Unique Skills

For a loving care relationship, I need to humble myself with my patients and appreciate their roles and contributions to their families, friends, and community. Inherent in this effort is for me to seek out those unique skills inherent in each person's life so I know more about who they are.

A patient who runs his own landscaping business told me the other day that he had been asked by one of his clients to install a mailbox. He had the same reaction physicians may have to a question we may think is common sense self-care issue (e.g. trial of OTC cough and cold medications for a mild upper respiratory infection); he wondered how "the man of the house" wouldn't know how to accomplish this relatively easy task. For additional background, the client is an anesthesiologist, the medical specialty involved in caring for patients during the pre-, peri and post-operative period. (For full disclosure, my own technical expertise isn't much different. In fact, I believe my wife changed out our mailbox the last time this home improvement item was needed!)

He went on to say that he and his team members have built a fair amount of trust with his various clients over the years. His daughter had even been asked, at one time, to help deep clean the same client's home in preparation for a holiday party. Following the job, she commented to my patient that this physician had a large number of books in his library and was obviously well-learned. His conclusion to me was highly informative and insightful:

"I don't have the toolset in my garage to put people to sleep. Why should I expect him to have the toolset in his garage to change out a mailbox?"

The medical applicability to this acknowledgement is that we may tease out additional information that is highly useful for the diagnostic work-up and treatment plan. We just have to be curious and tease out this additional information. More and more, work places expect the healthcare team to determine functional status and disability for work. Activities of daily working, if you will, can be just as important as your activities of daily living. In addition, we may learn, during our questioning, that certain tasks patients accomplish on the job or for their hobbies may be contributing to their underlying concerns as well.

We each have our various toolsets. We each have our skills. Find them and use them.

SECRET WORDS/PHRASES: "Job-related concern" "I think my problem may be related to my job / hobbies." For providers: "What do you know how to do that I probably can't do?"

Honor your Values

Values inform the overall principles of life we all follow. They are the basis of both upbringing and personal experience. Although I am a fierce advocate for certain measures and approaches that benefit the collective health of our communities, I am also a fierce defender of the freedoms you have from making decisions that are not consistent with your values. The irony is apparent in my own background as the son of a pastor and a teacher, professions that advocate for both personal faith and informed education. As a patient within the larger medical community, you serve as your own broker of honesty and forthrightness.

The issue of immunizations is probably the most common bone of contention for health professionals. A strong contingency exists within the medical community against anti-vaxxers, as they are called. These folks often have anecdotal stories they read on the internet (for which the patients rarely have a specific link or reference) but others have real experiences. One family I recently encountered had a grandmother who died of Stephens Johnson syndrome following an influenza vaccine. They predictably refuse the flu vaccine each year.

Other interactions have been from the less informed. A pregnant teenager advised me at one point she had done some research on the internet and didn't want her baby to be exposed to any unnecessary vaccines. This sort of naivete is both frustrating and challenging. As above, my advocacy stems from the Master of Public Health whereas my defense of freedom has its origins from my military service.

The ultimate charge to fellow professionals is to elicit patients' values and correlate them with the important moments and decisions in our practice. Critical decisions regarding end of life, the role of medications, initiation of lifestyle-related decisions such as dialysis or other life-changing issues require both open ears and a caring voice. Your unique self informs these values and we should honor them.

Do Nothing

A mentor and military leader once taught me the phrase, "Don't just do something; stand there." Too often we believe we are in an urgent situation when we actually have time to reflect. Particularly when there is a vetting process, we should pause or take a step back and survey the scene. We can apply this same approach to medical decision-making as well. Mindful consideration of the differential diagnosis is highly valuable, particularly when the underlying cause is not clear. In fact, the differential, as we call it for shorthand, is important to ponder even when we think the presentation is clear, preventing us from falling into the easier mindset that common things happen commonly. In addition, we should not fault (or perhaps even celebrate, applaud, or encourage) the brave souls who decide NOT to go forward with the next step in the evaluation or therapeutic process. An informed patient is sometimes the best partner to decide collectively to just stand there and be together.

Pronouns

I, we, you, and them are all potential dividing lines, especially when we use language to differentiate sides. If we see patients as a "they" separate from a "we," we are no longer on the same team working on challenges towards common goals. We have to be vigilant against creating an "us versus them" in what can otherwise lead to a particularly adversarial relationship in the patient-physician interaction. Let us use we more often.

Lost to Follow-up

Patients report they don't know what they are supposed to do 40% of the time they leave the clinic or office setting. Providers use big $25 words and important-sounding lingo that only causes more confusion. Providers can be terrible in communicating the plan but patients don't feel empowered to push back to clarify either. We fail our patients if they aren't on the same page. Ultimately, patients and providers alike suffer from poor communication. The proverbial dropped balls lead to the classic line: "lost to follow-up."

I have a sign above my door stating the following:
"WARNING: This doorframe has a mind erasing forcefield. Please ensure you have a Patient Plan upon checkout."

