“-isms” and robots: why I’m voting for Jo Swinson

From Wikipedia

Last week, I joked on Facebook that when I attended the Saturday Leeds leadership hustings (168 hours early), it would be helpful if one candidate could steal a baby or kick a puppy. It would make it much easier to choose between them, though I’ll not say which way my vote would have swung.

Beforehand, I noticed a Jo Swinson article in the New Statesman on the ethics and economics of artificial intelligence. Beyond facetiously suggesting that because of the article I would vote for her as the pro-robots candidate, I was undecided.

I have now seen them in person in Leeds and subsequently watched the North West hustings on YouTube. The criticism that they are too similar does not do the contest justice; the differences are there if you look beneath the surface.

There is no doubt that Ed Davey’s experience and knowledge are impressive. He rightly – both in terms of his audience and as a prospective government agenda – leant heavily on his green credentials. His explanation of how 15% of greenhouse emissions come from organisations which go through London, his wider emphasis on a green economy, and his advocacy for renewable energy as a source of jobs and investment for the future all served him well.

From his support for LGBT+ rights, pushing for support staff in the climate department to receive a living wage, to freeing a constituent from Guantanamo Bay, he is more than just the green candidate. Despite some (I think unjustified) criticism of his approach to fracking in coalition, his liberal and indeed Liberal credentials are a struggle to question. I believe he would be an excellent leader.

So why Jo?

Individually, many of Jo’s policies are for a Liberal Democrat perhaps unremarkable. She would rather spend money on early years education than on free University tuition fees. She believes companies should have to produce data on employee job satisfaction and social good. She has argued that automation will have profound consequences for our economy and we need to protect those that are most vulnerable to it.

When politicians – or indeed Jo – talk about transforming the economy, it is tempting to stop listening. On its own, it is a phrase devoid of meaning.

But when you start to take “transforming the economy”, putting “people and planet first” and add it to her rhetoric particularly on technology, you start to see her broader political vision. The manner in which she has discussed technology suggests that of the two, she better understands that it will not be enough to make renewable energy the new industry.

From Uber drivers to accountants, actuaries to Amazon delivery drivers, the problems of automation must be front and centre of that economic transformation. We need a plan for when the skill sets of millions are rendered obsolete by enough RAM and, yes, maybe even robots.

Jo has touched on universal basic income but like any solution she admits that it is neither a panacea nor without potential harms. I can’t tell you exactly why in her leaflet she mentioned her programming on a ZX Spectrum 48K, but when put in context of her rhetoric around technology, it adds to the sense that she has keener grasp of what will potentially be a more potent threat to our economic norms than even Brexit. You only have to look at the intergenerational poverty wrought across Wales, the East Midlands and the North by Thatcherism’s failure – either through neglect or malice, pick your poison – to properly reskill an entire generation of manual labourers.

Who has the best “-ism”?

From Ed, I get the sense of a man with an in-depth understanding of the ramifications of policy and how to best optimise them in every area. But I don’t have a sense of what “Daveyism” might one day look like. I know that it would involve investing in renewables and taking on the climate emergency. I know it would involve doing our best to protect individual liberty. And I know it would be an approach of internationalism. But it is a collection of liberal policies not seemingly tied together other than being individually good ideas. And that is, rightly or wrongly, what I took from Ed’s hustings performances.

With Jo, I see the start of a broader political vision. I can see what “Swinsonism” might begin to look like. Her argument is that we need to move away from old ideas that put GDP above all else. Couple that with the obstacles and opportunities she sees in the technological revolution. It could be the key to solving the climate emergency by transforming industries such as food and transport, both major contributors to CO2 production, but also needs to ensure that drivers of lorries, taxis and delivery are not left unemployed by drones and driverless cars.

Thatcherism was the idea that supply-side, free market economics would generate wealth such that gaps in inequality mattered less than absolute rises in living standards. Blairism advocated flourishing free markets with sufficient tax to build a proper welfare state. Swinsonism believes old economic models are obsolete and technology will render them more so: whatever our solutions, all roads must lead to empowerment of the individual whilst protecting the planet.

