Seven-day psychiatrists

Unless you’ve spent the last few months in a cave, you’ll know that David Cameron is dead-set on turning our NHS into a ‘seven-day service’.

He hasn’t given much detail on what it’ll look like, or how it’ll differ from the current set-up (in which doctors already routinely work 7 days a week), but the current arm-twisting of doctors into a contract which would force them to work more weekend days for the same pay shows that he really wants it to happen. Whatever it is.

So how might psychiatrists adapt to working routinely at the weekend, instead of just being on-call for urgent jobs and emergency assessments? Despite the mean and unthinking way that the government have gone about their proposals, I do think that psychiatrists could make substantial changes to their practice to acknowledge that mental illness doesn’t just work 9 to 5, Monday to Friday. It depends on the setting though.

I see relatively little point in asking consultant psychiatrists on inpatient units to work routinely at weekends. If they work on a Saturday or a Sunday, it would only mean they’d have to make up their time off on a weekday at some point, so nothing would move quicker overall. Unless other staff were in work on the same weekend days, like junior doctors and OTs, there would be limited effect from a consultant presence anyway. There would also be substantial legal and practical issues to having a different consultant work routinely on the weekend on another consultant’s ward (for example, if all the inpatient consultants were on the rota to come in at the weekend). Patients under section are meant to be under the care of their responsible clinician, and they’re the only people who can give them leave or discharge them. This person shouldn’t be chopped and changed. Also, psychiatric care is like painting a picture – no matter how good the artists are, if too many of them help with the project, you’ll just end up with a confused mess.

Could psychiatrists work more routinely in A+Es? After all, we know that liaison psychiatry services are patchy, but would consultant presence at the weekend fix this? Well…possibly….but in many smaller A+Es a consultant psychiatrist would be sitting around drinking coffee all day. In the larger ones, their juniors would still be seeing patients first (or else how would they learn), limiting their workload. I don’t see why they couldn’t be at home, available for emergencies, as they already are.

What about community and crisis teams – could psychiatrists work more for these at the weekends? For me, this is the most likely setting in which psychiatrists could be seven-day beings. It seems entirely feasible for them to hold emergency clinics and do emergency home reviews, as well as follow-up on the more distressed patients that have arisen during the week. If they work in a team of many consultants, there would be relatively little stress in running a rota of weekend shifts, as the weekdays would still be covered by colleagues. But this too could meet with implementation problems. Weekend GP surgery pilots have had to be cancelled recently as no-one turned up; perhaps that might happen to consultant psychiatrists too.

Whatever the proposed plan, there needs to be recognition of the following:

  • Psychiatrists work hard at weekends already
  • We are chronically short of doctors (and other staff), seven-day working is not a fix for this
  • Psychiatry requires continuity of care, seven-day working should not jeopardise this
  • Working more at the weekends will leave staffing holes during weekdays
  • Doctors should be adequately compensated for working more at weekends. The current contract offer is a joke.

As always I’m keen to hear how things work (or don’t work) in your area, and your ideas for the way forward.

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Advice for new doctors

It’s been 6 years since I qualified from medical school, and 6 days since my final shift as an SHO. Between those points I learnt a thing or two about being a junior doctor. Before I ascend to the heady heights of registardom and forget it all, I want to pass along a few bits of advice to the new crop of F1s. I hope it will be of use.

Firstly, get ready for a surprise. All that studying you did, all those placements and modules you went through, all the exams you sat and OSCEs you survived…are poor preparation for being a doctor. Real life on the wards is very different to textbook land, and the problems you have to deal with are entirely unrelated to your finals. Instead of being asked for 4 differential diagnoses for a third cranial nerve palsy you’ll be faced with questions like ‘does this wound look a bit funny?’ and ‘do I need to do anything about a bilirubin of 32?’

It’s normal not to have the foggiest idea about these things – you’ll simply learn to sound more confident in your totally un-evidence based answers over time – but if you aren’t sure, just ask. You never know if it might actually be important. You don’t know what you don’t know, and having a junior doctor who asks questions all the time is far better than having one who doesn’t (we wonder if they aren’t interested or are a bit full of themselves).

