The Empowered Patient

The Empowered Patient

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When you or a loved one enters a hospital, it is easy to feel powerless. The hospital has its own protocols and procedures. It is a “system” and now you find yourself part of that system.

The people around you want to help, but they are busy—extraordinarily busy. Nurses are multi-tasking. Residents are doing their best to learn on the job. Doctors are trying to supervise residents, care for patients, follow up on lab results, enter notes in patients’ medical records and consult with a dozen other doctors.

Whether you are the patient or a patient advocate trying to help a loved one through the process, you are likely to feel intimated—and scared.

Hospitals can be dangerous places, in part because doctors and  nurses are fallible human beings, but largely because the “systems” in our hospitals just aren’t very efficient.  In the vast majority of this nation’s  hospitals, a hectic workplace undermines the productivity of  nurses and doctors who dearly want to provide coordinated patient-centered care.

At this point, many hospitals understand  that they must streamline and redesign how care is delivered and how information is shared so that doctors and nurses can work together as teams. But this will take time. In the meantime, patients and their advocates can help improve patient safety.

Julia Hallisy’s Story

Julia Hallisy learned about patient safety the hard way. Hallisy’s daughter, Kate, was diagnosed with an aggressive eye cancer when she was five months old. Over the next decade, she went through radiation, chemo, reconstructive surgery, an operation to remove her right eye, a hospital-acquired infection that led to toxic-shock syndrome and an above-the-knee amputation.

“My husband and I spent years of our lives in hospital hallways, waiting rooms, and emergency rooms,” Hallisy recalls. “We became savvier and more educated the longer my daughter’s illness went on. . . .

“We slowly came to realize that the quality of healthcare she was receiving, as mediocre as it sometimes was, was actually far superior to the care other families around us in the hospital were receiving. They began to notice this discrepancy as well, and they wanted to know how we knew the things we did and who had given us such valuable ‘inside’ information. We had to explain to them that we had come across everything we knew . . . by watching our daughter suffer through medical errors, misdiagnoses and inexperienced medical providers, and investigating the mistakes and taking steps to make sure they didn’t occur again.”

Kate was treated at some of the finest hospitals in the San Francisco area.

She died in 2000. Kate was eleven years old

Empowering a Patient,  an Advocate, or a  Survivor

How could a mother handle such unspeakable grief? Hallisy decided to write a book that might help others. In 2008,  I reviewed it on HealthBeat.

At the time I wrote: “Remarkably, The Empowered Patient is not an angry book. It is not maudlin. To her great credit, Hallisy manages to keep her tone matter-of-fact as she tells her reader what every patient and every patient’s advocate needs to know about how to stay safe in a hospital.”

Recently, Hallisy emailed to tell me know that the book has now become a non-profit foundation: The Empowered Patient Coalition.

Go to their website and you will find fact sheets, checklists, and publications including, A Hospital Guide for Patients and Families that you can download at no charge. I found the Hospital Guide eye-opening. I have read and written a fair amount about patient safety in hospitals, but it told me many things that I did not  know.

For instance, did you realize that it is perfectly appropriate to ask your surgeon how many times he has performed this particular operation?

Are you aware that you (or your advocate) can—and should—read your medical records while you are in the hospital? (This may be the only way you will find out that your doctors disagree with each other about your treatment.)

Do you know what to do if you if you request a consultation with a more experienced physician because you have serious questions about the decisions made by residents –and hospital staff don’t agree that you need to talk to someone higher up on the ladder?

Below, excerpts from the Hospital Guide, and my comments in italics.

Patients and Patient Advocates Can Have Power

A patient and the loved one who  serves as her “advocate” can be empowered. Finding an advocate may not be easy.  Your patient advocate needs to be someone who has the time to be with you at the hospital, “or can take time off work,” Hallisy advises. And “the advocate should be comfortable asking questions, speaking to doctors about the patient . . .  Remember, not all people are capable of being assertive,” she writes  – no matter how much they care about you.” (Her emphasis.)

