The biggest threat to ICU? – Intensivists.

We are the biggest threat to the ICU; doctors, intensivists, the people that do our job.

Intensive care is the greatest specialty in medicine. Sure, I am biased, but I am allowed to be and really you should be excited about that, you should be grateful. There are of trainees up and down the country who, like me, apply for intensive care because they have a passion, because they want to be great single specialty intensivists. What do we say to these people?

We say ‘and what else will you do?’.

We say ‘when are you going to think about your second specialty?’

Sometimes we say ‘but you’ll never have the skills of an anaesthetist’ and often we say ‘it’s prudent to have a second string to your bow’.

If you’re a trainee and you haven’t heard that last phrase from a supervisor or mentor, I am surprised. But what does it mean? To have a ‘second string to your bow’. It is of course a phrase originating from archery and makes reference to having a second string incase the first one breaks. It is a back-up; the second string was never meant to be used at the same time as the first. A single, strong, resistant thread is what makes a bow effective.

This is not an argument against dual training. It is an argument that dual training is not the answer to burnout and it is not the right answer for everyone. It is an argument that wonders why we nurture so readily the expectation that you won’t ‘just’ CCT in ITU? Yes, we have created stand-alone ICM training, but are we actually encouraging it to stand alone?

Intensive care already has the benefit of drawing its trainees from different streams of core training and special interests will of course always be of value at both an individual and departmental level. There are however a myriad of interests and skills which can be developed and maintained outside of formal dual accreditation.

People will talk about job plans, they say ‘you know the reality is…’ They’re not wrong, job plans matter and remain a stumbling blog for a number of acute specialties. The Royal College of Emergency Medicine report ‘Stretched to the Limit’ found that 62% of current job plans were felt unsustainable by emergency medicine consultants and when asked what would support more sustainable working within their specialty the number one suggestion was to actually change the job plans ⁽¹⁾. Job plans are a reality that we created and we are the ones who ultimately have the power to drive the change that is needed.

Instead, we take trainees who want to be full-time intensivists and immediately instill in them a worry that there might not be job security with a single specialty.  As one of those trainees, it feels like a ‘computer says no’ attitude and the future of intensive care is surely more important than that?

People will talk about the mental toll, they will say ‘you know the reality is…’ and again they’re not wrong. There is an emotional toll to be paid of course, but when we insist this is absolutely unique to our specialty, we flatter ourselves. There are huge challenges to be met, but we are the ones with the power to make intensive care the most well supported specialty in medicine. Other specialties already do it much better and saying ‘it’s just too much, you have to do something else’ is an indulgence, it is a cop-out and it is not an answer.

In 2002, a survey of all intensive care society members currently working in intensive care found that 29% of respondents had signs of psychiatric morbidity, but the level of mental health problems was not associated with age or long hours of work⁽²⁾. They did however highlight that many important stressors that were identified could be modified by improved team work and resources. As a trainee, I am repeatedly ‘warned’ that stand-alone training is not sustainable because the hours are too long and ‘nobody wants to be doing that when they get older’. I am repeatedly advised that stand-alone training will lead to burn out and that dual accreditation is the answer. The truth is, there are no large randomized controlled trails that have examined strategies to counteract the phenomenon of burnout in intensive care doctors.

So yes, the future of intensive care is under threat, but its stands with an army of trainees, some of whom want to be single specialists. What sort of leader, recognizing that, would tell its soldiers ‘no, just give me 50% of your commitment, passion and drive’ and how can we expect victory in battle when we are so ready to tell our soldiers to just accept that the end goal, the career, is de facto not sustainable?

Intensive care could, I think, be the greatest stand-alone career in medicine, but until we are willing to support and create that reality; we are the biggest threat to the future of the ICU.

Listen to an audio of this blog and subsequent roundtable discussion – via ICN Podcasts

1. Royal College of Emergency Medicine, ‘Stretched to the limit’ A Survey of Emergency Medicine Consultants in the UK, https://www.rcem.ac.uk/docs/Policy/CEM7461-Stretched-to-the-limit-October_2013.pdf (accessed 21.11.2016)

2. Coomber S Todd C Park G et al., Stress in UK Intensive Care Unit Doctors, British Journal of Anaesthesia, 89(6): 873-81 (2002)

We will not move backwards

My maternal grandmother was born in 1923. In 1945 she worked as a laundress in Dublin. This was back breaking work, the sort of toil that makes Friday night on the floor in A&E look like an easy ride. In the Summer of that year she stood with 1,500 laundry workers on a picket line with the Irish Women’s Worker’s Union to demand not one, but two weeks paid holiday from her employer as a basic entitlement. The strike was monumental for more than one reason. Other working class unions identified with the laundry women’s struggle and offered support where they could, the power of the ruling classes, government and even the church hierarchy however rallied around the wealthy business owners and as a result the strike was dragged out over some fourteen weeks. For working class women in the climate of post war Europe, this hardship was not to be sniffed at; but they persevered.

