Should they stay or should they go? (A paean to physicians everywhere)

This is a reference to the situation encountered daily on medical assessment units across the country – and, likely the world.

(It is also a partial homage to The Clash)

The scene is set on any day of the week although weekends seem to me to reflect the greatest challenge; despite any attempts that evildoer of an ex-health secretary made to flatten-out the week and make Saturday and Sunday days like any other – he may have demolished medical resistance; he didn’t get to change society as a whole (thanks be to God)(And, I am sure the Holy One didn’t establish the creation story for some twerp to over-write).

Consequently, there are intermittent patterns of attendance both in A&E departments and assessment units (where patients are moved, if it is unclear whether they require admission or it is uncertain as to whether sending them home will be OK) – this depends on the weather – too hot or too cold is a factor, external events – World Cup, Royal Wedding, that sort of thing and, other unknown influences that determine human behaviour.

A person will arrive in the A&E department; they might meet a doctor who has a sense that the person is not well enough to go home, they then move (the person who has now become a patient), to the assessment unit (I use this generic term, as the place can be dedicated to medicine – heart attack, pneumonia, or surgery – ruptured appendix, bowel obstruction) (Each unit running with a different set of standards, cultural and social norms; that is a story for another day.)

The patient is then seen by (in this instance), a medical doctor, they try to determine a diagnosis – often based on the flaky evidence provided by the A&E doctor, create a case and start a treatment; the patient is then reviewed by a more senior doctor – ideally a consultant (someone like me) who determines whether the A&E doctor and the medical doctor who have seen the patient have it right – correct diagnosis, treatment plan, and, whether the patient can go or must stay – whether they are stuck a patient or can transform back into being a person (aka, home).

The patient is involved to a greater or lesser extent – dependent on their level of transformation from person>patient, the person-centred nature of the consultation, the preference of the doctor, the noise level, lighting, privacy, and many other considerations.

There are innumerable factors influencing each of these steps, for example, the art that is medicine (or pseudo-science, call it what you like), results in different interpretations of very similar findings (just as two people looking at a Jackson Pollock will see different shapes and forms), and the outcomes will differ.

The hospital systems do their best to corral patients down pathways with standards, guidelines and protocols, but, inevitably, given the complexity of being a human and the nature of disease, no one person can fit with one standardised plan – the patient is too old, young, thing, fat, non-compliant, their kidneys, lungs or heart work differently, and so on.

You are dealing with known unknowns and unknown unknowns and people like my friend George in Rotherham do their best to create some sort of semblance of order out of this – ensuring that every day, despite this randomness, people who have been waiting six months to have their hip replaced can proceed with surgery, all, within a pressurised tin-can of a system that, thanks to our government is turned-down several too many rungs on the gas; think baking a cake at the wrong temperature – it gets burned or ends up gooey on the inside; imagine a million cakes and too few cookers; you have the picture..

And, the doctor determining the stay or go situation is provided with ten, if they are lucky fifteen minutes to review, assess and determine what to do;

If the patient goes home, will they become more unwell? Will that virus actually reveal itself as a deadly bacterial infection? If they stay, we can monitor their temperature, do one more blood test, if they go, they might fall, if they stay we can make sure they are OK not just today but tomorrow;

The internal thought processes leading to a decision are infinite.

(Doing one of these ward rounds, whilst not particularly physically demanding, is emotionally and psychologically draining.)

And, if at the end of the Saturday morning, adequate numbers of decisions have been made as to who should stay and who can go home, enough to allow for the next day’s influx of people being mutated into patients, all is OK; inadequate numbers and the pressure increases, decisions are questioned.

When I started-out as a consultant in Doncaster, there was one guy who had an ability to discharge more patients at a weekend than anyone else; everyone knew, if he was on call, the hospital would be in a good place; there would be adequate beds to accommodate new patients and so on.

I don’t know how he did it.

He was undoubtedly a bright man, if, perhaps a little emotionally blunt.

He was hard working and committed; he was forced into early retirement.

So it goes.

Imagine the logic map that is required to analyse this – if A, then B and C or D; times a thousand. Distorted by a map of human emotion and experience.

Insane.

Anyone aspiring to manage this must be mad.

Sorry, George.

My request?

The next time you judge the decision-making actions of a doctor or nurse, therapist or pharmacist in the twisted milieu that is health (and social) care, pause and consider the challenges; patients (people who have given-up a degree of autonomy to be influenced by doctors, nurses and so on), have their own opinions, agendas, hopes, fears and anxieties.

Let’s fix the system.

Let’s get everyone out, free-up beds; minimise those wearing pyjamas and ensure independence;

We have a way to go before we reach this utopia.

I don’t know if we have even scratched the surface.

In most organisations (hospitals) vastly more effort is placed into discharging patients than ensuring that people remain people and are not inappropriately or unnecessarily admitted to hospital.

In some places there are admission avoidance teams, groups of nurses and therapists who struggle to ensure people are kept independent at home;

Most of this translates into a doddery physician (like me) wandering around an admission unit at nine am on a Saturday morning, pressurised, concerned about the 20 odd people still to see, thinking about risk, safety, safety-nets, autonomy, patient preference, pathology, bacteriology, mobility, drug-drug-drug interaction, patient and family opinions, social circumstances and so on.

Should they stay?

Well, often I just don’t know;

The more you can help those who are battling with complicated computer systems, old-fashioned medical records and (at the moment) extreme heat, the better!

dedicated to George and Penny