Posts Tagged ‘Communication’

Can we learn from the BBC’s crisis management?

By Dr Mike Roddis, director of Healthcare Performance - 20th November 2012 10:34 am

It had all the ingredients needed for a collective meltdown: accusations of a cover-up; a significant untoward incident with the potential to damage public trust; a high profile resignation; the launch of several inquiries; a media feeding frenzy; and questions in the House of Commons. But this time, the organisation at the centre of it all wasn’t an NHS hospital but another prominent public institution.

Of course, many NHS professionals will be all-too-familiar with the sight of an organisation in the throes of a crisis. On this occasion it was the BBC but there are a number of NHS trusts which have been plunged into chaos by financial difficulties, significant clinical failings or external events such as a decision to close a unit. In nearly every case, the problems are compounded by a lack of communication which allows rumour and even despair to take hold among staff.

In my own experience of working with hospital trusts in difficulties, the most common cry is that ‘no one tells us what is going on’. For this reason I would argue that one of the most important organisational objectives in a crisis should be to establish honest and open communication. Easier said than done I appreciate but without this, it will be impossible to restore morale and equally importantly, the care provided to patients is also likely to suffer. After all, how often have we seen hospitals where one disaster seems to follow another in quick succession?

I believe doctors in leadership positions within crisis-hit hospitals can play an important part in restoring calm and dealing with the anxieties of staff and patients if they are given consistent and useful information. Hospital trusts who keep staff in the dark about what is happening are unlikely to get their organisation back on an even keel but if information is not forthcoming, senior doctors should themselves be prepared to collectively approach hospital directors for answers to the questions of greatest concern.

By contrast, firing off letters to the press or expounding upon trust failings with outsiders will usually escalate the sense of crisis. To return to the BBC analogy, while some have argued that the readiness of the corporation’s journalists to question and even humiliate their bosses was a sign of strength and integrity, the sight of any organisation publicly picking at its wounds is usually disturbing for outsiders and is likely to further knock their confidence in the organisation.

For more junior staff working within struggling organisations, it may also be tempting to use tea breaks to gossip about the latest failures at the top but this is better avoided because it may simply add to a sense of powerlessness and frustration. Instead, I think it’s more helpful for individuals to adopt a business-as-usual approach, for their own sake as well as patients. Practical concerns about their ability to deliver patient care should be directed to their supervisor who should then be prepared to raise them with someone who has decision-making responsibility or if necessary to seek advice from an appropriate external professional or regulatory body, in line with GMC advice.

Of course, confusion over who is actually in charge is another common theme in crisis-hit organisations where senior staff are obliged to step aside. As seems to have been the case at the BBC, such leadership vacuums can easily result in organisational paralysis and instances of poor decision-making. As they are currently discovering at Broadcasting House, it is only by moving swiftly to re-establish clear lines of decision-making, accountability and communication that the confidence of staff and public alike can really be restored.

Healthcare Performance is run by two doctors with over 30 years’ experience of clinical governance and medico-legal work. It specialises in careers coaching, professional development and organisational trouble-shooting within the healthcare sector.

Patient preferences often ignored in decisions

By Mike Broad - 9th November 2012 9:15 am

Patients’ preferences are often misinterpreted or ignored in treatment decisions, leading to a ’silent misdiagnosis’ that is damaging to both doctors and patients, warn experts.

Albert Mulley from The Dartmouth Center for Health Care Delivery Science in the US, along with Chris Trimble and Glyn Elwyn, a visiting professor there from Cardiff University in Wales, argue on bmj.com that a doctor cannot recommend the right treatment without understanding how the patient values the trade offs.

Making an accurate medical diagnosis remains a source of professional pride for many physicians, say the authors, yet evidence suggests that the problem of ‘preference misdiagnosis’ is high.

For example, there are often gaps between what patients want and what doctors think they want. In one study, doctors believed that 71% of patients with breast cancer rate keeping their breast as a top priority, but the figure reported by patients was just 7%. And in a study of dementia, patients placed substantially less value than doctors believed on the continuation of life with severely declining cognitive function.

