Regular readers will know that Dr No is an advocate of Auric’s Law of Causes – happenstance, coincidence, enemy action – and it so happens that Auric’s Law has been met, indeed exceeded, in four out of four recent NHS encounters by family and friends of Dr No. In each case, the care provided was either partly or wholly inadequate and/or incompetent; and, by Auric’s Law, he concludes these adverse experiences did not arise by chance, but by malevolent force. The malevolent force was the NHS, or more specifically the doctors who provided (or in some cases did not provide) the care. All four cases happened in, or were related to, secondary (hospital) care, but more often than not the GP was also involved in, or at the least complicit with, the deficient care. In all four cases, either the patient or a relative was a doctor, and so an ‘expert witness’, able to ‘read’ what was going on. How much more poor care, one wonders, goes on, but is unnoticed, because the witnesses are lay, and lack the knowledge to read the signs?
Regular readers will also know that no one supports the NHS more than Dr No, and so the opening paragraph – which in effect says Dr No’s recent experience of the NHS is that it is crap – poses the obvious question: why on earth does Dr No support a service that is crap? The answer is: he does not – and hence this post. Instead, he supports what the NHS should be, and in the eyes of some, once got close to achieving. But today, with the help of Auric’s Law, he has come to appreciate that his cosy notion of a wonderful NHS is based more on rose-tint than reality.
The decline and decay of the NHS, and indeed British Medicine, because the two have for the last half century and more been one and the same, has come about, it seems to Dr No, because of two developments. The first, which he is not going to cover here, because he has more than covered, and will continue to cover, it elsewhere, is the introduction of a market, and all that markets entail, into what is a national service. The second, which is not entirely unrelated, is what, for want of a better phrase, Dr No calls the deprofessionalisation of doctors. Much, but not all, of the responsibility for that deprofessionalisation lies at the hands of medical educators and regulators, for it is they who are responsible for setting the curriculum, perhaps better put these days as tooling up the production line, and so are responsible for the doctors that fall off the end of that line; and today’s product, it seems to Dr No, is deficient in three core attributes: responsibility, authority and autonomy. In each of the four cases of poor care Dr No observed or has been told about, it was deficits in one or more of these core attributes that gave rise to poor care.
No doubt long and learned books can be written about the matter, but by way of an introduction, Dr No suggests there are two core trends that have given rise to today’s deficient, indeed defective, doctor. They are in their way fetishes; and like all fetishes, have the power, as it were, to distort the normal flow of events.
The first fetish is that of the team-player. This is the fetish that has above all else done so much to destroy traditional medical practice. It is the one that has given rise to that abomination, ‘the team’ – a can of incestuous scorpions if ever there was one – and all that follows: protocols, patient pathways, noctors and poctors, and the abolition of doctor to doctor referral. It is the poison that has given us the doctor who dare not speak his or her mind, for fear that ‘the team’ will sting the doctor; and the doctor who crumbles, and in so crumbling fails to do his or her duty to the patient, in the face of all powerful pathways and protocols. How far, we may observe, have we strayed from the proper doctor: a doctor with responsibility, authority and autonomy.
The second fetish is that of the doctor-communicator. This abomination, which is exactly what it is when it is given primacy – and which, we might add, gives an entirely new spin to the phrase spin doctor – holds that, above all else, a doctor must be a good communicator. The care may be crap, but so long as the doctor communicates well, then all shall be for the best in the best of all possible worlds. It allows, indeed encourages, the triumph of PR – public, or rather patient, relations – over care. It elevates warm, effective communication above arduous and proper doctoring. It promotes message management skills above basic but essential clinical skills – and in so doing gives rise to the doctor who is a master of spin, but a dunce at basic medicine. How far, we may again observe, have we strayed from the proper doctor: a doctor with responsibility, authority and autonomy.
That, then, is Dr No’s diagnosis of the ills that have overtaken British Medicine, and so the NHS. The prognosis is guarded, even bleak.
Speaking as a consultant, you seem to suggest that good communication with patients doesn’t matter. I would suggest to you that it doesn’t matter how good a doctor you are, in most branches of medicine, if you can’t help the patient to understand the problem they have, the potential solutions, and why you are recommending one course of action over another. I completely accept that this may be less important if you’re a pathologist, radiologist, work only in interventional cardiology, for example, but even those working in ITU need to communicate with patients’ relatives.
