THE FRUSTRATION OF MISCOMMUNICATION

Today, I’d like to share a recent experience. Each doctor involved in this story could have made the difference but there were mistakes and shortfallings at each stage with every doctor that was encountered. I’m not writing this to criticise these doctors, because I’m sure they are brilliant healthcare professionals…but I’m writing it to look at the overall situation from the patient’s perspective. The patient is someone I know quite well so I accompanied them to the hospital and was quite shocked at the way her problems were handled. I’ve received permission to share her story (so don’t worry about confidentiality), but for the purpose of this I will refer to her as X. There were a few key qualities that were missing which led to a compromise in the care of the patient, mainly the lack of effective communication and teamwork.

The background of X’s health problem was that she kept developing painful boils. This was an ongoing problem for which she had visited the GP many times and had been prescribed a course of antibiotics. The antibiotics did help the boils disappear, however they were only a temporary solution as not long after the boils would return again. After this repeat cycle of boils, antibiotics, boils, antibiotics, boils, antibiotics the obvious concern was why this problem was recurring. Each time she returned to the GP surgery with a new outbreak of boils, she was prescribed a different type of antibiotic. The latest one was known to have severe side effects of stomach pain and nausea for which she was advised to contact the GP if was experienced by her. The boil had also burst, creating a scooped out hole the size of a golf ball. This was clearly an open wound which would have a high risk of infection. At the same time, she had also developed a really bad chest and was experiencing severe breathing difficulties, the coughing was also very violent and had resulted in her coughing up blood a few times.

Any patient would be worried when presenting with symptoms of a chesty cough, blood being coughed up, stomachs pains, nausea and a burst boil which had created a deep open wound…so she called the GP.

X first spoke to the GP about the side effects of the medication she had been prescribed, explaining how her general health had also declined. The GP changed the antibiotic, explaining that the particular antibiotic she had previously been taking was more prone to being rejected by her body due to the fact that she wasn’t at her peak health. The new antibiotic would be better for boils and should help her situation, he said. It was really appreciated that he explained why the antibiotic did not have the desired effect and also reassured her by saying that the new mediciation was more likely to be successful. Explaining the reasons for doing something is always the preferred approach as patients have a right to understand their treatment. After this had been sorted, X asked the doctor about her concerns of coughing up blood and breathing difficulties that even her inhaler couldn’t ease. The doctor was surprisingly quite dismissive about this, attributing it to the ‘virus going around’.

This is fair enough though, he as a GP clearly has experience in this field in order to be able to differentiate something of concern from something not, although, it would she been more reassuring to invite the patient in and offer to listen to her chest. Doctors are really busy and he would have most likely had an incredible workload to get through before finishing his shift so I can understand why he didn’t feel it was necessary.

Over the night however, X appeared to worsen, so the next day she went to the Urgent Care Cenre with regards to her breathing. She was particularly worried as she had previously developed pneumonia. At the Urgent Care centre, a physical examination was conducted and the burst boil looked at. As soon as this hole was seen, the priority of the team immediately flipped from her breathing to the boil. The wound was so large and exposed meaning anything could enter it and could even lead to Septicaemia. This of course terrified X, especially as she had previously had Septicaemia. An emergency referral was made to a surgical unit in a different hospital for them to operate on the area. The operation, as explained to X, would cut two cm in diameter around the boil and then close the hole. She came home to gather her things and then rushed off for her emergency surgery.

At the surgical ward, the problem of miscommunication became more apparent. She saw a total of two surgeons over a six hour waiting period, each with very different approaches to the patient…which we can delve into very soon.

As soon as we arrived she was directed to a waiting room and then called by a nurse to assess her issue. The nurse immediately called the surgeon who examined the burst boil. The surgeon told her two things. First, that she didn’t indeed need surgery as the boil was very sterile. She explained how there was nothing more they could do and it would heal over time, explaining how X had been misinformed at the Urgent Care centre. She explained that all they would have done with regards to the boil was surgically burst it, but this had already happened which was a good thing. I was previously a volunteer at the Urgent Care centre and I had seen the way the doctors there collaborated with various specialties by contacting them and getting advice. This made me wonder why in this instance the surgical team wasn’t contacted from the Urgent Care centre so it could have been confirmed whether the surgery was actually necessary. The team at Urgent Care could have used the expertise of the surgeons to realise that the burst boil, despite looking very exposed, was not actually an issue.

The nurse and the surgeon also expressed how shocked they were at X’s breathing, they were bewildered at how this could be ignored and they sent her for an emergency chest x-ray. The surgeon told X to inform her once she had returned from the x-ray department, so the scans could immediately be looked at all the while making it quite clear that the was not a surgical issue. This surgeon was a very good communicator and I know that X felt the empathy and concern she had for her. However, at this point I did wonder why she didn’t choose to refer the patient to a medical team as there was clearly not much she could do from a surgical perspective.

