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Module 4: Caring in a Hospital Setting - Case Study in the UK

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Working Together for Health in Hospital

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We pin a lot of hopes on doctors. We expect them to know all that is relevant about the classification and treatment of diseases. We expect them to be able to make us better, and to give us an indication of what will happen to us next.
There are strong pressures on doctors to respond to this expectation - to be knowledgeable and confident, to set themselves apart from ordinary mortals.
Lesley Mackay is a researcher who, in 1989-90, carried out an extensive study involving over a hundred interviews each with doctors and nurses in five hospital settings in England and Scotland, exploring in depth how they saw themselves and their work.
She coined the phrase the ‘Great-I-Am’ to try to capture the perspective of the doctors and the ways in which they related to nurses, patients and others in the hospital setting.
A series of excerpts from her book (Mackay, 1993) will be quoted; to build up a picture of her argument about how doctors think.

For many of them, she believes, life in medical school and subsequently in a hospital sets them apart from other health care workers. We will then look at Mackay's argument in the light of the material on the audio clips.
Mackay calls attention to the image of junior doctors striding purposefully to the next patient, ‘the tails of their unbuttoned white coat flapping, stethoscope prominently dangling from one pocket’ (p. 63), a reflection, she says, of an attitude that ‘only I can deal with this’. She then develops this idea:
It is easy to see how junior doctors can see themselves as being the center of everything. The doctor arrives, decisions are taken, the action begins. Nurses, perhaps cross and impatient about any delay in the doctor's arrival, will be critical of any failure to take a speedy decision. The doctor learns to act quickly and decisively. The adopted persona of decisiveness becomes convincing, and the doctor rushes onto the wards, makes the necessary decision, and rushes off again, with smaller tasks perhaps left un-communicated or undone. (Mackay, 1993, p. 68)
Mackay argues that accepting decision-making responsibility, as doctors do, can be a stressful responsibility that they admit is ‘scary’.

It should not, but often does, mean that the doctor ignores the contribution of others, failing to listen to those who have more contact with and knowledge of the patient.
Here is another aspect:

"a continual effort is made to present a united front through which the patient is kept calm and protected. The way the performance is played is that the doctor has the leading role, the nurse acts as the assistant …

The doctor can question a nurse's actions … [but] … if a nurse were to question a doctor in front of a patient, the doctor's presentation of confidence and competence would be undermined". (pp. 112-3)

First, summarize Mackay's argument by reference to the following questions:

• What does Mackay mean by the ‘Great-I-Am'?

• How does she say that the ‘Great-I-Am’ attitude is produced?

• What results does she argue that it has?

Next, jot down your own reaction to this argument.

• Do you think it is accurate?

• Do you think it is fair to doctors?

The ‘Great-I-Am’ is an expression Mackay coined to draw attention to doctors’ belief in their centrality to health care. It can mean arrogance on the part of the doctor who might refuse to listen to co-workers or to the patient.

(But Mackay's account shows another side - where doctors feel that they are required to behave as if they are omniscient and always certain about a course of action, and have instilled in them a very strong sense of their own personal responsibility for outcomes and of the enormity of the consequences of error.)

The ‘Great-I-Am’ attitude, she argues, is also sustained in the daily organization of work by nurses, and by the ‘golden rule’ of no disagreement in front of the patient.
She points out that the ‘Great-I-Am’ can give the patient confidence that the doctors know what they are doing. But it can also feed doctors’ sense of their own importance and result in devaluing the contributions of others - particularly nurses. Where nurses do not speak up and challenge there is the potential for harm to the patient.
Reading about the ‘Great-I-Am’ provoked some strong reactions in a group of course testers.

• Some were dismissive:

"This is obsolete and of no value to the course; it's one-sided, good doctors do not have this stance, doctors are not the ‘Great-I-Am’ - they are humans!"

• For others, it struck a chord:

"Some doctors I have come across in hospital, also GP's, when asking for information they look right through you and ignore you - you do not need to think the ‘Great-I-Am’ to help people; I have experienced doctors’ wrong opinions three times - I think the doctors should listen to what people are saying".

It would be wrong to interpret what you have read as saying that all doctors behave in a ‘Great-I-Am’ way, or that they are always ‘uncaring’.
Mackay's point is that the preparation that doctors receive encourages them to be active, to decide quickly on a course of action, and to use their knowledge to get results. The model of medical activity that they learn is primarily about cure rather than care in the sense that we have been discussing it in this unit.
A cure perspective -stemming from the biomedical model - can mean keeping quite distant from the person who is the site of the disease.


Indeed, doctors can see this distancing as important in helping them think calmly about courses of action without getting entangled with individuals. Both James and Dave on the audio cassette indicated that they thought that doctors today are more alert to these issues than they have been in the past.
• Both the biomedical model and ways of working in the hospital tend to set doctors apart from others in the hospital health care team.

• This can produce tensions among co-workers and can distance doctors from patients.

• There is awareness of this among doctors, however, and not all behave in this way.