Your statements remind me of some of the orthopaedic surgeons I work with and these attitudes are rightly regarded as those of a dinosaur by most. Working in a team and communicating well with patients are important in delivering good care. It won’t be those aspects that have led to the mistakes your friends and relatives have unfortunately experienced. Working in a team doesn’t mean hiding behind a team; working in a team doesn’t mean avoiding responsibility for good clinical decision making and leadership.
The clinical history is the foundation of good clinical practice, and to be an expert historian depends on excellent communication skills. You’ve set up a false dichotomy; communication skills are clinical skills.
I’ve written about it on a few occasions e.g. http://abetternhs.wordpress.com/2012/03/20/confession/
but better than my efforts is this example by a septagenarian cardiologist: http://bernardlown.wordpress.com/2010/01/01/reflections-on-a-half-century-of-medical-practice-the-art-of-listening-to-the-elderly-patient/
Your criticism may have validity if the elderly clinicians were, by virtue of their more theoretically based training, better than us youngsters, but as any hospital recipient of trite GP referrals will tell you, quality of GP care has gone up, not down in the last few years.
The GP is the gatekeeper manning the gates between suffering and a disease label, between care in the community and a specialist referral. In order to make best use of the specialist, the GP needs to know how best to make use of their expertise. This is only possible with team-work. We GPs are stuck in our silos, and with the debacle of Every Willing Cowboy fighting for our referrals, the chance to develop close relationships is evaprating fast. We can learn a lot from our specialist colleagues.
Where we agree is in the need for regular assessment. Surely it would be simplest for all GPs to retake their MRCGP every 4 years, just as my plumber has to retake his CORGI exam?
J
Anon – Dr No is not saying an ability to communicate doesn’t matter. In fact, all three of the jobs that he has done – doctoring, writing and YachtMaster instructing – all require communication skills. So he does appreciate their importance.
Interestingly, all the communications you list are in the same direction – doctor to patient. Dr No is sure you would agree that, not only as JT notes in relation to history-taking, but more generally in consultations, things usually go better when the patients feel they have been heard. So, usually, the communication needs to be two-way. So – again – Dr No values the importance of good communication.
Similarly, the crew of a yacht is nothing if not a team. So Dr No also appreciates the importance of good teams.
Dr No’s concern is that in our desperation to correct the poor communication habits some doctors, and perhaps pander to the ‘patient as consumer’, we have given too much – far too much – emphasis to formulaic ‘smile now’ style communication, at the expense of clinical skills. All well and good knowing how to elicit a good history, or communicate a bad diagnosis, but if you can’t do anything with the history, and don’t know what the diagnosis is…
The trouble with many NHS ‘teams’ (but not by any means all) is that they are anything but teams: more like lunatics taking over the asylum, or the can of worms/scorpions suggested in the post. It is the rise (and rise and rise) of these far too common dysfunctional teams that concerns Dr No.
Dr No attempted to capture the tendency towards undue and excessive emphasis on communication and teams by describing them as fetishes. Good communication and good teams are vital; it is when they become fetishes that the rot sets in.
JT – Dr No is sadly all too familiar with what he used to call comedy referrals, an all-time favourite being one in which the entire body of the letter was ‘Patient thinks they may have married the wrong person, please see and advise’. It would have been even more of a corker if ‘advise’ had been replaced with ‘do the necessary'(!).
Interesting spin (whoops – sorry!) on the GP/consultant as team. Dr No thinks consultants are called consultants for a reason – they get consulted, by GPs (and other doctors) as well as patients, and he is not sure this consultant/consultee relationship is properly described as a team. But he does agree – there is much scope for cooperation and collaboration (which is certainly close to being part of a team). Our good friend Boots also described recently how giving GP trainees in hospital posts the right training facilitated appropriate referrals, as well as providing useful ongoing links between hospital and GP.
The painful irony is that the rise of protocols and patient pathways has all but destroyed the traditional consultant/consultee way of – and here again Dr No demonstrates he is all in favour of it when it is good and useful – communicating.
