10 Things Patients Love To Hate About Their Doctors

Patients have a love/hate relationship with their physicians.  They love some things and hate others.  Here is a list of things they hate, and actually take as a sign of incompetence, rather than just poor bed side skills.

  1. Being a slouch.  Patients take the lack of eye contact, hands in pockets and crossed arms as a signal your aren’t listening.  Lack of eye contact finishes it off. ( If your kid did this, would you feel they were listening?)  Lack of eye contact is the NUMBER ONE behavior that patients hate the most.
  2. Standing when the patient is sitting (or laying.) Sit down and look at the patient. 
  3. Standing far from the exam table/bed.  Patients are apt to think that YOU think they smell!  Seriously!
  4. Not being available.  When calls aren’t returned, patients hold it against you.  This also goes for being available while you are in the exam room.  I try to delay answering pages while I’m examining a patient, as I need to BE present for the patient I am examining,
  5. Giving the perception that you are rushing,  Please notice the word perception.  You may be hurried (harried?) but sit down, smile, and use humor if appropriate.
  6. Using technical terms.  Patients are intimidated by the words we throw about.  Speak simply. I don’t know anything about car engines and my eyes glaze over when the mechanic mentions words like “catalytic converter” or “repack the wheel bearings”.  Patients feel similarly about words like “congestive heart failure” and “synovial fluid.”
  7. Not answering questions.  If you don’t know the answer, tell the patient you will get back to them, or ask Dr. Bigg Bux, the orthopod, to explain exactly how the hip will be replaced.
  8. Don’t automatically say no, especially with out a reason.  I am ashamed to admit that I reflexively said no to a family request this past week, thought about the request, and then came back to tell them I could do what they asked.  Why was I so quick to say no?  Arrogance, time pressure, all of the above.  It took more time to change my mind then to do what they asked!
  9. Talking down to patients.  It is difficult to hit the sweet spot.  You want your conversations to be easy to understand but not juvenile.  You never know how patients will take what you say, but being flexible is helpful. 
  10. Mistrusting the patient/type casting the patient.  The book, How Physicians Think, by Jerome Groopman, has an excellent chapter on how physicians make mistakes when they stereotype patients.

Patients will also be less likely to trust you if you are of a different ethnicity, sex or culture.  These are harder to over come, and patients perceptions can be tough to change in these areas.  I still haven’t found a way around the fact that some patients prefer a male physician.  I happen to be female, and that’s one thing that ‘s not likely to change!

Resources: How Doctors Think, and Trust and Distrust in Organizations

Advertisements

Walk the Talk: the Patient Encounter

I am fascinated by how we physicians communicate (or not) with each other and with our patients.  As a medical student and resident NO ONE ever thought about how physicians communicated with patients.  We were always so focused on nailing the disease process and treatment that the patient was nearly ignored.  I don’t think I had a single attending that excelled in talking and listening to patients.  I have tried to self educate (isn’t that what most of medicine is?) and found a thoughtful curriculum for residents on line, from the University of Washington.  I will reproduce the salient points here:

  1. Have an opening introduction: “Hi, Mrs. Marlboro, I’m Dr. Pookie.”  (Hand shake, sit down, look at patient.)
  2. Allow the patient to complete their opening statement.
  3. Attempt to get the patients full agenda: “Mrs. Marlboro, what is the most important thing we need to work on today?” At this point, prioritizing the patients concerns is key.
  4. Set the ground rules: “Mrs. Marlboro, it sounds like stopping smoking is what we should focus on today.  Is that right?”
  5. Gather information, with a  mixture of open and closed ended questions.  Summarize and clarify with out interrupting.
  6. Actively listen, using non verbal cues as well as verbal cues.  (“Uh huh, ah…”)
  7. Explore their beliefs about the illness.  (Yes it’s hard to keep your mouth shut when a patient insists that smoking isn’t bad “because, Doc, I know you’ve heard it before, but I don’t inhale.”  Just heard this from a diabetic as he went on his way to the cardiac cath lab…  But try!)
  8. Acknowledge the patients feelings/values.  (“Yes, quitting smoking is really hard, even our President Elect thinks so.”)
  9. Share information in terms that patients understand.  (Save the free radical talk, two gene promotor theory of cancer for some one who cares.)
  10. Encourage questions: “what questions or concerns do you have?”
  11. Reach agreement on the treatment plan, actively encouraging patients to participate in the plan. 
  12.  IMPORTANT: TRY TO GAUGE THE PATIENTS WILLINGNESS  AND ABILITY ENGAGE IN THE TREATMENT PLAN!  The best plan in the world is worthless if the patient can’t/won’t follow it!
  13. Provide resources (hand outs, referrals etc.)
  14. Realize you can NOT cover every item at every visit. 
  15. Close the encounter by summarizing the treatment plan and setting up the follow up plan.

