of the patient in front of me because I’m rigorously trying to scribble down as fast as I can.

I don’t ever fully know what’s going on with each individual patient. And the turnover of patients is so fast, people become bed numbers because it’s so hard to keep up with who’s coming and going. I can’t confidently tell you what the plan is for everyone because honestly I can’t remember. The ward round is a blur. I pray that I’ve made a good list on my sheet or else it’s anyone’s guess what’s happening.

The moment the round is finished everyone disappears. It’s just me and my flimsy sheet of paper trying to figure out what the jobs are for each patient. There is another F1, but the rota is so choc block full of on calls that we hardly see each other. Honestly, I think the CT should be helping with the jobs, but surgeons don’t want to be on the ward, they want to be in theatre. So, all the menial tasks get dumped on the F1 (hence landfill). This is my experience anyway. Some of the other teams do have more conscientious CTs who help. I can understand that they need to put the hours in and fulfil their requirements for their ARCP like we do. I get that. But they’re still junior members of the team and should be helping out on the ward. When the rota gap happened and left the team with no F1s, I was surprised the telling off I got. (Even though it wasn’t my fault). I had foolishly believed the CT would be able to do his bit and hold down the ward jobs. Obviously not. It seems the team can cope without a CT but not without a F1. If all the F1s decided not to come in, surgery would crumble and just cease to move. You would think that would make us valued members of the team.

This isn’t to say that I can’t work on my own because I can. But so often I’m being spread thin across several wards. The bleeps go off constantly (guaranteed twice during lunch). Nurse A is calling from ward 1 and needs a discharge summary done (urgently), Nurse B is calling from Ward 2 because a patient’s blood pressure is 100/70 (yes, they feel fine), Nurse C is calling from Ward 3 because some fluids need prescribing (urgently). Nurse A wants to know how long for the discharge letter.

It gets to the point sometimes when I look forward to being on call just so I can escape that shrill call of my bleep and the person on the end who needs something done. And of course, it needs to be done A.S.A.P.

Leave a comment if you understand the feeling!

*core surgical trainees (CT): have completed the two year foundation programme (F1, F2) and are on a 2 year surgical training programme.

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Saying No

I feel uncomfortable saying no to people. Blame it on the people pleasing child in me. The one that wants to keep other people happy whatever the cost. The one who hasn’t grown enough self-esteem to just say no, simply and plainly.

My consultant wants me to do an audit. She mentioned it and in a roundabout way, I let her know that I didn’t think I would be able to. I hadn’t even completed the audit from my previous placement. She mentioned it again 5 minutes later and explained the project a bit more. At this point I could feel the pressure. Now my consultant is super nice and it’s the niceness that makes it even harder to say no.

Who am I kidding? I just don’t like saying no, particularly to someone above me, like my supervisor. I feel like by saying no, I might rile them and turn them against me.

I’ve been learning a few tough lessons over the course of the last few months. I thought I was a smart individual, but it seems like I have to go through the same type of situation over and over again before I learn my lesson. And each time I fail to learn, the lessons become harder and the consequences harsher.

I can see it now: I’ll take on this project, I’ll end up staying late multiple times after my shift to complete it, it’ll end up being subpar, I’ll be grumpy and unhappy and subconsciously take it out on everyone else.

I just need to be honest with myself and clearly let her know that I cannot. Already, I feel like I’ve got a lot on my plate, I honestly don’t think I could cope with the additional pressure of something else. Any spare energy I have, I want to spend it on me. I already give a lot of my energy to this job. And I don’t even like doing audits. GP audits are easier to do because everything is computerised, there won’t be any wading through pages and pages of notes trying to decipher handwriting. I just don’t want to.

Obviously, she doesn’t need to know all of that. But I should just be honest.

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Rota Gap

My surgical team consists of consultants, a registrar, a core trainee (CT) and a couple of foundation doctors. Because of the varying on call rotas, we aren’t all on at the same time. Like any rota, if there’s bad coordination then it may cause a rota gap, where there isn’t a sufficient number to cover the ward. This was Week 4 and it was already happening. To make matters worse, it felt like it was my responsibility to fix it.

