Friday, April 21, 2017
Observations from the Gurney:
Whether it is in a hospital or in a doctor’s office, there is a profound shift in the nature of an adult - adult relationship when one of the adults is a patient and the other adult is a physician! Who waits for whom - always? Who is lying down or sitting on an examination table (like a specimen) - always? For the patient, it’s all about being wounded and feeling vulnerable. It includes a feeling of less power, less control, emotional (as well as physical) vulnerability, uneven footing, and, at times, depersonalization. While physicians may feel confident in their mastery of medical knowledge, they may encounter similar emotions in their challenges or worries about how to transfer that knowledge. What is the best way to communicate or have a discussion with the patient and the patient’s family about what they know and what they don’t know? Their own emotional roller coaster may include fear, uncertainty, discomfort and even anxiety, sadness and yes, at times, powerlessness.
The one part of this scenario that should not have to occur is depersonalization.
I was recently hospitalized the night before my birthday, and discharged the day after my birthday. On my first full day in the hospital, April 11, I can't count the number of times nurses, techs and other staff asked me my date of birth (while checking my wrist band) and before administering one service or another. When I said April 11, there was no sign of recognition that today’s date is April 11 - today is this patient’s birthday! They could have commented (if they noticed): “What a bummer! You’re in the hospital on your birthday!” To one of them, asking: "Date of birth?" I said: “Today,” and she looked at me strangely (it was not the automatic response she expected!), and it took a few moments to catch on. It is evidence of how much of what goes on in the hospital is truly mindless. Any type of mindlessness cannot be good for patient safety or for professional satisfaction. What a lost opportunity to have the human connection every patient craves and each health care professional needs!
Too often, patients become a number, a date of birth, a condition, a diagnosis or just the occupant in bed 74b. I had more “human” conversations with the people transporting me throughout the hospital for one test after another than I did with most other hospital personnel.
Gawande writes about becoming a Positive Deviant, and the first of his five suggestions is “Ask an unscripted question.” A script helps to insure we are getting all the information we need; however, if it’s only the script we use, we are on automatic pilot and that’s not good for patient OR physician! My take on this is that if the only things we know about a patient is their medical history and medical condition, we are not treating a person - we are treating a diagnosis, or a wound or an organ. We might as well be back in medical school with our cadaver.
Do you want your doctor to give you your test results
standing or sitting?
Did you ever have the experience of a physician in the hospital coming in to your (or a relative’s) room to give you results of a test? I don't know if physicians realize it, but when the results are good, they come into our room, remain standing, tell us the result and leave right away. When the results suggest a larger problem, they pull up a chair, sit down and say "The results from your (fill in the name of the test) are back and ..."
My physician sat down! I knew immediately that the MRI showed it was more than a TIA. I’m not sure where my mind went or my blood pressure or my emotions. I’m not even sure if I heard everything she said next. Of course, she stayed a while to talk about the new next tests that were ordered, etc. Whose needs are being met when doctors decide to sit down vs. remaining standing? How nice it would be if physicians sat down no matter what the results are. Even with good results, they could talk with us and help us realize the extent and source of our relief and our fears. Those are part of the patient’s reality as well.
One other thought / realization I have had while recuperating: diagnoses protect physicians from the emotion of the patient’s experience. It is part of the labeling subculture - necessary for the treatment and billing part of our medical culture, but not sufficient for the caring and healing parts of the subculture we profess to be.
Communication focussed on the diagnosis allows professionals, who are acting professionally, to stay in their head and to protect their heart and gut. Even during the H & P, the questions are all about what happened and has it happened before, and there is less room for “That must have been scary!” or “You must have been wondering what was happening to you…”
This lesson was highlighted for me recently when a 3rd year medical student - who is in one of my Balint groups - told and eventually wrote beautifully about a series of encounters with a patient on one of his first rotations to observe real patient care. He commented that he really did not know how to do anything medical, so he just talked with this patient and listened. The result in the course of just several days of sitting down and listening to his patient’s story was the development of a profound connection between a patient and a health care professional - a medical student who was not yet a doctor. It seems we have it so backwards or upside down when the person with the fewest ‘medical’ tools in a medical system has the most time to sit and listen, while those with the most ‘medical’ tools have the least time to sit and listen!
When was listening (not just hearing) considered outside the realm of medical tools?
A crucial part of the patient’s healing comes with telling the story - sometimes more than once. We do not have to be psychologists to ask what an experience was like or what remaining fears and worries patients have. We can engage our humanity, validate their emotions, reassure them of our continued participation in their health and recuperation or readjustment journey and then take a deep breath knowing that we have met them where they are. We don’t have to be brilliant - just human - and that in itself is healing (sometimes for us as well).