A few months ago I looked after a patient from eastern Europe who presented with episodes of confusion and weakness. He had lost a great deal of weight, and his skin had become pigmented* over the previous four months. His wife, ever present, was highly critical of the care that he received even though we arranged three scans and a lumbar puncture within 48 hours of admission. After five days I raised the possibility of heavy metal toxicity (he was an electrician, they are prone to Manganese poisoning), although the differential diagnosis was very wide. Deliberate arsenic poisoning was on my mind, but it was way down the list. Still, if you don’t think about these things you never make the clever diagnosis. That’s what I tell my juniors.
Twenty-four hours later his wife arranged overland transfer to his home town in a Baltic state. The two of them just disappeared off the ward. The doctor who received them emailed me, asking for a summary. Two weeks later she sent another message informing me he had died. A post-mortem was refused. The case bugged me. I had a strong desire to travel out there, find the town, walk into the hospital (a grey, functional building in my mind’s eye) and demand an exhumation. Or, at the very least, find some tissue, a hair off a brush, an old toe nail, something to analyse. But then, what did this have to do with me? Our local heavy metal expert did not think the clinical features were typical, and really, how on earth could I achieve anything? It was not my concern. House might have jumped on a plane, or sent one of his photogenic protégés, but here was no professional or moral obligation for me to discover the truth. I had reached the limit of my responsibility.
There are other occasions when I find myself trying to define the limits of my responsibility. I have a patient who is alcoholic, cirrhotic… he is likely to die soon if he does not stop drinking. I have referred him to the appropriate agencies, but they require patients to attend of their own volition, to demonstrate an ongoing commitment. He will not. His mother writes to me asking me to sort something out. What can I do? I write to his GP and to the addiction services; I detox him when turns up in the emergency room. But I can’t own his alcoholism. As he walks out of the door, temporarily mended, he passes beyond my sphere of influence. That’s the limit of my responsibility.
Now imagine this: I travel to that Baltic state and confirm that my patient was poisoned (by his wife?). Justice is done, based on my little hunch. Imagine I admit my alcoholic patient, detoxify him, counsel him, work on him with psychologists and addiction specialists (to hell with ‘length of stay’ pressures)…until he is freed of his terrible illness. A phenomenal result. The extra mile, the refusal to recognise conventional limits, the difference between adequate and exemplary. Should I?
A more quotidien example. I started a patient on a powerful new medication (Azathioprine) one week before going on holiday. Foolhardy perhaps, but he was keen. I arranged for him to have a blood test a day before his departure, and I promised to tell him if it showed any signs that the tablet was reacting badly with him. But I was away that day and asked my registrar to look them up. She remembered, but at the end of the day, just before heading home. The results were not good. His liver had become acutely inflamed. Referring to the computerised patient information system she found that his phone number was not listed. There was no way of telling him to stop the new medication. She sent me a text – passing the buck back to her boss! I worried about it that evening, and awoke the following morning no more relaxed. I e-mailed my secretary over breakfast, at 6.30 in the morning, asking her to call the GP at 8 am, her first task on arriving at the office. At nine, when I arrived in my off-site clinic, she e-mailed me the patient’s phone number. I called. He was walking out of his front door when the phone rang. The taxi was waiting outside his house. Situation salvaged!
On that occasion the limit of responsibility had extended beyond working hours into my mind, where the danger of the situation festered and ensured that I woke with a single mission: to contact him. It’s a fairly unremarkable example, but it illustrates how the limits of responsibility enlarge in proportion to the risks that we take as doctors, with our patients. Every junior doctor I know works late. It is habitual, and it makes a mockery of the European Working Time Directive. Nevertheless, shifts are shorter, handovers are more frequent, and it is important that juniors learn to balance the instinct to ‘complete’ with the reasonable pressure to drop what they are working on, ring a colleague and get home.
So, while learning how to erect professional boundaries, they must also recognise the situations that demand an extra effort. They must identify the problems that will spill over into their leisure time, distract them during the weekend, force them to pick up the phone despite their family’s disapproving murmurs, and satisfy themselves that their patient is being looked after properly. Not every week…just now and again.
* Yes, we excluded hypoadrenalism!