Let me add: I realize that many adults don’t have someone who can be with them at the hospital full-time. But two or three close friends or relatives might share the job—though they will need to communicate with each other on a daily basis. And one individual should be the “point person” for the team.

The Patient’s Relationship with Hospital Staff.

Protecting yourself does not mean “demanding your rights” as a patient.

Hallisy recognizes that, like patients and patients’ advocates, many hospital workers are stressed.

In her book, she writes: “Don’t wait for staff members to breach protocol and then jump on them.  Avoid awkward situations by announcing your concerns to staff well in advance of the start of the procedure . . .  I always found it helpful to put the onus on myself by saying something like ‘I just don’t feel comfortable unless everyone wears gloves.’”

The truth is that even brand-name hospitals often are understaffed and their nurses are rushed. Studies show that even at our prized academic medical centers, as few as a third of physicians and nurses may be complying with hand-washing standards. Yet Hallisy notes, “patients are hesitant to say anything because they don’t want to seem to be suggesting that hospital staff aren’t ‘clean.’”

She offers a simple solution: “When our daughter was ill, we taped an eye-catching, easy-to-read sign to the door of her room. Using colored paper, we wrote ‘PLEASE WASH YOUR HANDS AND WEAR GLOVES AS APPROPRIATE’ in large, black letters. . .  The increase in compliance was so immediate and so dramatic that the infection control specialist made her own signs and placed them on the doors to all of the rooms in the pediatric oncology unit.”

Don’t Be Shy About Asking Questions

But while you don’t want to be confrontational, protecting yourself or your loved one does mean asking questions.

First, you should know who is taking care of the patient. “It is always appropriate to ask a staff member about their title and level of training or experience,” the Guide advises.

There are gracious ways to do this. For instance if a very young doctor comes into your  room, you might ask “Are you the attending physician?” (Chances are he isn’t; see the hierarchy below. But he’ll be relieved that you thought he might be.)

If  he explains that he is a resident, later, you might ask “how long have you been at this hospital?” .If it’s August, and he’s in his first year,  he has been a doctor for one month.

This does not mean that he should not be caring for you, but another, more experienced doctor should be supervising him. If  you never see that other docotr, or you feel you are in trouble, you should ask to talk to the “Chief Resident” or the “Attending.” Also ask if the hospitals employs “hospitalists” — doctors who are reponsible for co-ordinating the patient’s care. mm

Your Healthcare Team

“A healthcare team requires collaboration and communication” the Guide explains. “Many people are involved. The charts below will help you understand the levels of authority.” Sometimes, if one person cannot answer your questions, you may need to ask for a “nurse supervisor,”  a “nurse manager, ” or an “attending.” But you can’t ask if you don’t know their titles.

Physicians

Attending Physician

Fellow

Chief Resident

Senior Resident (Third year resident or above)

Resident (Usually second year resident)

Intern (Resident 1 or PGY-1; first year of residency training)

Medical Student

*ATTENDING PHYSICIANS are the most senior doctors directly responsible for your care. Simply stated, they are the bosses of the house staff. They are responsible for the quality of care delivered to each patient under their watch and they may also train and supervise residents (doctors–in-training).

If you encounter a problem that your attending physician cannot resolve, ask for the Department Head or the Medical Director. Department heads are doctors who manage specific areas in the hospital (such as orthopedics or pediatrics).  Medical directors oversee all of the staff doctors.

Nursing Hierarchy

Nurse Supervisor or Nurse Manager

Advanced Practice Nurse or Clinical Nurse Specialist

Charge Nurse

Staff or Bedside Nurse (RN)

Licensed Practical Nurse (LPN) or Licensed Vocational Nurse (LVN)

Assistive Personnel

(Nursing Assistants, Patient Care Assistants, Nurses’ Aides, etc.)

NURSE SUPERVISORS and NURSE MANAGERS are part of the leadership team and are considered “nursing executives.” There is usually a nurse manager or nurse supervisor available 24 hours a day who is the direct supervisor of the charge nurses.

With few exceptions, a nurse manager or supervisor will be available to patients. Nursing supervisors and nurse managers are overseen by a Director of Nursing or a Chief Nursing Officer (CNO).

