June 27th, 2007 by Dr. Val Jones in News
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Interesting article in the New York Times about doctors talking about themselves too much. Apparently, some doctors spend precious patient interview time talking about unrelated personal information (recent vacation experiences, family members, etc.). In fact, a recent study in the Archives of Internal Medicine suggests that physicians annoy patients with these misguided attempts at building rapport.
We physicians are trained in medical school to be more humanistic and compassionate towards our patients – but we are not given specific direction regarding how to achieve those goals. And let’s face it, we’re kind of geeky in the first place, some of us lack social skills, and we’re under a lot of stress most of the time. The result? Awkward conversations about the most innocuous things we can think of to break the ice – vacations, daily routines, the weather… and perhaps a lot of wasted time.
The research study has its limitations, though. First of all, it only studied physicians in Rochester, New York. Now, my husband is from Rochester – so I dare not say anything unkind… but culturally speaking, the Rochester crew is a little more chatty and casual in their approach to conversations than folks in Manhattan or Boston for example. So there may be a cultural bias at play here in the research.
Second, it’s unclear how much the personal commentary bothers real patients. The conversations were judged by researchers listening to recordings of fake patients who had no previous relationship with the doctor. It’s entirely possible that regular patients might enjoy the personal aspects of the dialogue and actually look forward to hearing how the doctor and his or her family is doing because they have a caring, friendly relationship.
And finally, the study doesn’t address the issue of how to improve the doctor-patient relationship if self-disclosure is so unsuccessful. The poor docs in Rochester are going to be left with a self-conscious uneasiness about idle chatter – and will again not know exactly how to demonstrate humanism as recommended in their medical school training.
But, I must say – that if my doctor spent our entire session talking about herself, I sure would be annoyed, and rightly so. Still, I think I’d like her more if she told me something personal about her own struggles. There’s a balance here – and the complicated interplay of human relationships is hard to measure with standardized patients, audio tapes, and a small geographical location. If your doctor is too chatty, just redirect him/her. You know we do that to YOU all the time. 
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
April 20th, 2007 by Dr. Val Jones in True Stories
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An elderly woman had had a
cardiac arrest and was resuscitated long after a lack of oxygen had permanently damaged her brain. Her daughter remained at her side day in and
day out in the Medical ICU, keeping watch on a hopeless situation.
Many staff had encouraged her to go out and get some fresh air, to take
care of herself… but she was compelled to stay with her mom 24-7 for reasons I will
never know.
I spent some time gazing at the patient’s face – it was delicate
and quite beautiful, with flowing white hair framing fair, soft skin. I wondered what she was like when she was
herself, if she had a gentle disposition, or a fiery wit. I wondered if she had loved her husband, and
if she had had a happy life… I wondered why her daughter was clinging to her,
barely able to leave her for bathroom breaks.
The situation continued for a few weeks – I was a medical
student, and wrote some very bland and unenlightening notes about the patient
each day, describing her unchanging condition.
I felt sad as I watched the daughter slowly come to realize that her mom
was already gone.
One day the daughter looked at me and said, “I think I’ll go
out for a bite.” I smiled, knowing that
this was a turning point for her, and gave her a hug. “I’ll watch her for you,” I said.
As it happened, the patient was on the “house service” –
assigned to the teaching attending of the month. She didn’t have her own doctor, so she was
followed by a team of rotating residents and attendings. The new team started this day, and were
somewhat unfamiliar with her case. I
dutifully updated them on the history and events over the past few weeks.
As I stood there with the team, rounding on the patient –
they noted that her lungs were becoming harder and harder to ventilate. “ARDS,” they said. “She’s going to code any time now.”
And then the unthinkable happened. The new attending, who was a bit of a cowboy,
said “let’s just end this madness. Turn
off the ventilator, it’s done.” The
residents looked at one another – one protested, “I don’t think we should do
that.”
“She’s already gone – look at her! Her oxygen is dropping, she has no pupillary reflexes,
she’s on maximum pressors…”
“But wait,” I said, “Her daughter would want to be here.”
