It may surprise you to know that most qualifying doctors in the UK never takes the ‘Hippocratic Oath’. Although it’s principles underlie much of the modern medical practice, it’s a little outdated. For example, we don’t ‘teach medicine to only the sons of doctors’ anymore and no others (e.g. no women).* Which is not to say ethics is ignored in the UK medical curriculum- in fact very much the opposite. I would say ethics and law formed perhaps as much as 15% of the undergraduate course at my medical school and at least 20% of the clinical side, not to mention underpinning every patient discussion and clinical decision besides.
The overriding principles of medical ethics are fourfold; 1) Autonomy 2) Beneficience (Do the best for your patient) 3) Non-maleficience (Do no harm) and 4) Justice (treat all patients fairly). I have been watching very closely events in Gaza over the past week, on social media as well as mainstream news, and given the above, am appalled at some of the attitudes my colleagues have.
First off, to date, over 150 civilians have died, with as much as a third of that number children. If you are asking “Children from where?” – then ask yourself “Are you a human being?” And then stop reading this blog because I have no time for you.
They are children. There is nothing in international law, the Geneva convention, the Bible or Torah or Qu’ran, or basic, human morality that justifies the murder of children in the name of ‘defence’. **
I have seen on social media colleagues who lambast ‘liberal’ critics of Israel saying they ‘do not know what it is like to live under existential threat’. Let me be very clear, there is nothing ‘liberal’ or ‘conservative’ about the views on the death of children by military attack. To use those terms implies a nuanced political argument about the death toll; ‘liberals’ would like less children to die, ‘conservatives’ are more pragmatic and accept a higher toll. In the 21st century to sit and debate whether civilian casualties are deemed ‘acceptable’ is abhorrent and appalling.
Maybe I don’t understand the unilateral support for any state regardless of it’s actions. I grew up in Britain, a country renowned for it’s continuous dismay and critique of it’s own government, in a countryside town as the only brown face in a sea of white. The only sense of tribalism I have ever encountered is as a doctor- the ‘tribe’ of the MBBS has it’s own vernacular, it’s own set of values, it’s own unique perspective on humanity and it’s own rigorous ethical code. Which is why I cannot understand doctors who put out statements in support of any military action, but especially those that have had such high civilian death tolls. The value of life to a doctor is his or her entire meaning – if they didn’t want to preserve and defend life from illness and suffering they wouldn’t have signed up. But we have a duty to apply those same principles to every part of our life. We must not only ‘do no harm’ to the patient in front of us, but be champions of that humanitarianism across the board- on social media, to our friends, to our families, to our Governments.
Evil only persists in this world when good people do nothing. I cannot imagine a stereotype closer to ‘good people’ than a doctor. Colleagues, please, live up to it.
*(in fact the majority of junior doctors and medical students now are women).
** The international law surrounding self-defense against occupied territory is very complex and makes for an interesting read if you feel like reading something important. See below; http://www.cjpmo.org/DisplayDocument.aspx?DocumentID=71 and; http://opil.ouplaw.com/view/10.1093/law:epil/9780199231690/law-9780199231690-e401?rskey=xMiUjV&result=271&q=&prd=EPIL
Patients admitted on a Sunday were more likely to die over the next thirty days than a similar cohort of admissions on Wednesday- the ratio was 1.16 and the result significant, suggesting a true result of increased deaths by 16%
94% of these ‘admissions’ were emergencies
34% of deaths occurred within three days of admission
You are actually less likely to die if you are IN hospital on the weekend – the Sunday to Wednesday ratio here is 0.92, or 8% LESS likely. As the authors also conclude, this likely reflects the fact that high-risk, non-urgent procedures are performed during the week.
For elective (non-emergency) admissions, the ratio was 1.62 for Sunday to Wednesday, suggesting a 62% increased chance of death. This, as the authors conclude, is likely biased by the fact that high-risk elective patients are brought in early in general for exactly this reason, therefore this is unlikely to be significant.
Of 10 conditions specifically looked at, only 7 were found to show the same increased risk: sepsis, acute renal failure, cancer of the bronchus or lung, myocardial infarction, acute stroke, and congestive heart failure.
