Communicating

My malpractice is through SVMIC.  They periodically sent out a newsletter with upcoming seminars and an article or two on ways to improve your practice/ decrease your risk of getting sued.  The current issue’s article is “Communicating with Patients Who Are Deaf.”

The article reminds us in health care of the Americans with Disabilities Act (ADA) which prohibits all physician's offices (except those operated by religious entities but notes the similar Rehabilitation Act of 1973 covers physician’s offices operated by religious entities) from discriminating against people with disabilities, including those who are deaf.

Key Points:

1.  The physician’s office must provide effective communication which meet the patient’s individual needs.

2.  The physician’s office must pay for the cost – qualified interpreter, video interpreting service, etc.

3.  If there are two equally effective methods or sources, the physician has the right to chose the most cost effective.  The caveat here is equally effective for the individual patient. 

4.  The physician’s office is prohibited from passing along the cost of providing the auxiliary aids/services to the the patient.

5.   The ADA does allow physicians to refuse to provide a specific auxiliary aid/service if doing so will create an undue financial burden (significant difficulty or expense).  This is hard to prove, as it isn’t as simple as weighing the cost of the service against the payment for the appointment.

Examples of auxillary aids and service include 1) qualified interpreter, 2) note takers, 3) open or closed captioning, 4) video interpreting services, and 5) exchange of written notes.

REFERENCES

1.  Deaf Patients, Doctors, and the Law:  Compelling a Conversation about Communication (pdf file); 2008, Florida State Law Review, Vol 35:947

2.  Communication with Deaf and Hard-of-hearing People: A Guide for Medical Education; Barnett, Steven MD; Academic Medicine: July 2002 - Volume 77 - Issue 7 - p 694-700

3. Department of Justice ADA Enforcement page 〈http://www.usdoj.gov/crt/ada/enforce.htm〉. Accessed 2/26/12. United States Department of Justice, Washington, DC, 2001.

Tips on Dealing with Difficult Colleagues

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. 

Recently I attended a CME course entitled “Dealing with Difficult Colleagues.”  It was part of my medical malpractice company’s risk management series to teach physicians/nurses how to lessen our risk of being sued. 

This lecture was given by Linda Worley, MD who is a psychiatry professor at UAMS.  She is a good speaker, easy to understand, engages the crowd, and knows her subject. 

My only complaint would be it focused only the “angry” or “frustrated” physicians who exhibit unprofessional behavior and did not include the ones whom you suspect might be difficult due to impairment (illness, drugs, alcohol). 

Difficult colleagues can impact a team (in office, OR, or hospital) by creating low morale, high staff turnover, inefficiency, decreased patient satisfaction, increased risk for poor patient outcomes, and increased risk of litigation.

Here are some of the A-B-C-D strategies given for handling “horizontal” hostility (or hostility handed from one person to another to the next in the team):

Acute Awareness

• Recognize verbal and non-verbal behaviors
• Do not ignore and let them grow
• Remember, they are often driven by distress

Be a leader

• Set a good example
• Refuse to engage in negativity

Communicate assertively

• Acknowledge conflict
• Respect others’ views
• Move to a private area

Dedicate yourself to making positive difference in the workplace

• Don’t participate in gossip, infighting or backstabbing
• Make daily deposits into the emotional bank accounts of others

When assertive communication is used in dealing with the difficult colleague both parties will feel they matter.  You should include “I” statements so the difficult colleague doesn’t feel attacked.  You should describe the situation/needs objectively.  It is always a good thing to give a genuine POSITIVE statement about the other person.  Confront your difficult colleague with honesty and compassion.

It is helpful for an office, clinic, or hospital to have a defined Code of Conduct as this sets up expectations and clearly defines appropriate behavior.  It also facilitates an objective discussion as it can be referred to as needed.

The following article was included in our information:

Our Fallen Peers: A Mandate for Change; Linda L. M. Worley, M.D.;  Acad Psychiatry 32:8-12, January-February 2008
doi: 10.1176/appi.ap.32.1.8

What They Hear….

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. 

This past week the comic strip Baby Blues has been doing a “When you say…..They must hear” series.  It has made me think this phenomenon in medical practice.

…..
Here’s one:
When a plastic surgeon says “Your scar will fade over time.”
Patients often hear “Your scar will disappear over time.”

Reminders to Self

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. 

My husband had a screening colonoscopy last Friday.  His nurse in the recovery is the only one I had issues with.  I, not my husband. 

All went well, but let me tell you he is not an ePatient Dave.  He did not read his instructions about when to quit eating and the prep.  I did.  I then reminded him along the way:  “Only clear liquids today.”  “You must take the Ducolax at 3 pm.  Do you want me to text you a reminder?”

Sometimes the instructions we give patients are clear, but not always read.

