Patient-physician relationship

Birthday party

Lonely birthday by Stephen Davies

It was time. After a week in hospital Mrs G, in her late 80’s, had failed to improve from a chest infection. Her frailty meant that the chances of making it out of hospital were shrinking. We were duty bound to discuss resuscitation. I knew what I thought: there was no way it would work. Before we entered the bay, I asked the team what they thought – all agreed. Was that their true opinion, or where they just following my lead? All one can do is ask. I looked to the senior nurse. She agreed too. It was not a difficult decision, medically. “By the way,” said the nurse, “It’s her birthday.”

            I approached the bed space. Mrs G was drowsy, but a hand on the shoulder and gentle rock caused her to wake. She had all her mental faculties, full ‘capacity’, as we say. I knew already that there were no family members living nearby. I started in the usual way, with a brief examination and review of the latest blood tests. Then I prepared to deliver my line – ‘I thought we should talk about what might happen if you get worse… if your breathing or your heart deteriorates… there’s a chance that your heart could stop suddenly… it’s called a cardiac arrest…’

            Her thin arm lay outside the sheet, and I glanced at the name band. The date and the month… today. There were no cards, no flowers. I paused. Was she even aware? “It’s your birthday,” I said. “Yes,” she replied, in a neutral tone. It had no significance for her. Birthdays are only as special as the people around you.

            Images of her as a young girl waking up in a state of excitement, 80 years ago, entered my mind. The juxtaposition between youthful health, optimism, a life not yet lived, and present reality… was stark. My words, formally raising the prospect of death, would symbolize the end of the dreams and ambitions she had nurtured. Perhaps most were fulfilled. I did not know.

            “Well, happy birthday anyway,” I muttered. She smiled weakly. We moved to the next patient. The tasks we had set ourselves – agreeing limits of care, completing a DNACPR form – were incomplete. “Not today,” I said to the team. “Not today.”



[Patient details changed.]


Anger management

The four humours


Riding into work, I watched the cyclist in front try to weave through the gap between a bus and the curb. The bus was in the cyclist’s lane, having failed to move out into the road properly after leaving the last stop. The cyclist couldn’t quite fit through the gap, and he smacked the side window with his hand. Then he shouted something unpleasant. The driver moved the bus out, the cyclist hurried on, and following through I glanced at the driver’s profile. He had the inscrutable, hardened expression of one who spends his days in the firing line, bearing the brunt. The cyclist’s abuse did not seem to register. The driver had acquired the ability to absorb negative energy without displaying any sign of impact.

I wondered… do we do this, in medicine?

Meeting anger (or its junior relations, impatience, frustration, exasperation) is inevitable when you work in the public sector. Customers, clients, or in this instance, patients, interact daily with systems that are both leviathan and byzantine. They come in fear for their own health or the health of a relative. Even when things go smoothly, from an organisational point of view, disease can lead to sudden changes, it can engender disbelief that nature can be so cruel, and cause unexpected grief… with the result that people feel angry. How could it be otherwise?

During an advanced communication skills training course, I learnt (if I did not know it already) that anger is not a primary emotion, but a sign of something else, usually fear of the unknown, or uncertainty. Sitting opposite an actor who recreated the tenor of previous real-life interactions with terrifying accuracy, I let anger unfurl itself, allowed it to fill carefully measured pauses, and drew out the underlying driver. To do this required active listening and genuine empathy, but also a little of the bus driver’s placidity.

The natural reaction, when accused, say, of disgraceful inefficiency, of trying to save beds, of ‘writing someone off’, is to defend oneself. It is tempting to tackle the issues forensically, and explain in detail exactly why a certain management strategy is being recommended. As the doctor, you have the details at your fingertips, you know your subject. You can easily out-argue an angry patient or relative with hard logic.

But to win the argument is not the aim. That will not win them over. The desired outcome is to let the person express their underlying concern, perhaps one they haven’t yet acknowledged even to themselves, and to help them resolve it. The route may not be pleasant, if bad news has to be given and its implications explored. The result may be quiet acceptance that this is life’s lot, and there is little more that can be done. Thus goes the narrative in which we calmly defuse a hot situation.

But there are times when the anger displayed is disproportionate to the situation. The underlying problem may not be fear, but an unrealistic expectation of how the clinical service runs. Or the hyperbolic reaction of an individual who is hard-wired to access fury at a low threshold. Doctors and nurses who work in Emergency Departments will know this.

