A Radiologists Journey by David Hill

When I was interviewed for my training post in radiology I was asked why I wanted to enter the specialty. I realised that the honest answer would not get me the job: “Surgery and I have come to the mutual realisation that I will never be a surgeon, and I can’t get a job in anaesthetics. The X-Ray department is the place in my present hospital where folk go to socialise over a cup of coffee. Everybody seems nice, so I thought I would give radiology a go”. Instead I gave the answer that I had prepared earlier: “Radiology is at the cutting edge of clinical medicine with exciting new diagnostic technologies being introduced and radiologists are pushing back the frontiers of minimally invasive treatment”.

When I started my radiology job the following week (yes, I was getting kind of desperate) the reality was somewhat different. Yes, there were some radiologists pushing back the frontiers, experimenting with new technology, but the reality of everyday radiology was somewhat different in 1980.

This was arguably the tail end of the golden age of diagnostic clinical medicine as an art form. As recent medical students we had been taught by some of the clinical gods of Glaswegian medicine that the key to diagnosis was a detailed clinical history and a meticulous clinical examination. Obviously, as a surgical resident you had to learn how to clerk-in 8 patients in an hour for routine elective surgery but, if you were a medical junior, then woe betide you on the ward round if you had not spent an hour or so on each patient taking note of every detail of their clinical and social history, and performing a meticulous clinical examination of every body system. That process would be gone through by the resident, the SHO, the registrar and/or the senior registrar. The findings would be presented to the consultant on the ward round, who would elicit further gems from the history, and clinical signs that had previously been missed. Some consultants would do that in a spirit of education; some would use those gems as weapons of humiliation against those who had missed them. A diagnosis would be made, perhaps with one or two alternative suggestions. The job of radiology was then, with the limited tests available, to confirm that diagnosis.

We had a limited arsenal of tests. Plain x-ray films were pretty good at what they did by present standards. Nuclear medicine scans wouldn’t be totally out of place today. There were various x-ray dyes and suspensions to outline specific body parts on x-rays, almost none of which are used today. Ultrasound machines and CT head scanners were almost unbelievably crude by today’s standards.

However, technology was rolled out in radiology and the diagnostic capabilities of the equipment increased significantly with the advent of whole-body CT scanners and MR scanners. In Dumfries at times we were near that cutting edge of technology, with the first full field digital mammography unit and the first multi-detector CT scanner in the country.

However, with the advance in technology, we have lost the variety of radiological techniques that we used to have. When I started in Dumfries as a consultant radiologist in 1986, in the first month I carried out 13 different kinds of radiological test, all of which required my practical input, and only one of which, ultrasound scanning, we still use. Now over 80% of a radiologist’s time is spent sitting at a computer screen looking at digital x-rays, CT and MR scans.

On a visit to Norway in 1999, I met a radiologist who offered to show me round her department. It had recently become fully digital with no x-ray film any more. All studies were reported on digital work-stations. It was way ahead of anything in this country and looked very impressive. I said it must make a tremendous difference to the way you work. Yes, she said, we are now computer operators sitting here all day and I can’t do this for another 20 years, so I am resigning and going to be a farmer.

I understand what she was saying. It is easy to feel like a hamster on a wheel, spinning ever faster but never keeping pace with the increase in demand for radiology. There are many reasons for that increase, currently around 5% per year, not least of which are the guidelines Angus talked about in last week’s blog.

There are upsides. There is an intellectual variety which we never had before, due to the wide range of pathologies we can image. You are sitting at a computer, so if you come across something you don’t know, you can go on a Google expedition to fill that knowledge gap. We still have a long way to go though before radiology (and lab tests) can give all the answers, so there is still a place for those old-fashioned clinical skills.

Dr David Hill (@davidmhill55) is a Consultant Radiologist at Dumfries and Galloway Royal Infirmary

Next weeks blog will be by Susan Roberts, Clinical Pharamcist

Guidelines in Medicine by Dr Angus Cameron

I qualified as a doctor almost 35 years ago. Looking back it seemed to be a period of relative innocence. Time and blurred memory makes the reality of medical care then fade, but I am sure that we didn’t use the word guideline much then.  There were some clinical “rules” of course, but the vast number of guidelines didn’t exist then. There was much more variation in the care that was delivered, with the doctors personal preferences going relatively unchallenged.

