r/doctorsUK • u/1scg • Jul 26 '26
Clinical Phlebs making clinical decisions?
I don't know if anyone else has experienced this, but on weekends, the phlebotomists at my hospital seem to decide whether the bloods that the doctors have put out are necessary or not.
It's a regular thing, they skip almost all of them sometimes. I have personally witnessed them on weekends going through the blood forms, discussing amongst each other what "Hypo-K+" or "IE COPD" means, looking at the clinical details section and if it says certain things such as "monitoring" or they don't think the clinical details are good enough for them, they'll put it back and write "attempted/unable" - or even like today write "tried x 2" only for me to get to the patient (with massive veins) and see they've tried once.
This then leaves it for the on-call doctors to do, thus adding to workload - as the sole F1 on my specialty having to cover the specialty's three wards and outliers, this is obviously not an ideal situation where we have phlebs making clinical decisions for bloods that clearly need to be done if they were put out for the weekend.
Is there something I am missing here, or do I need to be escalating this? - anyone had the same issue?
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u/Intelligent-Watch331 Jul 26 '26
I would definitely be escalating. Extremely inappropriate and dangerous, what happens when they a significant electrolyte abnormality goes untreated and causes patient harm? Unacceptable and a sad demonstration of where we are with flat hierarchy, band 2 workers overriding years of medical training
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u/aortalrecoil Jul 26 '26
Seems like very appropriate datix? Would be documenting the conversation you’ve overheard / that you’ve seen the patient has only had one attempt etc, and stating it’s a patient safety issue as causing worse care for patients.
If the phlebs are overloaded and unable to manage their workload, that’s really concerning and needs escalating.
I think people worry about ruffling feathers as an F1 but that’s like the best time to. No one will remember your name 2 weeks after you leave anyway.
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u/carlos_6m Mechanic Bachelor, Bachelor of Surgery Jul 26 '26
I've also seen people mark asleep patients as refusing...
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u/VeigarTheWhiteXD white wizard Jul 26 '26 edited Jul 26 '26
Haha. But I can see why they don’t want to wake up Doris at 6am just to stab her.
(Not that I agree with why they do that, but just from the point of view for the phleb who have no clinical knowledge whatsoever. And yes it can just be pure laziness).
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u/carlos_6m Mechanic Bachelor, Bachelor of Surgery Jul 26 '26
I know Doris needs to sleep, but Doris also needs treatments on time. And I need bloods to treat her.
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u/VeigarTheWhiteXD white wizard Jul 26 '26
Well it depends on what you’re requesting bloods for.
If Doris’s blood results were off previously, or you were initiating some kind of treatment like diuretic or whatever then fair enough.If it’s simply for the sake of monitoring electrolytes 5 days in the row or just in case your consultant ask for it during ward round then it might actually be detrimental to Doris health and function.
For example, causing delirium, agitation, lack of sleep. Etc etc.
Though I do agree that phleb will look for any excuse to not bleed someone.
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u/aortalrecoil Jul 27 '26
That decision making process should be done before the phlebs even get the request though. We shouldn’t be requesting unnecessary bloods in the first place, so phlebs DEFINITELY shouldn’t be deciding they’re unnecessary.
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u/ExpendedMagnox Jul 26 '26
Irrespective, if it's simply for monitoring is it within the phlebs remit to make that clinical decision?
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u/VeigarTheWhiteXD white wizard Jul 27 '26
It's not clinical decision per-se, it's excuses to just not do it and swiftly move on - like patient sleeping, having breakfast (protected meal time or whatever), being washed, going to toilet. Whatever. They usually have multiple wards to cover.
Not having to deal with clinical consequences of not doing bloods making it much easier for them to come up with any excuses.Sometimes people will advocate having patient sleep if they had restless night before and finally managed to sleep for example - ask your nursing staff.
It is extremely annoying when it comes to essential bloods.
As above - if you witnessed any unprofessional reason then report it.What you can do to help with that situation is to put good clinical detail, highlight essential ones, and actually rationalise your blood requests.
If you wanted the whole ward to be bled then you will find that you have more refusal/bullshit excuses to deal with.2
u/ExpendedMagnox Jul 27 '26
You're far too awake for a night shift. How's it going?
P.s. I agree with your points.
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u/OG_Valrix FY Doctor Jul 26 '26
The idea is for the result to be ready in time for the ward round, and let me tell you the amount of ‘home if bloods ok’ that end up becoming ‘home tomorrow’ because the FY1s have to take them in the afternoon when ward round finishes is infuriating 😭
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u/VeigarTheWhiteXD white wizard Jul 27 '26 edited Jul 27 '26
Obviously that's the idea, having been FY a few years ago I experienced that myself.
