My 10 favourite TV shows with a bunch of caveats because otherwise it gets weird

tv

I like watching TV and I watch quite a lot of it. I decided to only include series which have finished in this list. This means some of the best TV I have seen has not been included. It is also only fictional series because I did not really want to have to compare Dexter to BBC News 24. I also have not seen all of BBC News 24 (I will get to it on catch-up). I have also excluded mini-series or single dramas.

So the likes of The Americans and Black Mirror are not included as I had to draw a line somewhere. For instance, do I include the two seasons of The Good Place, a series I think is thematically and visually ground-breaking? Is it fair to compare that with twelve seasons of It’s Always Sunny In Philadelphia? So…for better or for worse, those are my criteria.

However, not everybody is going to like every TV series. People read books, watch TV and watch films for different reasons. For instance, if I go to the cinema, it’s usually to watch an action flick. Anything else, I just see as a waste of money.

So I’ve included reasons you might like it and reasons you might not.

Without further ado….

10. Angel

1999-2004, 5 seasons, 110 episodes

Starting with controversy…Buffy The Vampire Slayer is more original than Angel. Buffy is more important in terms of TV history. Buffy broke more boundaries, has had greater cultural influence and is more fondly remembered.

I still like Angel better.

Don’t get me wrong, I love Buffy The Vampire Slayer but if forced to rewatch one, I’d pick Angel every time. The first show I watched as a proper box set (on VHS, no less), its exploration of darkness and moral ambiguity was something I had never seen before on TV. Sure, Buffy touches on and explores these concepts; it is Angel‘s raison d’être.

The show has an entire storyline (apparently known as “beige Angel”) where Angel having a soul does not prevent him from doing at best the morally questionable and at worst the morally inexcusable, despite the premise of the show and the character being his desire to seek redemption for his past transgressions as a vampire. Though S1 is largely “monster-of-the-week”, S2-4 are largely parts of wider story arcs. Its cancellation means the second half of S5 is an almost amusingly abbreviated albeit unfitting finale.

Angel S1 runs concurrently with Buffy the Vampire Slayer S4. The show takes certainties within the Buffyverse – the soul guaranteeing good, its absence guaranteeing evil, the incontrovertible truth of ancient texts – and either bends or breaks them. Since Buffy The Vampire Slayer starts off as a show about teenagers, it is perhaps inevitable that when the Scooby gang become young adults, the tone of show felt strange and, at times, alien.

Possibly, the most striking change is that of Wesley, a supporting character and all-round wimp in Buffy the Vampire Slayer. His transformation over the course of the show is a slow burn made all the more remarkable as each episode-to-episode adjustment is rather unremarkable. It is only in hindsight one can see how much happens to him.

The only teenage character when Angel starts is Cordelia (also in Buffy). The show is undoubtedly about adults and benefits from being set in Los Angeles. The motif of darkness is emphasised by taking place largely at night in ropey-looking parts of the city. These differences make for a less iconic but to my mind more compelling watch than its predecessor.

Why to watch it: the snappy Whedon dialogue of Buffy with darker and more adult themes.

Why NOT to watch it: the annoying Whedon dialogue of Buffy with darker and more adult themes.

9. Peep Show

2003-2015, 9 series, 54 episodes

So…this is a bit different to the above. I really, really struggled with how I fit the comedy into here. How do you compare Peep Show to Angel?

The conceit of the series is relatively simple. All camera shots are taken from the point-of-view of a person in the show. from main characters to random passers-by. The two main characters are Mark and Jeremy. Mark has a stable job at an insurance company whilst Jeremy is a layabout who lives in Mark’s apartment whilst constantly borrowing money.

Neither are particularly well-adjusted. Their inability to form stable relationships whilst placing on a pedestal those whom they love or lust after leads to actions which are both pathetic and petty as they try and dig themselves out of holes they are in largely because they are pathetic and petty.

From trying to dispose of a dead dog to escaping to KFC whilst ostensibly being a birth partner, the slow but sure build not so much in plot but in the ever-increasing lengths to which the two go due to their insecurities means the series consistently surprises. Both are simultaneously terrible people and yet weirdly relatable characters. The wider cast of supporting characters – the stand-out being Jeremy’s addict-friend Super Hans – are varied, whilst equally morally ambigious and immature.

The series never tries to sell an overarching idea. There is no grand finale. To its credit, it is just two reasonably shabby but very human, human beings trying to “adult” and never really living up to societal, anybody else’s or even their own expectations.

Why to watch it: the large cast of selfish yet relatable characters finding themselves in increasingly ridiculous situations through their own patheticness is hilarious.

Why NOT to watch it: the large cast of selfish yet relatable characters finding themselves in increasingly ridiculous situations through their own patheticness is cringeworthy and far too immature to be funny.

8. House Of Cards

1990-1995, 3 series, 12 episodes

I tried watching the American House Of Cards – it is rubbish. Sorry. The British version is shorter, sharper and simply gets to the heart of the matter without any unnecessary posturing.

The monologues which break the fourth wall in the US version are essentially glorified plot exposition. They are there to explain things to viewers. The British monologues achieve more; they make you complicit. Frank Underwood is trying to tell you what he is doing. Francis Urquhart convinces you that it is the right thing to do.

Although Francis Urquhart’s rise in the first series is the best of the three, the whole thing is still worth watching. This is not a series about moral ambiguity so much as how much amorality one can get away with.

And if you’re feeling queasy about watching allegedly rapey Kevin Spacey, remember that this is a better and shorter series.

(Technically, House of Cards is one series followed by sequels, To Play The King and The Final Cut. Were this series released today, I think this would all be considered part of one show so that is what I have done too.)

Why to watch it: Machiavelli if he was a Conservative in a parallel post-Thatcher 1990s UK.

Why NOT to watch it: you liked the American one and something subtler is not for you. Or you do not really want to watch some creepy old British dude trying to get a better job in politics; is that not just real life?

7. Scrubs

2001-2010, 9 seasons, 182 episodes

Scrubs has the weird privilege (if that is the word) of having the worst final season of a good television show. Once described as “half as long as ER and twice as funny” (not that I can actually find a reference for that), when one first watches it, the intentionally jarring juxtaposition of humour and emotion takes a little getting used to.

There are a plethora of medical dramas out there on both sides of the pond. With the exception of the little-known mid-1990s UK series Cardiac Arrest, the general tedium of being a junior doctor is best portrayed by Scrubs. Since it is a comedy, it has less of an obligation to dramatise medicine. Further, it portrays pretty well, how the nature of fear changes with seniority from one of simply not knowing what you are doing to the known unknown that medicine is so uncertain.

It does not shy away from the horror of medicine. Patients die. People screw-up. Relationships are strained. The law is always around the corner. And healthcare breaks doctors and nurses as often as it fails its patients. Whilst the medicine itself may not be particularly accurate, the bit that matters for a TV show – the characters – feel real enough that as a junior doctor, it is (aside from Cardiac Arrest) the only show worth watching about my job.

In the final season, Scrubs attempted to add a series of new characters and set it in a medical school. It makes no sense. It is very very bad. It is not funny. It pisses on the legacy of the finale of season 8 and achieves nothing.

So watch the series but avoid the abomination of S9.

Why to watch it: a unique mix of off-the-wall humour with a nuance and emotional depth unexpected in a wacky comedy.

Why NOT to watch it: you hate the whole “Zach Braff is weird” thing. We get it. You are weird. How have they made 9 seasons of this?

6. Battlestar Galactica

2004-09, 4 seasons, 76 episodes

As a teenager, too old to be watching kids’ TV, at 6pm every weekday on BBC Two, there were shows that were just right for me. A double-bill of The Simpsons most days followed by a mixture of Star TrekThe Fresh Prince of Bel-AirBuffy The Vampire SlayerHeartbreak High and the original Battlestar Galactica (1979). They also showed Buck Rogers in the 25th Century but that was where I drew the line of awfulness.

Battlestar Galactica was not much better. The acting was bad. The dialogue was bad. The effects were bad (even for the 70s). Since it was a kids’ show, it was weirdly light-hearted given the premise was that 12 planets’ worth of humans had been annihilated by sentient robots they had created now led by a human whilst the crew of Battlestar Galactica were the species’ only surviving members.

When in 2003, I found out they were planning a mini-series, my expectations were very, very low. I was not only astonished when I watched it, I could not fathom how, whilst looking at the same theme, two different sets of writers (albeit with a handful of crossover) had managed to create such different visions in tone and scope.

The series explores everything. The breaking point of those in desperation and its effect on one’s moral compass. The nature of humanity and what it is to be human. The importance of a neutral judicial process. Why democracies matter. And perhaps least surprisingly of all in a series about sentient robots which look like humans, the blurred line between artificial and biological intelligence. It was, bizarrely, a series that made me understand suicide bombing not simply on a theoretical but on an emotional level too.

Even if you dislike spaceships and science-fiction, this series has so much to offer. Although sci-fi geeks love it, I know a number of folks who could not care less about lasers and faster-than-light travel who also hold this show in the highest regard.

Why to watch it: a groundbreaking show that raised the bar for how you build story arcs and characters, particularly in the world of sci-fi on TV, much of which had been notoriously bad. Not being a sci-fi fan should be no barrier to entry.

Why NOT to watch it: since 2004, the standard of television across the board has risen dramatically. Whilst it is still very good, much of the mini-series and the first season is not as well put together as it seemed at the time. So don’t get your hopes up too much.

5. Yes Minister/Yes, Prime Minster

1980-84/1986-88, 3/2 series, 22/16 episodes (38 total)

I watched this decades after it was originally shown. One would think that the jokes would be outdated or the references lost. And yet the masterful portrayals of minister (later Prime Minister) Jim Hacker (Paul Eddington) and his senior civil servant Humphrey Appleby (Nigel Hawthorne) conveyed the constant friction between political goals, and the civil service’s inertia to change and its desire to maintain stability.

Neither can be said to necessarily be working for the greater good even if both Hacker and Appleby both like to think they are. Given the current turmoil within British politics, this series perhaps provides some insight into how incompetent politicians make it to the top.

Having never worked in Parliament or Whitehall, I cannot comment on how accurate a portrayal of the civil service this is. I do know that strange traditions persist in the civil service and that like any large organisation, inertia against positive change is an issue not just for politicians but for many civil servants themselves.

But even if you do not care about politics or current affairs, this show is still very entertaining. In the end, it has the distinct advantage that it has a lot of very good jokes.

(I have ignored the 2013 series and some random two-minute sketch because, well, I only found out they existed recently, I cannot be bothered to rewrite this list and I am not sure how much they count as “canon”.)

Why to watch it: astonishing that a show could write so many jokes and so much satire that still remains relevant today, especially given how easy it is for political comedy to date.

Why NOT to watch it: jokes about privileged rich old white men taking advantage of the stupidity of other privileged rich old white men for the entertainment of an audience of probably mostly privileged rich old white men.

