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More on patient satisfaction

The patient satisfaction forms I mentioned in the last post? Are making it to the residency program now, courtesy of JCAHO (I think).

We were each given a packet of forms, printed on hideously green paper with black type (who made these, the Wicked Witch of the West?) to hand out to our patients.

JCAHO’s coming! Quick, gel your hands!

The statements themselves are in size 10 italic font (great for our elderly patients! so readable!) and range from “My doctor introduces himself or herself” to “My doctor is sincere, trustworthy, and doesn’t keep information from me.” Patients have to rate the resident on a scale of 1-5.

No mention of other things like “My doctor seems competent.” or “My doctor can answer my questions or direct me to more information.” Medical knowledge, it seems, is somewhat irrelevant in this brave new world.

In non medical news, I’m currently reading Wolf Hall, by Hilary Mantel. It won a bazillion prizes when it came out, and it’s being made into a movie in the spring. It’s a tad introspective, but I do like it. Also slogging through The Martian, by Andy Weir, my book club’s official selection, which … it’s like a survival guide to being on Mars. There’s lots of info on how to generate oxygen from hydrazine. There’s lots of “Yay! It worked!” or “Boooo! The generator failed!” which makes Our Hero (TM) sound more like a pre-teen girl than a 30-something mechanical engineer.

 
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Posted by on February 15, 2015 in books, clinic

 

Can’t get no

The clinics here do patient satisfaction forms, and periodically we get aggregate feedback emailed out. For the most part, this is a good thing — helps us understand issues with workflow, ease of scheduling appointments, all those things that as a doc we don’t have direct access to, but surely affects patients’ perceptions of our clinic and our overall competence.

Then sometimes we get gems like this:

HONESTLY some of the questions I answered I had to guess. I did not know how to answer them. I did not have the all the knowledge needed to answer them.

I don’t … I can’t even …. In what world do you blame the clinic for your own stupidity? And if you don’t understand the question because of jargon or something, just SAY SO.

On a bigger scale these stats (% positive reviews) are almost certainly being including in some sort of pen-pusher quality metric. It’s part of larger moves in Health Policy. In the private world, I hear physicians’ pay is being directly linked to patient satisfaction ratings, which seems like a great way to produce a community of candy-men and sycophants. In academia, departments with more satisfaction probably get more perks, or something. They keep promising us that we’ll move out of the basement one day, but with reviews like this …..

 
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Posted by on January 14, 2015 in clinic, PGY-3

 

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My last patient of 2014

I’m settling in to the ICU workroom for my last overnight shift, thermos of coffee at my side. We’ve got just five patients — the small blessings of working over the holidays, when elective surgeries are on hold and we just have to deal with the real emergencies: bleeds, clots, seizures that won’t stop on their own. I’ve already stalked the list of patients in the Emergency Department and satisfied myself that there’s no one likely to come to me. Time for Netflix….

Then the junior resident, the one in charge of the floor patients, comes in. She’s just heard about a stroke patient who got tPA at an outside hospital and is being flown to us. Tissue plasminogen activator is a clot busting medicine, developed decades ago and still our mainstay of treatment for acute ischemic stroke. It’s a mega-dose of natural anti-clot compounds, designed to help dissolve the clog in the artery the same way Drano works on shower drains. Then we watch them in an ICU for 24 hours, so we can do hourly checks and make sure they are not getting worse — worse might mean bleeding.  I’ve taken care of so many post-tPA patients at this point in my residency, it’s practically autopilot. I copy down the information the junior’s got — not much, just a name, date of birth, last known normal — and we await our new arrival. This lady’s in her 90s. They tPA’ed someone in their 90s? What were they thinking??? *

The patient shows up surprisingly quickly. She’s terrified, you can see it in her face. Because of the stroke, she can’t speak or move her right arm, but as she’s being transferred into the hospital bed, she reaches out her left hand and clutches mine — freezing cold — and won’t let go. There’s a swirl of people — the flight crew, nurses, me and the other resident. Someone tugs the curtain closed, and she is subjected to the usual indignities. Gown comes half off for an EKG. Swabs of her nose and her rectum (with different Q tips, of course!) because she’s been transferred from another facility and might could be harboring a superbug infection. People — including me, asking her to do a million things, raise this leg, close your eyes, open your mouth, can you feel me touching your arm? Throughout it all, she doesn’t let go of my hand. It’ll be ok, I tell her, you’re in the hospital. You’ve had a stroke. You got some medicine for it. We’re going to get another scan. It’ll be ok. I finally have to wrench my hand away to go back to the workroom and write my note.

