I spent a couple of nights in the medical assessment unit of my local hospital last year. I would not recommend the experience and the arguments about how hard it is to recover health in a typical hospital ward have been rehearsed before. The poor quality food, the problem of getting enough sleep, the lack of fresh air or natural light all make for a fairly unhealthy environment.
I was grateful to be getting access to medical specialists and some pretty sophisticated medical tests but what struck me about the experience was that even though the healthcare professionals around me were conscientious, efficient and very kind, patients still suffered a distressing amount of uncertainty and confusion about the care they were receiving. Some of this was inevitable: My condition was hard to diagnose. But much of it resulted from poor communication.
After being pronounced fit to go home but whilst waiting around for letters and tablets I noticed that the woman in the next bed was crying. When I went to ask what the matter was I discovered that she could not get hold of the neighbours who had taken her into hospital the day before and she was frightened that she would be forced to spend another night in hospital if no one could pick her up to take her home again. When I went to the nurses station to enquire I discovered that in fact her situation was well understood. Hospital transport had been arranged to take her home and because she had suffered a fall a home carer would be waiting for her to make sure she was OK and help her to bed. It had also been arranged that a social worker would visit her at home the following day to reassess her care needs. In other words everything had been taken care of. But no one had told the patient and she had spent much of the day feeling frightened and confused about what was going to happen to her.
Whilst the concept has been recognised for millenia medicine has only begun to appreciate the scale of harm caused inadvertently by the process of treatment in the last few decades. This is known as iatrogenesis. Culturally we have become familiar with the idea that medicines carry side effects and that these have to be weighed against projected benefits before deciding whether treatment is worthwhile. We are increasingly aware of the iatrogenic harm that can result from screening programmes, unnecessary medical examinations or poor quality medical consultations. But it struck me that there is a huge level of iatrogenic harm inflicted upon patients simply through being in hospital and we have not begun to measure or assess the impact this has.
The woman I met was in her mid-80s, widowed, without children and living alone. She had fallen at home which had two sets of effects. Firstly she was bruised and shaken and needed reassurance that she had not suffered any lasting injuries and that the fall had not been caused by anything serious such as a stroke. Secondly the fall had had psychological effects. It had taken a long time for help to arrive and reminded her that she was socially isolated. She talked to me about how much she missed her husband, how much she wished she had been able to have children, how frightening she found living alone and how much she now relied upon neighbours for help. Her hospital stay had effectively addressed the first set of problems. She had not broken anything and nothing sinister had been found when they ran tests. But the second set of problems had been completely ignored. I very much hope that after her discharge her social worker or GP will have recognised these issues and how to help her recover her confidence and get more out of life. But the 24 hours she spent in hospital only exacerbated this distress.
The difficulties of ensuring effective communication within large organisations are hugely underestimated. I don’t think there is a simple solution to the situation this patient found herself in and I am quite certain that whoever should have talked to her but failed to do so did so because they were busy helping someone else. But systems which attempt to identify and address iatrogenesis currently pay insufficient attention to this issue.