As a doctor on call in Paediatrics, we are encountered with patients who are anxious, worried and demanding. Some of these patients can be safely advised to go home with some treatment, refered back to consult their GP, specialist cares or admit to the ward to observe or treat.
This is not an easy task when you pass out from medical school or start working in a specialised branch of medicine (pediatrics, gynecology, cardiology, neurology etc.,). The reason we find it difficult is because in-experienced doctors do not think of common conditions but will always focus on complicated and rare illness.
The implications of our decision can have long lasting psychological impact on a growing child, parents, bonding and also adults. Every person who has been through investigations like blood test, scan or referred to specialist will find it hard to accept they do not have a major illness. The waiting to consult or the test result can be agonising and some start believing they already have the disease.
I started creating a simple flow chart or say a brain map that could be used to derive at a diagnosis quickly and help me decide who stays in and who does not..
JUNIOR DOCTORS TRAINING
As a Registrar working in a busy hospital, I was lumbered with six to seven junior doctors (SHOs) twice every year. This can be a daunting experience if the SHO is not confident, nervous, lacks the knowledge or understanding of various illnesses and the disease process or dangerous if the SHO is over confident and believes he or she knows it all.
As the on call senior doctor (Staff Paediatrician) who stayed in the hospital, we always expect the SHO to be safe but have the confidence to diagnose and initiate treatment. It has been very easy and pleasure to work with a doctor who is sensible, caring and had the confidence to make decisions and treat ill children brought to hospital.
Teaching or supervising doctors who are over confident was difficult but this helped me create my tool. These doctors often critisised my judgment and also made mistakes, which made helped me refine my clinical decision making pathway.
I started testing my simple Algorithms by sharing this with some junior doctors who lacked confidence. I prefferd not to share this with doctors who were over confident knowing they would not accept systematic approach.
After I was convinced this algorithm is safe and helps some to develop a simple systemized approach to mange emergency care in the hospitals.
I also wrote a simple programme in Psion PDA to help speed the process of decision making. I called this as “PAT” (Paediatric Assessment Tool).
This tool was divided based on age of the child, symptom and sub-groups of symptoms. After going through few questions (all in drop menus) the doctors will be advised to Crash bleep me, admitted for investigation or treatment in the hospitals, safely refer back to GP in the community or sent home with some treatment.
After testing this tool for few years I was convinced this is the way forward to help reduce in-equalities in healthcare. This will also reduce mistakes, cost of care and wrong doings like requesting blood tests, X Rays, Scans, procedures or admit patients to hospitals to boost doctors income.
In 1996, some hospitals started using Pre-printed assessment sheet. I strongly objected to this and criticised the authors for supporting this method. (Srivatsa KM, Preprinted assessment sheet. Qual Health Care, June 1996)
Royal College of Pediatrics was established in 1996 the number of inexperienced doctors working as consultants rapidly increased. Junior doctors (SHos) were not properly trained, lacked passion and were not enthusiastic to learn. The new eight hours shift made our job difficult because of poor communication and I know it will not be safe to continue working. Patients were complaining and I felt the quality of care had declined rapidly. I was asked to change over to the new SPR training but decided not to continue to work in the hospitals any more and so retrained to be a GP.
In 1999, I was working as an SHO (part of GP training). Here I noticed patients referred to psychiatry were not showing up and so organised a study to find out why the failed to show uo and how to make this system work better. This work was published in Psychiatrist Bulletin in 1999. (Kadiyali M. Srivatsa and Danny Allen. Reducing the time you and your patient wait. Psychiatric Bulletin March 1999 23:156-159)
After completing my GP Registrars post and passing the summative assessment, I obtained my JCPTGP and was registered to work as a GP in the NHS.
Initially I started working as a GP locum in and around London. Here I went through notes of patients written by GPs in the computer and was shocked because I could identify numerous clinical errors, poor documentation of clinical finding, vague terms that I was not familiar, wrong dose of antibiotics, irrelevant investigations and referral to specialist care.
I started collecting information and listing the presenting complaints and diagnosis and analyzing patient behaviors. I also published a website “GoToSurgery.Com” and offered advice using the email link. This was probably the first such sites. Even AOL Medical Symptom list appeared later.
In 2002, I became a father as so decided to find some regular part-time job and so found one in Woking in 2003. This was a The First Pilot GMS Nurse-led clinic established in UK.
