Several recent studies have brought to light some disturbing issues regarding patients, medical providers, and the relationships between them. These studies underscore the importance of positive relationships between patients and providers, and how important it is that healthcare consumers feel empowered to advocate for themselves.
Showing posts with label provider-patient relations. Show all posts
Showing posts with label provider-patient relations. Show all posts
Wednesday, September 19, 2012
Tuesday, September 04, 2012
Martine Ehrenclou and "The Take-Charge Patient"
Martine Ehrenclou is a well-known and talented writer whose books "Critical Conditions" and "The Take-Charge Patient" have received well-deserved attention and praise. I have been happy to become acquainted with Martine through our connections on social media, and I'm happy to provide this review of "The Take-Charge Patient", published by Lemon Grove Press in 2012. As always, I received no compensation for this post other than a review copy of the author's book.
Wednesday, May 16, 2007
Good Enough for Today
"So," I said. "Thanks for coming in to see me. It's been a while."
"I'm happy to see you," he replies. "I'm glad you called."
I check his weight, his vital signs, feel his belly, listen to his lungs, review his last labs.
"You know, I'm worried about my liver. I haven't been to the specialist for a long time."
"Why not?"
"I've been traumatized by the whole idea that the cirrhosis is turning into cancer."
"Wouldn't you feel less afraid and anxious if you had more information and saw the doctor?" I ask.
"No. Sometimes it's better just to not know anything." I think he's serious.
"You mean," I reply, "like what you don't know won't hurt you?"
"Yeah. Like that," he nods.
"Hmmm." I look at him and move my rolling stool closer to his chair. "I always think that information gives you the option of acting or not. Otherwise, you're just blind with fear and anxiety."
"Am I gonna die?" he asks me plaintively. "Can my cirrhosis be cancer now?"
"Well," I choose my words carefully and slowly. "Cirrhosis can lead to cancer if you're not careful. If you're drinking alcohol, it's like pouring gasoline on a fire."
We look at each other silently for thirty seconds or so.
"Tell you what," I say. "I'll call the liver specialist and see if he has an appointment open on a day when I can accompany you. Would it help you feel less anxious if I went with you to the appointment?"
"Are you kidding?" He stands up and offers his hand for me to shake. "That would be so helpful. You can do that?"
"We can do whatever we want," I reply. "I'll call tomorrow and make an appointment for next month before my vacation. Meanwhile, you take good care of yourself and come back and see your primary doctor on June 1st. I'll see you then, OK?"
"Alright," he replies. "That sounds great. I feel much better now."
"I'm so glad. Will you call me if you need me?" I hand him my card.
He accepts the business card and says, "I always lose your card. I'll put it in my wallet now." He tucks it into his leather wallet which he pulls from his back pocket.
"OK. See you on the 1st of June. My office will call and remind you of the appointment. And don't worry."
We shake hands. I pat him on his shoulder as he steps ahead of me and walks towards the exit. We've had similar conversations in the past. He's even put my card in his wallet at least three or four times before. Is this time different? Will he follow through after having been lost to care before? Hard to say. But each time we have contact, we're building trust, constructing a relationship, and moving towards a goal of empowerment and therapeutic partnership. Maybe he'll no-show on the 1st. Maybe he'll no-show to the gastroenterologist. But he showed up today. And for now, that's good enough for me.
"I'm happy to see you," he replies. "I'm glad you called."
I check his weight, his vital signs, feel his belly, listen to his lungs, review his last labs.
"You know, I'm worried about my liver. I haven't been to the specialist for a long time."
"Why not?"
"I've been traumatized by the whole idea that the cirrhosis is turning into cancer."
"Wouldn't you feel less afraid and anxious if you had more information and saw the doctor?" I ask.
"No. Sometimes it's better just to not know anything." I think he's serious.
"You mean," I reply, "like what you don't know won't hurt you?"
"Yeah. Like that," he nods.
"Hmmm." I look at him and move my rolling stool closer to his chair. "I always think that information gives you the option of acting or not. Otherwise, you're just blind with fear and anxiety."
"Am I gonna die?" he asks me plaintively. "Can my cirrhosis be cancer now?"
"Well," I choose my words carefully and slowly. "Cirrhosis can lead to cancer if you're not careful. If you're drinking alcohol, it's like pouring gasoline on a fire."
We look at each other silently for thirty seconds or so.
"Tell you what," I say. "I'll call the liver specialist and see if he has an appointment open on a day when I can accompany you. Would it help you feel less anxious if I went with you to the appointment?"
"Are you kidding?" He stands up and offers his hand for me to shake. "That would be so helpful. You can do that?"
"We can do whatever we want," I reply. "I'll call tomorrow and make an appointment for next month before my vacation. Meanwhile, you take good care of yourself and come back and see your primary doctor on June 1st. I'll see you then, OK?"
