patient relations


Some doctors have a great way of interacting with patients. They strike a friendly, humorous (when appropriate) note immediately, and the rest of the proceedings are just like a plain conversation. They can crack jokes that the patients find funny, and always have a wisecrack response to the patient’s jokes. This especially works for the young male residents, who pick up the inner city slang, and can speak that dialect without sounding fake.

I’ve never been like that. I can be professional, calming perhaps; I flatter myself that I’m good at explaining the problem and the potential solutions in understandable terms. But camaraderie and humor are not my suit.

So I was tickled today when I went in to talk to a patient who’d been giving the nurses a bit of a hard time, and suddenly found him laughing as though the two of us had a private joke. “I like your style, doc,” he said. “You and me get along. We understand each other. I like your style.”

I don’t know what I did differently, but it was fun that he was so satisfied. Now when I have to tell him something he won’t like tomorrow, maybe it will go a bit smoother. . .

A few hours into a busy morning – the kind that always develops when, building on a string of slow days, I have a stack of journal articles to read and paperwork to do – I got a nonsense consult. Nonsense as in, all the surgery attendings in the hospital already knew about the patient, and had discussed her condition at length and leisurely among themselves. As a result of this consultation, spread over three days, they had decided that the one attending should officially consult the other attending. Which means his resident, that is, me, needed to go put an official note in the chart to let the poor medicine team which was babysitting this patient know that the surgical attendings have changed.

So my seeing the patient and writing a formal consult was going to contribute absolutely nothing to the patient’s care or to my team’s knowledge of her; but it had to be written.

It didn’t make me any more enthusiastic that the picture I got from the chart before going into the room was of a patient seeking pain medication. Sure, she had a couple genuine chronic conditions with biopsy documentation of their existence; but she was on a lot of narcotics, plus some valium thrown in. She had been on disability for years, even before this most recent, serious problem cropped up.

I was in for a surprise.

She was polite, pleasant, and a very coherent historian (first clue; real seekers try to muddy the waters). She was able to tell me all the studies that had been done, and gave me a timeline of her symptoms and the path to the final diagnosis.

I asked how long she’d been on disability, and all of a sudden she started talking. She’d been injured a few years before, but had kept busy up till last month taking care of her father, whose health had declined precipitously. Last month he died at home.

I didn’t have to say anything at all; she just wanted someone to listen. She told me about her mother’s poor health and inability to care for her husband, about how painful it was to watch her father getting continually worse. She told me about how he joined the army right after Pearl Harbor, flew several bombing missions, and was eventually interned in Switzerland, then came back to get married and start a family.

There was a lot more – his death had hit the family hard, and it sounded like the siblings weren’t relating to each other well now – but I wasn’t looking for holes in the story any more. No slacker takes disability, then works 24/7 caring for a dying parent. Most healthy people don’t do that much.

At the end of that talk, I understand why psychiatrists don’t believe in physical exam. After that much sharing, it’s rather anticlimactic to ask if you can listen to the patient’s lungs.

Another of my patients died, and all I could think was, “Good, I don’t have to do all the DNR paperwork, I only have to fill out the death certificate, call the coroner, and dictate a death summary.” I guess I got used to death pretty fast.

Well, we could see it coming all day. The attending talked with the family some, and then got swallowed up in a deluge of real traumas. Everyone else went off to those, and I was left as the person senior enough to handle the ICU, but junior enough not to be absolutely needed in the ER, a very disconcerting seniority level indeed. Here Alice, take care of all the crashing ICU patients while we handle the wild stuff in the ER.

I’m not good like the social workers are with grieving families. I watched closely the other day, the last time a patient died, and the family was dissolving in the hallway. I hate watching people cry; it’s horrible to be involved, but outside enough that you can’t quite join in. The social worker was really good. The main thing I took away was a much higher level of physical involvement than the medical personnel usually allow themselves. So tonight I tried that, and it seemed to go ok; and other than that I said all the comforting things I could think of.

I hate being comforting, under any circumstances. The things the patients and families want to hear from you are usually at varying odds with the truth or with reality. I’m getting better at it, but it still gives my truth-gauge quite a twinge to make all kinds of reassuring statements: things will be ok, everything will be fine, it’s better this way, there was no pain, he’s comfortable, it will be all right. . . The phrases that people expect from doctors, need to hear from the doctor in order to have peace with themselves. . . I don’t really believe most of it, but I have to say it. . . like the parts of the Orthodox liturgy asking for Mary’s intercession; I don’t believe it, but it’s too important (and beautiful) to not say. . . So I read my lines, and try to give a convincing impersonation of a reassuring doctor.

I was going to keep talking, but it was getting too incredibly morbid. I’m tired of the ICU, can we go on to September now?

