I was involved in an unusual consultation this week.
I was sitting with my patient and his wife in their living-room.
My patient has problems with pain and breathing.
His wife has dementia.
He is supported by his son and his daughter, one of whom lives with him, the other in Italy.
That was what was odd.
It began before I entered his house.
I received an email from a colleague the day before.
She had spoken with my patient by phone. There would have been my colleague in the hospital, my patient, his wife and son in the room, his daughter who lives in Italy was on another phone dialled-in.
I’ve described before some of the challenges involved in what have become known as telephone consultations, these, as opposed to the real McCoy, face-to-face, in the clinic, more traditionally associated with the pre-Covid world.
It is very hard. Without access to facial expression, eye-contact, posture and all the rest, understanding your patient can be tough. Add to that the often associated hearing impairment and older person’s difficulty with manipulating hands-free and you can imagine the issues, even before the overseas relative joins.
My colleague gave me a clinical summary, an update of the case. She was looking at something specific, a patch that had appeared on my patient’s lung, found during an incidental scan as part of the assessment for the Covid he had caught in hospital when admitted for something completely different.
When the conversation began, my patient was in the room, sitting on a low-settee, his packet of Old-Holborn rolled-up on a stool, his wife, who only spoke once to my left (‘she’s got Alzheimer’s’ he mouthed when I entered the room) and his daughter first on the old cordless phone, then, when I spotted their iPad, propped on the table to my right. The other son who had been out when I arrived, eventually returned and joined-in, although like all late arrivals, he was on the back-foot, aware or suspecting he had missed something.
This was a long preamble to the topic of long-distance relationships, or more, family scattered around the world.
It seems there are two types.
Those whose who stay close to home, go to school, maybe university and return to live near their parents and the other who because of life, circumstances or work live hundreds of miles away.
When my parents were alive I was the latter.
They were in Glasgow, me in South Yorkshire.
Not that far, four hours in the car, but far enough that I couldn’t attend hospital appointments or help-out around the house. Not quite Italy or Australia but far enough.
As your parents age, for the most they need more support, particularly when their health deteriorates.
Back in the day I would order food via Tesco online, I would speak with doctors and social workers on the phone, it was always difficult.
I imagine my patient and the connection via FaceTime, a gift that didn’t exist when my parents were alive.
I think of my patient and his wife, living together yet disconnected by the unfathomable nature of her dementia.
When I meet patients who have overseas relatives I always try my best to reach-out, to stay in touch. Mostly this works-out. I’ve spoken to people in America, Europe, Asia and Australia. No one in South America yet.
I am always happy to share my email with relatives and patients. The struggle of getting past GP reception and hospital switchboards is, I believe a major impediment to the function of the health service. Email is so much easier. For the most this has worked although occasionally I am contacted in exasperation over issues that I can’t resolve – the problems of care agencies, the cost of over the counter medicines, that kind of thing.
It was a struggle to run the consultation with four people in different places, the patient, his wife, their son, their daughter.
It was a toughie. It took me an hour to unravel what was what, which medicines were which, what had been stopped, started, changed, what he could and couldn’t do, what he understood, what the family understood, the plans for further tests and follow-up.
Yesterday I visited another patient who had that morning received an appointment to see an ENT doctor. They had waited four months for the appointment. The appointment was the day before the letter had arrived. Go figure.
The complexity of our lives, of health and social care is immense. It is overwhelming. Some patients accept defeat and become passive, others keep on going. I am not sure where they get their energy. I guess it is desperation.
The challenge of three or four-way consultations is significant and yet, necessary. Time is the limiting factor, it snaps at your heals, it is you looking at your watch, calculating the travel time between patients, the next meeting, the time to write-up the consultation, and on and on.
Time and space.
This is an aide-memoire to help those caring for people with delirium.
It is also useful as a necessity for getting-on, for survival.
Have a good weekend.
For reasons of patient confidentiality I have changed some of the details in this blog.