The authors also conclude: “7-day access to ALL ASPECTS of care” could improve such figures, but further ‘economic evaluation’ is required to ensure efficiency with ‘scant resources’ [para]
A further third of patients in this study died after discharge
So to summarise, you are 16% more likely to die, over the next thirty days, if you come into hospital on a Sunday- 30% will die within three days (Mon-Tues), and a further 30% will die after discharge. This only applies to emergency admissions, and a list of medical emergency conditions.
One major criticism, published by the authors themselves, is the fact that any conclusion completely ignores the reason for admission and the route of admission- there are no routine GP services on the weekend, and the impetus to admit on a weekend has to be higher than the week when most people would hold out for the GP unless they were very unwell. This immediately selects out a group of sicker patients than might routinely come in on a Wednesday.
Now we will play a game called ‘Jeremy Hunt spectacles’.
I look at this paper with ‘Jeremy Hunt Spectacles’ and read the abstract ‘admissions on a Sunday…16% more likely to die vs a wednesday’ and then completely stop reading and decide that a) 15% is a rounder, more soundbite-friendly number b) this must be the consultants fault c) I should go and tell them, loudly and with contract renegotiations for the entire consultant body. Or more realistically d) this would be excellent to further my agenda of privatising the NHS (despite that later in the paper the private US system shows the exact same pattern).
Now I take off the spectacles and look again.
The paper shows that patients admitted on Sunday, overwhelmingly emergencies, do worse during the entire course of their illness episode than those on Wednesday, but they deteriorate during the next three days (30%) over the weekdays, or even after discharge (34%) ie all on weekdays or even weeks of admission. Of the commonest conditions they are all medical emergencies.
Therefore, the suggestion is there is a decreased level of care on a Sunday admission, assuming that the patients are not genuinely sicker on average as suggested above, and that exarcebates or worsens an illness episode greater than a Wednesday admission. This extra initial insult, in 16% of patients, is not survivable. The ward patients however, appear generally unaffected weekend or weekday.
So what do the Wednesday patients get, that the Sunday patients don’t get? Consultants? In every hospital I have worked in that is simply not the case. Think about the admission process; in A&E there is always a consultant, on a 7-day 24-hour basis. Most have 3 or 4 at a time. For this set of patients they go to acute medicine where the standard is a daily consultant ward round, some twice or even thrice daily. So that is not going to help Mrs Sunday.*
What is not there? Only limited access to their GP, which in turn increases the workload in A&E, limited radiographer and lab techs, echocardiogram technicians, reduced pharmacy cover, and the hordes of office hours staff – secretaries for vital notes from other hospitals, semi-urgent referrals to other teams, the list goes on. In other words the missing £20 billion from the £100 billion budget that has already been cut away.
So, looking at the same problem, where emergency admissions are the chief cause of the 15% bump in mortality, what is the rational response? To increase funding and GP resources, to staff and fund A&E and acute medicine and other acute specialties and to support community services.
Has this been done? No.
Instead- GPs have been pushed on to duties they didn’t want in the form of the wholly rejected Health and Social Care Act, at a conservative estimated cost of £1.5 billion , and instead of funding and supporting emergency admissions A&Es have been closed and the specialty chronically under recruited, despite warnings. In other words, the areas designed to prevent this exact problem, identified in 2010, have been systematically underfunded and cut by the current Government for the last 5 years.
So, is an attack on consultant contracts, who are already working weekends and nights in vital areas, going to save 6100 lives? Clearly not. The system needs to extend through the multidisciplinary teams and out of the hospital and into GP land and social care- this needs to focus on emergency admissions. So while there is a neat political capital in claiming 7-day NHS services is good for patients- it’s an appeal to convenience, not safety, and no regard to resource. If you want all the staff and equipment and resources available 24 hours a day, you will need another two 8 hour shift equivalents- another 300,000 doctors, 800,000 nurses, 310,000 multi-discplinary team members. If you have a spare annual £200 billion, this would be a good time to speak up.
And in the meantime Lord Prior, the parliamentary under-secretary of state for NHS productivity, quietly announces an inquiry into private charges and insurance to fund the NHS. I.e to move the system from tax-funded to full charge-based private healthcare. 
So, Jeremy Hunt, is not stupid. He isn’t ignorant- he is inflammatory. He is not incompetent he is corrupt. There is an agenda here far wider than doctor-bashing.
