Shout Outs

Updated 3/2017--all links removed as many no longer active.

Dr. Rob (@doc_rob), More Musings (of a Distractible Kind), is the host for this week’s Grand Rounds. You can read this week’s Grand Rounds Vol 8 No 25: Super Tuesday Edition here.

Welcome to grand rounds, the best around the world of medical blogging! 

For those expecting a silly recitation of today’s posts in rhyme, this post will let you down.  But don’t be sad, as I have provided with an alternate version of grand rounds on my other blog, Llamaricks, which (if you hadn’t guessed) is not quite as dedicated to the serious side of things. 

Since today is “Super Tuesday” ……

…………………………………………..

Check out Doctor David’s (@david65) blog for as he put it on twitter:  the “story I won't forget. Watch the video -- the look on my patient's face says it all.”  The post:  Music Can Heal

Well, maybe music can't cure cancer, but it can certainly heal the spirit.
Drew Seeley released a new song today that he wrote for my patient.
Watch the video here……

……………………………………………….

H/T to @tbtam who tweeted this: “ The Before. Sad, beautifully written , perfectly told. We docs have all been there. . jama.ama-assn.org/content/307/9/… (Need JAMA subscript).  The link is to an essay by Jennifer Frank, MD:  The Before

This is the before. A moment suspended like a bubble floating on a warm summer breeze gently but inevitably toward the ground. I feel the pop coming, an implosion of the very center of your life. Anticipating what this moment would hold, I nevertheless hoped for something different. To be able to eagerly dial your number and shout out the good news to you in a breathless rush. It's not what we thought. It's not cancer.

Instead I take a deep breath, pressing each number slowly, cautiously, drawing out the moment before the burst…………….

………………………………

Go read Elaine’s (was @medicallessons, now @elaineschattner) new post:  Harsh Words, and Women’s Health at Risk

I’ll open with a confession –

Women’s health has never really been at the heart of ML. Your author has, his­tor­i­cally, rel­e­gated sub­jects like normal men­stru­ation, healthy preg­nancy and repro­duction and natural menopause to her gyne­col­ogist friends. Sure, I learned about the facts of life. I even studied them in med school and answered ques­tions, some cor­rectly, along the way. By now, I’ve lived through these real life-​​phases directly. But these topics never drew me. That’s changed now.

Women’s care – and lives, in effect – are jeop­ar­dized on three fronts:……………..

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.

Role Playing to Learn Communication

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

I was alerted to this Archives of Surgery article (full reference below) by MedPage Today:  Role Playing Boosts Surgical Residents' Bedside Manner.

I find it intriguing.  Role playing gives you a chance for a “do-over” when you make a social or communication faux pas. 

So much of medicine is communication.  Those of us who have been at it for years, deliver bad news differently (learned the hard way) now than we did previously.  You choose your words more carefully (though I still occasionally screw up).  Some words are more emotionally charged than others.  Some patients want more information than others. 

The University of Connecticut Health Center conducted a prospective study  of a pilot projected designed to  teach surgical residents patient-centered communication skills.

The study offered 44 general surgery residents the opportunity to participate in the three-part patient communication curriculum: A pre-test, training, and a post-test.  Only 30 completed all three parts.

The pre-test assessed general communication skills awareness of the resident while he/she delivered a new diagnosis of either breast or rectal cancer to a patient. The evaluation was done by a standardized patient instructor.

The training portion required residents to attend a 90-minute workshop that involved a lecture from a professor of surgery and formal instruction from the director of the center's clinical skills program, followed by a 30-minute role-playing session.

The post-test assessment re-evaluated the residents by the standardized patient in a crossover fashion (those who previously participated in a breast cancer diagnosis now participated in a rectal cancer diagnosis and vice versa).

The study authors concluded:

Residents' assessment of their patient communication skills indicates that there is an immediate need for a formal educational curriculum. Our results show that case-specific improvements seem more amenable to measurable improvement than general communications skills, at least with the limited short-term training that we used. Such skills can be assessed over a longer period, perhaps by incorporating this model and assessments from year to year.

Surgical and nonsurgical residency programs will benefit by helping residents incorporate patient needs and opinions into the care team's decision-making process. Principles such as emotional support, transition and continuity of care, provision of information and education, involvement of family and friends, and respect for patient values and preferences will form the basis of our educational series.

REFERENCE

Pretraining and Posttraining Assessment of Residents' Performance in the Fourth Accreditation Council for Graduate Medical Education Competency: Patient Communication Skills; Rajiv Y. Chandawarkar; Kimberly A. Ruscher; Aleksandra Krajewski; Manish Garg; Carol Pfeiffer; Rekha Singh; Walter E. Longo; Robert A. Kozol; Beth Lesnikoski; Prakash Nadkarni; Arch Surg. 2011;146(8):916-921.

It Happens

Many of the surgeries I do are elective. They can and should be scheduled to be convenient. It happens – God laughs at our plans or life interrupts or …..

Last week was such a time for one patient. She called, very apologetic, “Dr Bates, I need to reschedule my surgery. My father is having tests done. He hasn’t been feeling well.”

I quickly assure her that no apology is necessary. Her family comes first. I suggest we simply cancel the surgery for now until the “dust settles.” She can call me back when she is sure things are okay with her family. We’ll reschedule then.

She is still worried. “The surgery center called me today. Do I need to call them? Will I need to pay them or anesthesia or you for the canceled time?”

Again I reassure her, “No, I’ll call them and take care of cancelling the surgery. No, we don’t charge you for surgery we don’t do. It happens. It’s okay to cancel surgery for whatever reason – another family member gets sick, an accident happens, you just get scared.”

It happens on both sides. Sometimes (as for me earlier this year when my mother had surgery) it’s the doctor who has to cancel or reschedule. Sometimes it’s the patient. I once had a patient not show up for surgery, only to find out later she had been in a motor vehicle accident the evening before her scheduled surgery. She turned out to be okay, but it really cemented how I fell about patients who call to cancel or reschedule. It’s okay. No need to apologize. Thank you for letting me know. (video removed 3/2017)