Medical Student Reflection VII

by Academy of Clinical Excellence on October 2, 2014

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The use of computers and electronic patient medical records has changed the practice of medicine. There have been improvements in efficiency, storage and sharing of information, and analysis of data. However, the insertion of a computer screen between a physician and patient, in my opinion, has somewhat negatively changed doctor-patient communication. During my Miller-Coulson rotation, one of my goals was to observe how different faculty members have navigated this new tool and used it to their advantage in improving communication. Overall, I found that there is much diversity in how physicians use the computer system, but they can be divided into 3 main categories: (1) those who use EPIC throughout the patient encounter, (2) those who never touch the computer, and (3) those who only use EPIC as a reference.

Those in the first group write their notes on the computer while interviewing the patient. They go from looking directly at the patient to looking at the computer screen while they type. When I previously saw this as a medical student, it was somewhat jarring. I noticed there were times when a patient would share something serious or become emotional, but the physician’s focus on the computer would take them away from connecting with the patient. I noticed, however, that Miller-Coulson faculty make a point to position themselves so that their body faced both the patient and the computer screen, providing for better eye contact. The physicians would stop typing as appropriate when a patient’s story necessitated their full attention. Overall, I saw ways to mitigate the use of the computer through body positioning, eye contact, and a sensitivity to the patient’s emotions.

Those in the second group do not use the computer at all in the room. They sit with their body directly facing the patient, and with their eyes focused on them throughout the interview. Usually, this physician will have looked through the records the night before and jotted down some notes on a piece of paper. He or she may write other notes with pen and paper during the interview, to be typed into a note after leaving the patient’s room or later in the day. This approach is more time-consuming, as a search through old records and a writing of the new note must take place before and after the encounter. However, the physician is able to fully focus on the patient and is more focused on social cues, non-verbal behavior, and building trust.

Those in the third group enter the room, greet the patient, and make small talk before starting the interview. They do not type through their questioning, but they may look up records or imaging on EPIC, research a drug’s side effects, or just type patient instructions before the encounter is over. Typing or dictating the note is left until after the encounter is over. I believe this approach provides a nice balance of using the computer appropriately without it intruding on the patient’s story.

This topic of patient-physician communication in the era of the computer has reached the medical literature. I recommend a short opinion letter entitled: “Computer-patient-physician relationship” published in the International Journal of Clinical Practice. It references data showing that “gaze and eye contact are strongly associated with patients’ perceptions of clinician empathy and interest in the patient and with patients’ satisfaction and trust, which beget adherence and better ‘hard’ health outcomes.” The author suggests ‘five commandments’ to navigate the computer era:

  1. Go over the patient’s chart before the patient enters your office or before going to the bedside. Have command of the essentials.
  2. Once you have addressed the patient, maintain eye contact and utter concentration. Willfully avoid distractions such as checking on e-mails or calls. Never skip examination of the patient.
  3. If you need to consult a database, textbook, or guideline – do so at once and let the patient know. Most patients will appreciate your caution and thoroughness rather than despise your lack of knowledge.
  4. Leave all documentation and necessary printouts to the end of the encounter.
  5. Always finish the encounter by leaving the computer alone and personally addressing the patient, raising issues of health literacy, shared decision-making and summarizing the current encounter and future goals.

Overall, I think there are multiple styles that can work to smoothly integrate computers into our doctor-patient relationship. From the Miller-Coulson faculty, I learned various tactics to overcome obstacles of the computer, such as: body positioning towards the patient and away from the computer, ‘blind’ typing, chart review before clinic, and sharing the computer screen with patients. I’m grateful for the opportunity to learn from such great clinicians as I develop my own style of doctor—(computer)—patient communication.

Reference: Schattner A. “Computer-Patient-Physician Relationship.” The Intl J of Clinical Practice 2014, 68, 790.