“It’s better for her not to have to go through this,” he
said. And he turned off the machine.
I gasped. “What will
we tell her daughter when she comes back from lunch?”
Annoyed by my persistence he snapped, “Tell her she coded
when she was out.”
Thirty minutes later the daughter came back to the ICU. As she walked towards her mom’s bed, the
residents scattered. Frightened, I
approached her. She could see from the
look on my face that something bad had happened.
“She’s gone,” I stumbled… “it just happened after you left.”
She looked at me as if I had convicted her of the crime of
abandonment. At that moment, her
greatest fear of leaving her mom’s side had come true – she wasn’t with her
when she died. She ran into the room,
saw that the machines were off and all was quiet. She fell to the floor and screamed.
That scream still haunts me to this day.
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
April 18th, 2007 by Dr. Val Jones in Opinion
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Ask any American if they think
their current healthcare system is operating smoothly and efficiently, and
you’ll hear a resounding “NO!” Adjectives such as
“confusing, complicated, and disorganized” are often used to describe
our current state, and for good reason. The science of medicine has
advanced enormously over the past 50 years, but somehow this rapid growth in
knowledge has been plagued by chaos. With every new therapy, there’s a
new therapist – and the result is a fragmented assortment of tests, providers,
procedures, and administrative headaches. So what does a patient in this
system really need? She needs a coordinator of care – a compassionate
team leader who can help her navigate her way through the system.
She needs a central location for all her health information, and an easy way to
interact with her care coordinator so she can follow the path she has chosen
for optimum health. She needs a medical home.
Primary care physicians (especially family physicians, pediatricians, and
internal medicine specialists), are ideally suited for the role of medical team
leader in the lives of their patients. It is their job to follow the
health of their patients over time, and this enables them to make intelligent,
fully informed recommendations that are relevant to the individual. Their
aim is to provide compassionate guidance based on a full understanding of the
individual’s life context. The best patient care occurs when
evidence-based medicine is applied in a personalized, contextually relevant,
and sensitive manner by a physician who knows the patient well.
Revolution Health believes that establishing a medical home with a primary care
physician is the best way to reduce the difficulty of navigating the health
care system. We believe that our role is to empower both physician and
patient with the tools, information, and technology to strengthen and
facilitate their relationship. Revolution Health, in essence, provides
the virtual landscape for the real medical home that revolves around the
physician-patient relationship.
What’s the advantage of having a medical home? Jeff Gruen, MD, Chief
Medical Officer of Revolution Health:
1. Care is less
fragmented: how many times have you heard of friends with multiple medical
problems who are visiting several physicians, each of whom has little idea
of what the other is doing or prescribing, and none of which are focusing
on the big picture? When a single physician is also
helping to “quarterback” the care, there is less chance that
issues will fall between the cracks, and less chance that consumers will be
put through unnecessary and costly tests or procedures
2. Care is better:
studies have shown that excellent primary care can reduce unnecessary
hospitalizations and assure that preventive tests are performed on
time. One study for example showed that the more likely
it is that a person has a primary care family physician, the less likely
it is that they will have an avoidable trip to the hospital. This
makes intuitive sense: a physician who knows you is critical to have if
you were to get very sick and need alot of medical
attention.
3. Care is more holistic:
medical care is part art and part science and good care requires the
clinician to understand something about the whole person they are caring
for. Many complaints that are seen in primary care practices are
physical manifestations of underlying emotional, family or adjustment
issues. A good primary care clinician who knows the individual and
family is more likely to strike the right balance between appropriately investigating
physical causes for complaints, and addressing more subtle underlying
causes
So to physicians and patients alike, we say, “Welcome home to Revolution Health.”
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
March 18th, 2007 by Dr. Val Jones in True Stories
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Always do right. This will gratify some people and astonish the rest.
–Mark Twain
My favorite writer of all time is Mark Twain. His keen observations and uncanny ability to combine wisdom and wit makes his writing incredibly entertaining, don’t you think? I thought it would be fun to take a few of his quotes and illustrate them with true stories from my mental archives.
