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I arrive well before 9am for work in a tiny cubbyhole in a general hospital, and then I start my battle with four different log-ins into my computer before I can go off and see the people I’m meant to see in various wards.
I am a senior registrar in psychotherapy and psychiatry, and my employing trust places psychiatry trainees in a general hospital setting as part of a placement in a teaching hospital. And so what follows is often the reality of my Monday morning.
There is invariably a password that doesn’t work, having asked me for a change the previous week the system hasn’t saved it for some reason. I then spend a few hours calling IT, staying on the phone, feeling homicidal while I’m told by a helpful tinny female voice (recorded, of course; in fact these days I get startled if I get a human response) that I need to fill in a form to prove my existence. A couple of hours later, during which the pressure builds because in my view, none of the ‘real’ work is being done, I manage to log in.
This is followed by three automated emails to say my problem has been resolved. Meanwhile, my inbox is clogged with requests for further forms to be filled, one to check vital past documentation, another to check risk assessments, and so on, so that I can stay on the virtual system that lets me do my job - listening to profoundly unhappy and vulnerable patients who need human contact. I think sometimes: what about me?
An email exchange with a community nurse in a local team ensues, about a patient I’m concerned about: a young woman with a 10-month-old baby, who lost her father recently and is struggling to cope. When she reaches her limit and begins to feel suicidal, she rushes out of the house into mindless activity, her baby in tow.
The assessing nurse directs me, with what feels uncomfortably like a sneer, to a form that will apparently tell me all I need to know: that the patient doesn’t fulfill criteria for follow up. The boxes in the forms have managed to quantify and qualify a human being; they have created an overarching tidy box to shut her into. The form says she occasionally has tea with friends. Translated as protective factors, that great overstatement, this means she has resources and support and is not mentally ill; she is coping.
Working in mental health services is a challenge these days. One gets an impression of working with a ‘virtual’ patient most of the time. I like to think of myself, like a lot of my colleagues, as someone who is still genuinely interested in people, even after endlessly morphing portfolio checklists have done their best over the years to snuff this spontaneity out.
I will concede that there is something to be said about electronic systems which make information transfer efficient and easier to communicate, but these days this really seems to have gone too far. In tandem with the disturbing turbulence in the NHS, our clinical work feels utterly contaminated by pop up forms, tick box exercises, surveys, bewildering portals into further systems which take one away ever further from the real concern: the patient.
When I read vitriolic political statements and manager-speak about the NHS and the shrugging away of good old fashioned gut instincts, I think that unless the health service somehow puts the real patient first, we will be forever inundated by fake declarations of concern about what is only, really, the ‘virtual’ patient.
Portia Gates is a specialty trainee in psychiatry. She writes under a pseudonym.
Very true in all aspects of medicine, not only psychiatry!!!
It all takes so much longer than it used to.
Yes true it's frustrating
Being doctor we aren't giving more time to computer and tick boxes, missing our patients needs
We Are giving more to computer
Please don't blame computerisation itself for this state of affairs: the problem lies with those who create on-screen forms which ask the wrong questions; or not enough of them; or don't ask for the right details; or deal with the responses in too simplistic a manner. This is why it is so important to have clinicians in the driving seat when these forms and protocols are created; and why it is also so important to refine the function of these forms and programs again and again, until they repeatedly and consistently produce a sensible, appropriate and clinically helpful output.
The problem isn't IT per se. It's IT that's designed for managers - and was probably designed in a country where billing for medical time etc. is vital.
Good IT that's designed first and foremost for clinicians is another thing altogether.
WORKING IN REMOTE AN ISOLATED SETTING:
I work in Shetland - there are challenges
Opening the local paper and reading either about a person being remanded in custody - sometimes active on my case load in substance misuse addiction services. We also read vitriolic political statements and manager-speak about our NHS Shetland and there is nowhere to hide. This will sometimes about how long a patient had to wait for an assessment by the CMHT - all emergencies are seen on the same or next day and all urgent referrals within on work week - our waiting times are 3 weeks for routine. If a patient are not happy with there treatment or diagnosis, the issue can become complex as they have gone to the local SMP and it was even discussed in Holyrood.
