In preparation for my assignment I began to explore medicine as an art as well as a science, looking at the way doctors communicate with patients ‘the art of the doctor-patient relationship’ and the interpersonal skills a lot of doctors have that can also help patients therapeutically rather than simply viewing them as a biological system that needs correcting. I then decided to look further at the idea of NHS targets in A&E compromising the art of this communication and hence preventing doctors obtaining ‘the story behind the story’. I’ve learnt through Whole Person Care that earning a patient’s trust is key in gaining honest crucial information that could help you get to the root of their troubles, revealing something sinister that they, the patient, could be waiting for an opportunity to reveal; something you as a doctor might have the resources to help with. Granted not every patient will be in such a situation but by putting the healthcare team in a state of rush, people that need extra help could slip through the current system. There is now less time for the vulnerable, frightened, and inarticulate patients, who become objects of annoyance rather than subjects of care1.

In 2002, 23% of patients spent longer than four hours in A&E. The four-hour target for processing patients in emergency departments was introduced at 90% in 2004 by the labour government and since 2005 has been at 98%. Some would see the emergency services as heading towards a conveyer belt like model, where damaged humans are repaired and off-loaded, with a change in approach from care to clock-watching. Group dynamics of healthcare teams perhaps shifting to keep managers and pen pushers happy, rather than the patients; managers, who themselves report to a higher authority, cajole, harass, and even occasionally bully staff to ensure the target is met and there are no breeches 2 perhaps also increasing stress levels in the doctors and other staff, compromising their performance. Obviously this is not a view held by everyone and some people associated with the health care profession and a lot of patients would see the targets as a positive thing; reduced time spent in the waiting room and a more economic use of resources and time; one doctor commented “the four hour standard came from asking patients what they thought was a reasonable maximum time to wait- The proof is to be seen in those hospitals with superb emergency department services 3”. It is easy to simply concentrate on the impact of doctors but other parts of the multidisciplinary team are also affected. Some views held by nurses relate to the immense pressure of managing patients within a limited time frame, while being watched by “Big Brother” 4 However the article I read summarises that the nurses spoken to also spoke of the many benefits and reduced trolley waits. The training of junior doctors is also something that is compromised and juniors may be discouraged by the speciality under these conditions. There are clearly many opinions and contradictions in the debate on this target; I believe this argument is one I have neither the medical experience or economic knowledge to fully asses and comprehend but it seems clear from a reasonably naïve viewpoint that holistic care has taken a back seat.

Maybe the four-hour standard is the best way to help the patients as a population, but it seems the vulnerable individuals and those that could be in danger may find themselves missing the perfect opportunity for help, this is the main aspect I wanted to explore in this research. this quote illustrates a clinical attitude which might be compromised. I can see how effective communication would be difficult to maintain in a stressed environment such as an A&E department where time pressures force you to use closed questions to reach a fast diagnosis rather than open ones to prompt honesty and develop trust over time; unfortunately the public perceive speed to be synonymous with quality 6 hence the reason why the public feeling is concentrated on the time it takes. I remember watching the bad examples of communication and thinking that I would never be like that with a patient but I can now see how the situation could develop for doctors. At medical school I learnt how to repair violins. It took many more years to hear their music 5 . I am starting to understand how much more there is to being a doctor than simply science and illness; a way of life and moral upstanding and not just a profession.

I tried to capture these ideas in my painting focusing on one of the vulnerable patients who has slipped through the net. I have overdramatized the concept in a comic-art style with the simple concept of a ‘monster under the bed’. The idea behind my painting is that the lady’s medical problem has been dealt with efficiently within the four hour target, the doctors have finished their work and the patient is left in a safe condition ready to leave. I decided to depict her smiling, as this could be a front she was putting up having not had the chance to gain a doctors trust. All would seem well and she has probably told the rushed doctor that everything else is fine; however, there is a monster under the bed. I wanted this to represent a personal turmoil she was keeping from the people who had treated her; ‘domestic abuse, depression’ or something else that is left behind and is slowly creeping back to haunt her after the doctor has left and she is going to be discharged. The clock is only marked one to four representing the four hour target and the hand is about to reach four hence why the doctor has been forced to move on. I chose to produce the painting in black and white tones; primarily because I wanted it to look clear and defined, I wanted the image to be bold and fairly obvious as to what it was depicting and secondly, because this would emphasise the eyes of the monster and clock hand which I painted in vibrant red. I wanted the person looking at it to firstly be drawn to these things and this influenced my decision for the layout of the painting, with the clock and monster in opposite corners drawing your eyes in to the patient at the centre. The painting is almost split diagonally down the middle by the bed with the bright white top right corner where the patients smile is facing ‘ideally where the doctor has just left’ and the advancing abyss on the bottom left side that I’ve tried to make look as if it is clouding over her as it approaches. I think the idea of the monster under the bed is a simple but poignant way to make a strong visual point.

I am very happy with how the painting has turned out; I have always had a passion for art and have produced paintings for both this and GP Attachment which has been a really nice break to concentrate on something different for a while. In a heavy science based course, I have been shocked and delighted by the chance to continue working in the arts, this is something I assumed I had left behind at secondary school!

(extract from a Bristol Medical School WPC assignment)

References

Nigel Rawlinson, Harms of target driven health care BMJ 2008; 337:a885
Geoff Hughes, The four hour target; Problems ahead Emerg Med J 2006;23:2 doi:10.1136/emj.2005.031948
Letter, Irving Cobden BMJ 2008; 337:a1255
Andy Mortimoore, Simon Cooper, The “4-hour target”: emergency nurses’ views, Emerg Med J 2007;24:402-404
Bub B. Communication skills that heal: a practical approach to a new professionalism in medicine. Oxford:Radcliff Publishing Ltd 2006
The Office for Public Management. Opinion research for the NHS plan. London :1999.