Category: Observations

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Blogosphere Medicine Observations

Fear and the Online Physician.

To follow up on my last post I had intended to write something that follows the style of an FAQ:

  • What if your patients read your blog?
  • What if your boss reads your blog?
  • What if your patients ask you for medical advice through your blog?

Fear underlies all of those questions, though, and it seemed to make more sense to address that fear.

If you are a physician and you are concerned about the vulnerability of having an online presence, what do you worry about? Do you worry that patients will learn to hate you? That your boss will find a reason to fire you? That random patients will “bother” you?[1. Why do some physicians worry that patients will find them online and “bother” them? What low opinions we must have of patients if we automatically assume that they will “bother” us! And what little faith we must have in ourselves to establish and maintain boundaries should that happen! And how grandiose we must be to believe that patients want to expend the time and energy to “bother” us!]

Would you do something on the internet that you wouldn’t do “in real life” as a physician?

All the people you interact with as a physician—your patients, your colleagues, that person who works in the system, but you see him only every few months—already have opinions about you. You build your reputation with the little things you do every day.

If you think patients are lazy, your behavior will reveal that belief. If you tell someone (a colleague! a friend! another patient!) that you think patients are lazy, that will eventually become common knowledge. If someone confronts you about that, you’ll manage it the way you manage it… and people will observe that, too.

Recording your belief on the internet that patients are lazy seems like a bad idea (because it is). Stuff stays online for a long time and people will find it. If that scares you, it should. But if you’re not doing things like that “in real life” now, why would you suddenly start doing that on the internet?

You might think that the lack of an online presence (or having an anonymous presence[2. It may be true that physicians, under cloaks of ostensible anonymity, can report and discuss problems in medicine with greater candor. Whistle-blowing can be a good and necessary thing. However, anonymity is ultimately short-sighted: It is difficult to maintain true anonymity on the internet. More importantly, if people know who you are, you have greater power and credibility to identify and solve problems.]) will protect you because if they can’t find you, they won’t talk about who you are, what you think, and what you do.

That’s not true. People already talk about you.[3. Yes, people are talking about you, but let’s be realistic: They don’t talk about you all the time. Or even all that often.]

And these are people who know what you look like, know where you work, and have experience interacting with you. Patients who don’t like you will continue to dislike you. They’ve probably told someone why they don’t like you. Who knows: They might’ve even shared their opinions about you on the internet. (As I have noted elsewhere: Having an online presence gives you the opportunity to shape your reputation on the internet. You already take active steps to shape your reputation “in real life”: Maybe you make a point of greeting everyone at work with a smile. Or overtly washing your hands in front of patients.)

The internet may be different medium, but the messages we send are the same. It’s also a place to learn and exchange ideas: What are other medical professionals learning? What do patients want? What problems are we trying to solve? How can we make things better? We’d like you to join the conversation.

As a physician you’re trained to discuss risks, benefits, and alternatives about interventions with patients. Having a presence online has its own risks and benefits. If you do decide to step into the online arena, know that you aren’t alone: There are many physicians who write on the internet. Join us.

Categories
Nonfiction Observations Reflection

Sea Lions.

The sun was beginning its ascent into the sky, though it had yet to peek over the horizon. An occasional harbor seal poked its round head through the surface of the dark water in the marina. The twinkling stars overhead were starting to fade.

Dozens of sea lions were piled on top of the rocky pier. The males, some weighing close to 700 pounds, barked and snarled at each other. A loud splash occasionally cut through the din when, during a quarrel, one of them fell into the water.

My friend and I walked along the platform. The wood planks creaked under our weight as we followed the path back to the shore. We spied a sea otter, curled up and snoozing, at one end of the dock.

My friend stopped walking.

“What?” I asked.

He pointed. My gaze followed his finger through the purple darkness.

Not six feet away from us on the pier was a heap of eight or nine sea lions. The smaller ones were farther away from the main walkway. A blubbery male, teeth showing and head raised, was seated on the platform. He was looking at us.