Since then of course, the technical care of patients has become much more standardised, and this has undoubtedly led to improvements in the outcomes for patients. The concept of clinical audit developed in the 1980s, and we started measuring how many of our patients got the standard of care that had been outlined by the relevant guidelines. Where audit results were poor we started improving to ensure that almost all patients who could benefit were treated according to the most up to date guideline.

There followed a period where guidelines began to multiply, and many of the most experienced doctors nurses and pharmacists found themselves sifting through clinical evidence from trials and spending long hours developing guidelines. They were published by a vast number of groups and soon there were also local guidelines in each Health Board.

SIGN (The Scottish Intercollegiate Guideline Network) was born in an attempt to give more authoritative and unbiased guidance to clinicians.  This was a world leader (and probably still is), publishing guidelines that tended to be much clearer than others, and also included an assessment of how strong the evidence supporting each bit of the guideline was, allowing the clinician to have confidence in interpreting the guidance that was presented. SIGN was, I recall, ground-breaking in that patient groups were invited to join the guideline development panels.

SIGN guidelines are published in glossy booklets that were sent out to all GPs. They had a wonderful smell of fresh ink, and although the format was largely standardised each had a different coloured cover so that you could rapidly find the one that you wanted in the pile of papers and magazines that lay in the corner of your room.  When they arrived in the post I would glance through them: Some were not really relevant to general practice (I was a GP in the Scottish Borders then), but they were to be revered, and not to be discarded. On busy days I saved them for later reading. A pile of them grew steadily in the corner of my consulting room, sadly neglected, and tending to stick to one another as the once sweet smelling ink dried and stuck them together. When I left general practice I had over 100 of them. I couldn’t throw them out, but left them in a neat chronologically ordered row for my successor who would no doubt wonder if I had lived up to the standards espoused by the guidelines.

Guidelines began to interest lawyers. Around about 2000, failure to follow a SIGN guideline was discussed by a Sherriff in Glasgow who was hearing a fatal accident inquiry into the death of a patient from epilepsy. The SIGN guideline was clear in saying that General Practices should have distinct clinics for patients with epilepsy to assist a practice in providing structured, proactive care. The sheriff was extremely critical of the practice in not having such a clinic. He noted that they had failed to follow authoritative opinion in their provision of care, and were therefore guilty of a significant failure. Inevitably lawyers and doctors began to view guidelines in a different light. Lawyers would read and understand guidelines when dealing with medical negligence cases, and doctors would worry about ensuring that they were following them, and keeping up to date with them.

Guidelines have been incorporated into the Quality and Outcomes Framework of the GP contract since 2004, and the payment to GPs is significantly determined by their compliance with guidelines in a number of diseases- giving another incentive for GPs to follow guidelines, even if they hadn’t already felt compelled to do so by potential litigation.

But I sense that there is growing concern about some aspects of guidelines, and I share those concerns.  This is difficult to say as a professional (still less a Medical Director) “How can you possibly want to ignore guidelines and bring back substandard care” others would say.  Des Spence, a regular (and somewhat irreverent) contributor to the back pages of the BMJ talks of the “tyranny of guidelines” and the difficulties of railing against what now sound like compulsory edicts rather than helpful guidance. And sadly there is increasing evidence that there are commercial interests hovering around the production of guidelines: Guidelines can help sell vast volumes of medications.

Let me try to explain some of the concerns I have about guidelines.

Firstly they are so often misquoted. If you go back to the original guideline they often say something along the lines of  “Drug X should be considered for ….”.   The cool and sophisticated pharmaceutical company representative who comes to see you will, slightly challengingly, suggest to you that the guideline says “Drug X should always be used”, and, not actually having read the guideline in detail yourself you feel obliged to consider changing your clinical practice in the face of what you believe to be incontrovertible evidence.  And of course the pharmaceutical rep (if you are unwise enough to see them) will have selected a particular guideline – there may be others that disagree.

