Psychology of doctors

Omissions: reading the Kennedy report on Ian Paterson

 

This imagined reflection by a doctor who worked with Ian Paterson is, of course, ill-informed. I was not there. But I have read Sir Ian Kennedy’s brilliantly written report (2013), and think that the messages it contains should be seen by the wider medical community. The report is 166 pages long, but perhaps this ‘story’ will help introduce people to it.

In the excerpts from the reports that follow the reflection, I have removed the names of clinicians. However, it is all in the public domain. The Kennedy report focuses on Mr Paterson’s unacceptable surgical technique, and the NHS Trust’s slow recognition and response. It does not examine the unjustified operations and investigations in the private sector, for which he was recently convicted.

This article sits with two other posts, ‘Why Michael didn’t blow the whistle: pub scene’ and ‘The eyes and the ears: why Adam blew the whistle’. Like those, it explores a doctor’s internal battle of the conscience, insecurities and the concept of moral bravery in the workplace.

 

***

 

“I wasn’t directly involved, but I was in a position to observe. When he was suspended I wasn’t surprised; it was high time. The criminal stuff, that did come as a surprise. I had no idea he was doing operations unnecessarily. But this is less about him than us, as a group. About me.

“We knew he was no good. His reputation preceded him, and as time went on a few people discovered firm evidence that he was an outlier. So your question is valid – why didn’t we act sooner? Why didn’t I?

Ian Kennedy

“When the weight of complaint was sufficient, action was taken. But before that, for years, we did what Kennedy said we did in his report, we worked around him. That’s what you do with difficult personalities. A jagged rock in the stream, which will not be eroded. The water goes around it. Decisions were made without him. He was excluded from the panel when the second surgeon was appointed. They couldn’t risk having him anywhere near the process.

“I watched him in the MDTs. He led from the front, made decisions quickly, and helped to ensure that the huge list of patients was dealt with. Snappy assessments and decisions were necessary. The referrals never let up. From time to time the oncologists pushed back, about the type of surgery, the need for revisions when you’d have expected a cure… but their searching tones changed to resignation after a while. They had done an audit on the resection margins, had proven he was an outlier, but nothing changed. What could they do? And anyway, they, the ones who were at the receiving end, who knew the outcomes were not right, didn’t actually work in the same Trust. You could see their faces, a bit fuzzy on the video link during the MDT… and they just looked neutral.

“The signal had been raised, the data had been forwarded… they say we are all managers, but we aren’t.  We are clinicians who rely on senior managers to tackle the problems while we get on with our jobs, which is seeing patients. That’s what they are for, to review the whole picture and make a judgment call.

“Okay, you say, what about your responsibility as a doctor to keep the pressure on, in the face of managerial inertia and an ongoing threat to patient safety. Well look at it… there was an external peer review around this time, and it concluded that apart from needing a few tweaks, the service was sound. In fact it was congratulatory. Once I heard that, I began to wonder if we, the doubters,  were the ones who had got it wrong.

“To keep the pressure on in this kind of situation you need to have absolute confidence in yourself. It’s got to be more than a suspicion or a sense of unease. So, if you hear that a review or an audit has been conducted, and that the people upstairs see no indication for urgent or fundamental change, you back off.

“Yes, even if you know, in your heart of hearts, that he’s probably doing harm. Because the risk in keeping your head above the parapet is substantial – not that it will be blown away, the NHS is not like that nowadays – but that your everyday professional life will become deeply unpleasant. There is enough sadness in cancer medicine, in the illness and grief we meet daily. If your interpersonal relationships breakdown, if you can’t look at your colleague in the eye or have a conversation, then coming to work becomes miserable. You might say that a little bit of discomfiture is nothing compared to protecting patients, but it’s all a balance. We go through our careers observing colleagues who may well under average, but we can’t act to remove all of them. Half of us are below average by definition, aren’t we? Quality lies on a spectrum. Who am I to say, not bring a surgeon, where one should lie on that spectrum?

“I did think about raising hell, once. This was when I met a patient who had a recurrence in breast tissue that should have been removed first time. She was living proof that his surgical method was wrong. There in front of me was the embodiment of disappointment and suffering, and also of dishonesty… because when she consented to her mastectomy she did not know that his particular method, to leave some fatty tissue behind, put her at a greater risk of recurrence. She, and her husband, assumed that the person in front of them knew best, that the expert was an expert, and would only suggest a treatment that was effective.

“When I saw the situation from the perspective of the patient, I shook myself out of my comfort zone, and I went to speak to someone. I won’t say who. And that conversation cooled my anger. Another perspective was provided. It was explained to me… that he carried the service, that he was industrious, not lazy… which you can’t say for everyone… that the patients trusted him and that didn’t happen accidentally, that there was actually an infrastructure in place for monitoring people like him, called appraisal, which he flew through each year. I walked away from the meeting with a new understanding. I didn’t have to sacrifice my professional quality of life, I didn’t have to go on a mission to get this guy out. Others were aware of the ‘problems’, and they were generally happy that although he was an outlier, he did not lie far enough outside the norm to be stopped.