While myself and my colleagues post #ImInWorkJeremy tweets in solidarity against changes to our contract, the political conversation is focused on us, while behind the scenes one of the greatest healthcare systems in the world is quietly dismantled by politicians and Lords with no democratic mandate to do so.
All doctors would like a 7-day NHS- we would like all the resources we have at the weekdays to do the best for our patients. Just come and witness the frustrated arguments with midnight radiographers and rushing to on call pharmacy at 11.55 am on a Saturday. But you learn to prioritise as well- that’s why you want to be the patient kept waiting, because the patient we are running to is usually the one in a hurry to die.
Perhaps Jeremy Hunt needs a lesson on prioritisation. Or perhaps he, Lord Prior and the rest of the Conservative government are not prioritising patients at all.
*In fact this is exactly the changes made at Northumbria hospital, mentioned in the same breath in the same speech by Mr Hunt as an example 7-day service, to increase acute medicine and A&E Services, NOT the entire hospital.
**. And for what’s it’s worth: this is day 6 of my 12 day shift. Lazy old me.
 J R Soc Med. 2012 Feb;105(2):74-84 doi: 10.1258/jrsm.2012.120009. Epub 2012 Feb 2. Weekend Hospitalization and additional risk of death: an analysis of inpatient data. Freemantle N, Richardson M, Wood J, Ray D, Khosla S, Shahian D, Roche WR, Stephens I, Keogh B, Pagano D.
“Doctors will have to demonstrate that they have “emotional resilience” before they are allowed to practice”, so writes Laura Donnelly in the Telegraph. The Comments, sparked by an exchange with Professor Terence Stephenson, chairman of the General Medical Council (GMC), seek to highlight the psychological demands placed on junior doctors today.
Emotional resilience is an important skill. There are lots of ways that undergraduate education can help students explore and anticipate difficulties they will encounter in their training. This aspect of training should of course be taken seriously by medical curricula but lets not pretend that resilience is an all or nothing attribute. It is fundamentally fluid. It is not like passing your anatomy exam and suggesting that it will be systematically tested at undergraduate level is frankly absurd. Will there be a resilience OSCE?!! – the mind boggles. Preparation for emotional difficulty is of course an important part of a rounded education but any reasonable approach would add more weight to helping junior doctors feel like there will be a system there to catch them when they fall.
I have a couple of issues though with arguments that tend to band around the word resilience like it is going to solve the problems doctors face in todays society. First of all, medicine has always been difficult. There has always been sadness and trauma. There have always been uncomfortable sights, uncomfortable exchanges and uncomfortable dreams at night. So what has changed? Why is there a sudden concern that doctors have become psychologically inept? After all, burnout is a very real concern. Things we encounter in medicine however are no more sad then they were one-hundred years ago. I would argue that what has changed is everything else.
As I have said before, I strongly believe that the training of junior doctors today breads insecurity. We are constantly forced to move around the country. Each time we are forced to gather proof of our professional attributes from a growing multi-disciplinary team; ward-clerks to health care attendants to physician assistants and consultants; a constant treadmill of snapshot assessments. Sometimes it feels like you may as well be standing in the middle of the room screaming ‘validate me, validate me!’. At the end of each year we have an annual review of competency and progression (ARCP). This process again has been reduced to a kafka-esque farce of box ticking and pseudo-assessment. A colleague of mine has genuinely been held back in training because a supervisor neglected to fill out an end of block report and then retired.
Next we could talk about the actual shape of training pathways in the UK. Young doctors are being forced to make life changing decisions about where their talents lie earlier and earlier in their career. There is no provision for allowing time within the system to time to explore your personal attributes and decide what career path you are best suited to. The treadmill keeps going and will not wait…as the queen of hearts said to Alice ‘My dear, here we must run as fast as we can, just to stay in place. And if you wish to go anywhere you must run twice as fast as that’. Lets not forget that should the DDRB have their way, the ability to change career paths will become such a difficult decision that even more weight will be added to those very early career choices.
Lets talk about down time. Many junior doctors still actually face fixed annual leave. The short rotations and on-call commitments mean organising significant amounts of leave is a administrative nightmare. Junior doctors find themselves begging medical staffing department for rotas just so they can find out if they can attend their best friends wedding, in fact I also know someone who had a great deal of difficulty trying to find out if they needed to worry about being be on call for their own wedding! My current placement means I can’t take any leave for the first three months. I then have 13 days to use up in the remaining 3 months, but I can’t organise these yet because I don’t have my on-call rota for that time. Oh and yes I’ve been warned that if I fail to take my leave, I will not be paid in lieu.