Evidence also shows that patients often choose different treatments after they become better informed about the risks and benefits, say the authors. One study found that 40% fewer patients preferred surgery for benign prostate disease once they were informed about the risks of sexual dysfunction.

Ensuring patients’ preferences are not misdiagnosed is not as simple as asking the patient what he or she wants, explain the authors. Instead it requires three steps: adopting a mindset of scientific detachment; using data to formulate a provisional diagnosis; and engaging the patient in three steps of shared decision making: team, option and decision talk.

Better diagnosis of patients’ preferences is not only the right ethical thing to do but it may also reduce the cost of healthcare, they add, as evidence from trials shows that engaged and informed patients often choose to have less intensive care and to become more careful about having lots of procedures.

More work is needed to understand whether these potential benefits could be realised in healthcare systems, they conclude, “but it is tantalising to consider that budget challenged health systems around the world could simultaneously give patients what they want and cut costs”.

Meanwhile, the health service ombudsman said that poor communication has fuelled a surge in complaints against the NHS in England.

Her report says the NHS needs to improve the way it deals with patients unhappy with the care they have had. It also highlights an increase in complaints about independent providers offering care to NHS patients.

Growth in medical miscommunication skills

By DR Whymark - 19th June 2012 9:43 am

There is an increasingly wide and bizarre diversity of communication skills in medicine. While simultaneously being one of the top priorities in the undergraduate curriculum, as well as the most common cause of complaints against post graduate clinician, communication skills have a lot to answer for.

Again it seems like the right hand of undergraduate training is misaligned with the left of post graduate working. Or is it? Does our new touchy feely teaching of medical students pave the way for future sloppy communication skills?

Medical students are increasingly polite, deferential even. Often coming across as timid or subservient when actually they are intending to reduce the formality and put the patient at ease. But does it? A pre-operative assessment with an open necked shirted and chino-ed youth introducing himself as “Hi, I’m John and I’m going to be gassing you this morning” would no more relax me than notification of unplanned immediate root treatment.

Despite being a genuine attempt to relax the patient and build a rapport, it does the opposite. You are not proposing a drink in the pub with the person, you are not trying to make friends with them. You are preparing to take responsibility for their life as they are anaesthetised for a surgical procedure and they should feel secure in your superior status and ability.

Further, this matey approach does nothing to dispel the rumours that anaesthetists are not (proper) doctors. I was once asked by patient whose son had not been accepted to medical school if he could go to college to become an anaesthetist. The patients don’t know. We have to tell them. We need to call ourselves Dr Whoever. I may even request our esteemed editor changes my Blog name to Dr Whymark to reduce the chance of reader over-familiarity.

Such inappropriate informality is not confined to clinical interactions either. The written word lacks emotion and it is only 20% of what we say that is effective, the remaining 80% coming from the way in which we say it. Thus a recent email sign off from a surgeon’s secretary ending with LOL left me puzzled as to whether she was giving me Lots of love or was Laughing Out Loud at my request for the next week’s list (which may not have been an entirely inappropriate response due to our ever evolving IT systems).

Age is no indicator for communication skills either. On a personal note, I arrived at a hotel the night before my study leave began and texted a colleague also attending with a chatty “Hi, I’m here now, what’s the plan for dinner? Which hotel are you in? See you soon hopefully, Caroline”.

I received a text back stating “Bar. 7. Paul” In his defence, it did indeed convey the required information accurately, succinctly and had punctuation - but lacked any warmth of feeling as regards the impending meeting!

It would have been far better to pick up the phone. Have a real conversation. We could even move away from the desk to walk and talk to people: face to face dialogue is much more productive.

‘Chalk and talk’ is considered the oldest, most basic, yet most difficult teaching skill. Perhaps we should now be teaching ‘walk and talk’ to achieve effective communication.

The communication ethos in the undergraduate curriculum seems juxtaposed to the increasing use of e-mail and texting in the workplace. We need to prevent this extending to the detriment of doctor/doctor and doctor/patient relationships.

Communication is vital when examining patients

By Dr Richard Stacey, medicolegal advisor, Medical Protection Society - 1st September 2011 9:42 am

How highly would you rate your communication skills? Most doctors would say theirs are up to scratch - however, a failure to communicate properly with patients, can and has led to some doctors being accused of inappropriate touching.