- Shannon Walker, MSIV

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Medical Student Reflection VI

by Academy of Clinical Excellence on September 18, 2014

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On my very first day of the Miller-Coulson elective, I eagerly entered the first patient room excited to observe the many dynamics of doctor-patient communication. A young man had traveled from another country with his parents to discuss the need for brain surgery to remove a tumor causing frequent seizures. I was curious to see how the neurosurgeon would discuss such a serious procedure while building trust with a family and addressing their concerns.

To my chagrin, I entered the room and could not understand anything. Fortunately for the family, Dr. Quinones spoke Spanish and they greeted him with hugs and kisses. Unfortunately for me, my Spanish skills were minimal at best. I had signed up for the Miller-Coulson elective to have the unique opportunity to learn communication skills by observing the “best of the best” at the bedside, and I wrongly assumed, in that moment, that I would have to wait for the next English-speaking patient encounter for this experience to really begin.

I soon realized my mistake as I recognized that in this setting, I had the unique ability to focus solely on the non-verbal cues within the discussion. For example, I noticed that Dr. Quinones walked in the room and greeted the family very warmly, with strong handshakes for the son and father, a hug for the mother, and smiles for all. When he sat down he turned his chair away from the computer and faced the family. More specifically, he angled himself towards the son. Later in the interview he would look at the parents to address their concerns, but through his body language, he made a point of identifying the patient as his primary concern while still validating the parent’s importance.

Throughout the interview, I noticed an augmentation and lowering in the tone of Dr. Quinones’ voice. Initially, his voice was enthusiastic and uplifting as they talked about life outside of medicine. Then as he began interviewing about symptoms and listening to the patient’s story, his tone quieted and softened. Most importantly, I heard his voice hardly at all as the son did most of the speaking. During this time, Dr. Quinones looked at him intently. After the son finished speaking, there would often be a pause before Dr. Quinones said something, as if he was still critically thinking about what was just shared. This reminded me of a quote I had heard previously: “Most people do not listen with the intent to understand; they listen with the intent to reply.” It was clear, however, that Dr. Quinones was not just waiting until the patient finished talking to reply; instead, he was digesting every word of the patient’s story.

When it was Dr. Quinones’ turn to speak, I noticed he spoke slowly. I could recognize that he said some of the same words twice, as if he repeated himself to ensure comprehension. He would pause his speech until the family members nodded. When the mother’s eyes began to tear, he reached and touched her on the arm while speaking in a calming voice. He paused and asked: “Preguntas?” After some serious moments, Dr. Quinones would say something and grin, and then the family would erupt with laughter. The serious tone would again return, but the environment seemed a bit more optimistic. Throughout the interview, Dr. Quinones would often use his hands to dramatize his speech, and he continued to sit at eye-level with the family throughout the interview.

During the next two weeks, I made it a point to observe the non-verbal communication skills of other Miller-Coulson Academy Members. There were other instances when a physician’s body positioning helped to focus on the patient and take the focus away from an over-bearing family member. In other instances, I noticed how touch, hand gestures, or even humor were used to emphasize a point or comfort a patient. I am grateful that my first patient encounter during the Miller-Coulson elective brought my attention to non-verbal cues so that this would be a focus for the rest of my experience.

Shannon Walker, MSIV

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meg

 

 

 

 

 

I was invited to write a guest post for the Arnold P. Gold foundation blog on any subject I liked. I shared my ideas about changing how we approach addiction medicine education: http://humanism-in-medicine.org/acts-of-affordable-caring-changing-clinical-culture-around-substance-use/

- Meg Chisolm, MD

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Social Media and Clinical Excellence

by Academy of Clinical Excellence on June 20, 2014

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Interesting paper from Academy member discussing how social media relates to clinical excellence:http://onlinelibrary.wiley.com/doi/10.1111/tct.12129/full

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Advocating for your patients

by Academy of Clinical Excellence on June 4, 2014

STEWART rosalyn

 

 

 

 

 

Understanding a patient and family’s values and goals for care is of utmost importance to being a great advocate for your patients. Sometimes this involves thinking out of the box and incorporating integrative medicine practices to achieve overarching goals to help always, relieve often and cure sometimes.