What about job placements? Once you’ve secured your national training number you’re forced to wait it out to find out which part of an often very large deanery you are allocated to. Will you have to move house? Will your children be able to attend their school? Will you be able to live with your partner this year? In a system that claims not to be able to take the vast majority of personal preferences into account, we have young registrars passing four district hospitals just to get to the one they’ve been sent to with absolutely no evidence that there was a logical reason for that choice, either in terms of service provision or training needs. I am one month into a five year training program with a new mortgage and I cannot plan my life past the next three months.
What of the media? Type junior doctor and any tabloid into a search engine and see what news you find. Here’s an example of the first four hits from the Daily Mail:
Now lets add into this picture the fact that the government with their ‘accept or prepare to be forced mentality’ has recently put us all in mortal fear of their grossly unfair contract proposals.
There are a great many of things responsible for burn-out in junior doctors today, but lets stop banding around the term ‘resilience training’ like it’s the answer. It isn’t. If the powers that be really want to improve the quality of life for thousands of juniors doctors in the country they would do well to focus on everything else.
This is not a letter about the ‘7 day service’ shaped political football which seems to be is perpetually in play. This is not a letter about the consultant opt-out clause. It is not a letter about the difference between elective and urgent care. This is a letter about the unjust and unsafe contract which the junior doctors of this country have been threatened with. I am by no means unique or particularly special among my profession, but as I stand aghast at the proposals being thrust upon us, I can only presume that you do not truly understand what they will mean for my colleagues and I. As Atticus Finch told us “You never really understand a person until you consider things from his point of view…until you climb into his skin and walk around in it.” This is a philosophy we often use in medicine, it helps us deliver patient centred care. I thought perhaps a personal story would help you understand why we have come out in force against the proposed junior doctor contract.
I am junior doctor in the West Midlands. I left medical school in 2011 and went straight into training, I worked hard to secure my higher training number and I am now an intensive care trainee at ST3 level. I am a junior doctor that works a minimum of forty eight hours a week. This of course does not include the hours outside of this spent developing my knowledge and skills. I hold myself to high standards. I participate in research and audit. I take exams. I care about patient safety and I try my best to be an agent for change wherever I work. As a junior doctor on an training programme, I work side by side with locum staff who do my work for four times more pay than me.
I am an junior doctor who takes time to hold her patient’s hands. I listen to patient narratives. I reflect on and learn from my mistakes. I support my junior colleagues. I engage in teaching the new generation.
I am an asset to your NHS.
I am a junior doctor who has not been able to plan my life further ahead than four months since I graduated in 2011. I cannot plan to go on holiday next summer or RSVP for my friends wedding in the Spring. I am a junior doctor who has not been on a summer holiday in the past five years. I am a junior doctor who does not yet even know if she will be spending this Christmas with her family or in work.
I am a junior doctor who cannot afford to stand down while your party impose a new contract.
Do you know that you are giving me a pay cut? The new contract will cut my pay by somewhere between 12 and 15%. I cannot understand how any government can look the doctors of this country in the eye and say we deserve this sort of pay cut. I feel this reality has been glossed over and dressed up as something else. Perhaps it is too uncomfortable or impossible for you to defend and so you have chosen to pretend it is not the case. Unless the bank are willing to take the equivalent sum off my student debt and mortgage repayments, I do not have the luxury of pretending anything.
Do you know that we have huge concerns that the new contract deliberately discriminates against women in medicine? That the contract will make it even more difficult for not only women, but those unable to do full time training for any reason to work within the NHS? Have you considered the effects of inhibiting this diversity in medicine? Do you understand that to place the massive burden of financial penalty on any doctor who realises that their skill is best suited to another speciality is not in the best interests of the NHS?
Do you know that the new contract would mean it would be perfectly reasonable for me to do a 12 hour shift with just two twenty minute breaks and if I start a shift at 8am I would not be entitled to any break until after 2pm that day?