An election is seldom fought on the same terms as the previous one. In 2017, nobody mentioned a Labour-SNP coalition. In 2015, few agreed with Nick. In 2010, a global recession had eclipsed the war in Iraq.

In a future where Ed Davey becomes Prime Minister, I might know what policies he intends to put in place. I don’t know what the underlying philosophy behind them is and I can’t instantiate what he would do in the face of change. Jo Swinson advocates ensuring that whatever the change, empowerment of the individual has to be the metric used to make every decision.

No, Prime Minister

There are two issues with the above. Firstly, neither Jo nor Ed is likely to be Prime Minister. Sure, the Tories and Labour may collapse but first-past-the-post means it is still more than likely the red or blue team will be in Number 10 after the next election. It would surely be better to judge them on their campaigning ability rather than some hypothetical political philosophy.

Secondly, I might be wrong about Jo. Politicians tend to fail more than they succeed. Both Ed and Jo were part of a coalition government that whilst successful in many ways (pupil premium, shared parent leave, same-gender marriage), irreparably damaged many people and our party too.

Nick Clegg may have been the darling of British politics in 2010 but it’s clear now that he made by his own admission many, many mistakes that would eventually be his undoing. And anyway, perhaps I’m reading too much into an equally disparate collection of Swinson policies whilst ignoring what guides the Davey political compass.

All that said, I think there is little to choose between them in campaigning terms (though I do think Jo is a slightly better media performer and public speaker) nor on their CVs. As such, I am left only with what they might want to do in power.

With Ed Davey, I feel I know what he would want to achieve in his first 10 weeks. With Jo Swinson, I think I might be able to figure out what she would do if she had 10 years.

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Doctors’ grades or ACCS CT2 (AIM) WTF?

tl;dr – F1 and F2 are Foundation doctors (years 1 and 2) just out of medical school. CT1-3 or ST1-9 represent the number of years a doctor has been in specialty training (you need to complete the Foundation Programme to enter specialty training).

Recently, I posted on Facebook trying to find out if anybody not in healthcare understood the grading system doctors used. The answer was “no”. So I’ve created a flow chart which is too small but I’m hoping when you click on it and enlarge it, it will be fine.

The American system is relatively simple – intern (year 1 doctor), resident (doctor in specialist training), attending (doctor who has completed specialist training). American medical school is longer and their postgraduate training programmes shorter than in the UK. Whether this better or worse is debatable but intern-resident-attending is a fairly simple structure.

Assuming you took no extra time out, the old British system went like this:

  • Year 1: Junior House Officer (JHO) (aka Pre-registration house officer or PRHO)
  • Year 2-3: Senior House Officer (SHO)
  • Year 4-7: Specialist Registrar (SpR)
  • Consultant

SHOs often flitted between different jobs and some doctors spent many years doing a variety of different thing. Once they decided on the specialty (NB: specialty not speciality – it’s not a dish) they wished to pursue, they would apply for SpR jobs using their CVs from their previous SHO jobs.

This system was introduced following the 1993 Calman Report which led to the 1996 Calman Reforms. These endeavoured to provide more structured training. Prior to this, there was a registrar (note, no specialist)-senior registrar (SR) divide.

Brave new world

The route you take depends on the specialty you enter.

Why don’t you build me up, buttercup…

Modernising Medical Careers (MMC) introduced the Foundation Programme and Specialty Training in 2007. The grades now go like this:

  • Years 1-2: The Foundation Programme
    • Foundation Year 1 (F1/FY1) – equivalent to JHO
    • Foundation Year 2 (F2/FY2) – equivalent to a year 1 SHO
  • Years 3-6/7/8/9: Specialty Training (length depends on specialty)
    • Specialty Trainee 1 (ST1) – Year 2 SHO
    • Specialty Trainee 2 (ST2) – Year 3 SHO
    • Specialty Trainee 3 (ST3) – Year 1 SpR
    • Specialty Trainee 4-6/7/8/9 (ST4-ST6/7/8/9) – Year 2-4/5/6/7 SpR
  • Consultant

The old JHO jobs consisted of 6 months in a medical specialty (respiratory, renal, gastroenterology etc.) and 6 in surgery (general surgery, cardiac, vascular etc.). Doctors would then apply for SHO jobs which again usually lasted around 6-12 months. After two years or more, usually you could go on to apply for a SpR job (or “number” meaning National Training Number).