*If the Nurse Manager cannot address your serious concerns”  the Guide says, ”ask for the Director of Nursing or Chief Nursing Officer (CNO).”

Questions Patients and Advocates Should Ask

Here are just a few questions, and examples of how to ask them:

“This pill doesn’t look like the one she got last night. Could you double-check just to make sure that this is what the doctor ordered?”

“Do you have a palliative care specialist who could talk to my husband about his pain? The medication he’s taking isn’t t controlling it, and I’m  worried.”

When doctors are ordering tests, the Guide advises: “Tell your providers that you are interested in understanding why each test is being ordered and what information it will provide. Ask, ‘How will this information affect my treatment plan’”?

Ask regularly if it’s time to take out your IV line. ( IVs should be removed when they are no longer needed. The longer they stay in, the higher the odds of an infection. It is difficult for nurses to keep track of all of the IVs. You can remind them simply by asking—without suggesting that the patient is being neglected. mm.)

Surgery

If you’re scheduled for surgery, Hallisy recommends asking the  surgeon:

“How many times have you done this particular surgery? Have you had good outcomes? What rate of complications have you experienced, including infections?”

“Expect specific numbers,” Hallisy counsels, “and not vague generalizations like ‘not many.’”

“Will you be performing my entire surgery? Will you be assisted by any other surgeons, residents, or students? If they’re assisting you, will you be present in the operating room for my entire surgery?”

“Will there be any non-medical personnel in the operating room such as sales representatives?: (Their presence could be a source of infection, or a distraction.” the Guide advises. More importantly, “the presence of a sales rep  also “could mean that the surgeon is using a new piece of equipment or an unfamiliar technique.”   (I, for one, would rather that my surgeon was using an older hip implant that he had implanted 100 times. The “newest” is not always the best.–mm)(

Ask your surgeon how you can contact him or his answering service in case of an emergency following your operation. Ask if he will be staying in town for the first few days after your procedure and how he can be contacted. If another doctor will be on call for him, be sure you have his or her full name and direct contact number. To understand why this is so important, click here for Helen Haskell’s story. mm

Your Medical Record

The Guide is clear: Federal law allows for patients or their agents to view their medical record during a hospitalization. Remember: if you want your advocate to have guaranteed access to your record, be sure he or she is named as your legal agent.

The guide recommends “speaking:to your nurse, the charge nurse, or the nurse manager to work out a ‘plan for access’ to view the record on a regular basis. Be respectful of the work flow of the unit and ask for the most convenient time and location,”  (my emphasis)

What To Look For In Your Medical Record

Are the notes legible? Is any information missing or incorrect? If you find an error or omission, ask for the hospital’s policy on adding your own brief note to the record to clarify.

Do the notes provide enough detail? Be sure the language is not too vague to accurately document the situation.

“Are the providers providing the rationale for their professional judgment? If they note  that a patient is ‘now responding’ or ‘clinically improved,’ they should include the facts that back up their opinions.

“Is the ‘differential diagnosis’ listed? A differential diagnosis contains all of the possibleconditions, with the most likely ones at the top of the list and helps the staff keep a broad focus. Be sure potential diagnoses are eliminated once testing rules them out.

Are the doctors communicating with each other?: “Notes should mention the opinions and recommendations of other providers and clearly indicate that they have consulted  with each other – either verbally or in writing.”

Do any of the doctors disagree with the treatment plan? Reading the notes will tell you which doctors have reservations and allow you to consult with them directly. (my emphasis)

As Hallisey notes in her book: “In one case, an orthopedic surgeon failed, for five days, to diagnose and treat a raging abscess in Kate’s biopsy site. He insisted that the site was not infected—and not the cause of a larger infection that had become life-threatening.”

Only later, when the Hallisy’s read Kate’s records, did they discover that some of the other doctors were as alarmed as they were.

“The other doctors were extremely reticent about coming forward with their own concerns,” Julia explains. “If we had looked at their notes in the chart, we would have known immediately which doctors shared our opinion and we could have pressed them to take a stand.”  (At that point, Halliisy and her husband went to the hospital and insisted on being able to read the medical record in real-time– as it was being written.)

