“And So It Begins…” – Why We Need To Talk About Medical Paternalism

Without being a “difficult patient”, I believe that I would have had to go 50+ hours without food whilst waiting for surgery, rather than the 30 hours I did wait.  Was it really a reasonable expectation that a patient fit around the inability of the hospital to forecast and plan surgical demand in that way?  Did anybody notice or care about the way in which my enforced fasting might impact my outcomes as a patient?

 

Almost two years ago, on the first day of our family Christmas holiday, I woke up in the middle of the night with kidney stones.  It was by far the most painful thing that I’ve ever experienced.  I don’t recommend it.

Since we were three hours south of Sydney, in a semi-rural area, it took a while to get help.  Eventually I was taken by Ambulance to the emergency department at a small local hospital, given a CT scan, and then transferred to a larger hospital in Canberra (two hours away via patient transport) for surgery.  With my encouragement, my family stayed at our holiday apartment, and I promised to rejoin them in a day or two.  Or so I hoped…

My stay in Canberra hospital was characterised by two incredibly frustrating events.  Both speak to the issue of medical paternalism, and the need to redesign our health systems around patients, not just the convenience of doctors.

The first incident happened like this…  I was transferred to the hospital in Canberra for surgery to insert a stent between the kidney and bladder, allowing urine to bypass the 6mm stone that was blocking my ureter and causing incredible pain.  I left the rural hospital after lunch (a sandwich) and was told not to eat, as I might have surgery the next day.  Upon arrival in Canberra, staff were non-committal regarding when my surgery might take place, but told me not to eat.  Fair enough.

By that evening, it was clear that the surgery wouldn’t happen until the next day.  Understandable, and I was okay with that.  I awoke the next morning, hungry, and continued my wait.  Again, no eating.  Just waiting.  And waiting…

By around 9pm it was again clear that I wasn’t going to have surgery that day either.  It was very frustrating.  I hadn’t eaten for over 30 hours.  I was again told I couldn’t eat because I might have surgery the next morning.  Only because I put my foot down and insisted did I manage to get somebody to find me a sandwich.  Without being a “difficult patient”, I believe that I would have had to go 50+ hours without food whilst waiting for surgery, rather than the 30 hours I did wait.  Was it really a reasonable expectation that a patient fit around the inability of the hospital to forecast and plan surgical demand in that way?  Did anybody notice or care about the way in which my enforced fasting might impact my outcomes as a patient?

The second incident related to medications.  Prior to the sudden discovery of kidney stones, I’d been suffering with a serious chest infection for which I’d been taking antibiotics.  When I arrived in hospital in Canberra I’d asked about whether I should continue taking this medication, as I was only half way through the course, and was still struggling with symptoms of the chest infection.  I received conflicting advice from nurses and junior doctors about what I should do, so decided that I’d ask the consultant when he eventually came by.

On the day before my surgery I finally saw the consultant for the first time.  He arrived with a posse of junior doctors.  He spoke a few words to me and proceeded to mostly speak to his juniors about me, right in front of me.  When he had finished, and was clearly about to leave, I interrupted and asked him if I could ask a medication-related question.  He clearly didn’t want me to, but I did anyway.

“I’ve been suffering with a chest infection and am taking antibiotics.  Should I keep taking them?  I’ve had conflicting advice…”.

“Yes”, he said.  “Keep taking them”.

And that was it.  He left.  But as he moved out of sight, but not out of earshot, he turned to his junior doctors and said loudly, “and so it begins…“.  These pesky patients, slowing me down with their unimportant questions was his implication.

I was stunned, as I’ve been stunned ever since.  If I’d reacted quicker I might have shouted out, “excuse me, what did you just say?”.  I don’t think I’ve ever experienced anything quite so rude.

 

Friends, these stories should serve as reminders that paternalism remains culturally entrenched in healthcare.  Structurally protected self-interest stands in the way of progress and innovation.  Until we address the culture of paternalism and the way in which medical processes are designed around the needs of the provider, we’re not going to see the changes that we need in our health systems.

 

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