“And of course, they were wrong. Perhaps they were all looking at each other, talking to each other, and hearing the same thing. Echo chamber. There is no real problem here… so many patients treated… targets met. Targets met… the echo.

“When, as a non-surgeon, you look at a surgeon, there is a certain awe. It sounds childish perhaps, and I’m no worshipper, but I know – we all know – that the job they do, cutting into others, is different. It takes confidence and skill to get through the training. There are technical factors that the non-surgeon cannot hope to understand. The interaction between tissue and metal is a mystery to people like me, I can’t judge it with confidence. The outcomes yes, but not the technique. That requires others to come in a make a judgement. The Trust did that… and we did not see the conclusions, not for years.

“These are not excuses. I am not proud of my inaction. I accept I played a part in the acquiescence. If I had made more of a fuss, perhaps fewer patients would have undergone bad operations. But for all of us to watch for 8 whole years between 2003, when the first concerns arose, and his exclusion from the Trust in 2011, it must have been something more than individual weakness… it must have been a permissive environment that prioritised surface efficiency over quality. Kennedy’s report focuses on the role of the non-executive directors, who incuriously accepted what they were fed by the executive, who had a rose-tinted view… on the secrecy of HR processes, on reports and audits being unsupported… organisational. Cultural. He does not put the blame on individuals like me, even though we were the ones of knew…

“And next time? That’s the problem you see. Although I can recognise my omissions in this case, I’m not sure I’ll act differently next time. Because you don’t know, until you’ve seen the proof, that the doctor you are worried about is a doing real harm, or is actually malign. You might have your suspicions, but the proof – which in this field is, ultimately, death – does not present itself.

“Unless we all agree that a certain degree of suspicion, a certain number of reports or complaints should result in suspension, we are not going to put these people on gardening leave just in case. Our clinical services could sustain it. There isn’t enough slack in the system. There wasn’t enough slack to give the two guys who were asked to write reports the time off from clinical duties to produce something quickly. It one of them took three months. We need the time and the space to work on these issues. We need to act on risk, not proven harm. In doing that, we might have to suspend five surgeons to confirm one case of unacceptable practise. ‘NNS, the number needed to suspend’ – do we buy into that? Perhaps we should, because when that risk is proven to be real, the time elapsed will have seen more patients come to harm while we vacillated.”

 

***

 

Excerpts from the Kennedy report on which this fictional reflection is based:

 

‘He came with something of a reputation as being a difficult person to work with. When he applied for the appointment, Dr _______, a senior manager at Good Hope Hospital, telephoned one of the Medical Directors at the Trust, Dr _______, to alert him to the fact that Mr Paterson had been the subject of an investigation and suspended in 1996 following an incident in which an operation on a patient had exposed the patient to a significant risk of harm. A review had been commissioned by the Royal College of Surgeons.’

 

‘That said, there was a level of informal knowledge. As one of the senior radiologists, told me, “To be honest, when we heard he was coming … it was, you know, ‘What’s gone on then?’ His reputation was well-known as being difficult and having open rows with a colleague at Good Hope. … it’s always a surprise to us why they took him on when they knew he was trouble”.’

 

‘Mr Paterson was described as high-handed to the point of being dismissive of colleagues. Forewarnings of this pattern of behaviour were already evident when Mr Paterson worked in the vascular unit. This unit was run in a very collaborative way, but Mr Paterson did not participate and rarely attended the MDT. When Mr Paterson moved to breast surgery, he behaved in a similarly challenging way. The hope was, it appears, that the managerial and governance arrangements in place would deal with whatever had to be dealt with. It was a forlorn hope.’

 

‘He had been the subject of an investigation and suspension two years previously by his then employer, Good Hope Hospital and had been required to undergo a period of supervised practice before recommencing laparoscopic surgery. The Trust was advised of this prior to his appointment.’

 

‘He is described as charismatic and charming and was much-liked by his patients. He was not, however, a team-player in an area of care which is absolutely dependent on clinicians working efficiently and effectively as a team.’

 

‘They [his colleagues] were faced by an awful ethical dilemma: what to do about the patients whom they were seeing who were supposed to have had a mastectomy but had not, in fact, had one…’

 

‘The Report overlooked a crucial issue: the issue of consent. Women were giving their consent to a mastectomy. But, on occasions, a variation of a mastectomy was being carried out; what became known later as a “cleavage sparing mastectomy”. This was not a recognised procedure. Women did not consent to it in any properly informed way.’

 

‘Senior managers saw Mr Paterson at the time as a highly effective surgeon performing efficiently, enabling the Trust to meet its targets.’

 

‘The concerns over Mr Paterson’s clinical competence went unaddressed. Mr Paterson continued to operate as before for nearly four years. The oncologists who were based in another Trust felt ignored. They had expressed their concerns and supplied evidence. They felt that no-one at Mr Paterson’s Trust was listening.’

