This post was inspired by two things – a talk at our hospital by Dr Umang Patel, Paediatrician and Clinical Transformation Lead at Aviva Health UK, during which he mentioned the ‘noble paradox’ where, to put it simply, good people end up doing bad things; and a paper ‘Culture, compassion and clinical neglect: probity in the NHS after Mid Staffordshire‘ (Journal of Medical Ethics, £) by Newdick and Danbury, in which the reasons why doctors appear as reluctant now as they ever were to report poor practice, are explored.
As ever in these fictions, I try to examine at a micro-psychological level, why doctors behave as they do. I do not presume to present a full or validated explanation.
Dev had always taken an interest in wider aspects of medicine; he had enjoyed epidemiology and public health modules at med school, he was tempted by the new focus on leadership in medicine, he looked at systems and wondered how things could be done better. After the Francis report, he asked himself, ‘What will I do if I see poor or uncompassionate practice?’ He did not know the answer to this, but knew that he would not ignore it if there were persistent or egregious examples. After all, hadn’t he read that ‘between 120 to 150 doctors must have known something was going badly wrong at Stafford Hospital yet few raised concerns through the proper channels’*
A few weeks after starting work as a Foundation Year doctor he became aware of a particularly uncaring nurse. She was abrupt with the confused patients, and scolded them occasionally. It was shocking to hear, but no-one else seemed to notice. Her manner did prove effective, as those she admonished tended to settle down and desist (for that shift, anyway). Dev was aware of no complaints, but, mindful of recent lessons learnt, promised to stay alert and take the uncomfortable step of reporting her, to someone, if things got worse. He would start by discussing it with his registrar. Perhaps today. He and the registrar had just completed a ward round, and Dev was being given his directions for the day.
“So that’s your mission. Get Mrs Wilkinson transferred. She’s been waiting over a week, the bed managers are on our backs, she’s getting tetchy. Spend a while getting the story straight in your own head, try to get through to the receiving team’s registrar and explain why he, or she, needs to expedite things at their end.”
“I’ll try. There’s lots to do for the other patients too.”
“That’s the trouble, we always have sicker patients to focus on and no-one has the time to devote their energies to situations like this. But today, let’s do it. I’m in clinic, but call me if they give you any grief.”
The registrar left, leaving Dev to contemplate tactics. It wasn’t such a bad day really, the in-patients weren’t too sick, there weren’t too many outliers. He walked into Mrs Wilkinson’s bay and touched her on the shoulder, waking her up.
“Mrs Wilkinson, it’s Dev, the doctor. Just to say, we’re going to pull out the stops today, try and get the transfer sorted.”
“I’d be so grateful. I know it’s not your fault, but I’ve been achieving nothing for the last week. I’m worried I’m going to have another attack before I get there, and be too unwell for them…”
“I’ll do my best.”
As Dev left the ward his consultant was walking in; she took him to one side.
“Dev, I’m sorry, but we’ve been singled out for being so efficient! Two clerking SHO’s have called in sick and they’re short down in the AMU. I had to put my hand up and say we were pretty much under control…and I volunteered you for a shift. Can you stay a bit over today, as the clerking shift runs to 8PM. And come in late tomorrow. OK?”
“Errr…OK, fine. Mike asked me to get something done urgently, might take an hour…”
“I’m sure that’s OK. If you could get down there by 11.”
Dev called the tertiary team. The necessary scans had not come through, so they had not been reviewed – hence the delay in the transfer. Dev was told to get them across straight away. He didn’t know how, but he would find out.
In radiology he waited patiently for an administrative assistant to come off the phone. The hospital to which they were referring Mrs W was not part of the usual network; the scans would need to be burned onto a disc and sent in the post.
“No way. That’s not acceptable I’m afraid. Can’t they be couriered?”
“We don’t do that here. Your department will need to arrange that.” Dev began to bristle. A familiar feeling of frustration began to build. The assistant told him in more detail what he needed to do. Two signatures, on a special form. His consultant, and the department manager…And the forms? We have them down here!
“Thanks. Will you burn the disc now?”
“I’ve got a load to do…look at this pile of requests!”