This the problem Dr No, teams within the NHS do not have a defined ‘Captain’, and no ship, as you know, can run on everybody is captain and reach shore! Hence the mistakes then the following cover up – hence, NHS has ‘gangs’ and not teams … again, this lake of identifiable, recognised and responsible and hence accountable leadership is precisely the reason for the failure of communication too, as nobody seems to be responsible for delegation of duties properly either! … and the reason for the reduction of professionalism too, since who exactly is ‘responsible’ for training who is vague too … and that leads to bad oral, then stagnation, frustration … etc
Dooms day,eh … it’s the truth though; the NHS has gangs not teams, and every member of so called team believes they are Don Carleone 😀
Fetishism is worship of an object as a displacement activity, so I think Dr No’s description as these things as fetishism is spot on.
My own disillusionment with much of the NHS originates with experiences of my own family and friends, for example: http://drphilyerboots.wordpress.com/2011/10/15/neglect-of-the-elderly/
I think that for the reasons Dr No cites, and a few more, the NHS has become institutionally incompetent. The individuals with in it are usually good people trying to do their best, but the structures of the NHS undermine rather than support them.
Communication is important, and improvements in Communication Skills is one thing that I do credit the Educationalists with. What does need to be borne in mind is that communication cannot be divorced from content. Communication is about transmission of information, in both directions. No amount of body language, nodding and open questions can compensate for lack of knowledge to ask the right questions, or to correctly advise the patient of their options.
Boots
Anonymouse – Dr No agrees – anyone who has sailed a yacht out of harbour, or taken charge of the care of a patient, knows that there can only be one skipper. The trouble is, doctors have forgotten this basic rule. There are no skippers now in medicine; and so the ship flounders.
Why does it always have to be about health?! Why not boats too … or, whatever? We’re all ears Captain No, I mean eyes 🙂
I think any of us with some years working for the NHS will have no delusion or illusion it is all well. Some of us tried to perhaps unwisely to make it OK for what would have gone wrong.
The danger is often professional jealousy and we have seen only the tip of the iceberg.
Sorting out the NHS is not about giving CEOs 50 times the pay of nurses who finds it hard to hold on to the jobs as CEOs just cut them to boost short term savings.
Those that are doing what they were told then hurt patients.
Would anyone like to fly away?
The pretending should be over. Medicine is not just about one group or another group of doctors. And if you are a good but pompous heart surgeon. Who cares how you communicate. Most of the time the patient cannot hear him. My friend had a rude one who was derogatory about the Statin she was on. (‘she had new vlalves): All rubbish, he said, I felt the vessels, they were find. My friends memory returned. Nice if he was not so rude about the new trend in unthinking medicine.
My friend was one satisfied patient!
One of the reasons Dr No outed himself was so that he could draw on his experience in non-medical fields. Since there are only a handful of medically qualified YachtMaster Instructors, so long as he wished to remain anonymous, he had no option but to remain silent on sailing matters. This, he felt, was a pity, because, as Belloc wrote, ‘All that which concerns the sea is profound and final’1, and Dr No, for one, believes that there is much to be learnt from sailing the seas which can be usefully applied in other fields.
Now – back to the business at hand. In the post, Dr No laid the blame for the sorry state of British Medicine at the door of medical educators and regulators, the latter of course being chiefly Stilton and his merry gang of goons. JD has already picked up on a GMC commissioned report out today on dodgy prescribing and its predictable media coverage, but Dr No would like to draw attention to this recent GMC patient questionnaire which allows patients to rate their doctor. There is of course the usual equity and diversity guff, but the key question is Q4, where the patient is asked “How good was your doctor today at each of the following?”. Of the seven items that follow, only two (4th and 7th) are properly and exclusively medical tasks. The first two (and so the two given greatest prominence) are soft ‘Have a nice day’ skills: ‘Being polite’ and ‘Making you feel at ease’. As any patient who has ever stared down the barrel of an endoscope or faced the pointy end of a scalpel will tell you, being made to feel ‘at ease’ in such circumstances is not, as they say, an option. The patient’s chief concern is to get it over and done with as soon as possible, and preferably emerge on the other side in one piece – in other words, they chiefly want their doctor to be not communication-competent, but medically-competent. The last thing they want to see and hear is a beaming doctor saying ‘Have a Nice Day!’…
But – that is what Stilton tells doctors they must do and score on if they want to be considered ‘good doctors’…dear oh dear oh dear: what have we come to?