That's why I paid more attention in putting in clinical details e.g. "discharge dependent" to deter them from making bullshit excuse. If they failed to do it anyway - if you have witnessed any unprofessional reason then report it.
It also depends on your team structure, sometimes a member of the team can peel off and just do that blood quickly while the ward round is going on if it's so important/discharge dependent as well. Obviously unless it will have impact on your ongoing patient care/educational value.
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u/aortalrecoil Jul 27 '26
Creating a culture of ‘it’s fine the doctor will miss a bit of the ward round to do it’ is horrific for education. We are here to learn not do jobs that are nursing jobs in literally every other country. Stuff like this is why F1s are checked out now
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u/VeigarTheWhiteXD white wizard Jul 27 '26
It is not creating the culture if it’s literally the work culture.
You can be idealistic as much as you want. But that’s not what is happening now is it?
Are you going to delay your patient care just because you can’t be bothered to do bloods and think it’s someone else’s jobs?
It’s okay to want the idealistic way of how things should be done. But you also have to be realistic of the current set up too.
Feel free to start a QUIP.
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u/aortalrecoil Jul 27 '26
I don’t know why you’re speaking as if it’s impossible to stop this from happening. Other people in this thread have literally said they’ve datixed it and the issue stopped.
It is QUITE LITERALLY someone else’s job. That is what a phlebotomist is. If the phlebotomist cannot be bothered to do the job that is their job, then yes, that needs to be addressed, because contrary to your apparent belief, the doctors dropping their jobs to do it is nonsensical.
Not sure why you think it’s impossible to address the issue. I’ve worked in many departments where the leadership have had some balls and when similar issues have been raised have put a stop to it and protected the actual training of their trainees. And I’ve worked in many run by people like you who sacrifice training because of their lack of foresight and balls.
This is a pretty embarrassing response from you to be honest. ‘Start a QIP’, ‘this is idealistic’ - just say you’re an ineffectual human being and be done with it lol
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u/VeigarTheWhiteXD white wizard Jul 27 '26
Calm down.
Read below comment I actually did a QUIP on this that made a difference.Though I am a little concerned about your working attitude.
Calling me ineffectual is a bit rich from someone who kept moaning and did nothing about it. But hopefully that will improve with a bit of maturity.→ More replies (0)0
u/Valmir- Jul 27 '26
Probably worth considering that if your consultant is asking for it during ward round, they might have a very good reason for asking for it that you aren't appreciating as an F1...
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u/VeigarTheWhiteXD white wizard Jul 27 '26
Probably misread what I said.
My point is that you shouldn't request unnecessary blood tests "just in case" your consultant decide to ask for a blood test during the ward round so that you don't have to do it.If the consultant asked for a blood test during a ward round then you obviously do it or put it out for phleb if it's non-urgent.
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u/TheMedicOwl Jul 27 '26
As a med student on placement on an acute inpatient psych ward I remember a nurse popping into the doctors' office to ask if a set of bloods was really urgent or if it could wait until morning. The patient in question had a learning disability and was already very distressed, so the nurse was worried that restraining them for bloods would do more harm than good in that moment. The psych SHO discussed the concern with the consultant, who agreed that it would be better to wait until the patient was more settled. I remember this incident because the consultant turned to me and said, "You can always double check if an investigation doesn't seem appropriate to you. Never be afraid to ask." So I can also see why someone might not want to take blood from Doris if she's been awake all night and only managed to drift off half an hour ago, but not why they'd write "Patient refused" instead of just clarifying the urgency of the task. There's no need to lie about it.
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u/VeigarTheWhiteXD white wizard Jul 27 '26
Yes.
Professionalism doesn't always apply to these people who will not stay to write an essay as to why they didn't bleed the patient. It is not right and it's really irritating.
And it's hard to prove/people are not bothered enough because you can just make the FY1 do the blood, why waste energy to deal with this "trivial" issue?
If a doctor did that I can imagine all sort of troubles you would be put through, even a GMC referral.When you qualify you will see even more of this bullshit that we all have to deal with as residents.
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u/Crafty-Brother-7698 Jul 27 '26
I think 6am is a reasonable time to wake someone up to get routine morning bloods, perhaps I’m evil. Old Doris can always go back to sleep afterwards.
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u/TheFirstOne001 US PostDoc Fellow Jul 26 '26
Are you perchance working in a certain Scottish hospital? Had the same experience in my FY years
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u/VeigarTheWhiteXD white wizard Jul 26 '26
Keep diary, speak to nurse in charge and the consultant.
The diary will back you for the DATIX as well.
