The practice of medicine in the ward differs in a number of ways from outpatient medicine. The first difference is the tempo. Outpatient medicine is more difficult and challenging because you have to make quick decisions, on less evidence, and without the assistance of the junior medical and nursing staff; on the other hand, as so many patients are normal, many are not seriously ill, and others although ill can be easily treated, the average amount of time spent on each patient is shorter. That is not to say that reassurance of a healthy but worried person is less valuable or difficult or time consuming than the treatment of pneumonia, but in general the pace is faster. Ward patients are talked to and examined at greater length, and they are subjected to investigations which require explanation, evaluation and consultation.
Although ex-servicemen, public schoolboys and ex-prisoners will have experienced communal living, most people find that admission to a ward takes a good deal of getting used to. Even if you have never sat on a bed pan, screened visually but not acoustically from an interested audience of twenty or thirty people, you can readily imagine that the experience might be costive.
In outpatients the patient is, as already described, not his usual self. Once admitted, he becomes even less so. In outpatients he knows that no major procedure will be carried out on the spot. Furthermore, he knows that the ordeal is to be short-lived, and that after an hour or two he will be back in the “real” world again, where he feels at home, and has a busy life to lead. In the ward, in sharp contrast, his time commitment is open-ended and the job, appointments, hobbies, duties and family ties which established his place in the world are abruptly suspended. He has nothing to do, and all his badges of office in society are removed. This is one reason why visiting time is so important for patients; visits from friends and relations serve to re-establish the patient’s identity, and undo the harm done to his ego by admission to the ward. The fact that he has had to be admitted augments his outpatient fears of the disease, and for his future. The admission itself may have given rise to anxieties about his work or his home circumstances. If the patient is unintelligent or unreasonable the burden of disease may be even more upsetting for him.
Ward staff, from Sister down to the merest crossing sweeper, all reinforce the patient’s “anomie” if they are anything less than exceptionally considerate. Ordinary consideration is not enough, because the patient in the ward often behaves in a manner which is quite unlike his own, and which is frequently hypersensitive and silly. Sensible people become obsessed with the idea that Sister prefers the patient in the next bed, or that the ward maid is giving them smaller portions of food, or that the doctors are giving more attention to the man opposite. Very often the man opposite gets more attention because his condition demands it, but this does not prevent the patient who is steadily getting better with minimal attention, from being jealous.
Ward staff, including students, have to take care not to reinforce any irrational feelings that the patient may have. The doctor’s manner should be as considerate as it would be when talking to someone who had been terrified by some awful event, or overwhelmed by bereavement.
If you recognise that admission to hospital makes people behave abnormally, you will be able to take up a professional attitude to their behaviour. An inexplicable outburst of rage or of crying can be looked upon as a “toxic” manifestation of the disease, rather than as bloody-mindedness. If you cannot suffer fools gladly, you should take up laboratory work. The proper doctor maintains his equanimity at all times. A patient once told Geoffrey Evans that he wasn’t getting anything to eat. Instead of telling him not to be a damned fool, Evans rounded on Sister and said “Are you starving this man?” The patient, recognising a just man when he saw one, was won over and agreed to accept the food which he had been refusing. Variations on this sort of response are constantly required from a proper doctor, and from a proper Sister too.
Over and above the necessity for admitting patients, there are advantages which come from the same sources as the harmful effects. Most patients adapt to being admitted, and when the stress of outside life is removed they may come to terms with their disease and its implications for the first time. After “institutionalisation” has occurred they are prepared to accept advice which they would not have taken in outpatients.
The ward patient has all the time in the world to talk, and the doctor should adjust his speed to that, wherever possible. A brisk ward round with a huge retinue, dashing from bed to bed, may be all that is required for the patient’s physical welfare, but it does not treat the whole patient. A round on your own, or with the houseman, or a nurse, taken at an unhurried pace is therapeutic in itself.
Ward Sisters used to frown when a doctor sat on a patient’s bed because it rumpled the sheets, but it has now become acceptable to do so. It makes the patient feel that you are not going to rush off and it gives him an opportunity to ask a question to which he had previously assumed you were too busy to answer. This concept of the busy doctor is firmly embedded in patients’ minds and you have to disabuse them of it; answering questions is an integral part of proper doctoring. If you feel that the patient has a question which he does not raise even when the two of you are alone, you can often answer it unasked. Many of the questions which trouble people with particular diseases are foreseeable, and you learn others with experience.
When talking to a patient who is in bed, stand near the head of the bed. Do not stand at the foot of the bed and shout. You should lower your voice—other patients will be listening in, and the patient has the right to privacy. The feeling of privacy is enhanced if you close the curtains round the bed.