Here Hallisy illustrates why patients and patient advocates must become part of the medical “team.” Together, they can help doctors and nurses who want to “re-form” how hospital deliver care, making sue that it is patient-centered, not hospital-centered,The goal is to protect patients like Kate, making sure that their care is as safe, respectful, and kind as possible.

Very likely, Kate wouldn’t have survived. But her journey through our hospital system did not have to be so hard.

 

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52 Comments on "The Empowered Patient"


Guest
DeterminedMD
Dec 21, 2012

I just hope someone else who is a physician will voice an opinion about this post as I am persona non grata here. What I feel is fair to say though, is simply this: the road to hell is paved with good intentions.

I also will say this: certainly reinforces the agenda of PPACA to me. Doctors are just glorified servants for the customer. Good luck Ms Mahar in selling this plan. Transparency is a great expectation, but, not practiced by the very politicians who crafted the legislation, eh?

But, politicians are the poster children for “do as we say, not as we do.”

Guest
Scott Briggs
Dec 22, 2012

Hello DeterminedMD.

Have you heard of “Crossing the Quality Chasm” or of patient-centered health care? The point of this post and of the book is that patients cannot trust the system to give them safe and effective health care. They have to step in, ask questions, and manage the process, along with the providers. Sorry if the providers take offense to this, but it just might save a few lives. As a physician, I would have expected you to acknowledge the situation and suggest some improvements, not just babble on about the PPACA and divert the discussion to meaningless dribble. One final point – politicians don’t provide health care, physicians and other providers do. Take some responsibility.

Guest
DeterminedMD
Dec 22, 2012

“They have to step in, ask questions, and manage the process, along with the providers. ”

Patients manage the process. Really? I’m sure your plumber or mechanic love you and this philosophy so much they hug you when you greet them.

Nothing less than the usual disingenuous intent PPACA supporters just echo endlessly. Good luck with all thosed providers who want less than knowledgable patients telling doctors, nurses, pharmacists et al how to do their jobs and stay in health care.

Wow, this rhetoric borders on corrupt these days. Yes, I want patients and invested supports as educated and encouraged in care as able, but, sorry, they are NOT in position to “manage” me.

Guest
legacyflyer
Dec 21, 2012

The Empowered Patient “Strikes Back” – I think the title says it all.

Think about the situations in which one “strikes back”:

– An action movie starring Bruce Willis and Rambo
– Vengeance against the enemy
– Retaliation against an ex spouse
– Mixed Martial Arts

As a Physician (aka – Health Care Provider) I don’t want anyone to “strike back” against me. I would like to do my best and hope that it helps the patient.

If someone is looking to “strike back”, I would rather retire. Good luck with the person who takes my place. Maybe they will enjoy this game more than I

Guest
rbaer
Dec 22, 2012

I don’t know – as a physician – where to come down on all that. Some of the suggestions above are common sense for a concerned and able patient or relative/friend, and I experience this being done in daily life. That hand hygiene according to most studies is still suboptimal is a shame and patient advocacy /pressure could be a blessing.

However, the idea of advocacy that emerges from the original post (24 hour supervision of all aspects of healthcare, likely with extensive questioning) may not be that productive and not as realistic as suggested. Just a few points: Most “advocates” know little about health care and many acts of nursing or physicians may seem of concern while in fact there is nothing wrong – it can be quite time intensive and distracting to address all possible concerns (of course a valid concern needs to be raised, and of course it is a challenge to identify the real and significant concerns). Overly aggressive pain medication can cause sedation, constipation, delirium and pave the way to addiction – the only appropriate intervention for the advocate, IMHO, would be to say to the loved one “I wonder whether you have too much pain. If you feel you need more pain medication, please ring for the nurse/discuss pain control with your doctor”.