She kept me awake for most of the night, that one. First with chest pain. Then with x-ray results. Then with labs being wonky. Finally at 3:30 AM, I’m jarred awake — when did I fall asleep? — by the phone: her daughter calling for an update. That’s when I learn that Ms. TPA was receiving a highly prestigious award (we’ll call it the Badass Award, for confidentiality’s sake) when she had her stroke. It all sounds pretty dramatic, involving foreign diplomats, the press, and paramedics swooping in. So then, of course, I stayed up Googling her — thankfully there’s no mention of the stroke in any of the dozens of local news articles that come up — but I did come across a video clip of her, a week or so ago, talking about the events that merited her the Badass Award. She was sharp and funny — reminded me of a radio clip I’d heard of Doris Lessing in her 90s, telling Terri Gross that she only got married “because biology demands that when a war starts that people should get married and have a lot of sex. As we all know.” (Terri Gross immediately changes the topic, thus proving that Doris Lessing is infinitely cooler.)

There’s something very intimate about hearing a person’s story in their own voice, whether on NPR’s Fresh Air or via a buggy local news clip. This was clearly a lady with a lot of street smarts, now with such a profound expressive aphasia she couldn’t even say her own name. As neurologists, especially as residents who spend most of our time taking care of acutely ill hospitalized patients, we almost never know anything about our patients’ pre-morbid status. The hospital, when you spend so much time there, tends to breed an insular mindset; nothing outside the hospital truly exists. So those reminders, that people lived before getting sick, and they will go on living after being discharged, are so so important to our ongoing training and work.

And so I’m little ashamed to recall my incredulity that “they” at the outside hospital treated my last patient of 2014. Because if they hadn’t, I wouldn’t have had the honor of meeting a woman who had provided so much service, with so few resources, and seen so much.

* More on physician preference (a.k.a. bias) and tPA here. The original article from 2013 is quite good (one of the few that have really stood out from the Green Journal) but hides behind a paywall.

[And yes, I know I’ve been AWOL. I just re-read my earlier posts, and geez I sounded depressed intern year. Residency’s really not so bad; maybe I’ll post more this year to prove it!]

 
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Posted by on January 1, 2015 in PGY-3

 

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Imagine this….

A little thought experiment:

Suppose you are a guy, pushing the edge of middle age, and have been diagnosed with a reasonably aggressive brain cancer. You work in a menial job and can barely afford your rent, let alone health insurance. You travel 2 hours each way to see your neuro-oncologist, just about the only one in the state who sees people without insurance. You undergo a extensive surgery to take the cancer out — what they can see of it, anyway — and then rounds and rounds of radiation. A follow up MRI shows your disease is progressing despite all that. Your oncologist recommends chemotherapy in the form of a little pill every day for 5 days out of every month. Sounds good, you say, except you can’t afford it. Enter the bureaucracy of charity care, weeks and weeks of paperwork to convince the drug company to let you have a few pills for free.

In the meantime, you start getting headaches, right around where the cancer is growing. They respond to Tylenol, mostly, but you worry about taking too much at once. You call the oncologist’s office for advice, and a nurse tells you to go to the emergency room. So your brother drives you 2 hours to the emergency room at the hospital affiliated with the oncologist, where they can see all his records and the results of the brain MRI you had done 3 weeks ago.

Your headache goes away completely with a little tramadol. The emergency department doctor decides to get a CT scan of your head (“to look for bleeding”) even though you haven’t hit your head or anything. The CT scan shows there’s something abnormal — hardly a surprise in a patient with a brain tumor! — and the report recommends MRI to get a better look. So the ED doctor comes back to you and says, “maybe we should get another MRI.” And you say sure, you’re the doctor, you know what you’re doing. So back to the scanner you go, this time for an extensive scan which shows that your untreated tumor is, well, acting like an untreated tumor — a bit bigger than it was 3 weeks ago.

At this point, it’s 1 in the morning. You’ve been in the emergency department for over 12 hours. Your headache is still at bay. The emergency department doctor wants a neurologist to come evaluate you for possible admission to the hospital. You agree, because they are the doctors, they know what they are doing. Reason for the consultation: “I don’t feel comfortable sending this guy home because he might have a complication. I just want to do what’s best for the patient.”

Those are weaselly words, “I just want to do what’s best for the patient.” Because this is where I got involved, as the neurology resident on call. I was consulting on a man with a known tumor, with known tumor progression, now with … more tumor progression. The chemotherapy he needed could not be provided as if he were admitted to the hospital. The box with the charity pills was being delivered to his house in two days. The last thing he needed was to be admitted to the hospital. What’s best for this patient would have been some recommendations about headache management, and being sent back home from the ED in a timely fashion. Instead, he ends up having to pay several thousand dollars for unnecessary imaging, not to mention wasting hours of valuable sleep. (Realistically, he’s not going to be able to afford that ED visit, if he can’t afford his chemotherapy; to recoup the loss, the hospital will artificially inflate the cost of services to those who can pay their way.)

We failed this patient at nearly every step of the way. First, he should have been given headache recommendations in clinic or over the phone, instead of being sent to the emergency department for a non-emergent (though annoying/troubling) symptom. When he did show up in the ED, neurology should have been called early for recommendations — certainly before 6 hours into his ED course. (I do complain about bullshit headache consults, but if someone with an established neurologic problem develops a new neurologic problem, we’d like to know.) The imaging should never have happened at all — there was nothing clinical to suggest a bleed, and the CT and MRI told us nothing that we didn’t already know.