Today’s quote is about doing the right thing. I remember a case where a young internal medicine intern was taking care of a 42 year old mother of 3. The mother had HIV/AIDS and had come to the hospital to have her PEG tube repositioned. Somewhere along the way, she required a central line placement, and as a result ended up with a pretty severe line infection. The woman’s condition was rapidly deteriorating on the medicine inpatient service, and the intern taking care of her called the ICU fellow to evaluate her for admission to the intensive care unit.
The fellow examined the patient and explained to the intern that the woman had “end stage AIDS” and that excessive intensive care management would be a futile endeavor, and that the ICU beds must be reserved for other patients.
“But she was fine when she came to us, the line we put in caused her downward spiral – she’s not necessarily ‘end stage,’” protested the intern.
The fellow wouldn’t budge, and so the intern was left to manage the patient – now with a resting heart rate of 170 and dropping blood pressure. The intern stayed up all night, aggressively hydrating the woman and administering IV antibiotics with the nursing staff.
The next day the intern called the ICU fellow again, explaining that the patient was getting worse. The ICU fellow responded that he’d already seen the patient and that his decision still stands. The intern called her senior resident, who told her that there was nothing he could do if the ICU fellow didn’t want to admit the patient.
The intern went back to the patient’s room and held her cold, cachectic hand. “How are you feeling?” she asked nervously.
The frail woman turned her head to the intern and whispered simply, “I am so scared.”
The intern decided to call the hospital’s ethics committee to explain the case and ask if it really was appropriate to prevent a young mother from being admitted to the ICU if she had been in reasonable health until her recent admission. The president of the ethics committee reviewed the case immediately, and called the ICU fellow’s attending and required him to admit the patient. Soon thereafter, the patient was wheeled into the ICU, where she was treated aggressively for sepsis and heart failure.
The next day during ICU rounds the attending physician asked for the name of the intern who had insisted on the admission. After hearing the name, he simply replied with a wry smile, “remind me never to f [mess] with her.”
The patient survived the infection and spent mother’s day with her children several weeks later.
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
March 16th, 2007 by Dr. Val Jones in Medblogger Shout Outs
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Richard Reece’s recent blog post echoes my sentiments – that it is important, in the midst of a broken healthcare system (and all the frustration that it creates), to stop and ponder the good things that yet exist. There are flowers popping up between the concrete slabs of our system…
Dr. Reece writes,
This is an anti-hero age. We no longer send bouquets or offer praise or optimism, beauty, life, or achievements.
Instead we doubt, dissect, disparage, analyze, impugn, question, and investigate.
Boy, do we investigate. We investigate Presidents, Vice-Presidents, Attorney Generals, Politicians, Army Generals, Priests, Physicians, and Establishment Institutions. The prevailing attitude is: if they or it have succeeded in our society, something must be wrong. Our most prominent heroes, even Mohammad Ali, have feet of Clay. So we send no flowers, only regrets that things are not perfect.
And physicians?
Well, they are the worst. Imagine. They err like other mortals. They occasionally misinterpret signs, symptoms, and results. They cannot guarantee perfect results under all circumstances. They cannot even repeal the Laws of Nature, or the inevitable Limits of Longevity. Physicians are not even omnipotent, omniscient, or omnipresent
…
Maybe we should praise our doctors and their institutions, considered many to be “the best in the world.” That may be why the U.S. introduces 80% of the world medical innovations and wins 80% of the world’s Nobel Laureates in Medicine even though we only have 5% of the world’s doctors. Maybe we should give our doctors flowers, instead of defoliating them. Maybe they should be our heroes, rather than our villains. American doctors are not miracle workers, but given limited resources and Nature’s limitations, they are damn good.
I encourage you to read Dr. Reece’s whole post. This excerpt doesn’t do it justice.
And if you’d like to give a shout out to a good doctor you know (in lieu of flowers) please comment here!
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
