Month: February 2014

Messengers

In hospital medicine, long term relationships with patients are rarer than one might expect. During training (which lasts until your mid-30’s, and even longer for those who prevaricate!) it is unusual to stay in one Trust for more than a year. Becoming a consultant allows such relationships to develop, and this adds a depth of understanding and reward that cannot be experienced as a trainee. These are with patients who have chronic conditions, who attend clinic regularly, and who are occasionally admitted to the ward with complications; they comprise a small number compared to the thousands of ‘one time only’ interactions that take place each year. The irony is that while familiarity leads to trust and sincerity borne of shared experience, it is the fresh, short term clinical contacts that present the gravest clinical and emotional challenges. In these circumstances doctors must learn how to fast-track the communication strategies that will have already developed when meeting a long term patient. The classic example is talking to the patient with a new diagnosis of cancer.

In my mind breaking bad news follows a U shaped dynamic; constructive, forward planning allows the patient to be lifted from the despondency into which the word ‘cancer’ will have dragged them. By talking about what can be done, who they are likely to meet, resources and timescales…glimmers of hope may begin to permeate the gloom, and the certainty of death is diluted. The presence, ideally, of a cancer nurse specialist, reassures them that there will be continuity and reciprocal contact. Together we talk about the support that will be available, and the priority that will be given to their case.

But it is here that the limited nature of my role as ‘first contact’ begins to become clear. For however empathic my style, and however embracing my words, I know that I will have very little do with what happens from now on. As the patient (and family members, if present) look at me and the intensity of the situation burns its way into their memory, I know that it is not my face that they will be seeing in clinic. It will be that of the oncologist, or the surgeon (should the tumour prove operable). Already I am beginning to deflect responsibility to others – ‘the oncologist will talk to you about that…’, ‘they will decide if you should have surgery in a special meeting, the MDT…’ ‘You’ll get an appointment very soon to see one of the lung doctors…’

Sometimes you do meet the patient again – if they become acutely unwell. This might be due to chemotherapy induced bone marrow suppression and sepsis, an inter-current pneumonia; anything that requires admission via the ED. They might just happen to be admitted when I am on call, just as they happened to come in under my care the first time. There may have been an interval of two months. She looks worse. You read the notes, and catch up on all that has been going on. Appointments here, procedures there, PET scans, problems…  You wonder if any of the things you said came true. Did the oncologist discuss prognosis with you – did you ask him the ‘big’ question (‘How long?’) that you asked me? Did the appointment come through? Did you wait too long? Did the nurse specialist call you to keep you informed? So much has happened since that first shocked conversation by the bedside, curtains drawn, your husband leaning forward, staring at the tops of his shoes mutely…the day I broke the news and tapped into your deepest fears.

It is not possible to remain involved in every patient’s journey, especially when their illness falls outside our own area of expertise. The best we can do, it seems, is deliver the first message skilfully and with conviction, while hoping that the promises we offer are realistic, and the undertakings we take on behalf of our colleagues are achievable. Beyond that, we cannot realistically hope to observe their progress or influence their experience. Trainees on the ward soon experience emotionally intense interactions that seem to be over just hours or days after they have begun. A working week might involve many such micro-relationships, and learning how to move nimbly  – but not too smoothly – through this gauntlet of emotions is hugely important.

spokenunspokenPAPER

Now in paperback, click icon to explore

Advertisements

Frigidarium: on post-mortems, and taking the plunge

 

Frigidarium

Frigidarium of the Baths of Caracalla, Rome (built 212-216)

The history of medicine is starred with single-minded men and women who were not afraid to look into the cold bodies of those whom they had failed to save. They did their best, but saw the post-mortem as a final duty. Thus they learnt what went wrong, and moved on to the next patient with greater understanding . In the modern era, pioneers have had no hesitation in dissecting patients whom they have come to know well, in order to learn – the case of Philip Blaiberg comes to mind, the second person to receive a heart transplant performed by Christiaan Barnard (19 months after surgery, his coronary arteries showed widespread atherosclerosis, now recognised as a feature of chronic rejection). It seems unthinkable that such a patient would not have a PM.

There are two types of post mortem: those performed by coroners and those requested by hospital doctors. Coroners remain active (more so since Shipman) and regularly take on cases where there is uncertainty as to the cause of death, but their focus is forensic and not inquisitive. The results of their investigations are not routinely fed back to medical teams, and they do not have the time or the resources to approach corpses with broad-minded medical curiosity.

As doctors we can still arrange hospital PMs if we wish, but we rarely do (personal observation). Since the organ retention scandal at Alder Hey the consent process has become far more demanding, and the consent form [accessible via this site] for relatives is very detailed (if not downright harrowing). Bureaucracy and nervousness are possible explanations for the rarity of hospital PMs, but I wonder if there is more to it.