Secondly, they are often unarguably correct when first developed, but over time they become extrapolated. A guideline may, for example, say, quite correctly, that patients with moderate to severe asthma should be given a steroid inhaler.  This is absolutely correct. But gradually this message is reshaped in practice, and the principle is applied to patients with less and less troublesome asthma, until the patient with only occasional mild wheeze is given a steroid inhaler with “doctor’s orders” to take them on a regular twice daily basis.  Taking a medication to prevent symptoms is of course more profitable for a drug company than only taking medicines when you are ill.

Thirdly, guidelines are often developed regarding patients who are relatively young, and who only have one particular illness. But in the real world this doesn’t happen often. As more of the population survives into older age, older patients (who metabolise drugs differently and who are more susceptible to side effects) have multiple illnesses, and so following the guidelines for each of the illnesses that they have (or are at risk of developing) results in patients facing a mountain of medication each day, often with resulting problems of confusion, falls, constipation, tiredness and the rest. So of course there are new guidelines developed on how to deal with polypharmacy – the use of large numbers of medication.

Lastly, some guidelines are found to be wrong as knowledge develops.  A group of researchers some years ago reviewed all articles published in the New England Journal of Medicine in the course of 1 year, and noted that 17  (I think it was 17, I haven’t got the reference to hand) of the articles showed evidence that a basic guideline needed to be either withdrawn or significantly corrected.

But let me end with my personal evidence that guideline development may be subject to commercial pressures, and that lobby groups may push to influence clinical practice.

A letter arrived two years ago inviting me to dinner in the Scottish Parliament. The letter suggested that as an opinion leader in medicine I would be very welcome to attend a dinner in Holyrood with MSPs and doctors, hosted by the Atrial Fibrillation Association. I’m easily flattered and accepted with eager anticipation. I noted from the impressive website that the association had been recently founded to “increase awareness of atrial fibrillation” (a condition where an irregular heart beat occurs which may lead on to stroke in some patients). Cynically I wondered if the association and the website had had funding from a drug company that was soon to launch a new form of anticoagulant that could be used instead of warfarin for patients with atrial fibrillation.  (Warfarin “thins” the blood and prevents stroke in atrial fibrillation). The new medicine costs almost 36 times more than warfarin and could potentially be used on thousands of patients who are currently on warfarin. While the new drug does not need regular blood tests to monitor its impact, it has only marginal improved effect in reducing stroke – and of course is not without problems itself.

The member’s dining room in Holyrood is impressive and I felt somewhat overawed as I sat at a table with MSPs some of whom I recognised from the papers. The meal was modest but accompanied by excellent wine. Half way through the meal an extraordinarily beautiful lady stood up at one of the tables and began to talk about atrial fibrillation, noting that it affects up to “one in four” of the population (in fact only about 2-3000 in Dumfries & Galloway), was associated with a “very high” risk of stroke (not an accurate representation)and was treated by a drug that was extraordinarily old-fashioned, used as a rat poison and extremely dangerous. She described in beguiling tones how the association needed support from opinion leaders such as the dinner guests to ensure that new advances in treatment could be made available to the population, along with a concerted screening problem to find patients with atrial fibrillation who had no symptoms. Her words implied an extraordinary number of patients of all ages developed strokes, and seductively implied to those present that the cost of a new medicine would be more than offset by the reduction in the number of strokes.  Her talk was very slick and convincing, but at considerable variance with conventional medical evidence. Several of the MSPs asked questions, and in the answers, the presenter urged them to push their local health boards to make the new drug readily available.  “This is such an important issue that it can’t be left up to clinicians to decide” seemed to be the message – “politicians need to unite to rid Scotland of its poor stroke record.”

I’ll never get invited back to Holyrood.  As an “opinion leader” I stood up and said that I felt anxious that this discussion was not about raising awareness of atrial fibrillation, but about raising an appetite for a drug that would not by itself reduce the rate of stroke in Scotland significantly, and would potentially increase our drug spend in Dumfries & Galloway by £3 million pounds. I felt I was ignored and was made to feel naive: The evening ended with several of the “opinion leaders” having their photo taken with the amazingly beautiful lady, and pledging to hold their local Health Boards to account and force them to take up the new medicine.

