Broken hearts, or why telephone consultations are less than 35% effective (homage to Heathcote)

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I visited one of my patients at home the other week.

I can’t remember the reason for my visit.

Her daughter, grand-daughter and great-grandson were in the room. The wee one was only a tot – three weeks old.

This was our first face to face meeting in over a year and it took me a while to recap on all that had happened to her in the intervening months – over and above the new addition to her family.

She’d been in hospital, had a heart attack, caught Covid, her arthritis had flared; all that kind of thing.

It was when her daughter said to me, ‘How can my mum still be alive? Her heart is only at 35 per cent.’

It took me a moment to realise that her daughter was referring to what we (doctors and those specialising in the heart) call ‘ejection fraction’. I’ll explain more in a moment.

At first I wondered where the daughter had heard this number, then, reading through the records I could see a number of telephone consultations with follow-up letters between my patient and her cardiologist.

In one of these ‘…heart has an ejection fraction of 35%…’ was mentioned. It was to this they were referring.

It is reasonable to worry when you hear ‘heart’ and ‘35%’ – this means potentially, if you flip the maths that 65% of your heart is somehow not working or broken, surely a bad thing. When your phone’s battery is down to 35% you worry, same too for petrol in the car, particularly if this is as good as it gets, in other words, you fill-up your car and you know you can only fill-up to 35%. That is on a good day.

I provided my patient and her family a short lesson in cardiac physiology (normal ejection fraction, that is the amount of blood your heart can pump-out at the end of each contraction is 65%) – when your heart beats, it doesn’t empty completely, this is normal. When disease occurs and the heart muscle is damaged, as with my patient, the pump doesn’t work as well and the amount of blood squeezed round the body with each heart beat drops, and as in my patient’s case, this was 35%.

35% isn’t great, but in context it’s less bad than thinking you should be at 100%. Many aspects of human physiology work this way – you take a deep breath then blow-out. You think that is 100% lungs filled, then empty – a ‘big puff’ when really there is air that is left behind, a big-puff might only be 70% of your lung volume, a regular breath is even less.

Back to telephone conversations.

This has become a standard means of patient-doctor interaction since the pandemic. It has always been a means of communication, it is merely come into the fore since things changed and ‘face-2-face’ became a political ping-pong that the government used to scapegoat the medics.

In the years before Covid I would have loved the opportunity to chat with my doctor rather than travel to the surgery, sitting in a room with coughing strangers, eyeing-up the others, wondering what their conditions might be (asthma, cancer, depression?), always expecting to be next. At my turn, the surgery would flash up my name on a red screen. Not only was I ‘Doctor’ but also ‘Rodney’ both words I don’t associate with who I am (I am Rod, just Rod.) – I would then wonder what the other patients would think about the doctor seeing a doctor and so on. My worry-mind would flip.

Anyway, the day of phones and now emails for contacting your doctor have improved things, at least, for me.

This is, I guess because I am a reasonable communicator and I can get what I want and, if the doctor says something like ‘ejection fraction’ I will know what they mean.

Doctors can be awful in their use of jargon.

The medical language, is, well, a language. It might have few verbs and conjunctions, it is still a mess of Greek, Latin, dysfunctional acronyms and abbreviations that to the uninitiated (that is, patients) often make no sense.

I used to work with a colleague who would preface half her sentences with ‘obviously’ as in, ‘Obviously the RCA is the cause of his symptoms’ or something like that.

Although doctors are being battered over the head for not enough F2F appointments, in reality, telephone reviews are much harder than seeing a person in the surgery.

Take away, facial expression, eye contact and body-language and it is far more difficult to know or understand what is going-on.

In my experience, most doctors would prefer F2F, it is the pandemic that has had a massively negative effect on the nation’s (world’s) physical and mental health and has led to a huge increase in demand for services (this applies across the board – hospitals, ambulances and so on).

Telephone consultations are efficient in terms of seeing more patients in a specific period of time, they are however of less quality.

There are not enough hours in the day for doctors to see all the patients F2F who they would have seen before the pandemic. Battering GPs over the head for this is just another form of political messing that BJ and his cronies like to employ so as to make private healthcare (his pals) seem more attractive.

The thing is, going back to my patient and the situation in general, if you are going to conduct just telephone reviews, you must acknowledge that you will potentially miss-out lots of information, the likelihood of miscommunication will increase, misunderstandings will be inevitable.

In my opinion, telephones are OK if you know the patient (you have at least met them in the real-world F2F once) and you have a reasonable command of English (You are screwed if English is not your first language and your patient’s English is not good, or if they are head-of-hearing) (add-in dementia or cognitive impairment and it is hopeless). Without this, the situation is fraught.

The same must apply to letter writing. Perhaps doctors should take plain-English courses. I hear there is software that can translate from medical into English. Something to consider.

In the end, my patient felt slightly better that her heart is only slightly broken, not completely kaput, obviously, there is a long-way for us to go before what is said is what is meant and what is heard is what is intended.

I’ll leave you with my favourite Heathcote Williams.

Heathcote Williams | No More Dodos


Asked what he’d do first if called upon to rule a nation Confucius replied, “I’d correct language.
If language isn’t correct
Then what is said is not what’s meant
And what ought to be done remains undone.
Morals and art deteriorate
And justice goes astray –
And if justice should disappear
Then people will stand about in helpless confusion.
So there must be no arbitrariness in what’s said.
It matters above everything.”

Asked to surrender in World War II
The Japanese used the word ‘mokusatsu’
In their response to an Allied ultimatum.
The Japanese word meant
‘We withhold comment – pending discussion’.
When their reply was sent to Washington
The crucial word was mistranslated:
Its correct meaning being changed for
`We are treating your message with contempt’.

The Americans claimed that their ultimatum had been rebuffed
So they were free to play with their new toys.
Two atomic bombs nicknamed ‘Little Boy’ and ‘Fat Man’
Were then dropped upon Hiroshima and Nagasaki.
A hundred and seventy-five thousand people
Either stood about in helpless confusion
Or were turned into radioactive dust.

Today ‘peace’ is mistranslated
And means a seething stalemate instead of calm;
‘Strength’ is mistranslated
And means paranoid force instead of right-minded confidence;
‘Defence’ is mistranslated
And means the compulsive accumulation of profitable weapons
Rather than the thoughtful exercise of skill;
‘Testing’ is mistranslated
And means the deadly detonation of a nuclear device Instead of a tentative experiment;
A ‘disarmament treaty’ is mistranslated
And means junking obsolete weapons because of economic restraints
Rather than abandoning technological violence;
‘First strike’ is mistranslated
And means last strike;
‘Security’ is mistranslated
And means danger;
‘War’ is mistranslated,
And we are invited to believe
That war means peace.

 Heathcote Williams

Published by rodkersh1948

Trying to understand the world, one emotion at a time.

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