The nurses trained for six months by nurses and not in medical school or doctors in the hospitals or GPs. I thought this will give me the opportunity to continue my research to create a simple software to help reduce patient visit hospitals and surgery because of the risk of cross infections and medical errors that devastate fellow human.
I was also appointed as the clinical tutor to train some nurses in Surrey University. This I was happy and assumed it is not a bad idea to allow nurses to manage routine clinical problems. Soon after I started work I noticed minor and some serious errors in diagnosis and treatment. Patients returned to see me with complications.
I wrote a letter to the Chairman of PCT and met the lady in charge of the nursing and the local walk-in-clinic and expressed my concern in 2004. The nurses following a protocol (Manchester Triage Scoring System) and some guidelines were making serious clinical mistakes.
The PCT also established walk-in-clinics in the town, railway stations and some chemist shops. The nurses (un-supervised) were allowed to offer advice, treatment in emergency out-of-hours service and NHS Direct.
I was very concerned and did not want to be blamed for errors that may result in death or litigation. Unable to get help from PCT, I decide to show the tool “PAT” to nurses and asked if the receptionist could priorities appointments. I was naïve to assume the nurses would like this simple tool but it was obvious they were not pleased.
The nurses had worked as doctors and were allowed to be on call as doctors, offered advice, treatment and followed them up for almost two years. I was not supervising their work but was seeing some patients who were managed by locum doctor and the nurses.
The number of patients badly managed had increased. I started finding simple and major clinical errors that resulted in complications. Some patients refused to consult them and I was helpless to implement changes to protect fellow human.
The nurses had become over confident and so were making more mistakes than before. They refused to use my tool to priorities appointments to help me prevent medical errors.
I contacted GMC, NMC and QCC, but did not get any help or support but was adviced to contact PCT.
Knowing PCT will not act, I published a letter in GP Forum and asked doctors if any one had come across nurses working as doctors and offering emergency care advice and treatment. The replies made it clear that I have to inform the PCT and so I did.
I wrote my first letter to the Chairman of PCT in February 2007 and followed by two letters March & April 2007
The PCT informed the nurses that I had raised concerns about their incompetence and so the nurses and the way this surgery was managed.
The nurses started asking staff about my behaviors, instigated complaints from some disgruntle patients who were not happy because their expectation (not offering to refer to hospital, prescribing antibiotics, not supporting to get them council house, developed reaction to some treatment, taking picture of white spot on a girls back, asking the girl to undress to clinically examine her chest) were not met.
I was told about a complaint in May 2007 and the numbers escalated gradually to four in 2008 and soon imposed a “Punitive Sanction” and started investigations. By prolonging the investigations and shifting the goalpost the PCT destroyed my passion, carrer, family life and ruined my finances.
In October 2009, I was forced to return to work despite me saying the staff, nurses and doctors (the locum was appointed to be the salaried GP) will instigate more complaints and fresh investigation will be traumatic and counter productive to my confidence and mental well being. This did happen as I said and so I refused to return to work in the surgery.
They did not find any wrong doings nor did the find any document in the notes to prove I am incompetent and a threat to patient care and refer me to GMC.
The PCT was so desperate to discredit me they have breeched Caldecott Principle and went through the clinical notes without patient or my consent.
The forced me to return to work in the same surgery and I refused because it is un-ethical as a doctor to work in a premises where people are harmed by nurses who are not trained to be safe. Despite letter from occupational health consultant, LMC Chairman, BMA and MPS telling them I should not be forced to return, they insisted and so stopped my pay in December 2009.
Because of financial difficulties, I asked MPS to get me permission to work as a locum in another surgery. The PCT allowed me to work as a locum and so I accepted a job in Hastings.
During my stay at home, I rewrote my “PAT” and called this “MAYA”. Because I was not working as a GP, I could not test this but I have visualized a “Virtual Surgery Concept”.
This is a project that will bring in the changes and unite the world.
This story did not end here, WHY? Because the nurses and their leader tried their best to discredit me so that they can claim it is not good and safe..
Unfortunately the atrocities, report of avoidable death in hospitals and increased hospital admission of children, compensation payment, complaints and canceling evidence.
The problems occurred only because the PCT, GMC, LMC, BMA, NMC, The Royal Colleges and the politicians did not act early to help protect doctors like me and my patients…
My creation “MAYA” is the answer and I know this will bring us all to-gather and unite us as one large family….
Please use the link or scan to order my book and help me fund Dr Maya Apps project.