Medical relativism: on prioritisation, excuses and kindness

In a recent Clinical Medicine article, ‘Doctors and others: reflections on the first Francis Report(£) Professor John Saunders writes, ‘People do not go into careers in healthcare to be cruel…’ and yet, ‘many experienced commentators…have witnessed an absence of kindness: an attitudinal change that resulted in substandard care.’ How does this happen? How do we explain the spectrum of kindness shown to patients that results in some coming away from hospital impressed by medical staff and some feeling neglected, as though they were a bother or a burden?

The explanation must lie in factors related to medical staff and patients. Patients come as they are of course, and there is little point analysing their characteristics in the quest to understand the spectrum of kindness. So, what of medical staff? They are human, and they vary. Some express kindness better than others, but even the poor ones are nice some of the time. Some respond better to quiet, unassuming patients who appear grateful, while others show their best side to those who are more demanding and articulate. Some engage fully only when they recognise some special factor – a common link, a mutual acquaintance, an especially tragic set of circumstances, or the perception of professional risk. Some doctors warm up only when the disease in question fires their intellect. None of these psychological explanations are defensible…all patients should receive the same amount of kindness. However, for some reason, some patients appear to deserve more kindness than others. It is the perception of deservingness that I wish to focus on, especially its root in the unavoidable practise of medical relativism.

I remember working in A&E departments (in the mid 1990’s) where waiting rooms teemed with dozing patients and red LED displays routinely flashed << 8 hours >>. By the time patients were seen their agitation had transformed to resignation, crushed by a sense of powerlessness. On the part of the doctors, a ‘warzone’ mentality seemed to foster a ‘Don’t complain, you’re lucky to get seen…’ attitude. In this environment indifferent care could be delivered, or witnessed, but ignored. That was the just the way it was. Kindness did flower, because there were good people, but the pressure on the system did not allow those flowers to cover the ground.

I wonder if the embers of that attitude smoulder in the minds of older doctors (myself included) whose behaviours were patterned by a sense of continuous battle. I certainly feel it rekindle now and again…for instance when a patient complains for reasons that appear unfounded (about a delay, a lack of explanation, an early discharge). I feel sure that they had good care, and find myself thinking, ‘What are they on about? We did pretty well by them. It was incredibly busy, there were people on the ward who were far sicker, we were a doctor down…’ I have fallen into the trap of medical relativism, making comparisons between one patient’s predicament and another’s.

We make comparisons between patients every day. It is part of being a responsible doctor. It absolutely necessary to prioritise, to treat the sickest first (and more intensively) while leaving the less unwell for longer. However, patients arriving in emergency departments, or those waiting to speak to medical teams on the ward, are concerned about their own problems. They do not see the complete picture…and why should they? They are anxious and preoccupied. Given this, is it surprising that they begin to feel hard done by if our explanation for their delay in treatment or attention includes a comparison, between their situation and that of another. The nurse answers the bell 30 minutes after it was pressed, to find a soiled patient;

“I’m so sorry, I was just finishing the drug round…”

So it seems the drug round was more important that their comfort. Perhaps it was, who knows? But the patient won’t see it that way. Or a family attends the ward to discuss end of life care with the medical registrar, who is ninety minutes late;

“I do apologise, I got held up with a emergency downstairs. I asked the ward sister to let you know….”

So the sick patient in the high dependency unit is more important than the dying patient on the ward, or the family members who gathered together in the relatives room nearly two hours ago, tense, expectant, not knowing what to say. What are the family to think of this?

One simple solution is to avoid making overt comparisons. Some of us may do this already, because it feels like we are making excuses if we go on about our other duties. It doesn’t feel completely professional to explain why we are late, or distracted, or less than focussed…because we know that our stress isn’t their concern. The danger in this policy of concealment is that patients see only the instance of neglect, but not the context in which that neglect arose. We may have justified our less than excellent performance by medical relativism, but the patients only see the end result. They develop a sense of de-prioritisation, and are not impressed.

I wonder if unchecked relativism might contribute to the kind of rationalisation and dismissal that allowed poor care to thrive at Mid Staffs. For senior hospital doctors whose careers have seen patients progress from timid supplicants to consumers of services with enhanced autonomy (and very different expectations), it is vital that we make a psychological leap – one that should come easily to anyone who has ever had to receive hospital treatment. Patients don’t care what the man or woman in the adjacent bed has; they are concerned about their own problems. They must be reassured the solution to those problems is at the centre of your, their doctor’s, thoughts, and not being forever shuffled and de-prioritised by the constant influx of more ‘deserving’ patients.

I started to write this post before the inflammatory word ‘warzone’ surfaced in the media once again. On May 9th 2013, Dr Cliff Mann, registrar at the College of Emergency Medicine, used it to describe the current situation in UK A&E departments. As the rising pressure in A&E is transmitted to the wards, maintaining an impression of patient centrality, of an importance that is intrinsic and not dependent on the needs and demands of those around them, will become harder and harder.

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