The Microstructure of Relationships

Friday, September 29th, 2006

I went to my local hospital, the Homerton in Hackney, for a consultation about my heart. (Essentially, it’s OK but when I had my appendix removed in Iceland two years ago, the exam found a regurgitating valve.) The reason for this morning’s visit was to determine if my echocardiogram suggested further tests.

Being a sociologist interested in law, I’m always looking to see how norms and rules are applied in everyday situations. What better than a large hospital. In addition to healing people, hospitals also manage expectations: how serious is the condition? how long will you live? can I lead a normal life? These and other questions are posed and the entire range of interactions that take place within the hospital then feed into the results that emerge from the experience.

Although these are “big” questions, it is the small encounters that help make the answers meaningful. My first encounter was with a receptionist. She was direct, positive and showed me where to wait. After 10 or 15 minutes, she became concerned that I hadn’t been seen whereas a number of patients who came after me had been called. I asked if the particular doctor I was supposed to see was in the hospital: he had done the original tests and I wanted him to make the comparisons between now and then.

Now things became a little vague. No one knew the answer. The receptionist asked a nurse to find out. The nurse left and never returned. I’m mulling over the possibility of leaving, but then I’m called.

The doctor I see is not the one I expected. Immediately, my expectations are lowered. Where is “my doctor” (I already possess him)? why am I seeing another having specifically requested “mine” (I have a moral claim over my doctor but none over others)? The doctor relieves the situation by tellling me that he’s taking the clinic but he has spoken to my doctor. Stability begins to return and this doctor is gradually being co-opted as a joint “my doctor”.

He is good at explaining things to me. I ask questions and he answers fully. I have the records of the tests, then and now, with me and I ask about differences. He draws diagrams of my heart and shows me how different testers get different results, which is then left to him to interpret within certain confidence intervals. These seem to vary between 5% and 10% and I wish I hadn’t done statistics as a graduate student, but there… He lets me probe environmental and hereditary possibilities. Yes, I should keep exercising, yes, my diet is along the right lines. In all, doubt is diminished, though never eradicated. His main purpose is to tell me that I should have some further tests.

While he is doing well, the rest of the hospital behaves strangely. I am sitting with him in a private room and there is a knock. The doctor says, “come in”, and an orderly enters and tells him that he must change rooms, that he has to sign forms. They talk for several minutes while I watch. He leaves and the doctor tries to recollect where we are in our talks. While I felt the doctor was aware of the difficulties of the situation, the orderly was carrying out his tasks without care. Was he disturbing a potential deathbed scene? He wouldn’t know.

After another 5 minutes the same orderly returned, again with more forms. I wanted to invite him to stay so that he could get to know me better. His visits were too tranistory and brief.

These interventions were clearly contrary to the spirit of the doctor-patient relationship. A clash between the hospital’s need to accomplish administrative and clinical tasks fell in favour of the former. How much better it would have been to leave the doctor and patient in privacy until finished. There was nothing urgent in the tasks assigned to the orderly. Small details in the experience that can depersonalize the relationship between patient and doctor.

As the consultation ended, the doctor restated something about high blood pressure being a cause. I know my blood pressure is low. He asked to wear a monitor for 24 hours to get a better idea. He thought the cardiology unit could fit one then and there.

I go back to reception to make an appointment for next year. The receptionist, a different one, asks me if 10 September 2007 is OK for me. Her consideration gives me pause. What will I be doing this time next year? At least, if the police ever ask me, I shall be able to say.

My next foray is to the cardiology unit. I am clutching my piece of paper which has both the appointment for next year and a request for me to be fitted with a 24 hour blood pressure monitor. I’ve been here before for my echocardiogram. This unit is perpetually full of patients. Hearts are good for business obviously. In one corner a TV is locked inside a secure box and plays the daily soaps interminably and loudly.

There are three receptionists. One is actively engaged with a patient; another is reading something; and the third is wandering around appearing to ignore what is happening in the unit. Eventually, I say hello to her and she has to respond. She takes my paper, glances at it and says, “You come back next year”. She’s read the wrong instruction. I point out the blood pressure monitor request, which doesn’t seem to interest her. She instead interrupts the busy receptionist to ask her about the details. This receptionist is now handling two patients simultaneously and unable to give either her full attention. Confusion reigns.

I take the paper from the clueless one and say, “Let’s deal with this when she has finished with her patient.” My helper drifts away to adjust the TV. A little later I’m in a booth about to be fitted with an EKG machine. I’m slightly puzzled since the paper had said blood pressure. I didn’t push the issue as the woman who is fitting the EKG is in a tense discussion with a man who is about to be her locum. It’s clear that they have totally different perspectives on how the machine should be fitted. She tells him to do it: he starts and she tut-tuts and tells him to stop. She refits the machine and is very brusque with him. Her locum shows remarkable patience and doesn’t lose his temper. At no point has she said, “please” or “thank you” to him.

Once again, I in the midst of someone else’s turmoil wondering what the consequences of this could be. The behaviour of this unit is not designed to pacify and reassure patients. It’s better suited to raising their blood pressure. Perhaps they are engaged in demand creation rather than preventing demand.

I wear the EKG for 24 hours. It is slightly awkward to sleep with, but I cope. Next day returning to the cardiac unit, while I’m waiting for the EKG’s removal, another receptionist asks me to wait as they have to fit a second unit. More puzzlement.

The EKG is taken away and a blood pressure monitor brought in. I’m made to wait a long time, almost half an hour, before it’s actually fitted. It’s a different woman this time. She says little until I say, “This is the machine that should have been fitted yesterday.” Her look says it all and she nods. There is no explicit acknowledgement of error. The process is one of elision where one stage flows seamlessly into the other. I don’t add to her discomfiture.

The blood pressure monitor is bloody awful. Every 20 minutes the thing pumps and squeezes my arm hard so that my veins are popping out and my skin turns purple. It also makes a noise every time it sets off. This is uncomfortable. Every time it goes off I feel like the Michelin man as my left arm raises of its own volition. I have no control over this thing. Yes, I could take it off but that would defeat its purpose. Neither my wife nor I sleep m
uch that night as the infernal machine pumps and grinds my arm. I can’t wait for the 24 hours to close.

Back at the hospital, it’s removed and I ask for the results. No, that’s impossible; only the doctor can give me those and I don’t know when I will see him. I insist that the EKG results are included, but I suspect they want to forget these.

None of the events related here are big or necessarily disasterous but each in its own way contributes to the warp and weft of our daily interactions. I am intelligent enough to cope with these. I know how to research what is happening and how to ask questions (perhaps not always the right ones). But for those less well-equipped, the situation is very different.

Medical matters by their very nature cause anxiety. In addition to curing disease, medicine has to calm fears and manage sometimes inconsolable expectations. There are clear information asymmetries in these relationships. The point I’m labouring is that although asymmetry will never be removed, how it is played out can be treated with tact and gentleness. It is too easy for those on the front line to become inured to the feelings of those in their charge. I don’t have the answer on how to maintain that feeling of “every time is the first time”, but there could be an emotional restocking–a true understanding of who is the other. Without this the microstructure of everyday life will repeat the errors and mistakes and no one will accept responsibility or be accountable.

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