Moreover, it has to be kept in mind that a lot of special attention that patient advocates direct towards their loved ones may end up being subtracted from other patients, because work hours of residents/physicians, technicians, RNs are finite. If rounds take, say, triple the time for one particular patient due to advocacy, it may mean that time needs to be made up elsewhere during rounds (even though the time may be more needed there), or, if rounds are extended, delays (of testing, meeting other families, doing a procedure etc) ensue. Of course one could consider blowing up the staffing ratios, but that would result in even higher HC costs, and subsequently less experienced (and likely less qualified) professionals – professionals doing more talking and less actual HC.

Being watchful and assertive may be needed at times, but consideration for HC professionals and other patients is also important – to a large extent, this is a zero sum game.

Guest
Dec 22, 2012

Thank you for sharing this information with us:

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Guest
Dec 22, 2012

Scott, Rupeshcharl, Legacy Flyer, Rbaer,

Scott– Thank you for commenting. Yes, this is not about “managing the doctor” or telling him how to practice medicine. It is about the very real problem of preventable errors, and, as you say, the need for “patient-centered medicine.)

–Rupeshcharl– I’m glad you found this useful!

–Legacy First, “The Empowered Patient Strikes Back” is not Julia’s title–nor was it the title of my post. (My post was titled “The Empowered Patient.”

Presumably, a THCB staffer came up with the headline. It doesn’t fit the tone of Julia’s book, the hospital guide, or what I was trying to say.
Obviously neither the patient or the patient advocate should view medical professionals as “the enemy”

–rbaer–
You write: “Most “advocates” know little about health care and many acts of nursing or physicians may seem of concern while in fact there is nothing wrong – it can be quite time intensive and distracting to address all possible concerns (of course a valid concern needs to be raised, and of course it is a challenge to identify the real and significant concerns).

Agreed. That’s why the hospital guide spells out very specific questions and things to look for. On the website you’ll find a short list of questions that you can use as a script in various situations. (Before surgery, for instance)

Julia understands that nurses and doctors don’t have time to answer a great many rambling questions. Her goal is to educate patients so that they can ask focused, pertinent questions. (Otherwise, you wear out the nurses and ultimately receive less attention.

On hand-washing,. Julia also says :”Don’t wait for someone to fail to wash their hands and jump on them. She suggests putting up a sign over the bed, on the patient’s door, asking everyone–including visitors–to wash their hands before touching the patient.

Finally, rbaer on the need for a patient advocate: please read Don Berwick’s wonderful book “Escape Fire”: (It’s a great read.) See the chapter describing the months his wife spent in the hospital. She was in three of our nation’s finest hospitals He is a highly respected physician and not at all confrontational (A gentle man–trained as a pediatrician.) Yes he reports that “virtually every day,”a serious preventable mistake was made. Usually, he was able to catch it in time. Often it was a medication mix-up–but not always.

Yes, our hospitals are hectic places. We need better systems. In many of our hospitals we also need more nurses and better supervision of residents.

On pain medication– any palliative care specialist will tell you that in the U.S. doctors and nurses have been trained to be too wary of giving a patient the right amount of pain medication. Addiction can be a horrible problem

.I knew a woman M.D. who had cancer, survived, but became addicted to her pain medication. She lost her medical license, lost her husband, lived alone for many years, and finally threw herself down an elevator shaft. This is a tragic story.

But many patients who don’t get enough medication are dying–addiction is not a worry–they are not going to survive. But doctors do need to provide the right amount of pain medication–so that they are not comatose, and are able to talk to loved ones.
Palliative care specialists and other doctors who specialize in pain know how to give the right dose, experimenting, as needed until they get it right.
It’s not easy,.
Most med school students don’t study pain or palliative care.
This is why talking to your doctor or a nurse is not the answer.
You need to ask for a palliative care specialist (most hospitals now have them.)

As you know, palliative care is not just for dying patients (that’s hospice)– it’s
for any patient who is very sick or in great pain.
Most patients don’t know this. Many don’t even know the phrase “palliative care”
In her hospital guide, Julia explains what it is.

I urge everyone to read Dr. Diane Meier on palliative care. You can look her up on HealthBeat (I’ve written about her and her work a few times.)