I’m old and cynical, and I should recognise that there are good people who work with the association, and there are excellent guidelines that have shaped medicine to become safer and more effective.  But sympathise with me in my belief that guidelines need to used with caution, with appreciation that there may be vested interests in their development, and that all too often they are becoming rules rather than guidance. In summary, “they should be considered” rather than followed slavishly – this is what professionalism is all about as we combine medical knowledge with sympathetic understanding of patient’s problems and preferences and provide holistic care.

I think as a doctor I shall keep out of Holyrood. And perhaps politicians should keep out of medicine.

Angus Cameron is Medical Director for NHS Dumfries and Galloway

Next week’s blog will be by Dr David Hill (@davidmhill55) Consultant Radiologist NHS Dumfries and Galloway

 

The Weight of History by Jeff Ace (@JeffAce3)

This is close to an anniversary for me. I arrived in Dumfries as the Acute Trust Finance Director on Saturday 15 May 1999, the same day that my home side Swansea RFC were hammering local rivals Llanelli in the Welsh cup final. This was not supposed to happen. Not the coming to Dumfries part; that has been largely wonderful from my perspective. Nor the rugby part, as Swansea’s win was as predictable as it was crushing. No, it’s the Finance Director bit that still puzzles me.

I never set out to be an accountant. I vaguely remember falling in with the wrong crowd after University and recall trying to explain things awkwardly to my mum and dad, but still feel a sense of shock that a few years later I’d become qualified. My results came in the post on the day that Wales lost to England in Cardiff for the first time for 28 years. With the new letters behind my name I was able to understand that, in both gross and net terms, this was a bad day.

What I’d intended to do, instead of this frankly unfathomable debits and credits business, was to work in something that built on my interest in history. By far the best teacher at my school in the Swansea valley was a gruff, chain smoking Cumbrian called Mr Fielding. He understood the power of ideas (and debate over ideas) in enthusing teenage minds all too ready to drift to other areas of interest. Amazingly, Mr Fielding could somehow generate a classroom of vibrant, sometimes almost violent, argument about the role of Thomas Paine in inciting revolutions or of Thomas Hobbes in averting them. For me, history was as cool as studying could get and I chose school exams and degree accordingly.

I’ve recently started wondering if my old interest isn’t coming back to haunt me. As Chief Executive, I have an appointment letter from the Cabinet Secretary setting out my role as the NHS Board’s “Accountable Officer”; essentially, this says that I will be held responsible for all of the actions and decisions of our local NHS. This is enough to give some sleepless nights at best of times but, at the moment, makes me particularly thoughtful. I’m thoughtful because the decisions that we make over the nature of health and social care in the next year or so will shape our population’s services for generations to come. The quality of our decision making will reverberate through this region’s future in a way that should give us all pause for reflection.

Take a tiny element of the acute services redesign project… We’ve recently made a final decision on the number of variable pressure isolation rooms in the new facility. DGRI currently has none that meet the exacting new technical standards and we’ve attempted to predict future demand (if any) for these specialist facilities. We’ve taken (often conflicting) advice, weighed up costs and impact on ward layouts and made a decision that four is the appropriate number. Now if clinical demands stay broadly as they are today, four is too many and our successors (as they arrive in their jetpacks?) will bemoan the waste of space and reduced flexibility of ward layouts. If, for example, extreme drug resistant TB becomes the norm or exotic new viruses appear, we have built too few and our successors (all cycling in?) will curse our lack of foresight – though I think they’ll be pretty relieved about the outcome of the 100% single rooms debate! Maybe the answer could be determined in a Swiss laboratory where a young researcher is on the cusp of a breakthrough to create the next generation of antibiotics; or perhaps she’ll get a text from her mates and go down the pub instead….

And remember, this is a small piece in the jigsaw of designing a facility that will be operational into the 2070s. Every one of our decisions (on bed numbers, ward layouts, electronic record management, clinical adjacencies etc…) presents similar uncertainties. I want everyone involved in this project, from staff giving up their time to attend yet another meeting, to Board members ratifying business cases, to be aware of our enormous historical responsibility in making the best decisions we possibly can.  

