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I am a fan of writing things down. I guess this won’t have come as shock to you but perhaps, because I am young and of the ‘next generation’ of NHS consultants, one might think I ought to be putting out bunting to celebrate our apparent movement towards a paperless NHS?
Personally, I have never been a fan of a pro forma way of recording things. I see its strengths, but in my experience, there is little space for thinking out loud. Once I admitted from A&E a middle-aged man who later unexpectedly died from an acute abdomen. When I looked back in his notes, that I had taken time to record a thought process was so important.
‘I don’t know what this pain is… it sounds like this… but these tests are negative… so could it be this?’
Recently, I have found myself looking at my pen and wondering how could I possibly do without it?
Usually when I have this thought I am in resus or out on the ward. I have seen a patient who has been referred because the parent team are worried they might need a higher level of care. I go through the background, I go through the results and observations, I speak to the patient and then I examine them. Next, I sit down and take out a pen from the top pocket of my scrubs and I start to put it all together.
Invariably, somebody will approach me less than ten seconds after the pen comes out ‘so what’s the plan then?’.
I will look up from my page and tell them the same thing every time: ‘I don’t know, when I’ve finished writing I’ll have decided and I’ll let you know.’
That isn’t me being rude, but there is so much to consider. What are the problems? Which of these are a priority? Do we have a treatment for them? Do they want it? Do we think they would benefit? Are they in a place of safety? What does benefit mean anyway?
Usually within five minutes, somebody else will have asked me the same question.
What’s the plan then?
Don’t get me wrong, I don’t advocate sitting down with your pen beside an acute asthmatic, haemorrhaging patient or cardiac arrest, but the reality is that most of the admission decisions I make are a lot less urgent than that. There is time for being rational. There is time for being thorough.
I’m sure you’ve been there too? You’re standing in resus beside a man who may or may not have reversible illness. His family are waiting on you to tell them the plan, the nurse needs to know what to tell the bed manager, the referring doctor wants to know the outcome of their referral and around you four other patients have their own problems and their own teams buzzing around them.
You are standing in the hustle and bustle, it feels like Waterloo Station, and how else can you make yourself room for thinking, if you can’t pick up your pen and look at a page? What other flag do you have to raise?
Seamus Heaney was right when he chose to pay such homage to his tool, don’t underestimate the value of your pen:
‘But I’ve no spade to follow men like them.
Between my finger and my thumb
The squat pen rests
I’ll dig with it’
By the Secret Doctor
Read the blog and follow @TheSecretDr on Twitter and Facebook
I have exactly the same process. I thought it was just me!