Vindication

Isn’t it great when you are proven right… When something you say, or believe-in, that is potentially counter to the persuasive mood, is shown, through scientific method to be the case?

I appreciate that this does not happen very often, although, the older I get, the more I seem to find that predictions made when I was younger come true.

Innocence and experience was the topic of an earlier blog; this can be interpreted in many ways; what I want to focus on, is something I discovered a week or two ago when I was talking to a group of junior doctors (yes, the same guys who are desperately trying to save the NHS).

I was running a seminar on quality improvement – that is, as I have also previously described, the method of making things better day by day, for people and patients working in health and social care. We were discussing what these new doctors knew and had experienced in the eight months since they had left medical school – all of them were still in foundation year one.

A common theme, in fact, something that made me open my eyes, was a collective agreement that most of them, during their short time in professional life, had witnessed treatment with which they did not agree.

Given the hierarchical nature of medicine, and also the trade/craft/experience design of the training curriculum, junior doctors are just that, placed in a position that is junior to those of the ‘senior doctors’ – inferring less knowledge, less experience, less understanding; yet…

We are all humans. A doctor at 24, having just left medical school may have only half the life experience of a 50 year old consultant under their belt, but when we look at this from an evolutionary perspective, each of us, whether we are five, 15 or 105 are all created through a process of incremental design that has taken place over millennia – the human ability to perceive distress, pain or anxiety in each other is something that has been built into our psyche, our neurology, our sense of self over countless iterations.

I know when another person is in pain because I know they are. I don’t need to have read a textbook or received a PhD in ‘pain’; equally, I can interpret at the level of the individual, the expressed and silent emotions of family and friends, of the patient themselves.

So, 25 years of experience or 100,000 years of evolution – which would you support?

Recent evidence suggests that in certain areas, medicine being one, the more you do, the less you potentially know – the more you are likely to have been influenced by your own personal biases, habits or preconceptions. This is not an argument against doctors working very hard and memorising lists of drugs, diseases, muscles and nerves – it is an argument against the assumption that one person knows more than another because they have been doing the job longer.

I am not discussing here the technical skill of surgeons, who we have over the past couple of decades designed special systems to alert us when one of their number is killing people – since Bristol and the associated scandals, surgical performance, outcomes and mortality have been the subject of public and rigorous scrutiny.

Physicians however – those of us (like me) who don’t wield a scalpel, who instead interpret the subtleties of human behaviour, blood tests and x-rays are subject to far less scrutiny, and this, by the very precarious nature of health and disease, care and cure, is just the way it is. If I am an uncaring, careless doctor, it is likely I will receive feedback or approbation – if I am just not very good – if my ability to discern the subtle differences between a potentially abnormal x-ray and one that is normal, is lacking, it is likely, given our current system, that nothing will happen.

And so, back to the junior doctors –

When asked how many of them had seen senior doctors treating patients in ways that they felt inappropriate, perhaps, offering invasive or painful procedures to those who were clearly dying, many of them confirmed this experience.

I suspect some of those there had expressed their feelings at the time of the ward round, had perhaps questioning the rationale behind a certain consultant’s action, however, the majority, suspecting that they were only ‘junior’ – new in the game of doctor and patient, remained silent, suspecting, but doubting themselves.

Through the work of Anders Ericsson, it has been demonstrated than on many levels of performance doctors who have just completed medical school are more able than those who have been in the job for decades – sure, experience counts for something, and I am not suggesting you get rid of me and me ageing colleagues; what I am suggesting is however, that the reverential, hierarchical nature of medicine is got rid-of, that the consideration that what I say is the case, is the case, is old thinking and only by bringing together our collective intelligence – that of the young and the old, the nurse, healthcare assistant, patient, relative and student can we hope to approach anything that is close to the truth.

My message to you all is to be strong, be bold, be respectful – as the song suggests, ‘respect your elders’ – yet, respect does not mean remaining silent, it doesn’t mean thinking that you don’t know – it means, following your convictions, listening to your instinct, that niggly feeling in the pit of your stomach, and stepping forward, questioning, smiling, and placing the interests of our patients before any sense of hierarchy, power or experience.

Seek forgiveness, not permission.