Like a mandarin floating down a river in a Chinese Valentine’s Day analogy, sometimes patient and healthcare system are just not ready to meet.
“Come on, pick up pick up pick up,” I snarled in frustration into the phone as I called for the sixth time that day.
Six times, in between patient on a public outpatients list, five times in between patients while running over time, four times about this family not attending their booked clinic appointment and me batting for them each time, three times leaving a message to please call us back as soon as possible, twice losing my cool with a medical student horrified at my expletives when it rang out into message bank, and one time too many excuses on my part to keep them on the waitlist.
It was also Chap Goh Mei and I had exactly zero minutes left before I would be running late to my Chinese Valentine’s Day plans.
We’d officially run out of second chances with this family. By the policy rule book we had run out of those two times ago.
We’d also reset the counter for “two fail to attends then exit from waitlist” countless times because I had gamed the system to change the face-to-face reviews for phone reviews when I could call through to someone, anyone, in the family.
That technically counts as a review, I would sheepishly say to admin, outpatient nurses, any other people nosing about wondering why I was still seeing this rule-breaking family.
And we all collectively turned a blind eye and heaved a sigh of relief when they did turn up, an hour late and angry with us for not finding them a more convenient afternoon appointment.
There was a canned and somewhat exaggerated click of a receiver on this, my final attempt to cheat the system by engineering anineffective phone review.
The family has FTA-ed for the last time now, and I knew the death knell of the somewhat hilarious voicemail message from the child’s mother — memorised it by now after two years of doing this. A joke, a tone which sounds so different when the stressors of managing a behaviourally aggressive child is siphoned off on better days without the scrutiny of doctors and allied health workers.
On the rare occasions when I managed to see this family, there was always so much anxiety, rage and sadness in the room; it was disarming to hear the sunny voice on the other side, betraying a personality and side of family life we probably would never have the opportunity to encounter.
Certainly not now, anyway. I was jolted back to reality by my own voice, cold and specific by nature of rehearsal.
“Hi there, it’s York, your child’s paediatrician. I’m sorry to tell you that you’ve been removed from our waitlist due to not attending multiple appointments. If you still need us to see you, please get a new referral from your GP and re-join the waitlist.”
I hesitated for a second, wondering what else could be said that would be helpful.
“Goodbye.” A belaboured and equally exaggerated click of the receiver, and that was the end of it.
I know the family will be ringing back in the next few weeks trying to return, and that there will be no further chances because I can no longer truthfully say that they will honour an appointment provided, and can make no solid argument based on existing evidence to push them ahead of the hundreds of children waiting to be seen – those families who may be ready for care, when this FTA family isn’t.
Working in community paediatrics is a constant balancing act between optimism, realism, risk, and that last remaining gram of patience for all of these to constantly intrude into life.
It is constantly challenging, frustrating, exhausting, but also in the rare moments, extremely rewarding and hopeful.
It’s similar to the age-old Chap Goh Mei tradition of putting your hopes and wishes for a partner whispered into a mandarin fruit and throwing it into the river, hoping that the earnest effort and care that went into a whispered wish would find its way along the current to a true connection. And that the person on the other side of the mandarin orange message service shares that connection with you in order to walk together therapeutically to the end.
But for all of us who have dared to date or work in community settings, the hollowing sensation of missed connections and patients drowning in inequities is such a common theme, fast becoming our norm.
Consider a mandarin, whose tree grew it the way it best could per postcode and fertilising opportunities for so many a year. Its parent tree, wishing it would have a good life, threw it from a little log bridge all the way in Warrandyte (local GP clinic reimagined), floating into the service.
It hits a snag immediately in some tree roots on the Yarra with the public health service’s triaging system. It realistically sits there for three years and rots to bits. But for the purpose of this metaphor let’s say it passes down the stream and into the bookings tributary.
During this three-year waitlist, the mandarin’s changed its number twice for safety reasons, and by the time its turn comes to be picked up by this eligible suitor, the bookings team can no longer reach it.
No worries, though, the romance goddesses rushing about on their clouds have always got a process for all mandarins in the river system. As the mandarin gambols away, carried by the eddies, an army of clerks and outpatient nurses call every associated number and send letters to the mandarin’s tree of origin, or calls the referring clinic.
Success! And the errant fruit bobs back into view and reach. Visible again, and ready to be cared for.
What happens next is a whole lot of trying to hold onto a very wet fruit that’s still reeling from the tides as it’s getting closer to the Yarra’s delta.
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First visit went well, a small connection made through the firecrackers-loud appointment of a room full of yelling family members and heightened emotions.
Then two missed appointments, the second of which was sneakily converted to a phone appointment to buy time, and on and on we swim, trying to keep heads above water – one party swimming hard and invested in trying to catch all the floating fruits apart from constantly missing the one flailing one. The other simply drowning in an increasingly choppy river and getting saltier with the expectations and management plans set with no added public funded help.
The clinicians trying to reel in mandarins watch some floating by rapidly into the ocean of unknown outcomes. Some eventually stop swimming against the swells, and there is a rude click on the end of the line.
So much goes into every single patient, every single family, every single appointment. The healthcare system certainly does not have everything it needs to suit the purpose of every single family. Unsuccessful connections happen at every single level of interaction, for myriad reasons.
Sometimes, the complexity of our patients’ lives is such that it is not possible to extend care, within the resources available to us.
I don’t think it is lost on any healthcare professional that social systems that perpetuate inequity in turn generate inequitable healthcare. One can argue without hesitation that it is the system, more than the patient, that is less ready for care in many instances.
There is nothing worse than starting a journey, expecting to go on together and for the mandarin to be fumbled. “You yuen meiyou fen”, or, “they had fate but no destiny”, as is the benighted story of so many Chinese dramas watched in my childhood.
Some people in life you were meant to meet, but the satisfaction of walking together to journey’s end was not for this lifetime, so to speak. If there was anything that the 8TV segment from 1930-2100hrs in Malaysia had taught me, it was that sometimes, the only thing left to do is to remember the good things, let go of what is beyond our control, and try again next time when fate returns with another chance to make things better.
Maybe this time, the system and family will both be ready for care.
Dr York Xiong Leong is a general paediatrician in Eastern Health, Melbourne, working in public inpatient and community paediatric services, and a medical educator with Monash and Deakin universities. One of the best compliments he has ever received is “Babe you barely live on this planet”.
