Brave new world: Efficiency at the cost of the person?

Last week I attended a pre-op clinic in preparation for my revision hip replacement next month. It’s fair to say that much has changed in the 15 years since I last underwent major surgery. Although some of my experience is new because I now attend a different hospital with different procedures, I was startled by the lack of humanity in the system.

At the pre-op clinic I was shunted about from one healthcare professional to another, clipboard awkwardly in hand with crutches, for them to tick off my list that they’d seen me – though it was phrased that I’d seen them, I wasn’t so sure. At one stage a nurse asked another, ‘Do you have Susanne? Can I have her next?’. I jokingly asked if I got a say…

I’d like to say that this system allowed for person-centred care but it felt like a highly effective system at the expense of individualism. Of the three or four health professionals I spoke to that day (not including my consultant, who has always been wonderfully person-centred in his approach to my care), only one treated me as an individual and took the time to find out what the situation is for me. She suddenly found that I am not a straightforward box to tick off and spent considerably longer with me than she expected. So, yes, I can see person-centred care is costly in terms of up-front resources but the potential is that by taking the time to find out about my individual needs, she will make my post-op recovery faster and easier. She also said it would help the nurses to have as much information as possible because they don’t meet the patient until they’re fresh on the ward from the recovery room.

At this hospital, like others, I will arrive on the morning of the operation, having followed hygiene protocols with body wash and nose cream, to ‘check-in’ my luggage and then join a waiting area. I will meet my luggage at my designated ward – to be determined during the op. While this sounds as though I am jetting off on an all-inclusive holiday I fear the ‘jet-lag’ may be worse and the culture shock considerable.

I am accustomed to being admitted to a ward the afternoon before surgery, meeting nurses, settling in and getting a feel for how things work. While many people may prefer the additional night at home, I think there is a lot to be said for this time to acclimatise – for the patient, their support network and for the nurses to get to know you; especially if you happen to be a slightly unusually shaped box, for example.

Of course, I fully understand and can see the efficiency of this system – I don’t doubt that it is saving money and has met many efficiency targets. However, when research shows that good communication and positive relationships with healthcare professionals and care givers aids our healing process it is hard to believe that this is the best approach. Additionally, research shows that being treated as individuals with our own identities (rather than ‘bed 3, revision hip’) lowers pain levels and heart rates, requiring less pain relief medication and leading to a speedier recovery.

Having had a lifetime of attending hospital appointments and undergoing surgery, I have just experienced the longest period in my life of not having open surgery. Previously I have been nonchalant about hospitalisations and I suspect my concerns about the forthcoming operation are influencing my feelings about these system changes. Perhaps the real issue is that I need the reassurance of familiar protocols? Oh Brave new world…

Tales from the communication wasteland: patient-provider communication

‘It’s my decision’
‘No, it’s not’
‘It’s my decision; it’s about me‘

This was part of a conversation overheard in an A&E department last week, through the cubicle curtains that provide a mere illusion of private space (see Goffman). Fortunately it was not a medical professional saying that ‘it’ was not the patient’s choice, it was the patient’s companion. For me, the pain of overhearing a conversation so far removed from the person’s autonomy was acute.

 

Last week I spent time in two different hospitals, communicating with a range of medical professionals. For once, my role entailed me being beside the bed, not in it. This was a rather peculiar experience and certainly helped me to recognise how institutionalised I am (I was shocked to find that I was able to predict accurately, and explain, many routines, systems, etc. to my friend though I had never been a patient in the particular hospitals concerned).

We experienced a range of positive and negative communication exchanges. The importance of encountering someone who takes the time to enter into a conversation or dialogue, rather than following the traditional paternalistic approach of ‘doing to’, was highlighted to us.

 

In the first hospital my friend experienced a nurse suddenly appearing and wrestling my friend’s arm, in order to take blood, and swabbing her nose and bikini line to check for MRSA. My friend was looking the other way, dosed up on strong medication and holding a conversation with the doctor when these actions took place. Needless to say she was rather surprised. I was appalled to witness a total lack of consultation – no explanation, request, forewarning, etc. When an orthopaedic FY2 spoke to my friend, she began to describe herself as being from ‘orthopaedics’ but stopped halfway, changing instead to ‘bone people’. Feeling patronised was not empowering for my friend…

 

Upon entering a different hospital, this experience of poor communication was highlighted for us by the fact that this second hospital DID communicate with my friend, checked she was OK with the blood being taken, etc.; in fact, they encouraged her to do the MRSA swabs herself.

The difference to her morale (and mine) was huge. The additional difference was the impact that this had upon her confidence in the members of staff and hospital she was in now. The process of being communicated with and empowered led to greater trust in the care she would be receiving overall. With greater trust, a more empowered patient develops. In turn, this can lead to a more positive outcome for the patient.

I understand that it is easy to view these encounters with the rose-tinted idealism of how things should be, if time and budgets had no bearing on these matters… However, my feeling is that the extra minute or two taken here and there to communicate effectively and empower the patient to be involved in their care, can lead to more positive outcomes.

 

From: The Proactive Patient http://www.closeyourmedicalpractice.com/the-active-patient/

 

Personally, I still recall with great fondness and respect a former consultant of mine: When he took over my care, and was going to operate on me for the first time, I was 19. I was accustomed to having surgery but this was only the second time that I would be signing the consent form personally.

My consultant did not hover at the end of my bed with an entourage for just one minute, barely looking at me, talking about me but not to me, then disappearing after barking orders at nurses and housemen, the patient’s heart left pounding having tried to catch the eye of the consultant to ask a burning question that remains unanswered… (I’ve been fortunate not to have any such consultant but I’ve witnessed plenty of these encounters.)

Instead, this consultant sat down at the side of my bed. He drew a diagram of what they would be doing and ensured I understood. Then, he looked at me directly and asked if I was sure I wished to go ahead. Once, he even waved at me across the ward!

 

The difference that these encounters made were enormous. That they have remained so clearly in my memory is testament to that. Indeed, through that one conversation my consultant had become a person to me; not an anonymous name and creature to be feared. It is an experience that made a fundamental difference to my encounters with him because we started at a very positive place. The effect was that my consultant immediately acquired my respect and confidence. In addition, I felt that I was an equal partner in my care – I became an empowered patient with autonomy thanks to that conversation, bridging the communication wasteland between patient and provider.