Beware the patient you don’t like

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He’s not on my ward, nor is he ( I imagine to our mutual happiness) darkening the door of my clinic. But if he was, I would not look forward to seeing him. 

Generally speaking, I like all of my patients and care deeply for their well being, I also get a lot of satisfaction from looking after them and making them feel cared for. Some of that caring is tied up in my responsibility for their well being, but I genuinely do care for them, 99.9% of them. Sometimes you get a patient that you don’t like. It doesn’t happen often and it usually doesn’t matter as the appointment or the consultation is over rapidly and forgotten quickly. It becomes more of a problem when you have an inpatient that you don’t like.

One of my great leaders (who is in fact married to a nurse) likes to say that if the nurses like you all the time then you aren’t doing a good job;  this is true, my recent frustration with a ward’s inability to record a daily running total of a fistula has meant I have had to “have a word”. I’m not here to be popular and many of my male colleagues are not popular at all or particularly liked, but they are respected and admired. This doesn’t work so well for me, or most women, and whilst I don’t require to be adored by all those I work with and operate on, I struggle to cope with people I dislike or dislike me.

Patients disliking me doesn’t cause me too much bother, I can hide behind extreme frosty professionalism and generally have the upper hand. Pissing off the nurses (rarely) or radiology (weekly) also doesn’t cause me too many problems. Patients that I don’t like cause me problems for many reasons mainly because I don’t want to go and see them, and when I see them I want it to be over quickly. These two things in combination are doubly dangerous and bad and lead to mistakes.

Having insight into this is something that they never teach you at medical school, they don’t even mention it. Beware the patient you don’t like; the man who makes lewd comments when you examine his abdomen, the racist patient who insulted your colleague, the patient who refuses to wash, the lazy one who won’t get out of bed, the angry man who isn’t coping with his diagnosis. They deserve the same service as the rest, maybe even a better service, because they are the ones where you will miss a problem or a complication.

You will fail to detect trouble in the earliest stages that in your pet patient you would have picked up 12 or 24 hours earlier. It might not affect the outcome but it will make you feel terrible and it doesn’t do your patient any good. So if you feel a heaviness in your heart when you see a dreaded name on your clinic or postpone and put off until last on your ward round the one you don’t like, put that feeling aside and go and see them.

The GMC has the following advice:

Establish and maintain partnerships with patients

You must be polite and considerate.

You must treat patients as individuals and respect their dignity and privacy.1

You must treat patients fairly and with respect whatever their life choices and beliefs.

You must treat information about patients as confidential. This includes after a patient has died.10

You must support patients in caring for themselves to empower them to improve and maintain their health. This may, for example, include:

    1. advising patients on the effects of their life choices and lifestyle on their health and well-being
    2. supporting patients to make lifestyle changes where appropriate.

     

    You must work in partnership with patients, sharing with them the information they will need to make decisions about their care,15 including:

     

    1.  their condition, its likely progression and the options for treatment, including associatedrisks and uncertainties
    2. the progress of their care, and your role and responsibilities in the team
    3. who is responsible for each aspect of patient care, and how information is shared within teams and among those who will be providing their care
    4. any other information patients need if they are asked to agree to be involved in teaching or research.9

    You must explain to patients if you have a conscientious objection to a particular procedure. You must tell them about their right to see another doctor and make sure they have enough information to exercise that right. In providing this information you must not imply or express disapproval of the patient’s lifestyle, choices or beliefs. If it is not practical for a patient to arrange to see another doctor, you must make sure that arrangements are made for another suitably qualified colleague to take over your role.17

     

    Show respect for patients

    1. You must not use your professional position to pursue a sexual or improper emotional relationship with a patient or someone close to them.12
    2. You must not express your personal beliefs (including political, religious and moral beliefs) to patients in ways that exploit their vulnerability or are likely to cause them distress.17
    3. You must be open and honest with patients if things go wrong. If a patient under your care has suffered harm or distress, you should:
      1. put matters right (if that is possible)
      2. offer an apology
      3. explain fully and promptly what has happened and the likely short-term and long-term effects.

     

    There are very few problems that don’t seem better after you have done a ward round.

     

    Twice as long and twice as much 

    As you know, I am getting old, being a part time trainee with several years of maternity leave has meant that I am finishing my training 7 years later than the original date. One of the many happy and incredible things about being a part time trainee is that as I have done all my on call full time, as the rota couldn’t support a part time on call member (apparently, I was too timid to disagree) and so I have been the registrar  in emergency theatre for a total of 10 years compared to the 6 years of a full time trainee. 

    This, as you would expect, translates into lots and lots of operations and one area where I have not struggled is in achieving the requisite numbers that have been deigned the minimum prior to being granted your ticket, your certificate of completion of training, the passport to consultant practice. 

    Whilst preparing for consultant interviews this week (a task which feels as big as the FRCS and not as fun) I came across this interesting document (link click here)  from the Nuffield Trust about emergency surgery and the future of providing emergency surgical care. 

