Sunday, 26 February 2012

What's best for the patient?

Last week I wrote about the importance of ensuring that patients and relatives are listened to, and also appreciate that they have been heard.

This week I have been reflecting on what it is like when you realise that you have failed in this ambition, and despite your best efforts, the people you are dealing with are convinced that you never listened, and as a result lose faith in you as a doctor.

This will happen to most of us at some point, and when it does, it is really important to spend some time thinking about what happened, what you did well, what you could have done differently, and what, if anything,  you can learn from it. 

The problem, as I see it stems from a situation in which the expectations of the patient and their relatives differ fundamentally from mine as a physician. It is always important to take great care managing the expectations of the people you serve as a doctor, but it is also important to take into account the different styles and preferences of these people, in particular where their wishes and ambitions involve an approach that does not conform to your usual way of practising. 

If you fail as a doctor to manage expectations so that the people you are working with disagree with what you are saying and reject your information, you are faced with the choice of continuing to disagree with your patients, or moving to where they are and working with them in the manner they would like.

This can be a difficult choice, because the it raises the possibility that you surrender your best opinion and work in a way that you do not agree with, and it perhaps asks you to administer treatments that you think are futile, and perhaps will cause unnecessary distress. There are of course systems in place for resolving conflicts and disagreements with patients and their families, and second opinions should be sought where the discussion becomes intractable. However, on a human level, you have to ask yourself as a doctor what is the best way to serve a patient and their family when they have lost faith in you as a physician. This is difficult, and at the very least, it demands that you are prepared to be brutally honest with yourself, in private. 

When faced with negative feedback in the manner I describe, it is common to feel that the problem lies with them, and not you. And sometimes that is true, but it is not helpful to your personal growth to use that as your stock response, as it is a missed opportunity. Remember, being the patient or being the relative of someone very sick is a stressful experience, and often they cannot be held accountable for the way they behave. We all do strange things when we are under stress, and part of our role as doctors is to help them through the stress, and another part of our role is to take some heat when that stress manifests with the need to vent some anger and frustration. 

However, I am not suggesting that such a role comes without a personal cost for you, because being criticised by patients and relatives can be very upsetting indeed, particularly when you think that you did your best, and particularly when you think that you actually did quite well.

This is where things become very tricky, because in many ways your reputation with the patient and their family cannot be rescued once it is lost. In this situation, take yourself off quietly, and remind yourself if you can of what really matters. The key question to pose is ‘What is best for the patient?’ The answer to this question may involve a range of different responses: it may involve you standing firm, it may involve you acquiescing to requests you disagree with; it might involve you stepping back from the patient’s care, and handing them over to someone else. And that’s the really hard bit- the experience can be so emotional, and so draining, that the risk is that the care that the patient receives can become tainted by disagreement. 

So my reflection for this week, is that however hard and personal the criticism may be, it is really important to do whatever is necessary to ensure that the patient gets the best care they can. 

Monday, 20 February 2012

Listening is the best medicine

I asked someone for help today, and they simply said no. Thankfully, this had nothing to do with patient care, or hospital at all, but rather involved something I am trying to sort out at home on a tight schedule. Nevertheless, I made it plain how my success in this small matter, which is important to me, relied on them taking ten minutes out of their day to do something for me. I wasn’t in a position to pay them for this extra effort, but had rather hoped that my straightforward appeal to their better nature would be enough. It wasn’t.

Now I have no doubt that my failure to secure the help I needed was a combination of my approach and the attitude of the other person I deal with. I suspect that if I had come across better, then there was a chance that I could have succeeded.

But having failed in this matter, I spent some time thinking about what it means to ask for help, and for that plea to be rejected. This is something that I have experienced from the other side many times as a doctor, and I haven’t always responded; I haven’t always been able to.

But what is important is that however empowered, or disempowered you are, that the person seeking your help knows that they have been heard. In the emotive, scary and overwhelming environment of a hospital, the need to know that the people looking after you or your relative must be very great indeed.

Our patients and their relatives often have ideas about the service we provide and how they are provided which differ from what actually happens. I have spoken before about the challenge of communicating issues that run counter to people’s wishes and expectations and how hard this can be, but I do not think that I have ever reflected fully on the importance of ensuring that however disappointed someone is what what you are able to do for them that they realise that you have listened.

Usually the best way to achieve this is to do what is being asked. But as we already know, this is not always possible. So what is the next best option?

I suspect that there is no magic formula, but it does require making concessions where you can, moving your stand point as much as you are able to, and being genuinely, and earnestly empathetic with the person you are dealing with. There is no one way to achieve this, and being successful involves you being yourself, being honest and listening careful. Only by responding to the real needs of the person seeking help can we hope to assure them that we are listening, and that we have heard.

