My newly admitted patient was at the end of a very long struggle with a devastating genetic disorder. He had been treated by some of the finest experts in America for his rare disease, and had come to my rehab unit for aggressive physical and occupational therapy. He was exhausted, but mustered the energy to tell me (probably the 100th physician to treat him) his complicated story.
Listening to this man, and examining his frail body, I realized that he had already explored every treatment option and avenue available. He had extensive conversations about his genetic variant, and which drugs could possibly modify his course. He had tried pretty much everything once, with little improvement. He told me that the team of experts at my hospital were rallying to repeat some of the costly treatments that had failed previously, to see if maybe this time they could make a difference.
As our eyes met, I realized that we both knew that these treatments were not worthwhile. I could see that he didn’t want to be “non-compliant” with his physicians’ recommendations, and was reluctantly willing to give their plans a shot. I knew that he needed to hear that it was okay to say “no.”
I took in a deep breath and voiced what we both knew to be true – there was no further need for IV medication. Now was the time to make the most of the function he had, to get him home with family support, and to focus on enjoying life rather than fighting a disease.
The relief brought him to tears. I began to put his socks back on his cold feet. He asked if I could leave them off.
I joked with him softly, “I guess your feet just want to be free.”
He smiled and nodded.
I didn’t order any tests or treatments, I just stood next to him in the moment.
And sometimes, that’s what a doctor is supposed to do.
Photo Cred: Max S. Gerber
I learned a valuable lesson recently about how difficult it can be to make the correct diagnosis when you see a patient for a very short period of time. In the acute rehab setting I admit patients who are recovering from severe, life-altering brain events such as strokes, head injuries, and complex medical illnesses. It is challenging to know what these patients’ usual mental function was prior to their injuries, and so I rely on my knowledge of neuroanatomy, infectious disease, and pharmacology to guide my work up. However, I have learned that asking the patient’s family members about what they were like (in their healthier state) is extremely important as well. Personality quirks, likes and dislikes, and psychiatric history all offer clues to ongoing behavioral challenges and mental status changes.
This fact was never clearer than when I met an elderly gentleman with a new stroke. He was extremely drowsy, non-participatory, and was not oriented to anything but his name. The stroke had occurred in a part of the brain that does not affect cognition, so I began to wonder if he had an infection or was having a reaction to a medication. I carefully ruled out all possible sources of infection, and I combed through his medication list and removed any potentially sedating drugs. His mental status remained unchanged for several days. I then began to wonder if perhaps he was suffering from significant dementia at baseline, and that he was living at home with more help from his family than they had initially reported. The therapy team and I began to consider a transfer to a nursing home. The family was horrified by the idea.
As it turned out, his grandson shared with me that he believed that the patient was autistic. Because his grandpa was elderly, he grew up in a time where not much was known about autism, and diagnoses of the condition was rarely made. He was therefore never formally diagnosed, but had many of the textbook characteristics. His stroke, combined with a sudden transfer to an inpatient hospital setting, was very distressing for the patient, and he had shut down to protect himself from the mental anguish. The “dementia-like” behavior that we were witnessing was merely an acute psychological reaction.
Armed with this new information, the therapy team requested family members to be present during all sessions – to encourage participation and to provide comfort and normalization of the transition from home to hospital. The patient responded beautifully, and made remarkable gains in his ability to walk and participate in self care activities.
I apologized profusely to the family for our period of confusion about his diagnosis and care needs, and offered reassurance that we would do our very best to help him recover from his stroke so that he could go home directly from the hospital. He did in fact return home, and with a little extra help from his daughters, he is enjoying his usual projects and activities.
As for me, I will never presume dementia without careful family confirmation again.
I’m often asked to do book reviews on my blog, and I rarely agree to them. This is because it takes me a long time to read a book – and then if I don’t enjoy it, I figure the author would rather me remain silent than publish my true thoughts. Most of the reviews that I end up writing are unsolicited, but today is an unusual exception. A colleague asked me to read her book, “How To Be A Rock Star Doctor.” I got half way through when she checked in to see how things were going. I had to tell her that I didn’t agree with some of her advice to young doctors, and I worried that she would be discouraged by my honesty.
