I’m exhausted

Welcome back to Dr Paul McCoubrie’s a 'view from the dark side' — a series looking at the world of surgery through the lens of a radiologist.

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“I’m absolutely bloody exhausted”

These were the words of one of my 50+ yr old surgical colleagues as they slumped into a chair next to me one morning. I felt a pang of guilt: they were everything I was not. I was still perky from a double espresso enjoyed at home an hour earlier; they looked rumpled and weary. I was calm and semi-reclined in a four-point adjustable chair; they had metaphorical steam coming out of their ears. Their palpable exasperation clashed with the soft ambient noise in the reporting room; the faint white noise of the air-con and the soft distant burble of radiologists, like monks reciting the daily office.

It seems that radiology reporting rooms are a safe haven for ageing surgeons. They know that the radiology department will normally contain a known face, a sympathetic ear and an opportunity to escape the bedlam of the clinical arena for ten minutes. I’ve stopped short of offering a weighted blanket, mug of cocoa and singing softly whilst stroking their hair.

Radiologists generally welcome visits from surgeons more than other specialities. It’s partly because clinico-radiological case discussion alters management of acutely ill surgical patients in 30% of cases. It’s an evidence-based intervention. It is also why radiologists spend about a third of their working week in meetings or prepping for them. It is also why such meetings are proliferating, ironically growing and spreading like the cancers we spend so long discussing.

Many surgeons have favourite radiologists. And vice versa. But surgical visitors are all welcomed, irrespective of being known entities or strangers, young or old, charming or irascible, friendly or venomously hostile. We radiologists do this for an unstated reason: feedback. You need to understand that radiology is like playing golf in the dark. We launch our reports into the ether and rarely find out how they land. Occasionally there is the metaphorical sound of breaking glass but otherwise eerie silence. We get used to it, of course, but do greedily pounce on any snippets of clinical feedback, even if it doesn’t entail being showered with rose petals and memorialised in song.

Anyway, on this particular morning, my colleague explained that they’d been on-call the previous night and hadn’t been to bed. They’d been operating and reviewing patients on the wards most of the night then attempted to do a post-take round. I was alarmed to hear that they were utterly alone; not a resident doctor in sight. And certainly no nurse on the post-take round. Apparently, nurses accompanying a ward round is a quaint memory.

This is a common theme I hear from all my surgical pals - more and more work is being shovelled onto the plate of consultants. And it isn’t just at the coal face of on-call, with increasingly inexperienced registrars, absent younger residents and over-stretched nurses. It is in clinic with more paperwork and less secretarial support. A friend used to see fifteen new patients in a clinic but can now only manage ten due to a spiralling bureaucratic burden. And yet who gets blamed for clinic being inefficient? Yep, you guessed it.

Keeping on top of surgical patient-related admin seems increasingly impossible. Pooled secretaries mean no one knows what is going on; the secretaries turn over faster than the residents rotate. Consultants increasingly do their own admin as they cannot rely on their secretaries. Don’t even get me started on electronic voice-recognition - it turns most consultants into very expensive typists.

It is, perhaps, no wonder that am I’m starting to see burnout in surgeons; more than just physical exhaustion. Burnout is traditionally a result of work that lacks meaning, a workplace that lacks any compassion and a workload that one is not in control of. Surgery is historically the epitome of meaningful. Curing disease, alleviating symptoms and restoring function - it is doesn’t get more meaningful than that. But increasingly surgeons don’t operate, perhaps once a fortnight. Or mainly during extra lists at a weekend when theatres are free. And with modern surgical management resembling a sausage factory (e.g. pooled operating lists), it neither compassionate nor under consultant control.

I see disappointment in surgeons of my generation. It isn’t so much at the current state of clinical practice as I think most people understand the fallacy of “things were better in my day”. They weren’t better; they were always crap, just a different sort of crap. I think the disappointment is more that consultants of my generation feel like we were lied to. We worked like dogs for a pittance (remember ADHs and 72hr weekend shifts, anyone?) on the basis that, as consultants, we’d be well paid and not have to get out of our beds at night. Technically, UK consultants are also not supposed to work more than 48hrs a week too. Curious that I (and many other consultants) have worked over 50 hours a week since I graduated 29 years ago.

Perhaps it’s no wonder we are all cheesed off and can’t wait to retire. But the worse bit is that this has happened on our watch. The progressive souring of consultant life has happened in the last twenty years. Our leaders have let it happen. Well, some bits of it. Pay has largely been out of our hands but conditions haven’t been. We’ve let things unravel; we’ve allowed job creep, had our altruism exploited and lost control over our working lives.

I was cynically unsurprised when the last NHS consultant contract negotiations were based solely on pay. Nothing in it about conditions. We missed the biggest opportunity to stop the systematic exploitation of consultants. How about paid meal breaks like the rest of the civilised world? Sabbaticals? Meaningful study budgets? Limiting working hours? Particularly curtailing night working for older consultants.

It is probably too late to make systematic changes for my generation. We’ll be long out of the door. But unless working as an NHS consultant becomes more sustainable, there won’t be a recognisable consultant workforce in the future. The next generation won’t stand for it; they are quite rightly not into being exploited.

In the absence of a magical fairy godmother, we have to take charge of our working patterns. A big part of sustainable consultant life is looking after each other. It’s the little things; a kindly listening ear, a timely coffee and a chat about a tricky case. Go on; go seek out your favourite radiologist today. And if you are offering; black with no sugar, thanks.