The Doctor’s Surgery Theodore Dalrymple
I long for the days when I was always treated by the same person
George Orwell said we have now sunk to a depth at which restatement of the obvious is the first duty of intelligent men.
I’m not sure that there was ever a time when this was not so. If I’m right, Man is not so much a fallen creature as a sunken one. There is, moreover, not much hope of lifting him from the depths to the surface, let alone the heights.
Nevertheless, I was pleased recently to see a restatement of the obvious in the pages of the British Medical Journal, namely a plea for the restoration of continuity of care. The latter has been systematically destroyed, or at least undermined, in the last decade or two – usually in the name of efficiency, but actually with the aim (or perhaps, more modestly, the effect) of deprofessionalising medicine.
If I’m asked, ‘Who is your doctor?’, I cannot say. I can give the name of the building, but not of a doctor in it who more than any of the others concerns himself or herself with me. I should add that I live in a small market town, where I now know many people – but not my doctor.
It is not only in general practice that continuity of care has largely disappeared. In hospital, patients are treated much as the parcel in a game of pass the parcel. Within a few days – sometimes only hours – they may come under the care of several ‘teams’. No one is in overall charge of a patient’s care, or at least no one for very long.
My late mother was in hospital for five weeks before she died and was seen by her consultant twice. Otherwise, she was attended to by a variable cast of doctors whose entrances and exits from responsibility for her care were numerous and fleeting.
Patients like continuity of care and there is evidence that it leads to better results. A doctor who knows his or her patients other than as ships passing in the night has a lot of implicit knowledge about them that cannot be conveyed in notes, least of all in computer notes. That doctor knows something of each patient’s character and temperament, whether the patient is stoical or one who complains all the time, and so forth. Much repetition of effort could be avoided if doctors had implicit as well as explicit knowledge.
There are drawbacks to continuity of care, of course, as there are to almost everything. Sometimes, a fresh view of a patient may uncover something a doctor who knows the patient too well misses because the doctor sees only what he or she expects to see. But the disadvantages of continuity of care are far outweighed by the advantages.
One might have thought that, of all medical specialities, psychiatry was the one that most carefully preserved continuity of care, but not a bit of it. I was once asked to look into the death by suicide of a psychiatric patient who, in the two weeks before his death, saw 11 different members of the staff; only one of them twice.
The sheer inhumanity of this, to say nothing of its stupidity and wastefulness, did not strike the managers who asked me to prepare the report. They could not imagine how horrible it would be to have to recount one’s agony of mind to ten different strangers.
Of course, lessons were learned (they always are, after reports): namely that more money was needed to provide a better service. How else could they pay for the meetings that were necessary to correct things?