The Night Shift
Those of you reading my blogs will know I am an advisor to Boards on executive pay and, as such, I am used to seeing people earning ‘big bucks’. I am happy to defend high pay if it is deserved. After all, we need people who create wealth, who create jobs, who under-write our economy, allowing us to invest.
On this occasion, though, I want to shine a light on the role of people who aren’t earning the big bucks. In this example, an emergency doctor. The kind you will have to rely upon when, at some stage in your life, you need to visit the Emergency Department. It seems to me that we are in danger of taking such heroes (for that is what they are) for granted and we do so at our peril. Without paying them properly, they will not be around when we need them.
Let’s pick a single role: a Senior Registrar. He or she will have spent six years in medical school, worked in many different hospitals and, during the six years since their graduation will have prepared for and passed at least one major exam, on average, each year. Now they are in charge of a major regional hospital’s emergency department.
The role pays £51k[1] per year. There is no bonus. That is less than a train driver[2], a lot less than a London tube driver[3], it is far lower than the starting pay for a London Business School graduate[4], less than an MP[5] and - for those just tuning into Jeremy Clarkson’s Farm for the 2nd time - less than a planning inspector and an auditor[6].
This blog is based upon the as yet unpublished facts from a single night shift, in a real but unnamed hospital, in January 2023.
It is 10pm on a Tuesday night, our senior registrar takes over the Emergency department (A&E). The department is in a critical state, every bed is full and many patients requiring hospital have been in the A&E for over 24 hours waiting for a bed on a ward. There are 30 major and 8 minor patient spaces and 8 resuscitation spaces. The senior registrar is in charge of four other doctors[7]. 90 patients are waiting to be seen in the waiting room, 9 ambulances are queueing up to offload, the nursing staff is down 2 senior sisters and 3 trained nurses, so the doctors must make do with agency staff with no emergency department experience. Those running the hospital say there is little or no chance of many beds becoming available overnight, beyond patients dying on the wards.
The first patient is a suicidal and self-harming mentally ill young women who has been seen in the department numerous times before. Whilst speaking to her, there is a call on the emergency ambulance line (a red Bakelite telephone nicknamed the “bat-phone”). An ambulance crew is on its way to the hospital with a patient who has experienced a suspected heart attack and is in cardiac arrest. The team tries everything. It is the Senior Registrar’s responsibility to end CPR and pronounce the patient dead.
The team is tired and sweating after conducting CPR and many other desperate measures, but acutely aware there is already an 8 hour wait for patients to be seen. They still need to find next of kin so they can call to let them know a family member has died. Whilst resuscitation was continuing, however, the mental health patient has smashed up her cubicle and then run out of the building. Security has been called to check the site cameras, but the patient has already left the hospital grounds.
The Police are alerted to report the patient as a high-risk missing person.
Back at the waiting ambulance queue - two more have booked in during the attempted resuscitation, one is an elderly lady who has fallen at home and been on the floor for an extended period of time, the other is an elderly gentleman who has a heartbeat barely 1/6th the normal rate. He is sweaty, pale and his heart rate keeps dropping - the ambulance crew have not been able to get any access to his veins and his blood pressure is very low. All 8 resuscitation beds are already full and therefore a patient must be chosen to give up a cubicle to allow treatment of the fading heart patient. There is one man who has been treated for an acute haemorrhagic stroke (a sudden and catastrophic bleed in his brain) and the Neurosurgical team do not believe he is a candidate for surgery. The senior registrar understands that this means the patient will die from this catastrophic neurological event. The patient must be kept comfortable, his wife and son with him by the bedside.
Time is short, they must begin treating the patient with a very low heart rate as it is clear he is moments away from a cardiac arrest. There is no choice: the patient with the neurological bleed must be moved to a space in which the body of the dead patient had been lying and move that patient to the mortuary. The team are painfully aware they still don’t know the name of the man who died.
The Senior Registrar must speak with the stroke victim’s family and inform them of the Neurosurgical advice and its implication. The family are extremely upset but understand, despite the indignity of having to move to another area so that another patient can be moved into their space.
The patient swap happens. The ambulance crew brings in their patient from the ambulance, the two patients literally passing one another in the corridor and the new patient is, as expected, extremely unwell, pale, nauseous, sweaty with a heart rate in the low teens’. After external pacing pads are placed, insertion of a cannula using an ultrasound and administering a specialist drug the patient’s heart speeds up. Success.
The patient is still complaining of chest pain and evidence from an ECG shows there have been nasty changes in the lower region of the patient’s heart, but he is stable enough for the senior registrar to step away. The cardiology team want him in the cardiac care unit but there is no space. A drug maintaining the patient’s heartbeat is infused which will keep the patient alive whilst he waits. The senior registrar can now step away and get back to the main dept.
In order to get the other elderly confused patient with a suspected broken hip into a cubicle, the senior staff nurse must move another patient into the corridor – the patient is stable but on an intravenous drip – his family complain about the move, but there is no alternative.
An X-ray shows a nasty fracture of the hip but the head scan shows no signs of any bleeding inside the skull. The senior registrar must brief the Orthopaedic team about the fractured hip and prepare the patient by injecting a nerve block into the hip to dull the pain.
The senior registrar is then interrupted.
One of the junior doctors, who happens to be of Indian descent, has sought out the registrar because her patient is demanding a ‘senior doctor’ for a second opinion. The senior registrar suggests she takes a breather, knowing she hasn’t stopped since they both arrived on shift five hours ago. He then moves to minor injuries unit, identifies and attempts to placate the patient who is loudly shouting that she wants an “English doctor! A proper doctor!”
The registrar reviews all of the key points from the patient history, her examination and the investigations ordered by the junior doctor. It is a more in-depth analysis than any other clinician would have done in the first instance. The points are reiterated but the patient then leaves the department, swearing at staff.
