Time to do things differently

<em>Nostalgia is denial, denial of the painful present… the name for this denial is ‘golden-age thinking’: the erroneous notion that a different time period is better than the one one’s living in. It’s a flaw in the romantic imagination of those people who find it difficult to cope with the present.</em>”

Woody Allen, <em>Midnight in Paris</em>, 2011.

When we were interns, some bright spark decided to give us pedometers to track how many kilometres we walked a day. This exercise soon turned into the usual ‘Strong Type A’ pissing contest so beloved of medics (male and female) as to who was slogging more. It turned out on average, we were walking 10-12km per day. Quite how I managed to do this and still gain weight gives you some insight into my lifestyle at the time. Regardless, working off a patient list of 25-30 patients, most doctors in an Irish hospital would be tracking between nine or so wards, possibly scattered around three or four buildings.

I always felt if you brought in anyone who’d ever run a business since the dawn of the Industrial Revolution in 17th Century Manchester, they would be aghast at the utter weapons-grade stupidity that this practice represents.

The benefits of cohorting patients within specialty wards are so self-evident that it almost feels unnecessary to list them. The benefits to patients of having both nurses and doctors well-versed in their disease area proximate to their bedside are obvious. For NCHDs, it would cut down on hours worked and frustrating slog. We all remember having four cannulas to do on patients in four different wards. Walking over, getting the code for the door, finding the stuff, finding the patient. Basically 10 minutes’ work crammed into an hour. For nurses, there’s the benefit of dealing with one or two teams on a ward as opposed to 10 or 11. For consultants, the knowledge that your patients are being looked after by experienced nurses with the proper skill-set is invaluable. So is the ability for the time-poor to be able to pop onto a ward where the vast majority of your patients are boarded to enable you to head off what begin as little problems at the pass. Five minutes of fire-fighting rather than a year of complaint-related anguish.

There’s more than that again. When it’s ‘your ward’, as a team of doctors, you take more ownership and leadership over ward metrics like hand-washing audits, falls and infection rates. Stuff that as a team with patients on nine or 10 wards flies over our heads like a flock of seagulls. Communication gets better through familiarity. A true team ethos develops as professional barriers are broken down.

So why on earth don’t we do it? Why do we persist with this model of the all-comers ‘medical ward’, which houses anything from heart attacks to strokes, to abdominal drains and traumatic brain injury? Why aren’t we making more noise about it? Given the fact that it would likely lead to better outcomes as well as reducing junior doctors’ overtime, lengths of stay and rates of infection, it would be an easy sell to those in power. In fact, it should be a no-brainer. Our surgical brethren cottoned onto it years ago.

To my mind, there are two road-blocks. One is the axiom that even in the 21st Century that lip service be paid at the altar of medical specialists, being in the first instance general physicians, in spite of the fact that for 20 years or more nobody has been coming back from overseas jobs where they worked like that. The second is a somewhat chauvinistic belittlement of the specialist skills of inpatient nurses. The outpatient specialist nurse in Ireland is frequently and correctly held up as a model of enlightened and efficient practice and often allowed to define their own role. His or her inpatient colleague, though, is at times regarded as little more than a slot on a rota or a bum on a seat, in spite of the fact that they are caring for many of the sickest people in society, especially in a system such as ours,which is so woefully understocked with intensive care beds. In a six-bay ward (inpatient or emergency department) they could be looking after drains, some acutely delirious patients, some people on telemetry, and expected to sort out the myriad social issues that delay discharge for others. We can’t give people lousy jobs and then berate them for doing it.

Maybe it is time to give them a break, a chance to develop their skills and practices. Maybe that might even be more important than the nostalgia of trying to preserve some of our own more outdated ones.