Not enough time with patients...

[McGillGrad]

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"We do not see the doctor for more than a few minutes a day"

I hear this a lot from younger patients (or from the family of older patients) on the inpatient wards now and again.

Would more time spent with the patient really change the diagnosis or treatment plan? I don't see how it would in most cases after the initial H&P was collected (usually in the ED and again in the assessment unit).

Do you think that spending more time with patients during rounds or during the day would help the patient as much as he/she thinks it would?

 

[ShyRem]

I think the issue is patients do not understand how much work is done behind the scenes. Lots of decisions are made on the basis of lab or imaging results and no one tells the patient why these tests are done, what they mean, and what is being done about the results. This should only take 5 or 10 minutes to explain and means the world to the patient. Many people feel time = care, but only because they don't know any better. Education is key.

 

[Dirt]

no one tells the patient why these tests are done, what they mean, and what is being done about the results. This should only take 5 or 10 minutes to explain and means the world to the patient.

I am appalled at how little is actually explained to patients sometimes on inpatient. It truly is a rarity when patients actually know what is going on with their care. This is partially the patients' fault as many of them do not take any sort of active role in their care, but at the same time doctors more often than not cannot or will not put in the time to explain things.

The effects of this may not change diagnosis but can absolutely change the course of the disease as it affects the patient's life.

The same often holds true for the outpatient world. There are so many times when a patient really just needs to talk about quitting smoking, or how to improve their diet and a 30 minute conversation would be better for them than anything else. Unfortunately this is just not feasible.

 

[Aznfarmerboi]

I am sometimes appalled at how little is actually explained to patients sometimes on inpatient. It truly is a rarity when patient's actually know what is going on with their care. This is partially the patients' fault as many of them do not take any sort of active role in their care, but at the same time doctors more often than not cannot or will not put in the time to explain things.

The effects of this may not change diagnosis but can absolutely change the course of the disease as it affects the patient's life.

The same often holds true for the outpatient world. There are so many times when a patient really just needs to talk about quitting smoking, or how to improve their diet and a 30 minute conversation would be better for them than anything else. Unfortunately this is just not feasible.

👍

Sometimes even when a patient wants to know about his/her care, it can be hard for them to find out. Some cant even find out because there are communication barriers. My grandfather who was vomitting blood had no clue what was happening to him besides him seeing bruises on his arms because he has poor veins for blood taking. I could not find anybody to explain what the hell was going on either. People walk in and out but nobody can explain to me what was going on. I cant even find the nurse handling him or a nurse manager. It might not seem like a big deal but he stayed in the hospital for an extra week because he denied all treatments since nobody explained to him why they have to take his blood 3 times a day or was giving him all the medication he was on. Heck, he had no clue why they scheduled an endoscopy for him or what it was?!?!?

 

[FutureInternist]

After seeing the patients in the morning, I usually give them a very quick synopsis about how that day is going to proceed (we will wait for your C-scope results etc), then during rounds, almost nothing gets explained since the attendings are usually out of there in about 1 minute.

The key is coming back after noon conference and taking an extra 5-10 minutes per pt (as needed) to explain any new info since the morning and what the tentative plan for the next day is.

Not always feasible but absolutely key in keeping patients informed and possibly more importantly, happy 😀

 

[GoodmanBrown]

"We do not see the doctor for more than a few minutes a day"

I hear this a lot from younger patients (or from the family of older patients) on the inpatient wards now and again.

Would more time spent with the patient really change the diagnosis or treatment plan? I don't see how it would in most cases after the initial H&P was collected (usually in the ED and again in the assessment unit).

Do you think that spending more time with patients during rounds or during the day would help the patient as much as he/she thinks it would?

I have doubts that it would help the patients, i.e. actually make them get better faster. But, honestly, think of how it must make the patient feel to be in that position. When you're car's broke, would you get annoyed if the mechanic says, "Oh we'll have your car fixed up in a few days for sure, maybe sooner, maybe a bit longer if things don't go well. We'll let you know when it's ready." Obviously you'd be pissed at the lack of information.

My wife's boss's wife had her baby prematurely and for about 2 days, they couldn't get a straight answer as to the timeline of getting the baby home. It's not like they could name a specific day. The doctors/residents/nurses couldn't even give a specific set of benchmarks. A feeding tube was put it, was taken out, and was put back in after the doctor said they'd leave it out to keep from irritating the baby's esophagus. All to say, yeah, I'd be kinda pissed to be in a hospital too without the doctor's spending some time telling me what's going on.