Speaking for myself, there is a stark contrast between the memory of a patient and the idea of their supine form giving up its secrets to the gloved hands of the pathologist. It is not mere squeamishness, but is, I believe, a more complex challenge. The cold plunge, from conversation one day to coarse incision the next, is shocking. Surely, the critic says, you are duty-bound to disregard such an emotional reaction, you must try to discover what happened. The 18th century, frock-coated and thick skinned physician in me thinks ‘Yes’… but the modern doctor, the one who reassured the patient on day 1 that they were looking at no more than a week in hospital, and who on day 3 began to talk about discharge dates, thinks ‘Wait… what good will it do him now?’  The sudden transfer from concern for the individual to the ‘greater good’ is too turbulent, too cold.

The emphasis in modern healthcare is, quite rightly, compassion, and this requires empathy – a form of connection. It encourages a move away from regarding the patient as a mere body, or a dynamic data set. There is emotional engagement. So when our patients die unexpectedly we experience shock, there is a compressed form of grief, there may be a hint of guilt…and while these muddy waters swirl across the scene, a question looms – ‘Shall we get a PM?’ Perhaps, sometimes, we need to regain some of that old fashioned, hard-headed hunger for answers, in order to catch the truth before it disappears forever. It is no easy task.

The good in him

heartblack

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.

oOo

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!”
“Mine’s urgent.”
“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.
“Soon. Soon.”
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?’

oOo

* 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

SPOKENcreatspaceCOVER

Students, you make us better doctors!

snow-white-mirror

 

As a medical student, I remember a consultant saying to me, “Watch what I do, take away what you like, forget what you don’t. Do that throughout your career and you’ll end up emulating the best of your trainers.” I found this strange, as it encouraged me to scrutinise the way senior doctors behaved. Now, as a consultant, I recognise that whatever I say or do is considered and judged by those I train.

This creates a pressure, to put across the best of myself. And that requires energy. So, if I walk into a clinic room and am told by the nurse that there is a student waiting for me, I may experience a brief “Oh…really?” Many students will have witnessed a slight deflation in the faces of doctors to whom they have been attached for the morning or afternoon – as though to say, “What a pain!” Their presence will change the way I conduct myself. I will have to be mindful of their need to understand and be involved with the consultations (otherwise they will become completely bored). And it will complicate my interaction with patients, should they appear hesitant or show signs of annoyance when I introduce the observer. What would have been a series of two-way interactions turns into into a three way, dual purpse conversation. All of this requires an investment of concentration and effort.

This apparent downside has advantages. Having accepted the fact that I have a student, I will move into a different gear. I become teacher and doctor. My behaviour tends to improve. If I find myself behaving less than perfectly, I will remind myself that the impression I am making is contributing to the development of that young student or doctor. They will either accept or reject my approach, not formally, not such that their impression will be fed back to me, but cumulatively. I do not want them to look back, fours years hence, and say, “Yes I remember seeing a consultant do such and such, and I told myself there and then that I never wanted to be like that with patients.” (We all have examples we can think of, I’m sure!) We only have to look back on our own evolution as students, junior doctors and middle grades, to recognise that the way we behave now is due to an accumulation of different experiences and different judgments. None of us want to display behviours that end up on the discarded pile.

What else does the student bring to the clinic or ward? He or she brings the need for clarity. Their questions have a habit of cutting through any pretence to omniscience that we may have maintained while trying to understand a complicated concept or disease. Just as a fallible maths teacher may crumble in the face of an apparently naive question about geometry from a 10 year old, so a medical student’s simple enquiry about auto-antibodies or cardiac murmurs can reveal the true depth of one’s true understanding. To avoid such discomfiture in the future, you may even go and look it up for first time in ten years. Sometimes, you find yourself explaining a complex situation to the patient and the student simultaneously. This generates a true sense of engagement, and can result in a successful scientific or technical interpretation, understood by both in plain language.

They can also work, quietly, to preserve our humanity, and perhaps such a simple quality as politeness. If I’m running late, it is easy to fall into a pattern of hasty turnarounds and compressed consultations. Any temptation to hurry the patient along will be countered by the knowledge that efficiency tricks and verbal ticks are being observed. I may know the patient has unanswered questions, which I ‘just do not have time’ to address. One look at the student’s face will tell me if I’ve been too hasty. Caught up in the ever-present temptation to hurry, the outsider’s expression serves as a barometer of decency.

Perhaps some doctors, supremely confident in the way they behave, are not influenced by the presence of students. Others may put on a performance, energised by the showmanship that expertise and hierarchy can encourage..although this can result in the patient being excluded from the interaction. It has to be remembered that the axis of primary importance in the room is that between patient and doctor, not doctor and student.

So having students around can be a good thing, for patients. And for senior doctors they are valuable too, as moving mirrors, passing influencers, potent in their ability to reflect back the best and worst of our ingrained medical habits. Saying that, I would not want to be followed by students all hours, all days. Because they require attention, they will necessarily slow down whatever medical process they happen to be observing. Sometimes it is nice just to get on with your own thing, in your own way, even if that does involve falling back into your own bad habits (or catching up on emails). But now and again it does no harm at all for someone to put a mirror in the corner. Sometimes that mirror will speak, and, venturing outside the comfort zone of silence, say ‘I thought you did that really well.’

 

SPOKENcreatspaceCOVER