I’ve been catching up on Professor Don Berwick, author of the recent NHS safety review. A powerful character, with a powerful, patient centred, emotional approach to healthcare – so emotional in fact that his audiences have shed tears, and readers have cried over his essays. He has said, of the patient-physician dynamic,
“Some say doctors and patients should now be partners in care…not so, I think. In my view, we doctors are not our patients’ partners; we are guests in our patients’ lives.”
The dinosaur in me finds it difficult to swallow that quote whole, and although I see the validity of the aspiration I know that it does not approximate to the truth for many doctors. In an (unsuccessful) consultant interview I was asked, ‘Who is the most important part of the team?’ I paused, thought to myself – ah, I know what you’re getting at! – and said, ‘Well, the patient.’ The questioner marked his paper and nodded; right answer…move on. Did he really believe the answer? Did I really believe my answer? Did he believe that I believed my answer – or was it all political correctness? My cool reaction to Don Berwick’s quote above set me thinking about the reasons why, for some, the doctor rather than the patient remains at the centre of the ‘team’. In this post I will explore the theory that perennial time pressure or overwork, a manifestation of understaffing, shifts the emphasis from one of duty (to the patient, to compassionate care, to perfectionism) to one of exaggerated self-importance on the part of the doctor. If humility is a necessary foundation to compassion, and pride can contribute to medical error, there may be something in it. It’s a subtle psychological trail – bear with me!
My time is precious and you’re lucky to have it
As an SHO I accompanied a consultant on a post-take ward round. He approached a young man who had been admitted as an emergency overnight. The patient was talking on his mobile phone. As my consultant neared the bedside the patient looked up, nodded and carried on talking. The consultant lingered for another 10 seconds, watched as the conversation continued, and turned away, saying, “That was it his chance to see me, and he’s lost it.” The whole team moved on, the patient had no idea what had happened, and he never benefited a consultant level review. I sympathised with my consultant at the time. Now, looking back, I think – hang on, you are only here because patients like him come into hospital. A consultant rejecting patients because they do not show due deference is like a shopkeeper throwing out customers – you are cutting off your own livelihood.
A more quotidien example? A Foundation Year doctor wakes a patient at 3 AM to take blood for a non-urgent but overdue drug level from a patient with difficult veins. The patient complains, verbally or non-verbally, and the nurse requests that the test be deferred to the morning. The FY says, “Look, I was asked to do this when I came on duty at 9 PM, this is the first opportunity I’ve had, this is my window of opportunity…” Once again, the emphasis is on the doctor’s convenience, on access to his expertise, and the patient must submit to his conditions if he wants to receive appropriate care. It’s not the doctor’s fault – he was seeing more urgent cases – but the system is personified in the doctor’s uncompromising expression.
This sentiment carries over into the outpatient setting. A patient rearranges his day to attend a 3.45 PM appointment only to find that the clinic is running 60 minutes late. He is upset. Behind the door the doctor feels harried and rushed. She has lost control of this one, not through indolence, perhaps because three patients in a row had problems that required more than their allotted 10 or 15 minutes. When the doctor and the delayed patient meet at last, both have a grievance. The patient dare not express his (at least not to the doctor herself) for his wellbeing depends on her inclination to do the best for him, to take the utmost trouble. The pressure of time warps a relationship that is already highly skewed in terms of power and vulnerability.
‘Her time is evidently precious, I’d better not ask that third question I was thinking about…I’m lucky to get any time at all by the look of this clinic…’
And for the doctor, what does the fact that this patient’s autonomy has been limited, compressed by the minute hand, mean? It means the patient is dealt with in 7 minutes…because,
‘…he didn’t have a serious disease, he didn’t need a twenty minute chat, and that’s OK, because, damn it, my time is precious.’
The overrun begins to correct itself, the sky begins to clear, all is well with the world once again. That is, from the doctor’s point of view.
The safety connection – ‘It will have to do’
The obvious link to make between time pressure and safety is that when tasks are performed in a rush, or in a state of fatigue or distraction, important steps can be missed or bodged. I think it’s more subtle than that. When doctors embark on practical procedures or a complicated analyses they are usually pretty focussed. But if that task is one of many that require completion in a set timeframe, and if the doctor’s presence has been eagerly awaited by the patient or ward nurses, I wonder if that sentiment – ‘You’re lucky to have me, I’m needed in another five places right now!’ – can foster a tendency to be satisfied with imperfect process, technique or outcome. No one can find a sterile gown…a nurse asks for 5 minutes to pick one up from theatres; the second drug chart is off the ward – can you wait a few minutes while someone fetches it? – ‘No, I’m in a hurry, I need to be somewhere else, it’ll have to do!’ It will have to do…the attitude that encourages compromise, the ‘normalisation of deviance’, the acceptance that harm is not only inevitable (which it is), but hardly worth trying to minimise.
The habit of self regard
In the days of 36 hour weekday shifts and 56 hour weekend shifts (9 AM Saturday to 5 or 6 PM Monday, no protected rest – the last time I did that was in 2002/3), the fatigue, clumsiness and emotional lability that built up during successive days and nights encouraged an inwardness, a continuous process of self-analysis and self-regard that made me the centre of each patient-doctor interaction. Sometimes this was appropriate, for example when preparing to insert a central line after 40 hours with just a few snatched moments of sleep on the sofa or the mess snooker table – it was a kind of risk assessment, am I up to this? But that habit, of wondering about how I was, how tired I was, how pressurised I was, has been a hard one to shake. It might have infected generations of doctors who now work in more relaxed circumstances, but who still approach their working day with an attitude of ‘This is how much I’ve got to give, I’m the important one here, take it or leave it.’
Service Starts Here
I was once told that in a United States hospital the staff wore name badges with little flaps which, when lifted, revealed the words ‘Service Starts Here’ printed underneath. When I heard this I laughed. It just didn’t make sense. Service? You call what we do in the middle of the night a service? We’re not hotel concierges, we’re doctors! But now, having read so much about how patients have suffered indignities or harms in NHS hospitals, I think I can see how a diminished sense of service can lead to a diminished sense of respect, for patients. The arguments above might go some way to explaining that. But it has to be recognised that lack of any resource leads to a seller’s market, where those have the expertise or skill that appears to be in such high demand can adopt whatever attitude they like. The patients will always come, they have no real choice in an emergency.
During my career I have witnessed huge improvements in junior doctors’ working hours, and I am hopeful that these will allow the sense of duty or service to thrive in future generations. I fear that for many doctors, whose formative years predated these reforms, the psychological consequences of being forever behind, forever tired, forever in demand, forever desperately needed, will continue to cast patients in the role of supplicants. In order to break down that sentient, and assimilate Berwick’s comment about being mere guests, it is necessary to downplay that sense of significance. As we pass through the lives of others, we need to tread carefully and take great care. They have not come to the hospital to see us, but to get better, and we just happen to be the ones they meet when they get there.
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