The first principle of health care is to “first do no harm”. In the complex system that we live we seem to have forgotten to whom we are responsible. The duty of care and the equitable distribution of such has taken a back seat.  The comfort of the staff is vital but their competence is far more important to our patients. Many seem to believe that our staff members being “nice” is the key to care. ThIs misguided notion is taking us into the weeds and missing the real problem in many institutions. Our real problem is competence and consistency. If the goal of our system is to provide consistent and dependable care we must first stand up for equity. The equity I mean is equity of care standard.

The care delivered varies wildly and the reason for such disparity is as varied. Fortunately many institutions have noticed the problem but their solutions seem worse than the problem. The government has stepped in because we have not consistent applied the care we know to be best. The government has used the same consumerist benchmark of satisfaction that is used in retail sales as a proxy for care delivered. This approach is sub-optimal at best. It is not likely to be the best measure. However, our opposition to these measures will not improve patient care. What we need to recognize is that patient satisfaction can be a good proxy if we work in a system where competence is priority number one.

Patient satisfaction is a complex fickle beast. We cannot practice from the point of providing a ‘satisfying’ experience. Our care should be directed at proving the best outcome to all. The only way to provide such care is if our systems are focused on designing best in class care systems and staffing such systems with competent staff. In recent years our systems has fallen into the sad and despairing state were we have lost focus on care and the competence of our staff. The misguided first basis focus on the social behaviour of the staff is driving the best out of the system and putting out patients at the mercy of the less competent, but ” nice”.  If our purpose is best in class care and superior outcomes there is only one matrix that matters. We must provide our patients with the best trained staff. Our efforts must be evidence bases and physician driven.


The coffee was much too hot and the air was much too cold, but she was perfectly happy with the world. The room was loud, but it seems she did not notice. As I tried to pass her I tipped her table with my backpack, and spilled coffee into her lap. As I frantically gestured to the barrister for assistance I notice that she had not moved an inch. No assistance was forthcoming. The shop was full and all behind the counter were busy supplying the assembled masses their morning dose of caffeine. I retrieved my sweater from my backpack and in the process spilled my headphones and various cables unto the floor. I tried to mop the steaming liquid from her legs and shorts. She did not move. It seemed as if she had not noticed that I was trying to get her attention. I tried to get her gaze, all to no effect.

I was immediately transported to my time on the inpatient psychiatric unit. There I was introduced to catatonia, and this was it. I was surprised and scared by what I was seeing. I was snapped back to reality as a baby started to cry. I looked around only to notice that the cry was coming from the floor next to her. It was a baby boy or I assumed so from the blue clothes. His crying snapped her awake and she shouted at me for spilling her coffee. I was startled, but happy to see her aroused. I hugged her in relief, but she did not share my emotion. I apologized as she picked up the baby and consoled him. Only them did she notice that the coffee had spilled into her lap. She was not bothered and continued to cradle the now quite baby. Her demeanor changed to a concerned loving mother and I was impressed by the rapid change.

As I sat I wondered what she was thinking while she was in that haze.
“Was I out long?” she asked.
“No, you were not, it was only about 3 minutes.”
“Thanks for getting the spilled coffee. Sometimes I am helpless.”
“What do you mean?”

Maybe I should have left it there, but my curiosity got the best of me. As she started to talk I was being drawn into a deeper more complex puzzle. She had delivered her son twelve months earlier by cesarean section, which was her first surgical experience. It was not planned, but she was having a complicated labor and her doctor suggested that a cesarean section would be safe for her and baby. Her had a long reassuring discussion with her Anesthesiologist and was comfortable with the plan. But the experience was more challenging.

As she talked the color went out of her lips and face. Her experience of the spinal was clouded by the coldness of the room and the warmth of her nurse’s hands. She was happy to be able to watch and she remembered the mirror. She watched as her prince as plucked from the warmth of her body to the cold of the world. She saw her stomach open and admired the hands of her surgeon. She watched to make sure all the layers were closed. While she watch her view started to get cloudy and her chest felt heavy. She quickly became aware of the beeping over her shoulder. She started to feel the approaching nausea and caught a glimpse of the heart monitor as the number fell slowly from 35 to less than 30. As her vision continued to get darker she could hear a sudden piercing sound and then blackness. She then awoke to the bright lights of the operating room and returned to watching her doctor close all the layers of her abdomen. It was all over and she was happy for it. Her prince was safe and warm in her arms.

“All I could think of for the next day was how beautiful he was,” she said.

I shook my head in understanding and lost all the questions I was contemplating. As she continued I notice that the baby had fallen asleep with his little fingers wrapped around mommy’s pinky. She did not seem as comfortable as he was and as she continued to speak I understood why. Her birthing experience was not as she had expected. For the first 48 hours she was great, but then she started to have moments of “haze” when she just could not remember or hear people around her. The first time it happened she was being taught how to breast feed by the lactation consultant. She was in a “haze” and did not hear the instructions being given to her. She continued to ask her consultant to repeat.

Her husband had returned to work and had not noticed anything different about his wife. He was an active duty soldier and was deployed less than 36 hours after the birth of his first son. She still could feel his hug and kisses, but he had not returned home. Her life was forever changed.

She had become a widow of war and trapped by the trauma of her berthing experience. I listened, but there was no word of comfort that came to mind. I was shocked by her story and lost in her grief.