The new system did away with this. You did two years of the Foundation Programme consisting of usually 3 x 4 month specialties per year. In F1, you had to do 1 medical and 1 surgical specialty but it also allowed exposure to areas such as GP, psychiatry, radiology, pathology.

It also largely avoided the situation of SHOs being “too experienced” and being unable to enter an SpR programme. An interview panel might look unfavourably on somebody who had done 4 years of SHO jobs without getting an SpR number; they might infer problems that had prevented them from securing a more senior job earlier.

It’s actually relatively simple – F1 is a year 1 doctor. F2 is year 2 doctor. ST1 is 1 year after foundation. ST6 is a 6 years after foundation. The number tells you how many years they have been in specialty training. However, confusingly, the generic term for those in specialty training was Specialty Registrar (StR) (as opposed to Specialist Registrar or SpR).

The idea was that once you’d applied for specialty training, you had a clear path achieving your Certificate of Completion of Training (CCT) which allows you to practise as a consultant.

…just to let me down and mess me around?

MMC was initially a disaster. It led to a bizarre situation where doctors in the old SpR programme had to apply for their own jobs in the new StR programme. Many ended up having to drop down grades because they failed to get jobs they had been doing for years.

Applications for specialty training began halfway through the F2 year. F2s had to choose what specialty they wanted to pursue after 18 months of practising medicine. In recent years, it has led to the “F3” year where doctors leave the Foundation Programme and use it to travel abroad or locum prior to starting specialty training.

The old SHO system gave doctors time to experience different specialties. Further, it meant that doctors often had broader experiences. Medical doctors who had done orthopaedics, vascular surgeons who had done neurosurgery, GPs who had done rheumatology – all of that experience was lost.

What the new system gives you in stability, it takes away in flexibility.

To confuse matters further, an Specialty Registrar Year 1 (ST1) is not the equivalent of an Specialist Registrar Year 1 (it’s a year 2 SHO in the old system). It’s why most people avoid the term “Specialty Registrar”. Colloquially, when people mean “registrar” or “reg” or “SpR”, they mean somebody who is ST3 or above in their specific specialty.

The core issue

So, it’s not even as simple as above. There are 6 “core” training programmes of which I am aware. Instead of doing ST1 & 2, you do CT1-3 and then enter a specialist training programme at ST3. (Yes, confusingly, you might go from CT3 to ST3.)

  • Core Medical Training – for most internal medical specialties (including acute internal medicine) and intensive care
  • Core Surgical Training – for most surgical specialties
  • Core Anaesthetics Training – for anaesthetics and/or intensive care
  • Acute Care Common Stem – for 4 acute specialties: anaesthetics, intensive care, emergency medicine and acute internal medicine
  • Core Psychiatry Training – for psych specialties
  • Broad Based Training – for GP, paeds, psychiatry and most medical specialties

In terms of experience in your field CT v ST makes very little difference. However, in an ST programme, it’s run-through – there is no application between ST2 and ST3 (generally). With the core programmes (called uncoupled training), you have to apply for an ST3/4 job once you’ve completed you core training.

You’ll see that you can get into anaesthetics, internal medicine, acute internal medicine, intensive care and psychiatry through two routes. You can also get into paediatrics by entering a dedicated programme as well as broad based training.

General Practice

GPs, the folks with the hardest jobs in medicine, are as ever much more sensible.

  • Year 1-2: the Foundation Programme (as above)
  • Year 3-5: General Practice Specialty Training (GPST)
    • Year 3-4: mixture of GP and hospital-based practice
    • Year 5: all GP
  • GP Principal (a fully trained GP)

Foundation – Specialist Training – GP…that is pretty simple.

