Acceptable in the Eighties

35 years ago today, I began my career as a doctor in the NHS. 1 year ago today, my oldest son began his medical career. I couldn’t be more proud of him. I also wonder what the future might look like for his career. Reflecting on my first day, the themes of my career were already there if I’d been able to see them; perhaps the same is true for him.

First morning

My first day began as a medical Junior House Officer with a morning ward round on the Coronary Care Unit (ward 8), in a small District General Hospital in Scotland. The second patient of the day had tetanus – a condition I have fortunately never encountered again in my career. They were being care for in CCU, because there wasn’t really an Intensive Care Unit for patients with non-surgical conditions. Fortunately, as a student in the USA on an elective, I had spent a lot of time in Intensive Care and had learned about ventilators to the extent that the medical consultant of the week was happy for me to be the main trouble-shooter and point of liaison with the anaesthetic department who provided the expert input for all matters IPPV. I was delighted with this responsibility. I was fresh out of medical school, full of knowledge of tests, interventions, drugs, fluid balance and patho-physiology – this really did feel like being a doctor. The consultant, DHJ was a new, young, charismatic consultant who was kind and considerate to me and other junior staff. He was refreshingly different to the stuffy and aloof consultants I’d encountered in Edinburgh teaching hospitals, even if there was also something of the trendy vicar about him. He would have been said to exhibit compassionate leadership, had such lingo been invented at that point, but that was a branding exercise still in the distant future. He used big words, but I understood them so felt clever. He demonstrated his considerable knowledge of medicine at every opportunity, and I was impressed. So here I was, feeling like the D’s Bs because I was responsible for the sickest patients in the medical unit and getting the chance to put my degree into practice.

First Afternoon

In the afternoon, most of the jobs having been sorted on CCU, I then attended one of the geriatric wards (ward 18). The afternoons would be devoted to Ward 18, with frequent interruptions to events on ward 8. As this was the West of Scotland in the eighties, there was no shortage of patients with myocardial infarction. The ward round here was a much less traditional affair. Its main feature was a ‘trolley round’ (no whiteboards in those days), where I was to present a synopsis of each patient in turn, while the consultant KDW and his staff grade would make management decisions and plans. There would then be a short walk around the ward.

KDW’s avuncular style should have put me at my ease, but I never really got to that place. He wanted to know about patients’ lives – their home circumstances, their families, their background, what they wanted or expected. He wasn’t nearly so interested in their lab results, radiology reports or ordering more tests and prescribing drugs. I was much more focussed on the investigate-diagnose-treat paradigm medical school had inculcated. He was kind, understanding and tried to provide guidance, but it was a struggle for both of us. I never quite managed to please my master on Ward 18 in the same way as Reverend Blue Jeans on Ward 8.

The most performative part of the process was where he would ask for the drug chart of a new patient. He would work his way down the chart line by line, scoring out most of the medicines I’d careful transcribed from the GP letter. In his broad Lancastrian drawl, he’d explain to me how a few root-cause drugs had led to polypharmacy – diuretics started for hypertension or mild heart failure leading to salt supplements, non-steroidals leading to a combination of antacids and H2 antagonists and so on. I worried about how risky it was to stop all these treatments which were in line with what the textbooks said. Of course, he was worried about how risky it was to continue all those treatments, with their significant side effects and potential adverse interactions. It was only a gradual process over years that made me realise that he (and many of his contemporaries) was practicing sensible medicine – trying to establish a big picture appraisal of the patient’s circumstances, trying to understand their family and social context, and trying more that anything else to establish what was important to them as a person. ‘Communication – the secret of good medicine is communication’. I would repeat that maxim to colleagues years later, and they probably never understood why I said it in the best Blackburn accent I could manage.

To treat or not to treat

In that first job, I liked both KDW and DHJ, but definitely found myself more comfortable doing tests, interpreting results and starting lots of new treatments. DHJ cared about his patients too, and would ask about home and family circumstances, but he was much more likely to order investigations, start novel drug regimes and generally ‘intervene’. KDW was more circumspect, more conservative and would always ask ‘what if we just do nothing’ and ‘what are the risks of treatment X?’ – when I was introduced to ‘Choosing Wisely’ years later, it could have been written by KDW.

I was fortunate enough to work with both intermittently through the first 4 years of my career, as I did hospital jobs of my GP training scheme with them. A significant amount of tension was apparent in their relationship over time, as the latter seemed to become ever more interventionist in approach, almost seeming to force KDW to advocate for an expectant or palliative approach to a problem – both verging on dogmatic. Their discussions would be particularly passionate when it involved patients who were clearly in the last part of their lives: KDW would argue for discussing limitation of care, DHJ would argue for interventions and treatment almost at all costs. There are no right or wrong answers, of course, and all decisions must be informed by meaningful and honest discussions with patients and their families. But I did find myself beginning to ask if we shouldn’t at least inform patients and their families what ‘raging against the dying of the light’ entails in an acute hospital setting before helping them down that path.

That eternal dilemma for doctors became a central part of my later clinical career as a consultant in Paediatric Intensive Care. Should we continue? Should we stop? Are we preserving life, or are we prolonging death? Internally, I would often envisage myself as adopting either a KDW or DHJ approach.

In my early days of Intensive Care, my inner DHJ held sway. It’s a speciality with relatively quick easy access to investigations, supports a very algorithmic approach and has access to a huge array of treatments – established and last ditch.  As I grew older, and started to acquire experience, it was KDW that loomed largest. I realise in retrospect that he was an advocate of what I colloquially called ‘sensible medicine’, but which later became legitimised in policy documents as ‘realistic medicine’ or ‘prudent healthcare’. He focussed much more on the ‘what matters to me’ and ‘person-centred care’ at individual level and was prepared to own the risk of not investigating, not treating according to the algorithm. He recognised the risk and unmeasured harms of ‘too much medicine’ but was either wise enough or brave enough to do the right thing for the patient rather than the safe thing for himself.

I didn’t stay in touch with either DHJ or KDW, but often wondered how they’d fared in the rest of their careers.

Who'd have thunk it?

As I was completing the draft for the National Clinical Framework in Wales, I wanted to find a key reference for one of the important components – that addressing what is appropriate (and what is not appropriate) towards the end of life is every clinician’s business, whatever their speciality. Everyone dies, and to think we can defer thinking about issues arising at this end of the journey to specialist palliative care colleagues is impractical and misses the point. I found a nice paper to illustrate it – a 2014 follow up study of hospital inpatients showed that almost 30% were in their last year of life. An important question from this publication was to ask if this is what we really want for our patients. Do people really want to spend their last months as inpatients in acute hospitals? It forces us to ask ourselves as clinicians whether we should be trying harder to be a bit more KDW and a bit less DHJ when people may be heading towards the end of life. Some may wish to rage against the light’s dying, but with the right information and good communication man might choose to try and enjoy their last moments in it somewhere other than bouncing in and out of acute hospital beds.

The paper’s main author…DHJ. Respect.

Closing thoughts

There are so many dimensions of the problems arising from ‘too much medicine’. Atul Gawande, for one, has written better on this that I could ever dream of. Addressing this problem is fundamental. The more diagnostic tests and treatment options we have, the more important we work out how best to deploy them, and to ask hard questions about how much value they really provide. But it is not just those who sit at a micro or meso level in a health system that need to ask those questions – most importantly it is those making clinical decisions every day.

I have changed the initials of the consultants. Both are people for whom I have great respect, and neither will know how much they have influence their examples have influenced my career*