 

‘They were told the good news from the Report of the Peer Review in 2005. They were not told of Mr _____’s Report, nor the less favourable views expressed by the initial and follow-up QA Visits in 2004, and the recommendations which followed. Good news was preferred to true news.’

 

“…we did raise that we had some concerns and we were told not to worry about it, so for the next few years we didn’t say anything”

 

‘They took the view that because they were not surgeons, they were defined out of competence. As Dr _______ put it, “I had taken the trouble to go through 100 cases, two thirds of my case-load for a year basically, and anything other than the most rudimentary examination of that would have shown substantial problems and the Trust took not a blind bit of notice of it and, not only that, they swept it … under the carpet”.’

 

‘When the Trust decided to make a new appointment in 2007, Mr Paterson was excluded from the process of selection, despite his being the leading surgeon, for fear that he would again put off any applicant. This is just one example of how senior managers behaved, towards Mr Paterson. Rather than confront him, they preferred to work around him.’

 

‘The new surgeon appointed in 2007 soon began to raise concerns about Mr Paterson’s surgery after seeing some of Mr Paterson’s patients, under the newly introduced system of cross-cover. The senior managers decided to launch an investigation.’

 

‘… if the issue of consent had been identified, as it should have been, a reason to require Mr Paterson to cease operating had existed for several years earlier.’

 

‘He [a colleague] talked of “raising his head above the parapet”. This speaks volumes about the perception of the way that the Trust then worked: that raising concerns was to be characterised as putting your head above a parapet, with the implication that the head would be shot at rather than welcomed and invited over the battlements to talk further.’

 

‘He realised that what he lacked was proof that women were being put at risk. The only way that he would obtain that proof was if women presented with recurrences of their cancer. And given that it might be several years before recurrences occurred, there was nothing he could do in the meantime.’

 

‘Evidence of actual harm, except in the most obvious cases, is usually hard to come by. It takes careful documentation, proper sampling and statistical analysis. Without all these, the concerns will be at risk of being dismissed. Dr ______ provided evidence but it did not show harm. It showed a deviation from accepted practice and a risk of harm.’

 

‘They told me that by the time their own concerns were coming to the fore, “everybody was aware of this”. One replied, “… it’s like stating the bleedin’ obvious, they already knew. … the senior management had been informed by the rest of the team, the consultants, and I can see that us adding our voice to that may have had – well, I don’t believe it would have had any effect but I can see that there is an argument that you could say, well, you know, you didn’t raise concerns as well but they’d already been raised…”.

 

‘…once the HR procedures were invoked, everything was covered by a blanket of confidentiality. Like others, they were kept in the dark.’

 

‘Organisations can tend to become closed, to exclude others and become disinclined to listen to the voice of “outsiders”. This is usually a bad sign in terms of the performance of the organisation… The “outsider” may see himself in such terms, feel he has done his bit and retreat to familiar territory.’

 

‘It is impossible to overstate the emotional burden that he and others shouldered for years. As Mr _______, who carried out an investigation in 2007, put it to me, while he did not want to emphasise the element of emotion in what he heard as he gathered evidence for his Report, “to see someone virtually in tears was an eye opener”.’

 

‘He realised that what he lacked was proof that women were being put at risk. The only way that he would obtain that proof was if women presented with recurrences of their cancer. And given that it might be several years before recurrences occurred, there was nothing he could do in the meantime.’

 

‘A concern about the practice of a clinician is raised. It is perceived as a criticism of the clinician rather than a concern about patients. The perspective is that of the clinician. The response of managers to the person expressing concerns is to demand evidence: to “put up or shut up”’.

 

‘The call for proof, in a situation such as the one under review, was based on two flaws. First, it proceeded on the basis that the issues at stake were scientific and technical and could and should only be addressed scientifically and technically. This is the way that clinicians tend to think. It is their comfort zone. And, it allows arguments about data and its interpretation to go on for years. The flaw is that, while there may be technical issues to address, the primary issue is that concerns are being expressed about the care of patients [   ] the proper response is to stop and look.’

 

‘Peer Review Visits do not have sufficient rigour to be regarded as a reliable guide to performance. They should either acquire the necessary rigour or be regarded as a useful exercise in bringing people together but not a serious examination. Currently, organisations may present the results of a Peer Review Visit in self-congratulatory terms, even though, on occasions, self-congratulation, on a more careful analysis, may be unwarranted. Patients and the public, therefore, should be alert to this when forming a view on the performance of a service or unit.’

 

‘Further light is cast on the failure to grasp the importance of consent by the practice, which I still encountered in 2013, of clinicians talking of “consenting” patients. The objections to this awful phrase are not merely linguistic. They go to the heart of a proper understanding of the relationship between patients and clinicians.’

 

Advertisements

Smoker and doctor

The approach to many hospitals is blighted by an oncogenic miasma of second-hand smoke. It’s less of a problem than it used to be, but even now I pass wheelchair bound patients coughing over a fag at eight in the morning. Depending on which entrance I use, there may be a sign above their heads saying ‘STRICTLY NO SMOKING’. My reluctance to tell them to stop, or to move beyond the hospital’s boundary, says something about my identity at work.