"Alright," he replies. "That sounds great. I feel much better now."
"I'm so glad. Will you call me if you need me?" I hand him my card.
He accepts the business card and says, "I always lose your card. I'll put it in my wallet now." He tucks it into his leather wallet which he pulls from his back pocket.
"OK. See you on the 1st of June. My office will call and remind you of the appointment. And don't worry."
We shake hands. I pat him on his shoulder as he steps ahead of me and walks towards the exit. We've had similar conversations in the past. He's even put my card in his wallet at least three or four times before. Is this time different? Will he follow through after having been lost to care before? Hard to say. But each time we have contact, we're building trust, constructing a relationship, and moving towards a goal of empowerment and therapeutic partnership. Maybe he'll no-show on the 1st. Maybe he'll no-show to the gastroenterologist. But he showed up today. And for now, that's good enough for me.
Thursday, May 10, 2007
Schwartz Center Rounds
A new concept made its way into my personal and professional orbit today and I wanted to share it here. This concept is something called "Schwartz Center Rounds", which, according to the official website, is "a multidisciplinary forum where caregivers discuss difficult emotional and social issues that arise in caring for patients." The organization is doing some very interesting and thought-provoking work, and we are considering applying for a grant to bring Schwartz Center Rounds into our workplace, where the stress of our work takes its toll daily.
The Schwartz Center website explains further: "Over 26,000 clinicians across the country participate in these interactive discussions and share their experiences, thoughts and feelings on different topics. Schwartz Center Rounds take place at over 110 sites in 26 states."
Developed at Massachusetts General Hospital, the center appears to focus its energies on communication skills, end-of-life care, cultural competency, and spirituality. Aside from the Schwartz Center Rounds model, other programs include specialized training for medical, nursing, and allied health students, a speaker series, The Compassionate Caregiver Awards, and a Clinical Pastoral Education Program for Health Professionals.
Simply the notion that an organization exists with the sole aim of "strengthening the patient-caregiver relationship" buoys my spirit. That we, as a group of professionals, may be able to apply and receive grant money to strengthen our connections with patients and support ourselves in our work is truly a beacon of hope. In a team discussion, we decided that, whether we receive the grant or not, we have to make it our mission to bring this level of healing and self-awareness into our midst. The work that we do---caring for the sickest, poorest, and most disenfranchised inner-city communities---can truly exact a heavy price on clinicians and administrative staff alike, on both the physical and emotional levels. Despite the stress of our endeavor to provide such cutting-edge care, our attrition rate is extremely low, a testament to the closeness and camaraderie that we share as a team. Many of us frequently remark how this group of people works so well under incredible duress with such grace. Still, no amount of camaraderie can counteract the stress-related illnesses that can develop when deeper needs go unmet. I am a walking example, and my healing journey is still ongoing.
Gone are the old-fashioned days of the private-practice physician who tends to the needs of a small geographic area from birth to death, delivering babies and pronouncing the deaths of elders at home. Healthcare has become a behemoth of specialization, splintered care, multiple caregivers, complex treatments, and a financial climate which often flies in the face of the essence of caregiving. Managed care often ties clinicians' hands, and caring for patients is made all the more difficult as providers jump through flaming hoops of bureaucracy to obtain the optimal treatment for deserving and ailing patients. The explosion of obesity, addiction, mental illness, and multiple comorbidities further stresses the system and the caregivers, and dangerous communicable diseases have only increased patients' fears and providers' need for increasingly specialized knowledge. It's a complex medical world in the 21st century, and fears of litigation only serve to make providing care that much more stressful.
Given the current healthcare climate, the complexity of patients with multiple illnesses, and the demands on all of us working in the field, there have to be valves through which the pressure is released. Addiction, alcoholism, workaholism, and burnout certainly do release pressure, but the subsequent damage done by these practices is all too real. Schwartz Center Rounds and similar models of self-reflection and development may be just what the doctor ordered, but it's a medicine that will only work if we take it.
The Schwartz Center website explains further: "Over 26,000 clinicians across the country participate in these interactive discussions and share their experiences, thoughts and feelings on different topics. Schwartz Center Rounds take place at over 110 sites in 26 states."
Developed at Massachusetts General Hospital, the center appears to focus its energies on communication skills, end-of-life care, cultural competency, and spirituality. Aside from the Schwartz Center Rounds model, other programs include specialized training for medical, nursing, and allied health students, a speaker series, The Compassionate Caregiver Awards, and a Clinical Pastoral Education Program for Health Professionals.