Finally, only the patient knows how much pain is “too much” As you know, pain is different for different people. Being told “No” you don’t need more medication” heightens anxiety –which increases pain.

Unfortunately, too many nurses and doctors think that the person in pain is
exaggerating, faking, looking for a “fix,” etc. Or that they should just ‘buck up” and endure it. (They’re “whiners”)

Read Helen Haskell’s story about what happened to her son.(I refer to her story in the post. (“To understand why this is so important, click here for Helen Haskell’s story.’) He was in great pain for four days in a modern, supposedly very good hospital. It turns out he was bleeding to death internally– abdominal bleeding. The nurse in charge insisted it was “just gas” The resident and other doctor who saw him didn’t believe him or his mother. His surgeon was out of town. (If he had been notified he would have known t hat it was a reaction to medication he had been taking.)
On the 4th day, he bled to death.
I realize this is a rare story, but it’s also a reminder: If a patient is complaining of extreme pain, this is a warning. Perhaps the diagnosis is wrong. And too often, in this country, people die in screaming pain. This just isn’t necessary. We have experts who know how to control pain.

Also, a palliative care specialist knows how to talk to a patient about pain, how to calm him, and can tell when the pain is real—and must be addressed.

Guest
MD as HELL
Dec 22, 2012

I totally agree. I have worked in the hospital for 30+ years. I have seen it all. I doubt a lay person can find meaning in today’s computerized medical record, since I cannot myself, but knock yourself out.

Which is why you should never go to the hospital unless you have no alternative at all.

Never be alone at the hospital. When you are sleeping make sure there is someone there watching over you.

Go to the proper hospital. Get transferred to the proper hospital. If you have time, pick your specialists ahead of time. If you go to the ER, you get little opportunity to do research. Go to a hospital with the reputation you want. It guarantees nothing, but it is a better start.

Beware of EMS. They will scare you into accepting interventions you do not need. On the other hand, if you are seriously sick or injured, remind them their most powerful life-saving move is to drive the truck to the hospital. Most delays on scene are EMS hubris and waist time and opportunity.

Bad outcomes still occur at the best hospitals. People die at the best hospitals, too.

Do not become adversarial for the sake of being an “advocate”. People at the hospital are trying to help you. Ask what each person is doing, especially when giving you medicines. Ask what it is and what it is for.

Remember: No one can make you sicker quicker than a doctor. Approach with caution. But develope a relationship with your doctor. The depersonalization of the hospitalist movement is a very bad thing. They cannot care like your own doctor. If your doctor does not come to the hospital anymore, then have him send you up the road to the medical center. If they have beds, you might as well go there and have have their nameless faceless hospitalists care for you instead of the local nameless faceless hospitalists that could not get a job at the big hospital.

Do not let fear motivate you to be a consumer of any part of healthcare. Just because insurance is paying for it does NOT mean it is a great value to you.

Stay healthy. Prevention is not he same as early detection.

Guest
Cassie Stegeman
Dec 30, 2012

Thanks for sharing your comment! I agree with your post. It’s the patients right to ask questions, ask for a second opinion, or even question medical professions. As a nurse, I have seen mistakes made and some close calls. Patients are in charge of there own health care and most importantly they are there own advocate. I much rather a patient or a family member question me rather than sitting back and potential cause harm to a patient. We are all human and mistakes do happen but as medical professions we need to educate patients and families to speak up if something doesn’t seem right!

Guest
DeterminedMD
Dec 22, 2012

Ok, the author of a post can’t pick her or his own title? I’ll go along with that premise for the sake of cooperation. But, good luck telling us to interpret the post to NOT infer a sizeable level of management BY the patient and/or invested supports. I mean, really, am I the only reader at this site who erroneously reads Ms Mahar’s posts to demean and diminish the role and value of physicians? Oh, she writes a good game of claiming she had physician supports, but, I do not believe it at the end of the day.

I do appreciate and say thank you for being allowed to comment, I hope my comments reflect my concern for the patient-physician relationship is sincere and genuine. The politics of what is behind PPACA is fairly overt and direct, do not let people get away from deflecting, rationalizing, minimizing, and denying what are truths to the legislation. But, you are all adults and can problem solve for yourselves.