If this was a restaurant, a train or a shop I would be the first to face them and ask politely that they stop. If there was no response, my natural reticence would do battle with my genuine annoyance/anger, and between them would work out whether I remonstrated or turned away – the older I get the more likely I am to escalate. But not with the smoking patient. Why?

It is because they are patients. What I want to say is, ‘Put that cigarette out. You know you’re not supposed to smoke here. Why shouldn’t you obey the rules? And don’t tell me you can’t go out because you’re in a wheelchair… one of the others here could take you.’ If no response, a part of me would want to continue, ‘You make this end of the hospital look horrible, why should all these people coming to work have to meet a cloud of smoke first thing in the morning… and look at all the butts on the ground, smoking doesn’t automatically give you the right to litter…’ And then, the transgression – a moral judgement, ‘Anyway, you wouldn’t be in here with this [amputation/heart problem/lung problem] if you didn’t smoke.’ This being said entirely without evidence, but as a manifestation of my frustration.

Yet even to ask them to stop or move is uncomfortable, because in doing so I am breaking out of the role of doctor, who strives to understand patients and shies away from criticism. Addiction is to be met with sympathy, allied to an agreed and constructive strategy to reduce it. When an alcoholic patient of mine returns to the ward carrying the smell of vodka, I am exasperated, but I do not criticise. That will do no good. Behaviour is challenged if clearly anti-social, but not overtly vilified. Doctors don’t come to work to tell people off.

So the doctor looks at the smoker, tuts, and moves on, leaving any correction to the security patrol who will surely pass by in half an hour or so. They, I hope, will not be inhibited by the instinct, magnified by training, to empathise and understand.

 

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.

 

Keeping the options open

There are many reasons why hospital doctors can be slow to engage patients on the question of DNACPR. This is one of them.

A frail patient agrees that a DNACPR form should be put in her notes. Two weeks ago she was admitted with severe pneumonia, and survived a week in ICU on a ventilator. Although she beat the odds, it was made clear to the family that if her chest deteriorated again, she would not benefit from being taken back to ICU.

The DNACPR decision is made a few days after she arrives back on the general ward, once the receiving team have taken the measure of the situation. In the event of a cardiac arrest her pulse might well be regained several minutes into the ALS algorithm (many are, after the elephantine doses of adrenaline that are given), but she would be very unlikely survive to discharge. Indeed, based on the therapeutic ‘ceiling’ set on her discharge from ICU, the option of returning to those same life support machines that are required to bring someone out of a post-cardiac arrest situation has already been ruled out.

DNACPR is clearly appropriate. The form is written. Everyone agrees, including the patient.

Then she vomits up a bowlful of blood. It looks like it could be a stomach or duodenal ulcer. Her blood pressure drops, but improves with some rapidly infused fluid, then some packed red cells. But the blood keeps coming, and it is clear that she needs an endoscopy to confirm the diagnosis and, hopefully, treat it. She is too frail to be brought down to the endoscopy department; her breathing is shallow, her blood pressure is labile. She needs to be stabilised in ICU. A phone call is made. The ICU registrar attends the ward. She flicks through the notes,

“She’s clearly not an ICU candidate. It’s all over the notes.”

“That was written in case of a respiratory deterioration. This is different.”

“How?”

“It’s a bleed. It could be reversed. I accept that she shouldn’t receive multiple organ support, but she needs two or three days of close monitoring, perhaps a bit of vasopressor support* if her BP drops to keep the kidneys going. If the endoscopist can stop the bleeding she could be out of there in a day and back on the ward.”

“It rarely happens like that.”

“I’m not comfortable with the idea of her bleeding out here. Yes, she is frail, yes if she arrests, I accept it’s over. But there may well be a straightforward, treatable lesion there.”

The registrar withdraws to liase with her senior. He attends. He reads the notes, takes in the DNACPR form, heads in to look at the patient, and emerges from the curtained bay.

“I think we should honour the DNACPR… keep her comfortable…”

The medical consultant stares, trying hard to disguise his disgust.

’Honour the DNACPR’! The DNACPR has nothing to do with her treatment in this situation. It is not a symbol designed to ensure instant palliative care. This is precisely why we don’t do DNACPRs when perhaps we should, because of this sort of….”

And he goes on, building up steam, accessing his frustration. In the end a compromise is reached… but the point has been made, and it is worth considering in more detail.

The question to consider here is – Do DNACPR forms materially influence a patient’s chances of being treated aggressively in the event of an emergency? On the face of it, they should not. The DNACPR is there to make it clear to whoever happens to be on the ward at the time, that the crash team should not be summoned. Death should be allowed to occur naturally. It says nothing about endoscopies, monitoring on the ICU, short term vasopressors… Moreover, every version of the DNACPR form I have seen emphasises that it is not irrevocable, it can be rescinded if circumstances change.

Yet, surely, there must be a close correlation between DNACPR status and ‘not for ICU’. The chances of surviving an ICU admission are driven by the same physiological parameters as those that determine survival after cardiac arrest. Looking at the figure below**, you can see how CPR sits at the apex of medical interventions, just above ICU.