This is getting better. I got to do another bronchoscopy today, and actually saw something useful (instead of just getting the scope jammed inside the tube and not being able to move; while the attending kept saying, “You see the carina? Go down the right side, ok, now go down the left side. . .” while I wasn’t actually moving at all, and then wanted to know why I wasn’t done already).

The rest of the residents want to know why it’s always my patients who need all the procedures. Somehow, I’ve managed to do almost all the procedures so far this month, without actually stealing anything from them. I wouldn’t mind if my patients would stop crashing, but I’m not controlling that. I need to make an effort not to pick up the sickest of the new patients every morning, so we can share the excitement.

At one point there were enough traumas coming in (as a general principle, men over 70 should not be allowed to climb ladders, and people over 90 should not be allowed to walk on stairs) that I was admitting by myself again. I got the sweetest little old lady, who very calmly coped with us running all around her in the trauma bay, and told me, “There’s nothing wrong with me, sweetheart. I know you need to check, but I’m really just fine. No, I never had any surgeries. I usually don’t come to the hospital, you see, until lately. No, nothing’s hurting me. I told you there’s really nothing wrong, you don’t have to worry.” There was something wrong (little old ladies over 70 always break something when they fall), but hopefully it won’t be too serious, especially since her first words, when I told her the bone was broken, were, “I’m not going to have surgery, ever, no matter what, so that settles it.”

The fun part was when her daughter came in to see her, and it turned out that I’d spent several nights, one night float month, dealing with this daughter’s post-operative complications. One night she’d have low urine output, another night an arrhythmia; then she got an ileus and was throwing up and I had to put in an NG tube; and so on and on, till I finally got off night float before she left the hospital. She was quite well now, and told her mother everything would be fine, she knew the doctor. It was sweet, but also a little daunting, that I’ve been in one hospital so long that I’m starting to treat families. I wasn’t expecting quite this much continuity in surgery residency.

Now that we’re getting down to the wire, I’m having the same butterflies I did last year at this time. The butterflies are riding a rollercoaster – first excitement at moving on then, and then fear at the prospect of having even more responsibility than I have now.

There’s also the vertigo-inducing exercise of turning around, as it were, and remembering how the second-year residents looked to me when I started last year. I revered them nearly as much as I revered the chiefs – and them I nearly worshipped (which is just as well, because the executive chief is the direct manifestation of the program’s control over your life). And then to turn back, and realize how lost I’m going to feel, and the interns are going to be looking at me with – hopefully not reverence, but a little respect. And looking ahead, the increasing certainty that the new chiefs don’t feel any  more confident with their role than I do with mine. . . We all perform for each other.

The unit has stopped whirling a little bit, and settled down to more straightforward feverpaced activity. I had my first patient go into a grand mal seizure in front of me – actually the first real seizure I ever witnessed, and she had to go and be in status epilepticus for nearly forever. The seniors were all off elsewhere, in traumas, so I was left rummaging through my memory of the neurology rotation in medical school, and telling the nurses, “Since this patient has been in status for the last 30 minutes, her neurons are seriously burning out now; and we’ve already tried multiple doses of three different medications, so at this point I don’t particularly care what medication that we have to get from the other end of the hospital that the neurosurgeons do in these circumstances, iv valium is the handiest thing we haven’t tried yet, go ahead and push it.” And it actually worked. After we stopped the seizures, then the neurologists, neurosurgeons, and seniors turned up, and of course all looked at me skeptically: “Who’s seizing? I don’t see the patient moving at all.” No, because she’s had high-dose ativan, dilantin, valium, and propofol, she better not be seizing. So I was reduced to imitating the seizure for them, and the EEG confirmed my diagnosis. But I can hardly feel pleased about handling it, because it makes this patient’s prognosis so bad, and the family doesn’t seem to understand yet how bad things are.

I’ve also spent too much time in the last week talking to doctors about their relatives in the unit. Something funny is up, there are so many doctors’ mother/grandfathers/aunts/cousins through here lately. It’s a tricky conversation. You have to show courtesy between professionals, and also deference, since they’re all attendings a long way into private practice, and you’re just an intern. On the other hand, mostly they’ve been in very non-surgical specialties (pediatrics, heme/onc, family medicine), so in all honesty, between their nonsurgical mindset, and how far they are from medical school and internship, I may be (and my attending definitely is) a little more familiar with the management of critically ill trauma patients than they are. I’m still trying to figure out the exact phrases to use for telling them something that they may or may not already know or remember. But they are certainly the most wonderful historians; they can tell you all the medical history, medications, allergies, and surgical history of the family member; it’s like having a walking medical record. And then there’s the concern that if I use a technical term incorrectly, they’ll walk away thinking, “What kind of incompetent residents do they have working here, they can’t even name the fractures correctly?” Mostly, though, it goes ok. Just as I would be in such circumstances, they’re very glad to get some definite information in medicalese – the guild language.