The patient encounter needs to be a balance between “patient centered skills” and “agenda setting skills.”  Interestingly, when a patient is dissatisfied, they underestimate by 8% how much time the physician spent with them, while if they are satisfied, they overestimate the time the physician spent with them by 20%!

Please see link from Society of General Internal Medicine below.   First author is Matthew F. Hollon, M.D., M.P.H., from the University of Washington. 

http://sgim.org/userfiles/file/AMHandouts/AM08/WC01%20Matthew%20Hollon.pdf

Allow Natural Death v. Do Not Resuscitate

“Allow Natural Death”

There is a movement afoot to replace DNR with “AND” or Allow Natural Death.  The idea is that patients and families are put off by the verbiage of DNR–that agreeing to a DNR is a death sentence.  Families and patients do not want to sign such an order committing them to what appears to be certain death.  However, Allow Natural Death puts distance between the final moments where the heart and lungs stop, and focuses on events leading up to death.  It is more than a change in semantics, it is a change in the way we talk about death.

AND appears more humane and, forgive me, natural.  Patients and families think that CPR/Code Blue results in saving most of the patients, most of the time, if TV’s ER is to believed.  But the sad fact is, resuscitation is frequently an invasive end of life maneuver that ignores dignity and natural progression.  Moving toward AND will require a shift in thinking whose time has come.  Patients and families want a peaceful, dignified death.  In order for patients to understand that death is a part of  life that can’t be denied, we as physicians will have to do what we aren’t particularly good at.  We will have to talk to patients and families about death.

We need to educate families (and ourselves) that death is part of living, and that sometimes it is best to let God and nature take their course, with out our highly invasive, technological, expensive interventions.  I think the place to start occurs when a patient that is  approaching the end of life.  That is the time  to get a grasp of what a patient wants/doesn’t want.  We shouldn’t wait until a patient is at death’s door to talk about the end of life.   Many patients want to die at home.  (Most, actually want to die at home, and sadly, most die in the hospital.)  The idea then is to address these desires when beforethe patient deteriorates so significantly that death is imminent.  For instance, is it appropriate to treat every infection?  Back in the day, pneumonia used to be called “the old man’s friend.”  Does the patient and family want to treat the pneumonia?  Do they want to go on toward intubation?  Does the 95 year old wheel chair bound patient WANT her fractured hip replaced–or would she be more comfortable at home with a decent pain regimen?  (Yes, just saw this last week when the orthopod called asking for “medical clearance” to replace the patient’s hip.  No one had thought about AND in this case.)   Just as important, does the patient and family want the new mass on chest Xray to be worked up in the 85  year old patient with COPD? 

These are excellent examples of when AND would be a well placed directive.   I think that AND is more than a directive, it is a direction to guide treatment.  Much discussion should go into WHAT treatments families and patients want.  I don’t think we can fore go DNR as it is a clear directive of what to do when a patient has a cardiopulmonary arrest.  However, I think “AND” should be a primary topic of discussion way before we ever get to DNR.

Currently, AND is not a legal replacement for DNR.  I don’t think it should be, but rather would use it as an adjunct to guide diagnosis, management and treatment.  I think it is the responsible way to help patients face the end of  life with dignity.  We need to get good at these discussions, and help our patients in realizing their ultimate decision: the manner in which they wish to die.

Just to be very clear:  this is in NO way a piece advocating that we help patients end their lives.   I am advocating that patients choose how much medical treatment they want as they near the end of their lives, and that we help them explore various options to make this decision.

How Doctors Think Outside of the Medical Box

It was a tough week in Pookieville.  I worked all week at one of my favorite hospitals.  I like working there because the specialists I work with are hypercompetent and always willing to help.  Furthermore, they like to chat. Well, they like to chat about interesting cases.