“They’re all urgent young man.”
The assistant left her desk to fetch him the form. Dev took his own request from the bottom of the pile and slipped it in higher up. He recognised the writing on one of those he had demoted; it belonged to a housemate.
Getting the scans away was just the first step. He would then have to tell the tertiary team that they were on the way, encourage them to seek the package, upload the discs, make a clinical decision, and get back to Dev with their final determination. His bleep went off.
“When can you get to AMU Dev?” It was the on-call registrar, who had been given his name as a volunteer.
He plotted a course through the hospital: consultant’s office (or was she in clinic?), manager’s suite on the eight floor, back to x-ray to pick up the disc, then the post room, where, he assumed, couriers were arranged once all the paperwork was complete.
Dev began to run. He laughed at himself – it’s not even a crash call…it’s a package!
In the stairwell a physiotherapist was taking a stroke patient up a few steps. Dev waited patiently for space to appear by their side, and when it did he leapt forward, with precision. But three floors up he encountered the same situation. He waited again, then jumped forward. The toe of his trailing shoe clipped the patient’s walking frame, and knocked it from the step. The physio compensated, taking the patient’s full weight.
“I’m so sorry!” said Dev.
“Careful!” she retorted.
Dev collected the first signature, then ran down up a further two floors. Three people stood at a turn, blocking it, doing nothing. Dev paused, excused himself, excused himself again, then nudged past. One of them looked up. Dev saw that he was holding a map of the Trust, labelled in Hindi. Dev knew the language, but he looked through the paper, into neutral space, pretending not to have perceived the truth of the situation – that this family were lost. He ran on. Still so much to do. He obtained the second signature, the package itself, and by ten past eleven the slim parcel was waiting for the motorcycle courier. He rang the registrar in London, and was told to ring back at 4.45PM exactly. Later, and the registrar would be in the afternoon round-up meeting.
The welcome Dev received in AMU was effusive.
At 4.40PM the alarm on his smartphone reminded him to extricate himself and get to a Trust phone. As he walked through the AMU, busy now, always busy at this hour, a patient called out to him. It was 4.42PM. Dev approached the bed space. An old man leaned forward, confused but distressed.
“Water.” he asked. There was water on his bedside table.
“Water.” He had water. But he needed someone to put it to his lips. 4.44PM. “I’ll tell the nurse.”
He got to the nurses’ station. The phone was being used by another doctor. At 4.45PM it became free. Dev grabbed it. A nurse moved behind him, and Dev turned to alert her to the patient’s need for water. The operator of the other hospital spoke, and Dev focussed on the main task of the day – the transfer. As he waited for the registrar to respond to the bleep, Dev saw, through a glass partition, the family of the thirsty patient arrive. He watched as they fussed over their father and exchanged unhappy looks. Dev turned his back to it, embarrassed by his small omission.
It all worked out. Mrs Wilkinson’s case was discussed in the round-up meeting, and her transfer was agreed for the following day.
That evening four families shared their experiences.
An Asian family spoke about the rude doctor who ignored them on the stairs. It’s the little things like that, the father explained, that make a hospital’s reputation.
A physiotherapist, over her pint, talked about one of the good looking House Officers who was getting too self-important nowadays. He has been quite kind when he started, she recalled.
The son and daughter of a very elderly man asked how it was, in this day and age, that a thirsty patient could wait forty-five minutes before being given a drink. They had found him desperate, parched, and had held the cup and straw to his grateful lips on their arrival.
And Mrs Wilkinson, when her relatives arrived, described how Dr Dev had taken it upon himself to make all the arrangements, how he had refused to let it slip any further, how ‘personal’ didn’t even come close, and how nothing could beat the NHS.
When Dev next saw the impatient, seemingly uncompassionate nurse, he watched her work. She was working hard. He didn’t much like her manner, and knew that someone needed to have a word, but he looked back on some aspects of his own behaviour the previous day, and thought – ‘Who am I to criticise?’
* referenced in the Newdick and Danbury paper, from ‘Annual Accountability Hearing with the General Medical Council. London, House of Commons Health Committee, HC 1429, Session 2010–12: para 42’ Link