I was very pleasantly surprised to find that she welcomed the criticism and actually asked me to write my review – favorable or unfavorable as I saw fit. She is the very first author to take that position (others have thanked me for not writing a review) and I am proud of her for it.
In essence, How To Be A Rock Star Doctor, is an easy-to-read primer for young primary care physicians looking to setup their first outpatient practice. The troubling part of the book (for me) was Dr. Bernard’s approach to the empathy fatigue that can set in for overworked physicians. In her view, we must “fake it” if we’ve lost it or don’t have it.
The book contains specific advice for how to appear empathic. Smiling broadly (no matter how one is feeling internally), dressing in a white coat, and exuding confidence, are recommended because we should see our patient interactions as an acting role – we are on stage, and they are depending on us to look/act the part.
Although Dr. Bernard rightly points out that there is research to support smiling as a means to achieving a happier mood, I was left with a certain uneasiness about the idea of putting on an act for patients. Something about the potential for dishonesty didn’t feel right to me. But then again, maybe the alternative – just being oneself – can create a poor therapeutic relationship if we’re in a bad mood for some reason.
I have heard many times that doctors can be uncaring to patients. Heck, I’ve even blogged about terrible interactions that I’ve had with my peers when I was in the patient role. But what is the solution? Should doctors learn how to imitate the qualities of a compassionate physician to achieve career success, or should we go a little deeper and actually try to be caring and let the behavior flow from a place of sincerity?
On the one hand, any tips to make the doctor-patient relationship go more smoothly should be welcomed… but on the other, if patient care is just an act, then what kind of meaning do our relationships have? If we act empathic do we eventually become empathic? Maybe yes, maybe no.
One thing I’m sure of, Dr. Bernard has opened an interesting discussion about how to handle stress, burnout, and create an excellent therapeutic experience in the midst of a broken healthcare system. She is willing to take criticism, and has endeared herself to me through our email exchanges. While I may not agree with all of her strategies to optimize patient satisfaction, one thing seems clear: she is as advertised — a rock star doctor.
Check out her book and find your own path forward.
A Cat Playing Whack-A-Mole
Medication non-adherence is a hot button topic in healthcare. Physicians lament patient “non-compliance” with their medical advice, and policy wonks tell us that more than half of patients do not take their medications as directed. Missed opportunities to control chronic illnesses such as diabetes, heart disease, and cancer surely do cost us untold billions of dollars and millions of quality life years lost annually in the U.S. But there is a flip side to the equation that no one is talking about. The costs of polypharmacy (over medication).
In my opinion, many Americans, especially those over 65, are taking far too many medicines. The unwanted side effects and medication interactions (both known and unknown) can be devastating. In my line of work (inpatient rehabilitation) I receive a steady stream of patients who have fallen and injured themselves or have been involved in serious accidents. An astonishing number of these incidents are related to drug side effects.
Take, for example, the elderly woman who had mild hypertension. Unbeknownst to her physicians, she was not compliant with the diuretics she had been prescribed. Each successive visit it was presumed that she was taking her medicines as directed, and that they were not sufficient to control her blood pressure. So the dosing was increased. Her husband dutifully picked up the new prescriptions from the pharmacy, and she collected them (unopened) in her desk drawer.
One day this spirited lady caught pneumonia and required a couple of days of inpatient monitoring and antibiotics at the local hospital. Her son decided to assist with her transition back home and stayed with her for a week, taking on both cooking and medication administration duty from his dad. He found all of her pills in her desk drawer and began to give them to her as directed.
Several days later the distraught son told me that his mother’s health had taken a nose-dive, and that she was hallucinating and acting uncharacteristically hostile. He took her to a more distant specialty hospital, where their initial impression was that she had advanced dementia, which had probably gone unnoticed by a son who hadn’t lived nearby for years. She would benefit from hospice placement.
The reality was, of course, that this poor woman was as dehydrated as a raisin and was becoming delirious from excessive diuretic use. Once I figured out that her son’s sudden, and very well-intentioned, medication adherence program was to blame, we stopped the blood pressure medications, gave her some water and she returned to her usual self within 24 hours.