I have more stories from vascular, but the best ones are so unique, they’re almost worthy of being published case reports, so I don’t want to tell them for a while, for hipaa-type reasons.

In general, I’m going to miss this month. Usually it’s a service the residents love to hate, because it’s so insanely busy, and the patients, though wonderful people, have a propensity to spiral at any moment. You have to have a much higher level of suspicion for all kinds of things, from heart attacks and strokes to UTIs and wound infections.

But I had perhaps the best chief of the year, and one of the best junior residents, and the attendings are great. Most vascular attendings are. There’s something about the field that attracts people who like to dissect a problem with protracted analysis (for ischemic disease in the leg, you can do almost innumerable angioplasties, you can do femoral-femoral bypasses, iliac-femoral bypasses, femoral-popliteal bypasses, femoral-anterior tibial bypasses, femoral posterior tibial bypasses, and all of the above with either harvested vein or one of three different kinds of prosthetic grafts; now let’s discuss which one would be best for this patient), and yet also enjoy intense surgeries which can last all day long and get into serious blood loss and potential for complications. It’s different from general surgery, which I think tends more toward quick, clear-cut solutions (either the bowel is dead or not, so you should operate on it, or not).

Sign-out at the end of the month is time-consuming. Figure 15-20 patients per intern, plus 5-10 consults, all of whom need to be explained in rather more detail than just the nightly sign-out (which, if the person’s been there for a few days, often consists of “post-op day three, eating ok, working on increasing activity and planning for discharge; no impending problems”). At the end of the month, you need to give what surgery was done, why it was done, what the other medical problems are, what you’re doing about them (on vascular, this consists of a lot of afib-coumadin and hypercoagulable disorder-heparin drip arrangements, as well as blood pressure meds and other things), what infections they’ve got and what antibiotics have been gone through so far, how well they’re walking, what their family situation is like and how likely they are to have good help at home when they leave, in addition to who needs surgery in the next few days and who’s at risk for major cardiac or respiratory issues in the near future. Plus, it’s nice to give the next intern a heads-up about which attending wants his notes written by a certain time, which attending hates consulting endocrinology, which attending wishes you would consult all the specialty services and don’t mention medicine to him, which attending does all the fistulas, and all the details that keep you from stepping on the invisible mines. That takes 3-45 minutes, if you’re both being conscientious; and then you still have to go and get signed-out to about your new service. It’s nice when it happens on weekends, there’s more time for talking. Otherwise you find yourself running up against the end of the day, when staying for an hour and a half (total, spread out) could mess up your hours.

And then, I also like to walk around and say goodbye to my patients, especially the ones who’ve been there for more than a day. I don’t know what they think, but I’m under the impression that we have a little bit of a relationship, at least some recognition by them that I work for their surgeon and have been trying to take good care of them, and it’s nice to give them some warning that a stranger will be walking in to wake them up at 5am tomorrow.

Pursuing the issue of work hours: suppose a patient dies right before change of shift. The family has been notified briefly on the phone (via a message, because no one is answering, or perhaps a conversation cut short by grief and shock), but won’t arrive for at least a couple of hours. If the day team goes home as planned, the only person there to talk to the family will be the night float junior resident, who, with all the good will in the world, is overworked. Even if he gets time to talk to the family, they’ve met him maybe once or twice before, and have discussed little of their loved one’s situation with him. The attending and chief who did most of the interaction with them will be gone. As residents, we’re not about to ask our attending his plans, but we doubt that he’ll come in from home, on a night he’s not on call, to discuss how one of his cases went bad.

Your initial response, and our instinct, would be for at least the chief to stay in the hospital (trying to use the time to study or do something else productive) or perhaps arrange to come in from home when the family arrives.

But the chief has been operating late into the night for the last several days, and was in the hospital almost the entire last weekend. Staying a few extra hours to wait for the family, or even coming back for an hour later on, will push him over the 80hr limit, and hinder him from fulfilling his responsibilities later in the week. He can either stick with the rules, and satisfy himself with having spoken on the phone, or ignore the rules, misreport his hours, and stay around to fulfill this last ultimate duty to a patient and family, to talk with them personally about the death.

This is an extreme but very plausible scenario which illustrates the basic problem with the 80hr rule: an outside agency (government, and the ACGME, which is not surgery-specific) imposes an iron-bound rule which sets our regard for the law and for honesty in our reporting at odds with all professional instincts and obligations, and leaves us feeling guilty no matter which we end up following.

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