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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.
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It’s no secret that medicine has become a highly specialized business. While generalists used to be in charge of most patient care 50 years ago, we have now splintered into extraordinarily granular specialties. Each organ system has its own specialty (e.g. gastroenterology, cardiology), and now parts of systems have their own experts (hepatologists, cardiac electrophysiologists) Even ophthalmologists have subspecialized into groups based on the part of the eye that they treat (retina specialists, neuro-ophthalmologists)!
This all comes as a response to the exponential increase in information and technology, making it impossible to truly master the diagnosis and treatment of all diseases and conditions. A narrowed scope allows for deeper expertise. But unfortunately, some of us forget to pull back from the minutiae to respect and appreciate what our peers are doing.
This became crystal clear to me when I read an interview with a cardiologist on the NPR blog. Dr. Eric Topol was making some enthusiastically sweeping statements about how technology would allow most medical care to take place in patient’s homes. He says,
“The hospital is an edifice we don’t need except for intensive care units and the operating room. [Everything else] can be done more safely, more conveniently, more economically in the patient’s bedroom.”
So with a casual wave of the hand, this physician thought leader has described a world without my specialty (Physical Medicine & Rehabilitation) – and all the good that we do to help patients who are devastated by sudden illness and trauma. I can’t imagine a patient with a high level spinal cord injury being sent from the ER to his bedroom to enjoy all the wonderful smartphone apps “…you can get for $35 now from China.” No, he needs ventilator care and weaning, careful monitoring for life-threatening autonomic dysreflexia, skin breakdown, bowel and bladder management, psychological treatment, and training in the use of all manner of assistive devices, including electronic wheelchairs adapted for movement with a sip and puff drive.
I’m sure that Dr. Topol would blush if he were questioned more closely about his statement regarding the lack of need for hospital-based care outside of the OR, ER and ICU. Surely he didn’t mean to say that inpatient rehab could be accomplished in a patient’s bedroom. That people could simply learn how to walk and talk again after a devastating stroke with the aid of a $35 smartphone?
But the problem is that policy wonks listen to statements like his and adopt the same attitude. It informs their approach to budget cuts and makes it ten times harder for rehab physicians to protect their facilities from financial ruin when the prevailing perception is that they’re a waste of resources because they’re not an ICU. Time and again research has shown that aggressive inpatient rehab programs can reduce hospital readmission rates, decrease the burden of care, improve functional independence and long term quality of life. But that evidence isn’t heeded because perception is nine tenths of reality, and CMS continues to add onerous admissions restrictions and layers of justification documentation for the purpose of decreasing its spend on inpatient rehab, regardless of patient benefit or long term cost savings.
Physician specialists operate in silos. Many are as far removed from the day-to-day work of their peers as are the policy wonks who decide the fate of specialty practices. Physicians who have an influential voice in healthcare must take that honor seriously, and stop causing friendly fire casualties. Because in this day and age of social media where hard news has given way to a cult of personality, an offhanded statement can color the opinion of those who hold the legislative pen. I certainly hope that cuts in hospital budgets will not land me in my bedroom one day, struggling to move and breathe without the hands-on care of hospitalists, nurses, therapists, and physiatrists – but with a very nice, insurance-provided Chinese smartphone.
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Whenever possible I make a point of rounding on patients with their nurses present. I rely on nurses to be my eyes and ears when I’m not at the bedside. I need their input to confirm patient self-reports of everything from bowel and bladder habits to pain control, not to mention catching early warning signs of infection, mental status changes, or lapses in safety awareness. Oftentimes patients struggle to recall bathroom details, and they can inadvertently downplay pain control needs if they don’t happen to be in pain when I visit them. A quick check with their nurse can clarify (for example) that they are asking for pain medicine every 2 hours, that they have missed therapy due to somnolence, that their wound incision looks more red, and/or that they haven’t had a bowel movement in a dangerously long time. All critical details that I wouldn’t necessarily know from talking to the patient alone. Some of this information is not accurately captured in the electronic medical record either.
On a recent trip to a new facility, I asked the head nurse when change of shift occurred. She was visibly perplexed and asked why I wanted to know. I explained that I planned to attend nursing sign out so that I’d be up to date on how my patients were doing. She raised her eyebrows to their vertical limit and responded, “I haven’t seen a doctor do nursing rounds in 30 years.”
That was one of the saddest things I’d heard in a long time. How is it that one of the fundamental features of medical care (doctors and nurses visiting patients together) has gone the way of the dinosaur? Most of my colleagues say they don’t round with nurses because they “don’t have time for that stuff” or that they can “flag down a nurse when there’s an issue” without needing scheduled communication. While I can sympathize with the fear of yet another “time suck” during a busy hospital day, I believe that rounding with nurses can actually save time, reduce medical errors, and head off developing problems at earlier stages (e.g. wound infections, intestinal obstructions, delirium, over/under medication and unwanted medication side effects).
You may think that coordinating nursing rounds with medical rounds is an insurmountable logistical nightmare, and if you have patients scattered throughout various floors of a hospital, that will certainly make things more difficult. But I have found ways to overcome these barriers, and highly recommend them to my peers:
1. Attend nursing sign out at change of shift if possible. Do not disrupt their hand-off process, but ask for clarification (or offer clarification) at key points during patient presentation.
2. Listen to the change of shift recording. Some nurses have their night shift team record their observations and findings in lieu of a 1:1 hand-off process during busy morning hours. This has its advantages and disadvantages. The good thing is that relaying information becomes asynchronous (i.e., like email vs a phone call – you don’t have to be present to get the info), the bad thing is that you can’t ask for clarification from the person delivering the information. If the nurses know in advance that the patient’s doctor is also listening in, they will leave targeted medical questions and concerns for you on the recording.
3. Do your rounds at times when medications are most commonly delivered. You will be more likely to run into a nurse in the patient’s room and can coordinate conversations as well as perform skin checks together.
4. Communicate with nurses (between rounds) when you are about to order a series of tests or dramatically change medication regimens. Explain why you’re doing it so they will be able to plan to execute your orders more efficiently (i.e. before the patient leaves for a radiologic study, etc.) This open communication will be appreciated and will be reciprocated (and may help to spark interest in joining you for regular rounds).
5. Invite nurses to round with YOU. If you can’t join their change of shift, consider having them join your medical rounds. You’ll need to negotiate this carefully as the goal is to streamline rounding processes, not double them.
A recent study published in the New England Journal of Medicine described a sign out process that reduced medical errors by 30%. This communication strategy involved 1:1 transfer of information about patients in a structured team environment (including nurses in some physician meetings). I anticipate that further investigation will reveal that interdisciplinary rounding (with nurses and doctors together) is a critical piece of the error reduction process. For all our advances in technology and digital information tracking, “old school” doctor-nurse rounds may prove to be more important in reducing errors and keeping our patients safe than other far more costly (and exasperating) interventions.
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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.
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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.