Although patients spend a good deal of time telling each other what the doctor said and discussing and comparing their situations, in the first instance this information is confidential, and the patient must have the right to filter out those parts of it which he feels are unsuitable for broadcasting. The doctor can have no idea which parts will be considered unsuitable, and must treat it all as though it is to go no further. A small side-room off the ward, where conversations with patients and their relatives can be held in private, is a boon. Patients may ask you about a fellow patient if they are worried about him. Without giving offence, you must give non-committal or non-revealing answers.
During ward rounds it is often necessary to ask Sister or one of the doctors about some technical aspect of the patient’s disease; but questions about the patient’s symptoms should be directed to the patient. If you say “Is he walking better, Sister?,” it makes it clear that in your view the patient is not sufficiently reliable to be able to give an opinion. Of course many patients are not reliable, but you ask them directly because it is insulting if you don’t. If Sister disagrees with the patient’s estimate of his progress she can either say so at the time, and then all three of you can discuss the matter, or if she thinks that would be unhelpful, she can tell you her opinion later.
The patient lies there, a yard or so below one’s line of vision, and there may be a tendency to forget about him. It is perfectly legitimate to discuss aspects of his disease in his presence, and many patients like it because it gives them an opportunity to learn about their disease. But though he is out of sight, he must not be out of mind, and everything which is said in his presence must be censored. I once heard a consultant on a ward round ask his registrar “What’s his survival time?”; the reply came back “Ten days.” The patient needed a good deal of convincing that they were referring to the fate of some labelled red cells. If there is any chance that the patient may be alarmed, the remark should not be made. If it is made, the doctor should make it clear that the remark did not apply in his particular case. If said convincingly this may be accepted, but it is better not to make such remarks. The ward round is essentially a series of consultations with individual patients, and all other personnel are in subsidiary roles. The patient holds the centre of the stage, and although he understands that you have to discuss him with other people he is the star of the show.
A medical student may make friends with a patient, and spend a lot of time talking to him. Patients are often fishing for information about their disease and students should remember that they are not in charge of the patient, nor are they knowledgeable enough either of disease or of human nature, to tell the patients anything. At the slightest sign that the conversation has moved into personal medical channels, the student should say that he doesn’t really know enough about the situation to talk about it, and that anything he said might be wrong and misleading. The student loses face, but that is infinitely preferable to damaging the patient. Students are not qualified to give advice until they are registered, and even then they have to make sure that what they say is in line with the intentions of whoever has overall responsibility for the patient. This applies not only to students but to all who come into contact with the patient.
One characteristic of a good clinician is his ability to make the “right” decision in evenly balanced situations. Whilst he may reasonably take pride in this accomplishment, the patient derives comfort from the concept that in his case, the decision is cut and dried. A surgeon I worked for was wont to discuss the site of the incision at the bedside. When he and his aides had marked the alternatives with the nail of their index finger, the triple responses on the patient’s abdomen looked like a plan for a complicated motorway junction. The patient’s face revealed his alarm. Even a discussion about whether a patient is fit enough for convalescence raises a question of premature discharge in the patient’s mind. The patient wants to hear that he is now ready for convalescence or that he will be ready by a certain date, or that it is too early to say when he will be ready. Whenever it is, he wants to leave the hospital confident that the time is exactly ripe.
Discussion about management should take place outside the ward, where doubts about the wisdom of a course of action can be debated in full. Some clinicians walk out of earshot and discuss the patient, but they may be within the range of another patient who may well retail a garbled version of what was said. Although the patient is out of earshot, he may be able to see the facial expressions and gestures of his medical advisers, and will draw his own conclusions. A kindly physician I worked for would say to the patient “We are now going to the other end of the ward to discuss your case,” which I felt provoked anxiety. If the decision is difficult, and further discussion is required which might upset the patient, an acceptable strategy is to tell the patient that you are thinking about his problem and will come to a decision later. Patients are pleased to think that their fate is decided by weighing up. It is tossing up which alarms them.
Generally, ward rounds are conducted with the personnel who are directly involved in the treatment of the patient, and these small rounds are the most satisfactory from all points of view. Sometimes for teaching purposes, or for the demonstration of unusual or interesting or difficult problems, a large crowd descends upon the ward. Patients should be told that a large round is about to visit, and all patients who are to be examined or taught on should be forewarned, and their permission and cooperation obtained. The number of people who examine the patient should be restricted to that number which the patient seems happy to allow. Examinations should cease well before he shows overt signs of satiety.
In the excitement of discussion on a large round, there is a tendency to forget that the patient is present. Nothing which is said should be antitherapeutic. Bored participants on the fringes of these large rounds should behave in a professional manner. Although you may be out of sight of your chief or of the patient, other patients will be observing your behaviour pattern.
As a registrar I had a useful lesson from a ward Sister. One of our patients was dying and I found the strain of daily visits with, as I thought, nothing to offer, discomfiting, embarrassing and emotionally upsetting because the patient was a nice woman whose illness had been long drawn out and unpleasant. As I approached the bed, I seized on the fact that her eyes were closed to tell Sister that I would not disturb her as she was “resting.” “Oh yes you will, doctor” said Sister, and she told me that it was essential to maintain interest, that the visit itself was therapeutic, and that there was almost always some aspect of the patient’s condition which would justify an encouraging remark. If not, juggling with the drugs would convince the patient that she was not being abandoned as hopeless. When you cannot cure, you are still bound to do whatever you can.
