Is it wrong to tell a pt...

[chagall]

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(a patient with whom you have had several long sympathetic discussions about his situation and to whom you have given all the resources that were available)...something along the lines of "if you can buy crack, you can pay for a bus pass."

Inappropriate?


(The med student in question was frustrated, not that that helps)

 

[Tired]

What service?

 

[surrender903]

sugery right?

 

[chagall]

no, medicine

 

[Tired]

Ah, you're screwed now.

 

[chagall]

Why? The resident seemed to think it was funny, and true.

 

[greenbean]

Why? The resident seemed to think it was funny, and true.

if it were surgery or ob, yeah, those ppl tend to appreciate sarcasm and make fun of pts as a rite of passage

on medicine/fmed/peds, this wont work, you have to show your 'sensitive' side and for a comment like the one u wanna make, expect repercussions on your eval, medicine ppl are pretty humorless folks, and im doing a prelim in med so im speaking from some experience

 

[chagall]

if it were surgery or ob, yeah, those ppl tend to appreciate sarcasm and make fun of pts as a rite of passage

on medicine/fmed/peds, this wont work, you have to show your 'sensitive' side and for a comment like the one u wanna make, expect repercussions on your eval, medicine ppl are pretty humorless folks, and im doing a prelim in med so im speaking from some experience

Yeah...the ironic thing is that I am really a very sensitive person and have even thought about going in to psych.

The resident also seemed equally frustrated at this pt, though.

 

[PugnaciousF]

(a patient with whom you have had several long sympathetic discussions about his situation and to whom you have given all the resources that were available)...something along the lines of "if you can buy crack, you can pay for a bus pass."

Inappropriate?


(The med student in question was frustrated, not that that helps)

Yes it's inappropriate, but I think it's more in how you say it and who was around. If you said it in a sharp or condemning way that offended the patient, I'd be concerned and I'm sure your attending would be as well. If you said it in a flat and dry way that was in the flow of the conversation (ie in the context of a 'getting your life on track' conversation), I don't think anyone would really care.

I loved my medicine rotation and I think the people around me had a GREAT sense of humor. Sometimes I found it hard to concentrate on my write ups and studying b/c I was so busy playing around with a residents and attending.

Also, I understand the frustrated thing, I had multiple crack/cocaine addicts that were really hard to talk to. You have to realize you're dealing with someone who doesn't have a great life to begin with and on top of that they're addicted to a really nasty substance that provides their life with at least a fleating feeling of happiness. Logic can break down in that equation so patience is key.

Good luck

 

[enanareina]

On psychiatry this month, we made many similar comments.

 

[chagall]

On psychiatry this month, we made many similar comments.

To the patients?

 

[RockShox]

I have dreams about making comments like these... like "Well its possible the Zocor is not working on your lipids but more likely that you are 600lbs and two-fisting donuts all day" or "Perhaps you have a rare form of resistant chlamydia or its just that you may try using a con-dam."

I am not saying you should be sarcastic (though it is tempting) in the way you described, but it will also do you no good to get in the habit of lying to your patients just because you want a smily face sticker in the end. You need to teach your patients and give them the honest facts about their health, diseases, and treatment. You will be able to master this skill.

One approach could be....after listening to several pages of personal life woes, say "I can imagine that these events are difficult. This is the reason why I counsel you now and in the future to immediately take steps to get off of crack. It is doing all of these terrible things and cost you so much financially that you cannot afford the basic life essentials. Eventually, it will kill you one way or another. What can I do to help you take steps toward overcoming this illness?" Or something like this. No different than telling someone with high-cholesterol that they need to choose to stop eating big macs.

People pay good money to get the professional advice we offer and they should get what they pay for. I am not saying it needs to be given like cold grits, but most educated professionals will be able to work out giving the truth in a non-judgemental, clinical, honest way.

 

[chagall]

One approach could be....after listening to several pages of personal life woes, say "I can imagine that these events are difficult. This is the reason why I counsel you now and in the future to immediately take steps to get off of crack. It is doing all of these terrible things and cost you so much financially that you cannot afford the basic life essentials. Eventually, it will kill you one way or another. What can I do to help you take steps toward overcoming this illness?" Or something like this. No different than telling someone with high-cholesterol that they need to chose to stop eating big macs.