“What if he attacks us?” my friend whispered.

Some of the other sea lions turned their heads and cast a wary eye upon us. The corpulent male guarding his tribe barked. My friend leaned back into me.

“He won’t attack us. They eat fish,” I reasoned.

“That thing weighs like 700 pounds,” he said. “He could crush us.”

The distance between the fleshy sea lion and the other edge of the platform was about three feet. There was no other way back to the shore.

“Just don’t make eye contact and keep walking,” I said.

He didn’t move. Shrugging, I slipped around my friend, kept my eyes down, and walked past the bulky creatures. My fingers could have patted their heads; their flippers could have smacked me into the water.

When I was about eight feet past the sea lions, I heard hasty footfalls behind me. My friend, unscathed by the animals, appeared by my side.

“That was scary,” he murmured.

“They could have eaten us!” he exclaimed once we were on shore. “They weigh a lot! Did you know that sea lions can run on land faster than humans can? Can you imagine a 700-pound sea lion tackling you? Into the water?”

“But they don’t eat humans. And we weren’t going to fight him for that dock or his clan.”

After a few moments of silence, he said, “You’re brave. You walked by them as if they weren’t there.”

I wondered about this later. My friend is not timid, nor is he nervous. Why did the sea lions rattle him so much?

The construction workers across the street shouted at me.

“Hey baby! Wanna gimme some sugar tonight?”

He was sitting on the stoop when I walked by.

“Konichiwa. An nyoung. Ni hao,” he called. “You speak one of those, right, honey? How do you say ‘I love you’?”

While I was waiting to cross the street, he came up to me and said, “You’re pretty. You’re pretty. You’re really pretty. Asian woman, you’re pretty.”

He waved at me from across the room. “Hey, doc! Do you do sex therapy? I want to learn more about that… from you.”

Of course. I am a woman, he is a man. What have I done in the past when I got attention I didn’t want, when I wanted to disappear?

“Just don’t make eye contact and keep walking.”

Categories
Nonfiction Observations Reflection

Michael.

Everyone noticed him before we boarded the plane. He asked the airline representative at least three times to confirm that he had a seat. He looked like an adult, but the tone of his voice was that of a child.

“Yes, you have a seat, Michael. It’s 7B.”

Grey cargo pants covered his short legs. The sleeves of his striped polo shirt collected below his elbows, making his arms look even shorter and his hands even smaller. His neck hid inside his collar. His fingers were short and thick. His glasses magnified the creases in his eyelids. Because his nose was flat, it made his mouth look wide.

The elderly man in the aisle seat had asked the flight attendant to stow his cane. Wrinkles burrowed into his forehead and surrounded his eyes. They revealed a lifelong habit of frowning. The elderly man heaved a sigh of resignation when Michael took the seat between him and me.

Michael sat down with conviction, then stood up and adjusted the nozzle so more air blew into his face. After sitting down again with resolve, he picked up the seat belt.

“What is this?” he asked, his fingers poking the thick padding. When no one responded, he turned to me and said, “This isn’t a normal seat belt. It’s weird.”

As other passengers filed past us, he greeted every third or fourth person.

“Hi! Hi!” He thrusted his arm forward across the lap of the elderly man. Without realizing what they were doing, many people found themselves shaking his hand.

“Hello! My name is Michael! Who are you going to see? I’m going to see my dad. He bought my plane ticket for me.”

“Oh… that’s nice.”

The elderly man sat back, leaned away from Michael, and sighed.

Michael turned off his cell phone. Turning to me, he saw me send a text message.

“You’re supposed to turn off your phone, like this, see?” He waved his phone at me like it was a baby rattle.

Shortly after the plane took flight, Michael reached his hand in front of my face and pulled down the window shade.

“Too bright,” he said as he looked back at the television.

The flight was about two and half hours long. Twice, Michael announced to the elderly man, “I need to use the bathroom.” The elderly man said nothing, pushed himself out of his seat with his arms, and stood in the aisle with sorrow on his face as Michael ambled his way to the lavatory.

