My adoption of Twitter coincided with the Liverpool Care Pathway (LCP) controversy. Naturally, I ‘joined the conversation’. The compact exchanges that followed forced me to examine and re-evaluate my views. The links to press stories (in newspapers I would not normally read) and blogs helped me appreciate how broad the spectrum of opinion is. The cases described in the media are enough to open anyone’s eyes to the risks, but the additional voices on Twitter, their views expressed vehemently at times, reinforced the fact that many more have witnessed, or at least perceived, poor practice. I am happier now to accept that the Pathway has not been used well universally, and perhaps, even though the pathway is intrinsically helpful, it needs to be changed to ensure better application. Nevertheless, because I have seen the benefits of the pathway, I have argued forcefully in its favour.
Engaging in the argument demands patience and moderation, because Tweets can be provocative. Accusations of murder are common, and for some this forms the backbone of their case against the LCP. It soon becomes clear when your interlocutor’s mind cannot be changed. The intensity rises, the argument gets personal. In some cases it becomes clear that the individual in question had a relative who died in difficult circumstances. Trust in the medical profession and the way it manages end of life care was damaged, and when things go wrong so close to home that damage tends to be irrevocable. Whatever the evidence, however overwhelming the number of voices in favour of the pathway, you are unlikely to overturn the misgivings of someone who has vivid memories of a relative dying in hospital.
Nevertheless, it seems reasonable to continue to argue, for Twitter is a place that gives you time to compose your arguments, and time to digest the points made by others. But here the difficulties arise. As doctors we are trained to sympathise and empathise with the relatives. When we talk with a relative of a dying patient we try to inhabit their point of view and understand what they are saying. If they are angry, we absorb that emotion. If they accuse us, or the hospital, or the system, of making mistakes, we do not challenge them; it’s not the right time. These are universal qualities of course, not restricted to doctors, but they are qualities that we have actively developed as part of our vocation.
This is why I find it difficult to maintain opposition to someone whose views are so clearly coloured by personal experience. In trying to overturn their doubts I fear that I am actually belittling their memories of a loved one. So, just as I would never allow myself to become involved in an argument with a patient’s relative on the ward, however much I disagreed with them, I am increasingly reluctant to have arguments with those who wish to banish the pathway. The same applies to those affected by poor care at Mid-Staffordshire, or relatives touched by medical error elsewhere. Doctors seem wary of challenging the validity of HSMR statistitics, knowing perhaps that Tweets may be read by families involved. It seems impolite. Does this reticence lead to a stifled, incomplete debate?
Perhaps doctors are too ready to adopt a ‘customer is always right’ approach. We often find ourselves speaking with people, be they patients or relatives, who challenge us. But we absorb the emotion, the occasional animus, the very rare invective; we step back, give it space, let it mellow with time. You can’t do that on Twitter, it’s about the here and now. And it’s loud. When doctors find themselves losing their rag, raising their voice, making it up as they go along, they tend to remove themselves from the scene. They disappear.