Our clinic and organization as a whole has a requirement that every patient leaving our facility receives what is called the Patient Plan. This simple document includes the reasons you came to visit and the various diagnosis codes associated with our discussions. Each clinical problem ideally includes basic instructions and "homework" for the patient to review as applicable. It also includes a list of active medications for future reference. Of note, the patient can also opt for an electronic version sent to their patient portal but the principal is the same. The patient has ownership of the instructions on their way out the door.

Granted, the quality of this document is only commensurate with the amount of effort exerted by the provider at the point of care, but it's a great way to document, ideally in plain words, what the expectations are for the patient and provider alike. These are, in essence, the "doctor's orders."

We spend an inordinate amount of time combing through reports called orders management. Our support staff is charged with sending out results, making phone calls and, for patient safety, quality and prevention, recalling patients who haven't accomplished their tasks. If you have undergone a diagnostic test or a lab draw, you deserve to know the results and their corresponding interpretation. If a referral has been recommended for a specialty consultation and you haven't heard back on how to schedule, you should contact your provider's office. If you aren't going to follow through with a recommendation for a test or referral, it's your responsibility too. Let us know why you don't think you need a medication, test or referral anymore; you may be wrong or you may be right but at least let us know! All of us have examples of patients delaying their care and suffering the consequences.

I implore you, as a patient... DON'T get lost to follow-up.

Be yourself / Provider / Honor your values

After a fairly heated but insightful discussion about preventive medicine, one of my mentors stated that a belief system (based, of course, on values) shapes the very lens by which you view the world and how you allocate resources. He noted that we could spend $100,000 per quality-adjusted life year (QALY) saved on a screening test, immunize a few hundred children, or decide, instead, to put up more roadside barriers or rumble strips on the freeway. I have known and accepted this concept for the purposes of political or social priorities but I had not applied the same principle towards the medical model.

Societal values shape the very means by which we celebrate the good catches (high sensitivity), malign the misses (poor specificity), or find a balance with how we spend our time and effort. Personal values shape the day-to-day decisions as well. 

Take care / Patient / Define health for yourself

The greatest foible I have seen from the medical community is to set forth the expectation that our patients will follow our advice based primarily on our authority and expertise while we disregard their values and expectations. We attempt to define health on behalf of our patients instead of allowing them to find and define it for themselves. Unless there is an overt threat to public health, our culture honors a laissez faire approach to honoring personal health choices and their consequences so it’s up to the patient to ultimately set their goals.

The healthiest person I have ever taken care of is a 92 year old lady who presented to me mid-summer for a follow-up visit. She had been in the hospital for a worsening episode of congestive heart failure (CHF) and her regular primary care provider was not available to see her post-discharge. I was the proxy doc for the day which happens in a busy practice with multiple partners and schedules. I didn’t have rapport with her nor did I know what her normal looked like but she needed to be seen. These visits can be some of the most challenging because each physician still has their own style and approach. In addition, a patient that looks terrible to the patient-naive physician actually looks better according to their more familiar provider.

Although I had never met her before, it was clear that something else was transpiring inside her frail body. She didn’t have any swelling in her legs and was breathing comfortably, but she was yellow. Her paper-thin skin had a tinge of the extruded hepatic substance called bilirubin, a byproduct from the breakdown of red blood cells. Her eyes looked similar, otherwise known as scleral icterus. She denied pain. The presentation of “painless jaundice” means only one thing until proven otherwise: pancreatic cancer. We talked for a bit with both her son and daughter, concluding that her CHF had dramatically improved but that her jaundice was of significant concern.

I ordered the laboratory tests, confirming that she had an obstructive process inside her biliary tract. She was readmitted into the hospital. The CT scan demonstrated the mass deep inside her belly. When posed with the question about what to do next, she and her family bravely opted for what I was hoping they would do: nothing. She did undergo a stenting procedure where a small plastic tube is inserted retrograde into the bile duct via an upper GI scope, allowing for better drainage of the liver, but she otherwise was at peace to go home on hospice.

I saw her one more time before she died. She had developed swelling in one of her legs. It was painful and her family wanted to know what could be done without too much intervention or trouble. It was a deep venous thrombosis (DVT), otherwise known as a blood clot, in her left leg. The preferred treatment is an injectable blood thinner which she used over the next 10 days to make her more comfortable as the body slowly resorbed the clot. She eventually switched to aspirin and, as far as I know, did not experience a recurrence.

This last visit was the inspiring visit that led me to believe that patients define health, not physicians. When I saw her that day, she was glowing, not from her skin color but from her pure essence. She portrayed a feeling of contentment I rarely see during a visit with anyone, let alone a terminal patient. Yes, the cancer was eating her from the inside out and causing her blood factors to inappropriately form clots in her legs but she told me how she was doing. Every Friday, her grandchildren still came over to play Euchre. She was visited once a week by her priest. She continued to read her Bible and do devotions. She was happy… and healthy.

Just two days before Christmas, my patient reached her final moment and died in the arms of her beloved son surrounded by loved ones. Her family brought over one of the traditional Catholic obituaries on a small bookmark-like card. I cherish these small but meaningful trinkets and reflect upon them in times of concern or self-questioning of why I went into medicine. You see, patients are ready to share their goals of health with us. We  just need to be ready and open to listen to them and help define it.