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Wilkommen to my blog - my name is Karin Purshouse, and I'm a doctor in the UK. If you're looking for ramblings on life as a junior doctor, my attempts to dual-moonlight as a scientist and balancing all that madness with a life, you've come to the right place. I'm currently a doctor/research trainee in oncology after spending a year doing research in the USA. All original content is licensed under a Creative Commons Attribution 4.0 International License.

Monday, 15 October 2012

I'm a patient - get me out of here!

My junior doctor chums and I have a cringe every now and then when we think of some of the 'catchphrases' we've developed.  Whether it's asking the patient 'if you've had a bit of a funny do' (read: fit, faint, fall or similar), joking with them 'you look far too well to be in hospital' or apologising for the cold pair of hands examining their chest/abdomen/arms etc by wittily remarking 'well, you know what they say - cold hands, warm heart!', I suppose it's inevitable to develop a stock response to common situations.

But, the one I am always happy to cringe at, is 'well, don't take this the wrong way Mrs XYZ.... but I hope I don't see you again any time soon' - which usually means, we've finally crossed our T's, dotted our I's and found a way for you to get out of here.

Don't misunderstand me - I'm not trying to get rid of my patients; in fact, often quite the opposite - but it is a small triumph for all involved when a patient is finally able to leave hospital.

It is one of the most frustrating part of my job that once a patient is medically fit, there is no certainty that they will be discharged soon.  The BBC is well on the case with this, and it's not a new issue. Although I work in one of the areas with the highest rates of this, it's something I have witnessed since being a medical student in all areas of the country I've trained in.

So what's going wrong?

From my perspective, there's one main issue.  Our old friend, Communication.

There are a lot of players when it comes to getting someone home, and unfortunately, they're rarely present on the pitch at the same time to talk about what's going on.  Patient's wishes are paramount, but input from the medical team, physios, occupational therapists and any other appropriate healthcare workers is needed to identify their needs in the community.  Families may feel they have extra information which may be useful, but this must be balanced with maintaining the patient's autonomy.  Then the social worker is loaded with all of this information and a whole other collection of issues (place of discharge, funding streams etc) come into play.  The difficulty is, a delay in information or progress from one of these groups can hold the whole thing up.  That can even start from a medical perspective, with many multidisciplinary teams being unwilling to start discharge planning until a patient is medically well.

Then there's the disjoint between health and social care.  People often ask me what sort of things I see most often as a junior doctor - an easy answer - it's usually some end effect of someone struggling to cope at home: 'off legs', falls, confusion.  I'm not denying there are often (mostly?) medical components to this as well, but there's a tendency to categorise - is this a medical or a social issue?  I think you'll find it's both.  But apparently we have to box them first and deal with them separately.  Except - it's not really dealt with when you spot the patient's name on the admissions board 24 hours after you signed the end of their discharge letter.  A large part of this is also the lack of support and backing we give the social worker.  We have a large team of healthcare workers of various disciplines that support a patient to discharge in hospital - but arguably the social worker has the toughest job of essentially getting a patient's whole life in order in as short a time as possible.  Basically, all hail the social worker.  We love you, and need more of you!  And finally, the most frustrating off all.  Vacant place in nursing home.  The paperwork's all done.  The patient's delighted.  Their family's delighted.  You're delighted.  And then the transport gets cancelled. And then they lose their place in the home.  And we're back to square one.

So what can be done?

I've worked in some hospitals where there's essentially a multidisciplinary handover every single morning - perhaps that would improve communications.  Efficient ward rounds would leave us with more availability later in the day to catch up with other healthcare workers on the wards, and of course families.  Speaking of the latter, having a more formal means of ensuring patients and their families have regular windows of time to access doctors, nurses, or indeed anyone who they feel would improve their understanding of what's going on.

If politicians, NHS managers, doctors, ANYONE, is serious about giving our ageing society a better deal, I'd suggest the medical/social interface would be an excellent place to start.  

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