In these situations, it is not always appropriate to absorb and to adapt. Sometimes it is necessary to respond, and to tell it how it is… if that can be done safely. On these occasions, the authority that resides in medical staff comes into play. ‘Sorry, that’s just not possible,’ or, ‘I’m afraid we’re not getting anywhere, I’m going to have to ask you to come back when you’re feeling calmer…’  Doctors are allowed to call out unreasonable behaviour. It is reasonable to display personality, and to demonstrate normal human reactions to challenging behaviour. In my experience this encourages the angry patient or relative to recognise that the person they are talking to is not a faceless representative of the larger organisation. They are probably doing their best. They can be injured by words. The situation is difficult for all involved, doctor or nurse, and patient. Let’s work it out together.

Perhaps, if the bus-driver he had been able to do so safely, he should have braked, stepped out of his cabin onto the road, and asked the cyclist to be reasonable. Or perhaps not; you never know what’s going to happen on the roads nowadays.


The gentle fiction


‘Through rose tinted spectacles’, by monstercoach


This time I was going to give the hard news. That was my agenda. He had been in out of hospital a few times, his cognitive and physical status fluctuating due to the underlying condition. There was no cure. So in they came to the clinic, husband and wife, beyond middle age but not yet elderly. I got into it quickly,

“So… the last few months, I’ve noticed, you’ve got weaker every time you’ve come in. The complications have been more difficult to get over. At home… you’re not getting out…”

He said nothing. Perhaps today was an off day, mentally.

“So we need to think about the future. What should we do next time you come in. And if you get really ill, an infection, or…”

His wife shifted in her seat.

I went on, using words I have used many times. About how there was only so much we could do if he deteriorated. About the possibility of spending his last days or weeks at home, if it looked like he might be dying. About things that might happen suddenly. Uncomfortable considerations, but necessary.

“But doctor, he’s doing OK really, isn’t he?”

What? Where was this coming from? I moved by gaze from the patient to his wife. She was winking at me. A classic, conspiratorial wink. No, I would not have this….

“Well, it’s important that we are very clear, and honest, about what we have seen over the last year. It’s been a downward trend…”

“But at the moment, he’s stable isn’t he? He’s alright.”

I looked at him. He was looking at her.

“Don’t want to hear any bad news, do we?” she said.

“No. No. There’s enough to worry about in the world…” he replied, laughing quietly.

I paused. The signals were clear. This was not the time to push it. So I changed tack.

“Well,” I continued, “To be fair, you haven’t been in for two months now. The new drug we gave you for the confusion seems to be working. And…” I turned to the computer, “Looking at your numbers, your blood tests, there hasn’t been much change there either. So yes, pretty stable!” I was getting into it now. The conspiracy of optimism. He needed this –  this gentle fiction.

We wrapped things up. I had achieved nothing definite in terms of anticipating how to handle future crises. We would have to see how it went. So much for my agenda. Perhaps that was the problem, developing an agenda in isolation.

“Back in two months then?” I suggested, “Unless you have to come in earlier.”

They walked out. There would be another time. Or, more likely, the hard truths although fully understood, would remain unsaid until the very end.


(Details changed)




Collected posts, Vol IV – click on image to view in Amazon

The Clean-Up operation

clean up


Julia had told the story of the heartless consultant many times. How he, a paternalistic but highly regarded specialist, broke the news to a patient that he had cancer in an overly matter of fact way before walking away from the bed, and, within earshot, saying, “Hopeless!” to the rest of the team.

Julia, very junior back then, thought the patient, Mr Field, had probably heard the comment, or at the very least seen the slow shake of the consultant’s head that accompanied it. The patient stared across the ward, and seemed to be analysing the half-caught words and the potent gestures, trying to calculate their significance for him. Julia attended the rest of the ward round diligently, but was distracted by the thought that Mr Field must be in some distress. She wanted to go back and check; what did he hear, what effect was it having on him…?

So at the end the ward round Julia rushed back to Mr Field’s ward and asked if she could speak with him. He agreed of course. Julia pulled the curtain round and asked, in the most open way she could, what Mr Field had taken away from the ward round. He knew he had cancer, and he knew what this meant – it had spread, it was incurable if not untreatable.

“And did Dr ________ say anything that worried you particularly?” asked Julia.

“No, not really, though I’ve got a lot more questions. He was quite brief.”

Thank God! Relief. He had not overheard the callous comment. Now Julia found herself in a tricky position. She had come back to ‘clean up’ the mess caused by her careless consultant, but in fact there was no mess to clean up. And to be honest Julia did not have the knowledge to answer all of Mr Field’s questions about treatment options and prognosis. She cursed herself for interfering, and cursed her consultant’s behaviour for driving her to come back and check.

