Monday, June 29, 2009

Remembering the Patient Perspective

Being a med student puts you in the unique position of understanding both the patient's side and the physician's side of a hospital visit. We are not yet comfortable enough with the medicine to think that the diagnosis, treatment, or prognosis are routine everyday occurrences, but we understand some of the physiology and consequences of illnesses.

This perspective often allows us to see flaws in the way physicians, who have much more experience than we do, interact with patients. Physician experience breeds complacency as broken bones, surgery, and even death become "part of the job". On top of that, many doctors are overworked, exhausted, and running on very few hours of sleep. With such a combination of exhaustion and fatigue, it is not surprising that the quality of a physician's bedside manner may be reduced. However, I think there is a basic standard that must always be met.

Yesterday, I was in the emergency room with a friend who had injured her shoulder. She was in pain and very concerned that her shoulder may be broken. The emergency room physician that came to see her was very direct and concise. He did not indulge her in any small talk and, thus, did not build any rapport with her. When he began to examine her, he pulled the chair I was reaching for away from me without saying a word, so that he could use it himself. Now, this physician was not particularly friendly, but I don't feel that he did anything wrong in this physician-patient interaction (even though the guy stole my chair!). He was efficient, he got the job done, he explained to his patient everything that he was doing to her and he also explained what she should expect to happen during her next hour in the hospital.

The next physician that saw her was an orthopedic surgeon. He introduced himself, explained to the patient that she had broken her clavicle, and presented her options. She could elect to have surgery to repair the bone immediately, which would mean she would have to stay in the hospital for the next day or two, or she could wait to see if the bone healed on its own over the next two months. If the clavicle proved unable to heal on its own, she would have to have the surgery anyways. Due to hospital policy, if she wanted to have the surgery immediately she had to decide while she was in the hospital, otherwise, she would have to wait the two months.

This orthopedic surgeon did the bare minimum that was expected of him. He answered all of the questions that were asked; however, he did not even attempt to convey any additional information that could be important to the decision at hand. I think he should have mentioned how either decision would affect the range of motion in the shoulder, any potential complications if she chose to wait two months and found she still needed the surgery, or how her short term quality of life would be affected if she chose to wait two months. He did answer all of these questions when asked, but what if they had not been asked? It's hard to make an informed decision if you aren't informed! While talking to me, she mentioned several times how she did not like the idea of having a foreign object in her body. He just sat there pretending he didn't hear anything, instead of providing his insight as an orthopedic surgeon and perhaps mentioning the evidence based data that supports inserting a metal plate into a person's body.

Worse of all, he kept mentioning how he was in a hurry because he was "off the clock". He explained that he started his shift at 1:00 pm, it was 12:00 am at the time, and he needed to get home to sleep because he had to be back at the hospital at 7:00 am. He pushed for a decision over and over again saying things like, "once I'm done this paper work you've got to decide", "we're on my time, I need to go home", and "listen ma'am, I don't know what is taking you so long". In short, the guy was douche. For him, surgery to repair a broken clavicle might be as normal as warming up leftovers for dinner, but for the patient, this was the first broken bone she had experienced, it was a big deal. Pushing her to make a decision in five minutes is not only incosiderate, it is unethical. He hadn't taken the time to teach her enough about the surgery to consider her decision informed.

I understand that he was tired, that he wanted to go home, and that he doesn't control hospital policy, but all he needed to do was take off his douche-bag-doctor-hat and wear his normal-human-being-hat to see that he should have explained everything. All it would have taken was a "look, I'm very sorry, but hospital policy states you have to give me your answer before you leave and unfortunately, I'm at the end of my shift. I've been here since 1:00 in the afternoon and I'm due back at 7:00 this morning, so I need to go home and get some sleep to be able to do my job properly. I really do apologize, but this means you are going to have to make a decision in the next ten minutes, which is really tough. Is there anything I can do to make that easier?"

If he would have spoken like that his patient would have been more comfortable with him and probably trusted him a hell of a lot more. In fact, she probably would have agreed to allow him to perform the surgery on her. Instead she thought he was a jerk and didn't want him to touch her, a response I'm sure he is used to from his experiences clubbing at a younger age...

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