Why are we still talking about SHOs?

The term “JHO” has completely disappeared. On the ward, folks refer to “the F1”. However, the old SHO in modern terminology might be:

  • an F2
  • a CT1-3
  • an ST1-2
  • a GPST in hospital

Rotas are still split: F1 (fka JHO)-SHO-SpR-Consultant in most places or just SHO-SpR-Consultant in something like anaesthetics. Theoretically, this should be:

  • F1
  • Junior Grade (SHO)
  • Middle Grade (SpR or equivalent)
  • Senior Grade (Consultant)

Within a rota, most folks have an understanding of the minimal level of competence expected of an SHO/junior grade or a middle grade/SpR in a given specialty. The issue previously had been that a day 1 F2 may not be able to stitch. A CT2 in surgery on their last day before ST3 might be able to perform a laparoscopic appendicectomy independently. Nonetheless, that guaranteed of a minimal competence means that SHO will persist for some time.

Who dares wins?

Of course, what if you don’t enter a formal training programme? If you can’t get an ST3 job, are you destined to leave medicine? Firstly, you can locum but not everybody does this

The SAS grade (Staff grade and Associate Specialist) are folks who have done some specialist training but for whatever reason left the programme. They then work at about the level of an SpR but will not be offered formalised career progression.

Historically, staff grades would need sign-off from a specific number of consultants to progress to Associate Specialist. This meant a level of responsibility somewhere between consultant and SpR. Staff grades were often looked down upon as those not good enough to make it in training.

That perception was probably never accurate and is certainly well wide of the mark now. The two grades have been combined into “Specialty Doctor“, occasionally SD in the notes. In some trusts, Associate Specialists have kept their titles. In others, they have become Specialty Doctors but retain their pay from being Associate Specialists.

Other grades include:

  • Clinical Fellow: usually operating at junior but mostly middle grade level either with other responsibilities or are pursuing educational or academic goals whilst keeping a hand in clinical work.
  • Trust grade/trust doctor: usually doctors with temporary contracts working for a specific trust and not in training.
  • Post-CCT Fellow: doctors who have completed sufficient training to be consultants within their fields but wish to subspecialise. Normally on the middle grade rota, they will almost exclusively work in their specific field e.g. cardiac anaesthesia or children’s anaesthesia.

Age is just a number

Surely, the age of your doctor will give away how experienced they are? Oh, ye of little faith. A colleague of mine entered medicine at the age of 35. She was 17 years my senior. She would have been an F1 age 40. If I had taken no time out (and not failed a year of medical school), in a relatively long training programme, I’d be an anaesthetic consultant next year, age 33.

We already have an issue where women doctors are constantly referred to as nurses. Women more commonly than men seem to be told that they are “too young” to be a consultant despite all the requisite training. Perhaps it’s the facial hair but in 9 years as a doctor I have never, ever been told I looked too young or that I was nurse.

Also, the numbers in your grade are only years of training in that specialty. If, like many of my anaesthetic colleagues, you did two years of emergency medicine prior to anaesthetics, you’ve done two years of relevant training which your grade doesn’t reflect. Equally true if, like me, you did 18 months of part-time locums in amongst your training, this is not included. Nor is research (well, it might be) or education (actually that might be too).

Add in so-called less-than-full-time (LTFT) trainees, who might do 50-80% of the hours, it might take 12 months to do 6 months equivalent of training. Again, age will tell you little about how well trained your doctor is.

Conclusion

The difficulty is, the more flexible your grading system, the more accurate the descriptions to fellow medics but the less accurate it is to both fellow healthcare professionals and patients. The less flexible it is, the easier it is to understand to non-medics (and even some medics) but the less obvious it is what level of training somebody has.

(And to answer the question, “ACCS CT2 (AIM)” means “Acute Care Common Stem Core Trainee year 2 – (Acute Internal Medicine)” i.e. in their second year of the Acute Care Common Stem with a view to specialising in Acute Internal Medicine.)

