The outlier

This imagined account of a patient’s dilemma is a sister article to the recent ‘Glances’

 – – –

I’ve never been one to make a fuss. I’m bad at complaining in restaurants, I accept poor service with a wince rather than robust criticism or demands for recompense. Shakespeare’s line in Lear probably applies to me ‘… he’ll not feel wrongs which tie him to an answer.’


One evening I developed indigestion after dinner – unusual for me. It didn’t go away, and then, overnight, a spasm of pain shot through my shoulder and into my left arm. This rang bells, and I called an ambulance. I spent three and half hours in the local emergency department, received several injections, and soon felt better. They were good to me, and explained that I would soon be transferred to a proper ward. It wasn’t a cardiac ward, but I clearly didn’t need to be in a specialist area for a single episode of angina.


I got there at two in the morning. I slept for no more than a couple of hours, watched dawn brighten the windows and waited to be reviewed by a doctor. I had it in mind that rounds would begin straight after breakfast.


Eight o’clock came and went. A team of surgeons (I asked a nurse who they were) breezed through in classic triangular formation; consultant at the front, increasing numbers of juniors and students behind. I knew they hadn’t come for me though, I didn’t need an operation! But it was at this point that I realized I was on a surgical ward. Of course! I had noticed various wound dressings, and pipes being attached to people.


Another, smaller, team arrived at nine o’clock. The two doctors, sans consultant I think, saw a few more of my fellow patients (mostly elderly)… but they didn’t see me. As they left I stood up to go to the toilet. I turned and watched the ward door close behind them with regret; I really wished I belonged to them.


By eleven o’clock I began to worry that I had been forgotten. I asked a nurse when I would be seen, but she did not know. “You’re post-take,” she said, meaning (I guessed) that I was new.


Half an hour later another team arrived. This one had an authoritative sounding consultant who listened to a précis of each case, walked purposefully to the patient’s bed space and shot the curtains along their runners with practised efficiency. He saw two patients and then paused to confer with the youngest member of the team. She held a list of names; I hoped I was on it. They started to move away. My reticence, my shyness, fell away. I had had enough. So I climbed out of bed, arranged the gown so as to ensure my dignity, and followed them. As they turned towards the nurses’ station I touched the consultant on the arm. He turned quickly. I said, “Excuse me, are you seeing me?” He looked at his junior and asked, “Are we, Rebecca?” She shook her head and said, “No. Not on our list?” “So who is my doctor?” I asked. “I’m afraid I don’t know,” said the consultant, “But you will be seen. Patients are seen every day.” That, I think, was his way of saying – ‘calm down, be good, let the system do its thing.‘ He had no idea how much it had taken for me to leave my bed and interrupt him…the consultant!


I was seen, at around half past one. The team told me how busy they had been. I was absurdly grateful. All went well, of course it did. Do patients ever get forgotten, or lost? I don’t know.

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Note: The term ‘outlier’ usually refers to ‘medical’ patients who are transferred to surgical wards, where the staff are more accustomed to looking after people who may need, or have just had surgery. You can also have ‘surgical outliers’ on ‘medical’ wards, where staff have less expertise in the more technical aspects of post-surgical care. Outlying occurs when there are insufficient beds for a particular group of patients, and the phenomenon is endemic in the NHS. It doesn’t usually matter, because the nurses have good general skills and the appropriate doctors are only a stone’s throw away. However, it is preferred that patients are located where their doctors are based, so that deterioration can be identified quickly and arrangements for discharge can be processed efficiently.

Problems with ensuring good care of outliers are a focus of hospital inspections (CQC), as evidenced by this release from The Queen Elizabeth Hospital King’s Lynn NHS Trust. The Royal College of Physicians, in its Acute Care Toolkit, focuses on the issue. Page 5 of this Board of Directors meeting from Royal Devon and Exeter shows how the numbers of outliers are tracked, and how their reduction seems reflect improved quality of care.

This post offers a small insight into the experience of being an ‘outlier’, albeit imagined by a doctor who has been touched on the sleeves many times with the question, “Are you seeing me?”


One comment

  1. Sorry to be so late responding this this post. A bit ironic I guess. A few years back my local doctor’s receptionist left a message on my answering machine while I was away for a few weeks, Returning I called the clinic and no one could track down the message that day so I just called every day for a few weeks until a note was “found” directing me to an appointment for further testing with my cardiologist’s intake person.

    Arriving I was informed a test I’d had 2 months before indicated immediate surgery but since I’d taken so long to answer the message the planned surgery was cancelled putting me on the in-hospital waiting ward. Officially I became, in Canadian classification of patients, a “walk-in” with “short expectancy.” The treatment I received was excellent and only after release (to early) I found out all post care services were not available to walk-ins.

    Second time I was miss-diagnosed for 5 weeks until all my organs had quit and was sent by air ambulance making me a “fly-in” I suppose. During dialysis I shut down and then became a “die-in” which I, suppose explains why I have to access services, again, on my own.

    I had thought to change my status in my new role as a cancer patient at a different care centre by being extra active in my care. No luck, the assistant oncologist yesterday berated my for “tying up the resources of the person assigned to be your helper” by asking for explanations about my care. In fact, it seems I’ve alienated the whole staff by his misinterpretation of something I said which he had placed at the end of my record, the rest of which he’d never read.

    As much as the medical system seems skilled, it seems also extremely fragile and out-of-sorts with disorder.


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