 

Although I cannot find the studies to confirm this, in my experience, most if not all patients who are not for CPR are also not for ICU. The two go hand in hand. Therefore, by filling out a DNACPR for my patients, I am also making a statement, that he or she should not be considered for admission to ICU. But what if that is not the message I wish to convey? I can make an explanatory note; I can use a better ‘form’ (eg. ReSPECT, recently promoted in the BMJ, yet to be used nationwide). But I cannot overturn the impression that a DNACPR form makes on many colleagues, that the death of the patient should not come as a surprise, and that efforts to reverse an unexpected but life-threatening problem should not be strenuous.

‘Honour the DNACPR.’ I have heard that phrase. It is because those six initials carry so much weight, and may exclude the possibility of life-extending measures, that I, and others, are sometimes slow to start the conversations around resuscitation.

The larger point I take away from this scenario is that forms, even subtle ones like ReSPECT or other treatment escalation processes, are ill-suited to the multitude of ways in which patients can change suddenly. Although they come with the caveat that they should not be used as blanket statements, they can be read as headline summaries about how to approach patients. Different doctors will read them in different ways. To keep the options open, many doctors will choose to delay allowing those headlines to enter the notes.

 

* a powerful drug infused to keep up the blood pressure

** Taken from Dahill et al, Improving documentation of treatment escalation decisions in acute care  BMJ Qual Improv Report 2013;2

[Fictional scenario]

 

For more on the reasons why DNACPR decisions can be delayed, explore this booklet…

Batteries are low: the work of engaging in DNACPR discussions

During a talk I gave to an audience of palliative care specialists two weeks ago (St Barnabas Hospice, Worthing, thank you for having me), I wondered how they found the energy to engage patients in discussions about dying all day, every day. The comment was undoubtedly naïve, because that’s not what they do, and the many positives that come from managing dying well must recharge the batteries. But for those like me who work in the acute hospital setting, and whose job it is to recognise the approach of dying, a form of exhaustion can occur. Sometimes this leads to missed opportunities.

Imagine a typical ward round in general medicine, or even within a narrow area like my own (liver disease): there might be three new patients with clinical features to suggest that rapid deterioration could occur at any time, which on a background of chronic disease or frailty indicates that resuscitation would be futile. It is my job to start a discussion about the place of CPR and escalation of care. Three conversations. Take a deep breath.

In the ideal world, where patients with chronic disease talk about their wishes well before admission to hospital, the door would already be ajar. Perhaps a documented plan (eg. ReSPECT, described in this week’s BMJ, UFTO, or UP*) would be produced from an overnight bag, or from a relative’s pocket. This paper, a symbol of prior reflection, would allow us to compare their goals with the facts of the situation.

It’s 9.15AM. The team is full of energy and caffeine. We have X patients to see, some of whom are on the road to recovery, some of whom have already been recognised as dying, some of whom have uncertain futures.

The trainees are attentive. They are learning how to do this (aren’t we all?). First patient. I complete my assessment, pause, then open the discussion. I won’t rehearse the words here – my version is not perfect, and it varies. If it does not vary then it shows I am just repeating some learned lines – an impression that it is important to avoid. (Interestingly, a patient involved in the BMJ’s article commented, in reference to a particular form of words, it was ‘as if this is what they had all been taught to say.’)

So I open the patient’s mind to the possibility of dying (be it suddenly or gradually). Perhaps their next of kin is present. They react in their own way. A faraway look is not uncommon. Sometimes a film develops over the eyes, glistening in the morning light of the nearby window. Poetry has no place here, but as a human, I am affected by the impact of my words. We reach an understanding – we agree – CPR is not the right thing to do. If the patient or a relative disagrees, we park it, and arrange to speak about it again, later. I walk away, unsure how to close the interaction. A hand on the arm, a swish of the curtain (‘or would you like me to keep it closed?’). There is no comfortable way, to be honest.

Outside the bay we complete the DNACPR form – put the bureaucratic stamp on it, for the benefit of others who might be called to see the patient in an emergency.

“Ok. Where to next?”

We see a couple more patients. Then the registrar says, “We probably need to discuss escalation with the next one, she’s —–.” We review the history, the data, and agree, yes, we need to anticipate the worst, even if, crossing fingers, it doesn’t happen during this admission.

I use subtly different words, but move in the same direction. This time there is a more overt reaction. And a longer discussion. The thought of dying has never crossed her mind. Nor her husband’s. Part of me brims with anger – she has an incurable, gradually worsening condition, she has been seen by her GP and in specialist clinics umpteen times over the last year; why has no-one brought this up? Why does it have to be me, now? I could just leave it. She might not deteriorate after all. Why not leave it until she does… but if that is at 3AM, and a foundation year doctor is asked to see her, and she refers to a registrar who has never met the patient, there will be hurried decision making, the patient will probably not be conscious enough to express their wishes, an ICU consultant will be asked to make a call based on scanty information…  bad medicine. It must be done now.

