Fillers Memorable patients

Up close and personal

BMJ 2000; 321 doi: (Published 08 July 2000) Cite this as: BMJ 2000;321:92

I recently had the opportunity to observe the progress of two middle aged women admitted to hospital after a stroke. I occupied the bed between them. Both had similar levels of impairment and had been in hospital for several months, and plans for their discharge were progressing.

Mary could easily have graced the “memorable patient” column. She was intelligent, articulate, despite severe dysarthria, was positive, willing to give anything a go, and had a wicked, infectious sense of humour. She was popular. Ruth on the other hand was quiet, and somewhat introverted, complained a lot, and found every step in her rehabilitation fraught with danger.

Around Mary's bed there was always a throng of visitors, and when they left it was difficult to see her for the flowers and garlands of cards. In contrast, Ruth rarely had visitors and had only a handful of cards. She told me that she preferred to sleep through visiting times to dispel her loneliness. Very occasionally she became animated and chatty, such as on return from a car trip with people from the local church.

It is generally accepted that personality and social support are the best predictors of recovery, and it will come as no surprise that Mary's functional progress was excellent and Ruth's was slow. What came as a surprise to me was not the contrast between the two women but the contrast in the way that they were treated. I saw the effects of throw away comments made by the staff, half joking, half serious, that built up the one and diminished the other. I watched the subtle differences in approach that could have unintentional but devastating effects.

Mary's small steps of progress were greeted with delighted cries of “Well done, you're a star. Keep up the good work.” Ruth's faltering steps usually provoked such responses as, “See. We told you you could do it. What was there to be so frightened of after all?” It was as if people believed that Ruth's fear of falling could be reasoned or even bullied away. I do not know how many of the staff had been able to sit with her long enough to learn that when she had her stroke she fell backwards down a flight of stairs. She remembers hitting every single step. Ruth complained of being ignored, and it was not paranoia. She gave little back to those who did try to help her. She did not have the energy.

It seemed as if Mary, who had everything, was given more, and Ruth, who had so little, had even that taken away. Have I been guilty of doing that? We can and should learn from our exceptional patients, but our understanding, compassion, and skills should extend to all our patients. I am starting to improve by acknowledging that my actions and casual comments can so easily and subtly undermine this ideal.

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