The staff at the front desk were very kind and organized.  Calls had been made the day before and I had insured the insurance information they had was correct.   I did not tell anyone I was a doctor.  I’m not sure if my husband did later or not.

…..

When I was called back by the nurse, she mispronounced my name calling me Rhonda (which I forgave easily).  She did not introduce herself to me.

As we entered the recovery area, she did not take me to my husband and assure me he was okay.  She took me to the desk and abruptly said, “You need to sign this.”

No explanation of what “this” was, so I replied, “What is it I am signing?  I don’t sign anything until I have read it.”

She then said, “It’s the discharge instructions.  He’s already been given them.”

Note she had not reviewed them with me.  I would be the caregiver.  Note also that I had no way of knowing if she had reviewed them with my husband (who is not an engaged ePatient Dave) prior to sedation or in his current state of post-sedation fogginess.

She said, “Sign it when you’ve read them then” and quickly moved on to some other task.  I felt like a box that was simply being checked off.

I reviewed them, signed it, and moved over to my husband’s bedside.

The nurse with no name came by soon after and told him it was time to get up and go to the bathroom.  She led him over and said to me, “You can go to the bathroom with him.” 

Me, “Why would I want to go to the bathroom with him?”

Her, “Well, you don’t have to.”  [I think she found me difficult and perhaps uncaring.]

She left him alone in the bathroom with his clothes.  After standing there for about five minutes, I knocked on the door and entered.  “Are you okay?”  He was dressed, but swayed as he bent over to try to put his boot on.

Me to my husband, “You can sit in this other area where we are to wait on your doctor and put your boots on.  Here let me help you.”

In hindsight, I think she meant for me to help him get dressed in the bathroom, not to watch him actually use the bathroom. 

………

Reminders to myself

1.  Check names.

2.  Always introduce myself.

3.  Slow down and tell patients/family what is going on and why. 

4.  Patients and caregivers need to be given the instructions.

P.O.U.R.

Updated 3/2017-- photos and all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

A patient with postoperative urinary retention forced me to review the topic, conducting my private M&M conference.

Without giving away too much on my patient – female, less than 50 yo, general anesthesia used, length of surgery 4 hrs, ambulatory/outpatient, foley used intraoperatively, fluids used judicially (though I do not know the exact amount given by anesthesia), pain meds (Toradol, fentanyl, and sent home with script for Percocet).

From the first reference article below

I made my usual call to the patient the evening of surgery, asked how she was, “how’s the pain?”, “any concerns?”, “any nausea?”, “are you eating and drinking?”. I don’t recall specifically asking about whether she had peed or not, but I do recall her saying she needed to end the call so she could go to the bathroom.

I received a call from her the next afternoon. “Dr. Bates, I can’t pee. I keep trying and all I can do is dribble.”

The surgery center graciously agreed to catheterize her. I received a call from them immediately afterwards, “Dr. Bates, her residual volume is 1000+ cc.”

The patient graciously agreed to have the foley left in place for the next 24 hrs. I called her later the same evening and we agreed on a time for her to come into my office for the removal of the foley the next day (and yes, I gave thought into leaving it for a second day).

The surgery center’s action kept my patient from having to check in through the emergency department, incurring a wait time and additional cost.

The patient’s agreement allowed me to treat her as an outpatient, helped me reduce the need for a second catheterization, and keep her from incurring more expense.

It was fortunate that the patient had weaned herself from the pain medicine by this time and was mostly taking only Tylenol. Her P.O.U.R quickly resolved.

I did not see this complication coming for this patient. Perhaps the foley could have been left in and removed in recovery. Perhaps anesthesia could have restricted fluids more (though they were careful).

I can think of no reason she might need a urology follow up. Am I missing anything? Where is KeaGirl when you need her?

REFERENCES

Predictive Factors of Early Postoperative Urinary Retention in the Postanesthesia Care Unit; Anesthesia & Analgesia, August 2005 Vol. 101 No. 2 592-596; doi: 10.1213/​01.ANE.0000159165.90094.40

Postoperative Urinary Retention; Anesthesiology Clinics, Volume 27, Issue 3, Pages 465-484 (September 2009)

Patient Safety in the Office-Based Setting; Horton, J Bauer; Reece, Edward M.; Broughton, George II; Janis, Jeffrey E.; Thornton, James F.; Rohrich, Rod J.; Plastic & Reconstructive Surgery. 117(4):61e-80e, April 1, 2006; doi: 10.1097/01.prs.0000204796.65812.68

Urinary Retention in Adults: Diagnosis and Initial Management; Brian A. Selius, DO, Rajesh Subedi, MD; Am Fam Physician, 2008 Mar 1;77(5):643-650.

Blog Rally for Free Speech

 Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

Thanks to T at Notes of an Anesthesioboist  and Paul Levy, Running a Hospital, for getting this going.

