The Hazards of Polydoctory

I started writing this, a little chuffed with myself as I thought I had invented a new word.

Alas, someone has beaten me to it, although their meaning is slightly different from the one I intend to use here.

In the Encyclopaedia of Ageing and Health edited by Kyriakos S Markides*, Polydoctory is defined as the situation where a patient sees multiple doctors and has different prescriptions filled at a variety of chemists, with non-prescription medicines purchased over the counter, adding into the therapeutic milieu – resulting in not just the bonkers/ logarithmic situation of prescribed drug-drug-drug interactions, but, with the addition of medicines such as Gingo biloba, Nytol (Diphenhydramine) and perhaps, Ginseng all creating a chaotic cocktail.

No. that is not my definition.

Polydoctory as I see it a situation which has only developed in the UK over the past 10 or so years, particularly since the dominance of specialised, ward-based medicine where specific units are dedicated towards the care of individual conditions – stroke, chest, renal wards, for example, and consultants are at risk of tunnel-vision, narrowed by the complexity of modern medicine, guidelines and regulation, and, the European Working Time Directive which limited the numbers of hours junior doctors are allowed to work.

This combination of events has resulted in a situation where patients admitted to hospital will inevitably meet not one or two doctors (as I can remember back in my student days of the now closed Law Hospital in Carluke), but five, perhaps ten doctors; this is not counting the nurses, therapists, pharmacists, healthcare assistants, radiographers, etc.

Yes – 21^st Century hospitalisation can be an impersonal affair.

Because of the great number of individuals supporting the delivery of care, communication and handover are critical.

Yet, when you discover the working patterns of doctors, the ward and bed moves of patients, a dangerous situation can arise.

It’s like a Hollywood movie… One patient, four beds, eight wards and a hundred nurses, doctors and therapists.

Yet – this is the reality.

I was reading through a patient’s notes today – before arriving on my ward she had encountered four different consultants alone – that isn’t counting the registrars, junior doctors, and so on.

Each doctor imprinting their own impression on the patient, conveying their interpretation of history and diagnostics.

Doc 1 ‘Yes, Mrs P, your X-ray shows that you have pneumonia.’

Doc 2 ‘Mrs P, you can go home tomorrow, it was just a chest infection.’

Doc 3 ‘Brenda, I am worried that you might have something abnormal with your x-ray, we are organising a CT.’

Doc 4 ‘Mrs P, you might not be swallowing correctly, we are going to puree your food and thicken your drinks.’

Doc 5 ‘We’ll arrange a chest x-ray…. Oh, I didn’t realise you’d had one already.’

And on and on.

There are those who consider medicine to be an exact science. The more informed realise it is somewhere between the two extremes of science and art, or perhaps, science, art and shamanism.

Imagine Michelangelo beginning a painting, Van Gough taking over and Jackson Pollock adding the finishing touches.

Yes, the picture would be unique and would likely fetch lots of money at auction, but you see where I am going.

What is the answer to Polydoctory?

Well, I envisage several possible solutions, the first, expanding, up-skilling and empowering the multidisciplinary team so that there are more staff able to maintain continuity of care; Rarely does one nurse speak in detail to another doctor or nurse about their patient at times of transfer – we endeavour to read medical notes (predominantly written by hand in UK hospitals), and establish meaning.

Chinese-whispers gone mad you might consider it.

Would you be happy to fly in a plane where the pilots swap-over with each other and just leave hastily scrawled notes? Well – that is modern healthcare.

A second option might be to work-out more meaningful timetables, in a patient and clinician-centred way, paying more attention to relationships – investing effort in their creation and development. This might mean more staff, it would however likely save huge amounts through reducing miscommunication and harm.

Alternatively, we could use technology, perhaps a digital video handover for each patient (held by the patient), doctors talking to doctors – as if!

We could try to move patients fewer times when they are in hospital. Each time a person who has dementia or delirium is moved they stay longer and their disorientation and risk of harm increases.

Even better, we improve the services in the community to help more people stay at home and avoid hospital admissions in the first place; then you might have another problem of Primary Care Polydoctory, but at least most surgeries have a fairly limited number of doctors and nurses to minimise patient confusion.

I’ll end with the story of an old man who lived along the road from me.

I popped in to see him a couple of times before he died and his wife reflected back on yesteryear when their local GP would hop across the road in his dressing-gown to tend to their daughter, and how that is not the relationship they have nowadays with their local practice.

Times have changed, and although you might not know your GP or hospital doctor as well as thirty or forty years ago, thanks to advances in technology you have a greater chance of recovery and living a long and healthy life.

Like the shaman talking to the guys in lab-coats, perhaps we need to aspire to something in the middle.