4. The West Wing

1999-2006, 7 seasons, 156 episodes

“Words when spoken out loud for the sake of performance are music. They have rhythm and pitch and timbre and volume. These are the properties of music and music has the ability to find us and move us and lift us up in ways that literal meaning can’t.”

Jed Bartlet

The West Wing  S3E06 (War Crimes)

Few write like Aaron Sorkin. He has all but admitted he has written for the likes Barack Obama and Steven Jobs, among the finest orators of recent years, and this is Sorkin’s magnum opus. His ability to write monologues and dialogue that move from funny to sharp to incisive to mind-bogglingly moving is second-to-none. It takes some gall to have a character refer to the brilliance of a speech made by another character – essentially Aaron Sorkin praising himself – and have it remain convincing.

It conveyed a positive vision of politics where most politicians, most of the time are genuinely trying to be good public servants. It largely sacrifices creating personal backstories to emphasise everything which happens in the White House. One might assume this detracts from the depth of the characters; instead it adds to the importance of what they do and conveys the all-encompassing chaos of the more than full-time job of White House staffers.

When Sorkin leaves at the end of S4, the tone changes and although in S5 the writers spend much time finding their voice to the detriment of the show (though it is still by no stretch bad), by S6 they find a new rhythm telling the story of an election in what effectively becomes a one-and-a-half season arc.

The West Wing is a very unique experience and an extremely historic show (sorry, in-jokes for once you watch it). If Battlestar Galactica raised the bar for science-fiction, this show and its 4 Emmys raised the bar for TV across the board.

Why watch it: wonderful dialogue and oratory, excellent story-telling and fits an ideal of what politics in so many ways ought to be.

Why NOT watch it: the dialogue is…nobody speaks like that! Why are they speaking like that? The hypercompetence of the characters is on occasion such a stretch it pushes the suspense of disbelief. Also, I know it was 20 years but that is a lot of low-key sexism and few good female characters, particularly during the Sorkin years (learn to write women, man!).

3. The Wire

2002-2008, 5 seasons, 60 episodes

I can hear it now. All the people reading this, unclear why The Wire is not number one. And their arguments are not without merit.

Largely a commercial flop when originally released, The Wire slowly built up sales towards the end of its run and after it had finished, once DVD box sets became cheaper and more common. It still sits at the top of many lists of Best Ever TV Show.

It was a breakthrough show for a number of actors including, oddly, two British actors Dominic West and Idris Elba who play a Baltimore cop and drug kingpin respectively. Elba received many plaudits for his American accent with many acknowledging West as having done an accent as well.

Ostensibly, it is a cop show where in S1, the police are after a drug kingpin called Avon Barksdale. Yet this is not goodies and baddies. Over the course of the series, your sympathy and empathy for the police matches that for the gangsters in its ebbs and flows. The same is true as the show explores the unions, secondary school education, local politics and the newspapers, bringing these all together in one very human web of tangled morality.

The creators of the show intended for it to be binge-watched, describing it as a visual novel, an approach which perhaps explains its lack of success with the traditional weekly TV format. Had DVD box sets and streaming been more prevalent at its inception, it perhaps would have gained earlier the commercial and critical success it now enjoys and deserves.

This a show where you have to pay attention. Key plot points can be dropped in as minor asides in dialogue. And unless you happen to be from Baltimore, in can take a little time to “tune in” to the accent and the slang.

Although the first season is the probably the best, the whole series feels at times more like a documentary. Indeed, in one interview with a man from Baltimore, he said he had stopped watching the series because why watch something he lives everyday?

Perhaps this is hyperbole but the exploration of how and why people commit crime, why police commit in acts of brutality, or why politicians lie is second-to-none; this all comes together to explain how institutions fail those they were designed to serve. That the show creators were from Baltimore (a police officer and a journalist) is clear. Its legitimacy is further bolstered by those born and brought up in the city who make up a significant part of the cast.

It is the most innovative show on this list and deserves its place in TV history.

Why watch it: there are no shows like it. Its worst episodes have more depth than entire seasons of some of the best TV shows.

Why NOT watch it: it is a slow, slow, slow burn. More modern shows like Mad Men and The Man In The High Castle are possibly slower but if you watch TV for escapism and light entertainment, this is not the show for you. And frankly, like the bloke I refer to, it can sometimes feel like a commentary rather than a story.

2. The Bridge

2011-2018, 4 Series, 38 episodes

A body is found across the national border on the Øresund bridge connecting Copenhagen, Denmark and Malmö, Sweden. Saga Norén, in a consistently fine performance from Sofia Helin, is a detective with the Malmö police department. She ends up working with Martin Rohde of the Copenhagen police to solve the case.

It is beyond me to diagnose Saga with Asperger’s/autism spectrum disorder though I do know her associations with it have largely been positive. Although it is a source of – I hope sympathetic – humour, the bond between Martin and Saga over the course of the show is clearly frustrating to both of them as it is heart-warming to the viewer.

It might seem strange to put a show which is essentially a bunch of whodunnits above The Wire with all the latter’s innovation and originality. It is an old format, the likes of which one sees in Poirot or Inspector Morse in 1980-1990s dramas, at one time seen as the height of intellectual TV and where eccentric protagonists reveal themselves through their investigations.

Yet The Bridge just does this well, the formula is barely recognisable. Arguably a plot-driven show rather than a character-driven one, to describe it as such is to do it an immense disservice. It does both as well as (almost (see below)) any other show on TV.

Somehow it coalesces perfectly: each episode pushes the overall story yet ends with a brilliant cliffhanger; each series tells a story-long arc about characters which may exist only within that series; but there is the overarching story of Saga and her struggle to find happiness whilst navigating the already difficult task of human relationships without the tools that most of us are given.

It is a story about a weirdo trying to find her place in the world mixed with stories of friends and colleagues and murderers and criminals plus the simple thrill of wanting to know what happens next.

So, The Bridge may not be particularly original in concept. It is a show about a police officer trying to catch a murderer; in that sense it is not as innovative as The Wire. Its innovation, and I think why it stands above The Wire, is that it brings together so many different ideas to tell so many different stories for a denouement that The Wire does not achieve in 60.

It is perhaps unfair given it is not something The Wire is particularly trying to achieve (indeed it is probably trying to do the opposite) but by the end of The Wire you feel you understand more of the failings of Baltimore. By the end of The Bridge you have gone through the trial of trying to make sense of who you are and what your purpose is.

Why watch it: exciting, funny, heartwarming, dark, wonderfully unpredictable with story layered on story layered on story.

Why NOT watch it: you hate the depiction of neurodivergent women on TV (and are thus a terrible person) or you dislike reading subtitles.

1. The Shield

2002-2008, 7 seasons, 88 episodes

When I started watching The Shield, I had little in the way of expectation. I had been told it was a good. It was fairly early on in my Netflix membership. I had a vague recollection of my brothers watching it when I was younger and sort of knew it involved dirty cops.

The series centres around the fictional Farmington district of Los Angeles, its police department and particularly its Strike Team, headed up by Vic Mackey (Michael Chiklis). From the get-go Mackey and his fellow team members are dirty cops who break the rules and the law to achieve whatever it is they want to achieve. Their seeming success means though a number of people through the series are suspicious, any investigation is high-stakes and has to be airtight.

Though Mackey is the primary protagonist, the show is an ensemble piece. Every significant character has depth, nuance and very few can be said to be outwardly good or outwardly bad. Some big names – Glenn Close and Forest Whitaker – have long arcs which only heighten the show’s high-stakes plots.

It is at times unclear if the series has one plot made of multiple components or multiple plots which all come together in its finale. Whilst The Bridge manages to tell its story largely through one central character, The Shield tells an equally gripping yarn but through the eyes of multiple characters whose individual actions and reactions ripple out and influence one another. 

What is so striking about The Shield and what puts it above all the other series I have seen is the feeling that over seven seasons it has been telling one brilliantly crafted story. Yes, The Wire has myriad interlacing plots but there is no particular need or obligation to bring those strands of story together at the end – part of the message of the show is how little things change.

The Bridge brings together a number of plots together but is largely about one character. The Shield manages to achieve what The Bridge does but with almost all its primary characters and yet has as many different plots as The Wire. The constant jocking for position between Mackey, Claudette Wyms (a detective), Dutch (another detective and her partner), Acaveda (the head of the department, also planning a mayoral bid), and multiple other characters builds towards a dark and climactic finale.

Given that complexity, it is almost astonishing that the show manages to tie up so many loose ends by its finale. I am certain that even if folks do not agree that it is the best show on TV, it certainly has the finest ending of any dramatic television show.

Why watch it: the most complete TV show of the lot, in terms of its combination of character arcs, story arcs and the interlacing of all to bring about wonderful conculsion.

Why NOT watch it: there is one bad episode in the 88 (well, not that bad). It has violence and sexual violence – not one to watch if you are looking for light entertainment. Otherwise…I cannot recommend it enough.

What I left behind

Breaking Bad

I just never thought it was that good. The A.V. Club published an excellent article which summarises my feelings (The case against Breaking Bad). In short, it is a series about one character; most of the others are surprisingly one-dimensional. Whilst the premise is fascinating, it lacks subtlety and there a large number of frankly dull episodes.

Star Trek

The original series, whilst of historical importance, is strangely paced for today and to be honest, even I struggle to watch it. The Next Generation varies wildly. My favourite – Deep Space Nine – was originally on this list but was beaten to the punch when I remembered House of Cards and Scrubs. I have not seen all of Voyager and Enterprise and have seen Discovery but the less said about all three (in descending order of rubbishness) the better.

The Killing

Arguably, it gave The Bridge all its ideas but ultimately it has been superseded. The Bridge does what The Killing does but even better. It is absolutely worth watching (and probably before The Bridge) but once I had seen The Bridge, I just felt I could not include it.

The Thick Of It

Once Yes Minister/Yes, Prime Minister was included, I realised that The Thick Of It whilst brilliant just seems so much less subtle. It is very entertaining but it just does not have the longevity of 1980s series.

Borgen

Often described as the Danish West Wing, I think the description is a little wide of the mark. Part of what made The West Wing fascinating is its exclusion of personal stories to concentrate on politics. Borgen does not do this. Still good, it is not The West Wing.

Miscellaneous ones that do not fit

Dexter is way too variable after its first series. Just watch that. Nip/Tuck is weird though entertaining but I do not know if it is worth the effort really. Rick & Morty is entertaining ridiculous animated comedy but not as good as those in the list. The Good Wife starts slow but goes on to become a topical and fascinating series but lacks the subtlety of the drams included. 

Firefly misses out because it never really had the chance to become brilliant (argh!). Babylon 5 has a handful of decent actors but the dialogue, S1 and S5, and even the special effects are atrocious; only worth watching for historical value if you are a big sci-fi fan because the story arc is, to be fair, quite something.

Ongoing series I like

In no particular order – The Americans, Archer, It’s Always Sunny In Philadelphia, Bojack Horseman, Goliath, Bosch, The Man In The High Castle, The Good Place…I think that is it.

Watch Bojack Horseman though. It goes from Rick & Morty ridiculousness to some genuinely affecting an incisive drama.

