Friday, 25 March 2011

Assumptions in healthcare

I was having dinner with friends earlier this week in a London restaurant when a couple sat at an adjoining table. The elderly man was very distinguished looking with great presence and he was accompanied by a stunning young woman, probably a third of his age.  She didn’t look entirely at ease but seemed happy enough, engaged in conversation with her companion. My two friends and I all immediately jumped to the same conclusion, that this lady was a ‘rich man’s plaything’.

How wrong we were. Later in the evening as we all got chatting, it transpired that this beautiful young woman was a highly respected barrister, a colleague of the lovely gentleman, who spoke with great affection about his wife, children and grandchildren. This was an entirely innocent business dinner.

I felt ashamed that I had allowed such an erroneous assumption to cloud my judgement and this got me thinking about the assumptions we make in healthcare.

Complaints made along the patient pathway are often due to assumptions, normally made on the part of the clinical team. Here are the most common ones:

Patients want to die at home:
Much is written about ‘dying at home with dignity’. ‘Dignity in death’ can mean very different things to different patients.  Not all people want to die at home – in fact some may be terrified at the prospect, especially if the level of care at home cannot be guaranteed. There is some wonderful work currently being done in the NHS, training clinical staff and carers how to have the appropriate conversation regarding care plans with patients and relatives.

Patients want full details about their diagnosis, treatment and prognosis:
Some do, some don’t. I have direct experience of two family members with terminal disease. One was involved in his own treatment and decision-making throughout the course of his illness, the other one didn’t even want to put into words the name of her disease.

Diagnosis can be done on face value:
Happily, most clinicians are not guilty of this assumption. But I feel I must mention the GP who took one look at me before he examined my very painful knee and advised me that it was ‘my age’. Following my insistence, an MRI scan and repair for a torn meniscus ligament proved him very wrong!

Patients understand what their medication is for:
Pharmacists and doctors often go to great lengths to explain to the elderly or those with learning difficulties how they should take their medicine, but they still get confused. You should never assume the medication is being taken properly, and always check. I had an elderly friend who for years took her pain killer every day, thinking it was her ‘water tablet’ and then took her diuretic (the water tablet) when she had a headache.

The patient doesn’t know what they are talking about:
Often they do. My brother was admitted to hospital with chest pains. The staff took one look at this sweating middle aged man and assumed he was having a heart attack, despite his insistence that his leg was painful. Fast forward a day and he is the only patient on the chest ward on crutches! The palpitations and sweating were due to a badly infected leg following an insect bite. No-on had listened to him.

Patients know their own bodies:
Probably quite a good assumption, or at least something to consider. Patient’s instincts should never be ignored.  There are many, many stories of women whose doctor told them a breast lump was nothing to worry about but whose nagging instinct was proved right when they insisted on further investigations. By the same token, just because they tell you they’ve hurt their back it doesn’t mean they haven’t got a kidney problem.

GP’s welcome the Health and Social Care Bill:
Some do. Many don’t. I shall be interested to see how many take early retirement over the next few years.

Orville Wright, the pioneer said – ‘If we all worked on the assumption that what is accepted as true is really true, there would be little hope of advance’

It would appear from my tale at the top of this blog that I’m not making much progress from the time when I was a young pharmacist, working in a retail pharmacy. A man came into the shop, asking for some cough mixture. I asked him to describe the cough, and he went into great detail, saying it was quite tight, worse at night and irritating during the day. I selected the best medicine and asked him if he would like to take a dose straight away. He shrugged his shoulders and said ‘ok’. After giving him the two spoonfuls, I joked, saying ‘there – you feel better already don’t you!’ Deadpan, he replied – ‘well not really – it’s my daughter who has the cough....’


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