Happy Festivus to all!

Guest
legacyflyer
Dec 22, 2012

Maggie,

Even if you didn’t pick the title, someone did and their choice of words is revealing.

Guest
platon20
Dec 22, 2012

I have several arguments with this article:

1. Asking for a “chief” resident is stupid, because usually they arent taking care of the patient at all and have no idea what is going on. Chief residents are NOT in the “chain of command” unless they happen to be on service that particular week or month. The chief resident’s job is split between clinical and administrative duties. Who you want to talk to is the SENIOR OR UPPER LEVEL resident, not the chief. The senior/upper level is the person on the team who actually knows what is going on with the patient, in many cases more than the attending does. The chief resident is someone you should talk to when the upper level or intern does something unprofessional, but they are NOT the appropriate person to ask for in terms of clinical questions about a patient’s care.

2. Maggie Mahar on her blog goes on and on about how nurses are better than doctors when it comes to taking care of patients, yet all of a sudden in this article all we hear about is how the “attending” is the captain of the ship and the “best” person to lead the team. What happened to nurses running the ship Maggie? Why such a sudden change in tone? All of a sudden you dont sound so confident about nurse practitioners being leaders of the healthcare “team”

3. Maggie Mahar also spends a lot of time on her blog talking about how attendings are too draconian in their hierarchy and dont run healthcare like a team sport. She states that doctors need to give up control of decisions and instead use a “shared decision making” model where no one person controls the show. Why did you suddenly reverse your position on this? Dont you like the idea of the attending, nurse, resident, intern, phlebotomist all with EQUAL decision making power? If thats the case, why are you arguing for people to escalate up a “chain of command”? I thought a “chain of command” is contrary to shared decision making?

4. Palliative care and pain management are 2 entirely different specialties with 2 entirely different areas of focus. We should not confuse the two.

5. Listing a “differential diagnosis” for the patient is stupid. What happens when I put down a 20 point differential that includes everything from terminal cancer to a cold virus? Are you seriously arguing that we should work up every single possibility on that differential? Dont you argue a lot on your blog about how doctors do unnecessary tests? Do you even know what the purpose of a differential diagnosis is? If you want to increase healthcare costs and greatly increase preventable complications, then listing a differential diagnosis for the patient is a good place to start. Good luck ruling out every single possibility with a tissue biopsy.

5. This “patient guide” or whatever you want to call it, is obviously written by someone who thinks they know medicine just because their daughter was a patient. They know just enough to skim the surface and be dangerous while not understanding what “good care” really constitutes. Thats not to say that you should never question a doctor, test, or therapy, because you should. But insisting on differential diagnoses and getting curbside consults from every doctor in the hospital makes outcomes and healthcare costs WORSE, not better.

Guest
MD as HELL
Dec 23, 2012

A differential diagnosis is a list of wrong answers.

Guest
DeterminedMD
Dec 22, 2012

Glad someone else picks up on the biases!

Guest
southern doc
Dec 22, 2012

“When you or a loved one enters a hospital, it is easy to feel powerless.”

It must be miserable to go through life seeing all relationships with other humans in terms of a power struggle.

Dealing with lawyers, priests, chefs, auto mechanics, plumbers, accountants, sales clerks, and on and on: do we have to approach everyone with an analysis of where the power is, and demand “shared decision making” (which I assume comes with shared liability also)?

Count me out.

Guest
Craig "Quack" Vickstrom, M.D.
Dec 24, 2012

I like the way you think, Southern Doc.

Guest
Ethigal
Dec 22, 2012

Thanks so much for this post, Maggie. The post gives helpful information, and the comments from healthcare professionals give good examples of the varied reactions a patient can expect. I know as a patient I would like to have a healthcare team that supports my participation in my hospital care. I’m going to select an M.D. for my care, if I can, that is open to patient empowerment.

Guest
Dec 23, 2012

Ethigal–

Thanks very much.