Should the NHS get rid of the *BLEEP*ing pager?

From the Oxford Handbook for the Foundation Programme (2nd edition) by Hurley, Dawson, Saunders & Eccles

In some sort of weirdly morbid onomatopoeia, the pagers which junior doctors carried all across the country are called “bleeps”. My Dad did his first house job in the UK in 1968 and they were introduced shortly afterwards. Up until that point, they had some weird light system which given my Dad has been telling the same 5 stories for about 50 years, you’d think I’d remember how it worked..

My bleep number as an F1 (Foundation Year 1 – first-year doctor) was 7144. If a nurse wanted to get in contact with me, they had to dial a prefix (let’s say 77), then the bleep number (7144), then the extension they were phoning from (let’s say 26723). So they’d dial 77 7144 26723. My bleep would bleep and the number “26723” would appear on my bleep. I would then find a phone, ring 26723 and they’d answer the phone.

There are significant advantages to this system. In the ten (I think) hospitals I’ve worked at over 9 years in the NHS, the system was roughly the same in each hospital. It worked throughout the hospital grounds (with one key exception). It’s been around so long, even the oldest, most technophobic staff understood how it work.

The actual bleeps themselves were fairly bulletproof. Whilst perhaps not as robust as the Nokia 3210 (it’s pronounced “thirty-two, ten” for you youngsters), you could certainly drop it without worry it was going to break. They rarely need batteries changing and the AA batteries they run off were readily available from switchboard.

It ain’t broke so, why fix it?

There are a whole bunch of issues with a bleep. By way of example:

  1. You bleep somebody and they don’t bleep back – how long do you wait?
  2. You get a bleep and phone back but get an engaged tone. Do you wait for the person to bleep you again or do you wait and then phone back on the same number?
  3. You answer a bleep but nobody is picking up. How long do you wait before hanging up?
  4. You bleep somebody but then the person that rings back isn’t the person you bleeped. You then have to go and find the person they’re ringing to speak to. Do you wait until that conversation is over or do you go and bleep from another phone? How long does the conversation have to go on for before you bleep from another phone?
  5. You get two bleeps in a row. The second bleep wipes the number of the first bleep. You don’t know how to bring the first number back because there are three buttons on the bleep with icons you don’t understand.
  6. You are seeing to a sick patient and get a bleep. There is nobody nearby. Do you leave the sick patient to answer, go and find somebody else to answer, or ignore it and hope they’ll bleep back.

Taking 30 minutes, sat in front of a phone, trying to contact somebody is a waste of everybody’s time. It has happened so many times in every doctor’s career.

Everybody’s got mobiles now, don’t they?

I spend a lot of time in theatres. Theatres are often in the basement of a hospital. As such, reception can often be very poor. Historically, hospitals restricted access to Wi-Fi (though this is largely changing); thus even Wi-Fi calling couldn’t get you through to people. Where Wi-Fi is available, this is useful for calling people but you can’t send anonymous patient data via messages.

Out-of-hours (OOH), it’s patently not feasible to have every doctor on internal medicine give their mobile phone out to every medical ward, especially if you’re covering multiple wards where you don’t normally work. And I wouldn’t be comfortable with my mobile being accessible to that many folks anyway.

What are the alternatives?

In terms of inter-doctor communication whilst on-call, now I’m on anaesthetics or ICU, I work in relatively small teams of doctors. For instance, when I worked at a tertiary children’s centre, there was me on-site and a consultant anaesthetist at home. Us having each other’s phone numbers worked well and we could actually text each other patient data as long as it didn’t use any specifics.

Hospital-at-night (now more accurately hospital-out-of-hours (OOH)) coordinators are wonderful things for bigger teams, particularly for the more junior junior doctors. They are nurse practitioners who triage OOH calls into job lists for doctors on-call.

Instead of an on-call junior having to stop to answer their bleep every time anybody needs them for something regardless of how urgent, they can work through their list overnight. It also means that sicker patients get triaged to more senior doctors by the nurses. Even in a world with mobiles which nurses could ring, it would clearly be frustrating if you got phoned every time you were needed.