Do you know what it is like to work in an understaffed district general hospital? My most recent medical placement had 4 filled slots on a medical registrar rota for 12. Do you think this new contract will attract more doctors into these jobs?
Do you think you could consider what it is like to have the weight of person’s life in your hands? Not in an abstract sense, not from the point of view of having to make decisions that affect a body of people’s lives as I understand you do. I want you to consider what it is like to stand beside a patient and their relatives and tell them that you will do your very best to look after them in hospital. Or tell them that your team has done all they can and you think they won’t survive. To hold their hand while they die or take on the responsibility of letting their family know that they have an incurable disease. To know that if you are too tired or too distracted by personal things you can make a judgement call that brings about a death. Can you picture it? What do you think your emotions might be? I can tell you that contrary to some opinions, I, like most junior doctors happen to be quite good at these things. We have gotten to where we are by displaying both strength and resilience. I am not however a machine and I do require to be well rested, supported, adequately recompensed and valued in my work place. As a doctor, I somehow feel ashamed that I have to say that, yet regrettably this is where I have been pushed.
During the London Olympics we watched the NHS held up as an ideal for the whole world to see; shiny happy doctors, dancing and singing with their colleagues. I am imploring you that if this government impose this unfair contract you will break us. Please understand that broken doctors do not dance, they do not sing and they certainly do not deliver a first class service.
…men who measured below average on agreeableness earned about 18% more—or $9,772 more annually in their sample—than nicer guys. Ruder women, meanwhile, earned about 5% or $1,828 more than their agreeable counterparts… “Nice guys are getting the shaft,” says study co-author Beth A. Livingston, an assistant professor of human resource studies at Cornell University’s School of Industrial and Labor Relations.
Several of the 12 “dark side” traits – such as those associated with narcissism, being overly dramatic, being critical of others and being extremely focused on complying with rules – actually had a positive effect on a number of facets of the cadets’ leadership development over time… “it appears that even negative characteristics can be adaptive in particular settings or job roles.”
But in some professions, like the military, you have to be tough… right?
Shawn Achor, author of the excellent book The Happiness Advantage, points out that top leaders in the Navy are supportive:
In the U.S. Navy, researchers found, annual prizes for efficiency and preparedness are far more frequently awarded to squadrons whose commanding officers are openly encouraging. On the other hand, the squadrons receiving the lowest marks in performance are generally led by commanders with a negative, controlling, and aloof demeanor.
…agreeableness, one of the Big Five personality dimensions, is linked with higher-quality friendships, successful parenting, better academic and career performance, and health… Based on the review of the literature, it is postulated that being agreeable may be the path to enduring interpersonal relationships, happiness, success, and well-being.
So is it just that simple? Be nice all the time? Sadly, no.
What I find across various industries, and various studies is theGivers are most likely to end up at the bottom. That’s primarily because they end up putting other people first in ways that either burn them out, or will allow them to get taken advantage of and exploited by Takers.
While we have a great deal to learn from total altruists, it’s a dangerous path. In some cases, yes, “Nice guys do finish last.”
(For Adam Grant’s tips on how you can be nice while protecting yourself from being taken advantage of, click here.)
Research shows not being aggressive limits goal achievement but being very aggressive hurts relationships. So what should we do?
3) It’s A Balance
We don’t merely respect people because of power… or just because of kindness.
Social psychologist Cuddy, an assistant professor of business administration, investigates how people perceive and categorize others. Warmth and competence, she finds, are the two critical variables. They account for about 80 percent of our overall evaluations of people…
But the tricky part is we always assume a trade-off between the two: more competent means less warm, more warm means less competent.
This idea of balance is pervasive. What happens when you see that uber-perfect person screw up a bit?
“If you’re too soft—no matter how competent and able you are—people may not respect your authority. But if you only have dominance and you don’t have great ideas, and you use force to stay in power, then people will resent you,” he concludes. “Being successful as a leader requires one to have both dominance and prestige.”
Harvard leadership professor Gautam Mukunda explains great leaders have supreme confidence — and humility. (Skip to 4:15.)
Of course, riding that line is extremely difficult. And there are biases that make it even harder.
Across a wide range of studies, Ambady and Rosenthal found that observations lasting up to five minutes had an average correlation of r = .39 with subsequent behavior, which corresponds to 70 percent accuracy at predicting outcomes…
Maybe you enjoy gambling but I don’t like those odds — especially over the long haul.