A group of bloggers is holding a blog rally in support of Roxana Saberi, who is spending her birthday on a hunger strike in Tehran's Evin Prison, where she has been incarcerated for espionage. According to NPR, "The Iranian Political Prisoners Association lists hundreds of people whose names you would be even less likely to recognize: students, bloggers, dissidents, and others who, in a society that lacks a free press, dare to practice free expression."

Hearing reports like these has prompted us to do a ribbon campaign. Blue for blogging.

Please consider placing a blue ribbon on your blog or website this week in honor of the journalists, bloggers, students, and writers who are imprisoned in Evin Prison, nicknamed "Evin University," and other prisons around the world, for speaking and writing down their thoughts. Also, please ask others to join our blog rally.

Articles of interest:

"Birthday Wishes for Imprisoned Journalist Saberi"
"Mir-Sayafi:  Iranian Bloggers Writings Bring Him to Life"
"Iran's Evin Prison Likened to Torture Chamber"

The Right Thing

I did a precertification for a patient. The precert was for breast reduction surgery. My office had reminded the patient prior to her initial visit that my office was not in her insurance network. We asked her to check her policy to see if she had out-of-network benefits as we didn't want her to get "stuck" with the bill, as it were. My office balance bills, but tries to be up front about costs.

I did the initial visit, reviewed why she felt she needed a breast reduction, did the exam, took measurements and photos, and then after she left sent a letter with documentation (photos, etc) for the precertification.

She received the letter (copied to my office) below which states that she meets her insurance requirements for the surgery. It then clearly states "If Dr Ramona Bates performs the surgery it will not be eligible for reimbursement."

She called to schedule the surgery for early September. I called her back and reminded her that if I did the surgery her insurance would not cover it (not the surgeon, not the surgery center, not the anesthesia, none of it).

"Would you still like me to do your surgery or would you like me to try to find someone in your network?"

"Well, I would really like to have my surgery in September. Do you think you could get me in to see someone soon enough that I could have it done then?"

"I'll try, but I can't guarantee that you might not have to consider a different time for the surgery."

So I called Dr PS1. He is in her network, but can't see her for the initial office visit until September and probably can't get the surgery scheduled until November or December.

Tried Dr PS2. This one, like my office doesn't participate in her insurance network.

Tried Dr PS3 and hit the jackpot for her! They can see her in a week and most likely get her scheduled (since the precert is already done) in early September.

I then called her back and told her the news. "Thank you Dr Bates. I don't know how I can ever really thank you."

 

Behavior of Surgeons

 Updated 3/2017--  all links removed as many are no longer active and it was easier than checking each one.

Did you happen to see this news article? It reported on the orthopedic surgeon who gave his patient (female) a temporary tattoo as he put it "to lighten their spirits". I ran this by the crew I worked with in the OR this morning and didn't give them all the details, just this:

"Did you guys hear the news report of the orthopedic surgeon who did a lumbar procedure on a woman and then put a temporary tattoo on her lower abdomen, in the panty region? The patient found it when she went to get dressed in front of her husband. She was reportedly very emotionally traumatized by it."

All of them had somehow missed this news item. Questions came.
"Did he know this person? I mean were they friends outside of the professional relationship?"
"Was the surgeon and patient joking about tattoos in the pre-op?"
"How much is she suing for?"
"The other members of the OR crew allowed him to do this?!"

In the end we all agreed that this was not appropriate for the surgeon to do. My crew would have felt comfortable to have pointed this out to me (had I foolishly tried to do such a thing).

I do not in any terms want to "justify" this behavior, but neither do I think that what these two blog sites and their commenters (here and here) are doing with this incident is appropriate either. It is unfair to "lump" all physicians or all surgeons in a group with this one.

I ran across a post on "A Doctor's Touch" yesterday. It is worth reading the entire posts and it's comments. I think that most of us physicians/surgeons try to do just this with both "touch" and "interaction".

In conclusion, as you can see, a doctor’s touch is an action which, if used wisely and professionally can provide a variety of benefits from psychological to diagnostic. Also, you can see that touch is missing when the doctor-patient relationship involves phone, video or e-mail communication. It is understandable why we who teach medical students stress touch as an important medical tool in its many ways. ..Maurice.

It's the wisely and more importantly the professionally that stands out for me in the above paragraph. I try to keep things professional. I try to treat each patient with respect. Read these wonderful blogs by fellow surgeons and you will quickly see that many of us are in awe that patients place their trust in us.

Surgeonsblog
other things amanzi
Reflections in a Head Mirror
Buckeye Surgeon
Someonetc (an orthopedic attending)

Medical Tourists

Updated 3/2017-- all links removed as many no longer are active. 

