Month: March 2018

Two strikes – when the patient ‘Did Not Attend’

The nib of my pen hovers over the ‘outcome’ form*. In the lower third are various options; Follow up x weeks/months, Await results, Discharge, Refer to another consultant, DNA – rebook, and finally, DNA – discharge. DNA. Means Did Not Attend. The patient Did Not Attend their clinic appointment. A stark term behind which there may lie many reasons, some not of the patient’s own making. But the decision to discharge will terminate the patient’s relationship with this clinic, and with me. Responsibility for monitoring them will return to primary care, or may evaporate entirely. Perhaps their symptoms, or the nagging thought that there was unfinished business in the clinic, will draw them back to the GP. The GP will decide whether they need to be seen again by ‘the specialist’, and if so they will need to write a new referral letter. Then they will re-join the waiting list. The process could take months.

NHS Trusts have strict policies on DNAs. After all, 1 in 10 appointments are not kept, and you can’t keep offering them to those who don’t come. The National Audit Office reported that DNAs cost the NHS up to £225 million in 2012/13. Failure to attend means that a slot was wasted. Another patient could have been seen instead. One strike and you’re out, some Trusts dictate. Many consultants are more comfortable with two. The first time could have been an ‘honest mistake’, a slip, a simple oversight. Too harsh then, to strike them from the system on the first occasion. But a second missed appointment must surely mean that either they feel better and do not want to be seen, or they have moved, or they are just too busy and choose not prioritise their health over everyday life.

In a study of 73 patients who had missed appointments, the reasons given were:

  • Forgot to attend or to cancel (30%)*
  • No reason (26%) [I’m guessing they literally said, ‘No reason.’]*
  • Clerical errors (10%)
  • Felt better (8%)*
  • Fearful of being seen by junior doctor (3%)
  • Inpatient in another hospital (3%)
  • Miscellaneous other (20%)

I have asterixed the reasons that seem genuinely to ‘deserve’ a discharge. They make up 64% of the reasons (or ‘no reasons’), so at least a 3rd would be discharged entirely unjustifiably, based on this sample. Those who were subject to clerical error deserve the opposite – a new appointment at their best convenience. I wonder if that happened.

This is Mr Jackson’s 2nd DNA. I know him. He has been coming to the clinic for three years, with a chronic condition that requires regular review by a specialist. Something must be up. We get on well. He may feel healthy, but his condition could be changing beneath the surface. I worry that if I discharge him he will never come back. The pen moves to ‘DNA – re-book’. But… but… why waste another slot when the chances are he won’t come back. The waiting list is long. Every appointment counts. I could call him up to find out why, but to be honest I don’t have time to chase up every DNA. I’ll write a letter to the GP stating that he didn’t attend and asking the GP to keep an eye on things. And another to the patient himself, to keep it personal. So, I’m not exactly severing all connection, but… I will discharge him. Discharges are important. Senior doctors have a duty to keep the lists turning over. And if he develops a complication, a cancer say, it won’t be my fault.

The Medical Defence Union has just published guidance on this subject. Pertinent to Mr Jackson, they say I should,

  • Respect a patient’s decision to refuse an investigation or treatment, even if you consider the patient’s decision to be wrong or irrational.
  • Explain any concerns clearly to the patient, as well as the possible consequences of their decision, and document your discussion in the patient’s clinical records

And that,

  • Previous knowledge of a patient’s circumstances, including the severity of their condition necessitating referral or follow-up, will need to be taken into account.
  • It may fall to a patient’s GP practice to follow up the patient who misses an appointment.

I circle the words, ‘DNA – discharge’. I dictate the brief letter to his GP: “I was sorry not to see Mr Jackson in clinic today. I hope that he remains well. It is important that he attends for regular surveillance. I would be grateful if this can be emphasised to him when you next see him, and I will write separately to him. For now he has been discharged.”

A bridge, a compromise, between bureaucratic imperative and therapeutic relationship. For all I know his family have taken him in to their home up in Yorkshire; or perhaps he has died. I don’t know. Or perhaps he’s decided that these appointments were a bit of a waste of time, as nothing ever seemed to change. He’ll find his way back, if he needs us. I’m sure of it.

Next patient please.

[Fictional patient]

 

* These forms (either paper or electronic), and the options available, vary between organisations.

The significance of children not attending clinics can be very different. Clinicians are enocuraged to use the term ‘was not brought’. This video explains why.

 

5th collection of articles, out now [click image to explore on Amazon]

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Introduction to ‘When Windows Become Mirrors’

 

  

When Windows Become Mirrors

The 5th collection of articles from Illusions of Autonomy

 

Dedication

To the readers of my blog who through their interest have encouraged me to keep writing for 5 years, and especially to those who have helped spread the word on Twitter, that powerful but mercurial invention.