Julia was used to coming back to patients – for the ‘clean-up’. Answering or mollifying patients and relatives after a consultant’s cameo performance, a mixture of information-avalanche from a great height, bedside teaching, and a communication style that did not meet the needs of the patients. She didn’t mind… the consultant couldn’t really be expected to deal with every query and anticipate every nuance of his patients’ particular psychological or social circumstances, especially in a limited time-frame. His phone was always going off, he was always late for some committee, he had high level responsibilities in the Trust that clearly occupied his mind when he was supposed to be focussing on individuals. He wasn’t that bad… just a bit thoughtless during the one-to-one sometimes.

Nevertheless, Julia walked away from Mr Field’s bedside and swore that when she was a consultant there would be no such faux-pas.

Some years later Julia became a consultant. She made sure that her ward rounds were protected from other business and worked hard to relate to the patients. At the same time she acquired other responsibilities and developed as a clinical researcher. One day, eighteen months after becoming a consultant, she was on a ward round. A 72 year-old woman with advanced lung disease had developed an ‘acute abdomen’, likely dead bowel. The surgeons weren’t keen to operate, but she would certainly die without it. Julia, a chest specialist, reckoned the risk of dying after surgery, from lung complications, was 40-50%. A classic ‘rock and a hard place’ situation. Julia went to see the patient, who was alert and understood everything. Just before entering the cubicle Julia’s phone rang – she answered. Another patient whom she hoped to enter into a research study had arrived downstairs for the final consent meeting. Julia had another important commitment, a one off, in half an hour. The morning was getting tight. She entered the cubicle and explained the situation. Certain death vs a 50% risk, if we can get an anaesthetist… so what do you think? Will you agree to surgery? The patient looked away, unsure, confused. Julia glanced at her watch – just a tiny tilt of the head.

“OK… Mrs Taylor… it’s a hard decision, we’ll leave it a little longer for you to think about it… perhaps wait for your family to arrive, discuss it with them.”

Julia left. Her team followed her, not sure what the next step was. Julia looked at her registrar,

“Can you come back in an hour and try to reach a conclusion, I’ve got to get going.” Then she walked away, her registrar by her side, and added,

“To be honest Diane, I don’t fancy her chances either way. Fifty percent may be optimistic. But the choice is… definitely die, or probably die. It’s a pretty hopeless situation.” As she said this a young man in everyday clothes passed them. He paused, then moved on.

Julia saw her research patient and attended her meeting. Then she walked back up to Mrs Taylor’s ward. There she found her registrar, SHO and a ward matron in with the patient, who was crying, and her son – the man who had walked passed her – bowed over the side of the bed holding his mother’s hands. Julia backed off and asked another nurse what was happening. The nurse replied,

“After your ward round we heard lots of crying… apparently one of the family overheard someone saying it was all hopeless… we had to get your team up to calm everything down, they’ve been here for an hour.”

Julia stood by the nurses’ station and looked into the bay. The clean-up operation was in full swing.


three covers

‘That’s not my area’

that's not my area

An account, written for the Guardian by an elderly patient’s daughter, described how nobody treated her as a complete person in hospital.

“Nobody will look at the whole of me,” my mum said on her third stay in hospital this year. “It’s like a department store. You go to a bit of it and they say, ‘Sorry we don’t do that here. We just look at this.’ Nobody is interested in my legs.” Her legs were massively swollen, dry and cracked and purple-black by this time.

It was a heartfelt cry for holistic care. And it touched a nerve in me, because I have heard and received similar accusations in my role as a hospital consultant. It got me thinking – What is expected? What is it that patients want?

The answer might seem obvious: Doctors and nurses who do not focus on individual systems or organs. Teams who address their patients with respect, as people with a past, a social existence, a meaningful and self-determined life lived for many years before circumstances forced them through the door of the hospital. All lovely… but what specifically? Patients want their thoughts and ideas heeded, their opinions acknowledged and taken seriously while treatment plans are formed. They want medically ‘trivial’ complaints given as much time as major diseases, as it this these that can irritate or reduce quality of life just as much. They want clear feedback on the innumerable tests. They want to know the plan and comment on it. They want to know how long it will all take. These considerations do not seem revolutionary; they seem nothing more than… decent. Nevertheless, it seems that we often fail in delivering such unspectacular aspirations.

As a consultant I am always careful to explore the broader reality beyond the defined limits of the specific organ or bodily system that has broken down. Well I try to. This approach is not entirely consistent, because there are times when a rigid focus on the area of danger has to be maintained. Patients and families understand this, I am sure. If the patient is bleeding rapidly from an ulcer, or crashing with heart failure, I may fail to probe the subtleties of their understanding and defer the social enquiries. Later, when things have calmed down, there may be time to develop a more three-dimensional understanding of the whole person.

