Abstract
“Why do you do critical care?” You could do something less onerous, less stressful and less likely to lead to burnout, career change or early retirement. This question is certainly one most intensivists ask themselves after a bad night or weekend, and likely a question asked directly or indirectly by your spouse, partner or, worse still, your children when yet again you’re not there when wanted and needed. When “Why do we do critical care?” is contextualised in a certain way, or asked at a certain time, the response is more than likely to be “Why am I doing this”, or “I can’t carry on doing this, I should do something else” or “I’m certainly not doing that job as a consultant”. It remains the case that the majority of intensivists in the UK still have an anaesthesia background, and the grassy bank of anaesthesia can look a lot greener when viewed in the evening light from the bare brown bank of intensive care. Many still plan on crossing to that greener bank in their later careers.
In this month’s JICS edition Grailey et al. “The Faculty of Intensive Care Medicine Workforce Survey – What impacts on our working lives?” examine the responses from 2014, 2015 and 2016 to the annual Faculty Workforce Census questionnaire. The workforce response rate of 36% by FICM members to these questions that impact on our working lives, and indirectly on our home and family lives, is of course disappointing and leads to potential bias which the authors recognise. We don’t really know why the remaining 64% of fellows don’t respond to the survey but can hazard a guess that “I’ve answered before, and last time it made no difference,” and “I’m too busy, I’ll do it tomorrow,” would feature strongly. The paper however is successful in drawing out certain themes, and does cast light on areas where, with work and resources the positives of a long-term career in critical care can be improved and enhanced beyond the 60% whose responses to their career choice are positive. Work life balance, reducing frequency of on-call, reducing stress and improving work intensity are all areas where work needs to be done to improve retention and aid recruitment to a lifelong career in Intensive Care.
We also know that big disparities continue to exist in intensivist’s job plans depending on where they work, and the nature of that work. Those working in big units often have on-site sessioned activity until late at night (or even all night – 1% of FICM responders). These consultants are less likely to have to re-attend to the unit because they are either already in, or because a resident junior on a senior tier can deal with the problem (probably the 46% who rarely have to re-attend the unit). Those working in small and remote district general hospitals may have out of hours on-call, but it is often not sessioned critical care activity, and as well as covering critical care for adults and children, they also provide anaesthesia cover for theatres and obstetrics. These consultants are much more likely to have to come in out of hours because there is no senior resident, and the resident available doesn’t have the competencies to manage the situation (these are probably the 45% who frequently, or always have to re-attend the unit). Where smaller hospitals have split anaesthesia from critical care, and the intensivist on-call rota is therefore more frequent, more onerous and not sessioned there is understandable negativity. It is hardly surprising that unrecognised out of hours work seems to be associated with wanting to stop doing critical care.
These major disparities in intensivist’s job plans make asking generic survey questions, and interpreting the answers very difficult. The authors recognise that drawing firm conclusions is difficult but suggest that negativity is higher in younger consultants. The prevailing mood of the workforce changes and is difficult to grasp and quantify. This mood can be glimpsed in the medical workforce’s social media responses to Hadiza Bawa-Garba’s striking off by the GMC. Between 2014 and 2016, 20% of those returning to work stated they did so to support a junior. It would be very surprising if the percentage answering the question in 2018 as to why they had returned to work didn’t show a significant increase “in order to support the junior” following the GMC’s ruling in the Bawa-Garba case. There will also then be a corresponding percentage decrease in the other possible responses. Swings in workforce mood need to be borne in mind when reviewing these surveys.
So really “why do we do critical care?” Recently, we admitted a young man in extremis who went on to die of refractory shock and multiple organ failure. A consultant colleague, nurses and the junior resident spent the whole of the first night at the bedside, and all but three hours of the second night in a continuous and increasingly desperate struggle to save his life. An ECMO referral was made and handled sensitively and expertly by the tertiary centre consultant but to no avail. After he died, the bedside nurse washed his body with his wife, and then stayed on to fulfil a promise to the patient’s father that he would take him to the mortuary himself so that he wasn’t alone on the journey. The patient’s family and friends were extremely graceful and profuse in their gratitude to the team, and the efforts made on behalf of their loved one. I tell this story because many of us do critical care because of this: being part of a dedicated team working together for a common purpose, the feeling that we can make a real humanitarian difference to the patient and their family, the proximity to death and therefore also to life, the passing on of skills and knowledge, the academic interest and the intellectual challenge. These are the reasons; they just aren’t always easy to put into words, and if the question isn’t asked in a certain way certainly aren’t the answers given.