Imagine the scenario: a patient presents at your surgery with symptoms you suspect could be caused by an infection. The standard examination includes palpation of the lymph nodes in the armpit and groin areas, which many patients naturally regard as intimate areas. If you have not told the patient where you need to examine, it could quite easily lead to misunderstandings and cause the patient to feel uncomfortable.

I also know of cases where doctors have received a complaint after performing a fundoscopic examination of a patient’s eye. During the examination, the doctor has rightly turned out the lights or drawn the blinds, but has failed to explain to the patient why the room needs to be dim, or that the examination is carried out from a very close distance - well inside what we would normally consider ‘personal space’. It’s in situations like this, where the patient is already feeling vulnerable, that further confusion can arise and potentially lead to a complaint.

I can empathise with doctors who can be so focused on obtaining the clinical findings that they simply forget to explain the nature of the examination, and don’t seek the patient’s agreement before proceeding. Still, situations like this can be avoided.

It helps to put yourself in the patient’s position - procedures that might be obvious to you, may need to be explained in full to the patient. Talking the patient through the examination as you are carrying it out can also help.

Clearly, patients should always be offered a chaperone before you conduct an intimate examination. But what about examinations that you don’t perceive to be intimate, but could leave the patient feeling vulnerable?

My rule is, if in doubt, offer a chaperone. The patient will see that you are aware that they could feel uncomfortable, and they’re likely to appreciate the gesture even if they don’t take you up on the offer. The decision lies in their hands.

If the worse comes to the worst and you do receive a complaint from a patient, the way you respond could be pivotal in whether or not the complaint is pursued.

Your response should be conciliatory and empathetic, and should explain how the misunderstanding occurred. Apologising for their distress can also go a long way to restoring the doctor-patient relationship.

Remember, the three crucial elements of avoiding patient complaints following on from a misunderstanding are communicate well; offer a chaperone; and sharpen up your examination skills.

Take the time to explain and gain consent before proceeding with examinations. You’ll not only reduce the chance of any misunderstandings, but help preserve the much-needed trust for the doctor-patient relationship to work.

Communicating with colleagues - advice for hospital doctors

Dr Sally Old, MDU medico-legal adviser - 29th October 2010 12:22 pm

The MDU has developed new guidance for doctors embarking on their first consultant post. In the third of a series of articles guiding you through the more common non-clinical challenges you might face, Dr Sally Old, MDU medico-legal adviser looks at the challenges of communicating well with GPs and teams.

Multidisciplinary approach

With care increasingly being delivered by multidisciplinary teams and with patients frequently being transferred between hospital and primary care, good communication with colleagues is essential to ensure patient care doesn’t suffer.

Communicating with GPs

Breakdowns in communication between hospitals and GPs can lead to problems with continuity of care and complaints and claims can follow. Two areas which often lead to difficulties are confusion over who has overall responsibility for the patient and ongoing monitoring of their condition, and problems with sharing information about patient’s medication and treatment. For example, a report by the Care Quality Commission in 2009 found that some GPs did not provide hospitals with information on adverse drug reactions, existing illnesses or known allergies prior to their admission to hospital. The report also found that hospital discharge summaries of patient’s medication were sometimes incomplete and inaccurate and often didn’t arrive in time for the patient’s first follow-up GP appointment.

The GMC advises hospital doctors to tell the patient’s GP, “the results of the investigations, the treatment provided and any other information necessary for the continuing care of the patient, unless the patient objects” (Good Medical Practice, 2006, paragraph 52).

The GMC also advises in Good Practice in Prescribing Medicines (2008) that the decision about who bears the responsibility for the overall management of the patient should be made after full consultation and agreement and should be based on the patient’s best interests rather than on the healthcare professional’s convenience or the cost of the medicine (paragraph 27).