At the same time as we’re determining the shape of the region’s acute services, we’re trying to reinvent our relationship with adult social care. Our aim is to try and operate essentially as one organisation that delivers the highest quality health and social care as close to people’s homes and communities as possible. It will be a hugely complex process, but one that is essential if we’re to meet future demographic and financial challenges. No UK health system can at the moment demonstrate such a fully aligned model of care, so we’re at the cutting edge of high risk innovation. Just where an accountable officer loves to be…

The third great change that we will need to deliver concerns our relationship with our patients and their carers. Bevan invented the NHS (or G.I.G. in the original Welsh) as a near monopoly provider of care and treatment. The traditional critique of monopolies is that they can become unresponsive to clients and slow to innovate; I think our clinical teams often make a nonsense of this view. Over the last few years in particular, we’ve seen an explosion of redesign and innovation that has reduced waits, introduced new approaches to treatment and made care measurably safer.

But this on its own is no longer sufficient. The challenge now is to bring the same scale of innovation and quality improvement to every aspect of our interactions with patients and their families or carers. This is partly to meet the big social changes of history; the patient in front of the healthcare professional in 2013 has different expectations from those of their 1948 counterpart (and we can guess that their 2050s successors will have higher requirements still). But it is much more about simply doing what is right, about providing the same ‘person centred’ care that we would want for us or for our families.

Of all the once-in-a-generation changes that we’re engaged in at the moment, this one is the most important and the most difficult. There were over 46,000 attendances at our A&Es last year, around 80,000 Outpatient appointments, over 20,000 hospital stays and hundreds of thousands of primary and community care interactions with patients in the community. The challenge of making each of these contacts of the highest value to the individual and family involved is enormous. But without that aspiration, I think the new hospital and integrated health and social care developments will not themselves deliver what our population needs and deserves.

So these should be our ambitions; to bequeath the coming generations with a fit for future acute hospital at the heart of an integrated health and social care service, where every contact with a patient or their carers is of the standard that we would want for our families. And if we can pull this off, then I think we’ll have made a decent bit of history.

 Jeff Ace is the Chief Executive of Dumfries and Galloway Health Board

Next weeks blog will be by Dr Angus Cameron Medical Director for Dumfries and Galloway Health Board

 

 

 

 

 

 

London 2013- International Forum on Quality & Safety in Healthcare by The Patient Safety Team

A quartet of quality and safety enthusiasts from NHS Dumfries & Galloway were fortunate to attend the BMJ/IHI International Forum on Quality and Safety in Healthcare last month.

We valiantly and proudly represented our Board and flew the flag for team Scotland with Poster displays on three of our improvement programmes:

• Safer Clinical Systems Approach to reducing Prescribing Errors in our MAU
• CAUTI (Catheter Associated Urinary Tract Infection) prevention bundle
• Active Patient Care – an approach to actively prescribe and deliver personalised nursing care.

We networked and met improvers from across the globe with whom we traded improvement stories, our aspirations for healthcare and put our collective minds to solving contemporary healthcare challenges.

 We were inspired, we were motivated we were awed by what has been achieved around the globe and wanted to share some of our stories with you.

Highlights from the Developing World

The  highlight had to be Dr Ernest Madu talking about the efficiencies and improvements to health made in the Caribbean and Africa though the use of telehealth.  The barriers overcome have been huge, barriers we still don’t seem to be able to overcome with patients and clinicians alike.  Faced with having no service though I do see how the introduction of telehealth to create a service may be easier to ‘sell’ to the population that where we are as we could be seen to be offering a lesser service. 

Ernest, a cardiologist trained in the UK returned to his native Jamaica to set up Cardiac Services. He firmly believes that all people have the right to world class healthcare regardless of their ability to pay. He founded ‘The Heart Institute of Caribbean’ and set about building world class care. A centre of excellence was built in Kingston, Jamaica with patients paying what they are able or not at all. He described himself as the Robin Hood of heart care, using the wealth of those able to pay to fund care for all. Satellite centres have been built across the Caribbean with telehealth facilities to link local communities and technicians to the advice from a network of consultants across the globe. Patients requiring surgical intervention are airlifted from their local community to Kingston for surgery that day.

Ernest has gone on to set up a virtual Doctors On Call Service in both the Caribbean and Nigeria using mobile phone technology to link remote communities to medical advice, care and treatment. He has championed innovative solutions to replace glucose monitoring strips which were too expensive and impractical for use in sub Saharan Africa – a truly inspirational man with a can do attitude!