I was particularly challenged this week because I had to think out of the box.  I will not share the details of the case, as I don’t intend this blog to be about medical cases per se.

When I picked up  my service, I  assumed care of a very complicated patient, with a disease process that was appropriately handled.   Unfortunately, there was an outcome that was unexpected and completely unpredictable .  It was also quite serious.  What I want to share is how hard it was to think out of the box, which was what was required.  Medical statistics and medical science can not predict all outcomes, which is when the “art” of medicine comes in to play.

I walked in to the room to discuss the latest bump in the road, and the various treatment options to remedy the latest bump.  Now, before I went in the room to talk to the patient, I had done my home work.  I had reviewed the latest bump in the road with the surgeons, specialists,  the sub-specialists and several of my co-hospitalists.  There was no clear consensus as to what should be done about this problem, just a general agreement that this problem was indeed, a big problem.  Most of my colleagues were glad they were not me, because it felt as if all options were fraught with danger to the patient.  “Glad I’m not the one that has to write those orders,” was the general feeling.

Great.

I explained to the family what the issues were, and that we were now in rock and hard place territory.  I explained that there were no randomized, double blinded placebo controlled studies for where we were at.  I explained the options, risks, benefits and side effects of each option.  I explained that  I had done my home work.

“Do you just fling sh– at the wall and see what sticks?”  One incredulous family member asked.

It must appear that way, when we can’t quote studies, and cite statistics and supply comfort from numbers.  We must appear like idiots when we have to use our experience, and our colleagues’ experience to make a decision when there is no clear cut decision, and when the road is paved with ill feelings and anger at an outcome only God could have predicted. 

But none the less, a choice on treatment had to be made. 

Here is how I made my decision on how to treat the problem:

  1. Identified the problem.
  2. Said “@#%*!”
  3. Asked everyone involved in the case their opinion, including the PharmD, and the head of the department of medicine.
  4. Came up with three options, and picked the one I felt was the safest with the best outcome.
  5. Reviewed options with the patient and family.
  6. Realized that there may be MORE options, once I talked to the family.  (Interestingly, the family was the most creative in looking at solutions.)
  7. Walked out of the room, made more phone calls, and finally came upon the solution that we ended up going with.
  8. Called a renowned specialist at the local University and got the specialist’s opinion, who was in concurrence with the ultimate solution I had crafted.
  9. Went back in the room (a bit demoralized, as I had said there were no other options, but now had come up with one.)
  10. Heard the family’s  intense relief at the more moderate, middle of the road option that we ultimately agreed to implement.
  11. Went for it.

So why I am writing about this?  Because it took me TWO hours to do all of this.   It took two hours for me to think and explore every option, and to finally come up with an option that seemed workable, and the least dangerous.  I took the time because I wanted to do what was best.   It was the family that was most able to think outside of the medical box, and who encouraged me to explore further.

Now, was this the right choice?  Only time will tell, and yes, sometimes as physicians we just have to throw sh– against the wall, and then throw some more, and then consult our colleagues, and then think again to find the answer when there is no right answer.

I just hope that in the future, I have enough time to think out side of the medical box.

How do you think out side of the box?

Play Nice in the ED: Why Hospitalists and ED Docs Should Be Friends

I do a lot of work as a hospitalist, and have noted a fair amount of antagonism amongst my colleagues towards the ED.  There seems to be a lot of bickering between ED docs and hospitalists as to WHO should take responsibility for patient care. More specifically, if a patient has been admitted to a hospitalist, but remains in the Emergency Department, which physician is now responsible for that patient’s care?

A few rules:

Patient care comes first.

We are all busy, and we are all good, caring physicians.

If a patient is still in the ED, and a crises occurs, the ED MD needs to be responsible.  If I have seen a patient in the ED, then I should be called. However, if a patient is in crises, shouldn’t the nurse notify the ED physician AND the hospitalist?  Of course!  To notify me a patient is getting “worse” when I haven’t had time to assess the patient is nuts.  But it happens all the time.  Common sense must be employed:  DO WHAT IS BEST FOR THE PATIENT!