There are other reasons why medical interactions in hospital may not feel holistic. Hospitals work by bringing specialists to the bedside in order to answer specific questions. The frail and elderly patient who has fallen, and who has multiple symptoms related, say, to a failing heart, diseased lungs and arthritic knees, might be found to have a blocked kidney. The opinion of a urologist is sought. Only he or she can give an expert view on whether an intervention is required to unblock it. They arrive at the bedside. They are pleasant, they are caring, but they have one thing on their mind – to answer the question. They will take all the facts into account; the frailty, the risks of anaesthesia, the opinion of the patient, the opinion of the next of kin if they are present (and especially if there is dementia), but they will stay focused on the urological issue. And should the patient, at the end of the consultation, ask if anything can be done about her painful knees, the urologist may well say those fateful, unpopular words, “I’m sorry, that’s not my area.”

All specialists have said this. It is no good pretending to be able to give an answer to the question. One can express an interest, but it is little more than a politeness to do so. For the knees, if symptoms cannot be controlled with simple analgesics, you need a rheumatologist or an orthopaedic surgeon. Another specialist. Another visit. Another focused consultation. Another floor in ‘the department store’, as said in the Guardian article.

How to make these consultations happen without leaving the patient feeling like the chap in the picture above who has his organs picked out, examined and put back again? Perhaps it’s about presentation and coordination. What I would want is a lead physician who comes round and sums it all up for me. Who draws specialists in to the ward when required, who assesses the advice that is given and sifts it for common sense. And in addition, perhaps, an experienced nurse who can answer some of the questions I feel too inhibited or embarrassed to ask the doctor when they came round. Like, ‘What is a urologist anyway?’

That sounds like a fair model. It is a clear aspiration, as summarised in the Royal College of Physicians ‘Future Hospital’ commission report;

Patients will receive the best specialist care wherever they are in hospital. For patients with multiple and/or complex conditions, there will be input from a range of specialist teams according to clinical need, with a single named consultant responsible for coordinating care.

It seems we are not there yet. ‘Hospitalists’, general internists who take an overview and coordinate care, may be the answer. In the meantime, geriatricians will often assume the role, for it is patients under their care who typically have multiple problems.

So finally, in response to the Guardian article, while I recognise only too well the phenomenon of ‘that’s not my area’, and admit that much specialist work does occur ‘in siloes’, I do not accept that patients are routinely managed in a non-holistic way. It’s not what I see happening around me. Most hospital care, I would maintain, is delivered in context, and with an eye to the complete picture.




A now traditional Christmas Carol-esque cautionary tale for busy doctors, which also owes something to another, less esteemed cultural influence…


Jim, a thirty-something medical registrar, stared out of an eighth floor window into the lifting darkness. With dawn came the prospect of home, and the end of his fourth night on call. He thought about going to the pub on his way back, but decided against it. Beer, at 9.30AM! What a mess.

A patient called out to him. Jim averted his gaze, the time-worn method of avoiding engagement with those who might distract him from more urgent tasks. But he was doing nothing, just staring at the city’s transition below, so he answered.

“Can I help you Sir?”

“Here, here.” growled the old man. Jim liked the look of him; there was humour in his eyes, a spark of cynicism.


“Come here lad. I’ve got something to tell you.”

“Go ahead. I might get bleeped away though.”

“No, you won’t.” The tone was oddly prophetic. With a thin arm he directed Jim to make himself comfortable on the bed. Then he began…

I was a doctor you know? I was. I don’t tell people when I come into hospital… at 85 I know very little that would help, medically. But I know how people should be treated. I’ve been studying you… Jim, isn’t it. You’re at the top of your game aren’t you. Slick. I’ve seen you field questions, referrals, crises. You know a hell of a lot, and you think clearly. You’re fast too. I was fast. I could get round a huge ward of patients in a couple of hours, I could see twenty-five in a clinic. At your age. Then… I changed. I slowed down. I annoyed those in charge of the hospital, I caused a backlog, but I had to, you see. Want to hear why?”


“I was doing a ward round. A man grabbed my hand, a bony hand it was – just as I grabbed your attention a moment ago. He pulled me down so that his mouth was at my ear, and he said – young man, you’re gliding, you’re gliding. Like you Jim. You glide. You’re fast and you’re smooth but you never touch down. What did he mean? He meant… I wasn’t connecting, wasn’t engaging. I wasn’t leaving anything behind. I was fast yes, I made the right decisions, mainly, but after I had left the patients they could barely recall the interaction. Do you remember seeing me yesterday Jim? Vaguely? You were in and out in a flash, focussed entirely on the medical facts. I was impressed, you made the right diagnosis and changed my treatment for the better, but I wanted to talk to you… about something else. I started, but you were already turning away. Teflon. Smooth. You didn’t realise I had something to say, because you were not open to the possibility of anything obstructing your serene progress through the ward. Leaving nothing behind…”

“How can you leave something behind with every patient? You’d be eaten away.”

