When patients are sick enough to require hospitalization, medical decisions often involve nontrivial tradeoffs between risks and benefits. They require discussions with patients and families from a variety of cultures and backgrounds. And sometimes these discussions break down.
Patient-clinician communication is increasingly recognized as an integral part of clinician competency. Indeed, family-centered rounding, increasingly practiced at Children’s Hospital Boston, is a critical step in this direction. Fully adopting this practice surely will enhance communication quality.
Yet, I suspect we’re still missing cues from patients and families, signs that our alliances with them are not sound. We can’t be maximally perceptive all of the time. It is busy, we are tired, we want to teach, we want to be efficient, and we want to get to the noon conference to learn to be better doctors.
Initial decision-making currently works about the same for every hospitalized patient. My experience is in inpatient gastroenterology. We review the medical data outside the room and make a plan. Then we walk into the room, make introductions, ask how things are going, do an exam, review the plan for the day, and move on to another patient.
Often this works well. But it’s not always apparent what patients or families really think about these conversations. When they misfire, we may find out hours or even days later that families have refused care or had harsh exchanges with staff.
Including communication as a system in work rounds – with the seriousness and respect given to organ systems — conveys that communication is clinically relevant.
Relationship repair follows, with a frank and caring approach. Our resident and fellow trainees learn critical communication skills through these conversations. Nevertheless, might there be a way to avoid some of these “flare ups”?
As doctors discuss impressions and plans for patient care, we often organize our thoughts into organ systems. I’d offer that we need to review another system – the communication system. This means recapping the communication successes or failures with respect to decision-making among the medical team, the patient/parents, and other staff, and considering changes in strategy if needed.
In a conversation with our GI fellows, a faculty gastroenterologist recently compared two families in her practice. One she approached with an authoritative style, the other with a patient-driven style, simply presenting the options. Because she had known each family for a long time, she understood how they wanted to make decisions, and felt her approach was the best in each case.
Explicitly evaluating communication will help us notice cues that our relationships with patients or parents need tending to. An exchange on our GI Inpatient Service might then sound like this:
[outside hospital room:]
Dr. Smart (Second Year Admitting Resident): John is an 8-year-old boy with a 5-month history of ulcerative colitis, now flaring for the third time requiring a third hospitalization. The differential includes C. difficile colitis, and less likely bacterial dysentery, viral gastroenteritis or atypical response to a medication. Related problems include underweight, worsening anemia, and an unusual rash. From a cardiovascular standpoint…
[two minutes later:]
From a communications standpoint, my conversation with Mother last night suggests, understandably, that she is scared and angry. When I said that John couldn’t eat, she rolled her eyes and started sending a text. I didn’t discuss this with her yet.
Stacy (Nurse): I am glad you said that. I also couldn’t seem to do a right thing in there without Mother glaring or rolling her eyes. I mentioned that the intravenous steroids were ordered, and she just shook her head.
Dr. Right, GI Fellow: Thanks, Stacy. We have emailed our social worker and John’s outpatient gastroenterologist. I think it is best if Dr. Smart introduces us, guides us to the pertinent parts of the exam, then I sum up and begin discussing the plan. Since Dr. Peace knows Mother well, she can mention communication with John’s outside gastroenterologist, Dr. Joy, and help maneuver if there is tension.
Dr. Peace, GI Attending: Sounds like a good plan, Dr. Right.
[inside room, five minutes later:]
Dr. Right: …so, we do think it makes sense to start intravenous steroids again…
Mother [interrupting]: Nope. We aren’t doing that. I knew you would be starting those stupid steroids again. That doesn’t make any sense to me. None of this is helping.
Dr. Peace: We are all really sorry to see that John continues to be sick. We’ve talked with Dr. Joy briefly, but it is true that we didn’t specifically talk about when we would start the intravenous steroids again. You seem mad, and I don’t think we appreciated your feelings about intravenous steroids.
Mother: Yes, no one listens to me. They make John crazy and his ADHD goes through the roof. I am also so tired. I want to talk with Dr. Joy.
Dr. Peace: Okay. We of course want to make sure we are all on same page about the intravenous steroids. Maybe it makes sense for us to continue to hydrate John, keep tabs on his blood counts, and if he feels like it, he can have a simple breakfast like oatmeal or a bagel. It is early I know—you could get a little rest and when we are done with our rounds we will see if we can get Dr. Joy on the telephone and we can discuss the steroids or other plans together?
Mother: Fine. Yes, I am angry, I am sorry if I interrupted and come across mean. I am just tired and I’ve had it.
Dr. Right: That’s okay. It is a rough day. We’ll see you later, then.
The conversation may have naturally produced the same result even if the team hadn’t addressed the communications system squarely before entering the room. On the other hand, Dr. Peace might have answered a page during the conversation, not knowing that it was important to be present for the entire discussion. Or Dr. Smart might have tried convincing Mother that steroids were necessary. Or Dr. Right might have simply suggested discussing the steroids later, confirming Mother’s view that she wasn’t being taken seriously.
Including communication as a system in work rounds – with the seriousness and respect given to organ systems — tells physicians, nurses, dieticians and social workers alike that successful communication and relationship building are clinically relevant. And that we have the opportunity to notice our successes and mend our disconnections every day.
Daniel Kamin, MD, was the initial medical director of intestinal transplantation at Children’s Hospital Boston, and recently has turned his career towards GI education. He is a member of the Ethics Advisory Committee at Children’s, and hopes to further explore the ethical frontier between the decisions made by doctors and patients.