Tag Archives: Healthcare

Parallel lives

parralel clouds

I am immeasurably proud of the NHS: the most successful model of healthcare the world has ever seen. If anyone within my earshot suggests that privatisation would be a step forward they rapidly regret it. But even I sometimes get a wake up call: a stark reminder of the absolute necessity of the NHS, and the horror we may face if the political right’s dream of marketised healthcare is realised.

On a recent shift as the Medical Registrar I received a call from an A&E doctor who wished to discuss a patient who had suffered a stroke. I was surprised as all patients with strokes are channelled into the acute stroke pathway: assessed and treated by a dedicated team and admitted to a specialised unit for consideration of thrombolysis; specialist investigations; and early physio, speech and language therapy. However the A&E doctor explained the situation and I agreed to admit Maria*.

I sat by Maria’s bed in the Medical Assessment Unit, and listened as she told me her story. She was a UK citizen who had been living and working abroad. Whilst at home one day she had suddenly experienced weakness on the right side of her body and her speech had become slurred. She was rushed to hospital and diagnosed with a stroke. In the healthcare system she found herself in she was not assessed for and offered thrombolysis. She had to provide a payment method as soon as her initial assessment was complete and the bills began mounting from there. With every test and treatment she was offered she faced an impossible decision: could she afford what was being offered in monetary terms; and could she afford not to have it in health terms? This trade off had devastating effects. She did not have intensive physiotherapy, speech and language therapy. She did not have relevant investigations. She did not receive the best, evidence-based treatment.

By the time she received advice from the British consulate, and was helped to return to the UK for ongoing care, she was significantly disabled. On arrival to our hospital she had dense weakness with stiffening of the limbs leading to pain. She was wheelchair bound and struggled to get from chair to bed without assistance. Her speech remained impaired, making it difficult to communicate her wishes and needs. We admitted her to a medical bed, and the next day the specialist stroke team began working with her to regain as much function as they could. She has a long journey ahead.

If Maria had been at home in the NHS she would have had world class healthcare. She would have been assessed for thrombolysis. She would have had early physiotherapy, speech and language therapy and nutritional interventions. She would have been able to focus all her energy on her recovery and not worry about mounting debts. She would have embraced every test and treatment offered by her medical team, who themselves would have been focused entirely on her needs, not the financial state of their department. 

I watched in horror as the NHS was dismantled by stealth through the Health and Social Care Act. I wrote fervent letters, I shouted, I demonstrated, but to no avail. I often wondered why there was so much apathy from doctors of my generation. A recent article, by a Guddi Singh, who I went to medical school with, suggests some reasons including: a lack of understanding of health politics; being fooled by government rhetoric on the “choice” and “clinician-led” agenda; fear of rocking the boat, especially with a lack of organisational support (from the BMA and RCP who were noticeably silent about the proposed reforms); and a wish to just get on with the job. Doctors have a proud history of advocacy, but this side of our role does not get enough attention in modern medical school curricula.

We have only begun to see the effects of the devastating changes of the Act. As the NHS is systematically cut, ground down and sliced into pieces for private gain it will only get worse. I never want to work in a system in which the first person a patient in need sees is a cashier. I never want to work in a system in which patients trade financial ruin against health and wellbeing. I never want to make decisions about a patients’ care based on cost, rather than need. I never want to see another patient like Maria, and I never want her story repeated right here in the UK.

This can’t be the future. We can’t let it happen. I will be joining Guddi’s call to action and fighting tooth and nail to keep the NHS in the hands of the people, rather than the corporations – the friends of the political class. Markets are not the answer to questions around sustainable provision of high quality healthcare.

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Read more about the devastating destruction of the NHS, watch slices of public services being handed over to private companies, and see the impact of these changes on services you and your family may one day rely on.

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Join us.

* names and other details changed to protect confidentiality

What’s in a name?

At work recently I felt like a broken record. “What’s their name?” I said again and again with increasing frustration as I received calls about patients who were referred to as “bed 3,” “side room 1,” and “bed 9.”