Simply the notion that an organization exists with the sole aim of "strengthening the patient-caregiver relationship" buoys my spirit. That we, as a group of professionals, may be able to apply and receive grant money to strengthen our connections with patients and support ourselves in our work is truly a beacon of hope. In a team discussion, we decided that, whether we receive the grant or not, we have to make it our mission to bring this level of healing and self-awareness into our midst. The work that we do---caring for the sickest, poorest, and most disenfranchised inner-city communities---can truly exact a heavy price on clinicians and administrative staff alike, on both the physical and emotional levels. Despite the stress of our endeavor to provide such cutting-edge care, our attrition rate is extremely low, a testament to the closeness and camaraderie that we share as a team. Many of us frequently remark how this group of people works so well under incredible duress with such grace. Still, no amount of camaraderie can counteract the stress-related illnesses that can develop when deeper needs go unmet. I am a walking example, and my healing journey is still ongoing.
Gone are the old-fashioned days of the private-practice physician who tends to the needs of a small geographic area from birth to death, delivering babies and pronouncing the deaths of elders at home. Healthcare has become a behemoth of specialization, splintered care, multiple caregivers, complex treatments, and a financial climate which often flies in the face of the essence of caregiving. Managed care often ties clinicians' hands, and caring for patients is made all the more difficult as providers jump through flaming hoops of bureaucracy to obtain the optimal treatment for deserving and ailing patients. The explosion of obesity, addiction, mental illness, and multiple comorbidities further stresses the system and the caregivers, and dangerous communicable diseases have only increased patients' fears and providers' need for increasingly specialized knowledge. It's a complex medical world in the 21st century, and fears of litigation only serve to make providing care that much more stressful.
Given the current healthcare climate, the complexity of patients with multiple illnesses, and the demands on all of us working in the field, there have to be valves through which the pressure is released. Addiction, alcoholism, workaholism, and burnout certainly do release pressure, but the subsequent damage done by these practices is all too real. Schwartz Center Rounds and similar models of self-reflection and development may be just what the doctor ordered, but it's a medicine that will only work if we take it.
Monday, February 12, 2007
Adherence versus Compliance
Just the other day, a conversation was born amongst colleagues regarding two words/concepts that are used almost interchangeably in healthcare. Adherence and compliance, those somewhat subjective measures of how well a patient follows medical instructions, appear in medical charts, professional journals, PowerPoint presentations, scholarly articles, and all manner of medical ephemera on a regular basis. These concepts are even the subject of professional workshops and conferences. Our conversation centered around the difference between the two, and what it means when we use one versus the other, both, or neither.
First, we should begin with definitions. "Compliance" is defined by dictionary.com as "conformity; cooperation or obedience; accordance; the act of conforming, acquiescing or yielding; a tendency to yield readily to others, especially in a weak and subservient way." Hmmm (hand scratching chin pensively).
As for "adherence", our friendly neighborhood Internet dictionary defines this term as "the act of adhering; adhesion; the quality of adhering; steady devotion, support, allegiance or attachment." Also quite interesting.
What immediately grabs my attention is the notion that "compliance" is defined as a type of obedience, especially a subservient breed of obedience. Perhaps this is also why I seem to notice the term "non-compliant patient" used so often in medical charts. In this culture where doctors are somewhat deified and in which medicine can often take on a paternalistic pallor, definitions of a patient's relative obedience to medical advice would be the language expected of medical personnel when documenting patient behavior.
When we providers see ourselves as offering the patient the best, most inarguable advice, we must implicitly expect a certain obedience or acquiescence to our prescribed treatments. We all have known patients who seem so eager to please us, so passive and opinionless, that we wonder how much of their ingratiating attitude is simply displaced desire to please a demanding parent. While we do at times feel like substitute parental figures---even for elderly patients---these are not healthy roles for provider and patient to assume. Wanting a patient to "comply" with one's advice does indeed seem that one wishes to "bend" the other's will towards one's own. How healthy can this be for either party on a psychic level?
Conversely, the definitions of adherence bring to mind notions of support, devotion, and attachment, with "allegiance" bringing to mind a sense of something shared cooperatively by both parties rather than forced upon one by the other. Using this term in relation to a patient does certainly seem to carry a very different tone which lacks a certain paternalism that "compliance" seems to engender. Partnership and bilateral decision-making come to mind, rather than unilateral command and obedience.
I am remembering as I write this post that the visit note forms which our agency uses has a small section entitled "Medication Adherence" in which we document our assessment of the patient's medication-related habits. Was it a deliberate choice to use "adherence" rather than "compliance"? I'll have to ask my boss.
In the course of my blogging, I seem to write a great deal about patients who are not exactly following the medical script. I note that I recently posted a missive entitled "Non-Compliance, Apples and Surrender". Did I think about my choice of words or did compliance roll right off my tongue, or rather, keyboard? I must say that when it came to the patient in question, I naturally chose non-compliance. Perhaps it is when patients seem to be making choices which we know will certainly cause them harm that we see them in this way.