***

This is the 5th collection of blog posts from Illusions of Autonomy. When I wrote the introduction to the 4th, A Hand In The River, I wondered if that would be the last. The frequency of posts had dropped, due I think to my increasingly specialised role – more interesting on the one hand, but less involving in terms of the everyday human and ethical problems that accompany general medical patients. But then things picked up. There were controversies around under-performing or frankly injurious doctors. Increasingly I reflected on the role of the senior clinician, and how you maintain the skills required to be a good doctor while spending less time on the front line. My perennial interest in resuscitation decisions continued to be prodded by difficult situations in my own hospital, and the frequently lethal nature of the illnesses affecting the patients around me led to reflections on how we (okay, I) communicate in busy and pressurised environments.

Windows into mirrors; reflections. The title of this collection comes from the long walks down dark corridors at three in the morning, when, coming from particularly difficult or stressful clinical situations as a trainee, I used to look in the night-blackened windows and see a haggard doctor who was unsure if he had done a good job. At those times, when our patients’ pathology insists on progressing while the pace of the great machine dials down in the dead of night, there is ample time for self-examination.

Part 1: Night & Day – observations on everyday behaviour in the hospital, good and bad…
Part 2: In Court – arrogance, negligence, and other sins
Part 3: Relating to people near the end of life – how doctors get it right & wrong
Part 4: Resuscitation decisions – not getting any easier
Part 5: Assisted Dying – a true battle of attrition
Part 6: Illustrated essays – on the history of truth in medicine, and how doctors respond after doing harm

 

Kindle (99p or equivalent), click here

Paperback (£5.99 or equivalent), click here

 

 

Checklist mentality

 

The case for checklists has been made so well – see this fantastic article by Atul Gawande – yet those responsible for embedding them struggle. They are an effort, an obstacle, an apparently petty imposition. I know it’s the right patient! I know they’re not on Warfarin! I know what equipment we need to do the procedure. It’s all so obvious. Yet, now and again, something goes wrong. Never events happen. (See the recent Health Safety Investigation Branch findings.) The wrong patient is operated on, the wrong tooth is removed, or an allergy is missed and a drug that is dangerous to them is injected. Checklists reduce these events, so what’s the problem?

My experience with checklists has been interesting. I am a proponent, a kind of champion, yet often I huff and puff as, on the brink of putting an endoscope down, the wretched piece of paper is waved at me. Grrrr!

The process of completing the particular checklist that we have developed takes a minute at most. It requires standing still (a problem when you’re in a hurry), focusing the team’s attention on the responses (for what is the point of the patient telling me they are allergic to something if no one else in the room is aware?) and communicating with the patient (a problem for some, especially when in a hurry).

Perhaps it’s this need to pause and be still that frustrates doctors and surgeons. We, they, like to keep moving, to flow through the tasks, to get to the nitty gritty (the technique, the findings, the pathology, the treatment) as soon as possible. It is this habit that is so difficult to break. It is a mind-set. And it reveals something about our approach our surgical lists. They are our lists. They have our names on them. Their character – relaxed, rushed, efficient, friendly, spikey, miserable – stems from our own behaviour and the clinical leads in the room. The checklist is an obstacle to our progress through the day and to a successful outcome. With this mind-set, the fact that it is the patient’s procedure can be forgotten; forgotten also the fact that around the surgeon buzzes a team of highly assistants without whom the procedure could not take place. The checklist is the best, probably only way to ensure that for a moment, everyone is focussed on that patient, and the last opportunity to identify possible harm is heeded.

Gradually, slowly, the checklist should become natural, and depending on your psychology, you feel that something is missing without it. We didn’t to clean our hands before and every patient contact; now, if I haven’t, I feel kind of tainted, as though there is something on my skin that hasn’t been taken off. They are clean of course, but the habit has become so ingrained my mind insists on the slap of antiseptic foam before moving on. In the same way, the checklist should become a door through which your mind insists on moving before embarking on the procedure.

I’m not sure I’m at that stage yet. If there are distractions, or if I am running very late, the checklist can be overlooked, until a colleague holds it up and pulls me back. I know that if harm does occur in relation to a surgical procedure, the absence of a checklist looks bad. Completed correctly, it serves to protect you, as the surgeon. It demonstrates that care was taken, and thought given to the patient as an individual, not as a ‘procedure’.

Most doctors and nurses are already converted. But the checklist mentality remains a change, and a challenge. As Gawande says, comparing the flair and fluidity with which surgeons like to move through their lists with the early astronauts from The Right Stuff,

‘…the prospect [of checklists] pushes against the traditional culture of medicine, with its central belief that in situations of high risk and complexity what you want is a kind of expert audacity—the right stuff, again. Checklists and standard operating procedures feel like exactly the opposite, and that’s what rankles many people.’

Expert audacity vs regimentation, again in Gawande’s words. This points to the same psychology I explored above. The audacity, the flair, the speed, all relate to the surgeon.

But it’s the patient’s procedure.