Tuesday, February 18, 2014

Mutual Respect and Trust

This interesting opinion piece from a pediatrician – Dr.Russell Saunders –expresses frustration with parents who don’t want their children vaccinated and I share that frustration. However, I also admit to having mixed feelings. I sympathize with Dr. Saunders, but I also feel a bit upset with him for falling into the trap that my good friend, Dr. Saul Weiner at the University of Illinois, describes as the “I-it” relationship trap. The “I” in the trap is the doctor who can easily see the patient as the “it” that should merely do as it is told. It often is easier and more efficient to just tell a person what the medical evidence suggests they do and move on to the next person, however the real job of a physician is much more difficult and nuanced. It is to be with patients and guide them through the uncertainty and discomfort that is illness by first recognizing what makes them unique as a person and giving them respect and trust and then applying scientific medicine.  Unfortunately, many physicians only focus on the respect they are due as the doctor -- and not on the respect they must give their patients -- and that impairs their ability to form a therapeutic relationship. In a sense, Dr. Saunders’ reasoning is evidence that medicine continues to cling to the belief that human beings are rational – that by presenting them with the facts, we can convince them. Behavioral economics teaches us otherwise.

Dr. Saunders says he is not looking to return to the paternalism that used to characterize medical care. However, we risk a new type of paternalism – one that places absolute faith in the medical scientist – a belief that the only way to proceed is the way the peer-reviewed medical journals and the expert committees declare to be correct. Dr. Saunders writes:

The physician-patient relationship, like so many other human relationships, requires an element of trust. I certainly neither want nor expect a return to the paternalistic “doctor knows best” mindset of bygone years, but I do need to know that patient’s parents respect my training and expertise. Refusing an intervention I desperately want all children to receive makes that respect untenably dubious.
There will be times when parents and I may not see eye to eye, but not where I’m using the best evidence at hand to support my recommendations. Maybe they’ll want a test I think is useless, or want to use a supplement shown to be harmful. Perhaps it will be a referral for an intervention shown to have no benefit. If I can’t hope to persuade them by making reference to the available research, what can I expect to be for them other than a rubber stamp for their ideas? If medical science can’t answer the meritless qualms they have about vaccines, when can I use it at all?

I read this and can’t help but believe that the author does not really believe everything he writes. for he seems to be a caring physician. I am sure he knows that respect for the parent would warrant a discussion of why parents feel and believe the way they do. That discussion would require an understanding of their values, their culture and their beliefs, rather than simply pointing to the “available research” as the right way. The approach he writes about implies that if you can’t understand the importance of the science, you are bad parents and not worthy of my help.

His opinion piece also lacks the humility that should be inherent in any mutual trust relationship, especially one that goes beyond a friendship and is a true calling, as medicine should be. Medical facts change; new research brings new insights every day. Nothing is “settled,” and everything changes, even vaccinations; new vaccine formulations are constantly being developed. The Salk vaccine for polio was a godsend and was the only right answer until the Sabin vaccine was developed.

That does not mean I would agree with parents who refuse vaccination and just say “yes” to their request not to vaccinate their children. I would not. But I would also not reject them out of hand and assume that if they can’t accept the available research, my answer should be to ban them from my practice.

Dr. Saunders’ opinion piece reflects many of the frustration in medicine today -- with one of the root causes related to the incentives put in place by health plans. I cannot help but feel that our approach to health benefits, and our push toward efficiency in medicine, has created a situation in which the building of mutual trust between a doctor and a patient has become almost impossible. Health plans tell doctors which algorithm to follow and reimburse them in ways that encourage shorter office visits, more use of physician extenders, and adherence to protocols -- no matter what the patients’ beliefs and values are. Following those protocols and practicing the way Dr. Saunders writes about -- refusing patients who do not follow “doctor’s orders”--will make the numbers look better for a practice, make it more likely to receive the health plan quality bonuses, and make it more efficient. It may also relieve physicians’ frustration in this modern day system.  But will it truly help those who are most in need? I am not so sure.

I can’t help but think back to my days in practice, when I treated patients who, due to their religious convictions, refused blood transfusions.  As a gastroenterologist treating people who suffered from acute gastrointestinal bleeding, I knew that prohibition against blood transfusions went against every care algorithm and every medical standard. I would always try to convince patients of the need for the transfusion, but always with respect for their beliefs and with the proviso that I would treat and help them no matter what they decided. That respect was critical for mutual trust. What was so very interesting to me was that these patients were treated successfully, and we did not lose patients at a higher rate than other patients who presented with the same problems. Many who initially refused transfusion did accept it as their condition progressed.

