Moose, A Therapy Pet In Idaho
As a traveling physician, I’m often asked if I have a favorite place to work. Since I have licenses in 14 states, I have an usual vantage point from which to compare hospitals. I know that people who ask this question presume that my answer will be heavily influenced by the town where the job is located, and all the associated extra-curriculars, environmental peculiarities (ocean, mountains, desert), and potential amenities. The truth is that very little of that is important. Over the years I’ve found that it doesn’t matter so much where you are, as whom you’re with.
As I’ve argued previously, true quality health care is not always predicted by reputation or academic prowess. It has a lot more to do with local hospital culture, and how invested the staff are in giving patients their all. In my experience, some of the very best institutions (in terms of reduced medical error rates, evidence-based practices, and an avoidance of over-testing/treating) are in rural areas. They are not on the America’s Best Hospitals list, but are hidden gems scattered throughout the country. Of course, I’ve also seen some abysmal care in out-of-the way places. My point is that hospital location and reputation is not directly correlated with career satisfaction or excellent patient care.
My favorite hospital is populated by perpetually cheerful staff. Their energy, enthusiasm, and constant supportiveness is remarkable. I once commented that I felt like a therapy pet when I arrived on the unit – everyone was so happy to see me, it was as if I were a golden retriever who had shown up for play time. That feeling can carry me through the most difficult work hours or complicated patient problems. It is so emotionally sunny in that hospital that the surrounding environment could be an Alaskan winter and I’d be ok with it.
Alternatively, there are hospitals where I’m regularly greeted with all the affection that Jerry shows Newman in the Seinfeld sitcom. You know, the eye-rolling, sarcasm-dripping “Helloooo Newman…” Yeah. In those hospitals where I’m made to feel like an unwanted nuisance, time goes by so slowly I can barely stand it. I fight to keep my spirits up for my patients’ sakes, but in the end, the negativity takes its toll. I could be located in the middle of northern California wine country at harvest season and want to get the first flight out. Seriously, your micro-environment is so critical to your happiness. Do not underestimate the importance of liking your peers when you choose your job.
Which leads me to my final point – if you’re thinking about relocating, but aren’t sure if you’ll be happy, why not “try before you buy?” Become a traveling physician (aka locum tenens) for a while to gain some exposure to different places and work environments. Your pre-conceived notions may be off-base. You may fall in love with a place you wouldn’t have thought twice about based on a state map… Because a map won’t tell you where you’ll be welcomed with open arms, versus ostracized by hostile peers. Find out if you’ll be a Newman or a therapy pet at your next hospital. It makes all the difference in the world.
In my last blog post I discussed how harmful physician “thought leaders” can be when they are dismissive of the value of other specialists’ care. I must have touched a nerve, because a passionate discussion followed in the comments section. It seems that physicians (who spend most of their time involved in clinical work) are growing tired of the leadership decisions of those who engage in little to no patient care. Clinicians urge lawmakers to turn to practicing physicians for counsel, because those who are out of touch with patients lack real credibility as advisers.
Interestingly, the credibility question was raised in a different light when I was recently contacted by a prestigious medical organization that was seeking expansion of its board membership. I presumed that this was a personal invitation to join the cause, but soon realized that the caller wanted to use my influence to locate “more credible” candidates with academic gravitas.
When I asked what sort of candidate they wanted my help to find, the response was:
“A physician with an academic appointment at a name brand medical school. Someone who isn’t crazy – you know, they have to be respected by their peers. Someone at Harvard or Columbia would be great. You must know someone from your training program at least.”
While I appreciated the honesty, I began thinking about the age-old “town versus gown” hostilities inspired by academic elitism. In medicine, as with many other professions, it is more prestigious to hold an academic position than to serve in a rural community. But why do we insist on equating credibility with academics?