We finish. It took half an hour. Not long in the life of the patient, relative to the magnitude of the subject under discussion. But very long in the context of a ward round. Never mind. The time must be taken.

We see some more patients.

Then we come to the third.

I enter the bed space. The visit proceeds along routine lines while I make a general assessment. Then I reach a fork in the path. Now is the time to level with them. But I am not up to it. I have left two patients in mute distress (possibly; how could it be otherwise?). I have re-formulated the words to keep them fresh and sincere and specific to them. I have struck a balance between brutal realism (I’m not one for drawing a vivid picture of CPR, but the act has to be mentioned) and sensitivity. I have asked myself, as we continued our progress along the ward, ‘am I bring too pessimistic here? If the other doctors they saw didn’t bring up dying, perhaps I shouldn’t either…’) – and I make a decision. Not today. Another day. Let’s talk about it on Wednesday. I haven’t got the energy. Or I’ll ask to the registrar to do it, she’s good.

“So are they still for resus?” asks the nurse.

“Yes.”

“What if they deteriorate?”

“We’ll cross that bridge when we come to it. Sorry.”

And so we move on, hoping that the worst doesn’t happen before we find the time and the energy – a very specific form of energy – to broach the subject.

 

 

* ReSPECT = Recommended Summary Plan for Emergency Care & Treatment; UFTO = Universal Form of Treatment Options; UP = Unwell and Potentially Deteriorating Patient Plan. According to the BMJ this week, In Torbay, where Treatment Escalation Plans were introduced to replace DNACPR forms in 2006, ‘30% of elderly patients now arrive [at the hospital] with a TEP.’