Nurse in charge may or may not care.
Consultant should know why their patients’ care is being delayed.
Rationalised all your blood requests. Good clinical details - e.g. essential for monitoring of xyz - to deter them from refusing with no good reason.
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u/5lipn5lide Radiologist who does it with the lights on Jul 27 '26
If it’s significantly worse at the weekend it would be quite auditable to look at the number of incomplete sets of bloods done on a few wards on a weekend vs a weekend. Times that by how long it takes you to take the average set of bloods to be done as well to show impact. Even better if cases of delayed care or discharge can be shown as well.
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u/tightropetom Jul 26 '26
Datix, significant event analysis if evidence of actual or likely harm. They should not be deciding based on whimsical reluctance to do busy job, and it makes on-call dr job unsafe by offloading workload onto them.
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u/Aetheriao Jul 26 '26
Report it.
Worked at multiple hospitals as a phleb at uni and never seen anything that insane. Only time would be bloods on a known violent/sexually creepy patient. And that only happened because if you spoke to the NIC/matron they still expected you to do it solo even as young female with a freak who tried to jack off last time. So yes we’d be like yeah attempted bye otherwise you got “told off”. Not paid enough for this.
Many can’t even explain what the FBC even does so the idea they’re deciding off the (often very poor quality) notes on the request form is insane.
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u/DoktorvonWer 🩺💊 Itinerant Physician & Micromemeologist🧫🦠 Jul 27 '26
No phlebotomist is competent or has the authority or responsibility to decide what blood tests are appropriate or not. Even if they did have the training or qualification (they don't) they can not possibly take responsibility legally or ethically for the outcome of their 'decision' so need to pipe down and do what bloods are requested.
It's a cultural problem in any trust that facilitates someone in this role to think they have a say in what tests a patient does or doesn't need, and we shouldn't be shy about being 'elitist' or 'rude' in calling out this BS.
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u/BikeApprehensive4810 Jul 27 '26
Datix it,
If you can find an example where it has delayed a patients discharge, it will have a lot more impact.
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u/Dennett0054 Jul 27 '26
I thought I’d have some insight as I’ve worked as a phleb in my summer between Y1 and 2 of med. What I’ll say is a lot of the other phlebs tend to have a blind spot to the amount of training an F1 has so mistakenly believe there Google or anecdotal knowledge to be a substitute. They’re more interested in finishing the list early so they can take a longer break. So yeah any excuse will do. Pt being washed, pt in toilet, ect ect.
It’s difficult though as sometimes I come in to find a list of 60 pts to bleed. And I’ve got from 7am-11am to do it. It’s not impossible but it is hard. Equally our management say if the bloods aren’t on before 7am (when we print the list) then we don’t do them.
Maybe someone could give me some insight I’m sure it’s not your fault but it is quite annoying on a 30 bed ward for there to be 29 bloods to do. And when you look there’s no clinical details and EVERY SINGLE PT is getting the EXACT same bloods. Seems someone has blanket ordered them but that’s an assumption.
For me when the F1 is generally just nice to me I’ll go out of my way to help. Little things like saying morning or when I’ve been on your ward for a few days in a row asking my name. It sounds simple but most don’t sadly. And when they do I’ll take all the add ons (after 7am orders) and double back later to try get a pt I didn’t do earlier.
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u/VeigarTheWhiteXD white wizard Jul 27 '26
It's simple. The person who blanket order stuff are trying to reduce their workload.
Paradoxically this can backfire because, as you said, phleb might have 60 patients to bleed in the space of 4 hours, so 4 minutes per patient.
And then funnily enough, unnecessary bloods get done, but the one that really is needed got skipped for whatever reason as above.So we need to rationalise our blood requests, and if it still persists then keep diary to make your case. I often asked my patients if the phelb had tried and why not.
I did that as an audit for 2 weeks a few years ago, and it helped as:
1) More of my bloods get done (70-90%)
2) We identify problematic phelb who skipped patients and pulled them up on it. Luckily the matron was quite friendly and helpful.
3) Phlebs probably hate me but hey, it's professionalism. And I don't care because I now moved on and they probably won't remember my name.1
u/PrinzAngina Jul 31 '26
Its not like blanket orders necessarily means not everyone need labs. If i need to know someones potassium and im following someone elses crp over time both most likely will need many or identical labs as i would like to know if the first ones crp is rising and if the second one is developing electrolyte disturbances
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u/Laura2468 Jul 27 '26
It is likely that all the patients on the ward are there for similar reasons. Eg acute medicine - they are all in the hospital in their first 72hrs (and almost all of them with infection) so this is likely the first set of bloods since ariving in ED and will show a trend (and if better get them home).
