Doctor discontent and EBM- challenges to acute medicine
Over the Christmas period in hospitals up and down the country (and probably throughout the world) there is a feeling of bonhomie among patients and staff alike. The wards are brimming with mince pies and more food than necessary. It is often quieter than other times of year, because people tend to be busy enjoying themselves with their families and friends. I have worked that type of Christmas on-call shift in the past. This year has been very different. I have been working on-call shifts as a medical registrar just after Christmas until New Year, and other than lots of mince pies, it has been crazily hectic.
Having recently come out of a stint in research to the busy on-call life of the hospital doctor, I have had plenty of time to reflect on how evidence informs practice and on the differences between research and clinical life. My first thought is that it is still hard for clinicians in 2011 to take time to access best evidence on the job while they are working if the flow of patients is too high, or the beds are full or the waiting time targets have to be met. Since Sackett’s seminal paper in 1996 on “what EBM and what it is not”, there have been many analyses and initiatives to improve the uptake of EBM in daily clinical practice. Guyatt wrote in 2004, “Estimates based on current rates of publication of randomised trials and completion of systematic reviews indicate that it would take reviewers until 2015 to produce the 10 000 Cochrane reviews required to summarise existing evidence”. The situation is even more daunting now. There have been great improvements, but many challenges face the integration of EBM into acute clinical medicine, including the increasing chronic disease burden of our populations.
There are plenty of other places you can read about the usual complaints of too few staff, not enough beds, too much management and not enough clinical practice. These are all valid points but I think another underlying problem is that when pressures occur within health systems (and these can occur at Christmas or at any time of year), doctors and nurses do not seem to be happy in their jobs. I must have been told by everybody from the porter to the receptionist, the ward sister to the consultant that the shift was “horrendous” or “it has never been like this” at some point in the last few days. Objectively, the number of patients coming into the hospital was much higher than other times of the year and there have been extra workloads such as the peak of winter flu. But we doctors and nurses went into their professions to look after sick people and make them well so we should be happy with this situation, shouldn’t we? We chose these careers, didn’t we?
Actually there is a rich literature about “doctor discontent”. Health professionals definitely want to look after patients and in many ways, when the workload is high, the rewards of our professions are higher because (we feel that) collectively, we are going “more good”. That is our raison d’être or at least our reason to come to work. I think doctors and nurses and allied health professionals are often exasperated when they have to work in conditions where they are not in control. In these situations, they often have to make decisions based on guidelines or orders from higher authorities with inadequate resources. Nobel Prize-winning economist, Amartya Sen, has argued for many years that human welfare and happiness are linked not just to alleviation of poverty, but are more linked to capabilities and freedoms. There is an analogy in the health professions where people also need autonomy and to work within a framework where they can fulfil their capabilities, albeit with safeguards to protect patients and professional standards. Unhappy health professionals do not serve their patients well and they may even end up resenting their career choice. Much more attention needs to be paid to this important aspect of health system planning.