Tuesday, July 11, 2006

Unfinished Business

Friday was what my dear departed granny would have termed "A bit of a B' ".

One patient in particular posed problems that were not immediately solvable. Siobhan, a single mum not in the first flush of youth, had had a "funny do" eight days before. It had left her with a funny feeling in her right arm and leg, very tired, and perhaps a bit weak down the same side. She has high blood pressure and had a similar funny turn three years back which got better in less than 48 hours.

Investigations then were all normal, so she takes meds for BP and a daily aspirin and was well until this latest turn. Still there's enough here to make me worry about stroke. So I had to worry her. Unfortunately she hadn't read the "Stroke Care Pathway" and so, thoughtlessly, she had not made any childcare arrangements so I couldn't just send her straight in for work up by the physicians. Some people just don't think things through do they ;-) .

First I tried to call the Medical Registrar to see if there was any way to get her booked for her MRI without all the bother of "the pathway". Switchboard at the hospital tracked him down, but "We can't put you through on this line, do you have a mobile?"


No. Or at least not on me. I don't generally need one in surgery. If I do bring it in the kids just use it to update me on their missing sports kit / flute / lunch pass / lunch... so I don't do that any more.

"O K we'll get him to ring you back."

Siobhan was ok to wait for a while so I asked her to take five while I saw the next punter. Five turned in to sixty five and still no call back, so we agreed she should go home to await my call.

Twenty minutes later surgery was over and I called my friends on the hospital switchboard and finally got to speak to Med Reg. He's a locum and has less clue what to do than me. We agree to try to get Siobhan up to the Medical Assessment Unit as soon after she has completed the afternoon school run as possible,

So I now ring her back, and get diverted straight to answerphone. Leaving messages in such circumstances can be ticklish. What if it's not her that gets to pick up the message? What indeed if it's not even her phone?

I ring again to make sure I've dialled the right number. I have. It's the same message. So I leave a "George Smiley" type message vague enough to not let ant cats out of any bag, but clear enough (I hope) to make it clear that I need her to call me back.

She doesn't. So I go home, late, worrying.

Monday morning and there she is at reception when I come in. We reprise Friday's consultation and try again. This time all works to plan and she departs surgery for MAU within twenty minutes, referral letter in hand. Later she calls back to say she has had her initial x ray and bloods done and waits for an MRI date, but has been let home to continue to care for her inconvenient children.

I can't help feeling we ought to be able to do this better, but there isn't an arm of the pathway for "Single mum" or for "Carer for elderly demented spouse" or any of a dozen other little wrinkles that make the "Stroke Care Pathway" inappropriate for a great many patients who might be in need of it.


greavsie said...

Similarly, it appears that schools aren't set up for 'Both parents working full-time' either.

Doctor Jest said...

And here's me having to take a day off for that very reason :-(

Geena said...

Ummm...yeah...you have a 'pathway' to follow when there are people hanging around who may just drop dead in a jiffy....right...sensible.

In a situation like that, doesn't social services have social carers who can care for the kids? Probably a redundant question.

btw - what's an 'ant cat'?

Doctor Jest said...

Drat that spell checker. Doesn't spot arrant drivel. That of course should have read "any cats". Feeling too lazy to re-edit today tho'.....

Re social services, only in extremis, and, please God, we're not quite there yet...

Shinga said...

I don't understand this. The people who create these pathways are supposed to create storyboards detailing/profiling the people who are going to be needing these services. The poverty of imagination that is involved in failing to anticipate that there might be people with sole caring responsibilities (there can only be around 12 m people in that position) is breathtaking. In fact, it is so divorced from the real world that it must be a pathology and must therefore require its own drug therapy. Hey - if social awkwardness can have its own drug, why not one for the imaginatively impoverished who are also out of step with modern life?

It's not helpful to suggest that either a slap upside the head or the PCT having to incur emergency childcare costs would be more immediately effective. Where is the long-term medication profit in that?

Regards - Shinga

Geena said...

Is that what's it about? Profit?

How the heck did the medical world wander so far from the basic concept of care.

Doctor Jest said...

Shinga-- And I thought I was cynical. You're probably right though....

Thanks also for the heads up re the grand rounds. I can see I'm going to have to up my game if this carries on....

Doctor Jest said...

geena-- the NHS is actually about "deficits" (that's underfunded services in the real world) rather than profit. But true to say, most "innovations" in UK health care lately depend on Drug Company sponsorship, so no profit margin tends to = no investment. It's the downside of monopoly health care provision.

Mr Angry said...

Sometimes I read this site and am utterly amazed that you've not gone round-the-bend working in the NHS.

How do you not lose it with alarming regularity?

Doctor Jest said...

Angry-- you've obviously not met my good lady recently.

Still, for me the basic motivation is trying to help people feel / get better. And most of the time I get to do that without too much interference. But no-one wants to read a long succession of "Turned up today and everything went right" posts. Plus posting the worst / best / funniest bits is a great way to let off steam.

Sorry if I've been grinding you all down. There's a frivolous Ghost post coming up that should help restore the balance a bit though.

Geena said...

Your posts do not grind me down. They are always interesting and its great to see a human side to a doctor.

My Mom still thinks Doctors are gods..she doesn't believe you poop and burp like the rest of us mortals.

Now we know you feel too...and think...some of you even think outside the box. Nice.

hey my wv is scrub..appropriate for a surgeon, non?

Geena said...

not that you're a surgeon..but ...you know...

Shinga said...