- Rosalyn Stewart, MD

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Academy in Hopkins Publication

by Academy of Clinical Excellence on June 3, 2014

Please read the following article in the June 2014 issue of 'Change - Moving Hopkins Forward.'

Academy Awards
The Miller-Coulson Academy of Clinical Excellence embodies the best in patient care at Johns Hopkins

http://insidehopkinsmedicine.org/change/060214/academy-awards.cfm

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Patient Satisfaction

by Academy of Clinical Excellence on June 3, 2014

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Patient satisfaction is most definitely an important healthcare outcome. Please see the link to an article and blog post about an innovative way to collect this information.

http://onlinelibrary.wiley.com/doi/10.1002/jhm.2220/pdf

AND

http://blogs.hospitalmedicine.org/Blog/hospitals-kowtow-to-press-ganey-and-hcahps-should-we/

-Scott Wright, MD

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Clinical Excellence Pearl from Pediatrics Noon Conference

by Academy of Clinical Excellence on April 9, 2014

 

 

 

 

 

I  attended a superb pediatrics noon conference last week. The presenter, Dr. Maggie Moon, emphasized the following stategies that can be helpful to use during a difficult patient encounter:

  1. Avoid labeling the patient.
  2. Treat the patient with respect.
  3. Work to establish a trusting relationship with the patient.
  4. Have self-awareness and self-control about negative emotions toward the patient.
  5. Keep a healthy emotional distance from the patient without becoming distant.
  6. Draw upon the virtues of empathy and compassion to understand the patient.
  7. Exhibit patience when working with the patient.
  8. Use non-judgmental listening to elicit the patient’s perspective.
  9. Establish a dialogue to determine if there are cultural, psychosocial, or personal experiential factors contributing to the patient’s behavior.
  10. Create the “third story” as a means of mediating the encounter.
  11. Share control with the patient and make concessions when possible.
  12. Set limits in a straightforward manner.
  13. Be tolerant but do not tolerate verbal or physical abuse.
  14. Involve the patient in the decision-making process.
  15. Negotiate a behavioral contract specifying what the patient is to do and what the staff is to do.
  16. Draw upon the expertise of other members of the healthcare team.
  17. Develop the practical wisdom of knowing how to deal with the inherent uncertainty of the difficult encounter.

- Rosalyn Stewart, MD, MS, MBA

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Of Efficiency and Effectiveness

by Academy of Clinical Excellence on November 5, 2013

I have been to several meetings recently where the topic of discussion is ‘how we can be more like the Mayo Clinic’. Mayo Clinic is held as a paragon of efficiency. Patients are seen quickly, consultations are performed rapidly, and diagnoses are made universally. It is not surprising that Johns Hopkins would be interested in emulating their model of success.

However, the Mayo Clinic differs from Johns Hopkins in many key cultural aspects. If you talk to the clinicians from the Mayo Clinic; the culture and the way that they attack diagnoses is entirely different from what we do at Johns Hopkins. Most significantly, there is only a small Inpatient Service. While St. Mary's Hospital is nearby, it is technically separate from the Clinic itself and does not enjoy the same infrastructure. Second of all, the conceptual model of clinicians at the Mayo Clinic is, “we all practice the same,” and, “don’t do anything crazy.” Any clinician at Johns Hopkins knows that this is not the culture at this institution. Finally, patients apply to be seen at the Mayo Clinic. It is rare that a patient without insurance is seen, and patients can be turned away when there “is no other intervention to be offered,” based only on the review of the record. Johns Hopkins prides itself on providing the highest quality of care to any individual in need.