On another occasion, I admitted a closed-head injury patient who had lost her front teeth after fainting and falling head first onto the asphalt in a grocery store parking lot. This was her third head injury in 6 months. A review of her medications revealed no less than six medications (that she was dutifully taking for various diseases and conditions) that carried a known side-effect of “dizziness.” We were able to discontinue all of them, and to this day I have not heard of another fall.
Just last week a wise, elderly patient of mine declined to take her blood pressure medicine. I explained to her that her blood pressure was higher than we’d like and that I wanted to protect her from strokes with the medicines. She smiled kindly at me and said, “I know my body, and I get dizzy when my blood pressure is at the levels you doctors like. The risk of my falling and hurting myself when I’m dizzy is greater than the benefit of avoiding a stroke. I’ve been running at this blood pressure for 80 years. Let’s leave it be.”
What I’ve learned is that although there are costs to not taking medicines, there are costs to taking them too. It is hard to say how many injuries are accidentally prevented by patient non-adherence. But we all need to take a closer look at what’s in our desk drawers, and pare down the prescriptions to the bare minimum required. I consider it a great victory each time I reduce the number of medications my patients use, and I would urge my peers to join me in the pharmaceutical whack-a-mole game that is so sorely needed in this country.
The American Geriatrics Society provides a helpful list of medications that should be avoided whenever possible in older individuals.
This post originally appeared on The Barton Blog.
It’s both expensive and time-consuming to obtain temporary coverage for a hospital or medical practice. Locum tenens clients have every right to expect high-quality care from the locum tenens providers they hire; but even the very best locums may not perform to their full potential if their onboarding isn’t carefully planned.
As a locum tenens physician with licenses in 14 states, I have much experience with the onboarding process. Here are 12 tips for facilities eager to encourage smooth transitions, foster good provider relationships, and provide excellent patient care.
1. Arrange for provider sign-outs.
Since lapses in provider communication is a leading cause of medical errors, you can protect your patients by organizing a face-to-face (or phone call) report between the current provider and the locum who is going to be assigned to their census. Studies have shown a 30% decrease in error rate when physicians hand off their patient panel in person.
2. Allow for at least one day of training overlap, if possible.
The incoming provider will adapt best to your unique environment and care process if he or she has the chance to “shadow” the current provider for a day. Various questions will naturally arise and be answered during real-time patient care. In emergency fill situations, this will obviously not be possible; but it will help ease transitions in cases where it can be done.
3. Get your IT ducks in a row before the locum tenens provider arrives.
Electronic medical records (EMR) systems are difficult to master, and attempting to learn how to navigate in a new one (or newer version of one) in the middle of a full patient caseload is a recipe for disaster. Logins and passwords should be set up long before the locum tenens provider arrives. EMR training needs should be discussed and planned for in advance. If an IT professional is available to sit with the locum during his or her first round of documentation attempts, so much the better.
4. Plan for a day or half-day of orientation.
A facility tour, combined with an in-person meeting of key hospital players, is extremely important. The following people should be included:
- Unit medical director
- Nursing and therapy supervisors
- Risk management staff
- Human resources
- Medical records staff
- Coding and billing staff
- Pharmacy staff
- Laboratory staff
5. Prepare a welcome packet in advance.
This packet should include important information about the organization, the assignment, and the facility, including:
- Site maps
- Parking instructions
- Orientation day schedule
- Door key codes (if applicable)
- ID badge instructions
- EMR login and password
- Dictation codes
- Cafeteria location and hours
- A hospital directory with key phone numbers highlighted
Make sure the locum knows who signs their time sheets and where their office is located. A coding “cheat sheet” may also be appreciated.
6. Invite the locum tenens provider to lunch or dinner at some point during their assignment.
This is a friendly way to show that you appreciate them, and you want to get to know them. Being on the road can be lonely, and most locums appreciate opportunities to socialize.
- See more at: http://www.bartonassociates.com/2015/08/18/12-ways-to-help-your-locum-tenens-provider-succeed/#sthash.6KV0S3vE.dpuf