Musings of “the new, junior guy.”


Last week I was at “hospital induction”, which I think is what the British call “introduction”. It is important to have introduction 32 days after you start working. Not to pass on critical information and material you need to start working, but to answer the question “what is this madness?”

When I first started my current job, I witnessed lots of madness. Most of it I could not believe was coming from a world recognized medical institution. Protocols followed as if they were the word of God, still every day I witness providers who never see the patient recommend “guideline” treatments for them. There are no shortages of “consults” which add neither knowledge nor insight to patient care. But they take hours.

For those of you who know me, this “medicine by numbers” or “McMedicine” is the antithesis of my being. It doesn’t take a doctor. Any idiot could do it (and frequently non-doctor idiots do). It is not good for systems or patients.

During a recent ward round, there was a patient who might score a 4 or 5 on his GCS assessment, yet as clear as day on the chart it read GCS 9. I laughed out loud and offered that was an extremely optimistic assessment. In layman’s terms, a moderate head injury with fair prognosis. There was nothing moderate about the injury and nothing fair about the prognosis. In informal medical parlance, this patient would be discharged to the “vegetable garden.” A long term care facility for those who will spend the rest of their lives contracted and watching reruns of Disney movies without blinking or talking until they succumb to pneumonia, a urinary infection, or other form of sepsis. In this age, there is nothing we can do for them. Just watch and wait to see if they are one of the miracle cases that suddenly get better due to no explanation other than “patient was lucky and healed themselves.”

I was immediately chastised by my superior as being cynical and having a low opinion of the ability and efforts of my fellow providers. A rather unfair assessment I must say, despite me desperately wanting to believe, all evidence to the contrary, that they simply don’t follow “”protocols” regardless of patient condition. On this occasion, they probably outright lied about this patient’s conditions.

But before I am mistaken as unduly accusatory, let me just come clean, I would have lied too.

I learned in induction that the facility has been beset in recent years with a series of very high profile “never” or “sentinel” events (depending on what form of English you speak); that is to say, events that resulted in serious harm, usually death, by entirely preventable mistakes. This is not to say it is a bad facility. Any high volume center will and has seen these things happen. It will happen again, all over the world, as sure as the sun rises. The reality is, no matter how good a system is designed, somebody is going to slip through the cracks at some point.

In my history I was fortunate enough to work with an industrial safety specialist. It was during my EMS career, and we were on a committee formed to improve safety and monitor trends. He lamented that most EMS providers did not take his knowledge or advice seriously, mostly because of his lack of “street cred.” In other words, he didn’t do the job, so his insights on how to do it safely were outright dismissed. Here in the UK, medicine suffers from the same problem. Most of the scientists are not clinicians also. They are literally studying things they do not do. No matter how they try, they will never develop realistic, credible experiments for process improvement. They are too far removed. Many of their recommendations are laughably unrealistic, but they have no shortage of advice. Not only do they not have “street cred,” it is evident many of them have no clue what happens when you are managing more patients than resources or safety permits. They don’t understand the level of fatigue after 16 plus hours of subsisting on nothing more than sips of water and whatever food you can stuff in your mouth between patients. They are blissfully unaware of the shortcuts and backdoors required to even keep the system functioning, forget efficient. They live in a perfect, paper world. Where everything is predictable and happens exactly as planned. It must be nice there. If the world was perfect, nobody would need medicine.

So naturally when things go wrong, as they will, rather than taking the steps to actually fix the problems, like provider to patient ratios, increased provider training and education, they resort to creating protocols or guidelines. They actually believe it is possible to create protocols and procedures with narrow limits that will in effect “regulate people to excellence.”

Getting back to my experience with the industrial safety professional for a moment, I learned a lot from that guy. Things which are extremely and immediately important to fire, EMS, and medicine, not only theoretical, but practical, actionable, information. Plus I have street cred. I am in the trench. In fact, being in the trench is where I prefer to be. Administrative and strategic duties are all fine and good, but I love to be the one “doing it.” I plan to be in that role until I am either carried out or physically can’t do it anymore.

But enough of my plans…One of the things I have learned from working with the finest people in the best organizations all over the world is: “You cannot regulate your way to excellence.” At best you can regulate to mediocrity, but what happens more often than not, is you regulate to ineptitude.
“The surgery was successful but the patient still died.”
It is meant to be a joke, laden with sarcasm, not the recipe for measuring your success.

But it is being used to not only measure success, but to pretend like it is good medicine. Most of the providers I encounter are following an extraordinarily tight set of parameters in treatment guidelines. Checking the boxes and following the algorithm is not only the measure of success, but the very point of the job! Actually seeing a patient is an avoidable nuisance, a step not required for success, especially when the treatment will be the same no matter what. This is justified by the term “clinical governance.” This “clinical governance” is a system in which lots is being discussed, recommendations made, but nobody is responsible. Nobody wants or even has the ability to deviate from guidelines. Not only that, anyone who even suggests deviating is “a menace to prudent clinical practice.” That’s me. The menace. The new guy. The young doctor who doesn’t understand or have not experienced yet. So I am told… I am also told “I’ll get it sooner or later…” Fat chance…The day I realize I am checking boxes, that I don’t actually need to see the patient, or that I do the same thing for all of them no matter what, is the day I will hang up my hat and call it a good career. I will also be proud of my ability to self-assess I am more of a menace than an asset at that point.

I don’t actually believe I am a cynic that sees my coworkers are purposefully messing up. What I believe is that my coworkers are trying to provide good medicine within an extremely narrow and rigid framework. If everyone who has a GCS <8 needs intubated, the only logical thing to do for a patient who has a GCS <8 that does not need to be intubated, who would probably be harmed by intubation, is to write on the paper “GCS 9”. All boxes checked, patient taken care of appropriately. It does make the paperwork and charts fairly useless though. After all, when the papers say what they need to say but do not reflect reality, what it means is that accurate information is not being recorded or conveyed. The continuum of care is not just broken, it is nonexistent. Every time a patient is seen it is effectively the first time, by every provider that sees them. That is a crack. Actually it is a giant gaping hole is a system set up to close gaps. Evidence you cannot regulate to excellence. “Clinical governance” seems to me more like systematic negligence. Maybe I am new to the organization, but I am not sure that is the goal they had in mind. That’s what I learned at induction; the method to the madness, but madness none-the-less. Thanks for listening today. It seems nobody here is listening or looking. See no evil, hear no evil, and speak no evil, then wind up shocked when there is an expose in the newspaper with peoples’ names listed as the parties responsible for the blame.