Of course, at times it is convenient and even desirable to omit a patient’s name in a conversation. It was suggested on Twitter that it may be better to overhear what ‘bed 9’ needs rather than ‘John Doe is ready for his haemorrhoidectomy,’ and in this case I agree! My worry is that in most cases there is no explicit intent to maintain confidentiality. Instead the convenience of referring to people by their bed number slips into routine communication. I have certainly been guilty of this myself. I worry that this is not merely disrespectful, but that it contributes to the dehumanising experience of being a patient, and negatively impacts on the doctor-patient relationship.

There are many factors that contribute to dehumanisation in hospitals. It is often not the fault of individuals, and I would certainly not suggest any of the nurses I work with are uncaring. Instead the environment and structures inherent in the way we work create an “us and them” divide where healthcare workers and patients are in different tribes. This extends to factors as simple as the clothes we wear, an example of “deindividuation.” I am always amazed by the dramatic transformation when a patient puts on their own clothes as they get ready to leave hospital, having previously only worn a generic hospital gown. They miraculously turn into a “person” rather than a “patient.”

Image from: http://healthland.time.com/2010/02/09/designing-a-glamorous-hospital-gown/

The design of hospital gowns is practical but does not enhance dignity

A recent paper by Haque and Waytz “Dehumanisation in medicine: causes, solutions and functions” explores this idea further, identifying a number of contributing factors, considering simple solutions, and also exploring examples of necessary and unnecessary dehumanisation. An example of necessary dehumanisation is that it reduces physician burnout: if I felt the same intensity of empathy for every patient undergoing a blood test as a typical non-healthcare worker would, I would be overwhelmed and unable to do my job. But there are many examples of unnecessary dehumanisation that we should identify, expose and address to ensure they do not affect how we think of, and care for, our patients.

Although as individuals we may aspire to a partnership model with our patients, our structures rarely facilitate this, and there is a danger that we see patients not as individuals but as tasks to be ticked off. I am much less personally interested that “bed 9 needs a cannula,” than I am that “Eve’s cannula has tissued again and she really needs her iv fluids.” And when I think about constructing a management plan, I am much less likely to take the time to explain my clinical reasoning and involve the patient in decision making if I think of him as “the PE in bed 3″ rather than “Bob, the lovely history teacher who has a PE.”

If and when I become a patient I want my medical team to treat my as an individual, consider my personal context and experience of illness, and integrate this into their decision-making process. I do not want to be referred to as “bed 2.” I realise that as a Medical Reg I would embody ‘the nightmare patient’, but something approaching this true partnership model should be what we aspire to for every patient, not just those (like me) who explicitly demand it. Many things need to change to achieve this ideal including; better data sharing with, and ownership by patients; better public and patient education allowing valuable discussion about trial data and the value and limits of evidence-based medicine; and a dramatic change in our IT structures such that they enhance rather than impede communication across arbitrary boundaries of primary, secondary  and tertiary care.

We should work to achieve system changes, but they will take time to implement. We can take immediate personal responsibility for our own actions and our own role in dehumanisation in healthcare.

A statement in Haque and Waytz’ paper that particularly hit home was:

“Medical education and training should also incorporate practices that allow physicians to emphasize the common humanity they share with their patients, specifically their shared mortality; illness narratives; and vulnerability to disability, suffering, personal loss, and other forms of uncertainty”

I am a passionate advocate for a strong educational focus on our common humanity, and for the power in sharing personal narratives, thoughts and uncertainties as professionals with the aim of demystifying and disempowering the role of “the health professional.”  I suppose that is one aspect of what this blog has tried to achieve. By sharing my personal experiences and exposing my doubts and flaws I hope to show the human side of my role as a doctor.

I have been inspired by NHS Change Day to consider what small changes I can make in my own practice that will improve the lives of my patients. I will be pledging to re-humanise my personal practice of medicine, by always using patients names as a constant reminder of their individuality. I hope that hearing  “bed 9 wants to see you” will become the exception rather than the rule. You can make this happen. Pledge with me

NHS Change Day