“Nice image! Like piranhas eh? No, no. It’s exhausting, it has to be. If it’s not exhausting you’re not doing it right. It’s called empathy, and it costs, in the short term. And to do it you have slow to down, and touch the ground.”

Jim nodded, not exactly in agreement, but too stunned to object.

“Anyway, just a little bit of feedback! Off you go Jim. Get home.”

Jim stood up, ashen faced. He murmured his thanks and walked away. When he arrived at the nurses’ station he turned to look at the old man, the gnarled old physician with bright eyes. The bed was empty.

“Talking to yourself were you? Bit tired?” asked a nurse.

“Possibly. Possibly.”

And he walked home, slowly.


book2 coveramazon


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.


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Tempting fate: the perils of reassurance

keats and pinion2

Keats as drawn by Benjamin Robert Haydon, and a bird’s wing (with pinions)


A patient comes to the clinic with common enough symptoms – say a slight change in bowel habit and a single episode of bleeding. It could be a cough that doesn’t go away, or a lump in the groin, or a pain in the back that doesn’t settle – but something about it has led the GP to refer on to a specialist. By the time he sees you the bowels have gone back to normal and the bleeding has settled. You examine him – all is well, but nevertheless you explain that the only way to exclude anything dangerous is to do a colonoscopy. But he is anxious, and presses you.
“Do you think it’s anything serious doctor?”
“We need to wait for the camera test. It’s impossible to say without looking inside.”
“But what do you think doctor? Honestly.”
“I wouldn’t want to second guess the test.”
“Well you must be worried if you think I need it.”
“Your symptoms are a bit worrying, as your GP explained to you. And there’s no escaping the fact that the main reason we arrange colonoscopies in these situations is to exclude serious diseases, like cancer.”
“But you don’t think…”
“I don’t want you to be worrying excessively over the next few weeks Mr. Evans. But I can’t rule it out.”
“Oh God.”
“Look. If you pressed me, I’d say that the fact that you haven’t had any bleeding or loose stools for 6 weeks, and your normal blood tests…suggest you’re probably OK. Lots of people get symptoms like yours and in the end we find nothing. But we must wait. Sorry.”
“That’s OK doctor. I feel better now.”

And two weeks later you see him again. You have already been informed that the colonoscopy found a cancer. Mr Evans had a staging CT scan yesterday, and there are suspicious lesions in the liver. It’s terrible news, although, in an era of highly effective chemotherapy and adventurous liver surgery, not necessarily a terminal diagnosis. He looks at you rather coldly. The hopes that you allowed him to develop, leading up to the colonoscopy, have been brutally dashed. You discuss options, plans, schedules…

Was it a mistake to proffer an opinion? Isn’t that what doctors are for? Nine times out of 10 your impression, your gut feeling as to the seriousness of the diagnosis, would be right; perhaps more than that, probably 99 out a 100. And by giving some encouragement, albeit with caveats, you ensure that many patients suffer less anxiety, or spend less time in unhealthy pre-occupation with their impending tests and results. And in 99 cases out of a 100 that encouragement proves well founded, until…you get it wrong. Then it feels as though you have misled the less fortunate patient – colluded in their natural wish to see the bright side, contributed to the trauma of the sudden, more precipitous fall.

After one of these experiences, you will be more guarded. For the next 6 months, the next year, you will maintain an inscrutable front, until, having received numerous negative test reports, you dare once again to reassure an anxious patient who comes with seemingly innocent complaints.

– – –

Sweet Hope, celestial influence round me shed

Waving thy silver pinions o’er my head.


Keats, To Hope, February 1815

– – –


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Making deals: the problem of the self-discharging patient

There are times when a patient’s dissatisfaction stretches the therapeutic relationship to its limits. Take this example – a man of 32 survives an eight day admission on the intensive care unit, for, say, pneumonia. He is discharged to the ward, but develops a pneumothorax – a collapsed lung. In the middle of the night a chest drain is inserted, he improves, and the following day his team come to see him on a ward round. The drain is out. What happened?

“I sat on it…the tubing.” This happens.

“OK, we’ll arrange for another one to be inserted this morning.”

