Please, sir, can I have some more signatures?

Authors: Yasmin Akram 

Publication date:  13 июн 2012

Yasmin Akram bemoans the rise and rise and rise of tick box training

Please, sir, can I have some more? Signatures, that is. We no longer stand in line with empty bowls vying for porridge, but rather, as medical students, we wave our dog eared placement handbooks under consultants’ noses in the hope that they will tick the box saying that they know that we know what a sharps bin looks like. Then as junior doctors we plead desperately with consultants for a few precious moments of their time to electronically sign off some of the many competencies we must show that we are capable of, only to find that the ward computer is not working. And then on finally managing to find one that functions, the system is so slow that we spend the 10 minutes between each competency apologising on the e-portfolio’s behalf to the consultant who is, rightly, increasingly irate. And that isn’t the worst of it. Colleagues have shown me certain specialty portfolios (that will remain nameless) where not only does each competency require two separate written reports, plus an uploaded piece of evidence, but on requesting an electronic sign off the consultant receives three separate emails to three separate links, each of which needs to be individually ticked off before the consultant can do an overall sign off for that one competency.

Whoever came up with these not-so-smart smart ideas designed to make sure that I do my job properly certainly won’t be getting a birthday card from me. They do not do what they say on the tin (make life easier), and to be perfectly honest I think they favour irresponsibility. Of course, no one would dream of asking a senior mate in the hospital to sign off a few procedures or leave cannulas for the evening on call and become increasingly scarce from the ward when they had ticked enough boxes. Would they?

Some days I probably took more bloods in an hour than the total I needed to get signed off for the whole placement. That’s the days when the phlebotomists hadn’t quite got to your ward when the clock struck 12 noon, shift end time, so the foundation year 1 doctor got the privilege of doing a phlebotomy round instead of taking a lunch break in the hope that the results would be back before 5. Of course, sod’s law would be that those were exactly the days the lab was understaffed and hence slow—and the days when Mrs Smith decided to drop her potassium to dangerously low levels. So, an hour and a half after your shift had officially finished you were running around the hospital trying to find a cardiac monitor.

The realities of short staffing and the European Working Time Directive are a gripe I will leave till another time; the issue at hand here is that, despite having done many of these blood rounds, somehow by the last week of the placement I had a sum total of zero directly observed procedures (DOPS) signed off. Yes, I could opportunistically discuss cases, but I did not see it as appropriate to do arterial blood gases only when the consultant came around or to waste the registrar’s precious time by making her watch me gain intravenous access when I had done it so many times before. Ultimately that is what I had to do, but no doubt at the cost of delaying patient care, not improving it.

How long do we go on with a system that punishes the good for the faults of the lazy? Surely there must be another way to weed out the grain from the chaff. Because this game has so many holes in it, virtually everyone gets through, competent or not, so long as they dance through the hoops. And ultimately if a bunch of tick boxes is all we are reduced to, why work any harder anyway?

Surely developing a culture of personal responsibility for learning and competence would work better. Studies have shown that ethics is more salient and people more honest when they are asked to sign at the beginning rather than at the end of a form. If the Hippocratic oath is no longer sufficient for us, maybe we need proactive agreements at the start of job placement, rather than the reactive tail wagging to get us through the bureaucratic red tape that we currently have.

At this rate, if the government and NHS managers continue to have their way, at 70 I will not only probably still be working but also be expected to drag a wheelie shopping trolley (full of the papers to which my life’s work has been reduced) behind my Zimmer frame and go begging bowl—sorry, sign-off sheet—in hand to an open plan office built from Ikea seconds (which is all the NHS will be able to afford) to ask someone younger and less experienced than me whether I am still competent to do my job.

Yasmin Akram specialty trainee 1 West Midlands Deanery, UK

Cite this as BMJ Careers ; doi: