Month: June 2015

Speed and compassion – the necessary juxtaposition

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Should a doctor feel guilty, or be criticised, if a patient walks into the consulting room and leaves four minutes later? (I think my record is two, if I am honest.) If I see a patient on a ward round and spend no more than three minutes by the bed, I do ask myself – on walking away – ‘where was the quality in that?’ Where was the care?

A typical day is peppered with such rapid patient-doctor interactions. The decisions made are about drugs, results, tests – the purely ‘medical’ side of medicine, and the information shared purely factual. However, every article one reads about patient-centred care elaborates on the work required to make a connection, to understand the patients’ concerns, to develop empathy, to truly understand in order to truly help. This complex process cannot occur during a fleeting visit. Nor even a series of visits. The fact is that much of medical interaction is devoted to algorithmic decision-making in response to the physical manifestations of illness. There is accuracy, there is safety, there may be ‘quality’, but there is little evidence of active compassion.

Behind each verbalised physical complaint there may be a flurry of unspoken anxieties. Those anxieties may be disproportionate to the severity of the illness (a 25 year old with food poisoning who worries they might have cancer for instance), but that lack of proportion is obvious only to those who know, the medically initiated. It is just this sort of patient who is likely to receive a very short visit on a ward round. Unless you ask, you won’t find out how deep their unease goes. So why not ask? Why not explore? There isn’t enough time. It is efficient medicine. It is fast medicine. Is it bad medicine?

Imagine the alternative. The universally compassionate doctor, intent on giving each patient a full opportunity to interact and expose those niggling concerns that would otherwise remain hidden and fester, might spend a good 15 to 20 minutes with each on a ward round. There may be 25 people to see. 15×25m = 375 minutes. Over 6 hours. That is unfeasible. Even 10 minutes (the average time spent per patient in a study on the use of a checklist, and a threshold mentioned in a Royal College of Physicians report) would result in 4 hours without a break – which is a stretch.

A junior doctor on a five hour ward round will become tired and lose focus. They will become anxious that there are only so many hours left in the day to complete the list of tasks. There will be less time to check blood tests at the end of the day, more jobs will be handed over to doctors unfamiliar with the patients, scans will be requested after the shutters come down in radiology. A consequence of spending more time at the bedside may be a sense of hurry away from it. There is a place for speed, it seems.

Most would agree that not every patient requires 15 or 20 minutes. Many patients expect nothing more than a quick update. If they have come in with a chest infection they may wish to know nothing more than the diagnosis, the treatment plan and the estimated length of stay. Others will require far more, and will not reveal their fears, or the impact that the illness is having on their lives unless time and space are provided and a degree of trust has developed. The experienced doctor may anticipate their questions. They may even coax them out, or formulate them, based on what he or she has seen before.

But speed is addictive. Everybody likes speed. It makes the place look efficient; it makes people happy. If the ward round can be wrapped up before lunchtime there may be time for relaxation and chat. The important administrative or multi-disciplinary meeting can be attended on time. If a clinic finishes promptly the nurses in outpatients will congratulate you.

The danger of developing a speed habit is that the default approach becomes little more than a fly-by, a surface skim, such that the visual or verbal clues indicating the patient needs more time are missed. This habit explains the experience of many – the worried or confused patients who ‘barely sat down before he closed my notes and discharged me,’ or those who report that their doctor ‘barely looked up from the computer.’ So how can one be fast and compassionate?

To achieve speed without leaving a trail of patients with unresolved questions and unvoiced anxieties, adequate time must be given to those who need it. The only way to do this is to be fast with those who can take fast (the simple cases and the easy cures, the untroubled, inconvenienced patients who are as anxious to leave as you are to move on), while remaining ready to slow down when the situation demands it. This requires a doctor to be adept at judging the deeper needs of their patients, and a willingness to step out the fast lane for a while.

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Destroyer of the faith

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A patient came to clinic with a sheaf of papers. In the four months since his last appointment he had researched the subject of allergies, found a private clinic and submitted himself to the most unconventional series of tests. The clinic sent him a long list of foods and substances to which he was supposedly intolerant, from ‘live oak’ to ‘cucumbers’ to ‘Penicillium, the fungus that produces Penicillin’. Based on these results he had scoured his diet for culprits and changed his lifestyle. But his symptoms persisted. He had evidently placed his faith and hope in this clinic. To me it was baloney. Yet here he was, seeking my opinion, and my validation of the answers he had found. It was a classic example of conventional medicine running up against a patient’s need to find solutions to unexplained symptoms somewhere, anywhere.