Moi - cynical? On a different blog I outlined my vision of the Brave New World NHS.

Bear in mind that there have been several recent studies reported that highlight missed-diagnoses and mis-diagnoses: we've had doctors fail to diagnose flu (last week's Trautner study), along with the doctors miss whooping cough story. Plus the recent Because the doctor isn't always right, while not rampant, misdiagnosis happens.

The title of the piece was reasonably balanced, but one of the commenters co-authored the book Internal Bleeding, The Truth Behind America's Terrifying Epidemic of Medical Mistakes. More publicity for Isabel and PKC.

The New York Times ran a piece blithely titled Why Doctors So Often Get It Wrong back in Feb. and it excited a lot of blogosphere comment then - hence my vague memory of someone doing an excellent job on rubbishing the reported autopsy statistics that claim autopsies reveal a 40% rate of misdiagnosis of which 10-12% are significant enough that the person might have otherwise survived...One highlight of the article:
"There is no bonus for curing someone and no penalty for failing, except when the mistakes rise to the level of malpractice. So even though doctors can have the best intentions, they have little economic incentive to spend time double-checking their instincts, and hospitals have little incentive to give them the tools to do so."

It mentions Isabel extensively in that piece.

Of course, in the UK, we've had the likes of Rod Liddle in the Times opining that it is time for GPs to stop acting as gatekeepers between patients and pharmacists or patients and specialists: Don't defer to doctors. A particularly choice selection:
"I know what I’ve got when I go to the doctor and I know in advance the most efficacious method of treatment. Now I realise this sounds arrogant, but there’s a lot of information out there, in books and on the internet. The same sort of information given to the general practitioners, in fact."

My proposals for the Brave New NHS to follow.

Regards - Shinga

Shinga said...

Brave New NHS continued.

Why involve error-prone medical staff at all? They're just lead astray by their knowledge. If patients are conscious and have the use of their eyes, just pass out the Diagnosis, You're The Doctor, Kit. For more sophisticated needs or the entertainment of people who like to scare themselves witless, then SimulConsult may be just the ticket.

Patients could triage themselves and go up to a counter behind which there is a menu of tests. We could order our tests without even needing a person to be on duty - some McDonalds drive-throughs in the US are using call-centres in Mexico and elsewhere to take orders and relay them to the appropriate unit. The driver still pulls up in the bay, but talks to a remote employee. McDonalds reckon they make much more effective use of employee time this way as it usually takes 10 seconds for one driver to pull away and another to pull in. So, I reckon there is a business model there for both the US and the UK.

Take it further, health services could offer do-it-yourself X-rays, like photo booths, with easy to follow instructions...With the helpful Latin tag to make it sound medical: Machina improba! Vel mihi ede explicatum vel mihi redde nummos meos! (That should be - You infernal machine!Give me a diagnosis/explanation or give me my money back - but corrections gratefully accepted.)

The reasonableness test will become: "Could someone with a reasonable education have diagnosed this using DIY measures and one of these computer programmes?"

Just think of the savings involved by removing an entire layer of bureaucracy - patients will be so empowered that the lack of continuity of care won't matter. There may well be a few mortalities here but you can't make an omlette...

Regards - Shinga

Doctor Jest said...

Geena-- my Baccalaureate is in both Medicine and Surgery so you are absolutely fine ;-)

shinga-- phew, thanks for the contribution. A lot of food for thought there. You are right there is an emerging trend to see the "Family Doctor" as anachronistic and irrelevant. When the bills start piling up for the unnecessary tests ordered by the "One Hit Wonder" drop in centre docs, or self directed patients, maybe someone will take note, if it's not already too late....

The essential problem is that the "gatekeper" role can't be measured for its effectiveness because you can't see what's not there.

Without wishing to sound unduly negative I tend far more to the views of Osler "One of the first duties of the physician is to educate the masses not to take medicine." and Voltaire " The art of medicine consists in amusing the patient while nature cures the disease." than Liddle.

Shinga said...

I hope that it is apparent that I am no supporter of the Liddle position - sorry if that wasn't clear.

With the growing emphasis on knowing family history and even genetic contributions to understand a medical history - I find it remarkable that the social history is being overlooked so readily when it is so important.

Do you have those quotations framed and on the wall in your waiting-room?

Regards - Shinga

Doctor Jest said...

Shinga-- Fear not. I took your posts as a Cassandran prophecy rather than a statement of your own beliefs and values. Sadly we do not have the quotes framed, just some bland and typical 1990's "Mission Statement".

I have got a Sappho poem on my noticeboard in the consulting room tho' FWIW.

In translation

"Both the moon
And Pleiades have set,
It's the middle of the night,
The hours are crawling past,
And I lie down to sleep alone."

An insomniacs cry from three milennia ago no less relevant today.

Of course for the original author the key word in the whole poem was "alone". But so it is for many people still. For all our sophistication and modernity we remain the same animals we were in antiquity and our needs have not changed appreciably either. Not so our demands however, which is roughly where I came in I think.

Shinga said...


I am one of those people who reads the noticeboards. Nearly 3 years ago I had to attend a GP as a temporary resident (throat abcesses the size of almonds - the memory is still with me). The noticeboard contained several testimonials to the fact that he was a doctor who was qualified to attend Himalayan treks, specialised in altitude medicine etc. - He even had letters from grateful Sherpas he had attended - completely fascinating. It made the consultation go like a breeze and helped me to ignore the squeezing of my outraged throat and glands.

There's a lot to be said for these noticeboards.

Regards - Shinga