Dear Dr Srivastava,
Just letting you know your patient died yesterday. I hope you have a good weekend.
At a chaotic time I appreciate when residents take the time to write but this time I can’t help thinking about the missing word: your patient died alone yesterday.
With large parts of Victoria in a second lockdown, frontline providers continue to show up to work and maintain a sense of normality for patients that we ourselves don’t feel. Thankfully there is no shortage of drugs or equipment, but nothing can make up for the fact that our patients are alone.
There is a ban on visitors for most hospitalised patients. Elsewhere there are appointments, queues and questions to contend with. The public health case for these restrictions is evident, but the human implication is indescribable.
Lonely patients stare at the walls or watch the ward traffic. The television is stuck on endless loops of grim news from different countries. But the lack of visitors isn’t a mere inconvenience; in hospitals like mine with overwhelmingly disadvantaged patients with multiple illnesses and insufficient command of English, this edict represents a real threat to their welfare.
Doctors rely on family members to understand the context of an illness. The dietitian notes that the patient is malnourished, but it’s the granddaughter who knows that grandma is depressed. The nurse can’t get the patient out of bed but the astute wife remarks on her husband’s slow cognitive decline. The “difficult” patient could be a war victim or someone who has lost his hearing aids.
Visitors are essential to filling the knowledge gap but they do something else vital: they feed their loved ones, nudge the water closer, coax them out of bed, and provide distraction. The drugs and interventions do some of the work but the support of those we love and who love us back is the real medicine that makes people better.
The ban on visitors has made the corridors fall quiet but now the wards are pierced by another sound that overwhelms us as we scramble to readjust. I am talking about the sharp rise in phone calls from relatives trying to get an update, relay important information, or worse, plead with us to bend the rules and smuggle them in to visit an elderly parent or a despondent spouse.
Picture a public hospital ward of 25 patients. Half may have some form of cognitive impairment ranging from transient disorientation to overt dementia. A third need assistance with walking, feeding and toileting. Some are combative, others are tearful, many speak limited English, and everyone resents being there. Add to this a growing fatigue among providers lending to unstable patterns of staffing. While there is sympathy for the lockdown decision itself, frontline workers again find themselves at the receiving end of a policy decision with strong implications but insufficient planning.
In ordinary times, the job of providing medical updates typically falls to doctors. It is an assumption (albeit questionable) that the doctor knows the patient best. Indeed, it’s common to hear statements such as “I am just the nurse” or “I’m only the physio.” But the doctor has no such choice and even the newest intern is expected to handle both simple and tricky calls before requesting backup.
Now the sheer number of phone calls is placing junior doctors under worsening stress, especially because, unlike some of their senior colleagues, they aren’t working from home. The essential task of a doctor is to make an accurate diagnosis, prescribe appropriate treatment and communicate to ensure that the plan fits the patient. But any extra hours spent on phone calls means hours subtracted from the bedside.
Doctors are still doing their usual duties but now, in the midst of rounds, paperwork and career uncertainty, they have inherited an after-hours job by default – answering dozens of phone calls from angry, demanding or plainly upset relatives. And while no one dismisses the task itself, there has to be a better way.
Nurses can not only recite what the patient ate and said but also sense pain, anxiety and existential distress. But many, especially inexperienced ones, hesitate to engage callers because they fear they don’t know their patient well enough. Modern nurses are hard-pressed to complete their usual duties only to later be buried in astonishing amounts of paperwork. And yet I struggle to think of any checklist that has superseded the sharp acumen of a good nurse.
Similarly, allied health providers and social workers have an expert understanding of the functional impact of illness. In routine care, their intervention relates to a specific need like assessing gait or recommending home services, but they too can capably provide medical updates with ready backup.
If personal care workers relieved nurses of their most time-consuming tasks they could be freed to talk to families. Employing more assistants to do the basics would free up the most senior allied health workers to lead conversations about much broader issues important to patients. Underpinning all this is interpersonal communication, the Achilles heel of medicine. Together we could do a lot of good – but a narrow definition of our role has led us away from the kind of range that is required for holistic patient care.
It is often said that there are things that only a doctor can do and indeed doctors’ groups have fought for the idea. While this may be true for certain things, when it comes to communication such thinking is costly and flawed. If the pandemic has highlighted one thing, it is the importance of collaboration and the urgency of emerging from our silos. If ever there were a case for us to sink or swim together, this is it.
“When the alarm goes off in the morning, I am starting to ask, ‘Why bother?’” a capable young doctor lamented, and I was reminded of Dostoevsky’s words: “To live without hope is to cease to live.”
Everywhere one looks people need hope, but those charged with nourishing the hopes of patients require their own measure of hope and understanding.
There are a lot of anxious relatives who want to know their loved ones are safe in hospital. They deserve an answer but reaching out to them is a collective responsibility. Changing a historically reactive system into a responsive one is a work in progress but there is an urgent need to act. Doctors unthinkingly saddled with the physical task and emotional burden of tackling all the phone calls are quietly burning out, the way doctors tend to. It would be a shame to say later that we never knew.
This article originally appeared in The Guardian and has been published with the author’s consent.
Image: FG Trading, iStock.
