Here’s a question to ask yourself: Are your daily goals and protocols as a hospitalist aligned with the needs of your patients and their loved ones?
I’d always considered myself to be someone who communicated well with patients and families, even while striving for efficiency and productivity in my work. But two recent personal encounters have me rethinking some of my ways.
The first was the admission of my son with Stevens-Johnson Syndrome the week before Thanksgiving–a very harrowing experience for any parent, and one that I pray none of you ever has to go through. Thankfully, he has done well and has recovered completely without long-term sequelae. Shortly after that, I became a patient myself as I underwent back surgery. Both experiences have given me fresh perspectives on what our patients and families experience and feel on a daily basis.
Here’s the first epiphany I had: We physicians don’t realize how intrusive and invasive our daily routine is to patients and their families. Many of the more “routine” procedures, tests and exams, which require no preparation on our part and which we perform many times a day, are less than routine to the patients on whom we perform them.
Little things such as a Foley catheter, a PICC line or removal of a surgical drain–to a patient, these aren’t trivial, and ideally, patients and/or their families should receive some discussion and preparation before they take place. Even a daily exam, especially one that involves the patient being disrobed or exposed, is something that needs to be respected, forewarned and not taken lightly. In the name of “efficiency” around the hospital, I know I am guilty of having taken just these things for granted and have not been as courteous or thoughtful as I might have been otherwise.
Rounding early on patients, while not always practical, is important to patients and their families. Even a brief visit, with an agreement to come back later in the day to spend more time, means a great deal. You’re giving them the impression that today’s data have been analyzed and acted upon, and that a plan for the day is in place. Rounding at 4 p.m., to a patient, means that we have wasted a day and missed opportunities to make needed changes in the plan. Patients and families don’t care what time we write a progress note, but they do notice our attentiveness to details regarding patient care–and early is better than late. If there is any way to save the “scut” work and to even consider “pre-rounding” on certain patients, they will perceive this as attentive and efficient , and they’ll appreciate it.
Making time to communicate with families is one of the most important but easiest to overlook items that we do on a regular basis. We regularly expect those patients who are “A+Ox3” to comprehend and communicate the plan to their family. But frequently, we overestimate their ability to do so.
Medications, especially narcotics or sedatives, sleep deprivation, pain and anxiety, all can have a big impact on the patient’s ability to process the details of our brief visit. They also make it necessary for us to have a clear conversation with those less impaired (the family). This may be the most important risk management strategy we employ on a daily basis. A simple phone call to a family member or an agreement to return later in the day to speak to the family contact, goes a long way, and creates trust in the patient-physician-family relationships.
Lastly, while this is certainly a “hot topic” in hospital medicine and certainly not one I would say has been overlooked, I would still like to put my plug in for clear, concise, communication with the PCP at discharge. I do believe that the traditional method we were all taught in residency to dictate discharge summaries has become obsolete.
Instead, we should rethink how we present information to the PCP and reorganize it so that important, pertinent information is presented early and does not require a PCP to read through a 4-page summary to realize that an acute hepatitis profile was pending at the time of discharge. Here’s what I would suggest as a format:
- Admit and discharge date
- Discharge diagnoses
- Discharge meds, with attention to or highlighting of any meds that have been changed or discontinued
- Pending studies or labs requiring follow-up
- Other issues requiring follow-up including specialist follow-up, if applicable
- Brief hospital course summary
- Summary of lab/imaging studies–just pertinent results, not a daily recount of the patient’s potassium levels
As part of our medical education, we were not forced to spend a day as a patient. Maybe we should have been. I learned a lot looking at what we do from the other side.