When the pilot announced that we were approaching our destination, Michael reached over, grunted, and pulled the shade up halfway. Through the double-paned window we saw the Pacific ocean, its waves rolling towards the coast in a never-ending parade. A squadron of pelicans glided over the water. Small boats left frothing white wakes atop the blue-green swells.

Michael reached over again and pulled the shade up a little more. We both continued to look out the window.

When the plane arrived at the gate, Michael bolted out of his seat, reached over the elderly man, popped open the overhead bin, and pulled down his backpack.

“I’m going to see my dad!” he announced.

An airport attendant boarded the plane and called Michael’s name. He raised his hand with the enthusiasm of a child who wants to answer a question first.

“I’m Michael!” he said. “Are you going to walk with me off the plane?”

I saw Michael a few minutes later outside the terminal and witnessed his reunion with his father. His father did not share physical characteristics with Michael; Down syndrome is not heritable.

They hugged each other and both smiled with joy. The extra copy of chromosome 21 did not diminish the love father had for son.

“How was your flight?”

“It was great,” Michael said. They began to walk away together, his father’s arm holding Michael close to him.

We judge ourselves by our intentions, but we judge others by their actions.[1. This quote is attributed to several different people, including Andy Andrews, Stephen Covey, and Ian Percy.] For people with overt disabilities or deformities, we are more forgiving of their behaviors because we are more charitable about their intentions.

Why do we not do the same for those people whose deformities or disabilities are not visible?

Categories
Consult-Liaison Education Medicine Observations Reflection

The Patience of Patients.

When I was a resident one of my attendings said, “You know why patients are called ‘patients’? It’s because they have a lot of patience. For us.”

Patients in hospitals do a lot of waiting. They wait for physicians. They wait for nurses. They wait to use the bathroom. They wait to undergo procedures. They wait for their IVs to stop beeping. They wait for the person next door to stop vomiting up what sounds like all of their internal organs. They wait for the person down the hall to stop screaming. They wait to eat. (Doctors: Reverse those NPO orders as soon as you can! Food is at the base of Maslow’s hierarchy of needs! Food is more important than safety and security of health!) They wait for the nursing assistants to finish taking their blood pressures so they can sleep. They wait for the unit clerk to answer the phone so a nurse can help them get out of bed without the bed alarms screeching throughout the unit.

They wait to feel better. They wait for good news.

No one has any idea how much patients wait in the hospital until you become a patient in the hospital.

Sometimes it’s not even clear what patients are waiting for. Hospital staff arrive and they have no idea why they are there:

  • “Hi, I’m the physical therapist.”
  • “Hi, I’m here to take you down for an ultrasound.”
  • “Hi, I’m the dietician.”
  • “Hi, I’m the consulting psychiatrist.”[1. Hospitalists: If you call a psychiatry consult for your patient, tell your patient. Most people, with or without psychiatric issues, do not appreciate an unexpected visit from a psychiatrist. “I’m not crazy! Get out of my room! No one asked you to come here!”]

Because of the nature of acute care in hospitals, rarely do things run on a consistent, predictable schedule. This lack of punctuality is not intentional; things change. Hospital staff triage patients all the time and, unfortunately, patients and patient care are shuffled around in order of acuity.

Thus, if you’re in a hospital and someone tells you that So-and-So will see you at 2pm, don’t believe it. Yes, So-and-So might actually see you at 2pm, but it takes extraordinary planetary alignment for that to happen. So-and-So might show up at noon… or at 4:30pm.

Yes, doctors wait, too. The waiting doctors do, though, is informed by the knowledge they have about why they’re waiting. Doctors wait for patients to come out of the bathroom. They wait for patients to go for a study or imaging test. They wait for family members to arrive to get more history. They wait for the pathology or study results to clarify diagnosis and treatment. They wait for information that affects what happens next.

Patients often wait without knowing what will happen next.