The junior doctor is already diligently reviewing the next patient, a sick 4yr old boy. There is no time to review this unfair, upsetting (and frankly racist) episode with her because the emergency phone is ringing again; a woman has been found on the side of a country road – she is coming by land rather than air ambulance. Whilst she was able to talk at the roadside, she has now gone into cardiac arrest enroute. The ambulance is 10 minutes away.
The senior registrar must now decide how to handle this major emergency and puts out a call to alert the blood bank and triggers a cascade of emergency alarms around the hospital, with senior doctors from the surgical teams, anaesthetics and intensive care teams all requested urgently in A&E.
The resuscitation bays are still all full, including a 4-year old girl who still needs very close monitoring but no active treatment. The paediatric team do not have space for her yet, but she must be moved to make way for the latest case. The patient arrives, pushed by several members of the pre-hospital emergency team (an elite branch of the paramedic services). Without giving further details, everything - absolutely everything - is done to revive the hit-and-run victim but finally, as a team, they withdraw resuscitation and call time of death.
The emergency team are sweating, dizzy and upset. But there is no respite. A receptionist finds the senior registrar to tell him the mental health patient from earlier in the evening has been brought back to the department by the Police. She has been left in the waiting room and the Police have left. She is now getting agitated, shouting, and swearing, threatening other patients. They don’t have anywhere in the department to put her safely.
The senior registrar must go out to the waiting room and speak to the girl, who is angry, demanding her ‘own room’, refusing blood tests and threatening staff. There is only one option: move an elderly lady with a broken ankle back to the waiting room in order to let this young mental health patient have that space. She cannot be left in a waiting room full of children and sick patients packed closely together.
Back in the main department, the next Ambulance crew have arrived with an elderly lady, who has an infection and needs antibiotics. There is nowhere to put her, so the senior registrar must decide who can be moved out to the waiting room to create space. There are no good options.
It is 5:00am. Just 3 more hours to go.
Note to the reader:
this is a real account from a single nightshift. Obviously, I struggled to articulate the complexities of this role as a non-medic, but it is clear to me that if we continue to believe this kind of dedication and talent can be bought cheaply (writing off such roles as ‘vocational’), as has been the case in the past, we are fooling ourselves. Of course, skilled private sector, high pressure roles deserve six-figure pay. Nobody can argue with that, because there is a marketplace. But the realities of supply and demand also apply to healthcare: 40% of junior doctors are considering leaving the NHS in the next 4 years, and a third are planning to work in another country[8]. Furthermore, as we show here (see our summary table below), the skills and experience required while working under duress, the patience needed in almost impossible circumstances, the technical excellence necessary all has a price – and when we add it all up, ‘vocational’ doesn’t cover it. That is the bottom line.
[1]
ST4 Registrar - Nodal point 4 - basic pay £51,017 p.a https://www.bmj.com/careers/article/the-complete-guide-to-nhs-pay-for-doctors. There is a 10% of basic salary for working 1:2 - 1:3 weekends and 37% for working nights. In total enhancements up to £33.60 vs £24.50 per hour (£51k)
[2] Source: The Guardian: £59k
[3] Source: The Spectator: £70-80k
[4] Mean offer to LBS graduates from their 2-year MBA class in the UK in 2022 was £89,084
[5] £86, 584 excluding expenses
[6] Planning Inspector in London are paid £51,000, requiring a one-year training programme; a newly qualified auditor in London is typically paid £56,500, requiring 3 years’ training and exams, but not a degree
[7] 1 x junior registrar, 3 x junior doctors between 1 and 3 years out of medical school with varied skills dependent upon whether they had had rotations in surgical or medical specialities prior to joining the Emergency Department
[8] Source: BMA poll Dec 2022 (see https://www.independent.co.uk/news/health/nhs-junior-doctors-quit-strike-b2252333.html)
Simon Patterson
Managing Director
simon.patterson@remunerationassociates.com
Valuing a Senior Registrar
Skill |
Examples from the Night Shift |
Leadership |
Taking over as head of a department that is under-resourced, leading in all the areas where outcomes are risky, the requirement is highly specialised or clear direction is crucial |
Teamwork |
Preparing an entire hospital team for incoming serious casualties |
Communication |
Putting across the key points of diagnosis and treatment in a very fast-moving environment |
Patience |
Moving from one high stress situation to another, where those around you are unaware how the combination of difficulties makes small problems into far larger problems |
Staff management |
Helping young and junior doctors deal with the less easy members of our society – the mentally vulnerable, the insensitive and poorly educated |
Technical excellence |
12 years of medical, surgical, anaesthetic and other experience, combined with 12 years of studying towards some of the toughest examinations faced by anyone |
Knowledge of human behaviour |
Knowing how and when to empathise with friends, and next-of-kin where difficult messages must be delivered |
Societal Responsibility |
Responsibility to fulfil primary duty (care and safety of patients) whilst acting as agents of public health services. |
Fast Decision Making |
Having to make quick decisions under pressure – time can be a matter of life or death, so it is essential to remain cool, calm and professional under intense pressure while making sound decisions |
Emotional Intelligence |
The ability to display tact and sensitivity. The ability to deliver bad news. The emotional maturity to remain professional, and explain the best course of action |
Professionalism |
Direct contact with the general public can be challenging, particularly when they are worried, are sick, are emotional or stressed (as explained above). Professionalism, at all times, means avoiding circumstances where the ability to treat patients is compromised |
Organised |
Using organisational skills to manage multiple patients , with varying needs, prioritising critical cases and having the flexibility to deal with ultra-emergency cases |
Attention to detail |
Unlike almost any other role, slip-ups can be fatal if they go unnoticed. Even small errors can have huge consequences |