Shared prescribing

If a consultant asks the GP to prescribe a drug for the patient you should come to an agreement with them as to how the treatment will be monitored and reviewed. The doctor signing a prescription takes legal responsibility for it so if you ask a GP to prescribe, you should familiarise them with the drug and its likely side effects. You have a responsibility to ensure that letters to GPs contain all the necessary information about the patient, their condition and the required dose regimen and frequency of the drug prescribed as well as the monitoring required.

If a GP is unclear about any aspect of the prescription, they may refuse to prescribe the drug or may seek clarification from you, which may delay the treatment.

To avoid some of these problems, you may wish to consider agreeing a shared-care protocol with GPs, which should include responsibilities and details of follow-up arrangements. The Department of Health and National Prescribing Centre, both have guidance on responsibility for prescribing between hospitals and GPs.

Junior doctors

When embarking on your first consultant post, you may be supervising and training junior medical staff for the first time. When junior doctors and students accompany you in clinics, on ward rounds and in theatres, it is important to obtain informed consent from patients for you to disclose identifiable confidential information for teaching purposes, which may include results of investigations and X-rays. Patients will also need to give their consent for any examination conducted for training purposes.

If you ask your junior doctor colleagues to record your decisions in the patient’s notes, it is your responsibility to ensure their accuracy. While it may be impractical to check each and every entry, you should ensure that they fully understand what has been discussed and decided for each patient and the importance that the notes accurately reflect this.

Referral within the hospital

When referring a patient to the care of another specialist or department in the hospital, or delegating care to another team member, you should provide all relevant information. When delegating a particular aspect of the patient’s care to a colleague, the GMC says you will still be responsible for the overall management of the patient, and accountable for the decision to delegate. You must be satisfied that the person has the qualifications, experience, knowledge and skills to provide the care or treatment. (Good Medical Practice, 2006, paragraph 54).

Handovers

When you are off-duty, you should be satisfied that suitable arrangements have been made for patients’ care in your absence. Furthermore, busy modern healthcare rotas mean that effective handover of patient care is essential. As a senior clinician you may need to lead handovers. As well as ensuring appropriate handover procedures are in place, you should ensure adequate time is set aside for handover. Try not to allow the pressures of clinical work to encroach upon this aspect of communication, which is essential for patient safety.

The National Patient Safety Agency, in conjunction with the BMA’s junior doctors committee, has produced a best practice guide to handovers.

It identifies common problems during handover such as failure to make roles and responsibilities clear, leading to members of the team assuming that someone else has provided a handover when in fact this hasn’t happened.

The guide recommends that all hospitals develop their own handover policy. Other advice includes:

· Involve all key members of the multidisciplinary team. Include all grades of staff as appropriate.

· Be aware of any new locums on the team and make sure suitable arrangements are in place to familiarise them with local systems and hospital layout.

· Ensure handover is at a fixed time, of sufficient length and in a room large enough for all to attend. Ensure staff rotas allow them to attend during work time.

· Distractions, such as ‘bleeps’ should be avoided, except for life threatening emergencies.

· Ensure handovers are supervised by the most senior-clinician present and have clear leadership. Avoid jargon and explain abbreviations.

The MDU’s new consultant pack contains 18 fact sheets on subjects such as communicating with patients and colleagues, good record keeping, supervising staff and marketing and media. It’s available free for MDU consultant members.

Communicating with patients - advice for hospital doctors

By Dr Sally Old, MDU medico-legal adviser - 28th September 2010 1:08 pm

The MDU has developed new guidance for doctors embarking on their first consultant post. In the second of a series of articles guiding you through the more common non-clinical challenges you might face, Dr Sally Old, MDU medico-legal adviser looks at the challenges of communicating well with patients and relatives.

Communication challenges

Any doctor who has ever experienced hospital care from the other side of the fence - as a patient - will appreciate the importance of good communication. A doctor who explains your condition, the possible treatments, their risks, benefits and any alternatives and who answers your questions clearly and honestly, is likely to instil you with confidence and trust.

But effective communication is not always straightforward in a modern hospital environment. Care is often provided by teams of doctors and other healthcare professionals, working in shift patterns and there is the potential for communication to suffer as a result.

