Maslow On Call – an inverted pyramid?

It may seem that the medical registrar on call is floating around serenely on a cloud of medical knowledge, ready to dispense advice left right and centre, and all the while coordinating the take so that the consultant knows where each patient he or she is responsible for, and what the plan, progress and prognosis is for each, all whilst maintaing their composure so that they appear unruffled, stress free and in control.

Well it may seem that way, and I am sure, for some that it really is like that. But, for mere mortals like myself, it is hard work. Sometimes really hard. Managing multiple patients at arms length, ensuring that the sickest get the right amount of attention but that those who have the potential to become sick are not allowed to deteriorate, and to ensure that those who are beyond cure are offered as much dignity and comfort as we can muster. Oh, and trying to keep the medical students entertained, the juniors educated, and the seniors informed. Yeah – there is lots going on.

What I have noticed recently is that my cognitive abilities, and the quality of the information I am able to convey about cases, and the acuity of my decision making seem to deteriorate significantly if I have not eaten, drunk or rested at all in the 13 hour shift. There are a few studies looking at the basic human functions which are monitored in patients – but in ‘normal’ controls of the staff looking after them – and the results are not exactly encouraging. A number of the junior medical staff on call at any one time could be classed to be ill by standard indices used to monitor their patients.

Maslow proposed a hierarchy of human needs in 1943. This is often represented as a pyramid, with the ‘basic needs’ of food, water, shelter, sleep and excretion at the bottom, and levels encompassing safety, love or belonging, esteem and finally self-actualisation. The self-actualisation strata contains ‘problem-solving’ ‘morality’ ‘creativity’ ‘lack of predjudice’.

The experience of junior doctors on call (and a number of other professions in the hospital) often includes a denial of the basic needs in an attempt to keep up with the demands of the job. This is in spite of the fact that to really perform at the best of their abilities, they should probably be satisfying all of the lower stratas of the pyramid to reach the higher functions of problem solving and creativity. Perhaps an inverted pyramid more accurately describes the priority given to each layer of the pyramid by on call staff.

It is not clear that doctors are ever going to adopt working patterns which allow them to always have water on tap, food available and time and space but it is important that we keep in mind the pre-conditions for high performance. Next time you see a doctor at work who is looking more like a patient than the person they are trying to clerk in, remind them that they owe it to their next patient to ensure that they are at least hydrated and fed – it really should not be an option when you consider the impact that they will be having on a person in need (or patient as we tend to like to call them)


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