“Should I tell my child that it is born out from egg donation?” asked a patient to a nurse I a Southern England fertility clinic. Other patients seek not ethical but directly medical advice from nurses. It is normal that patients ask nurses and assistants, but it is not normal that they address medical questions.
In some cases it is not always possible to have direct conversations with patients for a better patient experience or patient involvement. For instance, when the clinical situation is linked to stigma and patients are reluctant to be contacted or when physicians are not yet aware of patient centricity or not trained in non-clinical feedback conversations.
This was the case in the Southern England clinic, where for several reasons it was not possible to have access to patients. Instead we decided to work with those professionals with a closer relationship with patients. Physicians? As we will see, physicians can be socially and emotionally distant from patients. The closest professionals are nurses and assistants followed also embryologists in some cases.
Interviews are a good tool, but they often are used as a sort of dustbin, where organizational problems and frustrations are thrown. In other cases, interviewees tend to use interviews to represent their value and credit. To avoid this bias, a short participant observation of a couple of hours, allows the professionals to speak out their frustration or represent their value, but then, once it is out, they will guide you through their work, you will witness real situations instead of descriptions, and see how real healthcare works in real situations people have not chosen.
Patients don’t always trust doctors
Working that way with nurses and assistants, we recorded that:
- Patients do not express all their doubts to doctors: they pretend to agree with them
- Social distance to doctors is high
- Patients then discuss their doubts with assistants, socially inferior to doctors and to most patients, but somehow close
- Assistants and nurses function thus as counsellors and patients debate with them ethical issues and even treatment options
- Assistants and nurses have a far higher medical knowledge than they are supposed to have
- Doctors do not have control over their agendas and their day: they ask constantly nurses
- Physicians frequently have not read the full patient story: they call nurses to remind them on issues: healthcare
- Patient conversations with nurses and assistants contain a lot of patient insights that are not commercially used
- Workflows are sometimes designed for physicians, not for patients convenience
These observations match with those of James Rickert in the Health Affairs Blog, of Bauman, Fardy and Harris in the Medical Journal of Australia and those of the Spanish sociologists Verd and Massó in Barcelona clinics.
Bauman et all show that social distance between patients and physicians is high, as well as the pressure to treat as many patients per hour in order to have low waiting times: as a result conversations do not include patient feedback and there is lack of follow up. Yet evidence described by the author’s shows, that trained doctors in patient-centred care are more likely to achieve better outcomes in diabetes.
Also in orthopaedic surgery patient-centred care seems to produce better results, as Rickert writes: more feedback and empowerment lead to less external test, less technology and fewer hospitalizations. Rickert explains some of the reasons for doctor-patient distance and for patient inconvenient workflows: doctor payment is related to patient volume, not to care quality; in the private sector reward comes also from the amount of patients attracted.
All the emotional and closeness work failed to be given by doctors is finally done by assistants and nurses. This is why Verd and Massó observe how administrative staff solves patients problems (dates and appointments) and expectations in many situations not contained in any protocol, being close to patient and giving them solutions; they also describe, like the British clinic of the example, how patients take a higher administrative burden because of workflows designed for physician’s convenience.
The work not done by doctors is done by nurses
It comes out, that patients address to nurses and assistants to solve ethical and medical questions, simply because doctors are not trained to enter into meaningful conversations and take a patient perspective beyond the actual biomedical problem to solve. In a certain sense, nurses and assistants fill in a vacuum in physician’s competencies.
It is good if nurses and assistants are closer to patients than doctors; caring is different from healing, though closely related, of course. But a true patient centric healthcare organisation should skill physicians for patient-centred care in order to fulfil its mission, accelerate and improve results and, also very important reduce test, technology and hospitalization costs.