Another facet of credibility lies in physicians’ tendencies to admire only those at the top of their specific specialty. Dr. Lucy Hornstein described this phenomenon in her powerful essay on “How To Drive Doctors To Suicide:”
“Practice that condescending look and use it at hospital staff events. Make it a point to ignore newcomers. Concentrate on talking just with your friends and laughing at inside jokes, especially when others are around. Don’t return their calls, and don’t take their calls if you can possibly help it. If you accidentally wind up on the phone with the patient’s primary physician, just tell them you’ve got it all under control, and that he (and the patient) are so lucky you got involved when you did.”
A reader notes:
“And perhaps those of us who do see patients should get some self esteem and stop fawning all over [physician thought leaders] at conferences like needy interns.”
And finally, there seems to be an unspoken pecking order among physicians regarding the relative prestige of various specialties. How this order came about must be fairly complicated, as dermatology and neurosurgery seem to by vying for top spots these days. I find the juxtaposition almost amusing. Nevertheless, it’s common to find physicians in the more popular specialties looking down upon the worker bees (e.g. hospitalists and family physicians) and oddballs (e.g. physiatrists and pathologists).
While I try very hard not to take offense at my peers’ dismissiveness of my career’s value, it becomes much more concerning when funding follows prejudicial lines in the medical hierarchy. As a sympathetic family physician writes:
“I have observed the inequitable distribution of resources from the less glamorous to the sexy sub specialties despite obvious patient needs. Unfortunately, the administridiots who usually lack any medical training, opt to place resources where they are most likely to attract headlines.”
Yes, caring for the disabled (PM&R) is “less glamorous” than wielding a colonoscope (GI) (again, not sure who made that decision?) but it should not be less credible, or become a target for budget cuts simply because people aren’t informed about how rehab works.
It is time to stop specialty prejudice and honor those who demonstrate passion for patients, regardless of which patient population, body part, or organ system they serve. Excellent patient care may be provided by academics, generalists, or specialists, by those who practice in rural areas or in urban centers. The best “thought leaders” are those who bring unity and an attitude of peer respect to the medical profession. With more of them, we may yet save ourselves from mutually assured destruction.
Much has been made about physicians’ tendencies to interrupt patients. Studies have shown that patients are permitted 12-18 seconds of talk time before they are redirected (or interrupted) by their doctor. This leads to patients feeling that the physician didn’t listen or didn’t care. I believe that there is a way to solve the problem without wasting time or being rude. I have used this technique with great success over the years and it works especially well in the inpatient setting, when beginning a formal “history and physical exam.” In three simple words:
Physician goes first.
Before I enter the patient’s room, I perform a careful review of their medical records and imagine what it must have been like for them to experience the events leading up to our meeting. I reconstruct the emotional time line in my head and figure out which pieces of information I need to complete my assessment and plan. Then when I meet the patient (often for the first time) I begin by greeting them warmly and then telling them what I have gleaned from their medical records, and how I think they may have felt during the process leading up to their hospitalization. This establishes that I have taken the time to get to know their background, that I genuinely care about how they’ve been dealing with things emotionally, and that I am determined to correct the record if there are any gaps or errors. I then rely on the patient to fill in the details or clarify results that are unclear.
This strategy saves the patient from having to review historical information that the physician already knows about (which usually leads to the classic interruption at second 12-18 of the interaction), and provides structure for patient participation and input. It establishes trust with the new physician, and conveys empathy. It corrects the medical record when necessary, and maximizes the efficiency of the information exchange. To drive home the concept, let me provide you with two hypothetical conversations with “Mrs. Smith” – in the first case the physician will approach her in the traditional manner, and in the second, with the “physician goes first” method.
Establishing the “chief complaint” with Mrs. Smith – Traditional method
Dr. Jones: (entering hospital room where Mrs. Smith is sitting alone in her bed in no acute distress): “Good morning, Mrs. Smith. I’m Dr. Jones, the attending physician for this unit. What brings you here today?”
