Making decisions for vs. with the patient

As a 3rd year internal medicine resident, I have so many times made decision for my patients without asking them for their opinion about it. Most of the time, it has been as routine as starting a new blood pressure medication while not talking to the them about the possible side effects that I have found to be one of the important factors resulting in non-adherence by my patient to that medication and then having them labeled as “uncontrolled HTN in the setting of non-adherence to medication”.  What I have learned in only 3 years is that when it is a shared decision the results are much better, patients are less likely to be non-adherent and they  trust in me and team more.  Yesterday we had a session on the consent form and the value and importance of shared decision-making. We talked about catastrophic … Continue reading

Considering informed consent

After watching the Michael Skolnik story here at Telluride, the residents and faculty broke into small groups to consider the issues involved in getting proper informed consent from patients who are about to undergo procedures.  Faculty member Kim Oates later reminded the residents, “The consent form doesn’t replace the conversation. And the conversation
is not a conversation unless it is a two-way conversation.”Although the focus was on the humanitarian reasons for engaging in proper consent procedures, faculty leader Dave Mayer also pointed out that informed consent breakdowns are a top
reason for losing malpractice cases. He also reminded the residents of the value of encouraging people to seek second opinions, not only for the patients themselves, but also for the doctors: “We’re all biased towards doing the procedures
we’re trained to do. If you think you’re
not, you’re fooling yourself.”

Here’s a composite of pictures of the members of… Continue reading

QI Project Idea – Comments Encouraged!!!

Hi All,

As you are all interested in patient safety/QI, I wanted to run an idea by this very talented group and see if you had any thoughts/improvements/additional ideas.

Background: At the Washington DC VAMC there is minimal communication between the house staff and nursing staff, often the two groups don’t interact all day.  One of the biggest hurdles that residents feel they must overcome is being able identify which nurse is caring for their patients and how to get a hold of them.  The current work environment yields fractionated and adversarial relationships with the patient’s medical team, hindering a patient centered approach to treatment.

Aim: To improve communication between nursing staff and house staff with regards to patient care

Intervention: On day one of the rotation, all house staff will be taken to each medicine ward floor and introduced to the nursing staff.  Each team room… Continue reading

Shared Decision Making #SDM

Today’s discussions revolved around the importance of involving patients and families in care planning. We touched on a number of important topics within this theme — informed consent, outpatient medication choices, code status/goals of care, and much more. I appreciated that today’s SDM discussion was paired with a fantastic workshop on negotiation led by Paul Levy, which broadened the concept of negotiation for me. Some of the stories regarding SDM were striking. Parents having procedures performed on their children without their knowledge or consent. Patients consenting while heavily sedated. Many terrifying stories today. I think the toughest barriers to involving patients and families in care planning are the incredible asymmetry of knowledge and the difference in perception of severity between provider and patient. What I consider a routine procedure or a common medication may be the biggest risk/benefit decision the patient has ever had to make. We need educational systems… Continue reading

A reflection of our role as healers

Important topics were covered today including disclosure, transparency, consent, and shared decision making. It seems only logical that when these techniques are used, it not only empowers the patient, but takes away some of the burden from the physician. These decisions are to be made as a team. It is not our job to make a decision for the patient. It is also important to manage expectations, for both the patient and the practitioner. We should form an alliance with our patients to walk the path of recovery together.

Day 2-On Compassion and Professionalism

Professionalism according to webster’s dictionary  -“the skill, good judgment, and polite behavior that is expected from a person who is trained to do a job well”.

This afternoon we discussed whether it is professional behavior to reflect compassion, empathy, etc. using body language. In the right setting i think it is not only appropriate, but expected that a physician join a patient down the emotional journey of illness. This does not mean a physician is expected to cry every time a patient’s family is grieving, but it should not be interpreted as a sign of weakness. We sought this profession (I hope) because we enjoy being caretakers, and sharing in the joys/horrors of the human experience. Patients seek us because they want a person to help and guide them. In the right setting, letting your feeling get the best of you may be just what a grieving family member needs.

RP

I am so lucky to be in Telluride!

I am so happy to have read Nick’s post entitled I am not alone. This is probably still the most overwhelming sentiment that I feel.

Today really reinforced that although I am not alone, I am certainly not a good negotiator. I think that this is such an important skill in medicine, but particularly when we are fighting some uphill battles in our hospitals with patient safety issues. Particularly, with culture change and administrative leadership, I think it is so important to convince those in charge that your project/idea/need is worthwhile. But, in order to do so, you need some negotiating skills and need to figure out how you can advance their interests by advancing your own. This is definitely something that I will approach all future discussions with in the forefront of my mind.

Again, what an amazing cast of peers, leaders, and inspirational people! I am so lucky to be in Telluride.

Day 2

Greetings again, another great day in Telluride learning about patient safety. Focused on informed consent, a topic which seems straight forward but is very complex.

Seems like the process and forms that we utilize in getting consent for procedures varies a lot from institution to institution. It has always come across as a ‘permission slip’ to do the procedure for the patient. But to reduce it to that is really a mistake and disservice to the patient.

Taking time to do a proper informed consent, explain the risks, benefits and alternatives provides a level playing field for the patient to ask or question any unexpected events. It helps to add another set of eyes to evaluating the course of care and recovery.

The importance of a conversation can not be overstated.

Telluride patient safety roundtable Day #2
We discussed negotiation and various important concepts and strategies concerning negotiation. The negotiation exercises today were very helpful in illustrating and communicating the key concepts presented. Something I found particularly interesting was distinguishing interest from position. An important distinction as this can completely turn a conversation into a win-win for both parties if their underlying interests are addressed. Also, an interesting comment was made about the able to participate in a negotiation and at the same time having a different perspective where you are actually watching yourself from a balcony. This I believe is somewhat related to mindfulness – as an evaluation of your on mental processes and judgments.

We also discussed the informed consent and patient centered care. So many good points and ideas were brought up in discussion but something I hadn’t given enough thought to–the significance/importance the emotional stresses can have… Continue reading

Proud

I have had several moments this week when I have not been proud of medicine, but today I was a very proud resident of Poudre Valley Hospital and Fort Collins Family Medicine Residency Program. We were discussing the informed consent process and although I acknowledge that there is always room to grow, I was proud of the dedication to patient safety and education that our medical community exhibits and strives to achieve. I can’t wait to come home and share what I’ve learned to make us an even better magnet hospital!