“It was as though I wasn’t there”: the problem of the invisible patient

The CQC has published the results of its 2012 national in-patient survey. Some aspects of it were picked up by the Independent newspaper on 16th April 2013. One of the observations in the ‘Doctors and Nurses’ section is that:

There have been improvements in the results for questions asking about doctors and nurses, with the majority of respondents saying that:

Doctors (75%, up from 73% in 2011) and nurses (81%, up from 78% in 2011) did not talk in front of them as if they were not there.

 

What is the explanation for the other 25% who feel that their doctors did talk as though the patient wasn’t there?  

1) The doctors thought the patient was not listening, or not able to comprehend what was being said…but they were wrong.

The only way to avoid this would be never to speak to a third party (usually a colleague, often a relative) over a patient, even if they appear unconscious or severely impaired cognitively. That seems a sensible rule of thumb…but go to any intensive care unit and you will see very open discussions, concerning life and death, just feet away from sedated patients. It happens. Clearly, as medical practitioners, we are prone to falling into the trap of underestimating the degree of cognitive function in patients who appear, externally, to be unengaged with their surroundings.

 

2) The doctors conducted technical, impenetrable discussions with colleagues without taking in account the patient’s bewilderment.

Here I would like to mount a defence of doctors. On a ward round there are several tasks that have to be achieved. Most, but not all, can easily be followed by a non-medically trained person.

  • Greeting and introductions
  • Ascertainment of the patient’s current symptoms, feelings and concerns,
  • Confirmation of what has occurred thus far during the admission
  • Physical examination if appropriate
  • *Review and scrutiny of medical investigation
  • *Interpretation of above data
  • Agreed plan (in context of patient’s goals)
  • Communication of that plan to the patient

 

  • *Additionally, there may be opportunities for teaching.

 

The starred (*) elements may, in my view, evade the patient’s full understanding. This is because the language used will contain technical terms, Latin or Greek derived terminology and a cascade of acronyms. I experienced an example of this recently – there was patient with ‘the best bronchial breathing you’ll ever hear’. I explained to the patient that he had signs of pneumonia, asked him if the FY1 (the most junior doctor) could listen with her stethoscope, and had the following discussion with her and the team:

            ‘What did you hear?’

            ‘Loud breath sounds.’

            ‘How did it compare to the other side?’

            ‘Louder.’

            ‘Just louder?’

            ‘Different.’

            ‘I would say clearer.’

            ‘Yes, it was.’

            ‘And do you know why?’

            ‘The lung is solid…’

            ‘And that’s called….?’

            ‘Bronchial breathing’

            ‘Yes! Well done. And then you might look for other signs such as increased vocal resonance, vocal fremitus, signs that the sound waves are being transmitted through solid lung rather than open alveoli…you might see air bronchograms on the chest x-ray…Mike, what was the white cell count and CRP?”

            “12.8 and 87.”

            “Strep antigen, has that been sent…”

            “No. But he’s on Co-Amox and Clary…”

 

And it’s moved completely out of the patient’s sphere of understanding. I look down, aware that we have progressed onto discussing his laboratory results, and treatment…the mini-teaching session has segued into person-specific details, and the patient does not have a clue what we are talking about. If he was asked to comment on a survey he might well say, ‘They talked as though I wasn’t there!’

 

How do we avoid this? Vigilance. Being aware that every single word uttered will be heard and reflected upon by the patient. Any unguarded word. Comparisons with other, historical patients (‘…you remember the man we saw last week, on intensive care, he had the same signs…) may lead the patient to fear that they will follow the same course. Mentioning a theoretical differential diagnosis (‘…this could be tuberculosis, or a tumour can cause compression and distal collapse…’) will cause them to dwell on all the terrible possibilities. It’s just not possible to talk ‘freely’, even though there may be a purely medical justification in considering other diseases or treatments.

 

Two solutions to improving our conduct during those starred sections are:

            a) always use non-technical language

            b) move away from the patient’s bedside.

 

There are problems with both in my view.

 

a) efforts to avoid technical terms during conversations with colleagues often result in a pseudo-medical, strained and patronising tone, or in asides that contain semi-interpretations . For instance, ‘…we mean the lung has gone solid, from the pus in the air-sacs…it’s a normal finding, in pneumonia…fremitus, that means the sound vibrations are felt on the skin…’. Many patients would actually appreciate such interpretation, as it provides an insight into their own condition. Within reason I would support it, but, to be honest, it is the student or house office we are trying to teach about physical signs, not the patient. Certainly in communicating the interpretation and plan such non-technical terms must be used, but in their right place I think the ‘code’ that doctors use is necessary.

 

b) moving away can be cumbersome. It may also give the wrong impression, that something more grave is being discussed in secret. Afterwards, the team must go back to the bedside, so an additional awkward phase, wherein the team trundles off to the corridor or nurses’ station and then trundles back is introduced. To do that with each patient on a 30 patient ward round is probably unfeasible.

 

We must find a way of making the patient feel involved while having a discussion that they cannot truly be involved in. This is a demanding expectation. Clearly, in 75% of cases, we achieve it. Perhaps it is in those cases where alert and interested patients with complex and subtle problems that seem to require prolonged technical discussion make up the other 25%. In these cases the acronyms and the secret codes go on and on, interspersed with concerned glances back to the increasingly concerned patient in his or her physically inferior position on the bed…followed by a brief, concluding summary that reminds the patient of one of those comedy sketches where a dishonest interpreter transforms a 90 second string of Chinese into a two word English phrase. It’s all about sensitivity and empathy in the end.

 

My take home message would be – Yes, sometimes it is necessary to talk in a way that will not be fully understood, but make sure the patient is forewarned about those portions of the visit, and make sure you check that their degree of comprehension has been addressed with a suitably clear interpretation. And don’t leave without checking that their questions and concerns have been dealt with.

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4 comments

  1. I just read this again.Going on my own experience I’d say,just say to the patient you are teaching as well as treating.anything to make them feel you know they are there and you acknowledge that.It can be distressing.I found Moorfields Eye Hospital the worst in my personal experience

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