Patient privacy

Ensuring privacy in open wards can be difficult, especially where visitors are present and curtains are the only barrier to a conversation being overheard by people in neighbouring beds. If you need to discuss a sensitive issue, you might want to consider finding a private area or office. If you are breaking bad news, try to avoid interruptions, for example, by handing your bleep to a colleague for a few minutes and turning off your mobile phone.

Patients with special needs

Special consideration needs to be given to patients with specific communication needs, for example, patients who do not speak English, people with a hearing problem, patients who lack capacity and children.

For patients who don’t speak English, you may require an interpreter. Sometimes a family member can act as a translator, but this may not always be appropriate. For example, a family member may be reluctant to tell the patient complex information about their illness. It may be necessary to use a professional interpreter for key discussions, such as when discussing the risks and benefits of treatment or giving information about the prognosis of a serious illness.

If talking to a person with a hearing problem, it may help to use a quieter office or private area to avoid the background noise of a busy ward.

People with impaired capacity should be given all practicable assistance to understand and contribute to decisions about their care. They might need the help of a trained advocate or family member.

When dealing with children, care needs to be taken to explain things in an appropriate way. Older children with sufficient maturity will be able to take decisions about some aspects of their medical care.

Communicating with relatives

Appropriate communication with the patient’s family, friends and other carers is also important. The patient’s nearest and dearest often provide invaluable reassurance and support to their loved one and they will want to be kept informed so that they can understand how best to help.

However, any information provided to a family member must be within the context of the duty of confidentiality owed to the patient. Often patients will appreciate you speaking to their relatives and updating them of events, but don’t assume this is always the case. The GMC’s Confidentiality (2009) guidance now includes a section entitled ‘sharing information with a patient’s partner, carers, relatives or friends’.

The GMC says it is important to establish early on what information the patient would want to be shared, in what circumstances and with whom.

The basic principle is that you should only disclose confidential information about a competent adult patient if they consent for you to do so. This means you should seek permission from the patient to speak to their relatives. The patient will need to know what you intend to discuss with their family before they can give informed consent. Make sure they are aware of this includes aspects of their medical history that are relevant to the current illness but which may be sensitive, for example, certain infectious diseases or termination of pregnancy.

It can be helpful to have discussions with family members in the presence of the patient to avoid any confusion about what you have said.

Principles of good communication: at a glance

1. Explain yourself - make sure your patient knows who you are and your role in their care. It might sound obvious, but time spent explaining who you are and why you have come to see the patient, and checking they have understood your explanation, will help your consultation.

2. Keep it open - when taking a history or seeking patients’ views about their care, ask open questions. Try not to interrupt but regularly acknowledge what patients are saying.

3. Double check - repeat back what a patient has said to you to check your understanding. Check the patient’s existing understanding of their illness if you are covering a sensitive topic or communicating complex information and check that the patient has understood.

4. Look for clues - look out for non-verbal clues such as the patient nodding or looking confused or distressed. It’s also important to make eye contact.

5. Don’t presume - avoid medical jargon which will mean nothing to your patients. Consider using visual aids such as diagrams when explaining procedures and risks. Record your use of these in the notes.

6. Be considerate - avoid over familiarity and be polite, even if you are extremely busy, under pressure or tired. Give the patient a chance to ask further questions and explain what will happen next.

7. Make notes - record what has been said to the patient and what you found on examination. Sign and date your notes clearly. Good notes that are legible, accurate and written while the facts are still clear in your mind, are essential to continuity of care. For example, your colleagues may need to know what the patient has been told or which family members the patient is happy for the team to talk to.

The MDU’s new consultant pack contains 18 fact sheets on subjects such as communicating with patients and colleagues, good record keeping, supervising staff and marketing and media. It’s available free for MDU consultant members.

Mobile devices offer communication “step change”

By James Sherwin-Smith, CEO at devices4 - 17th September 2010 7:52 am

Devices4, a new charity focused on improving patient care by placing modern technology in the hands of health professionals, is currently compiling published evidence and commentary on communication issues within healthcare to support the charity’s objectives.

What’s most surprising from our review is how little progress has been made in increasing the use of mobile devices despite mounting evidence and support.