Mrs. Smith: (eyeing Dr. Jones with some degree of confusion). “Well, I just had surgery, and I guess I’m still a bit weak so they said I needed to come to rehab but I still don’t really understand why I had to change rooms. Did you know I had surgery? Yes, I was walking my dog on the sidewalk and he pulled a little too hard to lurch at a squirrel and the next thing I knew I was on the ground and my hip was hurting and I was all scraped up and I saw this man in the distance who started running towards me and then I think I passed out and when I got to the hospital, I don’t know, they were worried I had a seizure and then they did a CAT scan and then when I….”
Dr. Jones: “I see. But what I need to know from you now is what is your chief complaint. In other words, why are you here in the rehab unit?”
Mrs. Smith: “Well aren’t you the doctor? You’re supposed to tell me what to do when I’m here aren’t you?”
Dr. Jones: “Yes, of course. But I was hoping you could tell me in your own words.”
Mrs. Smith: Sighs heavily. “Well, I’m here because I fell down and broke my hip and then they found out that I hit my head too and then I guess they were trying to figure out if they needed to put a drain in or just give me seizure pills and I’m not sure how they decided but I don’t remember a drain so I guess… Isn’t all this in my records somewhere? Can’t you figure out what happened?”
Dr. Jones: “Yes, it’s all in your chart but…”
Mrs. Smith: “Well then why don’t you just read it instead of asking a poor old lady with a bad headache to tell you what happened all over again. Everyone keeps asking me for the same old story and I’m just so tired…”
Dr. Jones: “So you’re here in rehab because you’re tired?”
Mrs. Smith: “Well, I guess that’s it.”
Establishing the chief complaint with Mrs. Smith – “Physician goes first” method:
Dr. Jones: “Hello Mrs. Smith, I’m Dr. Jones, the rehab physician who will be taking care of you on this floor. I read through your chart very carefully and learned that you fell down on the sidewalk when walking your dog about a week ago. It looks as if you broke your hip as well as hit your head during the fall. I see that you had your hip repaired surgically, and that fortunately you didn’t need any treatment for your head injury because it didn’t bleed very much internally, but as a precaution you were given some anti-seizure medicine. I imagine that this sudden hospitalization was an unwelcome surprise for you – there you were just walking your dog on a normal day, minding your own business and whammo – now you’re here in the hospital with me!? Well, my goal is to get you back home as soon as you’re ready and steady enough. What is your main goal for rehab?”
Mrs. Smith: “Yes, well it certainly was a shock to get the wind knocked out of me. You hear about little old ladies falling down and breaking a hip but I never thought it could happen to me. Now all I need to do is be able to walk safely so I can go home.”
Dr. Jones: “Well, the good news is that you were very active prior to your fall so I bet you’ll do very well here because you have a good baseline fitness level. My goal is to help control your pain so you can make the fastest gains possible. I bet your hip bothers you and you may have headaches too.”
Mrs. Smith: “Yes, well that’s just it. I’m in quite a bit of pain when I stand up but I’m afraid of becoming a drug addict so I try not to take the pills…”
As you can see, the second conversation was much more successful in establishing a relationship with the patient and getting to the meat of what the doctor needs to know (the patient’s primary goal, her pain level, and what the barrier to treatment might be) without the frustration caused by traditional “open ended questions” and lack of structure – leading to interruptions and perceived lack of caring on the part of the physician.
In my experience, doing a little up front chart review and taking the lead in the first patient encounter results in a dramatic decrease in wasted time and need for redirection. So in the case of avoiding rude patient interruptions – taking the conversation lead may be the best bet.
This is an unusual case where putting the patient first involves letting them talk second.
I have spent many blog hours bemoaning the inadequate communication going on in hospitals today. Thanks to authors of a new study published in the New England Journal of Medicine, I have more objective data for my ranting. A prospective intervention study conducted at 9 academic children’s hospitals (and involving 10,740 patients over 18 months) revealed that requiring resident physicians to adopt a formal “hand off” process at shift change resulted in a 30% reduction of medical errors.
