RickInOz

When I got into medicine I swore I would avoid the inherent politics as much as possible. As far as I’m concerned the job involves trying to defy nature and as often as possible, rather than getting involved in organisation and logistic responsibilities. Unfortunately, the higher you move up the tree the more you are divorced from minute-to-minute hands-on clinical work and are drawn into the murky world of politics. I thought I’d share a recent experience that made me realise the difference between acting as clinician and being an arbiter.

Last Thursday I was the Duty Intensivist. This means acting as consultant overnight and having to make decisions about the bed state (i.e: who actually gets into an ICU bed). Previously when I was a junior registrar on night duty there was always an inclination to keep the sanctity of the unit intact by keeping out patients we felt didn’t require an ICU bed. As the Duty Intensivist doing the on-call from home I tend to towards the converse as:

1. It is extremely difficult to get a good feel for how sick a patient is over the phone. As a result it is always safer simply to ask the junior registrar to admit the patient as they may not have accurately reported the severity of the patient’s illness.
2. There are only two options for referrals – go to a ward or come to ICU. On the ward the patient may not be assessed again until morning, so has to be well enough to make it through to 8am without further intervention. This means it is far safer to admit unstable patients to ICU as I know they will be monitored and looked after properly.
3. If we send a patient to the ward and something goes wrong overnight then I get the blame for underestimating the severity of their illness. If I admit a patient to ICU who didn’t really need admission then they can always be discharged in the morning and no harm is done.
4. This is when the real political touch comes in – keeping other departments on side. The vast majority of our referrals come from Casualty (the Emergency Department) so we try to maintain a good working relationship. Obviously we don’t want them referring every little thing which is a temptation as they are constantly under pressure to keep up their throughput of patients and ICU is an easy disposal destination. But equally we don’t want them to feel that we are obstructionist and create ill will. Fortunately we have established a happy medium in which they tend to call rarely, but have something serious when they do call. As a result we (more senior officers being aware of this) tend to accept their referrals with little questioning. The junior guys often wonder why we admit these patients so tacitly, but whether that patient really needs ICU or not, it is more about the bigger picture and general train of referrals that influences this attitude. Thus, we gain some good will from them and can use this to our advantage another day.

I hope this all makes sense, especially the last point, and is sufficiently generic that it could apply to any job or area. If not then at least it might provide a little insight into some of the inner workings of my day-to-day work and be of some interest.