A recent journal article caught our attention. Titled Quantifying the economic impact of communication inefficiencies in US hospitals and published in the July 2010 edition of the Journal of Health Care Management, it suggests that the economic burden of communication inefficiency in U.S. hospitals is substantial, at over $12 billion.

The study draws upon existing academic research into health care communication, national statistics and primary research conducted by interviewing clinicians in seven different US hospitals. The authors constructed an economic model for the efficiency of resource utilisation, focusing on three areas where communication breakdown had an immediate economic impact:

Wasted physician time: $0.8 billion (6.7%).

Wasted nurse time: $5.0 billion (40%).

Increased length of stay for patients: $6.6 billion (53.3%).

The total came to $12.4bn (1.97% of total U.S. hospital revenue).

This led us to think, what would a similar analysis show for the NHS?  Using readily available statistics for England and some simple assumptions, we calculated the following:

Wasted doctor time: £98 million (9.3%).

Wasted nurse time: £510 million (48.2%).

Increased length of stay for patients: £450 million (42.5%).

The total comes in at £1.1 billion (3.44% of 08/09 income paid to hospital trusts).

The authors of the US study state in their conclusion “greater and more effective infusion of communication technologies into the hospital context can address communication challenges and aid in connecting to the right person about the right patient at the right time in interpersonal interactions among care providers.”

This is why devices4 is focused on increasing the acceptance and affordability of mobile phones for health care professionals. We believe that mobile devices can deliver a step change in communication practices within healthcare, through their support of different communication media: voice, text and data. This would benefit the healthcare system as a whole: making health care professionals more productive, improving patient care, and saving taxpayer funds.

In an economic climate where the NHS is being asked for £20bn ‘efficiency savings’ without sacrificing patient care, we think improving communication should be at the top of the healthcare reform agenda.

Complete a survey: devices4 are currently running a survey of healthcare professionals to better understand their current usage and attitudes to mobile phones. Click here to help.


A psychiatrist’s tale of going under the knife

By Dr P Grahame Woolf, consultant psychiatrist - 2nd March 2010 10:30 am

Doctors are notoriously bad patients. Before undergoing two cataract operations, I heard that familiar joke. Cataract replacement, with a 98% success rate, is one of the triumphs of modern medicine; would that psychiatry could come near to equalling it.

Cataract surgery is now generally performed under local anaesthetic, which provides the patient with a different perspective.

My initial assessment was a model of how these things should be, but pressures in the eye unit later undermined the ideal. The consultant surgeon conducted a thorough examination. An additional problem, double vision, was then explored by an orthoptist, who explained everything well. They recommended surgery on both eyes. I signed the consent form and was sent to book the operation. The booking clerk said there was a cancellation slot the next day, which I gladly accepted.

On arrival I was surprised to find myself under a different consultant surgeon with no explanation. I was seen by a nurse and then by the new consultant’s specialist registrar who would be doing the operation. The examinations were quick, mainly form-filling exercises. I learned that there was no operating list schedule, and that patients would be called to theatre in no particular order. As it happened, I was the last one, some five hours after the arrival appointment; no food to be taken whilst waiting. 

In the theatre ante-room there was repeat paperwork to eliminate risk of error; confirmation that I was the right Peter Woolf (not Dr, the IT didn’t have provision for that option); date of birth, which eye was to be done, etc.

Inside theatre, the scene was intriguing, with elaborate hi-tech machinery. I was laid down flat with my face covered, so one could not see what was going on. Background music played. The injections and processes were virtually painless. They involved what sounded like a dentist’s drill in one’s eye; you could feel it, but nothing hurt.

However, at one point, I sensed that all was not right. The consultant surgeon himself came in and took over, and the procedure extended to what felt like twice the expected duration, before on completion the team expressed relief and satisfaction.

Nothing at all was said to me throughout the lengthy process. Afterwards the consultant explained that because the new lens which had been inserted proved to be a faulty one, it had to be replaced, apparently a tricky exercise. The anomaly was so unprecedented that he had never encountered it before. The abnormal lens would be returned to the manufacturer with a complaint.