Not only are many of the cultural aspects different than those at Johns Hopkins; the Mayo Clinic has the unique infrastructure to excel as a highly efficient, clinical service. Their medical record system is excellent, outpatient consults can be obtained within a 24-hour period, tests are done and read in a very short period of time, and every patient leaves with a diagnosis, even if the diagnosis is simply the presenting complaint. In reviewing patients of mine who had been previously seen at the Mayo Clinic, I have found that an enormous battery of tests was performed and the diagnoses were often determined through “sheer brute force of testing.

The John Hopkins and Johns Hopkins Bayview are not an ultra efficient hospital. You cannot obtain complete outpatient consultations within 24 hours, or testing at a rapid rate with rapid interpretation of the results. This inefficiency seems at odds with our stance that we are the number one hospital in the country. But I think it is actually the explanation for ranking. Clinicians at Johns Hopkins Hospital are the best in the country at the “work around” and deal with multiple levels of inefficiency: scheduling inefficiency, testing inefficiency, consultation inefficiency, billing inefficiency, and grant administration inefficiency. But, by struggling to overcome these challenges, the faculty are more able and willing to “think outside the box”, troubleshoot, problem solve, and consider “crazy solutions” to clinical and administrative problems. It is this pressure that helps us innovate in a way the Mayo Clinic never has. This makes us an effective organization.

Schwinn can produce hundreds of bicycles at a low cost, and with decent quality. The old Italian man who labored in his basement painstakingly crafting the custom bikes for Lance Armstrong, worked at high cost with outstanding quality, innovation, and “out-of-the-box” thinking. Companies should be careful about switching from one type of service line to the other. The most recent example is Mercedes-Benz, who produced extremely high-quality luxury cars here in the United State. Presently, most people who buy luxury cars by Lexis or BMW, because there was a falloff in quality Mercedes-Benz as they attempted to increase the efficiency of their production at the expense of effectiveness. There are dozens of examples of this in the business world.

As a general rule, if you want to increase the number of a certain type of product, you make that creation of that product as efficient as possible. To that end, the application of grants and administration of research funding is one thing at Hopkins that should be of the highest level of efficiency. With the goal of obtaining as many funding opportunities as possible to allow us to carry out the cutting edge research that has made us great, the institutional application process should be as easy as possible rather than an added obstacle. Unfortunately, this is not the case for many departments. Our lack of efficiency in grants management is a cause for concern.

It is a private practice model to see as many patients, get as much testing, and bill at as high a level as possible for patient care. I see many patients for second opinions in my outpatient clinic. Increasingly, I encounter relatively straightforward diagnoses that can be determined through a comprehensive history and physical examination, that were missed by expensive and invasive testing. Private practice is, and must be, an extremely efficient process, seeing huge numbers of patients, making relatively simple diagnoses, and instituting treatments. Our role as a tertiary care center has always been the more careful evaluation of patients. The ability to think critically about our patients and narrow the differential prior to ordering a multitude of tests, has been a privilege that should not be taken for granted. Once the basic work-up is unrevealing, at that point we move forward with testing in a measured fashion, and with treatments that are outside everyone else's experience. This has always been our role. Increasing the number of patients seen, and approaching them with “brute force” efficiency, especially as second or third opinions, may decrease our overall effectiveness, and cause us to lose that we value most. This concept is in line wth Dr. Zeiglestein’s call to reduce expensive testing, I applaud this attempt not only at cost cutting but also to return us to our strengths.

 Before we consider changing our approach to patients and the fundamental concepts that have made this hospital the number one hospital in the nation for over 20 years, I would suggest a careful evaluation of which aspects within our institution we would like to be efficient, and those we must ensure are effective.

-Raf Llinas, MD

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New JAMA article: Crossing Boundaries—Violation or Obligation?

by Academy of Clinical Excellence on October 3, 2013

This is a great article by a physician who was reprimanded for giving a patient money to buy a prescription, which the patient otherwise couldn’t afford.  Raises interesting ethical issues of relevance to all of us who want the best for our patients.

http://jama.jamanetwork.com/article.aspx?articleID=1741827

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