Unless you have an Oscar for acting, faking for big stretches of time is hard. In fact, research shows acting smart makes you look stupid.
The only way to convincingly change how you’re perceived is to do it from the inside. (We often call this “being delusional.”)
And what’s even more insidious is that over time, we can become what we imitate.
You’re performing. If you perform for long enough you can begin to inhabit the role. You can begin to change who you are… When you’re acting out these roles, what you’ve got to remember is you are changing yourself. Over time you will change yourself into that person, so it had better be the person you genuinely want to be.
(For more on the techniques of FBI hostage negotiators, click here.)
Being a powerful jerk is a risky tradeoff — but so is being a total nice guy. And balancing is really, really hard.
So when we pull all this together what really is the best way to get respect?
5) How To Get Respect
You don’t need to strut around like a jerk but we can learn something from powerful people: confidence is vital.
Changing yourself is not inauthentic. Part of what people do is they change. They evolve, they can grow, and they can change themselves.
So what it is to be authentic? It doesn’t mean you can’t change, but it does mean that the changes that you make, again, have to be aligned with the sense of who you really are, and who you want to be.
If you’ve been promoted recently, you’re probably determined to do things differently than other managers. You want to remember your roots as a worker bee forced to please the boss. You don’t want to micromanage or discourage people. So you may avoid giving constructive feedback until you have a few months under your belt as a manager.
Here’s what you need to do instead:
1. Assure people you’ll be giving frequent feedback
People want more feedback than they’re getting. Everyone, especially young and hard-to-retain superstars, constantly say in employee engagement surveys such as Gallup that they’re discouraged because they’re not getting enough feedback.
And it’s not just that they aren’t getting enough positive pats on the back. Sixty percent say they don’t get enough critical feedback that can help them improve. (Click here to tweet this stat.) Tell them you’ll be giving feedback weekly (or more often) and deliver on that promise.
2. Invite their feedback to you in every feedback conversation
The feedback culture you want to create is an exchange. You coach them and they make suggestions about what you can do to help them reach their goals faster.
3. Envision success for everyone to focus your feedback
Spend a few hours imagining the team as wildly successful. Record on paper your images of what each individual and the group as a whole will be doing and saying in the future — six to nine months ahead on your calendar.
Imagine recognition by customers and celebration by company leaders. What capabilities will each person need to develop to achieve the vision? Use these notes when picking out the most important and doable feedback topics for each person.
4. Invest plenty of time to clarify and re-clarify goals
You’ll increase their buy-in for feedback if you’re all on the same page about expected outcomes. And you’ll decrease the chances they’ll be confused or discouraged later. The bosses people hate are the ones who can’t explain what they want, but are quick to criticize. You’re a boss who explains what you want — not what you don’t.
5. Give lots of positive feedback, but make sure it’s specific and accurate
You want to encourage people, but you don’t want to come across as a parent figure who praises everything. It won’t be good for either you or them if they become dependent on you for their self-worth fixes.
On the other hand, positive feedback that resonates with what they know to be a strength or a hard-earned accomplishment builds credibility with your employees. If they feel that you “get them,” they’re more likely to believe you when you point out improvement needs.
6. Make feedback so helpful and frequent that it becomes a no-big-deal experience
Although your first feedback discussions with people may need to be scheduled half-hour meetings, they’ll get used to unthreatening hallway chats where you suggest a new approach they can use with a customer, how to expedite a meeting or fast ways they can acquire technical knowledge.
They will start to trust you. The trust gets big when they know they can count on you to bring up problems and never surprise them later with feedback you’ve withheld.
7. Act on the feedback they give you
As you ask each team member how you can better help them achieve their goals, how you can support them and how you can help make it a better workplace, acknowledge the value of their suggestions. And act on all feedback that makes sense as quickly as possible to demonstrate you believe in the power of feedback.
In giving more, rather than less, honest, timely feedback, you and the whole team will discover that feedback is a big plus and you as a leader will enjoy huge success.
Anna Carroll, MSSW, through EverydayFeedback.com, specializes in workplace trends and training. In her recent book, The Feedback Imperative: How to Give Everyday Feedback to Speed Up Your Team’s Success, she helps leaders at all levels overcome their obstacles to giving feedback.