A Spoonful of Sugar

A doctor I work with asked if I had done a blog about giving patients bad news. She said it was on her mind lately. She had to tell someone they had a life-threatening illness and the experience kind of shook her up. "I've given bad news before," she told me. "But the older I get, the harder it becomes. Isn't that strange?"

She told me her mentor was a terrific communicator, and that she learned a lot from just watching him interact with his patients. We sat down and I asked her to give me a rough list of things she felt were important regarding the topic. Here is what she came up with:

1. Quiet room - Make sure the place where you talk to the patient is relatively quiet and safe from interruption. Turn off your phone or beeper. Give them your full attention.


2. What do they know? - It's always good to get a handle on what the patient is thinking before providing any in-depth explanation. Sometimes their point of view is colored by false information that can easily be dispensed with at the start. You need to ask.


3. What do they want to know? - Sometimes a patient wants everything spelled out in detail, and sometimes not. Try to ascertain how much you need to say, and be mindful of their comfort level. Often, they want a family member present to verify and confirm information. Be open to their needs.


4. Keep it simple - Remember that your patient didn't go to medical school, and talk to them in a direct, but simple manner that lays out the facts without overwhelming them.


5. Listen - Give the patient time to react. Don't force the issue. Let it sink in. Let them ask whatever questions come to mind. Just...listen.


6. Conclude firmly - Don't make the patient feel rushed. After you lay out the treatment options and have exhausted their curiosity, reassure them that you will be there in the future. Some doctors give out their personal cell phone number, but we have a policy against that in our practice. What we do offer is to have a staff member follow up with a phone call in a day or two. Patients appreciate the extra effort.

I thanked the doctor for sharing her insight, and she confided that her recent experience with giving bad news had gone poorly. The patient became aggressive and started blaming his family for his problems. "I had to remember that he was distraught," she said. "And that we were on the same side."

Apparently, she let him rant for a few minutes, and he finally relaxed and admitted that it didn't matter. What was important was how they were going to move forward. Sometimes patience is rewarded.

I'm sure many of you have an opinion about this. If you'd like to share your perspective in the comments, I'd welcome it. Thanks.

Ratings



I have previously written about online ratings services for doctors. I do a lot of work on the internet in my off-hours, and I know just how vapid and pernicious bad commentary is, so I am highly skeptical of any service that gives an anonymous forum where people can vent about medical care.



I'm sure it is empowering to many people who can feel intimidated when dealing with a medical professional, but I think it leaves a lot to be desired. After all, no patient is perfect. Many don't properly communicate their problems or follow their doctor's instructions.



Now insurance companies are getting into the ratings game, which is all part of their supposed quest for efficiency and customer service. I have to wonder where all of this judgment-passing is leading? Doesn't it create a climate of fear for the medical community?



A doctor friend of mine who works for another practice met me for lunch the other day. He was beside himself with worry, having just received a negative review online. He's a pediatrician and somebody accused him falsely of prescribing an adult medication for their sick child. He had no idea who the patient was, and couldn't recall any recent patient dissatisfaction.



He's a sensitive sort, and my kids all went to him, so I know he is a caring professional. I worked with him early in my career and I've never known any doctor who was so patient and lacking in the usual ego that can get in the way of good treatment. A few negative words on the internet and his entire career meant nothing to him--he was devastated.



"I'd like to think people take all of that with a grain of salt," he said, finally. "But the fact is I know it's there. Somebody cared enough to write it."



It's a good thing for doctors for to be aware and question their decision-making. It makes them better at their job. However, there's a point at which a course of action or a diagnosis has to happen, and sometimes mistakes will be made. The fallibility inherent in the process is what gives the medical profession a certain nobility. Every decision is a potential risk of reputation.



I'd give anything to ease my doctor friend's sorrow. He contacted the website and they are supposedly going to remove the false accusation. In time, I'm sure we'll both laugh about it. In time.



As always, I'd love to hear your thoughts. Do any of you have experience with online ratings?

Addicted

I'm a trusting person by nature, and so it wouldn't naturally occur to me that someone I work with might steal drugs to feed their addiction or sell to others. Sure, I've caught a few people doing this in the past, but there is something Polyanna-esque about my worldview that allows me to revert back to trusting people shortly afterward.

I'm feeling particularly vulnerable regarding this since a dear friend and co-worker got caught this week. Another co-worker privately told me that she confessed over a few beers one night after work that she was addicted to pills. Once I was made aware of the problem, it was just a matter of waiting.

The resulting confrontation was awful. She was in full denial and claimed she was being set up. She left without collecting her things or even a wave. Five years of working together gone in a heartbeat.

In retrospect, there were warning signs. I just chose to ignore them. Here, for your benefit, are some things you might want to look for:

1. Are they reliable? Is the employee calling in sick more frequently? Are they arriving late and leaving early?



2. How efficient are they? Are they becoming sloppy in their work habits? Taking shortcuts and drawing complaints from co-workers or even patients?



3. What about their appearance? Are they looking more disheveled lately? How about their speech--is it noticeably faster or slower? Any weight or mood changes?

I realize, looking this over, that there were some glaring differences in the woman at work. She once had been so open and easy to get along with, and in past 6 months or so, she had become more secretive and stand-offish.