“I don’t need one. I’m going home today.” Of course, the clue was there – he has dressed himself in his usual clothes.

“Well, John, that’s a bit premature. Your lung could collapse down again at any time. We were advised to keep that drain in for a few days at least, to make sure it wasn’t still leaking.”

“I’m fine. Listen to my lungs.” He lifts up the front of his shirt.

“I will, in a moment, but let’s just  agree on today shall we. You will stay, won’t you?”

“No. I’m going. I’ve already called my mate, he’s picking me up during his lunch hour.”

“We can’t…look John, if you go home there’s a good chance your lung will collapse and you’ll be as ill as you were overnight. It wasn’t good, was it?”

“It’s not going to happen again. You can’t tell me it is. Doctor, I’ve been very reasonable…very patient, with everything you’ve asked me…”

And so it starts. The suggestion, that we, the doctors, have somehow imposed on him.

“…I let you put me to sleep, go on the ventilator…two weeks I’ve lost, I’ve got people I need to see, things to do…”

As though the decisions we made were to inconvenience him…

“But I’m better now. They said on intensive care that the infection has gone, someone my age can get better a lot faster than…some of the old blokes you’ve got in here…”

“They were right. But it’s not safe at the moment. If it does collapse, you’ll be just as ill, if not sicker, than you were…”

And undo all the work that we have done!

“I’m grateful doctor. But I’m going. Today.”


What next?

I have heard all of the following categories of response in this type of situation. Some sound wrong, but are understandable; some are morally right but medically unsafe. Which would you choose?

A. “This is a hospital, not a prison…” The classic riposte. It’s true of course, treatment is entirely voluntary, and a patient, having been informed about the risks, has the perfect right to walk away. To me this response (which, I’ll admit, I have been driven to use) represents a complete breakdown of the physician-patient relationship. It is a surrender, to the complexity of the challenge. You might as well say what you’re thinking, which is ‘Fine, I’m DONE with you!’

How does this conversation end? Often, with this – “But you will need to sign a self-discharge form.” This may crystallise, in the mind of the patient, the fact that responsibility for what happens to them from that point on is all theirs. It is a form a brinkmanship, watching to see if they change their mind as they write their name. Brinkmanship really has no place in good medicine.

B – “We’ll let you go…but you must understand, if you do deteriorate your bed will be gone, you’ll need to call an ambulance and come to A and E…” The blackmail. By describing how difficult it will be to re-engage with the hospital you hope to dissuade him. You avoid invoking the emotional angle, emphasising how disappointed you are that all the ‘hard work will be undone’, but the loss of ‘the bed’ signifies this. The bed is the symbol of the care that they have received, and by losing it to another patient they sacrifice the therapeutic bond that duty and need forged between you.

John’s departure will be semi-condoned, so as not to require a self-discharge letter. But this is risky, from the point of view of the doctors, for if John does collapse and die on the high street, the medical team will have no documentation with which to defend themselves. By maintaining a relationship they open themselves up to criticism.

C – “I understand John, I’d want to go if I was in your position. But give us 24, 48 hours…please. That’s all we need. Then we’ll get you home, I promise.” The bargain. A false one at that, because you have no idea what the next day or two will hold. He may require another chest drain, or worse, transfer to a cardio-thoracic unit… it’s a lie (albeit well intentioned) to promise anything in medicine. You have paid for his compliance by making a commitment that you may not be able to fulfil. The push back, in two days, may be all the more intense.

D – “I understand John, I’d want to go if I was in your position. Let’s see what we can work out.” And you go on to explore a true compromise. He goes home, but you arrange for him to come up to the ward every day for a quick check over; or for the SHO to call him, to make sure he is still breathing well; or for the GP to do the same. A truly personalised approach. It sounds like good medicine – it takes into account his specific concerns, his anxiety to get back to work, his need for freedom!

But is it realistic? By making these arrangements you create extra work and unusual demands on your team, or the GP. John needs to be monitored or he does not; and if he does, he needs to be in hospital. Simple as. What sounds and feels reasonable may actually be unreasonable, even if it does maintain the therapeutic relationship.

E – “I understand that you need to leave. But let’s think about this…let’s put it into perspective.” Thus speaks the philosopher. You go on to explain, ‘John. If you don’t make a full recovery from this you could be in and out of hospital for weeks, months. If you can just spend some time focussing on your health now, even it takes longer than you’d like, you can get better properly and avoid longer term problems. Then, a year from now, looking back on this time it will be just a blip…you’ll be back at work, with it all behind you.” Such subtle mind-tricks can work, because they are, in fairness, reasonable. Patients who cannot accept their ill health, who continuously resist management plans that will entail longer periods of hospitalisation, might benefit from the odd dose of perspective. The danger, from the doctor’s point of view, is that of sounding patronising. After all, it’s not you who are away from work and family for weeks on end. The problem with this approach is that it doesn’t change a thing, materially.