Stuff I have not seen

The Sopranos and Seinfeldid not make the list because I have not seen them.

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Could May win a People’s Vote?

Remain 23

Source: https://www.youtube.com/watch?time_continue=6&v=_uU6Tk5g_Rw (I’m assuming Stronger In aren’t going to sue me for copyright).)

It would at least be bold.

With the ongoing spat between Theresa May and her predecessor, Tony Blair, announcing a referendum would be remarkable, even for her. Given May’s repeated promises on an early general election, one may be skeptical. However, here, she has gone further in attacking a former Prime Minster for suggesting it at all and calling it an “insult” to the office she holds.

Precedents in British politics at the moment are, like Sheffield trees, being destroyed all time. That two former Prime Ministers have intervened and that May has then responded would have been unthinkable 3 years ago. Yet it is unlikely that May would call a referendum on Remain v her deal; though all possibilities currently seem unlikely.

The BBC Presenter and chairman of The Spectator made a valid point. That May argues against the referendum at all is a sign that the People’s Vote campaign has made headway.

“Those who cannot remember the past…”

The Labour MP, Bridget Phillipson, argued today in the New Statesman that a future pro-EU campaign would have to make an effective positive case for staying. She admits she had to look up Stronger In’s slogan (as did I, despite literally having the T-shirt).

A future campaign would have to put front-and-centre the EU’s contributions to workers’ rights, its ability to regulate large multinationals (Facebook, Amazon etc.), and the enduring peace of the last 73 years. Indeed, I have previously argued it is not just a practical but a moral obligation too.

Above all, it would have to persuade voters that both immigration and freedom of movement were good things. Personally, I would start this through the prism of the health service (“immigrants uphold our NHS” or some such) but Stronger In 2: Even Strongerer would have to take on the past two decades of immigration skepticism in a country where Leave voters have – rightly or wrongly – never truly felt they enjoyed the spoils of free movement. Arguing a hypothetical counterfactual where food and fuel are somewhat more expensive adds little to the narrative, sparks even less in the imagination and means nothing to those now forced to choose between warm meals and a warm home.

So far, the People’s Vote has shown little appetite for this. Much of the rhetoric has been attacking May or the Brexiteers. The likes of Femi Oluwole of Our Future, Our Choice or Mike Galsworthy of Scientists for EU spend much time on Twitter highlighting flaws in their opponents’ arguments. Whilst there is positivity, their predominant narrative is one of anger rather than a positive, alternative vision.

I have no moral qualms with negative campaigning per se. But I worry that even in what would arguably be May’s worst case scenario, as incompetent a politician and campaigner as she is, her propensity towards repetitive platitudes would once again lead to a Remain campaign stuck in the mud, trying to fact-check whichever of those platitudes she had decided to plaster across the side of a bus.

Many of the myriad groups, centred around the People’s Vote campaign, are working together. They are unfettered by Cameron’s desperation to fix a fractured party. May would probably suffer attacks from hard Brexiteers. But it is nonetheless plausible that May could win the referendum so many Remainers seek because, so far, Britain still sees free movement not as a liberty to be lauded but rather a price to be paid.

Everybody is wrong about obesity…sort of

hero_image_obesity_0.jpg

The controversial Cancer Research UK advert.

Obesity – a body mass index (BMI) >30kg/(height in m)2 – is both common and a controversial topic.

Questions about obesity

Is BMI accurate?

Well…yes. And no. So sort of both.

The body mass index is inaccurate in certain circumstances but not as wildly inaccurate as is often implied. I’ve worked mostly in deprived areas. The issue is rarely that my patients are bodybuilders or rugby players. Their increased BMI is almost invariably due to excess abdominal fat.

Like any measure in medicine – heart rate, blood pressure, Glasgow Coma Scale, blood sugar, cervical dilatation in labour – it fits as part of a wider clinical picture. No, it shouldn’t be used alone but it remains useful for assessing and stratifying patients.

If you’re Mathieu Bastareaud then perhaps BMI is irrelevant. If you’re not, you should probably take your BMI seriously.

Does being fat cause cancer?

The advert pictured is the one that made me start writing something about this, alongside comedian Sofie Hagen’s objections to it which made various news outlets. The issue? “It’s only a correlation” or “no causative link has been proven”.

Well…Cancer Research UK begs to differ. It proposes three main ways. Fat secretes oestrogen, secretes insulin and IGF (insulin-like growth factor), and causes inflammation. These 3 processes cause more cell division. Cancer is uncontrolled cell division (essentially a growth that will not stop). So the more these 3 processes occur, the more cell division there is and the more likely it is that cancer will develop.

 

Obesity is correlated with cancer; few dispute this. Moreover, there are pretty solid biological mechanisms by which this may occur . Whilst more research should be done, it comes down to this: nothing in medicine is perfect.

Few things that we make claims for or do in medicine have the sort of evidence that the obesity-cancer link does. Indeed, if this is insufficient, then close every intensive care unit (ICU) in the world.

About the only things we’re sure about in ICU is timing of percutaneous tracheostomy makes no difference, lung-protective ventilation is good and restrictive transfusion strategies are probably better than liberal ones. There is lower-level evidence for other stuff but, like obesity, there is so much going on in ICU, it is difficult to isolate specific causality. However, far, far more research has been done into obesity, not least because there are way, way more patients.

Can you be “fat but fit”?

Or more correctly the MHO or “metabolically healthy obese” individual. These are folks who, when they have a variety of investigations, appear “metabolically healthy”.

Whilst this study and this study both in well-respected journals in their specialties suggest MHO is not associated with increased mortality compared to the healthy non-obese, there are plenty more which dispute the definitions, its existence or whether it is any healthier. This paper suggests that MHO is mostly a transient state that will become metabolically unhealthy obesity with time.

It’s not uncommon to see articles cherry-pick a study supporting MHO. Always be skeptical. Obviously, being fit and obese is better than being unfit and obese. But being fit and non-obese remains the healthiest option.

Bottom line: obesity is very likely to be bad for your health and is a cause of cancer.

How to lose weight (in your mind)

obesity-map-full-hi-res-1

This “obesity map” shows all the factors which lead to obesity. Source

Sure, at a personal, physical level it’s about reducing calories, reducing calories and reducing calories. And slightly about exercise. But seriously – it’s all about reducing calories. But on every other level, obesity is terribly complicated as this image shows.

However, the National Institute for Health and Care Excellence (NICE)’s guidelines have very little about what psychological advice to give to a person trying to lose weight. We know that we unfairly stigmatise the obese, that that stigma becomes internalised, and that the stigma is harmful to our patients. Moreover, the internalisation itself has correlations with poorer physical health morbidity and mental health morbidity (i.e. morbidity meaning other diseases). Thus, fat-shaming almost certainly does harm and is probably associated with poorer health.

What should doctors actually say to obese patients?

I mean, actually, literally what words should come out of the doctor’s mouth? If a patient walks into a GP’s consulting room with a lower respiratory tract infection requiring antibiotics, is this the time to bring up a patient’s weight? What about a woman with a BMI of 43.3 (5’7″, 20st) who attends for her 12-week scan? Or after 3 months coming off a ventilator because, at their weight, they really shouldn’t have been having their hip replaced (I speak from experience on this one)? And if none of these…when?

This paper by Rand and colleagues entitled “It is not the diet; it is the mental part we need help with.” looks at the myriad non-physical causes of obesity. To put this more crassly, why do obese patients keep picking up the fork?

If somebody presents with obesity, giving them advice about dietary changes is rather like telling footballers they need to score more goals than the other team or this advice from Sir Ian McKellen on acting in Extras. Whilst superficially true, it gives no insight on how to complete the task.

(As an aside, it is worth noting there are patients, particularly in poorer areas, who genuinely will not have insight into their condition. It is still worth pointing out they need to lose weight to be healthier/score goals to win.)

A 2015 systematic review by McGuigan and Wilkinson demonstrates that obesity is associated with healthcare avoidance, in part due to perceived or actual discrimination. If patients think healthcare professionals will be mean to them, they won’t seek healthcare.

Obese patients will respond poorly if they’re depressed, anxious, suffering from post-traumatic stress disorder, and/or any other mental illness or psychological issue. The causality goes both ways. Depression probably causes obesity as much as obesity causes depression. The latter will be created or at least reinforced by aforementioned societal stigmas.

Bottom line: psychology and mental health are probably as important as calorie-counting in managing obesity (and doing exercise but honestly it’s almost all about diet, exercise is good for you on its own terms).

What does it all mean?

If you deny BMI is useful, you’re wrong. But we ought to ask more about mental health, rather than simply doling out dietary advice.

Ultimately, the UK does a bad job of tackling these factors but in part, for healthcare professionals in all professions, one shouldn’t underestimate how difficult discussing obesity is to do well. I’d be intrigued to know if there is a study where the first step in discussing a patient’s obesity was to talk about their mental health.

PS: the lower respiratory tract infection was probably a virus.

Follow me on Twitter @rajacexplains

Dr Hadiza Bawa-Garba – part 2: what the courts said and why it matters

Reflection FICM screenshot

So as you may have figured out from the title, there is a first part which you should read first because it is the first part. Read the first part!

There, I vaguely summarised the court cases. Here I go into a more detail.

I’m also less comfortable with this bit as I am not a lawyer but I’ll do my best to hit the salient points.

Coroner’s Inquest – July 2013

Firstly, there was a coroner’s inquest where details such as Dr Bawa-Garba’s mistake in stopping resuscitation and her admission that her care was sub-par come to light. The Crown Prosecution Service (CPS) only decide to prosecute after the findings of the inquest (see para 34 of the High Court judgment).

Crown Court – 4 Nov 2015

Dr Bawa-Garba is convicted of gross negligence manslaughter in Nottingham Crown Court. A month later, she is sentenced to a two-year suspended prison sentence on 14 December 2015.

This is a criminal conviction. In criminal law, the standard is proof “beyond a reasonable doubt”. The excellent The Secret Barrister, in an article I now can’t find, makes the point that even if the jury think a defendant probably did it, that’s insufficient to warrant conviction. (They also have a rather thoughtful piece about the context of Dr Bawa-Garba’s case.) Contrast this with “on the balance of probabilities”, the usual standard for civil law.

It is a criminal offence for jurors to discuss the case they hear. You sometimes hear lawyers say one cannot “go behind” the jury’s decision. That is to say, you cannot and should not make assumptions about why the jury made a certain decision.

(There is the 2013 case of R v Huhne and Pryce, a prominent Liberal Democrat and his wife, in which the judge ordered a retrial because the jury, to put it bluntly, asked him such stupid questions they clearly didn’t know what they were doing. But this is very rare. Both Chris Huhne and Vicky Pryce went to jail following the subsequent retrial.)

What is gross negligence manslaughter?

I try to avoid Wikipedia references but Page 7 of The Sentencing Council guidelines on manslaughter essentially corroborates the following:

…gross negligence manslaughter involved the following elements:

  • the defendant owed a duty to the deceased to take care;
  • the defendant breached this duty;
  • the breach caused the death of the deceased; and
  • the defendant’s negligence was gross, that is, it showed such a disregard for the life and safety of others as to amount to a crime and deserve punishment.

