October 7, 2019

When listening without prejudice to a careless whisper, we must all be praying for time

Despite the unwarranted taking of the title of at least one of my favourite tracks of all time, I felt moved to address the other side of the coin to the one movingly described in Nandi Jordan’s article ‘Listening without prejudice - why doctors need to listen and act on patients' concerns’. 

There are some uncomfortable truths, and we need to say them, out loud.

  • The NHS is not a bottomless pit with unlimited resources.

  • Resources are scarce.

  • Humans make human errors, in every walk of life.

Nobody can fail to be moved on hearing of errors made by clinicians, sometimes small, which result in injury to those who they entered the profession wanting to assist. 

And that includes the individual healthcare practitioner accused of and sometimes guilty of that inadequate or negligent care.  It is often forgotten that such practitioners are left distressed and with crushing self-doubt as a result of what may have been one slip in an otherwise unblemished career.  They must internalise and own that error to learn from it and to teach others, but they have to live with it.  And some cannot.  We hear of those who leave the profession following such events and, more tragically, of others who self-harm, engage in substance abuse or make tragic decisions as a result of the pressure and responsibility for patient well-being that all those involved in healthcare carry. 

But is it as simple as doctors not listening to patients? I think not.

Of course, there are some cases where a practitioner will have failed to listen carefully or at all to a patient’s concerns or those raised properly by family of friends of those patients. That is indefensible, and I am not here to defend such conduct. But…and we knew there was a 'but' to this, that is only half an answer. 

No death or injury is ‘acceptable’, but there is an emotive question that must be answered with the best available science. 

I return to the universal propositions given above and address the question by way of worked example.

Not every headache is a subarachnoid haemorrhage ("SAH").

  • An average GP will see four to six patients complaining of headache in a working week. In one GP practice with eight GPs, that is between 32-48 'headache patients' per week. 
  • The incidence of SAH is six per 100,000 per year.
  • On the available data, assuming (which they do not) that all SAH patients presented via their GP (rather than via A&E where many will first present) an average fulltime GP with an average list size of 2000 would see one new case of SAH every eight years.
  • A GP will therefore have to decide which of the 2000+ 'headache patients' they see in that eight-year period might be a SAH. 

Certainly, some of the patients seen by a GP in their working week will tell them something akin to “This is the worst headache I have ever had”.  It may well be so.  But most, if not all of them, will not be a SAH.

Those who give a history or whose examination leaves a GP with nagging or overt uncertainty are likely to be sent by the GP for an emergency CT scan to exclude SAH. So far, so good. 

Invariably, the patients sent will be scanned within a matter of hours and found to have a normal CT and, happily, reassured that there is no sinister pathology. Also, happily, within the group sent for CT, a small number will be quickly identified to have a SAH and treated expeditiously.

But, it is possible, and indeed likely that somewhere in the group of 'headache patients' screened out by the GP, there will be one or more of that group who did have a SAH. Ms Jordan’s approach would seemingly advocate “listening” to all of those patients and arranging a CT scan for each.

Without needing to descend into specifics, if one assumes that there are three CT scanners within any patient’s local hospital, it is easy to imagine what would happen if GPs sent all ‘headache patients’ for CT.  Even looking at the single eight GP practice described above, that would be something in the region of 40 patients per week.  From one practice.

Even those then thought by their GP to be at risk of having had a SAH will be queued behind others who are more likely not to have.  That wait may last days.  And in that time, those who had a small SAH or the ‘berry bleed’ warning that can often precede the major event, may suffer catastrophic consequences during that period.

The tension is obvious, and difficult.  But medicine requires clinicians to make careful and balanced judgements.  And that is imperative in a world of finite resources.

Nobody is infallible.  Sometimes, errors of judgement are made despite best and all reasonable efforts. 

Those who undertake admirable work for claimants requiring compensation and restitution necessarily conduct a risk assessment at the beginning and decide which cases have merit and are likely to succeed.  On some occasions, a claimant's solicitor's judgement will be shown to have been wrong where they had declined to act or ceased acting and where that same claimant goes on to succeed with another firm. 

However, no firm could sustain the financial burden of taking on every potential claim.  The entire firm would fail under the weight and financial burden of doing so.  The need is to ensure that there are sufficient resources and resilience to take on and serve those who they identify as having a likely claim. 

The analogy is obvious.

The outliers prove that everyone can be wrong sometimes.  They do not prove that the model or the need for careful management is wrong also.  When things go wrong, we can all agree that there is work and learning to be done.  Indeed it must and is being done.  Learning and self-criticism are necessary parts of that and we must route out erroneous practice.

Listening to patients is only the first step, and one that cannot be skipped.  But looking backwards and assuming that a patient suffered injury because they were not heard is unfairly simplistic and does a disservice to those practitioners who will, from time to time, and not through a failure to listen, get it wrong.

We all need to listen carefully to each other.