Finally, there is the approach that fewer doctors, in busy wards, confronted by aggression or apparent ingratitude, will take; that of sitting down, ignoring the rush of oncoming clinical traffic, and exploring what it is, really, that troubles the patient. For there is bound to be a source of stress, be it financial, inter-personal or domestic that can be identified and addressed. Perhaps it’s an addiction; perhaps it’s their turn to look after the kids this weekend. To find out what it is requires an ability to ignore the simmering anger, and to understand the emotional heat created when illness afflicts younger generations who are use to running their own lives quite satisfactorily in normal circumstances. A tall order, that only the most disciplined can succeed in – and on a good day at that.




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The patient as riddle


‘Speak friend and enter’ – riddle on Westgate of Moria (Fellowship of the Ring)

Recently a patient said to me, ‘Thank you for taking an interest.’ This compliment reveals a whole world of problems. It says, in ascending order of alarm –

  • Up until now no-one has been interested
  • I’ve been looking for someone to invest their time and attention in my problem
  • …because until someone takes an interest in you, things don’t get done
  • …and if you don’t manage to find a doctor who is interested in you, you’re on your own
  • Will anybody actually engage in my problem if I’m not interesting?

So what role does interest play in the patient-doctor relationship?


A patient enters the clinic room. Another referral, another challenge. But the referral letter includes some tantalising pieces of information, and the patient describes how an unusual symptom developed three weeks after returning from, say, Bolivia. Sparks of interest meet the kindling of barely remembered lectures on tropical disease; you search your memory, plan some investigations. After clinic you make a special effort to expedite a scan or ensure that a special blood test is sent away to another lab. The game is afoot. The game? Is this really a game?

Doctors are problem solvers. There are many problems to solve in medicine, and until you qualify those problems are generally intellectual – a combination of pattern recognition when presented with pathology, and cross referencing disparate physical symptoms or signs with the huge database of information that has been created during your medical education. At his or her purest, the useful doctor is an inspired search engine, able to discard irrelevant diagnoses and focus on the probable, before seeking confirmatory data to back up the initial hunch. In training the focus is knowledge and its application. How many doctors reading this, as students,  left a ward full of ill patients in a huff, muttering, ‘No signs, no signs!’?

But the first day on the wards presents very different problems to solve, such as how to prioritise an unmanageable list of jobs, how to persuade a radiologist to perform a CT scan in the desired time frame, how to placate the nurse who needs you to re-write a drug chart while you run off to an emergency. A job that seemed cerebral becomes predominantly organisational, and this can make some young doctors downhearted. Then, if you persevere, learn how the system works and become more senior, the opportunity to make diagnoses and test hypotheses yourself comes around. You admit patients, see, hear and feel the signs that you once read about in books, and start to believe in medicine again! You begin to see ‘interesting cases’.

The high priests

What advantage do ‘interesting cases’ have? By virtue of the clinical features that these patients report or display, they generate energy. They stimulate conversations, the swapping of ideas, the easing open of dusty books (or more, likely, tapping into PubMed), the seeking of multiple opinions…the chase is on to get the right answer and find the right treatment. While such focus is commendable, if not vital in some urgent cases, the price may come when doctors get carried away in the search for jigsaw pieces that fit the puzzle and lose sight of the person before them.

In ‘5 patients’ (available to read for free here) the late Michael Crichton wrote about the game that can play out when a student or trainee and their supervisor spar over the meaning of various clues, and presented an impenetrable piece of dialogue as an example:

Student: “The patient has kidney disease consistent with glomerulonephritis.”

Visit (by which he means a resident or attending, I think-PB): “Was there a recent history of infection?”

Student: “Anti-streptolysin liters were low.”

Visit: “Was there a facial rash?”

Student: “LE prep and anti-nuclear antibodies were negative.”

Visit: “Were there eyeground changes?”

Student: “Glucose-tolerance test was normal.”

Visit: “Did you consider rectal biopsy?”

Student: “The tongue was not enlarged.”