Still, I knew she had gone through a painful divorce and I strongly believe in giving people latitude to work out their problems. Her work was still of a professional enough level that I even told some people to back off when they criticized her for being short with them. I explained that she was going through a rough patch and would eventually work things out. I still hope that's true.

Any stories or insight you'd care to share would be more than welcome. I appreciate you listening to mine.

Promotional Tools



As a rule, I like to promote from within. I think it gives my employees a sense that they are working toward something, and that good effort will eventually be rewarded. However, I am answerable to our doctors, and there is a standard which must be upheld regardless of who the candidate for promotion is.



The main thing I look for in someone who will be taking on a supervisory role is a certain self-reliance. Are they are a problem solver? If they need frequent management, they are not going to be able to handle the responsibility.



Another important aspect is good interpersonal skills. Not only will the right person have to be able to get along with everyone, but they will have to be mature enough to handle the shift in office dynamics from co-worker to boss. It can be a heady change, and the pressure can sometimes make even the most amiable person somewhat overbearing.



Once I've made the promotion, I provide a complete listing of what the new position entails, including the necessary training, and my goals and expectations. I want the person to feel complete comfort within the parameters of the new job, so they can stay focussed on learning.



For me, the hardest part is letting go. Usually, a person needs a few months of coaching and then they're on their own. I love being a resource, and miss it when my advice is no longer sought (it's the same way with my kids!).



How about you? Any tips or rules of thumb you care to share regarding promotions would be most welcome. Reader comments are always so helpful!

It's About Time

One of our doctors' pet peeves is talkative patients. She likes people and gets along with them well, but small talk is not her forte. During one of our weekly meetings, she made a frustrated comment about how she felt some patients really slowed things down by not being direct. It got me to thinking about time management.

Of course, she was just venting, and there is no appreciable way to measure the delay caused by chatty patients. Also, even she realizes that friendly, open communication is vital to proper medical treatment. Still, there were other elements to consider regarding office efficiency. As usual, I made a list:

1. Study work processes - Have each staff member review their work habits to see if there is any redundancy and overlap. This will give them a greater sense of job ownership, and make them feel less threatened by the idea that they might be wasting time. Make sure to include the physicians and nursing staff as well. Perhaps there is a more streamlined way to get patients in and out of examing rooms? Have a friendly, catered lunch meeting where everyone can feel free to brainstorm.


2. Be specific and focused - Train your staff to answer phone inquiries as quickly as possible. If they need to call someone back, have them offer a specific time as a deadline so that the patient doesn't call again during the interim. Make sure the staff only uses their breaktime and lunches to do things like checking email or making personal calls.


3. Schedule according to strengths - Some folks are morning people and some need a few hours and a couple of cups of coffee to hit their stride. When possible, have the early birds open and the nightowls close.


4. Take it easy - Once you've made the push for greater efficiency, received staff input, and implemented everything, take a deep breath. There are limits to how efficient a group of people working together are going to be, and there is also the natural pace of your practice to consider. You don't want your patients to feel rushed and you can't fear the bottom line--volume is only part of the profit margin equation.

I recently had a staff member secretly tell me that he was grateful for one of our streamlining ideas. He said he had been covering for another employee and didn't want to make waves by complaining. When the other employee volunteered the change in our meeting, he said he nearly fainted. The ways in which people fail to communicate never ceases to amaze me.

As always, I'm very curious about tips you might have to use time more efficiently. Any tricks of the trade you'd care to share?

Super Tuesday


I have tended to avoid writing about politics much in this blog due to the controversy it sometimes creates. I have learned that many of my readers are very conservative, and I am by nature quite liberal. So I try to stick to my profession and the subjects therein.



But in honor of Super Tuesday, and as a resident of California, I'm voting and wanted to share my enthusiasm. I hope you will all indulge me, and perhaps share your own viewpoints.



I am undecided at this moment as to who I prefer: Hillary Clinton or Barack Obama. Both are inspirational in their own right. I am still angry with Hillary over her votes supporting the Iraq war, but I realize that was part of her goal to play smart politics and most of the democratic party voted with her on this.



Barack Obama is solid on the Iraq war, but I feel he's vague in many other respects. In many ways, I feel his promise is what he may do if given the chance, since he's still very new to the national stage, and lacks Hillary's experience.



As many of you may have heard, there was an effort in California to try to give universal health care for all residents. Unfortunately, it failed, but I believe (or want to believe) that all of the democratic candidates will make an effort to create a more inclusive health care program for all Americans. I think this is something we as medical professionals can all agree would be a good thing.



Frankly, the republican candidates don't seem to care a bit about health care. They think the current status quo is just fine. In many ways, I admire John McCain, but how different would his administation be from the current disastrous one? Hasn't he compromised himself too much just to get where he is?



Mind you, I'm just asking. I have no desire to sway anyone's opinion. I just hope by writing about politics and sharing my own beliefs, I might inspire you to express yours. If you were part of Super Tuesday, I hope you got the chance to vote. No matter which side of the spectrum you are on, your viewpoint really matters.



I invite everyone to leave a comment. Support a candidate. Let your voice be heard. Whatever is on your mind, I'd love to hear it!