 

~~~

Books! Click to explore…

The unknown quantity

What determines if and when patients ‘turn the corner’? I have never understood.

In my world of acute-on-chronic disease, where patients suffer sudden and life threatening reverses, there are numerous stories of unexpected turnarounds. Our efforts to prognosticate accurately have led to many scoring systems, all of which have been ‘validated’, but when applied to individual patients who surprise you with twists and turns, their relevance appears diminished. However bad the numbers, we treat, we support, we try to save… unless the presentation comes at the end of a long and well recognised decline, and we (the patient, the family, the team) are thoroughly ‘signed up’ to palliation. That circumstance remains a rare one, despite the increasing value we give to conversations about death.

So we are guided by experience – that fickle teacher.

Last year a very sick patient came in. He struggled, we struggled; he responded to intensive care support, we felt satisfied that our decision to advocate for aggressive treatment was the right one. He deteriorated, we isolated the infection. We talked the family through it, and suggested that not give up yet. He fluctuated, weakening a little with each reverse, until… weeks later, he died. All that hope. All that work. The ‘numbers’, at one stage, had looked better. But that is the nature of the disease. Unexpected complications. Hidden infections. Sudden ruptures.

The grim picture joined the file of failures that I, and all doctors, compile in their memories from day 1. It is called experience. But the way such memories absorb the light colours our view of the present. That is the whole point of experience, of course; to change the way we approach similar circumstances in the future.

The shapes and lines of that patient’s clinical course remained etched in my mind when, months later, I recognised an almost identical scenario. Her liver function looked the same during the first week. Her slide into an intensive care bed occurred over similar interval. I was ‘guarded’ in my prognosis, but I knew what was going to happen here. I knew. The road home presented too many traps and potholes for her body to negotiate, given the advanced nature of her disease. Any and each of them could kill her in a few hours. As time passed, her clinical course described the usual sinusoidal curve. The downslopes were not catastrophic enough to justify withdrawal, and the upward gradients were not sufficiently sustained to launch a bid for convalescence.

We reacted to each complication with urgency. Our policy was unchanged – treat, support, save. But my heart was not really in it. I did not have hope. I know I communicated that to trainees. Those muttered opinions as we walked out of intensive care. But at no point did we hesitate or withhold. And time passed.

Until… she returned to the ward. She turned the corner. She had climbed far enough up the hill for the swirling, sucking mists of death to no longer have a hold on her. Then she went home.

A trainee asked, “You know _____? I thought you said the chances of her surviving were…” I stopped her there, and turned the case into a occasion to teach on the subject of uncertainty. 

Is it a ‘survival gene’? Poor science. Then what? We do not know. Probably, luck is involved. When such large unknowns are involved, when the rules that underlie our attempted predictions appear unfixed, pattern recognition can lead to erroneous conclusions. Sometimes it’s better just to treat, support, stand back, and try not to outthink the disease… hoping that they turn the corner.

 

See also, Patterns and pride: diary of a medical anecdote

 

 

portfolio

Click image to explore all the author’s writing projects.

 

So superior… – making judgements on medical care

 

amberspyglass

The Amber Spyglass (or what a retrospectoscope might look like)

 

Patients may see many doctors during the assessment and treatment of a particular illness. In the transition from primary to secondary care, medical opinion becomes more specialised, and the knowledge of the doctor facing the patient deepens in that particular area. Doctors become more confident in their opinion, and in the light of information are able to judge the quality of the decisions taken earlier on. This means that the specialist must, either privately or openly, pass judgement on what has gone before. Usually there is no controversy, because nothing incorrect was done. But sometimes, looking back, it becomes apparent that clues were missed. Things may have been done ‘sub-optimally’… according to the specialist’s very particular expectations.

The decision then has to be made – do you, as the specialist, tell the patient what you are thinking, or not?

The answer to this would seem simple. If by omission or commission the patient has been harmed, there is a responsibility to be open about it. However, harm is difficult to define, and the grey zone between delay and harm is broad. An abnormal blood test performed fifteen months ago might, if interpreted correctly, have led to an earlier diagnosis – but who can measure by what degree the patient’s life has been affected?

For the patient, finding out that two years ago a scan showed some early signs of liver damage, or that an abnormal vitamin level went unnoticed and uncorrected (contributing to months of fatigue), the conclusion is bound to be that things were not done well. The question of blame arises. The patient may ask  – what do you think should have been done? What do you think about the quality of the care I received? Patients, in fact all people who receive a service from a professional, like to benchmark. It is natural.

It isn’t just at the transition between primary and secondary care that judgements on the quality of care may me made. On the wards, once a patient is established under the care of a specialist team, questions may be asked about the time it took to reach a diagnosis, or about the appropriateness of initial treatment. If the wrong diagnosis was reached (say, heart failure rather than chest infection), was the error acceptable? Was it just the way medicine works, with the correct diagnosis emerging over time, as pennies dropped and more experienced people made their assessment – or was it just bad medicine?

The temptation for doctors is to close ranks, and to present the hospital, or the health service as a whole, as a seamless unit where information comes in and decisions are made, by individuals yes, but by professionals who are part of a larger machine. Individuals shouldn’t be criticised; rather, blame the system.

I remember once, as a registrar, the family of a deteriorating patient asking me the name of the doctor they saw in casualty, who they felt did not diagnose the illness quickly enough. In the relatives’ room they pressed me hard, and demanded details. I felt that the presentation was complex, and that the quality of initial assessment had been satisfactory, if not genius. So I refused to give a name. I talked about the ‘team’. In my wisdom I felt that it could not help the situation to offer up an anxious SHO, and that the request reflected the family’s grief and uncertainty. The family needed a focus on which to direct their anger with the situation. Was I right or wrong?

On other occasions, in clinic, I have had to explain as best I can the decisions made by a doctor – often a GP – whom I have never met. I may end up saying things like, “Well, based on the information that was available eighteen months ago, it wasn’t unreasonable to monitor the situation…” Or, “Perhaps another doctor might have referred you six months earlier, if they had a special interest in this disease, but yet another might have waited a year. There is no right answer.” Or, if the patient asks me up-front whether I think their GP is any good, based on what has happened before, “It is not fair for me to pass judgement… I see patients with your problem nearly every day, and I come to this with a very specific expertise. Your GP has to decide when to refer… and it’s perfectly reasonable to monitor things for a while first.” I may say this even I think, privately, that they can’t have been that up to date with modern medical thinking on the topic in question. But who am I to criticise? What do I know about psychiatry or gynaecology?