I wouldn’t take the angry comments on this thread as indicative of “varied ‘reactions among health care professions” so much as examples of how a handful of very angry doctors feel about patients, shared-decision-making, and patient-centered care.

Guest
legacyflyer
Dec 23, 2012

That’s right Ethigal. Those of us who don’t like the idea of patient’s “striking back” are just a handful of “very angry docs”.

And Maggie, who talks to a few selected docs from time to time, has a much better feeling for what docs are thinking than practicing physicians who interact with other docs several times a day.

Oh, and I have a bridge for sale – cheap!

Guest
DeterminedMD
Dec 23, 2012

For me, just validates my opinion of the philosophy by the author. If physicians don’t echo an opinion, then they are just irrelevant, or better yet, just out to harm patients. Remember, there is a partisan agenda here, with them or against them. God forbid more doctors than not do not embrace the customer is right mentality that is the backbone of PPACA.

Oh, I’m sorry, that is the backup to the buck comes first mentality that drives political agenda. Let’s be clear, the doctor’s concerns to the process aren’t last.

Doctor’s concerns are irrelevant. Look forward to all those specialty nurse leaders running health care by 2016. Will enjoy their malpractice coverage rates equalling ours as well by then.

Guest
Dec 23, 2012

platon 20–

Let me suggest that you Google Dr. Atul Gawande and read what he has to say physicians working a teams, physicians working with nurses,

Then Google Dr. Diane Meier on palliative care and “pain,”

I don’t know who you are. As usual, people like you hide behind aliases.

But they are two brilliant highly-respected M.D.s You might learn something from them.

Guest
rbaer
Dec 23, 2012

Maggie,

I am sorry that you fall into a confrontational pattern (that the THCB triggered by – by your own admission inappropriately – headlining your post.

Platon brings up mostly valid points (IMHO in a somewhat needlessly adversarial tone). Palliative care and pain medicine are different specialties – I do not think it is the central issue here and there is not much helped by arguing about this point.

He (Platon) “hides” behind a pseudonym like most physicians including myself do on the THCB, for reasons that you probably know but that I would be happy to explain if needed. To comment on someone’s anonymity on an internet forum is not a sign of particularly advanced discourse.

Also, I note that an artificial polarization is kept up by several posters lumping all the posts by various assumed HC providers into one camp. I think I wrote a differenciated post, and even MD as hell “totally” agrees.

I want to make clear – again – that a lot of patient involvement and many of the above suggestions do make sense, if used appropriately and with consideration. The huge problem that barely anyone wants to talk about is that patient (and family ) participation are always (or even just mostly) beneficial. This is a completely unfunded assumption. Please read Dr. Brawley’s book “How we do harm” to read 2 long and IMHO representative anecdotes of patient/family centeredness resulting in net harm.

I would argue that lack of patient involvement and medical errors are hardly on top of the list of pressing flaws of the US health care system – I would emphasize (with Dr. Brawley and, actually, Ithought, MM) that profit centeredness resulting in overtreatment of the insured and undertreatment of the underinsured are the main issues.

Guest
rbaer
Dec 23, 2012

After some more reading, I have to briefly come back to the “palliative care” issue. While “palliative and hospice care” are one board certification, some do use the term “palliative care” for the management of chronic nonfatal conditions (and even fewer for the treatment of curable conditions), with special consideration of psychologic and spiritual factors. I would say that the vast majority of the medical community INCLUDING most palliative care teams would not use palliative care for pain management in an inpatient who expects cure or significant improvement (of course it is possible that there is some regional and institutional variation).

Guest
southern doc
Dec 26, 2012

“As usual, people like you . . . ”

What a bigoted, hateful phrase. The true spirit of intolerance.

Guest
Lori
Dec 23, 2012

That nursing hierarchy is not really correct. Nurse managers/supervisors and ARNP/clinical specialists are not necessarily more knowledgeable than some staff or specialty nurses. Some specialty nurses even know more than some doctors about some facets of health care. Moral of the story: just ask for credentials, level of education, etc, before making lists like that. Thank you.