The conversation ‘jumps from mountain top to mountain top’ as both parties demonstrate that they know what the other is referring to without saying what they mean explicitly. They are caught up in a trail of clues and deductions; if the patient were listening (as is often the case on ward rounds or teaching clinics), they would be bewildered. But patients do tend to tolerate such jargon heavy, exclusive exchanges, recognising that they are relevant to their own condition even if they are beyond their understand. In such scenarios paternalism, even sacerdotalism (whereby doctors act as mediators between humans and the unknowable mysteries of the body) rise again.

house white board     The whiteboard

A seductive game

As non-patients, we enjoy such games. Hence the popularity of TV shows like ER (created by Crichton) and House, where the plot is driven by a race against time to understand the relevance of various medical clues. Despite the human interest, the success of these shows depends on the writers’ ability to find a good medical topic, be it radiation sickness or the clichéd ‘lupus’, and set up a sense of jeopardy. The famous whiteboard, on which House’s photogenic team record their ideas, illustrates how medicine must, when pared down to its essentials, focus on the facts. The working title for House was ‘Chasing zebras, circling the drain’, zebras being rare conditions. House was itself inspired by the work of a New Yorker journalist, Berton Roueche, who wrote up real life cases of medical detection from 1940s until his death from suicide by shotgun in the 1990s. Eleven Blue Men (1953) presents 11 such cases, and is for sale in hardback on Amazon at £143! There is no doubt about it, doctors and non-doctors alike are fascinated by zebras.


The film Bigger Than Life, starring James Mason as a patient with polyarteritis nodosa who becomes addicted to cortisone, is based on Berton Roueche’s work.

It and Thou

Back in the real world the physician Jeffrey Ennis explored this progression from the factual to the holistic explored by reflecting on his own experiences. He presented to hospital with neurological symptoms such as shoulder pain and tongue numbness, which were eventually diagnosed as due to Guillain-Barre syndrome. He contrasted the attitude of the emergency physician, which he found ‘insensitive and depersonalizing’ with that of the neurologist, who was ‘comforting’. Ennis then invoked the philosopher Martin Buber’s categories of ‘I-It’ and ‘I-Thou’ relationships, and concluded his piece with this:

‘The physician-patient relationship is the vehicle through which such care is provided. In an I-It relationship, the patient and the problem are objectified, allowing the physician to collect and analyze data about the patient’s problem in an effort to offer a solution. Taken to an extreme, an I-It relationship can be dehumanizing.

 At the other end of the spectrum of human interaction is the I-Thou relationship, where the physician experiences the patient as an emotional being. This allows the clinician to empathize with the individual’s situation and to offier psychological support. Taken to an extreme an I-Thou relationship can result in the clinician becoming confluent with the patient’s emotional state. As a result of this, the physician becomes psychologically paralyzed and is unable to offer objective clinical assistance to the patient.’

Buber Martin Buber, philosopher

There is clearly a place for both, but they lie on a spectrum. In my mind the balance tips towards the I-It in emergency situations, where the jeopardy is greatest and the unknowns are numerous. Then, having achieved a degree of safety and stability, the doctor can move towards the I-Thou end of the spectrum. This approach might seem reasonable, but…it fails. It fails because patients are at their most distressed and vulnerable during that early period of uncertainty, and it is at this time that they need to see human qualities and a willingness to empathise. Traditionally, nurses have been better at recognising psychological distress in emergency situations, and have been able to compensate for doctors’ tunnelled medical vision. However, as doctors, the ability to retain an awareness of the whole patient rather than the just the relevant physical features can soften a potentially petrifying experience. Away from severe emergencies, the ability to keep an eye on the Thou without letting the clues in the It slip through unnoticed remains an important medical skill. Melding the two – forensic analysis and human warmth, always was a tall order.

The essence of satisfaction

Most conditions and presentations are easily recognisable and do not excite a fascinated reaction or the doctor to go to the textbooks. It is not acceptable for this majority to perceive themselves as boring in the eyes of their doctors. To each patient their own ailment is of paramount interest, and the doctor who fails to reflect a sense of uniqueness will come across badly. But for those doctors who derive genuine professional pleasure only from the interesting patients, a career in which the majority are not interesting may prove challenging. How to resolve this?

My advice would be – do your best to work in a field that you find interesting and enjoy the ‘game’ when you are required to play it. However, no specialty or department that I know of is exclusively populated by patients who succeed in creating those intellectual sparks. If it doesn’t come naturally, it behoves doctors to develop ways of deriving interest from patients in a way that does not rely solely on their medical condition. The rewards of making the right diagnosis are fleeting, because once made the process of arriving at it becomes irrelevant. It is treatment and management, which may be long term for chronic conditions (such as lupus, for example!), or barely effective in others, that really matters. Moreover, it is the patient’s wellbeing as a whole person, not a collection of affected organs, that is the true measure success. If we as doctors are not ‘interested’ in that, ultimate satisfaction will be denied.


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