Manslaughter by gross negligence, Wikipedia, 6/2/18

Or: you were meant to look after somebody; you didn’t; because you didn’t they died; that you didn’t was super bad. (NB: super bad is sort of a technical legal term. The “gross” mandates the negligence be “truly, exceptionally bad”.)

That means that if you screw something up but a patient doesn’t die, you can’t be convicted of gross negligence manslaughter. (But don’t do that because you can still face other consequences. And also it would still make you a bad doctor. And person.)

There is of course a great deal of interpretation as to what is meant by “amount to a crime and deserve punishment”. We’ll get to that later.

Why was her sentence suspended?

Judges have to consider whether sending somebody to prison will actually make much of a difference. There are broadly 5 reasons to send somebody to prison: punishment, deterrence, rehabilitation, public protection and to give something back to the community. Given the consequences of a criminal conviction for a doctor, it’s likely the judge saw this as sufficient.

The Court of Appeal – 8 Dec 2016

So this bit of the case may seem slightly odd . Dr Bawa-Garba’s lawyers made what amounts a series of fairly technical challenges around one issue: that the instructions the Crown Court trial judge gave to the jury were misleading. Firstly, there are two submissions on the use of the phrase “significantly sooner”. If you really want to, you can go to paragraph 23 of the judgment for the details, but the arguments were rejected.

There was a third submission: that the judge did not specify that if the effect of the enalapril was the dominant cause such that then Dr Bawa-Garba’s actions would not have made a “significant contribution” to Jack’s death, she should not be convicted. And finally that given when the arrest happened, Jack was past the “the point of no return”, the judge gave insufficient direction to the jury that any actions that happened after this point should not be considered in the decision to convict. The Court of Appeal rejected both these arguments too.

Little of this questions the facts of the case – they examined whether the Crown Court judge had explained the case, the law and the jury’s duty sufficiently clearly to the jury. Really, I don’t think any non-lawyer or indeed most lawyers can argue that the Court of Appeal was wrong.

The Medical Practitioners Tribunal Service – 20-22 Feb 2017 & 12-13 Jun 2017

The Medical Practitioners Tribunal Service (MPTS) suspended Dr Bawa-Garba for 12 months following her conviction and appearance at the Court of Appeal.

What are the PSA, GMC and MPTS?

Let’s break down the acronym bingo. The General Medical Council (GMC) is the regulatory body for doctors in the UK. Every year, I send them some money and they keep my name on the Register of Medical Practitioners. As such, I maintain my licence to practise medicine. You can check any doctor’s registration status here by simply searching for a name. Try it with your GP!

These days, all doctors have to revalidate every 5 years. This involves collating evidence that you are keeping up-to-date such that you can safely practise. This only started in 2012. When I qualified in 2010, no such process existed.

There are other bodies for other healthcare professionals – the Nursing and Midwifery Council (NMC) (for nurses and midwives), the General Dental Council (GDC) (for dentists) and some others for pharmacists, opticians and optometrists and bizarrely for osteopathy and chiropractic (bizarre because they’re not real medical treatments).

The Professional Standards Authority for Health and Social Care (PSA) is an overarching body that is responsible for the above regulatory bodies. In short, it regulates the regulators.

What did the GMC do here?

They argued that Dr Bawa-Garba should be struck off the medical register. Dr Bawa-Garba’s lawyers argued suspension was the appropriate sanction. The MPTS agreed and suspended her for 12 months, such that should she complete sufficient remedial training in that time, her suspension would be lifted.

The High Court – 7 Dec 2017 & 25 Jan 2018

The hearing happened in December but the judgment was published in January.

In its simplest terms, the GMC argued that the MPTS gave too much weight to the systemic failings present (which the Crown Court had already heard) and insufficient weight to the Dr Bawa-Garba’s personal culpability. For me, the key line is here:

“…the [MPTS] Tribunal did not respect the verdict of the jury as it should have. In fact, it reached its own and less severe view of the degree of Dr. Bawa-Garba’s personal culpability.”

para 41, GMC v Bawa-Garba

The phrase “did not respect the verdict of the jury” in essence suggests that the MPTS decision had to make sense in the context of the Crown Court decision. The MPTS cannot come to a decision which relies on the jury’s verdict being wrong; it cannot de facto retry the case.

The judgment notes that it’s not that gross negligence manslaughter necessitates being struck off the medical register (though it’s rare not to be). It’s that the MPTS’s conclusion relied on Dr Bawa-Garba being less culpable and the systemic failure being a bigger issue than was found in the Crown Court.

Is this the GMC’s fault?

There has been a lot of shade thrown the GMC’s way, particularly the way of Charlie Massey, its Chief Executive. I’ve even seen Facebook screenshots of his pay with comments complaining about it. He was previously an aide to Jeremy Hunt.

However, when one reads many of the criticisms doctors have of the GMC, they are largely about the events which led to Dr Bawa-Garba being convicted. Given those systemic failings were considered in the case, it is then very difficult for the MPTS to use those as an argument against her being struck off, even if the MPTS is an organisation specifically designed to deal with doctors’ fitness to practise in a way the Crown Court is not.

As is often case when anger and fear abound, it’s difficult not to take aim at the nearest target. I am unclear that the GMC is at fault here. Indeed, if it is, then so the High Court judge.

Should doctors just get over it?

Context is king. The Secret Barrister‘s account of the Bawa-Garba case implies that juries may not be the correct way for cases around technical issues such as medical negligence to be heard (though they do not outright argue for this).

Is it possible within the time constraints of court for a barrister to truly convey the context within which doctors and indeed all healthcare professionals work? It is very well saying, “working the NHS is difficult”. But to explain how tought it is to think straight when your bleep won’t seem to stop going off, you have multiple sick patients, you’ve not eaten or passed urine because you haven’t had the time to think about it, and you are not being sufficiently supported by your seniors or they are too busy to help: that is surely impossible to explain at trial.

I don’t know how you show the frustration of sitting at a computer screen that has taken 5 minutes to log in, then crashes, then you log in again. Then you think about whether or not to try another computer, knowing you will have to go and find one that’s free and possibly go through the exact same scenario. When you get in, the blood results system takes another 5 minutes to load. So you’ve now taken 10 minutes to find one set of results.

You then realise the results aren’t back so you decide to ring the lab. You don’t know the number and there’s no phone next to the computer. You try to find a free phone on a ward you don’t know. You don’t have the number for the lab so you dial 0 for switchboard.

You wait on the phone for another couple of minutes but then you get a bleep. You answer your bleep and it takes 10 minutes to get the information about the patient that you need to see. You then ring switch but they’re busy so it takes another 5 minutes to get through. They put you through to the lab but you are on the phone another 5 minutes and decide this must be the number they use during the week and not the weekend.

You ring switch for a third time, take down a couple of numbers and eventually get through to the lab. They give you some of the results you want but not all. 30 minutes after trying to clarify one set of results, the consultant whose post-take ward round you’re supposed to be on has seen two other patients and asked you to order some tests – unfortunately, you don’t know why they need ordering and in the midst of the ward round you forget to ask the consultant before she left to see another patient.

This is just a sample of the chaos. How can it be possible to demonstrate this sort of frustrating disorganisation to a jury of your supposed peers? And how can one explain that this doesn’t stop because people are sick? People are always sick – these are the facts on the ground in a hospital.

Comfort zones

It is also not clear how a registrar on maternity leave is supposed confirm she is ready to come back to work. Many days, you will be outside your comfort zone; indeed how else can you get better at your job? But this what Donald Rumsfeld refers to as a “unknown unknown” – talk to any doctor back from a period of time off. Gauging the limits of your own competence is incredibly difficult. And most of your colleagues just think you’ll be fine because they remember you as a highly competent practitioner.

Reflection

Written reflection is a mandatory part of training for junior doctors and increasingly all doctors. All reflections which include patient information should be anonymised but it can be clear from a reflection which patient is being discussed if the case is sufficiently unique (which it undoubtedly is if you’ve reflected on it).

Pulse, a GP magazine, has reported that though written reflections weren’t used against Dr Bawa-Garba in the trial, expert witnesses were allowed to see other parts of her e-portfolio. Further, Dr O’Riordan – the consultant on-call – documented a verbal reflection with her which was submitted in court. This is troubling given it would be difficult for Dr Bawa-Garba to contest facts within it. It is unclear how much this influenced the jury’s decision.

I personally will continue to write written reflections. However, what I write which be much more considered.

Medical notes

These used to be about communication with other doctors. Now, more than ever, I treat these as an argument to a coroner or judge as to why I have taken a particular course of action. More and more, I explain my reasoning in medical notes, often in much more narrative form than is traditional. Bad documentation was noted through this case – as somebody who is already quite meticulous, I intend to be even more so, particularly in difficult cases.

Why openness matters

Doctors need to be able to discuss mistakes honestly and mostly without fear of reprisal. On hearing that Dr Hadiza Bawa-Garba’s practice would have to be “truly, exceptionally bad” and “criminal” to warrant it, the jury found her guilty. Doctors reading the case will think about cases where they have come close to doing serious harm – when only luck prevented them from being in Dr Bawa-Garba’s shoes. Can twelve lay people really judge the diagnosis of septic shock (albeit with expert testimony) in the same way as they can judge dangerous driving?

I question whether court, in the context of medical negligence, is fit for purpose. Let’s be clear, this is an unusually stark reaction from the medical profession. Often, you read about these cases in the BMJ, shrug your shoulders, and accept that the care was indeed quite bad.

Learning from mistakes is how we keep people alive in the future. So many patients simply want their negative experiences to stay theirs alone. If litigation increases, so do unnecessary tests and an attitude that giving somebody all possible care is the same best possible care. Keeping a 90 year-old with dementia on a ventilator and attached to lines for three months only for her to die anyway cannot be considered best practice. But if intensivists fear prosecution, it may be what becomes the norm.

It is good that Jeremy Hunt has launched a review into manslaughter in healthcare though doctors will be loath to trust him following the junior doctors’ strikes. Nonetheless, I hope to see changes in the legal system that mean doctors can really, truly discuss when things have gone wrong.

Dr Hadiza Bawa-Garba – Part 1: what does this case look like to medics?

Dr Hadiza Bawa-Garba, a paediatric specialty registrar, was struck off the specialist medical register a few days ago. Pulse, a GP magazine, provide a timeline for her case. In summary:

  • 18/2/11 – Jack Adcock, a 6 year-old boy, dies in Leicester Royal Infirmary of sepsis secondary to pneumonia whilst under the care of Dr Bawa-Garba.
  • 2/11/15 – Isabel Amaro, a Portuguese agency nurse involved in his care, is convicted of gross negligence manslaughter and is later struck off.
  • 4/11/15 – Dr Bawa-Garba is convicted of gross negligence manslaughter.
  • 29/11/16 – She applies to the Court of Appeal for “leave to appeal”; it refuses her application.
  • 13/6/17
    • She is suspended from the medical register for 12 months by the Medical Practitioners Tribunal Service (MPTS).
    • The MPTS reject an appeal from the General Medical Council (GMC) to strike her off the register.
  • 25/1/18 – She is struck off the medical register by the GMC following their appeal to the High Court.

