Heroes Not Zombies

Orthopaedic surgeons at St Louis University School of Medicine were a bit puzzled when their clinical tests on patients post hip surgery indicated they were recovering well but the patients own reports didn’t confirm that. What they did was ran a parallel questionnaire which amongst other things asked about emotional well-being. The two sets of results didn’t correlate

“What we found was surprising – the clinical test found good-to-excellent results, while the self-test taken by the same patients showed significantly worse recovery.”

Now, to you and me that might not be a surprise but, strangely, to these surgeons it was a shock. You know why? The surgeons see themselves as technical fixers. In this case they were fixing hips and they were assessing how well the new hips worked. But they are being confronted with the fact that the hips in question are inside people and people are a lot more complex than just the bits of their bodies.

You can’t but applaud this conclusion from Berton Moed MD

“The number one issue is recognition – we need to acknowledge that there’s more going on with patients than what current clinical tests tell us,” he says.

But wait, his suggestions for what do about this problem is worryingly medicalised –

“Do we need to look at other interventions besides fixing their hip? I think we might have to,” he says. “That could include bringing in social workers and psychologists to work with the patients in the areas that surgeons, who often are super subspecialists, may not be able to deal with.”

OK, I’ll let the “super” and “sub” bit connected to the “specialists” go for the moment but do we really need social workers and psychologists to help patients recover? Because surgeons don’t know how to address a patient’s issues and feelings?

Please, let’s recognise that people are always more than the sum of their parts and that every health care intervention should take into consideration the whole person, not just the wonky bit! Recovery, true recovery, from an operation is a complex phenomenon. If we don’t recognise this we are in danger of wasting a lot of time and good effort only doing half a job. Every surgeon and every nurse on a surgical ward should be able to address and care for the human needs of the patients in their care.

By the way, just what is a “super subspecialist”? Someone who only has the skills to deal with bits of people?

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Morag Wilson, a 32 year Dietetics Manager in the NHS committed suicide by stabbing herself with a kitchen knife then throwing herself from a bridge 100 feet above the Manchester ship canal. The coroner said she was driven to this sad end by the pressures of her job. Specifically, Agenda for Change had produced very disparate outcomes for dieticians in her region and resulted in widespread resentment amongst staff. The coroner said this

“I find it extremely sad that a young woman with such a lot going for her, very dedicated to her work, has been reduced to despair by the pressure upon her at work,” he said. “When people introduce these rules and systems perhaps a bit more thought as to what effect they will have on people would be helpful.”

The NHS should be a people focussed organisation – focussed on the patients and those who deliver the health care. Targets, budgets, managerial processes, should all be measured against the impacts they will have on people. Please, can we have a health service that cares, that really cares about people?

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BBC news reports today that Loyd Grossman has attacked government for failing to take patients’ nutrition seriously. In response, the Department of Health “spokesperson” (why are these people always anonymous?) says

A Department of Health spokesperson said: “Hospital food has improved greatly over the past few years.

Wow! It has??!! Well I work in an NHS hospital and I can’t say I’ve seen any improvement in hospital food, so that got me wondering…….improved how? What has improved? The food has improved? I popped across to the Audit Scotland site and found a report on catering in NHS hospitals in Scotland dated last November.

They found that NHS spending on food and beverages (that’s not the catering costs including staff pay and so on, it’s just the cost of the food and beverages) rose from £2.23 per person per day in 2001/2002 to £2.34 in 2005/2006 (and they point out that’s less than the rate of inflation over that period) But that’s an average! The hospital where I work actually spends less than two pounds per patient per day on food and beverages. (about £1.60 actually)

OK, so it’s not rocket science, but what do you reckon? You think the DOH spokesperson is right? The food has improved “greatly” in recent years but they’re actually spending less on it?

How can we expect sick people to get better if we don’t feed them well? Surely a sick person needs even better nutrition than a healthy person does? Here’s my question to anyone in the DOH “What’s your daily spend on food and beverages for your family?” Then compare that to what a hospital patient is given and ask yourself if there’s a problem here.

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….that might seem like a strange and obvious statement, but the reality is that health is experienced by individuals which is why we need a health service which is patient centred, taking a holistic focus to understand the differences between people as well as their similarities (what diseases they have). However, the other side of the partnership in healing is the health care professional – doctors, nurses and other professionals. There’s a strange distortion of “Evidence Based Medicine” which seeks to reduce the whole of health care to numbers, as if people don’t matter. We see this in the way that randomised controlled trials are conducted using methods which explicitly seek to exclude the individual people effects – you never see any mention in a research paper of who the individual health care professionals were who actually interacted with the nameless and faceless patients in the trial. It’s as if we can only rely on studies which exclude the effects and contexts of human beings. This has always struck me as strange.

In any GP partnership, patients quickly suss out which doctor is good for which approach. Those who want to be given time to talk about their problems seek out the doctor who listens. Those who want antibiotics seek out the one who is best known for prescribing them without lectures…….and so on.

Doctors are not clones. They are individuals too. In good health care each of us needs to find a doctor we can connect with, one who is on our wavelength. Yes, we want a surgeon, a physician, a GP who has good up to date technical knowledge and skill. That’s a given. But we need more than that. We need a good human relationship with him or her.

So, I wholeheartedly endorse Dr Everington of the BMA today who says

Doctors feel under attack, the government wants to turn everything into something that has just a monetary value. Vocation, dedication and lifetime commitment to patients and the NHS has little value in this new world – we are just financial commodities.

There’s a process going on in the NHS known as “Agenda for Change“. It’s central tenet seems to be that every job in the NHS can be described according to the knowledge and skills required to do that job, every person can have their knowledge and skill level assessed, then anyone with the requisite level for a particular job can do that job. The actual human beings become dispensible and interchangeable. The whole process is demoralising for thousands of NHS staff. People matter. Personal, individual qualities and characteristics matter. Two different people doing the same job will interact with people differently. In health care this matters. In a factory making widgets it maybe doesn’t. But GP surgeries and hospitals are not factories and people are not widgets.

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A study published in The Archives of Internal Medicine looked at how doctors greet their patients. In particular they studied how often doctors used the patient’s name and how often they greeted the patient with a handshake. They claimed to show that most patients wanted to be greeted by name and with a handshake and that many times doctors failed to use the patient’s name. However, the statistics on the handshaking are fascinating –

Seventy-eight percent of patients surveyed wanted a doctor to shake their hands, while 18 percent did not. In the taped sessions, doctors and patients shook hands 83 percent of the time.

Read that carefully. 78% of patients said they wanted the doctor to shake their hands. 83% of time the doctor shook the patients hand. What does this mean? That doctors are shaking patients’ hands too readily? That more patients get their hands shaken than wish to do so? Funnily enough, there’s no comment about this strange anomaly.

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