Why was it my responsibility? I didn’t understand it either. It seems it was on me to find someone else to fill the gap. Which I’d tried to do. I’d asked other F1s, multiple times, whether they would be willing to cross cover for at least one of those days: and I got subpar responses. How hard should I have pushed? If someone said no, what else could I say? I didn’t feel it was my place to coerce people. It wasn’t an easy position to be in. I ended up feeling really sorry for me, in dramatic fashion silently screaming ‘why is it always me?’

What made it worse was getting flack from the core trainee and then by the registrar which I didn’t appreciate. (At this point it was just me as the other foundation doctor was now on zero days, so I was the only visible one if that makes sense). The rotas are online. You can see your own rota and everyone else’s on the surgical firm. So, I really didn’t appreciate the CT making it my fault that he wasn’t enlightened earlier. Excuse me?

Where else in this country would it be the employee’s responsibility to make up for the rota co-ordinators mistake? Where else would the responsibility lie on the most junior member of the team to sort out. It’s the kind of additional stress that I don’t need. And it’s the kind of thing that makes me feel resentful.

I think I just assumed that the rota that had been provided would be right. I appreciate I could have escalated earlier, but in that time, I was trying to get cover. Anyway, the issue was resolved by me offering to come in and cover those couple of days even though I was supposed to be off (but I can take those at a later date).

Please comment below, I’m really interested to know what everyone’s opinion is.

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Driving Home

I open my eyes and sit up in my car seat a little. A minute later, I start the engine and continue my drive home.

I’d just finished a busy night shift. Non-stop, constant running from ward to ward for most of the 12 hours. I’d come on the shift with more than 10 jobs already waiting for me. The F1 on call was apologetic as she handed over a few more. What can you do? Some days are just busier than others. Add that to the patient that was deteriorating before our eyes and it’s easy to see why there was a back log.

I spent a lot of my time on this patient, his blood pressure kept dropping despite giving him 4 L of fluid. By the end of the shift he was taken to HDU for more support.

When the day team arrived, I was relieved to shrug off all responsibility and head home. I couldn’t be happier to get into my car and hit the pedal.

The tiredness never hits me in the beginning. I’m usually fully awake and smiling as I head towards home. It’s towards the end when the monotony of driving in a straight line without having to change lanes or stop or think plus the steady soothing hum of the engine starts to gently carry me away. I’m on autopilot. Ever so slowly the road markings start to blur, it feels like I’m drifting a little bit to the left, my lids feel really heavy…

This doesn’t always happen; I can often make it home without stopping. But there have been times I’ve come off the motorway, stopped at the side of the road or once at a local Tesco, switched off the engine and just closed my eyes.

Time passes, I open my eyes, turn the key and away I go.

It’s scary what tiredness can do. I had a colleague tell me that she thought she’d nodded off on her way home and was jolted awake by a horn from the car whose lane she’d started to drift into. The fear and the adrenaline spike kept her awake all the way home.

It’s hard work that we do. It’s just scary to think about what the consequences could be.

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5th May 2017

lunch

At 1 o’clock, I went to the fridge to get my lunch. If there’s one thing I look forward to during a shift, it’s lunch time. Half an hour of (supposedly) uninterrupted break time. So when I found a good point between jobs to get lunch, I dropped everything and headed straight to the staffroom, smug  in the knowledge that I wouldn’t need to line up for the same carb-loaded meal I had yesterday (pizza and chips). I opened the fridge, nothing immediately jumped out to me, so I had another look. No lunch. Stay calm, there is probably a reasonable explanation.

Turns out the reasonable explanation was that one of the health care assistants had thrown it away. What, with the container? No, the container was safe. The contents, not so safe. She apologised profusely but said she was just doing her job.

I didn’t have anything to say. I was not happy. Just one more reason why I resent the system.

