The new normal
DR JOHN ZORBAS, CHAIR, AMA COUNCIL OF DOCTORS IN TRAINING
Something strange happened to me recently that reminded me of how badly calibrated our frames of reference can be. I’m a dual trainee, and with the new training year upon us, I was migrating from the calm and collected ivory tower of the intensive care unit, back down to the chaos and madness in the pit of the emergency department. It’s clear that I like really sick people; I just can’t seem to decide on the speed of sickness that I prefer. Fast or slow? I relished the change of pace. It was frenetic. We were getting things done. I was happy.
And then we had a teaching session. One of those beautifully peaceful moments when you leave the emergency floor and you enter the tranquillity of education. We discussed stroke management. I spoke about ultrasound. So far, so good. All normal. Our director of training asked us how we were going and he made specific mention of just how busy we’d been lately. I took note and thought “OK, so we’ve had a busy few days. Nothing new here”. He kept probing and then the other trainees started talking about the pace. It then became abundantly clear to me that the last few weeks were not normal. They were chaos. The cubicle pressure, the acuity of the presentations, the backlog in the hospital… none of this was normal. Not by a long shot.
It might not sound much, but I was quite shocked by just how incorrect my frame of reference was. If you don’t have a good frame of reference, you start to misjudge things that happen. What you explained away as a quirk of the system could quite easily become a serious medical error. And so, with this new calibration I started to re-hash the events of the past few weeks. What had I missed? If this pace wasn’t normal, had I expected too much of my juniors at any point? Had I been too hasty with investigations, or documentation? What pressures had I placed on my nursing staff? Looking back with this new frame, I made my peace. Yes, things were fast. No, they hadn’t been unsafe. But I remained shocked with this error of calibration. The compass was off, and a bad compass leads you to icebergs.
I’ve been a doctor for eight years now, and in that time, I’ve had to recalibrate on several occasions. I’m no expert and I’m certainly no source of truth, but here are some common “normalities” I’ve encountered along the way:
It’s not normal to excel at every assessment along the way, and it’s normal to fail. We’ve created this system of training in which hypercompetitive medical students vie for the “best” internship (whatever that is supposed to mean) and endlessly buff their CVs to achieve immortal greatness in the specialty of their choice, to the exclusion of all others. This type of system demands that doctors perform at 100 per cent of their operating capacity, at all times, which just isn’t reasonable. I’ve spoken before about the green and red lights of assessment, and the dire lack of orange lights along the way. This isn’t normal outside of medicine and it shouldn’t be normal within it. We need systems of assessment that don’t demand shiny whitewashed walls of achievement. The odd coffee stain isn’t just acceptable, it should be encouraged. It should be a badge of honour, because stains draw attention, and they allow you to focus on how to improve yourself rather than improving at assessment. Use your frame of reference to improve, not to impress.
It’s not normal to not see your loved ones for days at a time. My partner works shift work as well, and our training has meant that while I rode the escalator down into the pit of mayhem, she’s taken the elevator to the top of the afore-mentioned tower. She relishes the opportunity to have a good laugh when I call from ED for ICU to please come and join the party. We’re less jovial about our jobs when we’re passing ships in the night, only seeing each other at the start and finish of shifts for a quick chat and a kiss goodnight. Now don’t get me wrong, we’ve chosen this life and these rosters. However, no matter how you paint it, it isn’t normal. We have had to take these runs as a sign to slow down and be sure to spend quality time with each other. If you’re going to roster work, make sure you roster life.
It’s not normal to be so close to death all the time. I’ve chosen two particularly bloody specialties, and death (often horrific death) is not uncommon. And yes, your temperament for death will be part of what guides you to your specialty. But death like this shouldn’t ever be normalised. We need to remember to debrief with those around us, especially for new staff who might not be used to the abnormality of death on invasive organ support. To extend this further, I’d like to also point out that death of our colleagues is never, ever normal. It should be treated with the utmost of seriousness and should always result in an organisational response. We should never expect doctors to just get back to business as usual when they lose a peer.
It should be normal to enjoy your job. It should be normal to be proud of your profession. It should be normal to have a healthy workplace culture. Sometimes we hit these points of normality and at other times we don’t. For my part I’m going to keep checking that compass. Pick up the deviations before we get lost, lest we run into icebergs.