Dr Bawa-Garba will no longer practise medicine in the UK.

Sources

I am neither a lawyer nor a paediatrician; my opinions are my own. Further, I do not have the transcript from the 2015 Crown Court trial – my sources for the original trial are the judgment from the 2016 Court of Appeal hearing. the Record of Determinations from the MPTS tribunal in February & June 2017 and the 2018 judgment from the High Court. I don’t have access to the coroner’s inquest.

54000 doctors is a website set up by Dr Chris Day, an Emergency Medicine trainee who fought a legal battle against Lewisham and Greenwich NHS Trust over whistleblowing. On it, is a letter concerning Dr Bawa-Garba’s case signed by four paediatricians and another doctor involved in the Child Death Review for a London Clinical Commissioning Group.

I have purposefully referred to this letter sparingly as I cannot easily verify the facts within it.

The story

Jack had a background of Down’s syndrome. He was on enalapril for a heart condition described as a “hole in the heart”. He also had a bowel abnormality. He was prone to chest infections. When well, he was a happy child who enjoyed playing with his sister.

10:15 am – Jack arrives at the Children’s Assessment Unit (CAU) from the GP having been off school the previous day. In the surgery his breathing was shallow and lips slightly blue.

10:30 am – Jack is admitted to CAU.

10:45-11am – Dr Bawa-Garba reviews him. He presents with a 12-hour history of diarrhoea and vomiting. He is lethargic and unresponsive and does not flinch when a cannula is inserted. His peripheries are cold and his temperature is raised.

Dr Bawa-Garba takes a blood gas. He is acidotic and has a high lactate.

A “blood gas” is a blood sample taken for analysis of partial pressures of specific gases, ie levels of carbon dioxide and oxygen. Machines for blood gas analysis are available in emergency departments, intensive care and, depending on the hospital, other areas.

The test also shows levels of blood acidity, lactate levels and bicarbonate levels. More modern machines can show levels of electrolytes and haemoglobin but these latter results are not as accurate as a lab sample. Staff can see the results within 2-3 minutes of the sample being run. This does not include time to obtain the sample and get it to the machine.

She diagnoses gastroenteritis with moderate dehydration and prescribes a fluid bolus.

11:30-11:45 am – Jack improves after being given fluids. Dr Bawa-Garba is cautious with fluid administration due to the Jack’s pre-existing heart condition.

12:01 pm – he has an X-ray during which he is “sitting up and laughing” and reacts to having his finger pricked

12:12 pm – on a second blood gas, results are better.

12:30 pm – the X-ray result is available but at this point not seen by Dr Bawa-Garba.

12:00-3:00 pm – Dr Bawa-Garba sees other children including performing a lumbar puncture on a baby. Nurse Amaro stops monitoring Jack’s oxygen saturations, records a high temperature at 2:40 pm and Jack’s nappies require frequent changing (presumably from diarrhoea). Nurse Amaro does not inform Dr Bawa-Garba.

3:00 pm – Dr Bawa-Garba reviews the X-ray and prescribes antibiotics.

4:00 pm – Nurse Amaro administers the prescribed antibiotics.

4:15 pm – Dr Bawa-Garba reviews blood tests ordered at 10:45 am. The results were not back until 4:15 pm due to a failure in the hospital’s electronic computer system. She was unable to obtain them “despite her best endeavours”.

4:30 pm – Dr Bawa-Garba flags a rising CRP (a blood test) with the paediatric consultant, Dr Stephen O’Riordan alongside the patient history, pneumonia diagnosis and treatment. She spoke to him again at 6:30 pm but does not raise concerns. There is no specific mention that she tells him about the high lactate and acidosis.

7:00 pm – Jack is transferred from CAU to Ward 28 “out of Dr Bawa-Garba’s care”. Jack’s mother administers his enalapril though this had deliberately not been prescribed. (It is unclear when she did this.) The plan to omit enalapril is not documented.

7:45 pm – Jack’s heart “fail[s]”. (I have no idea what this means!)

8:00 pm – A crash call is put out. On arrival, Dr Bawa-Garba stops resuscitation as she mistakes Jack’s mother for a different patient’s mother. The other patient has a “Do Not Resuscitate” order. With 30 seconds to 2 minutes, another doctor identifies the mistake and resuscitation is restarted.

Despite resuscitation, Jack dies at 9:20 pm.

The context

Dr Bawa-Garba was a Specialty Trainee Year 6 (ST6) in paediatrics. It takes 8 years of specialty training to become a paediatric consultant. This was her first shift in an acute setting after 14 months of maternity leave. She was asked to cover the CAU, Emergency Department (ED) and the ward.

(54000 doctors claim that there should have been a second registrar – a doctor of Dr Bawa-Garba’s level – to cover CAU, effectively leaving her doing two people’s jobs. They also claim the covering consultant was away teaching. I’ve not been able to verify these facts from the two legal sources to which I refer.)

The computer system was down for some hours. Nurse Amaro was an agency nurse who primarily worked in adult medicine. Dr Bawa-Garba worked a 12-13 hours shift without a break by the time of Jack’s cardiac arrest.

How bad is this?

So…I qualify the following comments by repeating that I was not at the trial, I was not in the hospital looking after Jack nor have I reviewed the notes. I’m not a paediatrician though I do look occasionally look after sick kids (probably more so as I’m soon moving to a paediatric anaesthesia rotation).

Initial management

Most of the initial management seems pretty decent. The diagnosis of gastroenteritis (infection of the stomach and bowel, occasionally referred to as “food poisoning”) is not unreasonable and is a condition not treated with antibiotics (indeed they can make it worse). The primary symptoms are diarrhoea and vomiting. This can lead to shortness of breath.

Dr Bawa-Garba gives Jack a fluid bolus and by the time the X-ray happens at 12:01, he’s laughing. That’s a massive improvement from the description of him being limp and unresponsive to pain initially. The second blood gas being better is also reassuring.

This is nonetheless difficult to judge. Should she have informed her consultant that there was a floppy, acidotic child with a background of previous cardiac surgery presenting with a high lactate? Possibly…but then he was getting better after she’d initiated treatment. It’s not unreasonable to initiate your treatment, see what the result is and then call the boss. Especially, if you know your senior is highly likely to institute the same plan as you.

X-ray

There is a 2½ hour delay between the X-ray being available at 12:30 pm and her review at 3:00 pm. It is impossible to say what happened in this time. Doing a lumbar puncture in a baby is no small feat. It’s entirely possible she had spent 2½ hours treating a baby with meningitis.

It also appears nobody informed her the X-ray was being done but in fairness to the nursing staff, it’s not that unreasonable – it’s the doctor’s job to chase up investigations she orders. If the diagnosis is gastroenteritis and the X-ray is not expected to be positive, it’s still understandable that Dr Bawa-Garba prioritises other sick patients over Jack and does not tell the nursing staff to let her know when it’s been done.

Dr Bawa-Garba admits she should have reviewed the X-ray earlier. It is unclear why she believes this.

Consultant discussion

This is where it gets a bit trickier. If Dr Bawa-Garba didn’t mention the blood gas results to the consultant, that’s pretty bad. Then again, at 4:30, Dr Bawa-Garba may have been unaware that Jack’s oxygen saturations were not being monitored and she was not aware of the high frequency of diarrhoea. The continuing high temperature would probably have made little difference to treatment.

(NB: 54000 doctors suggest that she did tell Dr Riordan but he thought the results unremarkable as Dr Bawa-Garba didn’t “stress” their importance. There are some numbers in the 54000 doctors letter. If any of this is true, Dr Riordan’s practice is questionable at best and at worst, gross negligence manslaughter.)

(Presumed) Cardiac Arrest

It is not specifically noted from the judgments where Jack had a cardiac arrest at 8pm. The MPTS record notes a crash call was put out at 8:00 pm so one must assume ward 28.

As an aside, some time ago, Do Not Resuscitate (DNR) orders were switched to Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) – one can resuscitate somebody with fluid but this is not what a DNR is intended for.

At this point, the trial notes that Jack was beyond the “point of no return” which, from what I’ve read, is a reasonable assumption. In adult medicine, it is certainly rare for somebody to survive a cardiac arrest secondary to septic shock.

How bad was Dr Bawa-Garba’s failure to correctly identify the DNR order? To be honest, given the situation Jack was in, the 30 second to 2 minute delay will have made little difference. Even in a different situation, with otherwise good quality CPR, it would be very difficult to claim that stopping for 30 seconds to 2 minutes would be the key to surviving. I can imagine making the same mistake. I think every doctor can.

It’s worth noting Leicester Royal Infirmary is a tertiary centre for paediatrics. As such, there will likely be a number of children who have DNR orders in place ie it is probably not highly unusual. It is only human that after 12 hours with no break, she picks up the wrong set of notes (or is even handed the wrong set) and sees the DNR without checking the label properly. Yes – even in the case of a DNA-CPR order, I can imagine this happening.

Enalapril

Enalapril is an angiotensin-converting enzyme or ACE inhibitor used to lower blood pressure and treat heart failure. They are potent drugs. It is the only class of anti-hypertensive anaesthetists insist on stopping prior to surgery. From the outside, it seems odd that an ostensibly improving child suddenly went into cardiac arrest.

My best guess, and I emphasise guess, is that the enalapril may have been significant. Again, I was neither at trial nor in the hospital so I cannot say whether that’s a reasonable assumption. Without knowing the child’s blood pressures and heart rates in the intervening period between 12:00-8:00 pm. But enalapril has an onset of action of 1 hour and peak effect between 4-6 hours – it seems Jack’s cardiac arrest was somewhere between 1-2 hours after its administration.

If the nurses were asked about the drug and the mother was told she could give it despite it not being prescribed, that would be shocking. Enalapril has a long duration of action (it’s usually taken once daily); a couple of hours without the drug would have been highly unlikely to have killed Jack. The Court of Appeal notes that the deliberate nature of Dr Bawa-Garba’s omission was not documented; whilst this is good practice, it is not essential. Doctors should expect that drugs which are not prescribed are not given as regular medications are otherwise routinely prescribed.

If they were in doubt, nursing staff should have checked with doctors if the omission was deliberate. If this was simply a mother understandably doing what she thought best for her son – giving him a life-saving medication – that is a tragedy.

Questions

The pressure Dr Bawa-Garba was under was immense. Without timely blood results, a junior doctor down, 14 months out of practice, an adult-trained agency nurse on a kids’ ward with anyway too few nurses and a patient who was when she last saw him getting better and who had presented with atypical symptoms of pneumonia (although all kids can get diarrhoea and vomiting when they have an infection), I find the absence of any investigation into the wider issues difficult to parse.