The first or second year I was in practice I received a call from Dr Gaspar Anastasi. He had been the head of my plastic surgery residency while I was at Boston University Hospital. He was calling to ask me to do follow up for him on an otoplasty patient who lived in Arkansas. I readily agreed. In fact, I was honored that he would ask.

These days we think of the medical tourist as someone who goes to another country (ie. from the USA to Singapore for an operation), but in some ways the same issues may arise when the patient simply goes out-of-state to have a procedure done. They are not always ready, willing, or able to go back for follow up. This is especially true if a complication arises, be it small (missed stitch) or large (wound infection). They may have used up all their vacation time and not want to take the days off for travel.

I have had patients come to me from Nevada, Arizona, Texas, Louisiana, Tennessee, and Mississippi. Usually because they have family that lives here. They plan on staying with them while they recover. Still, I ask the ones who are more than 3 hours away if they are willing to stay around 10-14 days after surgery before agreeing to do the procedure. I ask them if they are willing to return if the need arises or if they have a local physician who is willing to help out. I try to make them think about what could happen. Even the ones who live closer I try to outline the follow up that will be expected.

There is a nice article in this month's Contemporary Surgery Journal discussing the ethics of caring for/refusing to care for a patient who comes to you with a complication after having their surgery elsewhere. You can read it here (may have to register).

A former patient presents with general malaise and reports having had low-grade fever. The examination is unremarkable, but laboratory tests indicate an infection not isolated to an organ system. Groin and blood cultures are positive for MRSA.

A while ago you diagnosed an abdominal aortic aneurysm in this patient, but she went to India for aortic endograft placement. You are considered an authority on graft infection. What should you do?

A. Tell her to return from whence she cometh.
B. Alert the media to the problem of cheap international medical care.
C. Advise the patient to sue in International Court.
D. Care for her as you would any patient.
E. Tell her that once a patient leaves your care, she leaves permanently.

My answer is D. Though I wish the patient would come to me for the entire "package", I would do what needed to be done. I would prefer to meet them before the initial surgery, but we don't always have that luxury. I would prefer that I could try to get them to do their care (if it is available, though specialized care is not always) closer to home or at least at a distance they are more willing to travel as needed. I would prefer that the surgeon call me and let me know that he would like me involved in the postop care.

Is it possible that this concept of international travel for surgery is here to stay? Most likely. So maybe the patient should find a "local" surgeon who would be willing to do the postoperative care when they return. The patient could then give their "international" surgeon the name, address, phone number, and e-mail address of the "local" surgeon so that information could be communicated and care coordinated.

What would your choice be?
Article:

The Medical Tourist Whose Outcome Went South; Contemporary Surgery, Vol 64, No 6, pp 290-291; James W Jones, MD PhD, MHA (This article was condensed from: Jones JW, McCullough LB. What to do when a patient’s international medical care goes south. J Vasc Surg. 2007;46;1077-1079.)

How much pain will there be?

Often I am asked about pain. I'll give you a couple of examples.

"Will the it hurt?"

This from a patient who wanted her earlobe repaired. She had missed out on a pair of diamond ear rings for Christmas, so now she had worked up the courage to have the repair done.

"I have to use a needle to put the numbing medicine in your earlobe. There will be a little pain with that, but you won't feel any pain with the actual repair. You may feel me gently move your ear as your cheek and the surrounding area won't be numb. You may also hear me cut the suture with the scissors as I will be working so near your ear."

"So you have to use scissors?!"

"Yes, I will use scissors for the suture. I will have to use a knife to cut the skin."

"But I won't feel you cut?"

"Correct. Your earlobe will be numb."

"Okay"

So I keep chatting with her as I get the local ready and do the injection. I finish and turn to busy myself with getting everything else set up for the procedure.

"You're done? That didn't hurt."

I smile and say, "Good. That's all the pain involved. You won't need anything other then ibuprofen when the numbing medication wears off."

Example Two

A young woman who wants a cosmetic breast procedure.

"How much pain will there be after surgery?"

I recheck her surgery history. None listed. No children yet.

"Have you ever had any cuts that needed stitches? Any broken bones? Pulled muscles?" I'm looking for something to compare the pain/soreness to.

"No."

"Well, the pain of the incision is often a burning, stinging kind of pain for the first several hours. Think paper cut. Then there will be a pain similar to a deep bruise. The first couple of days are the worst. Remember it will feel less painful, less sore each day."

She seems satisfied, but I am left wondering how I could better prepare her. When someone has had surgery before, I can use it as a reference point. The purposed surgery will have less, similar, or more pain involve. When the patient is female, has had children, and the surgery is breast implants -- patients have taught me that it feels very much like "when the milk first comes in--full and tight" initially. That often helps when discussing this question.

Anyone have any suggestions when it's the patient's first surgery and there seems to be no history of painful injury (past surgery, past injury, etc) to use as a reference point? I am always looking for better ways to communicate with my patients.