How Do You Put “Relationship” on a “Sign-Out”?

by Academy of Clinical Excellence on December 8, 2010

Dr. Charles Rammelkamp, my mentor at Cleveland Metropolitan General Hospital, taught my class of residents the importance of the continuity of relationships in the care of patients.Our firm cared for patients both in and out of the hospital.If “your patient” wasn’t followed by you personally, he or she was followed by a member of your team, essentially a small group practice.

Rammel, as we called him, taught us that relationship is the most powerful tool in our black bag.The institution of resident duty hour rules along with the imminent tightening of these rules, the increasingly shortened patient lengths of stay in hospital, and the burgeoning documentation and regulatory requirements have seemingly changed the delivery of care in academic settings and have eroded the time available to spend at the bedside and in the clinic-- time that is all important for building a therapeutic relationship. “Continuity” has been replaced by “episodes of care” linked, but quite tenuously, by discharge summaries and“sign-out” lists. The Joint Commission’s National Patient Safety Goals Standard on hand-off communications notwithstanding, I haven’t figured out a way to put “relationship” on my sign-out without either burdening my colleagues or sewing discontent with the patient and their family.

I lost a patient recently.He was particularly special to me.Our relationship had transcended cultural and religious differences.We had shared celebrations and then several weeks ago his family and I had to endure his sudden death at the end of a complicated hospitalization that spanned multiple hospital services and teams.He and his family sought my counsel at every juncture even when I was “off-service”.I would not have done anything differently therapeutically from what my colleagues did during his hospitalization but the “hand-offs” and my input did not and could not include the relationship that had been forged over time, through adversity and celebration.In the end only I could guard him, not leaving him alone. It was left to me to tell his family of their loss and to try to console them.For me, it was an inconsolable surreal scene.The “covering” team could not manage that transition of care.

Please share your thoughts.

Edward Kraus, MD
Division of Nephrology
Johns Hopkins University School of Medicine

 

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Tiffany Speer December 21, 2010 at 5:41 pm

It's so rare to find physicians who truly care about each individual they see. My family and I are so grateful for a very special man at John Hopkins Children center in Baltimore, Maryland. This man saved my life time and time again and is now treating my younger sister. When most of the doctors in Pennslvania said I was dieing for unknown reason...one doctor sent me to John Hopkins to Dr. Peter Rowe who took the time to really look into my case and save me. I owe my life to this doctor! Even with the distance from Allentown, PA to Baltimore, MD-- it has been well worth it! even today, I have yet to find any other doctor who could manage my illnesses, I can't even go to a PCP without explaining what is in my medical record. It would be great to find continuity care like his around the world. I could go on and on about this doctor. I hope to make some changes in health care with my health information technology degree with quality control, documentation, etc... I'm looking forward to possible benefits from an electronically health record nation wide. Many doctors could learn from the amount of detail Dr. Rowe has. Yes, he is all around a model example of a doctor.

Anonymous December 21, 2010 at 10:26 am

I find in my practice, throughout healthcare, this subject of caregiver/patient relationships is one that ALL practioners can and should give attention to. I find, Dr. Kraus, the same as you do, that most other practioners mistakenly undervalue the connection between caregiver and patient. Taking the time to forge such touching relationships can make the difference of whether the patient and their families are involved, proactive, trusting, and compliant with the treatment and care recommended. Gone is the day that patients have respect for their caregivers simply because of the credentials behind their names. For many, it is the understanding from conversations and actions that show their caregivers are vested more than from just a standpoint of protecting a license. It is on a personal level that we most often touch and affect lives. Even if that should be, as Dr. Kraus showed, in the giving support to family during the passing of a patient. Thank you for sharing your thoughts and experience.Anastasia, RRTRespiratory Care Department

Erin December 10, 2010 at 7:52 pm

Even in my few months as a new intern, I have definitely witnessed the power of touching doctor-patient relationships, as well as felt the void when that relationship was not there. Especially at end-of-life situations as described by Dr. Kraus, there is no substitute for having a physician who knows far more about you than the 30-second hand-off. That is the difference between medicine and healing.Thank you for sharing, Dr. Kraus.

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