 

To incorporate these results into my management plan would have been dishonest, as I had no trust in them. However, to reject them out of hand felt insensitive, for they represented his laudable and sustained attempt to manage his condition (‘dangerous’ or ‘significant’ pathology having already been excluded by endoscopies and scans etc). What to do?

 

Negotiating a route between respect for a patient’s inclination to seek answers and the concrete wall of ‘evidence based medicine’ proved difficult. He asked how he should phase out various ingredients, when he should phase ‘cumin’ back in… I looked at the surreal report, at the list of intolerances, waffled a bit, looked up, and said,

“Mmmm… I’m not sure how much we can believe in this.”

His face fell.

“Oh. It had a good write up on-line.”

Then, to soften the impact, I said,

“Well, sometimes we aren’t quite as up to date as we could be, and I’m not saying there’s nothing in it, but I have never seen anything like this. I would be guessing if I gave you advice based on this.”

I put the papers down.

“It seemed really accurate,” he said. (Then why aren’t you better? I thought).

I wondered, quickly – what benefit is there in destroying a patient’s faith in something non-evidence based? His future health and quality of life was going to depend more on his sense of control over his symptoms than my ineffectual interventions. Yet, to support and encourage him on this journey into the world of unproven techniques and internet based analysis could be seen as collusion in nonsense.

He kept referring to the report. I studied it. The more I looked the less I believed. I chose to be definitive,

“To be honest, I can’t believe any of this.”

I lined the papers up and pushed them towards him. Then I gave some general advice, none of it likely to bring much comfort. He left.

 

I reflected. This man walked in with the rudiments of a plan. He walked out with a handful of (expensive) scrap paper. In denying the validity of his faith in those tests I had slammed the door on a route to wellbeing – an unproven route, but a way forward nevertheless.

 

This is the challenge. For every concrete interaction with ‘normal’ medicine, patients are likely to seek any number of alternative answers. As rationalists, trained to prize evidence above all, we instinctively reject such interference, but in doing so we risk rejecting our patients.

 

[some details altered to preserve confidentiality]

 

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In praise of the hole punch

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I once worked with a consultant who had worked with a consultant who, I was told, used to take patients’ case notes and dangle them by the spine. He would look disdainfully at the loose sheets of paper that fell to the floor and walk away muttering, ‘File them!’ Terribly arrogant, but I can see where he was coming from.

During their first 72 hours in hospital patients tend to move quickly, from the emergency department via an admissions unit to their allocated ward. Every professional who interacts with the patient writes an entry and files it. When ward rounds happen hastily and the highly educated ‘scribe’ rushes to complete the summary before his or her team moves on, this step is often missed. The file may be a temporary plastic one, without a clasp, or an ungainly brick stuffed with tattered and fading correspondence from the 1970s and 80’s. Where the new notes should go nobody really knows, and the patient is not in one place long enough for that essential person, the ward clerk, to sort it all out.

So I come to review a patient. I find the folder, a conventional buff set. The new papers have been serially slipped between the front cover and the first page. There are about twenty sheets, in some disorder. They are like a pack of cards, thrown down and swept up from the carpet – some are upside-down, some are back to front. The narrative is broken, the recorded facts are scattered. Crucial clues, be they clinical signs, blood results or subtle observations made by nurses… they are all there, waiting to be read, noticed and integrated into the whole. But until they find physical order, and until that order is processed by a medical consciousness, be it a consultant or another member of the team, they are useless.

I am not a tidy person by nature, but when it comes to notes I get pernickety. I have spent significant periods bent over notes, de-shuffling and finding the right place for various documents. In order to file paper, one needs a good hole. Holes are important, and I have made a study of them. Raggedy holes, made by poking those plastic binding spikes through the paper, are no good… the edges are soft and predispose to wear and tear. In a few days those sheets drift free and disappear. Sharp pencils make decent holes, but who carries a sharp pencil nowadays?! One can reinforce raggedy holes with bits of dressing tape folded over the page’s edge, or, in desperation, sticky name labels folded in the same way… anything, to reinforce the hole!

But the best way to make holes is with an industrial, unbreakable, unconquerable hole punch. How many times have I roamed the wards for such a prize? They scythe through paper with a mighty, emphatic press, leaving a true core of sharp-edged holes. And then… then the paper can be filed! All that the patient has given, their recollections and complaints, and all that has been unearthed during subsequent investigation, some of it legible, some not, lies ready to tell the story.

I feel better now.