“YachtMaster Instructor”
Wow, respect! You can certainly teach those medical educators a thing or too about good ‘planning’ for one thing Master! Or how about team spirit? ‘Real’ teams I mean of course where everyone has ‘one’ goal, to get the boat to shore, in one piece, safely safely, and enjoy the trip at sea too. Or maybe how without strict discipline the boat can and is likely to face trouble and danger … or the value of a ‘well done sailor’ either top down or bottom up … with a smile
Auric’s Law? I’d always believed that this was the unwritten rule that UK doctors’ mouths, since Bevan’s declaration in 1948, must always be “stuffed with gold”
Rat – there may well be more than one Auric’s Law – but, as a member of SPECTRE, Dr No follows Goldfinger’s Auric Law – for now.
There is nothing wrong with stuffing one’s mouth with gold, if it is well deserved … it should be encouraged too
After all, reward should suit the endeavour, or they’d be no successful economies at all, or any achievement or innovation to celebrate
I like happy >._.<
In spite of apparent differences of opinion earlier, it seems that Dr No and those commenting are now closer to agreeing on the essential attributes of an independent medical practitioner.
The problem arises with the imposters, or the fetishes as Dr No calls them, that are being imposed upon us by those who have not gained our respect. The good and noble vocabulary of communication, teams and leadership is being debased. Perhaps the fetishes should be renamed by putting “f” standing for the “f word” as a prefix to the terms.
I.e. f-communication, f-teams, f-leadership would help distinguish the debased form from the noble form of these words and would help prevent doctors and patients alike from becoming confused.
N.B. The “f-word” being “fetish”
Of course.
Dr No is spot on and the couple of misplaced comments on communication tried to spin Dr No’s comments out of context to make a very bad point.
Communication is important but context please, these days students spend far too much time learning politically correct things like communication skills, governance, audit etc and the basics are forgotten.
The point about team players is spot on also, this culture of happyclappyness is the perfect environment for top down bullying as no one is ever allowed to speak out against poor practice or bad care. It is much more healthy to allow a healthy exchange of different opinions.
The best point is that of medical deprofessionalisation and this has come for many reasons, two big ones being shoddy educationalist regulation by the GMC and EWTD.
Competency based training has replaced getting some decent experience and the results are not good, despite what the educationalists may say….
“Competency based training has replaced getting some decent experience and the results are not good”
Totally agree, as I have always said before. Yes you need protocols and competency procedures but there must be also room for the doctor to think and innovate on their own and, as you say, gain from hands on experience and not just machines and simulations, docs are very intelligent lot after all. However, that is one thing, that needs serious attention, and the importance of communication is another, and you can never get enough of that, hence, like clinical experience, communication should be a lifelong endeavour too – and a smile does make the medicine go down.
Good medicine is about both, and a free to operate and criticize doctor too.
In Dr No’s early days, there were protocols – the active management of labour springs to mind – but there was nothing remotely related to competency based training. Instead, we just did as much as we could. Any delivery; then any episiotomy repair (DN was an oddity – he preferred controlled tears) (all this before formal qualification); then, as an SHO, forceps, then LSCS – we were baying at the heels of our registrars to let us do it. We felt mostly well trained, and hungry for the feel of steel and catgut in our hands. We were driven to become proficient, even the best, and knew it was only by doing it that we would ever become so.
There were serious flaws in that system, but, all considered, it bred real surgeons and doctors. Nowadays, we have ‘all will be well in the best of all possible worlds’ doctors, who don’t know their arse, let alone their patients arse, from their own or their patient’s elbow. We need to find a middle way.
Aim = Safety
Hence, competency based training, if done correctly can and will save lives Dr No, the problem is, as we discussed before, the lack of proper leadership to ensure that kind of training is done properly [Anyone can sign you’re competent!], then there is this specialty within a specialty within a specialty which turns a doc into a production line machine and eventually cancels their ability to think at all, leading to safety problems, or the very thing you set out to better … and frustration, and stagnation and low moral … etc, not forgetting having to return cases back to GPs for re-referals and spend more instead of less as you thought you would! The other day I heard an ST3 doc say “Why did I study medicine for over a decade just to end up doing what a vocational course can teach an amateur to do at the end?!” This doc was right too! It is a grave mistake to take your brightest and turn them into dump machines, but that’s training a la MMC now!
So, we all here agree on a fundamental aspect; bring back doctor training to excellent British standards as was before!
Not the 100 hour week though, but a doc who is rounded in knowledge and hands on experience and not stuck in blinkers, just like the top docs and professors, who are now a dying breed!
Oh dear!