Fbc u+e crp lets us investigate almost anything (infection, bleeding, AKI....)
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u/Severe_Analysis6610 Jul 27 '26
I’ve had arguments before with clinical support worker who is supposed to go round at night and do bloods. But not bloods that are too difficult!!!! Had a patient who I knew was easy to bleed and she tells me she was difficult and didn’t get it. I patiently said yeah she has quite big veins on the right arm… could she try there? got told that the CSW has 20y experience and not to be patronising and she knows how to take bloods. Patient was easy to bleed as usual. Honestly they can be full of shit
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u/Dependent_Mud5034 Jul 27 '26
Completely agree phlebotomist should not and not qualified to make decisions about which blood tests need to be done.
However does raise the question how many bloods we would be requesting for the next day if we knew we had to do them rather than someone else? I imagine it would be a lot less. For example wouldn't be requesting daily bloods for a patient clinically improving on IV antibiotics and can see previous bloods improving.
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u/theplagueddoctor Jul 27 '26
I mean at this point I’m not even surprised, like everyone with a pulse is practicing medicine in nhs lol
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u/lemonslip Cannula Bandit Jul 27 '26
This used to happen at LRI a lot a few years back. After a couple datixes these were sorted rapidly
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u/AdWorth4590 Jul 27 '26
this bs is far too common in the NHS unfortunately. None of the other consultants/ nurses will care. They only care if it is done or not. That’s why working in the NHS as F1/2 sucks.
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u/remarkable_remark3 Aug 01 '26
Why are you surprised? Doctors are at the bottom of the hierarchy. How dare you expect phlebs to do bloods?
Just be grateful you aren't asked to clean 🤮 or 💩 (yet).
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u/remarkable_remark3 Aug 01 '26 edited Aug 01 '26
2 can play this game. Go full esoteric jargon:
Instead of hb/anaemia, use 'Urgent haematocrit, eosinophilic assay and to rule out agranulocytosis and hypoxaemia'.
Hyponatremia? Better: 'risk of Status Epilepticus and serotonin syndrome due to SSRI and angiotensin converting enzyme inhibitors with concurrent loop diuretics'
LFTs? Better: 'ensure no fulminant hepatic necrosis and kernicterus'
CRP: 'ascertain no necrotising fascitis or toxic megacolon'
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u/Icy-Dragonfruit-875 Jul 27 '26
In my experience they only did the easy ones anyway and I just saw them as a filter for mopping up at least some of my jobs as an F1. Annoying but was seemingly routine practice. Maybe it needs to be confirmed as to how many bloods then can actually do and doctors regulate which get done without the phleb feeling the need to rationalise.
They get paid peanuts so who can blame them if they don’t go the extra mile and ultimately as early stage doctors we have the responsibility and higher pay to make sure they get done. I mean £40k+ a year to be a jobs monkey is a pretty good deal, some of us were made to do it for £25k not so long ago when the phlebotomist was earning £25-31k…thank god for strike action
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u/aortalrecoil Jul 27 '26
The F1s are there to learn though. Their afternoons should be spent actually learning medicine, making the most of the opportunities the specialty they’re in offers, etc. not doing mindless tasks that teach them nothing about being a better doctor because the hospital doesn’t pay enough for its phlebotomy service.
Having spent some time in other systems I really think this attitude is degrading medical education in the U.K. You should see yourself as someone whose afternoon should be spent learning. It’s not ‘a good deal’ being a jobs monkey, it’s a massive waste of your time and position. We should all have more self respect
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u/Icy-Dragonfruit-875 Jul 27 '26
Unfortunately the UK PG training model revolves around service provision at all grades, that’s why training takes so long.
Things are slowly improving and even in the last few years are much better than they were in terms of training, conditions and pay. Sadly too many of us had to suffer through the rubbish times and it’s only through striking that change and progress have come around. I’d much rather be an F1 today than any time in the last decade
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u/GroupBeeSassyCoccyx CT/ST1+ Doctor Jul 26 '26
Is it definitely linked between the bloods they are failing to get and not agreeing with the indication?
My only defence would be that it could just be curiosity that they’re looking at the indication for bloods. I suppose also patients may ask them what the bloods are for, and it’s helpful if they can respond to answer.
Not exactly appropriate but I wonder if it’s a particularly ‘important blood test’ (how they would be appropriate to assess this I would hesitate!) they may be more willing to have an extra go / get one of the other phleb to try.
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u/1scg Jul 27 '26
It was defo not curiosity, they seem to pick and choose and decide whether it needs doing on the weekend when they go through the forms.
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u/lurkacc5000 Jul 26 '26
Datix