If you work in a hospital, remember that most patients have an extraordinary amount of patience, given the circumstances. Yes, there is a minuscule minority who have the frustration tolerance and impulse control of toddlers, but that is not a common means of coping in adults. (Physicians tend to call psychiatry when this happens. This is not a common consult.)

Do what you can to orient patients to what is going on. Give them approximate times for your visits and if you are running late, send a message to them to let them know. (Technology could help here: What if we could send text messages to patients through the television? or if the text message could become a voice message on their in-room telephones?) If patients are not around when you come by to see them, leave a note to let them know that you’ll try again later. (Technology could help with this, too.) Tell them why you don’t want them to eat after midnight. Tell them why you want them to work with physical therapy. Tell them the purpose of the bed alarm.

Help them understand what they are waiting for. Don’t take their patience for granted.

Categories
Consult-Liaison Medicine Observations Policy Systems

Ever Seen a Hospital Orientation?

Perhaps more important than the actual “rules” of hospitals is how these “rules” are communicated to patients.

Medical students spend two years training in a hospital before they work as physicians. It often took me over a week on a specific service (e.g., surgery) to understand its routines and rhythms. While it is true that patients and hospital staff have different roles in the hospital, how can we expect patients to understand their roles upon admission?

Those of you who work in hospitals might be thinking, “But patients don’t have roles in the hospital. They’re there to receive care.” Of course patients have roles in the hospital. When patients deviate from the roles you think they should play, that’s when you start calling them “difficult” and then consult psychiatry.

In general, hospitals have not honed their skills in orienting patients to their roles in the hospital. Rarely does anyone tell you what to do or what to expect when you go to the hospital. This orientation may happen on an individual level (thank you, nurses!), but it is an uncommon institutional practice.

Consider all the places you visit that are not “yours”, though you might be labelled the “customer”. How about fast food joints? They often have signs that tell you where you order your food and where to pick it up. The cash registers tell you where you pay. Shallow corrals tell you where to line up. Those are small details, but they help define your role and shape your behaviors while you are in the fast food restaurant.

Hospitals would do well to adopt the practices of airlines. Have you been on an airplane? Remember how you paid attention to the safety announcements before your first flight? The flight attendants tell you how your seatbelt works, point out the exits to you, tell you about the flotation device that is disguised as a seat cushion, and how to work the oxygen masks that will appear if the cabin pressure drops. It only takes a few minutes. And, in case you want to review the information on your own, they include all of that information “on the card in the seat back pocket in front of you“. Have you ever looked at that card? There are few words on it: It aims to be universally understood.

Why not include a small booklet—comic book?—in each hospital room that provides similar orientation?

Consider hotels. Not only do hotels have written material in each room about hotel operations, but some of them also have a television channel dedicated to hotel features and operations!

Most hospital rooms have a television bolted to the ceiling or to the wall. Why not develop a “hospital channel” that offers similar information about hospital operations and features?

A skim through Google shows me that some children’s hospitals (in Cincinnati and Chapel Hill) have created YouTube videos that offer hospital orientation to kids. Why do we not do the same for adults?

When I have worked in hospitals, I often felt like there wasn’t enough time for me to do everything I needed and wanted to do. When I sat in my mother’s hospital room, I was surprised with how much waiting we did. That time could be used to teach patients and their family members what to expect during the hospitalization, like when the doctors typically round (and what “rounding” even means) or what to do when the IV starts to beep.

If you work as a hospital CEO or at a similar paygrade, I encourage you to work on easy-to-understand materials that orient patients to their roles in the hospital. Realize that patients want their hospital stays to go smoothly. They want to know what to expect. The vast majority of patients don’t want to “bother” hospital staff. They want to help hospital staff so that the medical staff can help them. Patients don’t want to stay at the hospital longer than they have to.

Understand that hospital orientation is like building rapport on an organizational level. Data shows that effective communication between physicians and patients leads to better patient health outcomes. If the outcomes are better on an individual level, why couldn’t outcomes improve on an institutional level?