Many patients who are admitted to the wards will have been on long-term medication. A common sequel of admittance is that all the medicines which the patient brings with him are stopped and new ones substituted. If the patient has been admitted because his long-term medication was unsatisfactory, this may be the correct thing to do, but frequently the patient is admitted for some other reason, or the dosage of medicaments simply needs adjusting, in which case a changeover to new drugs may be disadvantageous to the patient because it takes time to get the dosage right, and new drugs mean new side effects. Frequently the drugs will be stopped by a newly qualified houseman, and he may be undoing months of work by someone who is more experienced. The merit of each drug should be assessed on the basis of its effectiveness in that particular patient, and on its suitability in the circumstance of this particular admission to the ward. If the admitting doctor is unfamiliar with the drug, he should look it up before he stops it. If he is unfamiliar with it and the dosage needs adjusting, he may prefer to change to another drug which he has experience of using. There is no doubt that you get better results with drugs if you have experience of handling them. But this improvement is “bought” at the expense to the patient of a period of experimentation. The patient’s faith in the doctor who prescribed the drugs is impaired if they are all stopped, and they should only be stopped when they are clearly inferior to some newer drug. I have heard housemen explaining at the bedside that the patient’s previous medication was hopelessly inadequate, and such statements, whether correct or not, are antitherapeutic.
Discharge is a crucial event for the patient. Each patient should be privately interviewed by the registrar who has supervised the admission. The patient should be given a summary of his situation and the opportunity grasped to ensure that he understands what he has been told on previous occasions. Clear instructions about management of his illness should be given, and the patient must be allowed enough time to ask questions or to register any complaints. An appointment should be arranged for a follow-up visit to outpatients, unless this is unnecessary.
If the patient is to continue to take drugs after discharge from hospital, he should be given an adequate supply to tide him over until his general practitioner can see him; if the dosage is likely to need adjustment in the altered circumstances of life outside hospital, he should be told of the possibility, forewarned about the symptoms and signs of inappropriate dosage, and told what action he should take.
The general practitioner depends on the hospital for an adequate account of the patient’s stay in hospital. The findings, the decisions which were made, the therapy administered, and when necessary to be continued, should be described in enough detail to enable the practitioner to take up the reins again smoothly.
Discharge summaries frequently arrive too late, and every effort should be made to get them out in time for the practitioner to read them before he sees the patient again. When this is not possible, the patient should be given a note with the basic information which the practitioner needs, especially the dosage of drugs. The patient should feel that the hospital and the practitioner are both part of one integrated service.
Another example of the “insanity” of inpatients, which will not seem quite so insane if you have been an inpatient yourself, is their preoccupation with getting out of the hospital regardless of whether or not this will damage their health. Doctor patients, who often, but not invariably, realise the consequences of such premature discharge, may behave in the same way. The boredom, the noise, the discipline, the food, the lack of privacy, and the depression which results from being surrounded by other sick people, combine with the effects of disease and its treatment to make people ignore their instinct for self-preservation in their desire to escape. On a ward round a student told William Evans that the patient they were examining wished to take his own discharge. “Why do you think he wants to do that?” asked Evans. “I’ve no idea sir,” the student replied, “we have hardly begun his treatment.” Evans turned to the registrar and said “Make certain that this student is warded before he qualifies.”
Patients who discharge themselves rarely come to any harm, and doctors who advise against it tend to err on the “safe” side, as of course they should. When faced with a patient who has summoned up the courage to take his own discharge, against everyone’s advice, having signed all those forms, remember that he has had a great deal to put up with, and that he may not have the self-discipline to continue. He may also have motives for discharge which he is unwilling to reveal. Remember too, that you may behave in exactly the same way in similar circumstances. Your natural exasperation at the thought that all the good work may be undone, to say nothing of the annoyance at having your advice rejected “after all you have done,” should be concealed. You are paid to treat the whole patient, and it is he who has to suffer the treatment. Practising medicine is its own reward, and the patients owe neither compliance nor gratitude. It is your duty to make it perfectly clear to the patient if you feel that he should remain in hospital. Your manner must be neither hectoring nor disapproving nor threatening. It should be doctorly; if complications develop because the patient leaves prematurely, you are prepared to treat them. The patient has not “blotted his copy book,” and no offence has been taken.
When the patient is in the ward there may be no necessity to make notes of changes in his condition or of the treatment policy, because these matters are very much in people’s minds, and the staff may be too busy to write them down. When, at a later date, an attempt is made to ascertain the course of events during the admission, the notes usually prove inadequate. Students and junior doctors can do much to remedy this situation by making a précis of the important events and policy changes.