Indeed, I’m left with a number of questions. (I accept these may have been answered at trial and have simply not been included in the Court of Appeal judgment’s summary of the case.)

Specific to the case:

  • What observations were done between 12:12 pm when the second blood gas was done (meaning Dr Bawa-Garba must have seen the patient) and his cardiac arrest at 8:00 pm?
  • More specifically, what were the blood pressures and heart rates, key in assessing the level of shock? (Note, blood pressures are done less frequently in children than adults but this is still a basic and pertinent observation.) How frequently did Dr Bawa-Garba request observations be done?
  • If blood pressures and heart rates were being measured, how frequently? Was Jack triggering the hospital early warning score system such that Dr Bawa-Garba should have been contacted? If he was triggering, why wasn’t she contacted? If he did not trigger it, how can it be expected that Dr Bawa-Garba know Jack is getting sicker?
  • What was Dr Bawa-Garba doing between 12:00 pm-3:00 pm? What efforts have been made to discover this? Was she seeing patients sicker than Jack had initially appeared?
  • Did Jack’s mother discuss the enalapril administration with nursing staff? If so, did nursing staff advise her either to give or not give enalapril to Jack? What prevented them from discussing this with Jack?
  • What were the blood results? Would they have made much difference anyway? There is no mention of electrolyte abnormalities. Dr Bawa-Garba already knows he has an infection. The raised CRP is marker of infection but a single result is not a particularly useful marker of infection severity.

The wider organisational issues:

  • Why was she covering GP referrals, A&E referrals and another ward? What is the usual cover for this? What efforts were made to find cover given it was a Friday and so regular administrative staff were in?
  • Why didn’t the consultant on CAU step down to do the registrar shift or the regular ward consultant step down to cover so Dr Bawa-Garba could cover CAU?
  • Even if the computer system was down, why weren’t urgent blood results being phoned through to CAU?
  • How often was CAU understaffed with nurses?
  • How often were there too few juniors?
  • Were these concerns escalated to management?
  • If they were, what did managers do?

Doctors’ vs the public’s interpretation

The reason that so many doctors have come out in support of Dr Bawa-Garba is that this just looks like a normal day in the NHS. This post is not meant to conclusively prove Dr Bawa-Garba’s innocence or guilt. It hopefully gives you an insight into some of the thoughts doctors will have reading this case. Though I’ve attempted to be neutral in this post, I can’t help but feel a kinship with those tweeting #iamhadiza.

“Manslaughter by gross negligence occurs when the offender is in breach of a duty of care towards the victim, the breach causes the death of the victim and, having regard to the risk involved, the offender’s conduct was so bad as to amount to a criminal act or omission.”

p. 7, Manslaughter Guideline Consultation, The Sentencing Council, 4 July 2017

The definition on Wikipedia is of negligence such that “it showed such a disregard for the life and safety of others as to amount to a crime and deserve punishment”. (Though this is Wikipedia.)

I suspect many doctors will read this account and think “I’m simply lucky to have not gone to jail”. I will talk more about openess in Part 2 but take this quote:

“I never, ever want another family to go through what we’ve gone through”

Nicky Adcock, mother of Jack Adcock, Leicester Mercury, 25 January 2018

For entirely understandable reasons, Nicky Adcock may have inadvertently achieved the opposite. Indeed, I cannot even begin to blame her given the tragedy she has endured.

However, consider the case of Elaine Bromiley, a woman who died after a poorly managed anaesthetic emergency. Below is the story of her remarkable husband Martin Bromiley who, rather than suing the doctors, went about trying to find out why his wife died and how he could stop it in the future. Dr Bawa-Garba’s practice was, I think, significantly better than that of the doctors caring for Elaine Bromiley yet so many more lessons have been learned from that – and probably lives saved – than will be from the death of Jack Adcock.

In Part 2 (now available), I’ll try and explain some of legal aspects and why much of the interpretation of the case is wrong but its consequences for all healthcare professionals but particularly doctors-in-training (aka junior doctors) are profound.

Edit (30/1/18): the Crown Court does not publish judgments routinely – this post previously implied otherwise. I did not mention that there had been a coroner’s inquest where systemic failures should have been examined. I also mistakenly referred to Chris Day as an EM consultant – he is an EM trainee.

The tax on doctors’ time

motorway_m1_yorkshire_2007-08-13

 

A couple of days ago I was listening to the excellent New Statesman podcast which had a section on the NHS winter crisis. In amongst some very good points about why major system overhauls are not technically or politically feasible in the UK, they ended:

Stephen Bush: But there are multiple reasons that doctors are leaving to go to other countries many of which are to do with policy choices actively made by the government. But the policy choice not to tackle the housing crisis does mean that if you are in possession of a medical degree, the attraction of staying in London and not being able to buy anything other than a small flat within commutable distance to the hospital where you work quite antisocial hours to being able to buy a fairly large house –

Helen Lewis: yeah, and there’s been a great decline in hospital accommodation as well. I was talking to someone who’s got –

SB: in New Zealand or wherever.

HL: – yeah, exactly – two siblings who both are doctors and for various reasons have ended up practising abroad it is, that it is, very difficult with, and it’s the kind of the other side of globalisation, we talk about importing workers in lower-skilled industries to undercut us. We’ve got the problem at the other end which is we’ve got workers with high-level qualifications. It costs us a lot to train a doctor and then we’ve got a problem retaining them working in the NHS. Yeah again it’s another thing where just small things if you to talk to doctors who get to like only having a single bed in hospital accommodation. You know like they change around the way that on-call works that kind of stuff. You’re just slowly pissing off a group of people who have got a lot of individual power to go “huh, yeah bye. See you later”.

(That was totally not worth the effort to transcribe. But anyway…)

Helen Lewis is right – but lets talk specifics.

Ten years’ ago hospitals stopped providing accommodation to their F1s (Foundation Year 1 doctors – the first year of being a UK doctors). Arguably, this was a hangover from when we did 24 hour on-calls but it was still nice and to be honest, most F1s would rent privately rather than use often quite poor standard hospital digs.

The advent of a 12-hour shift pattern has obvious benefits – doing a 24 hour shift where you’re up the whole time is physically and mentally punishing. It was also accompanied by the European Working Time Directive which mandated an 11 hour gap between a 13 hour shifts and limited the number of hours one could work in the week.

Disseminated in time…

There are a couple of things to note, however. Firstly, the mandated time off doesn’t mean you’re not just generally tired. I did one, fairly quiet night shift on Friday night. Unexpectedly, I was still feeling quite tired 26 hours later.

When you do weekday (4 nights Mon night to Fri morning) or weekend nights (3 nights Fri night to Mon morning), at the end you spend two days jet lagged, trying to do as little as possible to recover. At 31, many of my colleagues have kids who don’t exactly understand this, let alone the other stresses and strains of home life.

…and space

Further, there’s an uncertainty which I’ve mentioned elsewhere in my blog. An acquaintance living in South Yorkshire told me that her husband, a paediatric surgeon, had been told with a week’s notice that he was moving to Newcastle for 2 years. They had at least one child, I think they may have two.

Yorkshire and the Humber Deanery is split into 3 schools, West Yorkshire (based around Leeds), South Yorkshire (Sheffield), and North and East (around Hull and York). The first two of these have historically filled their posts. Indeed, when I applied for anaesthetics, Sheffield and Leeds were competitive.

The difficulty was and is, fewer people apply for East Yorkshire. There has recently been a drop in the number of applications to Yorkshire and the Humber Deanery.

Because training posts were not being filled in the East, the deanery decided new applicants at an ST3 level (Specialty Trainee Year 3) would be expected to train across the deanery, with some reimbursement of travel and accommodation. There are two different ways to complete your first two years of anaesthetic training (Core Anaesthetic Training or the Acute Care Common Stem) but the point is, anaesthetists ready to move to the next stage were being asked to train, potentially, anywhere between Chesterfield and Scarborough.

Yes, we have been lucky in Sheffield; that all hospitals were commutable was a significant attraction of the school. When compared to the Northern Deanery (which includes hospitals in Carlisle and Middlesborough), the North of Scotland (an entire school of anaesthesia albeit limited to Aberdeen and Inverness from what I can tell) and Wales, Yorkshire and the Humber is not significantly bigger. It’s 186 miles from Rhyl to Cardiff, compared to the mere 100 from Chesterfield to Scarborough.

Your choices are to move every year; live in two places, coming back on weekends off; or commute long distances (possibly staying over on night shifts). None of these are straight-forward particularly for colleagues my age who have kids.

It takes 9 years of postgraduate training to be an anaesthetist, meaning you’ll be 32 before becoming a consultant and having a permanent contract. If you have the temerity to want to do research or an educational qualification, you have to increase that. In specialties such as cardiology or surgery, whilst not technically mandatory, to get a job you’ll need to time outside of training whether as research or a subspecialty fellowship. Completing training before having children is not always possible.

To an extent, none of this is unique to medicine. Soldiers earn less and are away from home longer. Other jobs mandate long commutes. Factory workers do night shifts for little pay. Nurses get paid less for an equally stressful job.

However, when one combines recurrent jet lag from night shifts, prolonged training before being able to settle down, the uncertainty of where one will be in 12 months, the inflexibility of training, the increase in retirement age, recent disputes with government over payincessant workplace assessments and exams, lack of rest facilities, and the possibility of dying on the way home from work, Helen Lewis’s “slowly pissing off [doctors]” encapsulates the factors that are chipping away at doctors’ numbers and doctors’ morale.

PS: for the non-medics, the phrase “disseminated in time and space” is a description used in the diagnosis of multiple sclerosis. This post has nothing to do with MS – the phrase just seemed apt and will ring a bell with medics.

Free speech, persecution and sinful gay sex

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Former Liberal Democrat leader Tim Farron was interviewed on Premier Christian news where he said he regretted stating that gay sex was not a sin.

(You only need to listen to about a minute of this clip.)

Farron’s points are, I think, these. Firstly, that politicians should be allowed to hold personal views on behaviour which they may think abhorrent, immoral or sinful but defend people’s right to practise such behaviour. Secondly, later in the interview, he states Christians shouldn’t have to hide their faith to get elected (though he admits he wouldn’t want an American system where politicians essentially fake it).

To an extent, he has a point. One could think “gay sex” immoral but still support its legality. A woman may think abortion abhorrent but still be pro-choice if regardless of her personal beliefs she does not support imposing them on others. Or in Farron’s case, a vegetarian who doesn’t propose the prohibition of meat consumption.

Freedom of speech can never be absolute. The classic example is it is not legal to shout “fire” in a crowded theatre. Here, it’s clearly reasonable to limit free speech. And often criticism is mistaken for a curtailment of free speech. Take the recent example of Virgin no longer selling the Daily Mail.

Farage is wrong. If Virgin is banning the Daily Mail, then so am I, at every point I am not selling the Daily Mail. Virgin are still allowing customers with a copy on to the train.