The Aravind Eye Care System in India has been described as the McDonald’s of healthcare, designed with mass customisation in mind they have employed lean thinking to develop an eye care system for very remote and poor communities. Their mission is simple – ‘to reduce needless blindness’. They have worked with communities to train locals to perform sight tests, to prescribe and make glasses in local communities. Mass screening camps are set up and IT enabled vision centres have been established in local communities. Those requiring surgery are bussed to regional eye clinics where their surgery is performed and they are returned home the next day. The volume of patients having surgery each day is phenomenal with theatres designed to enable a constant flow of patients.

Do we have something to learn in terms of flow?

How do you work with opposing clinicians/ practitioners?:

• Let them set the standards they want to work to and then ask them to work with finance, exec team, management to work through how that can be best achieved at no additional cost (or lesser cost)
• Allow training opportunities and networks to develop , discussing how service can be delivered  and thus giving opportunity for career and professional development/ progression

• YOU WILL NEVER ERADICATE OPPOSITION – YOU MUST HAVE BRAVE PEOPLE INVOLVED WILLING TO PUT THEIR HEAD ABOVE THE PARAPET. 

Voice of the Customer – Are we listening?

 ‘“[The customer] may be dependent on us. We are also dependent on him. He is not an interruption of our work. He is the purpose of it. He is not an outsider to our business. He is part of it. We are not doing him a favour by serving him. He is doing us a favour by giving us the opportunity to do so.” Gandhi, M.

 A quote for all staff room/ changing room doors?

 15 STEPS CHALLENGE – Alice Williams

  ‘ I can tell what kind of care my daughter is going to get within 15 steps of walking onto a ward’ 

 Ask patients and carers what their first impressions were and see how staff can enhance this ensuring that we are inspiring confidence and trust even at first impression.

  Robert Francis QC

The highlight of the conference for me was Robert Francis speaking about his report into the Mid-Staffordshire Enquiry.  He spoke with such passion and care, it felt like he really meant what he was talking about. 

 “Is the patients voice heard? Don’t let complaints become just a statistic”

 He spoke about how we need to learn from what happened in Mid-staff and make the NHS a safe place to be cared for in.  I suppose for me, because there was issues with HAI highlighted in Mid-Staff, and it was clear what had gone wrong, I could think about what aims we have in our own infection control team and make sure they mirror those practices that are deliverable and safe, and not those that have no clear/standardised process.

 He talked about failures in the healthcare system, saying that all NHS Trusts and NHS Health Boards need to learn from the report.  We need to be proactive in assessing what it is we need to be able to deliver safe and effective care.  And not all of this costs money…we can start off by having that one person make a change which may impact on organisational culture.  Having data available and reports like the Francis report can drive cultural change by identifying the best from the worst performers and learning from the best. 

I think the strongest message I took away from it was that everybody has the same common goal – to provide the best possible care for our patients – we just need the right processes in place to be able to do this.

 

Patient Engagement  – The New Blockbuster Drug?

One of the BMJ streams focused on patient engagement, and this made me realise that actually the majority of our systems are designed around us, the staff, instead of our patients.  Our homework from this session is to change our questioning from “What is the matter with you today?” to “What matters to you?”  Maureen Bisognano, CEO and president of IHI highlighted this with two poignant patient experience examples. Upon entering the ward A there was no member of staff available to check if it was Ok to visit, later the family overhead the clerk asking “who let them in?”  Upon entering ward B, the family were assured by staff that they could visit whenever they liked and they should check their relatives daily goals on the whiteboard above their bed.  This whiteboard contained the key daily goals that the patient identified from the earlier discussion with the ward round team when they were asked “what matters to you today?”

Which ward would you rather be in?

Social Media – Get Tweeting

I was very glad of the promotion of Twitter by Ken Donaldson, otherwise I would have missed out on several significant opportunities at this conference. Firstly, every session had its own twitter feed which was used to capture learning, comments and questions.  This was great for keeping up to speed with sessions which you were unable to attend and spreading learning to others beyond the conference-10,000,000 impressions estimated from the conference.  I also find it much faster to search publications such as the BMJ and Health Foundation instead of navigating the websites.

