Day 58 - First Community Patient (21/11/2017)

This should probably be marked as a landmark point in the diary, as today was our first visit to see a real-life patient. This was an opportunity to go to the patient's home, and chat with them about their conditions, how they managed them and how they got on day to day within their circumstances. I obviously can't be enormously specific because of the sensitive nature of the information but I feel like we covered an awful lot so I'll try to reflect here as much as possible while it's still fresh in my mind.

In the morning we headed to our community base in Southam and received our patient's clinical history, worked out some rough questions we wanted to ask (thankfully WMS did provide a list of the areas we would need to cover) and made our way to their residence. Everyone had made an effort to be extra-presentable - it's the first time I've been able to wear a tie since getting here, as the hospital dress code doesn't permit them and it would be a bit much elsewhere.

We made our way tentatively inside, and greeted the patient before sitting down. There were four of us together, with two asking the bulk of the questions and two taking notes (my role), although we found that these distinctions lessened over time as the conversation flowed more naturally.

While we started off talking about primarily medical issues, the focus became heavily oriented more towards the social care side of things rather than pathology - presumably the entire point of the exercise. We had an older patient for whom walking was difficult, so they were dependent on a mobility scooter to get out and about. They were very insistent that health was as much a state of mind as anything else, and seemed incredibly cheerful and optimistic.

I took the opportunity to ask what the patient thought constituted a good doctor or healthcare professional, as they had been managing multiple medical conditions for some time. What seemed to be most important, both in terms of doctors and other healthcare staff, was appearing to take an interest and 'having a smile on your face'. Routine seems to be vital - getting to know the same people and feeling that those people genuinely care for you was the main thing that kept cropping up, with the patient describing an excellent doctor that checked up on them out of hours 'just to be sure everything was going alright'.

Eventually the framework sort of fell apart and we just ended up talking about anything - the patient's childhood, their marriage, their family, their plans for Christmas. It was nice given how academic the course feels sometimes to just sit and talk to someone who couldn't ask us anything about anatomical structures. There were some interesting things that went along with that, such as them misunderstanding a couple of underlying causes for their illnesses, or not believing past smoking could be affecting them now. We also had to navigate the occasional remark about 'increasing numbers of foreigners' or 'needing to speak about four languages to walk down the high street'. I don't put these comments here flippantly, as were all clearly unsure how to deal with it. We didn't want to antagonise the patient at all because it wasn't relevant to do so, but equally we did not want to appear like we were endorsing attitudes we did not necessarily agree with. It was also clear the comments were not meant mean-spiritedly either, and I think it's very easy to forget that for older members of the public, they've seen enormous amounts of social and cultural change happen whereas we've been brought up in a (relatively) more diverse environment.

After that we made our way to a pharmacist to speak to the people who worked there, asking questions about how they integrate with other healthcare services and their general role. The main points that came out of this were the difficulties they faced trying to compete with chain stores and hitting the targets set for them by the government. In the former case, the price of drugs in pharmacies is regulated, with large and frequent fluctuations. This makes planning very difficult for independent retailers and reduces their profits, while larger stores are able to stockpile enormous quantities of drugs and are therefore less affected by the changes over time.

The idea of targets was also a bit unsettling - we haven't heard much about clinical targets in our medical education so far, but we know they exist for NHS trusts. The pharmacists are incentivised to carry out MUR (Medical Use Review) consultations, which aim to ensure patients understand why they are taking their medicines and how to take them effectively. A minimum number of MURs are to be completed by the pharmacy each year, with effective financial penalties if they are not met. From the staff point of view, it was difficult to fit in the requisite number of MURs, and often trying to meet their targets actively interfered with their ability to interact with their patients as they would wish to and ensure a better standard of care. This was particularly important for this independent store which was heavily used by the older community who preferred getting to know the staff and build up rapport.

After lunch we met with a relative of the patient we had seen in the morning to go over what we had learned and ask about how the patient's management influenced their lives by proxy. In this case very thankfully the relative did not feel unduly burdened and was able to look after the patient effectively, as they lived close by. I asked them their own view on what made a good medical practitioner, and they echoed the same feelings as before - actually feeling like they were being listened to and genuinely cared for made all the difference, as well as simply having respect for the patient. We were able to share some insights into our medical course and all reflected our experiences with the fast-paced history taking sessions. It seems to be the little things that are important, things like connecting with a patient on a personal level and taking time to do the ICE (Ideas, Concerns, Expectations) elements properly. These things sound incredibly obvious, even callous to not consider doing, but the time pressure of the consultations seems immense, even at this early stage. We will obviously become more confident at doing the various procedures, but in a currently declining NHS and increasing automation, how will that connection be affected over the coming years?

After our meetings we returned to the base to type up our notes, passing our colleagues who had unfortunately broken down. We were taking paper notes throughout the talks, which we then typed up and saved to our encrypted memory sticks, provided by the university. We then debriefed with our community supervisors about what we had learned, any concerns we might have, and then the paper notes were taken from us and shredded - the university has been highlighting the value of confidentiality, which while a bit of a technical pain is incredibly important as it would be so easy for information to accidentally slip out where it shouldn't. I made a point of mentioning that the notes would be shredded to the patient's relative, which they seemed to really appreciate being told. I immediately asked for them to pass that information on to the patient, and felt bad for not having let them know myself. It's certainly the sort of thing I would want to know.

There's been a lot to write in this post and I wish I could have said more, but for the sake of preserving confidentiality I can't. Safe to say it's been a very valuable insight into the life of a patient - 'person with an illness' would perhaps better indicate what I mean. Away from the hospitals and expensive machinery, those with chronic conditions have to manage them, at the expense of a lot of the activities and daily pursuits we all take for granted and they're still reliant on community-level healthcare staff for that. When we qualify (fingers crossed) we will take on part of that responsibility to 'not just treat people like numbers' in a system that increasingly demands that staff do.

And while it's easy to simply paint the government as the villain and blame increasing bureaucracy for that change, I don't think that's the intellectually honest thing to do either. I think of the United Kingdom NHS as nothing less than a modern miracle, a creaking and tired engine kept running by the goodwill of its staff that's still able to accomplish unbelievable things each and every day. The population is growing older, placing ever-increasing practical demand on the service as purse strings draw tighter, a problem exacerbated by our impending withdrawal from the European Union and the uncertainty that generates. The managers and the financial planners will undoubtedly have to make incredibly difficult decisions, knowing that it is likely their necks on the line when the next incident and subsequent wave of public outrage appears. I don't envy them at all. Something will give eventually, but whether it'll be the human touch, the budgets or both I have no idea at all.