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Getting A Medical Opinion

I had a really sick patient over the weekend. Everything I gave him seemed to have a temporary effect. The surgical registrar reviewed him, then asked me to get a medical opinion.

The way the bleeping system works is you press a single number, the bleep you’re trying to reach and the number of the extension you’re calling from. (The handheld phone didn’t have the sticker which tells you what the extension number is, but I knew the number off by heart anyway). I bleeped the med reg (medical registrar). No answer. I bleeped the assisting med reg. No answer. I waited. They’re probably really busy. I should just be a little patient. So I waited a little more. I might have bleeped a couple more times. Then I bleeped the critical care team because I was really worried about the patient. No answer. (In hindsight, I can see why this should have been a clue)

A little later I finally got the med reg to see my patient.

I left the med reg to it and tried to get on with the growing list of jobs. It was fast becoming a sea of green, amber and red requests. I was on a different surgical ward when I picked up the phone. I can’t remember who I was going to call or bleep but I flipped the phone over to check the extension number and I froze. Like actually stopped in my tracks and didn’t move. These were the four same numbers I’d dialled in earlier when I was trying to get the med reg. I cover these wards so often I’d mixed up extension numbers in my head. So every time I’d bleeped, they had probably been ringing this phone on this ward, whilst I waited on a different phone on a different ward.

What a stupid, embarrassing mistake to make. Obviously, I didn’t own up to it. This particular med reg wasn’t the kind you would have even a slightly humorous conversation with. I imagine he would first stare me down  until I disintegrated, then later make me the butt of every joke, till the end of time.

*embarrassed face emoji*

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A Fresh Start?

Things have picked up a bit in my new placement, which I appreciate. (I might soon regret this). But for now, I’m just relieved to be in a new team, doing a new job.

The first few days were hectic. Nothing major, just a moderate amount of jobs that kept me busy enough. I cover around 4+ wards, so there’s a lot of to-ing and fro-ing. The first day was an immense amount of to-ing and fro-ing, which meant I got tired really quickly. Over the next few days, I tried completing jobs by working my way through one ward, then moving onto the next one. It made things a bit easier but the nurses and patients didn’t play to my masterful plan, but nonetheless I was running around a whole lot less.

Even though it hasn’t been super busy, it’s enough of a pace that I’m constantly on my feet. And I need to be quite conscious of time so that I don’t stay too late. I’m trying to be organised and get things done as quickly as possible. This is why I try to delegate jobs if I can. If there’s something that I need to do, I’ll have to do it. If it’s something that potentially a nurse could do, then it’s super super helpful if they do it. The most tedious of jobs are cannulating and bloods, the bane of my existence.

The setup, the cleaning, the procedure itself, the clean down, then putting all the extra bits back in the right places. It’s all just too time consuming. You can imagine the immense gratitude I feel when I come across a nurse that can put cannulas in. My eyes roll to the back of my head with a silent prayer of thanks. I appreciate the nurses trying and having a go.

On Thursday, one of the nurses bleeped me on the ward to say her patient needed a cannula for his antibiotics. She’d tried and couldn’t get it. Fair enough. But I was still a bit annoyed, not at her, but at the cannulation situation. I get there, put one in and leave, I’ve still got quite a lot to do. Discharge summaries to write, other people to bleed (I think phlebotomists were on strike that day), scans to request etc. I get called an hour later, to put a cannula into the same patient I’d just put a cannula in because he pulled it out. Irritated, doesn’t begin to explain…

At that point, I still had a backlog of uncompleted tasks and I was annoyed at the idea that I had to go redo something I’d just done. It wasn’t the nurses or the patient’s fault. These things happen. I explained I wouldn’t be able to get there as I was swamped, and that if she could or anyone else could try but I wouldn’t be able to get there quickly.

When I got there, there was a tiny plastic cannula, nicely bandaged on the patient’s arm. I’m not sure who put it in, but it was like seeing a rainbow on a rainy day.

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