So what drives this instinct to obfuscate? Is there a justification? Surely, in an era of transparency, the patient should know exactly what I am thinking.

It may be a desire to nip a potential complaint in the bud, even when I think a complaint (formal or informal) might be unjustified? If so, am I right to forestall what a more objective person might regard as a necessary corrective?

It may be loyalty to the larger medical community – an instinctive reflex to shield colleagues from criticism, just like in the relatives room on the ward all those years ago.

Or perhaps it is based on my acceptance that the practise of medicine will always involve variation in knowledge and in quality. Not every biochemical clue will result in the same decision. Each doctor will have developed their own store of knowledge, a unique bank of experiences and memories on which to base their decisions. As long as the decision was not clearly negligent, or so stupid as to warrant immediate correction, we are bound to let borderline or ‘sub-optimal’ decisions go without making a song and dance. We might hint in a letter back to the GP, or in a comment to a trainee’s supervisor, that next time a different decision should be made, and perhaps in that way we reassure ourselves that we have tried to improve the quality of the system as a whole. But patients are excluded from this feedback loop. They may go home entirely ignorant of the fact that things could have been done better, and may not read between the lines of the letter that they are copied into.

In modern medicine patient involvement is key, and transparency is a central pillar. We have a duty of candour which applies to identifiable errors of a certain gravity, and no doctor will overlook a pattern of behaviour that clearly puts patients at risk.  But no such duty exists for reporting back on the grey cases where some educational improvement can be made. Is it reasonable not to inform patients in these circumstances? Would it help them? Or would it just cause confusion, and a loss of faith?

Over time I have become more honest about the non-scientific nature of medicine. Sometimes I begin a discussion with the patient with the papers spread out in front of me, or the blood results on the screen, and talk through what may or may not have been going on in their body over the last few years. If I think a spike in a liver enzyme might have been an early signal, which in retrospect was missed, I will tell them, but without loading it with an opinion. It’s just a fact. The ‘retrospectoscope’ can provide a false image of the circumstances that existed years before. Now you are here, let’s sort it out. There is no point in opining from the security of the specialist’s chair. Misdiagnoses are made there too.

In this way patients can begin to understand that the narrative of illness may follow numerous detours and diversions before the destination – a firm prognosis, a treatment plan – comes into view. Care is not homogenous, and variability, while sometimes permitting the occasional detour, is an inevitable result of human involvement.

 

book4coverfinal

New collection – click image to explore on 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.

***

Instant E

instant E

 

After 13 hours of almost constant work I got home and fell asleep at 11.30PM. At 1.30AM the phone rang. I answered, to hear about a patient vomiting blood in resus. He was jaundiced. This was going to be a variceal bleed, and I had to go back in. The thick nausea that accompanies interruption of deep sleep, with the last, hastily eaten meal still heavy in my stomach, brought out the worst in me. I had plans for the following day; I would be useless now. The night was gone. It would take hours to get in, get to theatre, do the endoscopy and get away again. I hated the patient for doing this to me. I imagined him – an alcoholic, no doubt, who had binged and taken another self-induced hit to liver. Now he was now suffering the consequences. In the middle of the night.

As I sped down the almost empty motorway and let cold air in to blast away any residual mental fog, I anticipated my attitude. It was going to be business like. No way was I going to be touchy-feely – there was a job to be done: get the patient anaesthetised, look inside, seal the bleeding point, get out, get home. Then sleep. Sleep.

The white-light glare of the resus bay rekindled any neurons that had not been required to drive the car. I read the casualty card notes and glanced across from the doctors’ station to the relevant cubicle. The curtain was drawn.

I walked in boldly. He was awake, but groaning. There was blood on his chin and in the bowl that he grasped to his chest. He had all the signs of cirrhosis.

“Hi, I’m Dr _______. What happened?”

“It just started doctor.”

“Have you had liver problems before?”

“Not like this.”

“But you’ve been told there’s a liver problem.”

“Oh yes, years ago.”

“Due to alcohol?”

“Of course.”

“Any hepatitis infection, anything like that?”

“No.”

“And… the drinking, have you been drinking recently?”

“Yes. Every day…”

Really? – I thought to myself. You know your liver is scarred and shriveled yet you carry on. I just don’t get it.

“How much, recently?”

“Two, three bottles a day.”

“Wine? Cider?”

“Wine.”

“Right. Well, I’m sure you’re bleeding from a ruptured blood vessel in your gullet, we need to put you to sleep for a bit and do a camera test.”

“OK.”

I presented him with a consent form, and muttered about the risks and the benefits. He signed, an uncoordinated scrawl. I walked away, but he had more to say,

“I knew this was going to happen. They told me. Ever since I started drinking, after the accident…”

And then he told me why. Why he had taken to alcohol. The industrial injury, the chronic pain, the enforced retirement, the gap… the gap in his life. My tiredness melted away and the focus, on my own discomfort, was re-directed. Just a few words was all it took. Context. The story. The reasons.

I approached the bedside and spent a little more time telling him what would happen. The possibility that things could go wrong when I was trying to seal the bleeding point, that he might have to stay on ICU, might be transferred for a shunt up in London, might die. He nodded. It wasn’t news.

“Got any family?” I asked.

“Yes. But not here.”

*

In the car on the way home, as dawn nudged its way under the edge of night, I felt good. The job was done. The sense of satisfaction was high. But for that hour after I was woken I did hate him, in a way. I wished he didn’t exist. But that was when I didn’t know him. He was a name in a cubicle half way down the motorway. At that moment there was no context, and therefore no empathy, only a natural and not unusual reaction to being woken up. It was the situation I hated, not the man. Before I arrived there was no man, only a problem.

*

So who’s interested in the reactions of a grumpy forty-something old who’s getting tired of being on call? You’re paid for it! You get a 5% supplement for being available to come in for emergencies. Get over it!

Well, it is important to examine the reaction to fatigue and disturbed sleep, because it is at these times that patients see the worst of us. The veneer (is just a veneer?) of compassion is often tarnished in the early hours of the morning, or with the hangover of a recent sleepless night still lingering in the system. The trick at such times is to know how to access the human in ourselves. For me, nowadays, such interruptions are rare and anti-social hours are few. Back in the day when I roamed the wards in the early hours I frequently transformed into a ‘technical’ doctor, asking closed questions, focussing on defined tasks and having no spare resources with which to make human connections. It is a biological inevitability – we are less human when we are supposed to be in bed. Yet a third of our patients’ lives are lived between midnight and 8AM. We have to find a way to be nice at those times. How to do this? In the case I describe it was by imagining a life disrupted by external events, and the undeserved downward slide into addiction. What if that happened to me? A window into another person’s unlucky life, mixed with a dash of imagination – two elements that when mixed can produce instant empathy.

 

Note: I have changed details in the patient’s personal history

*

New website: http://www.philberrycreative.wordpress.com

creativewebpic