The other side of the stethoscope

By Dr Brian Maurer

For many years, I have practised as a specialist physician in a major hospital. Recently, I have had the opportunity to view the world of hospital treatment from the other end of stethoscope.

Since last September, I have gained personal experience of the real patient world, a world that for the elderly usually means the simultaneous management of a number of different conditions of varying complexity.

The patient's view of this process is not easily communicated to or understood by their numerous carers. Now, better informed but with some trepidation, I offer this account of my own experience as a patient.

I can summarise what I have learnt by affirming that the standard of care that I received in the hospitals I attended bears comparison with that provided anywhere in the world.

However, I have also learnt that coordination of care can be a major problem and poses major difficulties for patient and practitioner alike.

Over the past seven months, I was admitted on five occasions to three hospitals - two private and one public. One was a planned admission to a private hospital; four were emergency admissions, one to a public and three to private hospitals.

On each occasion, the standard of care was excellent, the diagnostic process prompt and appropriate treatment protocols instituted immediately.

No delay was experienced at any stage of the process. The care received from all the staff involved was exemplary. The only disquieting feature I noticed was the bizarre arrangement on one of the private hospital wards for drug dispensing.

At some times this appeared to be the responsibility of the nursing staff and at others of the pharmacist attached to the ward. Confusion between proper names, trade names and newly-substituted brands occurred on a number of occasions, causing major confusion.

It was reassuring to find that appropriate protocols were in place for dealing with acute and emergency problems in both the public and the private hospitals. The public hospital admission was precipitated by unstable angina.

Within an hour of presenting to the hospital an angiogram had been carried out and an ominous blood clot removed. I was discharged the next day.

The first acute private hospital admission followed a week later and was due to collapse of a spinal disc.

Acute ambulance transfer was followed by rapid treatment of the extraordinarily severe pain, and within two hours an MRI scan defined the problem. The diagnosis was cancer of prostate which had spread to the bone, leading to a collapse of a lumbar vertebra.

Radiotherapy started later that day and and drug therapy followed. Pain control protocols were very effective and partial mobility was regained over the next two weeks.

The various experts who were consulted discussed therapeutic options in depth with me and the lead clinician, a genitourinary surgeon, supervised the implementation of the agreed policies.

The skill displayed in coordinating the contributions of specialists in cardiology, cancer, pain management, rheumatology, radiotherapy, head and neck surgery and ophthalmology was admirable.

The disciplined response and compassionate care of the nurses, allied health professionals and care assistants was remarkable. This and their high morale were very reassuring, especially given the sustained attacks which have been made on health care professionals in recent years.

The days immediately following discharge posed a number of problems. Continuing pain and the need for high dose pain medication, loss of confidence and limited mobility, difficulties in dealing with the multiple medications (more than 12 at one point), the times at which they had to be taken and uncertainty about the future, all contributed to incipient depression on my part.

Coordination of care threatened to become a major problem, given the number of disciplines and specialists involved, organisation of follow-up visits, and changes in therapy with the possible knock-on effects on overall management of my treatment.

The willingness of my GP to assume responsibility for overall care averted this threat and he remains the linchpin of my care. At his suggestion, texting and email became the basis of regular communication between him, me and all the specialists involved.

Combined with the necessary visits, this proved to be highly effective in maintaining morale and ensuring appropriate changes in management. Loyal support from family and friends was critical to combating depression.

Subsequent acute admissions, one for recurrent severe pain and one for a severe nosebleed, were treated with equal competence.

Four months later, I realise that life will never return to what it was before and that the future is, to say the least, uncertain.

Nonetheless, it is possible to derive some reassurance and consolation from my experience.

I find it reassuring because in my hospital catchment area, acute emergencies can be dealt with appropriately and promptly, according to agreed protocols; that the resources to implement these protocols to international standards are available in at least some of our hospitals and that these resources can be mobilised at any time, day or night, when they are needed.

It may be that my favourable experience may not be reproducible throughout the country, given the acknowledged national shortage of specialist consultant expertise and that some areas still lack adequate diagnostic and therapeutic facilities.

I hope that the current reconfiguration of the hospitals and emergency departments will deal with this problem and provide a consultant establishment and technical backup sufficient to deliver a round-the-clock service.

My experience shows what can be done even with relatively limited resources.

The potentially harmful effects of the fragmentation of patient care that arises from the complexity of modern medicine can be avoided by properly organised co-operation between the various specialists involved in the management of the patient.

The primary consultant should assume responsibility for the coordination of care while the patient is in the hospital.

The GP should assume this role after discharge. Modern methods of communication can facilitate this process.

Patient, spouse and family education are essential when managing complex illness. Particular care is needed to ensure that medication and dosage are understood.

Organising cooperation of this kind is quite difficult and should be a major part of the lead clinician's responsibility. It requires flexible work practices and a willingness to make time available to devise a plan to meet each patient's particular needs.

The dedication of the professionals and the kindness and support of friends has restored my faith in the basic benevolence of human nature.

The concern shown by so many has been truly remarkable and humbling. It will not be possible for me to acknowledge individually all the letters and expressions of goodwill that I have received, but they are a source of continuing consolation.

Even more, the visits and support of my colleagues and many friends continue to be a source of strength. I can never thank them enough for repairing some of the damage done by the vicissitudes of life, erasing much of the cynicism acquired over the years and reminding me of the good that is in all of us.

I recommend Christopher Hitchens last memoir Mortality (Atlantic Books 2012) to all of you as bedtime reading.

(This article also appears in the journal Cardiology Professional)



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