For many providers, I think there is a certain proprietary quality to some provider-patient relationships. Within our practice (and many others, I'm sure) there is constantly comments like, "She's my patient" or "He's not mine, he's hers." Ownership can be a positive aspect, meaning that the nurse or provider is taking responsibility for the individual's care. Similarly, our patients will say, "That's my nurse" or "She's my doctor". These are all socially acceptable and understood notions of belonging, of connection. We simply must be cautious in their contextual use.
Coming to the close of this particular missive, my jury is still out whether I feel it is "wrong" to use the term "non-compliant". It is certainly food for thought, and very worth pondering vis-a-vis my own practice and documentation. As I learned in nursing school, medical and nursing notes are legal documents, and labels which we apply to patients can haunt them for the rest of their lives, often coloring how a new provider will feel about a patient before even making their acquaintance. Not only do we carry the responsibility to do no harm in relation to our care, we should also be careful to do no harm with our words.
I may need to revisit this question as time goes on, and welcome any comments on the topic. This particular blog entry is very much a process of thinking out loud, and I welcome any reader to do the same. (But will you comply?)
First, we should begin with definitions. "Compliance" is defined by dictionary.com as "conformity; cooperation or obedience; accordance; the act of conforming, acquiescing or yielding; a tendency to yield readily to others, especially in a weak and subservient way." Hmmm (hand scratching chin pensively).
As for "adherence", our friendly neighborhood Internet dictionary defines this term as "the act of adhering; adhesion; the quality of adhering; steady devotion, support, allegiance or attachment." Also quite interesting.
What immediately grabs my attention is the notion that "compliance" is defined as a type of obedience, especially a subservient breed of obedience. Perhaps this is also why I seem to notice the term "non-compliant patient" used so often in medical charts. In this culture where doctors are somewhat deified and in which medicine can often take on a paternalistic pallor, definitions of a patient's relative obedience to medical advice would be the language expected of medical personnel when documenting patient behavior.
When we providers see ourselves as offering the patient the best, most inarguable advice, we must implicitly expect a certain obedience or acquiescence to our prescribed treatments. We all have known patients who seem so eager to please us, so passive and opinionless, that we wonder how much of their ingratiating attitude is simply displaced desire to please a demanding parent. While we do at times feel like substitute parental figures---even for elderly patients---these are not healthy roles for provider and patient to assume. Wanting a patient to "comply" with one's advice does indeed seem that one wishes to "bend" the other's will towards one's own. How healthy can this be for either party on a psychic level?
Conversely, the definitions of adherence bring to mind notions of support, devotion, and attachment, with "allegiance" bringing to mind a sense of something shared cooperatively by both parties rather than forced upon one by the other. Using this term in relation to a patient does certainly seem to carry a very different tone which lacks a certain paternalism that "compliance" seems to engender. Partnership and bilateral decision-making come to mind, rather than unilateral command and obedience.
I am remembering as I write this post that the visit note forms which our agency uses has a small section entitled "Medication Adherence" in which we document our assessment of the patient's medication-related habits. Was it a deliberate choice to use "adherence" rather than "compliance"? I'll have to ask my boss.
In the course of my blogging, I seem to write a great deal about patients who are not exactly following the medical script. I note that I recently posted a missive entitled "Non-Compliance, Apples and Surrender". Did I think about my choice of words or did compliance roll right off my tongue, or rather, keyboard? I must say that when it came to the patient in question, I naturally chose non-compliance. Perhaps it is when patients seem to be making choices which we know will certainly cause them harm that we see them in this way.
For many providers, I think there is a certain proprietary quality to some provider-patient relationships. Within our practice (and many others, I'm sure) there is constantly comments like, "She's my patient" or "He's not mine, he's hers." Ownership can be a positive aspect, meaning that the nurse or provider is taking responsibility for the individual's care. Similarly, our patients will say, "That's my nurse" or "She's my doctor". These are all socially acceptable and understood notions of belonging, of connection. We simply must be cautious in their contextual use.
Coming to the close of this particular missive, my jury is still out whether I feel it is "wrong" to use the term "non-compliant". It is certainly food for thought, and very worth pondering vis-a-vis my own practice and documentation. As I learned in nursing school, medical and nursing notes are legal documents, and labels which we apply to patients can haunt them for the rest of their lives, often coloring how a new provider will feel about a patient before even making their acquaintance. Not only do we carry the responsibility to do no harm in relation to our care, we should also be careful to do no harm with our words.
I may need to revisit this question as time goes on, and welcome any comments on the topic. This particular blog entry is very much a process of thinking out loud, and I welcome any reader to do the same. (But will you comply?)
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