We work as a husband an wife team and we are 24/7 1 in 2 on cal.l
Although we live on an island off the main island, it feels as if every one knows you - patients serve you in various shops and say halo at the buss station or check what you have in your basket - When I have a luxury bottle of whisky - it is always for my dad.
But - I have daily contact with patients, and I can care. I feel like a doctor. Our it in Shetland is one log on to get to your desktop and our IT support is one phone-call away and glitches are mostly managed on the spot. I know all the physicians in the local hospital and they are very helpful. We don't have any inpatient beds and our place of safety is a bed in the general ward. They are willing to do inpatient detox and admissions for elderly that we need to rationalise medicine for. They are willing to admit patient for clozapine titration that just lives to far away and remote to do it all in the community. We meet monthly as SWIDDER - Shetland Wide Inter-disciplinary Doctors Educational Resource and go for a meal afterwards - that is unfortunately not the GP's on the most remote islands who VC in.
We need to guard against professional an personal isolation and it is more difficult to get CPD and PEER Groups organised.
I work with the anesthetists, midwives and A&E. Liaison is a large part of my work and I am also the local addiction psychiatrist - we do CHRT work as assertive outreach, link with specialist services in Aberdeen - overnight ferry or flight away for support for perinatal, complex addiction patients, eating disorders etc. We also have to admit to Aberdeen - Cornhill as we do not have an Inpatient ward.
We struggle to recruit because the Mental Health Services had been historically managed differently which resulted in shortcomings in delivering a true 21 century recovery orientated service. But things are slowly changing.
We need locums from time to time as we take one month a year leave together and we have electives for students - 5 year and unfilled F1 and F2 places - not everyone wants to face the remoteness - no Topshop no Starbucks no McDonalds no M&S no Waitrose etc and also no mobile phone reception at home - but fast internet connection.
Your article reminded me of all the advantages to life and work here - I often moan about the disadvantages but will celebrate our choice to come here. Especially after reading your good old moan
Entirely agree. There is a concept called "attention shift" when inadvertently the clinician is thinking of forms to fill including risk assessment and clusters and overlooks vital clues given by the patient. On balance, once electronic notes are added in, access to information is superior to what we had before, though it depends on the quality of information that has been inputed in the first instance.
Of greater significance I am concerned we are walking into something similar to the lead up to the 2008 Banking Crises which in retrospect seemed obvious. People making major decisions have become distanced from the frontline and depend on instruments like cluster grouping to understand patients and plan services. However these are blunt instruments and do not take into account that human beings are unpredictable, complex and inconsistent. At some stage this information trumps professionals opinions and advice.
...and to get the boxes ticked , the advice is "You have to say the actual buzz word/phrase if you really want to get help "
..... and so ,......
not only are the patients/job applicants/ social work requesters not saying what they mean/feel......... but the receiver is builds up a misinformed picture of what the issue is ...
....so by the time the "twa meet ", there are actually already 2 barriers to break down.
Checklists and tickboxes have done wonders for patient safety to prevent errors , they are amazing for doing quick snapshot audits of practice , but as the 5th comment above , it is fundamental that the right question is asked . I agree, too little time is spent on developing, humanising and testing the questions to make sure that they do in fact give the answers that help to effectively "triage" patients to the interventions right for them.
Every person has an entirely unique story which shapes them, and it serves some purposes to push all the different story shapes in to the same square /tickbox. I also remain to be convinced that all this proliferate reliance on IT is humane or indeed will prove to be the cost effective use of anyone's time in the long run.
Enjoyed reading this Portia, and all the comments - The Other Side
I could not agree with PORTIA more . I am fortunate enough to have been trained more than 4 decades ago when we actually saw and laid hands on real patients in ward rounds/ when trainees were actually told to go and" chat"with the patient and find out what was the real problem/which has not been elicited in the history. And by jove did we sometimes not make profound discoveries about unrelated issues that had brought the patient into hospital bed . How it helped the Consultant to make rapid diagnoses and management was simply awesome if not educational for all concerned.
It seems to me that the human contact with the patient is being increasingly sacrificed for tick boxes. We are now failing to get to the bottom of the problem and take a holistic view of the patient because of tick box exercises. Now the pressure is on to show figures i suppose this continues to compromise real patient contact ( listening to patient ) and satisfying their concerns.
The general public needs to be aware of this and modify their expectations of doctors in general.