People pay good money to get the professional advice we offer and they should get what they pay for. I am not saying it needs to be given like cold grits, but most educated professionals will be able to work out giving the truth in a non-judgemental, clinical, honest way.

I know, and the first approach you mentioned was very similar to what I'd been saying to the patient for days and days (although I like your way of phrasing it, I have to say). He was refusing to go to drug rehab, but he was open to some other options...going to AA/NA meetings, taking days off work so he could work on getting physically healthier, etc.

Then just on the day he was supposed to be discharged, he started coming up with a myriad of excuses of why he had to stay in the hospital instead...it was too hot outside (he has AC in his apartment), he didn't have money for a bus pass to get to AA meetings (although there are some within walking distance of him), etc etc etc...hence the bus pass vs. crack comment.

With this particular patient, I just felt that at some point, he needed to take personal responsibility for his own life. That we could treat him, help him with his medical and maybe even social problems, give him the resources he would need to start to get off drugs and do well.

But when someone says it's "ridiculous" that he has to pay for his own transportation to specific AA programs (when this person should have funds, given a job and a crack habit), it seems the obvious solution is to give up the crack habit in favor of a bus pass. Clearly not a solution the patient was happy with. And I'm not happy with how it turned out either. But maybe I at least gave him something to think about.

 

[RockShox]

With this particular patient, I just felt that at some point, he needed to take personal responsibility for his own life. That we could treat him, help him with his medical and maybe even social problems, give him the resources he would need to start to get off drugs and do well.

But when someone says it's "ridiculous" that he has to pay for his own transportation to specific AA programs (when this person should have funds, given a job and a crack habit), it seems the obvious solution is to give up the crack habit in favor of a bus pass. Clearly not a solution the patient was happy with. And I'm not happy with how it turned out either. But maybe I at least gave him something to think about.

No problem glad to give an example...I think we should watch lots of British shows. Those Brits have mastered the art of telling you that you are a goof but doing it in such an elegant sort of way.

As for the assessment of what you did...I think here in lies the problem. All of us can read what you did and Monday morning quarterback it to death...but we weren't there and thus have no idea the progression of this man's care. I get that you felt as though you did what was, in your judgment, in the patient's best interest. As with any intervention then, you look to the outcome to measure success. If I give a med I follow-up to see if I got a positive result. Same with the advice we give to patients...follow-up with this man (if you can) and see if you got any positive results..if so great...if not change the way you treat.

Additionally, I am not positive, but I sense that maybe you got some flack over something you said to this man from your team, is that the case?

Lastly, this is what we are in school to learn anyhow. We all watch attendings and are in awe at the skills but they have taken years and thousands of patients to get there. You learn from all these experiences. Even if your advice turns out to be a poor choice, you will learn from it and the patient was not harmed in the process, anyway, words can't possibly be as bad as poking an old lady 500 f*#king times in the neck trying to place a central line, which I have seen several residents do (It's like sweet criminy already can we just get a surgeon please?)

 

[noncestvrai]

Stupid crack heads.

noncestvrai

 

[Blade28]

sugery right?

no, medicine

Now now, no need to ascribe to stereotypes! 🙂

 

[fakin' the funk]

(a patient with whom you have had several long sympathetic discussions about his situation and to whom you have given all the resources that were available)...something along the lines of "if you can buy crack, you can pay for a bus pass."

Inappropriate?

Not necessarily. I believe that being honest with patients about their condition is very important. This includes telling your obese patients that their health problems are caused by their obesity, and telling your crackhead patients that their addiction may be ruining their life.

It's all in the delivery: say the above line in a joking or mocking way and you look like a douche, say it in a firm and serious way and it looks like tough love.

 

[Dr JPH]

(a patient with whom you have had several long sympathetic discussions about his situation and to whom you have given all the resources that were available)...something along the lines of "if you can buy crack, you can pay for a bus pass."

Inappropriate?


(The med student in question was frustrated, not that that helps)

No.

Although if the patient starts walking home and collapses from heat stroke...you better believe the hospital will get sued.

Dont ever be afraid to tell the patient the truth...unless you are afraid what they may do with the information.