Secondly it was a strike by women, who stood firm in their worth at a time when they did not have the luxury of being able to expect equality and when they won, they won a right which was extended to all Industry workers in Ireland.

In 1948, my grandparents married and over the next 15 years between 1949 and 1964, my grandmother had twelve children. When the youngest of her children was about 9 years old she returned to work as a cleaner in a hospital and continued this work until she was seventy years old.

In 2012, the British Medical Journal (BMJ) quoted Professor Jane Dacre, then medical school director of University College London as saying

“when the 2007 female cohort [of specialty trainees] become consultants, female consultants will be 55% [of the workforce]. So feminisation is a fact. There is a tsunami of women coming through” .

Personally, I take a little issue with an increase in female consultants being compared to a natural disaster (!) but 9 years later it is interesting to note that according to NHS employers current data, the proportion of female doctors employed as consultants is actually still just 32%. The interest in a growing cohort of female doctors at this time sparked the BBC headline ‘women docs weakening medicine’….a headline which has been be periodically dragged out since, perhaps most notoriously in recent times by Dominic Lawson in The Times.

My grandmother was a tower of strength. She was a giant and I have told you her story because it is one of the reasons I am lucky enough to have grown up knowing the truth; that feminine is anything but weak. To me, the idea that the association of female workers with weakness has continued to drag at the heals of female doctors, even in the twenty first century, is unbelievable. More than unbelievable though, it is just wrong.

You will understand now why, when I tell you that the idea that being female would ever be seen as a negative attribute when I became a doctor was not what I expected at all. Thoughts like that were just not part of my world. When I was half way through my medical degree however I was assigned a placement in intensive care at a district general hospital. As is the norm, I very much looked up to the male consultant we were attached to, but when I told him it was my dream even back then to do intensive care medicine as a career, he told me it was not a career for females. When I left the hospital that evening, my world fell apart. Dramatic as it sounds, I was honestly devastated. It was like I had been hit with a wrecking ball; all this time I had no idea I was inherently inadequate and what was I supposed to do with my dreams now?

Thankfully this was just a temporary break in my self esteem. I soon remembered who I was and where I came from and I have never encountered a similar attitude from any of my intensive care mentors since. In fact my experience since has been very much the opposite and I have some consultants at University Hospital Coventry and Warwickshire to thank for that.

Yesterday The Department of Health Published it’s own equality impact assessment (EIA) on the junior doctor contract they have lined up for imposition and we were reminded that the facade of support for gender equality in the workplace is depressingly fragile. As a female I read the words with absolute disbelief and perhaps simultaneously the most comforting and frustrating thing is that every single male doctor I have spoken to has shared the same reaction.

“We consider that any indirect adverse effect on women is a proportionate means of achieving a legitimate aim”

“…could give rise to inequalities implications…..but if this were the case we consider that any impact would be justifiably legally as indirect impact resulting from a legitimate aim”

“…while this may disadvantage lone parents (who are disproportionally female)….in some cases this may actually benefit other women, for example where women have partners…”

I will not linger on the point that the ‘legitimacy’ of aims are only as trustworthy as those in charge and that so far, The Department of Health have not at any stage proved that their association of the new junior doctor contract with a so called ‘seven day NHS plan’ is remotely justified. Their aims are far from legitimate and if you take one piece of truth from this writing I would like it to be this, that junior doctors have never been a barrier to improvements in NHS services.

The language used by the department of health in their EIA is both frightening and deeply concerning. But this time, I have absolutely no intention of letting my world fall apart, temporarily or otherwise.

The question of course is where do we go now? This is not something I know the answer to, but I know this much; we will not go backwards. We will not accept a contract that attempts to once again kindle the discrimination of female doctors in the medical workforce.

So let me be clear Mr Hunt, I am a female doctor, I am an asset to our NHS and I will not be collateral damage in your plans.

Do you believe in magic?

I didn’t go to private school; most of the Latin I know is from Harry Potter. When I hear the word radiculopathy, I snigger because it reminds me of the defensive spell one must utter in the presence of a Boggart*
Doctors are taught to provide care based on evidence. We are people of science. But sometimes we are more than that. Sometimes the care a patient needs isn’t about the facts. Sometimes the most important thing we can give to a patient relies on the quality of humanity.
Humanity means kindness, compassion, consideration, tolerance and so much more then I could ever hope to define or fully understand. Nobody will tell you the world of a junior doctor is glamorous. Often it’s about long shifts, missed sleep, new guidelines, overdue assessments, discharge letters and paperwork. There have been days, when knee deep in revision notes and highlighter pens, the thought “F#*K this I should have gone to Hogwarts” came to mind. These are the days I need to feel the humanity in what I do.
I am of course first and foremost a person of science. But I am also grateful that sometimes medicine is about the indefinable. Sometimes it is about the magic.

* If you don’t know what a Boggart is, you haven’t lived.