6 years ago, when comedian Daniel Tosh was heckled after joking about rape, a number of comedians came to his defence. One argued comedians should be allowed to say “almost whatever they want” and the audience could laugh or not laugh. Heckling aside, the criticism Tosh received is not limiting free speech – it’s free speech in action. You can’t say something and then get angry when others say they think you’re an idiot.

More than anybody, politicians must to be careful about what they say; it can have profound consequences. And politicians accept that – it’s a price of the job. (If you don’t believe me, ask the US State Department about their opinion of President Trump’s tweets.)

This is particularly true for the Liberal Democrats; our party’s manifestos are created democratically. Each policy has to be voted through by the party. The leader is there to advocate policy even when they disagree, a principle which killed Nick Clegg’s political career.

Is there a glass ceiling for Christians?

Yes but no.

He was asked this question originally by Cathy Newman in 2015 after he was elected leader. After two years, when asked repeatedly in 2017 he still had no answer until finally admitting (well, lying) that he didn’t think gay sex was a sin.

It would have been perfectly reasonable for him to say “if you want to know about sin, ask a priest; I’m a politician”. He didn’t – he responded by saying “we are all sinners”, which in the Premier Christian Radio interview he admits is evasive. However, one cannot say “I want to be an openly religious politician” and then complain that one is quizzed on what those religious beliefs are.

Further, Farron admits in the interview that most people don’t understand what “sin” means. As such, he understands that when he says he thinks “gay sex” is a sin, most will interpret that as, “gay sex is a bad thing”.

The glass ceiling is for those whose Christianity justifies abhorrent beliefs. That’s exactly the sort of glass ceiling we should be trying to build.

The false equivalence of immutable characteristics with religion

There is a wider issue here on how criticism of religious belief is conflated with the persecution of minorities. If you are an ethnic minority, LGBT or disabled, it is not a choice. A religious belief is.

Clearly, abuse of religious people simply because they dress or act differently is unacceptable. Shouting at those exiting a mosque because they have “Muslamic ray guns” is indefensible (though it is worth noting that such abuse is usually couched in nationalist terms, religion effectively being used as a proxy for racism). I also don’t think it’s acceptable to criticise a politician’s religious beliefs if they wish to confine them to their personal life.

Liberal Democrats are supposed to support progressive causes unapologetically – calling “gay sex” sinful does the opposite. Claiming to be a Christian is no defence. Moreover, using the term glass ceiling to equate systemic discrimination against women in the workplace with the right to call “gay sex” sinful is indefensible. Or to put it more succinctly:

PS: so…you may have noticed I referred to “gay sex” in quotes. It’s because it’s a form bi-erasure. If two bisexual men have sex or two bisexual women have sex, neither is “gay sex” – no gay people are involved. Unless Tim Farron thinks homosexual sex is a sin but is fine with same-gender bisexual nookie, we shouldn’t really be using the term “gay sex”.

Brown atheists

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The Grand Mosque, Kaaba, Saudi Arabia in 2014 – original image

In the last week, I’ve read two excellent books on race: Why I’m No Longer Talking To White People About Race by Reni Eddo-Lodge and The Good Immigrant by Nikesh Shukla. Both books give an excellent summary of Britain’s issue with race.

I read Eddo-Lodge’s book first. Though the book is indeed very good, I found the first couple of chapters initially irritating due to the seeming lack of discussion of British South Asians and virtually no mention of British East and South-East Asians. In the Histories chapter, amongst the descriptions of riots, there is no mention of the 2001 Bradford and Oldham riots involving British South Asians. Perhaps this was an editor’s choice but it still left me feeling slightly empty even if I enjoyed the book as a whole.

As such, I then found The Good Immigrant which is a collection of essays – one from Eddo-Lodge herself – from a variety of first- to third-generation immigrants of colour. (Amusingly, my partner already had a copy which I realised halfway through reading the version I’d bought on Kindle.) This book too is excellent but only one essay is written by a non-religious person.

What brand of immigrant am I?

I am Asian/British Asian according to the 2011 UK Census categories. This makes me part of a 7.5% minority or 4213531 of the population. I am also of Bangladeshi heritage – 447201/4213531 or 10.6% of the Asian/British Asian population and 0.8% of the total population. Even amongst Bangladeshis, my parents are from the city of Rajshahi putting me in the 5% not originating from the northeastern district of Syhlet (p 247); a minority within a minority within a minority, if you will. (For comparison, there are 1864890 black Britons – 3.3% of the population.)

I’m also of “No religion”. Now, the 2011 Census would suggest that makes me a part of a 14097229-strong group, about 25.1% of the total population (though the British Social Attitudes survey suggests this number is closer to 53% and is probably the more accurate number; a debate for another time).

Put those together and what do you get? The 2011 UK Census states there are 6093 Britons of Bangladeshi ethnic origin with no religion (0.011% of the population, 1.3% of Bangladeshi Brits). At this point, the percentage becomes meaningless other than to say, it’s very small and probably an underestimate.

I am nonetheless privileged. I’m privately educated, straight, able-bodied and am in full-time professional employment. Further, I’m arguably a very “white” Asian. My favourite sport is rugby union and when I go I often joke about being the only Asian in Twickenham (though not always true – last time I went with my brother).

I don’t eat many “Indian” sweets – I’d much rather have Dairy Milk. I drink alcohol – haram according to the beliefs of of the 402428 (89.9%) Muslims amongst the Bangladeshis in Britain. And I spurned Bhangra and Bollywood for 2000s indie and Netflix.

At least, I’m a doctor, I guess.

Coconuts

I have been to Bangladesh a number of times though not for 16 years, shortly after I finished my GCSEs. There are a number of reasons for this which I’m not going to go into here but it’s why I am irritated by Britons with South Asian parents who are deeply patriotic to Pakistan, India or Bangladesh only to tell me they’ve never been.

Bizarrely, it was a white friend who revealed the term “coconut” to me. She had gone to school in Leicester with a large number of Asian pupils. A coconut is a brown person who is white on the inside. Initially, I was unaware Asians use it as a pejorative term, a less harsh version of “race traitor” or “Uncle Tom”.

For most of my life, most of my friends have been white and so – as you may have gleaned – I largely associated Asian culture with my parents and with Islam. Indeed, I’ve probably had more South-East Asian, East Asian and black friends than South Asian ones. To some minor extent – and fitting with a stereotypical teenager – I felt the need to rebel against my parents. But not really as I was pretty much a goody-two-shoes at school.

In fact, my parents are remarkably liberal for Muslim, Asian parents. They never tried to arrange a marriage, never asked much about the fact I drank at Uni and after the age of 12, allowed me to make my own decisions about religion, even if it meant I’ve ended up faithless.

The bottom line is, I often feel far more at home in typically white environments than Asian ones. Much of the constant explaining of culture people of colour have to do, I don’t. I don’t have to explain why I don’t drink alcohol, my religion, my “weird” hair, my different clothes, my accent.

Don’t get me wrong, I have on a number of occasions been asked “but where are you originally from?”, “Telford” apparently being an insufficient answer. I’ve had a patient assume I was interested in the cricket score. I’ve been mistaken for another Asian doctor with whom I have never worked (despite the fact he is thinner and half a foot taller than me). And I’m still taken aback that so few people know that Bangladesh used to be East Pakistan and fought a war for its independence.

And yet – I’d still rather sample a real ale in a hipster pub in one of the whitest parts of Sheffield than watch Bollywood or listen to South Asian music.

As-salamu alaykum and other bones of contention

Every now and again, somebody would phone the house, immediately saying “as-salamu alaykum” and speaking in English nor Bengali. My brothers and I would invariably respond with “hello” until the other person spoke a language we understood.

I know this is a pretty standard greeting in Muslim countries but ultimately, I am not a Muslim. I have had a couple of people assume I was religious for no other reason than skin colour. They all have the same look of confusion as they try to pigeon hole a brown atheist. And to be honest, this is white and brown people equally.

Muslim countries the world over persecute atheists. Most have blasphemy laws. Raif Badawi languishes in jail having been lashed by Saudi Arabia for apostasy, possibly awaiting more. Ahmed Rajib Haider, Avijit Roy, Washiqur Rahman, Anata Bijoy Das, Niloy Chaterjee, Faisal Arefin Dipan and Ahmedur Rashid Chowdhury Tutul were all Bangladeshis killed, most hacked to death, for expressing secularist views. Shahidan Kassim, a Malaysian government minister, has said atheists should be “hunted down”.

Faith to Faithless is a UK-based charity founded by ex-Muslims Imtiaz Shams and Aliyah Saleem. Run by volunteers, it helps those seeking to leave religion. This video on their website created by VICE News shows the lengths some have to go to stay safe.

In it, we see a British man who has his kneecap fractured and wrist broken defending himself from attackers after fellow Muslims discovered he had become an atheist. There is a British woman who age 17 escaped the imprisonment of her family when they discovered she had a boyfriend. And worst, the story of an atheist woman (by whom the the above photo was taken) who tried to flee Saudi Arabia and the possibility of being murdered by her brother.

“…clowns to the left of me, jokers to the right…”

Brown atheists are in something of a bind, even in the west. The conservative right will not defend them because they are atheists, refugees and/or immigrants. Progressive liberals will not defend them because they criticise Islam and the cultures of conservative minorities. And when Britain thinks of atheists, it thinks of a male, pale and stale middle-class former Oxford professor. What could be more privileged than that, right?

Personally, it puts me in something of bind too. I get the desire for safe spaces at Universities. There isn’t really a de facto neutral position on free speech – if you have no safe space policy and discussions are dominated by straight, middle-class, able-bodied white men, that’s hardly conducive to the sort of open discussion free speech proponents advocate. Indeed, it’s still a safe space, just a safe space for straight, middle-class, able-bodied white men.

But if an organisation set up by two brown atheists escaping persecution is not allowed to criticise the religion responsible for their persecution, the notion this is about defending victims is a pretence. At the point you’re banning an ex-Muslim human rights activist Iranian woman, you’re not doing safe spaces properly.

Millions of Muslims go about their day without persecuting anybody whilst themselves being marginalised because they dare to wear non-Western clothing, no doubt, but this is something of a #notallmuslims #notallreligiouspeople argument. Yes, there are women wearing a hijab who do so freely and may have very good reasons for doing so. The difficulty is, the ones who are forced to (like Rana in the VICE News video) tend to shed them when they get the chance. And at the point they’re still wearing them, they’re not in a position to speak lest they get slightly killed.

Yes, there are Muslims tolerant of LGBT people. But that’s different from being an ally of LGBT people, particularly LGBT Muslims and ex-Muslims. And where Muslims (or Hindus or Buddhists or whoever) don’t support LGBT rights, they should be roundly and routinely criticised for it.

I once had a white person point out to me that Muslim-majority countries’ illiberalism was very complicated and one could not place all the blame on religion. I didn’t realise quite how patronising a bit of whitesplaining that was at the time but I’m not doing that.

I’m saying that if you think Islam has nothing to do with the persecution of atheists in Muslim-majority countries, it’s no worse than saying men having nothing to do with sexual assault because #notallmen.

Most of those victims are brown and you should care about that, even if it makes you feel uncomfortable with Islam.