Whilst I was an F1 in 2010-11, the hospital piloted Blackberries with an app which sent you your list of jobs. You ticked them off as you went along on the app and this let the OOH coordinator how busy you were. I assume it was more efficient; it was certainly less stressful.

Glorious! Let’s just switch it all online!

Woah, there. I’ve worked in hospitals where bleeping is online, ones where the nursing observations are online, ones with prescribing online, ones with notes online and currently work on an ICU where everything (with some minor if important exceptions) is computerised. Blood results and investigations are the only things which have been online in every hospital I’ve worked at.

A new system always come with problems. At one of the hospitals I worked at, the problem was there was a dead zone for bleeps. Unfortunately, it was on ICU where I, as the 2nd on-call for anaesthetics and ICU, covered crash Caesarean sections and paediatric arrests. If either went out, switchboard would have to ring ICU to ensure I wasn’t there.

They introduced a slightly bizarre system where the crash team carried mobile phones which said “cardiac arrest” when there was an arrest call (I think they’d set it as the ringtone). Being modern-ish mobile phones, the batteries didn’t last very long and even though there were (eventually) chargers and battery replacements, if you were busy and forgot your phone only had 30% charge, when you later went to put your head down for an hour, you might not realise it had run out before you woke up.

(They also introduced a replacement to the bleep system which relied on Google Hangouts. Unfortunately, Hangouts is due to be retired at the end of the year so, that’ll be fun for them. I thankfully don’t work there any more.)

All the systems I mention have had teething problems. The biggest issue is not user-friendliness (though that can be an issue, particularly for short-term or supply posts). It’s generally that the NHS usually has rubbish hardware. So even if you introduce your fancy new app, it doesn’t work.

So is Matt Hancock right?

To be honest, probably.

Whilst not an early adopter, I am quite happy trying new technology. The ICU system I mentioned earlier is the best NHS computer system I’ve used; indeed I and most of my colleagues agree that it is very likely to have saved lives. When I have to go back to ICUs that use paper, I just find the whole thing incredibly frustrating.

Computer systems are like any other system. There is an inevitable period of change. They need to be slowly but surely improved and updated. It will, frankly, probably be crap for at least the first 12 months.

But my question to folks who want to keep the bleep is this: would you be happy to return to paper blood results and films for X-rays? And if you’re not somebody who has to regularly bleep people, this probably isn’t the debate for you.

Like any government initiative, I await it with large and healthy doses of cynicism but this is a much more sensible challenge that Jeremy Hunt and Andrew Lansley who respectively took on junior doctors’ pay and the entire structure of the NHS.

Trying to get rid of bleeps seems a much more feasible and achievable goal, if for no other reason than a lot of trusts have made waves to do it. It just needs to be done right; that’s where I remain cynical of any government initiative.

PS: If you want to hear my fun opinion about fax machines, it can be found here.

Leaving a political party

So this post isn’t a judgement about the newly formed Independent Group (TIG) and its 11 members (Tiggers) per se. Rather, just a comment on what it’s like being in a party.

I’m a pretty minor activist in the Liberal Democrats. I’m on the local branch executive (a subset of the local party which represents Sheffield) and I’m a candidate for a very much non-target seat.

In the 4 years since I became a Liberal Democrat, I’ve enjoyed being a part of the party. I have my frustrations and it is a lot of hard work. But when I look particularly at my branch and my constituency, I believe our candidates will make Sheffield and the country better places to be.

I cannot imagine being active in a party for years and decades and seeing that fall away. To feel so alienated that your party no longer feels like the one you joined. It was probably how many Lib Dems felt when the party entered coalition. And it is clearly how members feel about both government and opposition now.

Throughout a campaign, you bond over your shared beliefs and shared experiences. The challenge of living in a city which has letterboxes round the back and the front; meetings which go on longer than anybody intended; and the decision as to when to ask a (usually older) councillor to sum up their point because they’ve spent 5 of the 10 minutes of their Q&A rambling. Victory is sweeter and defeat easier to bear when they’re shared.