Wednesday, 15 February 2012

Half term thoughts on the Health Bill

At lunch today with my wife, we were reading the papers, and got into an interesting conversation about the Health Bill, prompted by a lead article in the Independent, outlining that patient satisfaction with the NHS is the highest it has been in the last 10 years. This got us on to a conversation about the case for change, and what the Health Bill has been designed to do. I outlined to my wife the same case I outlined to you in September in this blog, and underlined the aspects that I have felt are key to uncovering what the bill is all about: namely the removal of the responsibility of the Health secretary to provide comprehensive healthcare for the people of the UK (dealt with to some extent by the last round of concessions), the change from PCTs serving a geographical area, to Clinical Commissioning Groups servicing the lists of patients of their constituent GP practices, and the removal of the limits to the amount of private work that hospitals can engage in. Rather than rehashing the same arguments, take a look at what I wrote before:

In having this conversation, what struck me the most was how long these issues have been apparent, and how long it has taken to percolate it's way through to the media. My views may not be right, and they may not even be very perceptive, but in the ongoing discussion no new evidence has emerged to make me refine them further: they are based on exactly the same evidence that was present 4 or 5 months ago. The delay in them reaching the popular agenda is not down to the availability of information on which to inform opinion, it is down to the much more diaphanous issue of how issues become important to the popular imagination.

I find it difficult to get excited about books that other people have excitedly recommended to me, and have to wait until I reach a point where I independently want to read a book before I am able to read it. This is partly driven by my deeply ingrained counter-suggestibility, but it is also partly driven by the problem of being told what to think and why. I don't want to have to like a book because someone I know and like loves it, and I do not want my reading of the book to be constantly influenced by reflecting on why my friend enjoyed it so much.

The same is true of big issues that are important to other people, for reasons of happen-chance, before they are important to you. It is hard to be effectively hectored into treating something with urgency and gravity, because no one wants their firmly held beliefs to be bullied into them. It is crucial that on significant matters, we all have the chance to find our own way there, that we are encouraged and supported to give the matter some air-time, but that we are not harried or cajoled into agreeing with others, because that is the popular belief.

So my brief point on this holiday blog, is that I am glad that the health bill is front page news, and I am glad that it is being discussed in newspapers and on news programmes, but I am no longer miffed that it has taken so long to make it on to the agenda. The time delay we have experienced was not wasted time, but time in which lots of people spent lots of time reflecting on what they thought and what they believed, and coming to well-reasoned conclusions, on both sides of the argument. We all need the time and space to work out what we think, and the key thing is that the bigger the issue, the more time and space we should have.

Sunday, 5 February 2012

What is common sense?

At a conference I went to last week, I was struck by a recurring comment from different speakers. One of the themes of the conference was how to prevent unnecessary admissions to hospitals, and most of the speakers advocated the use of some decision-making tool (the dreaded protocol) in order to ensure that junior doctors had a better chance of making the right decisions consistently.

However, each of the speakers that promoted the use of protocols also criticised junior doctors for failing to use their common sense on occasions, and rigidly (incorrectly, they asserted) sticking to the protocol.

This struck me as unfair for a couple of reasons. Firstly, the practice of asking junior doctors to refer to protocols to guide their decision-making is borne out of the recognition that absence of protocols leads to inconsistent and sub-optimal decision-making. One of the challenges of learning to be a doctor is accessing the right knowledge and process in the heat of the moment, and protocols are an invaluable way of calming the waters, giving the time to focus, think and do what is best for the patient.

Junior doctors recognise that there is always the possibility that they may make a mistake (they are usually terrified by the prospect), and therefore are comforted by having the treatment pathways laid out before them. This means that they can focus on assessing the patient, instituting the correct treatment, and not spend too much time trying to figure out what the right treatment is.

The main pitfall of protocol-based medicine is that is relies on the assessing doctor having a high degree of certainty that the diagnosis is right, but such confidence is often hard to come by, either in the middle of a busy shift, in the middle of the night, or in a new specialty. Most protocols recognise a degree of diagnostic uncertainty, but perhaps not enough.

This is the moment that junior doctors need support, and we all need to ask whether we either offer or receive the kind of support we need from other people we work with to make the right decisions; a piece of paper outlining what you need to do in a given situation is really helpful, but it does not replace the comfort of the guiding hand of a colleague.

The second source of unfairness comes from the suggestion that the mistakes that junior doctors were making were a failure to apply common sense. But who’s common sense are they applying? Was it the common sense of someone dealing with the real stress of being a new doctor, in an unfamiliar specialty, trying to remember a hundred different things, or was it the common sense of an expert, who has worked in the field for a couple of decades? Is it fair for me to make a distinction between the two?

One might argue that common sense is by definition universal, and you would be right. My point is that the decisions on which these consultants poured scorn sounded silly in the context of consultants who have had the chance to learn and adapt to the stresses and requirements that the junior doctors they are criticising are still trying to adapt to. If one remembers that bad decisions are made by young professionals not just trying their hardest, but also trying to deal with lots of different types of challenges, then mistakes become forgiveable and indeed predictable. The responsibility, therefore,  becomes ours to ensure that they receive the support that they really need.

I often remind myself how hard it has been becoming a doctor, and how much courage it has taken to pick myself up from my failures. I need to remind myself that the need for courage has not disappeared, and I need to be prepared to fail again.

People I meet often seem to forget that becoming a doctor involves some graft, and they weren’t always as accomplished as they are now. Perhaps we should remind each other a bit more.