Thankfully though, in another strange twist of events, situations in which you’ll have to make a decision won’t be as common as you think. The vast majority of your time will be spent writing in the notes, ordering scans, taking bloods and chasing the results, and writing discharge summaries. For some new doctors this can be a let-down, but these are actually all deceptively important jobs that require practice and effort. Don’t knock them. A clear discharge summary which explains the details of the admission and the plan can be priceless for a patient who would otherwise have no idea what was going to happen next. An efficiently ordered and chased scan can save someone days in hospital (near all those resistant bacteria). Making sure follow-up appointments are booked ensures that your patients don’t just deteriorate unchecked at home and get readmitted. Be proud of running a tight ship.

All that said, there will be times when you’re the one in charge of an emergency situation, usually when you’re on call or managing the ward when everyone else is away. In these spots, trust your instincts and training (A, B, C, D, E…), listen to the nurses and call for help really quickly if you think you need it. You probably will, and this is fine – medical school basically only prepares you to be good enough to do the basics and call for help. It’s your job to ask for help, watch and learn, which is actually pretty cool. Your seniors shouldn’t mind and if they do, it’s their problem. Again, we much prefer junior doctors who call us every 20 minutes to ones who manage things they aren’t sure about, by themselves, in a quiet corner of the ward.

On the subject of colleagues, value them. Especially the nurses. They’ve been doing their jobs for years, they’ve seen tens if not hundreds of new doctors so they know when you don’t know something, and they can get you out of really sticky situations. If you mess up, which you will at some point, they’ll be there to back you up, but only if you’ve been nice. And despite the fact that they lack a bright, shiny new medical degree, they do actually know a lot about acute management of sick people. When I was half-asleep at 4am on one of my first night shifts as a surgical F1, the high-dependency bay nurse basically talked me through an acute assessment of abdominal pain, while somehow making me feel like I was doing it myself. I remember it to this day and I still owe her a G+T.

There will be times when it all gets too much. You will be stuck in a high-pressure environment for over 50 hours a week, seeing one gravely ill human being after another, some of whom will be very nice, and then die. There will be nothing you can do to help many of them, which is another nasty shock. Some of your colleagues may be cold, demanding and uninterested. It is normal to feel upset and overwhelmed. Crying is okay, but talk it over with your friends and colleagues and make sure it doesn’t turn into anything more serious like depression. Look out for your colleagues too. Try to keep your hobbies going, stay in contact with your family and take all your annual leave. And alcohol might be a fun way to de-stress at medical school, but it’s a dangerous way to cope as a doctor.

Bearing that in mind, there will also be amazingly fun times. Being a junior doctor is still a bit like medical school, in that you get taught a lot and have a close-knit group of peers, but better in some ways as you also get paid and get some respect. This is cool. Patients are incredible people, the things you will see, hear and do will be revelations to you, and you might even help someone in a critical way. And mess parties are fun. Savour this time, because no matter how hard your rota is, you’ll look back on it a few years later and slightly wish you had that time back again.

Finally, more about patients. Medical school may have taught you that patients come into hospital to have one or more well-circumscribed medical problems fixed, at which point their lives will resume normal service. This is rubbish. Patients end up in hospital for many reasons, a lot of which aren’t things like ‘crushing central chest pain’ or ‘right-sided weakness’. They come in because they get a bit dizzy and their carer – the fifth new one in 2 weeks – panics. They come in because their sodium is low due to diuretics and they weren’t confident to get to the GP for monitoring. They come in due to falls in cluttered houses and UTIs from dehydration. The important message is, fixing the acute problem is only half the job. To wholly help someone, ask yourself what the real reasons are for their admission, and tackle those. Furthermore, don’t just treat symptoms but ask the patient what they want from life – it might not be relief from pain but the physical strength and freedom to visit their grandchildren. Facilitating these desires is what being a good doctor is really about.

Good luck, best wishes, and remember – if you’re not sure, just ask. There are generations of former new doctors there to help. We just look a bit older and grumpier than we used to.

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