PookieMD's Blog: Where Physicians Learn About the Business of Medicine

Part of what makes medicine so difficult is the constant time constraints we are under (or perceive we are under.)  I have grappled with ways and styles of communicating effectively, and some days are better than others.  I found a monograph entitled “The Four Habits Approach to Effective Clinical Communication” by Richard M. Frankel, PhD, et al to be helpful. 

Following is an excerpt on delivering bad news.  I find giving bad news particularly challenging, as frequently, there is nothing to say or do that makes it any better.  Hopefully following the steps below will allow physicians to do it with greater grace. 

• Prepare for the visit by having an appropriate time and place  (not the hall way of the hospital!)
• Have a plan for what you wish to accomplish.
• Get the patient’s perspective before giving your own.
• Use clear, unambiguous language, and be brief.
• Be silent after you have delivered the news to allow the patient to process the information.
• Limit the goals of the visit once the news has been delivered. (In my experience, once you say the word “cancer”, patients become unable to process further information.)
• Check for patient and family understanding.
• Plan the next steps for short, medium and long term goals.  (E.g. “tomorrow, you will see brilliant Dr. Oncologist, and then next week likely start chemotherapy.  Long term, you should recover fully.”)

Good luck out there.  Let me know if you have ways you deliver bad news to patients that seem to ease the pain.  Isn’t that why we are physicians?

I do most of of my work in the hospital, and have tried to find ways to be more effective and efficient.  Premium is the time I spend with patients, so I try to be efficient with the paper work and phone calls to allow me to spend more time with patients.  Here I my top tips for making it through the day:

• Bundle your work.  When I go on to each floor, I get the charts I need, and prefill out the vital signs, labs, x-rays and assessments.  I check the MARS daily and note “medications reviewed.”  I also read other physicians notes so I fully apprised of other physicians’ plans.  I can always add to my assessment/problem list.  This allows me to go in to the patient’s room fully versed and ready for questions.  When I use an EMR, I prepopulate all my notes, and order medications and studies first thing to get them done faster.
• Tell patients when you will call their families.  Sometimes it’s more efficient to call families daily, as you end up spending less time in the end.  I make all phone calls in the afternoon when I am finished rounding.
• Never schedule family meetings in the morning, if possible.  I schedule them for the afternoon, again, hopefully when I am done rounding.  I believe that I owe it to my other patients to have seen all of them before I spend time in an extended family meeting.  I know this is not always possible, but I try to mindful that I have at least 15 other patients that need care as well.
• Write legibly.  Avoid pages by ward secretaries asking if you wanted lantus or lanoxin.
• Consider giving your pager number to families.  This can avoid endless telephone tag, and I have NEVER had a family abuse this.
• Learn every EMR short cut you can.  I use EPIC and Meditech, and am still learning all the bells and whistles.
• Call specialists early in the day.   One of the benefits of pre populating notes is that you can see problems early, and call specialists in sooner vs. later, resulting in better patient care.
• Make sure you have answered and addressed ALL your patients’ and families’ concerns before leaving the room.  Before exiting, ask if anyone has any other concerns or questions that need to be addressed.  Avoid complicated explanations.  Yes, you will still get pages from nurses asking you to come explain (again!) to the family why Grandpa needs antibiotics for his pneumonia but you will cut down on these calls.
• Use a check list.  When I am rounding, I have a paper list of my patients.  I have several columns that I check off as I see each patients.  These columns are headed as follows: meds (I check this off when I have reviewed their medications), labs (checked when labs are ordered for next day), x rays (checked off if I have ordered studies),  and note (when  note is completed.)  I also put here anything I want to follow up on.
• Communicate with nurses effectively.  When they call you, make sure you know what they want, and insist on read backs on all verbal orders.  If you are changing the treatment plan,tell the nurse!  They are your front line on getting things done, and can make the wheels turn.

Good luck out there!  One of my friends (an ID doc) asked if being a hospitalist was like being an intern.  Some days it feels like that, but other days it’s like butter!

What tips do you have?

Today I received an email warning me that JCAHO was expected to visit one of the hospitals where I work.   The headline on the email was “JCAHO Site Visit Imminent.”  Shivers immediately ran down my spine.  I hate the fact that hospitals turn themselves inside and out for JCAHO, and that hospital administration basically has a JCAHO cam to keep track of where JCAHO may appear next.  God forbid that there could be a violation and the hospital get dinged.

I think we should all be mindful of patient safety, “effective communication between caregivers”, safe use of medications, and clean hands.  (The email states it pertly:  “gel in, gel out, every patient, every time.” )  If we as care givers aren’t cleaning our hands we DESERVE to be sanctioned!  Since when do we only care about clean hands, patient safety, signed orders and effective communication ONLY when JCAHO is about to come?  The email even reminds us that there is a special hand book we can carry around with us in case the JCAHO examiners pin us to the wall and interrogate us.

So why do I care?  Because I care about patients.  There needs to be SYSTEMS in place to insure patient safety and excellent care.   Sending an email is not a system, it’s a quick fix with out substance.  I am cynical because such emails pay lip service to these important standards, and do nothing to create long term change.  It is the Hawthorne effect: change will occur briefly, but then revert to the norm once the attention is removed.  So Mr. Hospital Administrator, here are five  steps you need to take LONGTERM:

1. Insure there are FILLED hand gel dispensers EVERYWHERE.  How many times have I tried to use an empty gel can?  It needs to be part of house keeping’s job to check these dispensers two times per day!
2. How many times have I asked for a sitter for a patient to avoid falls, poseys and over medication, only to be told it costs too much?  If you are serious about reducing these never ever events, provide the resources, not just an email reminding me to keep patients safe.
3. Have pharmacists review every medical reconciliation.  One of the hospitals I work at has no system what so ever to fill the medical reconciliation out.  The physicians usually end up doing it, close to discharge sometimes! Identify WHO is to fill out this valuable paperwork, and put in a system to make sure it is completed AT admission or the next day.
4. Hold surgeons to the same standards as the rest of us.  Yes, the surgeons bring in the money, but how many times is there a pre-op h and p on the chart?  One hospital I work at has a hospitalist assigned to each elective joint surgery.  The hospitalists make sure there is an h and p, and follow the patient through out.  The idea is that the hospitalist will make sure there are less medication errors, and prevent problems before they occur.  I think it is a great system, and hopefully my perception is reality.
5. Institute check lists on patient handoff at every level.  Yes, radical that I am, I think physicians should have to follow a standard hand off system too.

Well, I’m sure that hospital administrators every where are racing to implement systems just as I described.  (What are you smoking?!)  In the mean time, I suppose I should tuck a copy of the “Survey Readiness Guide” into my white grey coat with the dirty sleeves.

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

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

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!