Now, what about the patients that are not in crises, but about whomthe nurse has questions?  First, I hate it when nurses call me and ask me if Mr. Prinzmetal should be on telemetry (or ask me to designate a level of admission, say observation or ICU) when I haven’t even seen the patient.  The ED physician should have a good enough sense of the patient to designate where (ICU/floor/telemetry) the patient should go. By all means, if I disagree I will change that designation.  So, please don’t call me with THAT question and waste more of my time (and then wonder why I haven’t seen the admissions that have been called to me.)

Now, as to other questions like potassium replacement, sure, call me.  But, please, please, please do NOT call me with major management questions before I have seen the patient.  I hate it when the ED doc calls me to ask if they should start heparin or nitroglycerin drips on cardiac patients.  You have seen the patient, and made the decision that they have an acute coronary syndrome.  You don’t need my blessing to act accordingly.

When the patient gets to the floor, they are my responsibility. Period.  I am watching over most of the patients in the hospital, as we are consulted on most orthopedic patients, and a fair amount of the general surgery patients.  I just ask that ED docs watch over the patients that are physically in the ED.

ED physicians, if you are busy, it means by extension, I am busy. We need to realize that the ED impacts the entire function of the hospital, and directly effects the work flow of hospitalists.

ED docs: here is my pledge to you:

  • I will say thank you every time you save my butt.  I know how many times you have put in lines and run CORs for me when I am crushingly busy.
  • I realize that for every patient I see, you see three.
  • I know that your job is challenging, and sometimes thankless.  I appreciate it everytime you are able to divert the bottom feeders.
  • I will be thankful for the work ups you do.
  • I will bring you candy my next shift.

This post is in response to “Lost in Transition” regarding handoffs at the Moving Meat Blog.  Thank you, Shadowfax and Whitecoat for the dialogue!  See:  http://allbleedingstops.blogspot.com/2008/11/lost-in-transition.html  and http://whitecoatrants.wordpress.com/

How To Listen So Patients Will Talk

I wish that in medical school and residency we had spent more time learning how to communicate.  We finish training stuffed with knowledge (think a brat on a grill!) but are horrible at distilling that knowledge to help people.  As a hospitalist I have tried to hone my interviewing skills, but feel that I could use some improvement.   Here’s my own two cents on how to interview a patient  (of course, I’m a doctor, I’ve got an opinion!):

1) Read the chart before you go in.  I have gone back and forth on this, wanting the patient to tell me what was wrong in their own words, but finally have settled on, “Hello, Mr. Hurting, I understand you have had chest pain (or warts, or whatever) for the past two days (weeks, months, decades…).  Could you tell me more about it?”  I have started doing it this way, because, when I used to say, “Hello, Mr. Hurting, what brings you to the ED today?”  inevitably I would get a wisecrack like, “My wife.”  or “The ambulance.”  I’m hoping my chart reading before hand makes me look smarter!  (I have a personal theory that if I had a British accent, I would appear smarter, but that’s a whole different blog.)

2) Please slow down, and don’t interrupt the patient.  Let them get their spiel out, before you jump in with the questions.   Try not to turn the interview into an interrogation.

3) Review the medication list (the med rec, which I think is your best friend!) every time, using trade and generic names.  Many patients will know one or the other, but not both.  Hopefully you will not encounter the dreaded, “I take the little peach pill” scenario.

4) Try to answer the following questions:
–what is my diagnosis –(why am I sick?)

–what will happen next?  (What tests, treatments, other specialists?)

–when will I be informed of the test results?

–will it hurt?

–when will I get out of here (the hospital)?

–and of course, when can I eat?

5) For pity’s sake, introduce yourself and shake hands!  (I know, this post is slanted towards hospitalists today.)  Give the patient and family a card.  I occasionally give my pager number to so called “needy” families.  I find that they take comfort knowing they can get hold of me, and seldom abuse this.  I must note that some of my colleagues frown on this.  (“We don’t do that,” one of them said frostily.)

6) Always ask, “Do you have any other questions or concerns you want to share with me?” before concluding the interview.  I also tell patients and families how they can get hold of me.  (“Ask your nurse to page me.  We have someone here 24/7.”)

Please feel free to share your suggestions.  My communication skills are a work in progress, and I bet yours are too!