Thursday, December 03, 2009

Increasing levels of bureaucracy

Having requested my holiday leave* at the end of my rotation, I have finally finished surgery and will be going on to accident and emergency next month.

* I can never call my holiday leave "annual leave" as I get the leave four times a year. It can only be called annual leave if I can bunch up all my leave into one massive holiday, where I probably go back to England.


I've only just left a surgery department where they recently opened another ward. This means another twenty six beds available and more opportunities for patients to receive treatment and surgery. This maybe good for the nearby population but does not bode well for junior doctors. We do not receive an increase in manpower, meaning an increase workload. I'm not complaining, having already left the department already.

This is just one of several examples of the increase level of bureaucracy in hospital work. It has been steadily creeping into the workplace. It comes with the organization you work with. The larger the organization, the more paperwork and guidelines you must follow and there is no bigger organization than a government installation. In recent months I have noticed how anal some people who set out these guidelines really are.

The first example I encountered was writing management orders for intravenous fluids. In the past I could just write what intravenous fluids I want for my patients in the management orders sheet. If the intravenous fluids contained potassium, I would have to write it on the drug sheet, which is fair enough since overdosing on potassium is very dangerous. For some reason, this policy was changed so I have to write ALL intravenous fluids into the drug sheet, whether or not it contained potassium or not. Also I have to write the frequency more explicitly. In the past I could write "2D1S Q8H" which means "two units of dextrose 5% and one unit of sodium chloride 0.9% every eight hours". Now I have to write "2D1S Q8H per unit/pint*" which means a few more seconds. If you are writing this for every week for every patient, the amount of time spent doing this starts to build up.

*Whoever writes "per pint" for intravenous fluids or even blood products is wrong. A pint is 565 ml, whilst an unit of intravenous fluids is always 500 ml, whilst for blood products it is usually 330 ml. Just being pedantic.

Another example of bureaucracy I have just encountered is blood taking. In the past we had to use a barcode system to print labels for blood specimens if we want to type and screen a patient. For those of you who don't know what that means, it basically means knowing a patient's blood group so we can give blood just in case. We had to use an electronic device to make sure the patient's identity was correct. It's quite similar to the mobile phone 2D barcode system you see. It would be fine if it was just for blood typing but now we have to use it for EVERY specimen, whether it is blood, sputum or urine. It is so annoying and so cumbersome and so time-wasting! At the end of the day, we want to avoid mixing up the patient's identity with somebody else but the specimen taking is still being done by a human and the placing of the label is still done by a human, which means it is prone to error. Putting another level of checking may reduce this type of human error but at what cost?

Bureaucracy is fine but there is a limit as far it can go.


sam lo said...

Hi, as a current medical student in HKU I'm quite interested to read about your experience and thoughts as a practicing doctor. I'm humbled that you can be so open about your depression. Anyway, I like the entry, and bureaucracy has its origins from UK, but there are definitely limits as you suggested.

Keedon said...

Replace the B word in your title with S, for Standardisation.

While it certainly pains the hardworkers like yourself to follow the new protocol, it has strengths in keeping things explicit and universal across the system in your workplace. We are known for our poor handwriting, and too poor patience as surgeons, but these "barriers" do do others good, including the nurses or lab staff.

Very frequently medical communications break down because of short cuts taken by someone else in the team. This can potentially turn bad for the patient, however low the probabilty is. A change in protocol is really, just a change in culture to prevent a mistake from happening.

While I am too junior to comment on the Rx you should take for your depression, how about waking up half an hour earlier each day to compensate for the extra writing you have to do. Best coffees are brew fresh in early mornings.