Next morning I returned to the department and the bandages were removed. Two sets of eye drops were supplied, to be taken alternately, hourly for a fortnight. It was a relief to have two eyes again.

At the follow-up clinic a fortnight later there was paperwork again, to plan for the second operation. It all seemed de novo. I was asked: “Do you want it done? It’s entirely up to you”, as if the decision had not already been made. The same risks explanation, as per the leaflet supplied, and a second consent form to be signed. In that rushed interview in a busy clinic there really was no time for, or encouragement to ask, pertinent questions.

Once again I was sent to arrange the second operation with the bookings clerk, from whom I learned that for various reasons the first opportunity would be several weeks later. On enquiry I learnt however that my original consultant could to do it the next week, so the clerk went off to explore whether I might be re-allocated to the original team, with which I had experienced such good rapport.

She returned to tell me firmly that was not to be, “you’re now under Mr X and must stay under him”.

Whilst waiting for the second operation recovery continued steadily, with the gratifying experience of regaining colour clarity and brightness, which I had been losing over the years without realising. Between the two operations grey morning skies seen through the right eye became blue through the new left lens.

At pre-examination before the second operation the same routine was repeated, with people in the clinic behaving as if they did not recognise me. I mentioned having not being told what had been happening during the previous prolonged operation. The response was: “No, we don’t talk to the patients in case it makes them more agitated”. I said that for me, the opposite would apply; written note was taken of that preference.   

In theatre again the atmosphere was tangibly less relaxed than the first time. The consultant was present throughout. The theatre nurse sounded less confident than the previous one.  After some time things began to sound fraught.  There were problems with the new lens; another was needed: “Should it be the 70 or the 70.5?” Some equipment available was not as wanted: “the straight one, not the curved one”. No reassurances or explanations were addressed to me.

Eventually all was complete. Sitting up again I was assured that the operation had been completed, technically perfectly. Surrounded by all the high-tech equipment I said that, being a doctor myself, it would be interesting to watch one of these cataract operations in theatre. The SpR thought that would be “against rules” but that I could look them up on the internet. 

During the evening, worrying visual manifestations occurred. The bandaged eye produced a coloured show, with bright, kaleidoscopic effects which somehow swamped the vision of the other eye. A thing like a shimmering coloured table cloth appeared - scary! My worried wife phoned the help number provided for nurse advice but failed to get through. 

On the next morning - as the great freeze of 2010 got under way - I returned early to the hospital, worrying whether the retina might have been affected (detached retina is one possible complication on the patients’ leaflet).

I told the clinic nurse that I had a worry. She did not know me, nor that I was a doctor, as I re-iterated when asked to give my particulars all over again. “Well, I’ll put down, you like to be addressed as Dr.” The SpR saw me in due course, and reassured me that the visions were not sinister; probably some “edge optical effect” of the “very large replacement lens” they’d put in. 

Despite the typically harrassed atmosphere (the snow had disrupted travel for both staff and patients) I did pursue some questioning and received from the lead consultant, who was also at the clinic, another explanation of my bizarre kaleidoscopic visions: “just the jelly rolling around in the back of the eye - it sometimes picks up the retina a bit but only quite slowly”. I also mentioned that the atmosphere had seemed fraught at the second operation, with the nursing assistants unable to find instruments, etc?

Several weeks later, at the final out-patients review I was called in from the corridor loudly, Peter Woolf, by that same consultant (as if he hadn’t connected who I was?). Again the various people who saw me that morning seemed unaware that I was a doctor. A nurse asked how long I’d been one and seemed impressed that I answered “about sixty years”. Later the consultant reassured me that the two operations were perfectly normal “apart from circumstances”.

This is, of course, just one story; one with a happy ending, that could be widely duplicated. But the message has to be that time constraints loom large in medical practice, whether it be GP appointments or a busy specialist hospital department that is, in a way, a victim of its own success.

The staff have no time to achieve rapport with patients; instead there is an expectation that patients are totally deferential to an overly stressed clinical team. There is plenty of scope for improvement in everybody’s best interests - however busy a clinic.   

Tips on making your New Year’s resolutions a reality

By Susan Kersley - 16th December 2009 11:58 am

As we come to the end of another year it’s that predictable time for time to both reflect and look forward to a better life in 2010.

