|Change of pace|
|Monday, 11 March 2013|
The workload expectations placed on older consultants must change or else we risk endangering patient safety and the health of consultants themselves, so writes Dr William Harrop-Griffiths
First of all, some admissions: I am 54 years old; I have been on call for the NHS for 31 of those years; although I do not yet have any grey hairs, I daily expect some to appear; I have only one arthritic joint in my body (the distal interphalangeal joint of my left little finger as it happens); my laugh lines are no longer laugh lines; I enjoy my clinical work hugely; I want to stop doing on call.
However, I do not want to stop doing on call because I do not enjoy it or because I find it stressful. I thoroughly enjoy it and, although it is without doubt stressful, I find it to be the positive stress that comes from being faced with a challenging clinical situation for which you are appropriately equipped by training, experience and expertise.
My base hospital became a major trauma hospital a little over a year ago, so being on call is often ‘interesting’ – you do not know what is going to come through the door of A&E next. Given this excitement and positive stress, why would I want to give up my on call? There is more than one answer to this.
Being on call is a nuisance. But it has always been a nuisance. What has changed is my ability to recover from disturbed sleep and from a disturbed sleep pattern. This is far from abnormal for my age. Contrary to popular belief, sleep requirements do not decrease with age. Above the age of 45, the number of night-time awakenings increases (and not just for the usual middle-aged male reason), with a concomitant deterioration in sleep quality. With age, repaying sleep debt by increasing sleep time becomes more difficult – ask anyone who was able to do an ‘all-nighter’ in their twenties and you’ll find that, 30 years later, one bad night on call ruins their ability to concentrate for the next few days. Whatever the rules of the EU in their laudable attempts to wipe out age discrimination, you cannot legislate against the physiology of ageing. It is, therefore, reasonable to assert that the ageing consultant should be treated differently.
We ‘senior consultants’ may have experience, wisdom and sagacity, but we are more at risk – and thereby put our patients more at risk – if we are placed under the pressure of fatigue. This is certainly true for anaesthetists – there is a positive association between age and both frequency of litigation and severity of injury in patients who initiated the litigation.
A recent study from North America showed that this effect was noticed in the over-50 age group, and was more marked in the over-65 age group, with 50% more litigation in the over-65 group than matched colleagues aged less than 50 years
Is anaesthesia in any way different from surgery and other medical specialties in the stresses it places upon the ageing consultant? Anaesthetists are traditionally held to be less macho than surgeons, and more likely to complain that they feel unwell or tired, and these differences are arguably very much in their favour from the safety point of view. What they share with surgeons and with other primarily procedure-based specialties is the certain prospect that every so often something will go suddenly and disastrously wrong. Even the fittest and leanest patient can develop an unexpected and life-threatening complication such as anaphylaxis, and the patient’s survival can then depend upon timely and accurate treatment by the anaesthetist. Impairment by fatigue or any other factors can prove disastrous in such circumstances.
However, it can be argued that although the majority of surgeons now provide on call services only for their subspecialty, many anaesthetists continue to work in ‘general’ on call rotas that not infrequently offer them challenges well outside their normal clinical comfort zone. My consultant urologist colleagues are only very rarely dragged out of their beds at night and, when they are, it is exclusively for matters relating to the genito-urinary tract. In the last two weeks, I have had to provide care at night for patients undergoing thoracotomy for a stab wound to the chest, cervical spine stabilisation for acute quadriplegia, profuse bleeding after Caesarean section and laparotomy for faecal peritonitis. I am not complaining at my lot, but I am pointing out that anaesthetists are placed under at least as much pressure – and often more – than our colleagues.
What solutions can I offer to the inevitable drive to make us work later and later into the seventh decade of life and even beyond? First of all, we must be mindful of the changes that ageing brings and the difference in its effects on different people. Occupational health departments should become proactive in enquiring about consultants’ abilities to cope safely with the rigours of their clinical workload and in particular on call, rather than waiting until a consultant overcomes their in-built and traditional reluctance to admit to what is too often perceived to be weakness or lack of moral fibre in approaching occupational physicians and asking for allowances to be made in their workload because of age or chronic illness.
Departments of anaesthesia and surgery should develop policies that do not wait for consultants to ask for an opt-out of heavy clinical workloads; they should plan a default position that the intensity of out-of-hours work should scale down beyond 50 years old unless the individuals concerned specifically ask to continue. Weekend, daytime emergency lists are an ideal substitute for night time work for senior consultants who wish to continue their input into emergency care and to share the workload with their younger colleagues. Our salary scales and Clinical Excellence or Distinction Awards systems have arguably created an upside-down world in which the key roles in a department such as Clinical Director, College Tutor and Educational Supervisor are usually offered to younger consultants in order to boost their curricula vitae. Perhaps we should give these roles to those who are arguably best suited to them – the more experienced consultants. Whatever the complaints about the move from final-salary pension schemes to career-averaged systems, this change at least means that the consultant who is three years short of retirement does not have to continue to work flat-out to maintain their salary in order to maximise their pension.
We all agree with the assertion that we should put patient safety first. I think we can also agree that a reasonable response to the current and likely future financial pressures upon the NHS is to ask those of its employees who are fit and capable to work for longer. However, if we do not act quickly to change the expectations we have of older consultants, we will risk significant impairment to patient safety, significant adverse effects on the health of the consultants themselves, and we also risk an understandable early exodus of experienced doctors from clinical work that will result in the loss of valuable experience and judgement, which in turn may also impact on patient safety.
Dr William Harrop-Griffiths
Consultant Anaesthetist, Imperial College Healthcare NHS Trust, London and President, Association of Anaesthetists of Great Britain & Ireland