The MPs will have left with heavy hearts. Many in their local parties will have been enraged, old friendships broken, and cries of “traitor” will still be ringing in the ears.

Whatever your opinion of TIG – cynical opportunist carreerists or MPs willing to put their country first – the choices weren’t made lightly. For whatever they’ve gained, they’ll have certainly paid a hefty personal price.

What is going on?

So, 7 and then 8 Labour MPs and 3 Conservative MPs have formed the Independent Group, now being abbreviated to TIG (hopefully meaning we can refer to them as Tiggers soon).

The Home Secretary has stripped a teenager of her British citizenship for joining ISIS as a child, potentially breaking international law.

A Tigger did a racist on TV only to have the headlines fall squarely back on Labour when another MP claimed TIG may have been funded by Israel.

A former member of Militant who was booted out of Labour 34 years ago was readmitted then booted out again two days later for antisemitic tweets he’d made in the past (and stood by).

David Cameron has claimed the three ex-Tory Tiggers should have stayed to form a “modern, compassionate Conservative party”, presumably being unaware of events since his resignation and subsequent exile to his shed to write an increasingly irrelevant memoir.

A UKIP MEP suggested he’d stand for the Conservatives against Anna Soubry only to be told his application to be a member had been rejected (although his tweet sort of implied he was going to fight Soubry).

And there’s an amusing video of the Labour candidate for the North East mayoralty being unable to define Labour’s Brexit position (even though now it’s actually fairly clearly a customs union).

And Bernie Sanders is running for president again.

Anyway, I’m going to bed on the suggestion that apparently there are to be more defections tomorrow.

Some Muslims are angry a gay told their kids “hey, it’s OK to be gay”

Whilst posting this breaks my “try not to get distracted, you’re supposed to be revising” rule, I was intrigued by the story of Muslim parents protesting Andrew Moffat teaching No Outsiders, a book he wrote which, I think, is now used to teach the Equality Act 2010 (including LGBT rights, the ostensibly contentious issue) to kids.

Let’s be clear – the Muslim protestors are wrong albeit not representative of all Muslims. That said, a 2016 ICM poll found that 52% of UK Muslims thought homosexuality should be illegal (I couldn’t find a comparison with the general population) and that 47% thought gays were unacceptable as teachers (14% for the general population). Perhaps then, they’re representative of quite a lot of Muslims.

LGBT rights and Islam is a strange intersection for progressives with Islamophobia itself something of a nebulous term. Attacks on Islam aren’t per se racist but often anti-Muslim bigotry is inextricably mixed with racism. The EDL thinly veil their racism with claims they simply oppose Islam. Clearly shouting “raghead” at a woman wearing hijab is both anti-Muslim bigotry and racist.

But how about claiming it’s wrong to wear hijab? One could argue it’s Islamophobic; but what do you say to the woman who’s escaped Saudi Arabia to the UK who only wore it on pain of a beating? To her, it’s a symbol of oppression being proudly worn by British citizens.

Subsequently claiming Islam is an awful, medieval religion maybe insensitive and even unhelpful but it is certainly not racist, particularly if it comes from an ex Muslim. And it’s clear that a gay teacher telling children it’s OK to be gay (some of whom know or will conclude they are gay themselves) should be defended.

There are a couple of things to conclude from this. Firstly, LGBT rights trump rights to religious expression. Being religious is a choice, no different to holding political beliefs. Being LGBT is not something you can change though even if it were is not something you should have to.

Secondly, I strongly suspect that were this a predominantly white Christian group à la the Westboro Baptists, progressive protestors would have been out in force, defending Mr Moffat. Muslims don’t get free passes for being bigots. It does sometimes feel that progressives are concerned with protesting against brown groups for fear of looking racist, forgetting there are plenty of gays and atheists who are brown too.

One can argue British Muslims don’t have a responsibility for every terrorist act committed by a Muslim extremist. It’s harder to argue that they don’t have responsibility for the homophobia so pervasive amongst their communities; we should all be holding them to account.

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.