The New Year is also a time for resolutions and vowing that you really will keep to them. This year, instead of setting unrealistic goals, you could spend more time considering the way you’d really like life to be. How are you going to live with the challenges of life as a hospital doctor, and deal with them differently, next year?

Here are five tips:

1. Set clear boundaries: don’t expect others to be mind-readers. Stop yourself getting frustrated if colleagues, nurses, or secretaries don’t seem to understand what you want them to do. Maybe you’ve made assumptions and haven’t been really clear about what you are expecting from them.

2. Decide what you really want. When you know what it is you want then you will be more able to tell others and no longer have to put up with unsatisfactory performance.

3. Communicate clearly. Give a positive feedback sandwich if you are not happy with the way someone is behaving. Say something complimentary then get to the point about what it is you really want - end with something positive about them.

4. Be responsible for yourself rather than everyone else: you can’t always be responsible for others’ feelings. You may be avoiding making a decision for change because you think someone will be upset. Tell them what you are going to do and when and then allow them the chance to deal with it in their own way.

5. Improve your self-care. Stop neglecting your own needs and care of your body, mind and spirit in whatever ways are good for you.

Susan Kersley is a retired doctor and life coach.

Improving cultural awareness in your communications

Bob Mathers - 18th November 2009 10:28 am

A company, Today Translations, recently placed an advert in The Glasgow Herald seeking speakers of ‘Glaswegian’.

Candidates, it said, must understand “vocabulary, accent and nuances”. The boss insisted there was a genuine need.

She said: “We’ve already had calls including someone who said they could speak English, German, French, Spanish, Italian - and Glaswegian.”

A former lord provost was insulted, claiming: ”I travelled the world and nobody failed to understand me.” He missed the point which is that accents can create barriers and cause difficulties. Accents in themselves are fine as long as they are understood.

Within the NHS, there is still a greater likelihood of overseas qualified doctors failing in postgraduate exams and job applications than indigenous doctors. Part of this has to do with the cultural barriers encountered. Is it the case that if the appropriate vocabulary, accent and nuances go missing in action, the perceptions, expectations and assumptions of colleagues can lead to prejudice?

Historically, more delegates at our workshops have been from overseas, underlining for us the importance of clear communication. It’s obvious. You are not effective or influential if you cannot communicate clearly. Articulating, questioning and listening can all suffer because of accent. Yet we are either too embarrassed or reluctant to risk accusations of political incorrectness, to point this out.

Trainers have better opportunities to pick this up in 1-to-1 sessions. Making general observations in public and personal ones in private, works - ask any wage negotiator.

Individuals, although resident in UK for some time, can still have gaps in their communicating framework. Many, described as having a ‘communication problem’, do not have a problem at all. They just have a strong accent. Is this the tip of a cultural awareness iceberg?

In the safe environment of the training room we have people pronouncing ‘v’ as ‘w’ to the point of distracting from the content of their presentations or emphasising the second of a four syllable word when it should be the first. Amid peer discussion, practice and much laughter, we all deal with it in our own way. It reinforces for us the elemental nature of fun, although humour can sometimes be cruel.

If you’ve ever sat at a crowded table where everyone but you is laughing at something you get a sense of the loneliness of the outsider. But the transition from confused person struggling with subverted cultural norms, into a confident member of staff cannot be managed by ignoring behaviours which do not match cultural expectations.

How can we assist individuals to reach their potential? The right climate will encourage any plant to grow. Important qualities which help to create a strong performing, developmental climate are professionalism and leadership and these start with each of us.

As a recently fired trust director said: ”Byraway see thae furriners, nae affence but haufa thaim dinna unnerstaun wut we’re oan aboot. It’s a pain in the erse tryin tae get yer point acroass. Ahm definitly gaunae go fur wanna thae interpretatin joabs.” (for a translation, please contact Today Translations)

This is Bob Mathers’ final article in this three-part series on communication. Read the first and second parts.

Bob provides non-clinical communications training for health professionals. Email him on bobmathers@btinternet.com or call 07816 230 213.