This is a series of blogs starting from the day I was diagnosed with an acoustic neuroma. If you want to start at the beginning then please follow this link:
Last week a friend attended an important medical appointment and was told ‘Chemotherapy may not make a difference’. When we were discussing this later, my friend was still unsure whether this was because the prognosis was so good that it would not make a difference or because the prognosis was so poor… The consultation had lasted an hour!
Communication and language are at the heart of the healthcare professions but we seem to be losing the art of speech and compassion. Even interactions between healthcare professionals are becoming more pressured and dictatorial in the normal working environment and the healthcare professionals, who are largely altruists, are being harmed. Trainees are asking for advice with difficult conversations and often trainers need to point out that the altercation is often not about the way they behave but rather the stress of the individual they have encountered.
Losing 50% of my hearing has made me appreciate language and communication now more than ever. I watch others and find that non verbal signals fill in many gaps of a conversation as increasing background noise obscures my hearing. This observation also demonstrates the unease and dismay when hard-working professionals try their best to provide excellence within a hard pressed NHS environment but they face words used by others which clearly evidence a lack of value and respect.
A factor must be the limited funding within the NHS causing undue stress and that desperate strive to do more with less. Words used as drivers are efficiency, productivity and income. Quality, safety and excellence risk being lost and we are all responsible for ensuring that these words continue to be flagged alongside the daily conversations within the NHS at every level.
Is another factor the introduction of the electronic patient record into the NHS environment? Members of nursing staff now sit in ward bays on computers inputting patient observations and drain outputs. The laughter and banter, where staff and patients interacted, is still present but is a rarity as the pressures of the new safe staffing ratios and lack of workforce bite. Doctors work with antiquated computer hardware with software that outstrips the bandwidth in the NHS so that the system churns so so slowly. The doctors continue to do ward rounds and desperately try to enter the patient information on the ward round in the fewest words possible as there will be no time once the ward round finishes. Nursing staff are seldom on ward rounds as there are multiple specialities rounding at the same time. Speciality wards have long since disappeared as the number of beds within the NHS have reduced in cost cutting exercises. Gone are the days (when I qualified in 1991), where Sister would send all visitors out, in preparation of the Consultant ward round, with all prescription charts and notes made available at the end of the bed especially the x-rays in brown packets! Woe betide the house person who did not find that missing x-ray packet as that would be the only one the Consultant would ask for! There are certainly many improvements with the electronic patient records as the charts and x-rays are readily available but it is at cost of patient facing time and the art of conversation.
Recently on a ward round, we approached a patient who was clearly visually impaired. As normal, I introduced myself and took her hand. I asked what she could see, as each patient has a different visual impairment. The team introduced themselves and we discussed her clinical symptoms and management plan. It was important to individualise the management plan with her due to her visual impairment. She cannot see her feet and therefore is unable to recognise the early signs of problems with her foot. In fact as her foot is insensate, all early warning signs fail. This increases her risk to sepsis with a foot infection as she is diabetic and systemic infection can take hold very quickly. The juniors asked me afterwards how I worked out that she was visually impaired so quickly as I had not met her before. To me it was obvious as she was not watching what was happening on the ward but I learnt the skill of observation and deduction from my seniors and time spent with patients. It is now very easy for the entire medical team to log on to a computer remote from the patient, review their history and clinical symptoms without even talking to the patient. A second ward round in the afternoon may assimilate blood results which completely change the direction of a clinical management plan. As this decision is taken in an office, the junior team may forget or be too busy to go back and ensure the patient and their family are aware or even more fundamentally, the nursing staff who will enact the plan. We all need to work harder in the NHS to role model the communication that you or I would wish and deserve to experience in any medical interaction.
The frustration with communication in the NHS was also exemplified when my father was in hospital. Trying to find out what had happened during the day in my father’s care was a daily battle. Working families struggle to visit in ‘normal working hours’ of the medical staff and out of hours medical staff do not have the time or knowledge to address family concerns. This year at Croydon, we will try a communication board at each patient’s bed side where both family and patients can write down any questions they wish to have answered, I will let you know how we get on but if anyone has a good idea to overcome this particular challenge, please do let me know!
The challenge of communication in the present day does not seem to be isolated just within the NHS. I was talking to a Black Cab driver recently whose father had recently been into hospital (and could not praise the NHS enough). He commented on the diversity in the NHS workforce and expressed his concerns with BREXIT looming on both morale and workforce numbers. As with most Black Cab Drivers, his communication style was interactive and that innate ability to put you at ease as soon as you got into his cab. He shocked me with the stories of abuse he had received, both verbal and physical during his hours as a cabbie. Despite innovation in technology, we seem to have lost courtesy and respect as a high value commodity. Community welfare has been exchanged for individual prosperity and development. Has the I replaced the We?
My hope is that is has not! The world has become a much smaller place. My father travelled by ship from India to the United Kingdom in the 1950s which took weeks. Letters from my father to his family would take an age as they travelled by Airmail and then he would wait even longer for the reply. Now we email, Skype and FaceTime to stay in contact with our friends and family across the world. People have migrated across the Continents, have settled and married between different cultures and created new rules by adopting the best from both. What an opportunity to respect, value and embrace cultural norms as well as differences. Would I be viewed differently at work if I wore a sari, a suit, a dress or salwar kameez? Sadly, I think I would, despite the clothing worn by the same person. How do we teach society to be tolerant and have value and respect for all cultures?
We all need to role model the behaviours that we cherish and value. We have a responsibilty to call out behaviours and words that do not attest to a society that values all. Our politicians and celebrities carry a heavy responsibility to evidence their integrity. Respect and value should be their mantra every day, every time. Society needs to make clear this is the expectation of the public. We should not ban cultural dress nor dialect but embrace and incorporate this into our multicultural world. There should be a common understanding that what is said may not be heard in the same way by others as our cultures vary. This high level communication skill should be embedded into our training programmes in all public facing services to ensure that we all hear and understand the common language. What we should all expect in return is common courtesy in an old-fashioned way.