X went for x-ray and came back to the ward where she told the receptionist that the surgeon had told her to let her know as soon as she returned from x-ray. The receptionist said she’d let her know. We sat in the waiting room, X’s condition getting worse with a high fever building up and symptoms such as dizziness. After waiting for over an hour to be seen for what was described as a an ’emergency’ X decided to check to see if she could take any medication for her fever. She went to the reception desk and the lady there seemed completely unaware that we were still here. Very quickly she realised her mistake of not informing the surgeon and later it became apparent that the surgeon had actually returned home whilst we were at the x-ray department. A nurse urgently came to see X who noted some observations. It was clear she had significantly worsened so she immediately called a surgeon to assess her.

Now, taking a step back at this stage…there was quite a few things which could have made this flow much more smoothly. It’s a wonder whether she would have been seen if she hadn’t raised her concern about how she was feeling. The failure of the receptionist to inform someone of a patient who needed ‘urgent’ intervention led to he condition deteriorating. The failure on part of the surgeon to effectively handover her patient to somebody else when she knew she was leaving mid-way led to a misunderstanding and compromise in the patient’s care. The lack of communication was the main cause of this problem.

Back to the story. As soon as we entered the consultation room with the surgeon he began addressing us in a different language (which we didn’t understand). I do think this was highly unprofessional and doctors should not presume a patient speaks a language when indeed they don’t. The only language would be able to communicate in was actually English, so she responded telling him that she wasn’t understanding. He then replied, with no explanation, no observation of the empirical evidence from the blood tests or the x-ray: “you can go home.” I could see X was quite taken aback by his abrupt response and she asked about the tests. He then clicked on the computer and then said, “The bloods are a bit raised, the x-ray’s not that bad…so you can go.” I did think this was not a very professional approach and definitely would not have reassured the patient.

X tried to find out more. Each time she asked a question he appeared to become more and more frustrated, replying in a very vague and unprofessional manner such as when asked what to do if her breathing worsened he responded, “Whatever, go to surgical, go to medical.” He also made a remark, undermining the patient saying that he doesn’t know why she decided to come to a surgical ward anyway. He clearly did not know her background and the fact that she had been referred to the surgical ward. This was further confirmed when X asked about whether coughing up blood is something concerning and he shook his head, using quite aggressive body language saying “what coughing up blood?” When she told her it was written in her notes he responded, “Well how am I supposed to know, I haven’t read the notes.” This was a very unprofessional and unnecessary remark.

First if all, doctors should read the notes and ensure the understand the background of a patient before making conclusions about them and telling them they could go home. I understand why he was probably unable to read the notes as he would have been very busy and suddenly given a patient in an emergency. I do empathise with the doctors in the sense that it would be difficult to fully read a patient’s notes to a full extent especially when considering how overstretched the NHS services are and how pushed for time they would be. I think if even the GP was to have meticulously read my X’s notes he would have picked up that she did have a past history of pneumonia and then acted on her breathing sooner.

In the end X did end up returning home having had achieved nothing in the whole day. The problems she was facing before she went in were still standing and the only form of reassurance she had to go off was that her chest x-ray was not that bad. The last encounter with the surgeon made me reflect on a quote that I want to be able to implement in my clinical practice in the future: “Treat the patient, not the disease.” The surgeon wasn’t really concerned with the wellbeing of the patient after he learnt that it was not a surgical issue. He was only interested in playing his role with regards to the surgery and nothing else when h should have actually taken a holistic view of the patient and taken steps to improve her overall wellbeing even if it was beyond his own skills. There were several things which could have been done differently and all in all if each person involved placed the wellbeing of the patient at the centre than just tunnel-visioning on their own roles a day could have been put to better use and time of healthcare professionals not unnecessarily wasted.

Just to give an overall picture to those of you that possibly skipped straight through to the conclusion, these are the ways in which the whole patient experience could have been improved:

1. The Urgent Care staff could have utilised their connections with various secondary care specialities and gained advice on whether a burst boil would require surgical intervention before making the emergency referral.
2. The first surgeon who saw X could have referred her to a medical team after realising that it wasn’t a surgical issue, thus providing the right level of care for the patient by those who had the right level of expertise to deal with it.
3. The receptionist could have ensured the message was delivered, preventing the patient from deteriorating and time unnecessarily being wasted.
4. The second surgeon could have displayed a more profession attitude taking a holistic approach by demonstrating a greater focus on the overall wellbeing of the patient, rather than losing interest because it wasn’t a surgical matter for him to solve.

This experience was not the most sound and perfect way in which a patient would hope to have their medical problems dealt. I have learnt the true extent at which a lack of communication and teamwork can implicate a team. This was the day before Christmas Eve, so there would have been staff shortages and I appreciate the difficulties doctors can face which resulted in this outcome. I’m not taking this negatively, and in all honestly having observed the story I have foretold has just boosted my motivation. I want to be able to take that extra step for each patient and be the doctor who could have turned this whole situation for the better.