People seem to be interested in medicine for different reasons. There does seem to be a spectrum in ophthalmology in which people range from ‘do it for the pay’ all the way to ‘do it for the patients’, with some variation allowed as to where people may fall on that bell curve at any given moment.

There are dangers of course with both extremes. Extremists are always very dangerous people. Even in ophthalmology. Bashar al-Assad of Syria was an ophthalmologist who once worked at the hospital in which I work now. In fact, The Mirror newspaper once attempted to get a quote from some of the staff here as to how he was as a person but either they were too junior to remember him or they were too frightened to supply a quote so no Swansea statement was forthcoming in the end.

What prompted me to think about this was primarily a member of the team taking a lot of leave, all of which they were perfectly entitled to, in such a way that caused the most bang for their buck. There are experts I have heard of that know how to use half days and sick days for absolute maximum advantage, to the extent that they rarely have to do any unpalatable work at all. Sometimes ophthalmologists are very content to take long periods of sick leave and don’t seem to care at all what disasters are unfolding with their patients. Which I guess prompts the question: whose responsibility exactly are the patients? On that same spectrum there are those who shrug and say ‘management’ as if that somehow releases them from any responsibility, while others take all the weight of the world on their shoulders and are utterly crushed by perceived patient expectation.

When a staff member calls in sick, some will be perfectly content to cancel patients at short notice without a moment’s hesitation, those toward the middle of the spectrum will try and triage those who are cancelled and those at the other extreme will cancel nobody and try and see everyone as everyone needs to be seen. Those valiant souls suffer through stress and work but paradoxically in the end get punished for it by the patient as well, as these gargantuan efforts at superhumanity are more often as not viewed through the spectrum of long running delayed clinics and harried stressed staff with no time to converse, rather than any real appreciation of the added burden taken on by others at no extra pay for their own good.

If we are mere employees, then who stands up for the patient and ensures they get seen? Management can be a mixed bag but trying to get hold of anyone after 4pm is pretty impossible in most places, so I hardly think they are in any position to bear responsibility for the patient one way or another. Simply saying “it’s management’s fault” is akin to saying “I am actively deciding to do nothing to help with this particular problem”. It is a cop-out and there is a reasonable argument to be had that everyone who trundles out that phrase when they were asked to suggest actual solutions to a problem deserves to be beaten with a pipe. If a trainee, or indeed anyone, books strategic leave so as to do as little work as possible, whose fault is that exactly? The trainee? The approver of the leave? Management? The patient? Nikita Khrushchev? Everybody? Nobody?

“Perhaps there is a role for being frank with patients about our own powerlessness.“

It boils down to whose responsibility the patient actually is. On the face of it, the hospital, but in reality it is mostly the consultant in charge who is expected to do what is in their power to provide a reasonable service. It is their name on the door, their name on the letter and it is them that the patient sees as being the public face of the otherwise faceless hospital. But taking too much responsibility on board can lead to great stress. I remember a medical school lecture on mental health disorders in which it was claimed that those at the bottom of an organisation had no stress as they had no responsibility and no power. Those at the top had little stress as they had both responsibility and also power. It was those middle managers that felt the stress the most as they had nominal responsibility but little power to help things. It was they that jumped through windows and sometimes had nervous breakdowns.

I certainly felt as if I was having a nervous breakdown trying to square the circle of fitting what felt like 600 patients into three and a half free patient slots. Otherwise it was overbooking, delay and damaged sight. I spent time trying to convince a friendly staff grade to give up his study session to help in clinic to get through the patients. I attempted to set up extra clinics to cope, though the particular circumstances did not warrant an extra payment it seemed so they would have to be done for free. During all this, blocks of patients already booked would be suddenly cancelled to release doctors for eye casualty or to train nurses to inject and the mass of despair would deepen such that it threatened to be a black hole that would suck me in and never release me.

This is not a stress one feels as a trainee. Some consultants never feel it either. Some feel it too much and it makes them ill. What is the answer to long-term coping? How can a person do what they can and not go utterly insane? How best to avoid having to jump off the hospital roof? After long discussions with colleagues it seems that the best coping mechanism is to do what you can but admit to yourself that not many problems can be solved in their entirety by the consultant in charge alone. That some, and possibly most, problems are institutional and will always be present. That we should make peace with the fact that we may fail to solve these things. That perhaps there is a role for being frank with patients about our own powerlessness. Is medicine still a vocation then if we are not really responsible and have no control? If we had more power would it help? In the end Bashar al-Assad had a great deal of power in running Syria and that didn’t work out so well either, so perhaps there is indeed some merit in shrugging and blaming management after all.

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Gwyn Samuel Williams

Singleton Hospital, Swansea, UK.

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