A View from the Other Side of the Consultation Desk

A View from the Other Side of the Consultation Desk

 

Sarah Nicole Dunkerley, BMBS, MA (Oxon), MRCS (Eng), PGCert (ME)

Perm J 2018;22:17-134 [Full Citation]

https://doi.org/10.7812/TPP/17-134
E-pub: 03/23/2018

ABSTRACT

In this reflection on being both a physician and a patient, I consider the events that happened to me as a patient with cancer and how this will change my practice as a doctor in the future.

INTRODUCTION

Every day in my role as an orthopedic trauma surgeon, I deal with people who have their lives turned upside down because of a completely unexpected event. Normal life is carrying on when, bang, something happens. This event may be not seeing a vehicle in a side mirror, an unexpected noise spooking a horse, or tripping at the top of the stairs. A single moment changes everything. All the trials and tribulations of normal life are suddenly inconsequential. Rapidly the expectations of normal life such as being able to work and care for themselves, or even their very existence, is challenged. The future that they had mapped out, whether it be for the next few days, weeks, months, or years, is suddenly destroyed.

Physicians see this every day. But as the years go by, on call days merge into one, and one clinic becomes indistinguishable from the next, it is easy to lose touch with what our patients are really going through. Emotional self-preservation can diminish empathy. Pattern recognition is vital to focused case management, but there is a risk that classification leads to a loss of individuality and desensitization toward our patients.

It is easy to assume that we are just the physicians, the providers of care, and are totally separate and immune to this patient experience. The process of identifying and treating conditions artificially separates us from our patients. This allows us to believe that the patient experience cannot happen to us. We are wrong.

In April 2017, I was going about my normal working day, putting the final touches to my afternoon presentation to the orthopedic trauma team, and wondering if I had time to take my 1-year-old daughter to buy some new shoes after work. I went to a routine follow-up clinic appointment, where I was told a biopsy from a suspected benign lesion had very unexpectedly been identified as probable metastatic cancer. My life was suddenly blown into a thousand pieces. I am 34 years old, have a little girl to look after, and am an orthopedic surgeon. This couldn’t be happening to me. But it did.

A LEARNING EXPERIENCE

The several months after my diagnosis have been some of the toughest times of my life. But I have also learned a huge amount about myself, my family, and my wonderful colleagues. These past few months have been spent in a complex network of appointments, scans, surgeries, second opinions, conflicting advice, and uncertainty. As I now emerge from the other side of this fog of bewilderment and confusion over what my treatment and future might hold, I want to share what I have learned and how I will act differently after this experience.

No person exists in isolation. The patient in front of you is entwined in a network of people and decisions. What happens to that patient has implications for many other people. Whether it be the patient’s ability to look after children or an elderly relative, his/her mother who is worried halfway across the country, the work colleague who is about to cancel his/her holiday to cover for that person, a patient’s health condition can deeply affect a whole web of situations. Minor decisions to us as physicians can have huge consequences for people’s lives and livelihoods. In my role as a surgeon, I am now much more careful and diligent to ask all my patients about their job responsibilities, if they provide a caring role for children or elderly people, and if there is anything logistically I can do to improve the situation. I am much more supportive in amending dates and timings of clinics and procedures around my patients. I now routinely send a copy of my notes in a letter to the patient so s/he can answer questions from family or employees. I try to provide a rough estimate for every patient in terms of length of hospital stay and likely time to return to independence so that the person can plan his/her schedule and inform those around them with as much notice as possible. As physicians, we often talk about patient-centered care, but I believe that we also need to consider the patient in the context of his/her place in the complex society in which we live.

As a patient, time moves incredibly slowly. Physicians juggle the demands of many patients, and it often seems like there are not enough hours in the day to get everything done. As a patient, with only one focus and each decision having huge consequences, time drags. It can seem incredibly reasonable that we might tell a patient that his/her case is going to be discussed at the trauma meeting in four days’ time, or they need to wait for the multidisciplinary team outcome next Wednesday. For patients, this time seems like a lifetime, and their life is put on hold waiting for the result. Obviously, decisions and treatment take time, and there is often little that can be done to improve this. When counseling patients, I now explain why this time is needed, detail what steps will be involved, and make sure they always have a point of contact. Most of all, I make sure they are contacted as soon as a decision has been made.

