The first call arrives on Friday evening: “I have an 84-year old failed discharge.”
“An 84-year old patient”, I think, but the resident seems harried.
“He’s weak, mildly confused, and a bit breathless. He has some chest pain and vague abdominal discomfort. Cardiology won’t do anything for a minor cardiac event. Respiratory want a CT before they’ll even see him and surgery want a different scan. Gastro say it’s not their problem and neurology will consult but not admit.”
I ask: “How about the team that just discharged him? Can’t they readmit?”
“No.”
Not wanting the resident to waste any more time, I suggest he admit the patient to internal medicine, the default home unit for “rejected” patients. He apologises for his failure to do better but I reassure him that patients come before politics.
The night resident calls at midnight. The elderly patient she inherited but doesn’t know seems a little worse but another round of phone calls hasn’t helped. I give advice on managing the deteriorating patient.
It’s 2am and my phone rings again. The patient is exhausted and breathing a little harder. Those hours of waiting have done him no good and now he needs intensive care. But intensive care won’t take the patient just yet, wanting to hear from me what the capable resident has just spent an hour explaining. Exasperated and profusely apologetic, she calls me.
Perched on the edge of the bathtub, trying not to wake the entire household, I insist on taking care of the patient who has deteriorated as a result of a lack of concerted action.
Wary of entering another circular argument about who the home team should “really” be, I urge putting the patient first, hesitating to sound holier-than-thou, but keen to avert a disaster. Intensive care reluctantly accepts the patient and I feel victorious as if I’ve achieved a personal best. I text the resident who wondrously observes how nice it must be to have the power to effect change. Just once in a while, I think wryly. But what a strange, adversarial world it is where a resident imbibes that good patient care depends on who one knows.
There’s a final apologetic text, the resident feeling guilty for having disturbed me all night. I know exactly what’s going through her mind for I was once there: will the consultant be angry? Will I get a poor reference for being incompetent? Was I aggressive enough? I reassure the resident for being the patient’s champion all night and tell her it’s my job to back her up.
Lying awake, I calculate the true cost of all the phone calls that weren’t about patient care as much as navigating the unnecessary roadblocks. How many patients waited even longer to be seen as the night resident played diplomat? And what was my risk of making a serious error the next day after an interrupted night? I am old enough to understand the dangers of practicing medicine without sleep – an extra zero after a drug dose or charting milligram instead of microgram is all it would take to harm a patient. And worst of all, the poor patient having put his faith in our hands had no idea of what had happened behind the scenes.
The next morning, a new round of calls gets underway to coax various teams to see the patient. Individually, we’re good people. As a team, we struggle.
Meanwhile, the patient is exhausted after being probed, prodded and moved throughout the night. No sooner did he settle, he was wheeled away somewhere else.
“All those tests but no one explained why”, he laments weakly.
I don’t have the heart to tell him that he might have got by with half as many, had someone taken ownership of his care.
We had struggled to find someone to look after an elderly man who didn’t have a single-organ illness. Rejected by multiple teams, he became unwell enough to be admitted to intensive care, immediately increasing his chances of morbidity and mortality. The continuing lack of ownership was a surefire way of receiving fragmented care in an increasingly complex healthcare system. And yet, his case was hardly unique – people like him were to be found everywhere, faceless and “stateless”, shuffled from one floor to another, transferred between multiple doctors, all in search of a real home.
Someone changes the blood pressure tablet that worsens the kidneys. Someone adds a new antibiotic but fails to stop the last one. One adds a diuretic but ignores the delirium. Another sees the delirium but figures someone else should treat it. And so it goes until the patient leaves hospital with a new list of medications which clashes with the old one, and he gets so rattled that he simply stops taking his medications. But instead of eliciting understanding, he is labeled “non-compliant”, prompting a groan from the very professionals who could have helped the patient avoid the debacle in the first place.
The “not my problem” patient is a growing entity, each organ under a different specialist, the whole patient under no one. Medical training elevates the niche specialist above all else and payment structures favour reduced length of stay and shorter waiting times, from emergency to surgery. Medicine preaches the value of holistic are but reduces the incentive to care for frail, elderly and complex patients with chronic conditions who require more time and greater deliberation. Incidentally, there has never been a more bloated bureaucracy dreaming up costly innovations that are often imposed on doctors without an impact on actual outcomes.
In medicine, there is a creeping harshness towards patients that didn’t use to exist. I can’t help thinking that in their hearts, doctors know what is the right thing to do but faced with competing interests, and hardened by circumstances, they look away. This is a recipe for dissatisfied doctors and bad medicine.
But in an ageing society where no one has only one health problem we can’t afford to look away. By failing to examine the underlying structures that make such episodic and unfulfilling care possible, we are all signing up to become the patient who is no one’s problem but society’s nightmare.
• Ranjana Srivastava is is an oncologist and Guardian Australia columnist
