You are just starting on duty as the junior doctor of a busy medical department. It’s 8pm. The outgoing doctor – who has been on duty for 13 hours – is going on a date tonight and is keen to leave. You have 10 minutes to hand over thirty patients.
Both of you stand in the doctors’ office, crowded with papers, computers and other staff coming and going. You go through the list:
1) Mrs Mabel’s GCS is fluctuating. She needs an urgent review. Looks like she’s going to die. You’ll need to talk to the daughter.
2) Mr Dobbs needs a catheter because he has only passed 10mls of urine in the last 2 hours. We’re waiting for his bloods. He may be in renal failure – or it could be outflow obstruction. If you can’t place it, you’ll need to ask the urologists to assess for a suprapubic.
3) Mr Kahn’s bloods need to be re-taken because they haemolysed. The nurses tried, but they are short tonight. You’ll have to do it yourself. If his white-cell count is has risen, you’ll need to do a septic screen (X-ray, urinalysis etc) and start him on a broad spectrum cephalosporin. Don’t forget that he’s allergic to penicillin.
The list goes on. You scribble down the necessary jobs, concerns, and worries. 15 minutes later, your colleagues is out the door. Each of your patients has had 30 seconds or less of your joint handover time.
You take the bleep – 5 unanswered calls – put your newly annotated list in your back pocket and head out to Mrs Mabel’s ward.
As you arrive at the nursing station, the ward leader approaches you looking anxious. “Thanks for coming! Can you review Mr Jones. We think he may have inhaled a bit of his chicken dinner. …”. Your beep goes off again.
As so it starts … and so it goes on … for another gruelling 14 hours.
Thankfully, Mrs Mabel doesn’t die. But sadly, Mr Ashley does. He was number 26 on your list. You were supposed to review him, but you just didn’t have time …
This – you may be surprised to hear – is the scene all over the world.
Busy junior doctors use bits of paper, snatched conversations, bleeps … any means necessary to keep the ship afloat, stop people dying and hopefully discharge them home.
If you don’t believe me, let me suggest you do this test: go to your nearest hospital, look for a junior doctor, stethoscope around their neck, marching purposefully between wards. If you’re in doubt, find one with a hunted look in their eyes. Stop them – apologise for holding them up – and ask if they are carrying a patient list in their back pocket. Chances are they will say yes.
Why is this?
In the age of Google, Facebook, WhatsApp and WeChat why does one of our highest-risk industries rely on such means? The answer is remarkably simple. There are roughly 10 key questions that doctors need to answer when they are on duty:
- Who is trying to die and therefore needs my immediate attention?
- Who do I need to see in the Emergency Room / A&E?
- Who else needs a physical review and examination?
- Who needs bloods/catheter/canula/art-line/central-line?
- Whose results needs reviewing?
- Who needs a new or different prescription?
- Whose relatives are asking to see me?
- Who needs a discharge summary?
- Who needs a consent form before theatre?
- When can I eat? (Note: as the shift progresses, this question rises higher and higher up the list. It is often never answered)
They also need to know:
- who’s on my team
- what’s their phone number/bleep and … crucially
- which of these questions are they already answering.
Unfortunately – and here’s the rub – none of our million-dollar Electronic Patient Record (EPR) or Patient Administration Systems (PAS) are focused on answering any of these questions in any systematic fashion. They are concerned with process, with recording what went past, with accounting.
Which is why – illegally, but with the tacit approval of their seniors – many doctors use WhatsApp and other messaging apps to keep track of critical patient information.
This is heinous. The more so, if you’re a patient or a relative. It is clear we need to find ways to improve this. (In the spirit of full disclosure, I should say that I have worked with a UK team to create a product – Careful Online – that helps answer all these questions, and more).
It’s reassuring that the health secretary Matt Hancock has promoted more digitisation – but if we’re not careful we will repeat the mistakes of centralisation, top-down control and poor design that dogged Connecting for Health for so many years.
But for the sake of our patients, all over the world, and especially the likes of poor Mr Ashley, there is a pressing need to understand and satisfy the real information needs of doctors on duty.