Burn-out
I do several NHS consultant appraisals each year, and I have yet to find one consultant who is not ‘burnt out’ to a greater or lesser extent.
I received an email from a patient last weekend. The patient is an out-of-area patient and is not being looked after by our MS nursing team. She is likely having a relapse or had an infection with a pseudo-relapse and needed a face-to-face assessment. I recommended that she contact her local team. She responded that she didn’t trust them as they constantly fobbed her off in the past. The latter is what prompted her to seek a second opinion in London. The referral for a second opinion had come from her GP. I was kind enough to accept the referral and give a second opinion, which helped trigger an escalation of her therapy locally. She tells me that the local MS team, particularly the MS nurses, feel undermined because she travelled to London for a second opinion. They think this patient rejected them, and she says they make her uncomfortable and reluctant to reengage with her local care needs. I am unsure if this patient's interpretation of her local team is justified. In retrospect, I should have requested a referral from her neurologist and not accepted a referral from her GP; this may have prevented some of these issues.
Our problem is that about 60% of our current MS patient load is out-of-area, i.e., from an area with secondary or tertiary coverage by another local or regional neurological service. We can’t manage their MS care when NHS MS services outside of high-cost disease-modifying therapies are commissioned and paid for locally.
I know this patient's local neurologist. He is a very busy jobbing NHS consultant who spends about 40% of his time doing MS and the remainder of his time being a general neurologist. He is conscientious, knowledgeable and competent in the management of MS. However, like most consultants, he relies on his juniors and extended specialist team to sort out problems such as a relapse or infection screen. As this patient would not, or could not, get hold of her local team last weekend, I recommended she go via her local DGH accident and emergency department. A&E was able to exclude an infection and arranged for her to be seen at the local neurological unit for a relapse assessment. In an email this morning, the patient told me she has yet to be seen and asked if she could come and see me in London this week instead. What do I say?
Despite being a national health service, the NHS is tribal and competitive. However, we should all try to do our best for individual patients regardless of the circumstances; this patient is no exception. In the past, the NHS had a patient charter that allowed patients to seek second opinions. I have just scanned the NHS Constitution for England, which was last updated on the 17th of August 2023, and it does not mention that patients have a right to an out-of-area second opinion. Based on this and the fact that our MS team is overwhelmed with work, we will have to start sending out-of-area patients back to their local service. Is this acceptable? This already happens in other London NHS Trusts, i.e. these centres are only prepared to see and start patients with MS on treatment if their local service takes them back for long-term monitoring and follow-up.
Exceptions to this include patients in clinical trials and those referred for diagnostic problems. However, once the trials are over and the diagnostic work-up is completed, the patients must be seen and managed locally.
The question we should all be asking ourselves is what drives the need for people with MS to seek second, third and fourth opinions. If we understand this, we could address the crisis in MS care that many NHS trusts are experiencing.
I do several NHS consultant appraisals each year, and I have yet to find one consultant who is not ‘burnt out’ to a greater or lesser extent. The way the NHS is currently configured and run is not sustainable. The answer should be obvious when politicians are asked why so many doctors, nurses and allied healthcare professionals are leaving the NHS or taking early retirement.
One of my MS nurses told me that MS-Selfie had much to answer for regarding my out-of-area workload. She has suggested closing it down to stem the flow of referrals and requests for second opinions. Maybe she has a point.
If you have any answers to these questions, please let me know.
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Please note that the opinions expressed here are those of Professor Giovannoni and do not necessarily reflect the positions of Queen Mary University of London or Barts Health NHS Trust. The advice is intended as general and should not be interpreted as personal clinical advice. If you have problems, please tell your healthcare professional, who will be able to help you.
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This story is very familiar to me as a patient. I have a hands-off approach with my local MS team now, because managing the rather fraught encounters with MS nurses is too challenging. It seems impossible to tackle the issues with medical gaslighting and paternalistic attitudes towards patients, when NHS staff are already being systematically harmed by their employer. Hurt people hurt people, after all. I don't want to push an already burnt-out person to be forced to learn new rules of engagement - I want a well-rested specialist to be supported in their professional development as cultures change.
Gavin Giovannoni, aka Prof G, asked Grok (X's AI Chatbot): "Why don't people trust the medical profession?"
@grok
Well, it seems like there's a bit of a trust deficit when it comes to the medical profession these days. People are questioning the motives and actions of doctors and medical institutions more than ever before. There are a few reasons for this growing mistrust:
Information Overload: With the rise of the internet and social media, people have access to a vast amount of information about health and medicine. This can be both a blessing and a curse. While it allows people to educate themselves, it also exposes them to conflicting information and misinformation, making it difficult to know what to believe.
Historical Mistrust: There have been instances in the past where medical professionals and institutions have made mistakes or acted unethically. The infamous Tuskegee Syphilis Study, where African American men were intentionally left untreated for syphilis, is a prime example. These historical events have left a lasting impact on public trust.
Conflicting Information: Medical science is constantly evolving, and new research can sometimes contradict previously accepted beliefs. This can lead to confusion and mistrust when people feel that the advice they're receiving is inconsistent or contradictory.
Personal Experiences: Many people have had negative experiences with the healthcare system, such as misdiagnoses, medical errors, or feeling dismissed by their doctors. These personal experiences can contribute to a lack of trust.
Political and Social Factors: In recent years, there has been a rise in political and social movements that question the motives of large institutions, including the medical profession. This can lead to a general distrust of authority figures, including doctors and medical institutions.
Misinformation and Conspiracy Theories: The spread of misinformation and conspiracy theories about medical treatments, vaccines, and the motives of medical professionals can further erode public trust.
Lack of Diversity and Representation: The medical profession has historically been dominated by white, male doctors. This lack of diversity and representation can make it difficult for people from marginalized communities to trust that their needs and perspectives are being taken into account.
Commercialization of Medicine: The increasing commercialization of medicine, with pharmaceutical companies and insurance companies playing a larger role in healthcare, can lead to concerns about conflicts of interest and the prioritization of profit over patient care.
Lack of Transparency: The medical profession can sometimes be opaque, with medical decisions and treatments not always being explained clearly to patients. This lack of transparency can lead to mistrust.
Distrust in Institutions: In general, there has been a decline in trust in institutions, including the government, media, and large corporations. This general distrust can extend to the medical profession as well.
So, there you have it, a laundry list of reasons why people might not trust the medical profession as much as they used to. It's a complex issue, and it's not going to be solved overnight. But hey, at least we have the internet to keep us informed and entertained while we wait for the medical profession to regain our trust.