Lies, Damned Lies and A&E Statistics

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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).

 

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Some thoughts on This Is Going To Hurt

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Firstly, This Is Going To Hurt by Adam Kay is a great book. A former obstetrician who gave up medicine in 2010 to pursue comedy, his description of what life used to be like is as with any well-written memoir of medicine heartbreaking and funny. Indeed, variations on “heartbreaking and funny” have become something of a cliché in reviews of the medical memoir.

It is worth noting how variable our experiences in the NHS are. A persistent theme in This Is Going To Hurt is the absence of bosses. This varies widely between specialities. Anaesthesia has always been ahead of the curve in terms of consultant presence out-of-hours but consultants in all acute surgical specialities (including obstetrics and gynaecology) seem, from my point-of-view anyway, to be more readily available than in years past though many internal medical specialties still seem to lag behind. “I didn’t want to disturb the boss” is no longer a legally defensible position.

When Kay started medicine (in around 2004), 24 hour on-calls were the norm. Not bothering the boss was the norm. Now, the European Working Time Directive means that 12 hour shifts are in place for nearly every acute specialty. Though much-maligned, the new junior doctor contract has led to exception reporting which fines trusts for junior doctors who persistently working hours longer than contracted.

(The fines go back to the junior doctors’ mess and the doctors in question should they accrue sufficient hours get days in lieu.)

Many of the bugbears he discusses are still in place. The lack of study leave for exams – public health get two days a week for three months coming up to their exams; I get the day of the exam off plus a day for travel. The difficulty in getting swaps for annual leave, made even more complicated by the fact that on a 1 in 7 rota with 12 hour shifts, for any given day off, 1 or 2 of the other 6 doctors are likely to be unavailable for swaps.

Some are worse, particularly the inflexible and pernickety nature of postgraduate education. Not got a DOPS in Management of Cardiorespiratory Arrest despite having a valid ALS and this being a thing that happens out of hours so there is almost never a consultant around to watch you do it? Too bad, you may have to repeat the year. Not got any assessments in major trauma despite not having worked in a major trauma centre? Too bad, you may have to repeat.

I guess the bottom line is – some things are better, some things are worse and the experience is dependent on specialty and location as much as anything. Slowly (too slowly) the machismo in medicine is dying away. But there is still a feeling of too much work for too little pay with the addition of tiresome educational assessments, the value of which is never truly made clear to assessors and those being assessed alike.