What was the intervention exactly? Details are available via mail order from the folks at Boston Children’s Hospital. It may take me a few weeks to get my hands on the curriculum (which was supported by a grant from the Department of Health and Human Services). I’m not sure how complex the new handoff initiative is in practice (or if it’s something that could be replicated without government-approved formality) but one thing is certain: disciplined physician communication saves lives.
I myself (without a grant from HHS or a NEJM study to back my assertions – ahem) proposed a set of comprehensive communication practices that can help to reduce medical errors in the hospital. My list involves more than peer hand-offs, but also nursing communication, EMR documentation strategies, and reliance on pharmacists for medication reconciliation and review. It is more than just an information exchange protocol for shift-changes, it is a lifestyle choice.
I applaud the I-PASS Handoff Study for its rigorous, evidence-based approach to implementing communication interventions among pediatric residents in children’s hospitals. I am stunned by how effective this one intervention has been – but a part of me is saddened that we practically had to mandate the obvious before it got done. What will it take for physicians to adopt safer communications strategies for inpatient care? I’m guessing that for many of us, it will involve enrollment in a workshop with hospital administration-driven requirements for participation.
For others of us – regular communication with staff, patients, and peers already defines our medical practice. But because (apparently?) we are not in the majority, we’ll just carry on our instinctual carefulness and wait for the rest to catch up. At least now we know that there is a path forward regarding improving communication skills and transfer of patient information. If we have to force doctors to look up from their iPhones and sit around a table and speak to one another – then so be it. The process may improve our lives while it saves those of our patients.
Judging from recent articles, surveys, and blog posts, the medical profession is remarkably demoralized. Typical complaints range from “feeling like a beaten dog” to “living in humiliating servitude,” to being forced to practice “treadmill medicine.” Interestingly, the public response to these complaints is largely indifferent. The prevailing attitude (if the “comments sections” of online articles and blog posts are representative) seems to be unsympathetic: “Poor doctors, making a little less income and not being treated like gods anymore? You have to do extra paperwork? You have to work long hours? Welcome to the real world, you whiners!”
But thank goodness that practicing medicine is more nuanced than the Facebook stream of hostility that we are subjected to on a daily basis. If patients spoke to me the way online comments read, I’d surely have quit medicine years ago. But my reality is that patients are generally grateful, attentive, and respectful. This could be because I work in inpatient rehabilitation medicine, a place where patients are screened for motivation to participate in their care, but I don’t think that’s the whole story. I have experience working in other settings across the country (including Emergency Departments), and I have found a significant number of good-natured, engaged patients there too.
I think that to some degree our attitudes shape our work environments. Patient and peer dispositions are in part a reflection of our own. Try approaching a frightened, sick patient with an arrogant, dismissive tone and see how your professional relationship with them (and their families) develops. There is a negative cascade that physicians can trigger (perhaps unwittingly) when they are rushed, curt, or inattentive. Beginning every new patient relationship with a caring, respectful, detailed history and physical exam lays a foundation of trust for future interactions. Once you have established that positive rapport, the daily grind (along with what my friend, Dr. Steve Simmons, has nicknamed ‘C.R.A.P.P.’ – Continuous Restrictive And Punitive Paperwork) is much more bearable.
As physicians we have the power to make our careers as meaningful or soul-sucking as we choose. Reducing the C.R.A.P.P. in our work lives can help (I’ve tried outpatient, “concierge style” practices and inpatient locum tenens assignments with good success), but that’s not the most important factor in enhancing work satisfaction. The relationships built by allying ourselves with patients, and shepherding them through this broken system, are where the rewards lie. They hold the keys to our professional fulfillment because nothing can beat the joy of helping those in need.
How do I know that patient appreciation is enough to make medicine worthwhile?
Because I still don’t hate being a doctor.