I have spent hours, if not days, during the past few months waiting for a hospital switchboard to answer, leaving voice mail and messages on answering machines for people who never call back. I know the system, how it works, and who does what. I was glued to my phone for months, not knowing when it might ring or what snippet of news I might hear next. I felt reluctant to put my cell phone down or go anywhere with poor reception in case someone called and left a number I couldn’t make out, or no number—or worse—no message at all. I once left my phone inside while I took the recycling out, and of course, I missed an important call, and it took me three hours to get back in touch. It wasn’t the caller’s fault; he’s a busy person. Many people told me they would call me back, and they didn’t. It became an ongoing joke to me and my husband: Guess what? No one called again! However, one nurse specialist always called back the next workday, or her colleagues would. And if I didn’t answer, she left me a message saying who it was, when she was available to answer the phone, and when she would try again. I can’t tell you what a difference that made to me. Previously, I would not have even considered that this information and reliability would be important, but to me it was amazing. Now when I call a patient or patient’s family member, I always leave a message and contact details and try again in half an hour. I respond to every Email asking me to call a patient as quickly as I can, and if there is going to be a delay, I write a quick note, so the patient can be informed when to expect my call.

There is a huge amount of work that goes on in the hospital that as a patient you don’t see, hear about, or even realize exists. As a more informed patient, I realized what a fundamental role these hospital staff play. The support “specialties” play a huge role in patient care but can so easily be overlooked by the patient. Where would orthopedic surgeons be without any imaging, specialist scan reports, blood test results, or a secretary? For me, the pathologist has played a crucial role during my cancer diagnosis. The surgeon provides the tissue, but it is the pathologists who find out what the problem might be. Their knowledge of special staining, receptor status, and diligence over finding tumor margins have determined my treatment more than anything. I’ve sent my pathologist a thank-you card. I’m not sure many pathologists receive thank-you cards. But she made a huge difference to me, and I wanted her to know. It is easy as the front-line physician to receive the praise and the thanks, but this experience has humbled me in realizing we are perhaps a smaller cog in the wheel than we sometimes think.

Hospitals can be frightening places, especially operating rooms. At work, I try to spend as much time as possible operating. I know how it works, how many thousands of operations go well, and how safe it is. As I shuffled into the anesthetic room wearing my fetching antiembolism compression stockings, I was scared. However irrational it is, there is something about handing over control of your body to someone else that will always be terrifying. Before I went into surgery, my wonderful surgeon bent down and looked me in the eye. She told me she would look after me. Her reassurance and the smiles and professionalism of all the operating room staff made such a huge difference to me. In a busy operating day, it’s easy to lose patience and become irritated at minor inconveniences. I have changed my attitude to contact with patients on the day of surgery. I now focus on explanation and reassurance. The first thing I do now when I’ve finished an operation is find the family member in the waiting room. Dictating the operation note can wait. At the end of the operating day to-do list, I sit down with each patient, explain how the operation went, and what will happen now. I will never forget how important smiles and reassurance were to me.

I have spent hours sitting in different waiting rooms. Once my husband and I had been waiting so long that we ended up playing a game of “If you were on a desert island and could only have 3 items, which would you choose?” In the oncology waiting rooms, there is a certain understanding among the patients. People there don’t talk to each other (that would be very un-British!), but I have observed reassuring smiles among my fellow patients. It is easy to spot the person who is frightened and often tearful at the beginning of his/her cancer journey. As my husband and I entered one oncology clinic for the first time, it was obvious that I was the youngest person there by about 20 years. The pity and sympathy on many people’s faces initially made me upset, but actually this reaction was from a group of people who knew what I was going through. It is amazing that in a group of patients, there is enough empathy for the other people around them. Seeing another patient exiting a consultation room desperately upset and knowing that person didn’t hear the news that s/he wanted to can have a palpable effect in a waiting room. Patients get support from a variety of places, and I have begun to recognize and appreciate this more. Specialist nurses, charities, and patient support groups can all be there for our patients when we are not, and advertising these services to patients from an early stage can provide a huge benefit to them.

CONCLUSION

In the end, I didn’t have metastatic cancer, but rather a rare primary tumor, which has been completely excised. I feel I have been incredibly lucky. Perhaps we forget for our own emotional protection and to survive in the jobs that we do, but it is worth remembering that our patients could be us. Stepping back from our role as a physician and seeing things from the patient’s perspective is something all physicians should do from time to time. That reassuring smile, the extra time explaining something again, or the return phone call all make a difference. As I pass the oncology center on my way into work, I often look up to the building in which I was treated. I remember the kindness and dedication of the people who treated me. I also think of those people I met along the way whose journeys did not have such a happy ending. I hope my experience makes me a better and more compassionate physician.

Disclosure Statement

The author(s) have no conflicts of interest to disclose.

Acknowledgments

I would like to thank the outstanding oncology team at St Michaels Hospital in Bristol for their fantastic treatment, care, and empathy. I would also like to thank all my family and friends for their support and kindness. But mostly to my amazing husband and daughter who have been my tower of strength every step of the way. 

Kathleen Louden, ELS, of Louden Health Communications provided editorial assistance.

How to Cite this Article

Dunkerley SN. A view from the other side of the consultation desk. Perm J 2018;22:17-134. DOI: https://doi.org/10.7812/TPP/17-134

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