Helen lay on a trolley in the Emergency Department. So far the care had been good. Her leg still hurt, but the staff seemed to be getting on with things – taking blood, injecting antibiotics, dressing the horrible wound through which bacteria had gained access to her system. When would they put her in proper bed though? They hadn’t yet decided which ward to send her to; that seemed to be the problem. The trolley was hard and narrow. Her arms were pressed against the cold metal of the side-rails. And the noise! So many people calling out or giving instructions.
A voice she recognised pierced the hubbub. A man’s voice, distinctive. It was the doctor who had come down to examine her leg. Her doctor! She could just about make out his shape through the gap in the curtain. He was on the phone, and he was agitated. She followed his words. Of course, Helen could only hear half the conversation.
“No. Sorry, but no. It’s not surgical, there’s no way this lady will need surgical management…”
“It doesn’t matter what the protocol says, I’m not accepting her. There’s no compartment syndrome, no bony involvement…”
“Well call my consultant if you like, I’m not taking her onto my list. There’s no indication. She’ll just sit on our ward getting antibiotics, my consultant won’t want to see her, she’s got other complex problems that need medical care… no!”
He hung up. A more junior colleague, a female doctor, joined him. He gestured emphatically in Helen’s direction and said,
“In future please don’t accept referrals like that. I’ve had to turf her back to medics, they started going on about what if she needs plastic surgery or debridement. We can come and give an opinion if her foot goes bad, but we’re not having her on our list. Waste of time.”
He walked away from the station and passed Helen’s bay. He kept his eyes down but Helen followed him with her gaze and made the briefest of eye contact when he glanced in. The doctor smiled weakly. He had no idea that she had heard him. He carried on walking, but Helen called out,
“Ah doctor!” He stopped and stood by the curtain.
“Yes Mrs Thomas?”
“So will you be looking after me? Am I going to your ward?”
“Errr… no. The kind of infection you have is best looked after by the medical team. I’m a surgeon, so I’ve asked that the medical team look after you on their ward.”
“I see. But they said I might need an operation on the wound. It’s very severe.”
“We can always do that later if need be. But you’re better off under the medical doctors to start with.” He moved on, but before he was out of earshot Helen muttered,
“I wouldn’t want to be a waste of time.”
The doctor slowed for an instant, then carried on. Helen had no idea whether he felt bad, embarrassed, or if he just didn’t care.
We all know that negotiation over the ownership of patients is a reality. Imagine if they could hear the arguments that sometimes take place. That is what I have done here – imagine a sad scenario in which a patient hears ‘her doctor’ doing his best to wash his hands of her. I’m not sure if such accidental indiscretions have occurred in reality; I suspect they have.
Medical diagnosis and early management are not clear-cut exercises, and working which teams should look after patients can take time. Robust conversations take place in which doctors explain why they should, or more commonly should not, take responsibility. If it’s a 50:50 call it can come down to pure assertiveness. Or, sometimes, the heartfelt intervention by a senior nurse who recognises that ‘Someone’s got to look after this poor lady! Sort yourselves out!’
It may be shocking for non-medical readers to hear that patients are not automatically welcomed onto the lists of medical teams. It sounds inhumane. Yet there can be good reasons. The worst thing for a patient is to be admitted under a team that is inexpert in the management of their medical condition. This can lead to delays, avoidable deterioration or even clinical disengagement. It is important to be taken over by the most appropriate team, but determining which team this is can be a struggle.
There are unseemly struggles behind the scenes in many customer-, client- or user-facing organisations. In acute and emergency medicine, where patients are by definition experiencing vulnerability and disempowerment, any sense of rejection is bound to have a very negative effect. So, doctors, next time you feel the need to argue over a referral and start horse-trading over individuals, imagine what impact your words might have on the patient, should they accidentally hear you!