    Hidden inside it is this rather terrifying table that shows how many trainees make the minimum numbers of operations performed independently (this can include supervised operations as long as you did it) from each subspecialty. 


    I’m sorry if you can’t read it well here, it’s in the document. The gist is that the average newly qualifying consultant has done nowhere near enough. No wonder there is so much talk of fellowships following CCT to “get your numbers up”. 

    It terrifies me as a parent, as a daughter, as a soon to be trainer of trainees that people are being signed off having not reached these requirements. 

    I’ve personally taken out over 200 gallbladders and assisted and watched about another 70 be taken out. I still worry about doing something awful to the common bile duct, or God forbid, the hepatic artery. I would say I feel ok about gallbladders, I think after another 200 I’ll be a lot better. After 600, I hope and expect to be good at gallbladders. 

    I am an average surgeon, most of us are, I am of average intelligence and motivation. I probably have above average insight into the complications of bile duct disasters as I worked in a liver unit for a year and dealt with the biliary messes of the region. So, here’s me, of average abilities in my view, about to embark on the start of my real career having done four times the number of gallbladders recommended by the JCST. I have a healthy respect bordering on distrust of the timorous beasty gallbladder. How must the chap who has only done 50 feel? Or not even managed 50? He must be shiting himself. Or worse, be totally deluded that he is the emperor of gallbladder removal. 

    Hartmann’s resection; this operation can be sublime or it can be a mess beyond imagination. They recommend you do 5 of them!!  I have almost 50, and would still worry about fucking the ureter and getting the rectum closed nicely and safely. 

    The JCST and the GMC were most insistent that I attend an ATLS course (£550), as well as a poxy management course that would embarrass 12 year olds it’s so bad (free thankfully) and of course Training the Trainers (£780). There are all sorts of other boxes that must be ticked, like having some observation of your teaching and audits etc. Nobody gets away without doing these courses and the waffly bits for their CCT so why are we letting people CCT without doing the operations? Arguably that is the most important part of training a surgeon, that you have actually produced a surgeon, not a person with some certificates. 

    I started work in the final days of the 48 hour weekends and 24 hour on calls when we would work shifts that left you destroyed. I now work in a 48 hour week limited environment but have gloriously managed to get away with the impact of this on my training by being part time, working less in theory, but I go to theatre the same as a full timer and I have been going for almost twice as long. Which makes me think I should be so much better than I am, but I am distinctly average on a good day. It just shows that you can really train anyone to do anything given enough time! 

    One of the questions I am preparing for at these awful upcoming interviews, is if I feel being part time has hindered my training in any way. On the contrary, it has been the biggest advantage imaginable, I have had twice the time to do twice the operating. And it’s not just me, the other part timer I know is the same. 

    It would be interesting to know from the JCST if part time trainees are hitting their numbers as from my limited survey of me and one other, we have both exceeded by a mile the minimums required. 

    Clinic 

    Clinic 

    Clinic used to full my heart with dread. There is no worse way to spend the afternoon than drinking vile coffee and seeing patients who were expecting the boss and instead get you, the trainee. 

    They look confused and clutch the letter, rummaging in their best handbag to produce a crumpled but precious appointment note with Mr Consultant. You are quite clearly not he.

    Perhaps we should send them a note saying they will be seen by Mr BlahBlah’s team rather than the great man himself and therefore head off this disappointment. I used to feel sad at this as well and agree that they were probably quite right to be miffed at getting me and not the boss. 

    As a junior registrar I would often have to go and ask permission to put them on the waiting list or ask advice on which scan to request. They would look at their accompanying person in a slightly worried way, wishing (I imagined) that the man behind the adjoining door I kept disappearing behind would just make an appearance. 

    Now I sometimes actually enjoy clinic, even a busy overbooked clinic. A number of things have contributed to this, firstly I actually know what to do now, even for weird and unusual things and heart sink things (three years of vague pain with no cause found…) and I must somehow communicate that confidence to the patient as they don’t look worried. Clearly, I am also no longer “a girl” and not looking 23 anymore has helped considerably with my credibility. 

    One of my very great leaders, a professor of surgery, tells me that the goal of every ward round and clinic encounter is to make the patient smile. When he told me this I didn’t quite believe him but doing my clinic last week all of them were smiling when they left. Even the chronic pain one, who the first time I met her left me wanting to bang my head on the desk repeatedly. She arrived with a box of cakes to thank us. 

    One of my rules of clinic, which medical students would be wise to remember is that the patient has gone to considerable effort to be there. They have washed and dressed in anticipation of your examination and they have often involved family and incurred cost in getting to see you. They deserve in return that they are seen by a reasonably well dressed, clean and presentable surgeon.

    No matter how much I enjoy a clinic I am always glad when it is over and the dictation is done on the three or so people who have failed to attend. I like to bring them back to clinic just in case there was some legitimate reason why they hadn’t come in today. OK, the real reason I tend to give them another chance is that the greatest joy in an overbooked clinic is when there are four no shows.