Sunday, May 5, 2013

Reviewing the Past - Out patient clinics

Once, when I had a proper job, I asked a consultant I was working with, why he asked patients to come back to the clinic every 3 months - his answer was “to train the junior docs".  At the time I was a little surprised by his candid answer but when asked whether there might be any evidence to suggest the most appropriate frequency of appointments he did not appear to be interested.

I was a little surprised but that was back in 1992 when the purchaser/provider split first came along and I thought that as the purchaser we might have some leverage in examining what went on in OPDs and what we might do to improve the experiences of the people waiting in clinics and also increase the satisfaction of the professionals working there. Alas nothing came of it and I went off to do another proper job and in 1996 started my PhD research that examined people's experience of diabetes care. I didn't really appreciate it back then but the dominate experience of diabetes care IS outpatients and so my research was quite unique and that context of people's experiences was not fully explored at the time. The findings from my research identified how the experiences were often about uncertainty, disruption and anxiety leading up to an appointment, during the visit and for some weeks after. No one talked about coming away from the clinic feeling better about themselves and/or their diabetes management quite the opposite. The overall experience could be summed up as transitional a neither here nor there experience – betwixt and between.  

My motive for undertaking the research came from my complete and utter dislike of my role in OP clinics. I was a nuisance to the nurses in OPD as I would sit in the waiting area inviting questions and inciting dissatisfaction from the patients. I would not do what I was supposed to which was to stay in my room and be like the doctors, summoning people to the room when it was their turn. I also used to go to great lengths to delay my arrival at the clinic. In the days before mobile phones (i.e. no one could contact me away from the office) I could procrastinate a great deal; often fitting in a few home visits and a trip to a GP’s surgery on my way to the hospital from my office in a Health Centre. this was all just so I could put off the inevitable slog of the diabetes clinics. They ALWAYS ran over. We were there from 1pm until after 6pm most Wednesdays and alternate Fridays were nearly as bad. The diabetes clinic was notorious in the department and the OP nurses hated being assigned to the clinic.

I have been prompted to revisit my PhD beginnings and my “proper jobs” back in the day after reading Anne Cooper's blog about her experiences of outpatients as person with type 1 diabetes ( ). I am saddened to think that the way the clinics run and the experiences of folk attending the clinic sounds very much like the experiences in my research over 15 years ago. To satisfy my curious mind I did a quick search to see what has been written about the OP clinic – other than that by sociologists (1) and forward thinking folk like John Launer (2) whose interest in narrative and stories set him apart from the usual medical commentary.

Here I found remarks on teaching in OPD (3) – maybe the clinic is just about professional discourse and that the patient has little to do with it. The patient presents as a medical curiosity a problem to be solved – much better in OPD than on the ward (4) – a lot goes on that I hadn’t appreciated in the medial discourse – much food for thought and insightful. Yet again the patient presents as a site of surveillance and the vagaries of a poorly performing body as a problem to be solved rather than the human being with the appointment, someone to get to know and forge a relationship with..
I wonder if my PhD would have made any difference if I had got it. Somehow I think very little and maybe blogging about it in this way might get a bigger readership than that elusive thesis.
References and further reading

1. Strong PM . The Ceremonial Order of the Clinic: Parents, Doctors and Medical Bureaucracies. London: Routledge, 1979

2. Launer J (2012) Waiting Rooms and the Unconscious Post Grad Med Journal 88; 361-362 available from

3. Williamson J (2012)Teaching & learning in outpatients clinics The Clinical Teacher 9; 304-307

4. Watkins P (2004)  Outpatient departments: a unique opportunity for understanding illness Clinical Medicine 4,2; 97-98


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