 

It also provided an invaluable networking opportunity.  I resonated with a lot the tweets that one particular person was posting and I asked to meet them at the NHS Scotland stand.  This person turned out to be a nurse from Grampian who has been involved in the SPSP medicine reconciliation work so we had lots to share; the power of twitter!

 

Are you on the bus?

 

This weeks blog was by Maureen Stevenson, Patient Safety and Improvement Manager, Laura Graham, Clinical Pharmacist, Mhairi Hastings, Nurse manager – Hospitals PCCD West  and Natalie Oakes, Senior Infection Control Nurse

Next week our blog will be by the Chief Executive Officer Jeff Ace and will be on “The Weight of History”

 

Abuse of the Body – Person-centred Care by Dr Ewan Bell

“Abuse of the body” barked the Orthopaedic Consultant at me and my mum. I was a quiet, shy, under-confident 11 year old boy, who had just got into the Under 12 Scotland Gymnastics team, when I noticed a lump on the left-hand side of my left knee. A cyst on my cartilage, apparently all due to me “abusing my body” as a gymnast. I needed an operation I was told and would have to stop doing gymnastics; otherwise “the same might happen to the right knee”. I can remember my mum driving me back to primary school that day, me crying with fear in the back of the car.

Although there was a Paediatric ward in that DGH in Glasgow, the Orthopaedic Consultant told my mum that I was to be admitted to the Orthopaedic ward where “they know what they’re doing”.

Several weeks later, wide-eyed and terrified (both me and my parents) I was admitted to the Nightingale Orthopaedic ward, which was full of elderly patients, every one of them lying in bed. I was clearly the youngest in the ward by far! An officious Nurse showed me my bed (on the left in the middle of the ward) and started asking me questions about my past medical history. My mum and dad wanted to speak to the Orthopaedic Consultant, just to clarify what was going to happen the following day in theatre. They also wanted to know who would be doing the operation. But he wasn’t available the Nurse said and anyway visiting time was over and my parents had to leave. And there I was, with only books and comics and no mum and dad, until the next day. My parents never did get to speak to the Consultant before I went to theatre.

The next day, all that I can remember is vomiting after I was given some intravenous sedation before I went to theatre and then waking up in recovery, vomiting again. My parents were not allowed anywhere near me. I had excruciating pain in my left knee. My next memory is waking up with a bandage wrapped around my left knee and coming round, just as my parents walked in (at visiting time of course). No-one spoke to my parents before they entered the ward, so when my mum approached my bed and saw a tube sticking out my left knee, with blood draining into a bottle lying on the floor, she promptly fainted. When evening visiting time was over, my parents were ushered out the ward. My last memory of that day, was watching my ashen-faced parents walk down the ward to go home, pulling the sheets over my head and crying myself to sleep. Lonely, scared and in pain.

The next day I was still in pain, but that didn’t coincide with the “drug round”, so I had to wait. Never mind, my younger brother (6 years old) and sister (9 years old) were coming to visit me that afternoon –they’d soon cheer me up! But no, they were “too young to come into the ward”, so they had to sit outside and wait. During visiting my parents reported to the Nurses that I had developed a temperature. The Nurses asked my parents if they “wouldn’t mind opening the window behind his bed to cool him down.”

Eventually my parents did get to meet the Consultant who explained that there had been a “bit of a problem”. He had been called away to an emergency and his Junior had performed the operation. He had “nicked an artery and a nerve”, but “don’t worry, everything will be fine”.  And on that note, he had to leave, as he had an important meeting to attend.

Okay, so I can hear you say – “it was just a cyst on the cartilage – nothing serious”, and “it was nearly 35 years ago and things have changed since then”. But have things really improved since then? Do you communicate appropriately and effectively with your patients? Do you actively listen to them? Does your ward have open visiting hours? What are your patients lying in bed at night worrying about?

 

And here’s the challenge. What can you do to make your service truly person-centred?

 

Dr Ewan Bell is a Consultant Clinical Biochemist and is Clinical Director for Diagnostics at NHS D&G

Next Weeks blog will be by the Patient Safety Team who will be giving us some highlights from the International Forum on Quality and Safety in Healthcare 2013