Moral of the story: think a little before you order a test. I know it’s fun sometimes to shotgun your way through medicine, and there is an academic curiosity in a lot of what we do. And be real careful about using the phrase “I want what’s best for the patient” — it makes you come across as a condescending asshole.

 
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Posted by on March 17, 2014 in PGY-1

 

I’m alive!!

Yes, my friends, I do exist. Somewhere deep in the depths of the hospital…

No but really. PGY-2, my first “real” year of neurology, has been unbelievable. In a good way. The hours are longer (hence the lack of keeping up with this blog) but so so very much better. Try as I might, by the end of intern year I really just did not care about cirrhosis.

I’m working an overnight in the neuro intensive care unit at the moment. I was admittedly terrified of the ICU — after my horrible month in the medical ICU as an intern, when I felt like the Angel of Death more days than not. I am not sure that I like it, exactly, but it’s much more manageable than the MICU. My tiny brain can only handle one organ system at a time, yo!

Currently reading: 1493 (Charles C. Mann) as well as The Grass is Singing (Doris Lessing). Oh, and also Wolf Hall (Hilary Mantel). Only one organ system, but oh-so-many books!

 
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Posted by on February 28, 2014 in PGY-1

 

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Rain = baking!

I had a golden weekend, but because it’s been the wettest summer on record, the Gods of Rain once again ruined my plans to go hiking.

Not that I’m complaining, mind, because I used the opportunity to make some wondrous messes in the kitchen.

Read the rest of this entry »

 
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Posted by on August 18, 2013 in PGY-2

 

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Behind

I spent the week in subspecialty clinics, which was awesome. Except for one thing: the schedulers.

Patients are usually scheduled for follow-up appointments, in 30 minute slots. Occasionally there is an initial visit, which gets an hour. So today, I got to work at 7, spent an hour reading about the 6 follow-ups on my schedule, because even though they are well known to the clinic, they are not well known to me.

My first patient was scheduled for 8, but of course did not show up until 8:15. So by the time I’d seen her, staffed her with the attending, and written her refills, it was nearly 9. (And she was the easiest on my list.) And so it went for the rest of the day, as I slipped further and further behind. I had 2 extremely complicated patients, each of whom took over an hour even before I talked to the attending. Both of them actually need psychiatric care, which I am not qualified to provide — one does not think he needs a “shrink” and the other has limited resources. But when someone tells me they are actively suicidal with access to weapons, I’m not gonna be like “Well that’s not my problem, see ya later!”

Meanwhile, some lady showed up on the wrong day (her appointment is actually later this month) and the schedulers tried to guilt me into seeing her. “Look,” I said, “I’m nearly 1.5 hours behind as it is. She can wait if she wants, but I’m going to see the people who have appointments today first, since they’ve already been waiting.” (She didn’t wait, thank god).

I deferred all my notes, which I hate doing because I worry that patients and plans will blend together. As soon as a patient walked out my door, I went to the waiting room to get another. I felt like a revolving door, and I was rushing slightly toward the end, because I had to get to the Main Hospital, 2 miles away, for a conference.

I saw my last patient, scheduled at 10:30, at almost noon. Skipped grand rounds, disappointingly, because it was on prion disease, and who doesn’t like prion disease? Drove back to the Main Hospital for conference, then had an observed H&P scheduled for 2, then holed up in an empty room for 2.5 hours to write all those notes. Luckily I had no afternoon patients.

It was like this on Wednesday afternoon, too, when they scheduled me for 5 patients between 1:30 and 4, except between a late start and a rather ponderous attending, I didn’t finish seeing people until 6. I was teaching a class that night, so I couldn’t stay to write notes; instead I came back to work at 6:30 in the morning to write them all before Thursday clinic started.

This issue doesn’t happen in the Resident only clinic, I think because the schedulers take staffing-with-attending into account; it nearly doubles the visit time because you have to catch the attending (They are usually staffing 3 or 4 residents at a time), present, and have the attending at least eyeball the patient. But I suspect this is what clinic is like in the Real World of private practice — this revolving door mentality, never feeling caught up, which is frustrating to doctor and patient alike.

(The other frustrating thing: when I left clinic at a little after 5, the support staff, including the schedulers who pushed me into this, were all long gone. As a matter of fact, when I was waiting for the attending on Wednesday, I asked one of the staff if I could bring my next patient back and then staff two together — she said no because “I’ve already cleaned all the empty rooms.” It was 3:45 and she was ready to go home.)

So folks, next time you are pissed that your doctor is running late, remember that she is just as mad as you at a totally broken system that serves no one but the administrators.

 
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Posted by on August 9, 2013 in health policy, neuro, PGY-2, residency

 
 
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