“I’m the sleepy doctor”

Doctor Resting Head on Wall

When I see paediatric patients, I often introduce myself as the “sleepy doctor”. I explain that I’m going to “make you sleepy, not me”. It’s an awful joke and I’m fairly sure in no way builds rapport but I find it mildly amusing so I’ve stuck with it.

On my Facebook profile, I recently created a completely non-scientific poll to determine what rest facilities on-call doctors have. The guesses ranged from:

  • On-call room with bed
  • Camp bed in an office
  • Jacuzzi, free bar*, money counting room, fairground…
  • Variations on “lots of opioids”
  • One of the many spare NHS beds

The truth is “many and none of the above”.

I’ve worked in about 10 different hospitals and rest facilities vary. Often anaesthetics has different facilities to the rest of the hospital because of restrictions on where we should be at any given time.

The hospital I’m currently at is unique – both on-call anaesthetists have a room with a bed in it. This is very much the exception rather than the rule. The only reason it happens is because, bizarrely, consultants regularly work night shifts at the level of their junior colleagues at the trust. As such, the managers would have to claw the rooms back from the cold, dead hands/absent posts as the consultants got a job elsewhere.

Normally, medics and surgeons have to make do with the doctors’ mess. This is usually a glorified living room with sofas plus blankets and pillows with which one makes do. Often, there isn’t enough space for everybody to sleep lying down.

When I was still doing internal medicine as a junior grade, I rarely had time to get any sleep anyway. Although the work isn’t as intense as my current job as an anaesthetic/critical care registrar, there’s more routine work. Putting in cannulas, taking blood, rewriting drug charts, clerking patients. As out-of-hours anaesthetist, you’re usually either doing nothing, or you’re doing something pretty full-on.

A&E almost invariably doesn’t have rest facilities and they would be perfunctory anyway. They will have a kitchen with seats in it. If you’re lucky, they seats will be comfortable ones which you can sleep on. Given you’ll probably have somebody beating you with a stick to meet the 4 hour target, it’s kind of irrelevant.

As for me, in the last 4 years as an anaesthetist and intensivist, I’ve been provided with, in order of comfort:

  • A dedicated room with a bed in it
  • An office with a mattress + linen in it
  • An office with a two sofas long enough for you to lie flat for two doctors to sleep in
  • An office with a reclining chair that doesn’t go completely flat
  • An office with a two sofas neither long enough for you to lie flat for two doctors to sleep in
  • An office with two reclining chairs for two doctors
  • An office with a broken airbed (brought in by a doctor) that was (unsuccessfully) supported by pillows
  • A bunch of chairs in a handover room that were really not very comfortable

I’ve been to one trust, as a locum during the day, where the regular juniors said the trust actually provided beds to all on-call doctors. Again, this is very, very much the exception.

Why doctors don’t deserve rest facilities

The term “on-call” historically referred to a doctor who was at home and only got called in for the most dire emergency. Simply, there was just less stuff a doctor could do – calling them in the middle of the night was pointless. Doctors being on-call for 24 hours didn’t actually involve being in the hospital.

In the second-half of the 20th century, that changed and by the 1990s, doctors were still working 24 hour shifts but were often awake for the majority of those shifts. (And were often paid half-time for working out-of-hours). Doctors basically working harder than they did during the day, were paid less for the privilege and weren’t really “on-call” – they were dealing with the sickest patients in the early hours of the morning.

Nonetheless, doctors normally lived on-site and so could pop back to their accommodation for shut-eye when they got the chance. As such, the hospital didn’t have to provide beds specifically for doctors on-call. (Note: the accommodation was of the standard of old-school University halls of residence – one of the consultants joked you had to be careful when you got out of bed in case you stepped on a rat.)

Various reforms came into place not least the European Working Time Directive 2003 which limited working to fewer than 48 hours a week. As such, hospitals introduced shift systems similar to those used by nurses. EWTD mandated rest periods of 11 hours between the 13 hour night shifts.

Once this was done, hospitals argued that they were not obliged to provide somewhere for doctors to sleep. After all, they were on shift just like nurses, healthcare assistants, midwives, porters etc – why did doctors need sleep more than everybody else?

It’s not an argument without merit. Indeed nurses are instructed not to sleep on their night shifts.

Why doctors deserve a warm bed at night

Firstly, the notion that nurses and other staff shouldn’t be allowed to sleep on their breaks at night is garbage. The Association of Anaesthetists of Great Britain and Ireland (AAGBI) recently produced resources for hospitals on protecting from fatigue. They have specific advice on what to do at night within which they state that a “15-20 minute nap can significantly improves alertness” echoed by 2006 Royal College of Physicians publication stating similar. This fits with our understanding of sleep physiology.

Doctors are basically drunk when they drive home:

and so unsurprisingly have accidents:

and some die because of exhaustion:

So why is it different for doctors?

Arguably it’s not. But doctors-in-training (so-called junior doctors) are often obligated to live long commutes away from their hospitals. The rotational nature of the training programmes means that I live in Sheffield but have to work in Barnsley (35 min away at rush hour), Rotherham (25 min) and Doncaster (50-60 min). Sheffield is the smallest anaesthetic deanery in the country; the deanery is now changing to cover Yorkshire and the Humber.

A colleague who recently got on to the specialty training programme for anaesthetics was told her first post was over 1 hour away from both her home and any base hospital in the nearest city (where they calculate travel times from) outside of rush hour. This suggests a commuting time of closer to 70-80 minutes. She was told there was no accommodation available. Following a 13-hour night shift, she would be expected to drive 70-80 minutes, 4 times in her week of nights.

Another colleague’s husband was a paediatric surgical trainee. He was told with two weeks notice that he would be moving to a hospital 2-2½ hours away. They had a toddler at the time. Clearly, this is not commutable but the short notice and variation in distance to travel makes organising your life very difficult.

At about 1pm today, I attempted to open a beside cabinet. I couldn’t find the handle as I thought it was at the top left of the door and it wasn’t there, albeit with only the bedside lamp on. I assumed the handle had fallen off. I pried it open then discovered that the handle was actually halfway down rather than at the top. I felt like a prize idiot.

At 5am the day before, with 13 hours less sleep, I was operating an ultrasound machine and trying to site two lines into somebody’s internal jugular vein (translation: big vein in neck, near the carotid artery, involves big needle). Here’s a video if you’re wondering what it entails:

As mentioned above, the AAGBI has now produced standards of what they think hospitals should offer their anaesthetists overnight. There is no reason this shouldn’t be applicable across all specialties. I also don’t think the standards are unreasonable for people who are commuting long distances regardless of whether they’re doctors, nurses, porters or clerical staff.

A mattress in a room normally used as an office seems to me a reasonable demand. A bed or mattress in a currently unused room also seems reasonable. Indeed, a ward not currently used and switched to a series of rooms for doctors to sleep in would make the most sense, particularly for sleeping after night shifts before driving home.

I think it’s the responsibility of an organisation which mandates its staff switch regularly between day and night shifts to provide adequate rest facilities. You shouldn’t be having an accident on the way home because of tiredness. And you certainly shouldn’t be dying.

*hospitals did used to have bars. Now, it’s a “bring your own” affair.**
**we don’t really bring our own alcohol.

Lies, Damned Lies and A&E Statistics

cardiac-arrest1

First, the 4-hour emergency department (ED) target is NOT A TARGET FOR PATIENTS TO BE SEEN IN ED and never has been. Let me repeat that – it not a target to be seen.

The target is to be seen and discharged from ED. That might be home or it might be transfer on to a ward or it might be transfer to another hospital.  The term “seen”, widely used by the media, suggests it will take that long for a doctor to see you which is untrue.

Indeed, many patients attending ED many not even need a doctor – many minor injuries can be managed by nurse specialists or advanced nurse practitioners.

Why is Emergency Medicine struggling to recruit?

I know three anaesthetists, who are all former emergency medicine (EM) trainees. Although I haven’t worked in EM myself, I have worked in a trust whose (ED) had its trainees removed due to poor training. Work was then provided by locum EM doctors.

(There 4 basic grades of doctor – F1, SHO, Registrar/Staff Grade, Consultant. In new money, that’s F1, F2/CT, ST/specialty doctor/middle grade, Consultant but the old terms are still used.)

This can happen in any department: the workplace does not provide good training; it therefore doesn’t attract the best consultants; it has poorer outcomes, has difficulty attracting staff, is overworked and develops a negative culture; it provides poor training and in the worst cases (as above) it loses its trainees; and so the cycle continues. Breaking it is not easy.

Is this due to the targets in ED? Maybe but only partially. Unfortunately, I can’t find the anonymously written article in the Guardian where a doctor explained she enjoyed emergency medicine…which is why she became an anaesthetist.

One of the aforementioned former-EM, now-anaesthetic registrars pointed out to me, that given anaesthetists cover critical care out of hours in most of the country, it is actually them who sort out the worst emergencies, not the EM doctors. Most are sorted out in the ED, but often it is critical care rather than EM who have the skills to provide more definitive treatment.

It’s not universally true – a surgical registrar discussed a hospital where actually EM rarely called anaesthetists unless they were certain a patient needed to go to critical care or theatre. And even then, the patient would be intubated, have lines put in and be ready for transfer before coming to critical care. In all the hospitals I’ve worked in, not only would this not happen, EM consultants didn’t have the expertise to even do it.

What the hell do you know, Raj?

It should be noted, this is not the experience of an EM registrar but an anaesthetic and critical care registrar on the receiving end of referrals. But it is problematic when, as was the experience of a GP friend, the locum EM registrar in your department is in fact a plastic surgery registrar whose qualifications and experience from abroad have not been examined properly. I have certainly worked with EM specialty doctors and more worryingly consultants whose practice left something to be desired in my, my anaesthetic and critical care colleagues’, and my EM colleagues’ opinions.

The sort of situation described above, where a patient can be stabilised in A&E, may very well be a thing of the past. A not-uncommon complaint is senior doctors spending the bulk of their time trying to discharge less sick patients quickly, rather than helping in the resuscitation room because other specialties (such as general medicine or intensive care) can cover for them there.

This is not universally true and I’ve worked with excellent EM consultants and registrars who leave only when there is nothing more to be done but there is an understandable pressure for them to meet targets. Indeed, talk to folk who worked in ED before the 4 hour target; I’m not sure an 80 year-old waiting 12 hours on a trolley in a corridor with a broken hip represented a better run department.

EM is an amazing mixture of the minor and major; doctors who can suture scalp lacerations, stop nosebleeds, manage suicide attempts and run trauma calls and cardiac arrests. It is a also specialty which begs to be done at less-than-full-time (say 80%) – continuity of care is a non-issue but burnout potentially is, especially given the ridiculous rotas for its trainees (8pm-4am? That cannot be good for the soul).

Who knows? Maybe they’ll even get to manage some emergencies rather than having to discharge patients with “non-cardiac chest pain” at 3 hours 59 minutes. Also – watch Cardiac Arrest. It’s really good (if old).