 

[OveractiveBrain]

You are asking the wrong question. You spend more time at a patient's bedside to get more information. You spend time doing a physical, trying to tease out information. The patient could give a **** why you want to stay longer. They dont know what a differential is, or even how many diseases youre thinking about why you ask them questions. They want you to stay longer because they want to be heard, because they want to be sure they get their time in with the doctor, because they want to get better.

Question 1: Will more time spent in a room make the treatment plan change? No. Of course not.

Question 2: Will more time spent in a room make the patient feel better? Maybe. Probably not. Especially if its not quality time.

Question 3: What can we do to make a patient feel better? Ah, finally, the RIGHT question. People are inherently stupid, selfish, and emotional. Dont challenge me on that, you know its true. They are sick. They want a doctor to see them. Why? Because doctor's are smart. I WANT TO SEE A DOCTOR. But it wont change your management or your outcome. What is "managemernit?" and "ootcamses"? I WANT A DOCTOR. MAKE ME FEEL BETTER. we've got you on 37 antibiotics for your one pneumonia with a PORT score of 3, you shouldnt even be here. I WANT A DOCTORRRRRRRRRR! Even if a patient doesnt expressly state it, thats what they want.

So, in order to do that, you have to come up with a means of addressing their selfish emotions. It is one of the most frustrating realizations I have made. The quality of care is irrelevant. The speed or how fast a diagnosis is made is irrelevant. Patient satisfaction is about playing into people's emotions.

You fix the problem of "I dont see me doctor enough" by improving bedside manner. You do that by

(1) Sit Down. A physician who sits for 5 minutes is perceived as being in the room 3 times as long as one who stands. Sitting means youre listening. Standing means you are ready to leave at any time.

(2) Listen. You have the answers. You know what youre doing. The patient really doesnt understand the difference between Vanc+Zosyn for HAP versus Ceftriaxone+Azithro for CAP, nor do they care to. They want their voice heard. They want to know that their concerns have been voiced, heard, and understood. They do not want to rationalize the reason they have HIV, they may want information, even a shoulder to cry on. The things buzzing in your head is not what they care about. Its whats buzzing in theirs they really care about.

(3) Hold their hand. Man what a money maker. Medical students are, on average, horrendously socially awkward. Physical contact without the expressed intention of a physical exam? I cant. I need a nurse to observe. Ill be sued. The patient is dirty. And smells. Im not touching that. Gross. Well...Yes. Do it. Patients like you more. Obviously, if they withdraw from you, dont chase them, but human contact makes the patient melt in your hands. Emotionally, not literally.

(4) Come Back. Pre-Rounds is stressful. Youve got 27 patients to see before resident rounds / morning report / whatever. If one patient takes too long, tell them you will come back in the afternoon. Then actually come back, and do steps 1-3 again.

You spend 10 minutes with a patient. 5 in the morning, 5 in the evening. Bam. Patients love you. Patient satisfaction sky rockets. Management stays the same. Diagnosis, prognosis, and length of stay the same. Patient satisfaction goes up, no one complains.

Do not reason with patients or try to fight it. Stupid, Selfish, Emotion-driven patients want to feel better. Trick them with some simple lessons

 

[KeyzerSoze]

(3) Hold their hand. Man what a money maker. Medical students are, on average, horrendously socially awkward. Physical contact without the expressed intention of a physical exam? I cant. I need a nurse to observe. Ill be sued. The patient is dirty. And smells. Im not touching that. Gross. Well...Yes. Do it. Patients like you more. Obviously, if they withdraw from you, dont chase them, but human contact makes the patient melt in your hands. Emotionally, not literally.

No, for the love of God don't hold the patient's hand. Speaking as someone who has spent a considerable amount of time as a patient, that would have creeped the hell out of me.

 

[wholeheartedly]

Also speaking as someone who's spent considerable time as a patient some human contact is nice. Maybe it doesn't have to be holding a hand, maybe just a quick grasp of the hand and release. I had one doctor after a particularly lousy appt. place his hand on my shoulder and give a squeeze saying hang in there on the way out the door. I appreciated that a lot. I think there are also ways to get this across without actual contact too, a certain way of looking at someone, a sympathetic facial expression, just saying "this sucks huh?" can have the same impact. I do agree that you can make the patient feel like you've made more of an investment in them without actually increasing the time investment.