Primum Non Nocere

What a catastrophe that the “junior doctors” (sic) in England are going on all-out strike on Tuesday and Wednesday this week.  Even emergency cover is being withdrawn.

I’ve had experience of an all-out strike of doctors in training, twice, in New Zealand.  At the time, I was Clinical Head of the Department of Emergency Medicine in Middlemore Hospital, Auckland.  I can’t remember what the issue at stake was – pay, conditions, whatever.  What I remember was the experience of working in that environment, when there was a skeleton staff made up entirely of consultants.

It was intensely interesting.  The consultants’ modus operandi was entirely different from that of the doctors in training.  There was no sense that any of the doctors were trying to satisfy somebody else’s agenda, whether it be their boss, Management, or the General Medical Council.  Instead, the consultants met their acutely unwell patients at “the coal face” (an unusual experience for many of them) and practised medicine from first principles.  They thought pathophysiologically.  First they took a very careful History.  Actually, almost everything they subsequently did was predicated on the History.  The physical examination was focused on the relevant systems, and any investigations were parsimonious, designed to answer specific questions, and extremely focused.  It was fabulous.

That’s not to say the situation was ideal.  There had been a very high profile appeal to the public beforehand, not to attend the emergency department unless it was absolutely necessary. For better or for worse, this had an effect.  Therefore the consultants, whether they knew it or not, experienced a light work burden.  Even so, by the end of a long haul, most of them had had enough.  I remember trying to refer somebody to one of them towards the end of a shift; he said, “I can’t think straight.  Can you sort it out?”  I put the patient into our short stay ward and looked after him.

This upcoming strike in England really is a catastrophe.  It bespeaks a failure on all sides. What I think it really tells us is that the relationship in England between doctors and politicians is profoundly toxic.  Isn’t there a discernible pattern here?  Mrs May got off-side with the police; Mr Gove got off-side with the teachers; now Mr Hunt is off-side with the doctors.  The pattern is archetypically British.  In the antipodes in the 1980s, I recall the doctors went to the politicians and said, “This is what we need.”  In England this decade, the politicians went to the doctors and said, “This is what you will do.”

This impasse raises the whole issue of what the role of a Health Minister should be.  Do we need one at all?  What expertise does he bring to the table?  Of course it is clear that democratically elected MPs should be responsible for the hypothecation of taxes towards a specific human endeavour, and it is also clear that such elected officials should be empowered to deliver the substance of their election manifesto.  Obamacare would be an ideal example of this.  But at what point does party policy descend into micromanagement?  Should politicians really be fixing waiting times for patients who have a cancer diagnosis?  Or the target that 95% of all emergency department patients should be discharged within 4 hours?  Should they really be organising the rosters of doctors in training?

If I were Health Minister I like to think that I would outline a policy direction in broad brushstrokes, then hand the budget over to the doctors and nurses, tell them to get on with it, and put my trust in them.  I wouldn’t wish to browbeat them and I certainly wouldn’t wish to make them miserable.

Yet the medical profession has made itself vulnerable to this sort of treatment by lack of cohesion and lack of leadership.  If only the ancient Royal Colleges could bury all the historical hatchets, stop being so tribal, and come up with a real sense of unity of purpose, the medical profession could be one of the most influential bodies in England, and across the UK generally.  If they were truly proactive, and spoke with one voice, and said, like the Aussies back around 1989, “This is what we need to do”, the politicians, even in this authoritarian land, would have to listen.

As it is, you have the prospect of 48 dangerous hours commencing tomorrow morning.  I’m writing this at 8 am on Monday morning.  You would think that the Health Minister and the Chairman of the BMA could shut themselves in a room, bang their own heads together, and come up with some sort of compromise, no matter how ramshackle and interim, that would avert a strike.  Instead, we see this perilous display of brinkmanship.  Both of them are waiting for the other guy to blink first.

Something will happen.  It doesn’t even have to be as a result of the strike; bad things happen anyway, and it will not be difficult to point to a cause-effect relationship between lack of staff and an adverse outcome.  At that point, doctors in training will begin to lose popular support.

This is really bad medicine.  It breaks the first law of medical practice: first, do no harm.

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