That taught me a valuable lesson: Science is necessary for care, and following the most up-to-date recommendations is important, but nowhere near as important as respecting your patient -- and fostering mutual trust in such a way as to be not only a doctor, but a healer

Monday, February 10, 2014

Speaking and Hearing

Doctors and nurses often don’t speak English. They speak “medicine.” When I was a young medical student at Columbia University, Dr. Lewis Rowland was the new Chairman of Neurology. Even then, he was already a giant in the field, but he was, at that point, a young giant. In my eyes his greatness was as much a function of his ability to understand the need to communicate clearly as it was his knowledge of and research in neurology. When a medical student would present to Dr. Rowland -- which was always an occasion of great anxiety -- the student’s knowledge of neurology and the diagnosis of neurological diseases would be tested, but so would his or her ability to speak English. The minute a student stated “the patient had upper extremity weakness,” Dr. Rowland would stop the student and say in a questioning tone, “upper extremity?” He would then, with great flair, state, “Oh, you mean arms!” He would never let a student or a resident get away with speaking medicalese when English was available.  

Yet even when a doctor or a nurse makes an attempt to avoid medical jargon and speak English, the fear and emotions that are part of every medical encounter makes hearing what is said extremely difficult. In a recent New York Times blog post entitled “Lost in Clinical Translation,” Theresa Brown -- who is an oncology nurse and an author --talks about the need to pay more attention to both what doctors and nurses say and what patients hear. She starts her post with the following analogy:

A classic “Far Side” cartoon shows a man talking forcefully to his dog. The man says: “Okay, Ginger! I’ve had it! You stay out of the garbage!” But the dog hears only: “Blah blah Ginger blah blah blah blah blah blah blah blah Ginger …”
As a nurse, I often worry that patients’ comprehension of doctors and nurses is equally limited — except what the patient hears from us is: “Blah blah blah Heart Attack blah blah blah Cancer.”
Her choice of the word “translation” in her title is especially meaningful for me. I have often said that in medical school I did not learn how to practice medicine; I only learned the language of medicine. As someone with a great love of the English language, I was struck at how different the way medical professionals communicate is from the way the rest of the world communicates. The intent is often good, and that is to be precise when plain English may not be precise enough.  That is not only limited to the medical world. It seems within every discipline and within every culture, there is a language all its own. When I decided to go back to school to study business and work toward an MBA degree, it was because I was already involved in discussions having to do with healthcare costs and management systems, and I was frustrated because I did not know the language. I felt I needed the formal coursework to learn to translate from medical to business.

In our society, when we speak of healthcare, if we are speaking from a point of view of legislation, the language is government. When we speak from a point of view of costs, the language is economics. When we speak from a point of view of technology, it is “techno-speak.” And so we speak multiple languages, even when we think we are all speaking about the same thing: healthcare. For me, that is all just noise, as the real language of healthcare is the conversation that occurs between a person in need and a health professional, even if that professional is a professional office worker in a doctor’s office. That, for me, is what being patient-centered is really all about.

But whatever the language, and no matter how well it is translated, it’s also important to remember that what is said may not be heard. Ms. Brown’s blog article points out that challenge. She described a situation early in her nursing education when a patient who was in the hospital for a pulmonary embolism (medical speak for a blood clot that travels to the lungs and damages part of the lung, making it difficult to breath) is seen by the medical team who explain her condition to her. She writes:

“To me, just at the start of my nursing education, the explanations were clear and easy to follow, and I felt hopeful they would give my patient some comfort.
After the rounding team left, though, she turned a stricken face to me and deadpanned, ’Well, that was clear as mud, wasn’t it?’”
Taking time to communicate clearly – and even more importantly, to ensure that the communication is heard and interpreted in the way it was intended – is part of the art of medicine, whether that art is practiced by a doctor, a nurse, a therapist, or even a clerk at the front desk. I fear we will not focus enough on this communication as we move toward efficiency as the goal of a cost-conscious health system.  Without taking that time, and leaving the understanding between the medical professional and the patient wanting, the efficiency that results is a false efficiency – and costs will actually go up.

As we, as a country, struggle with medical costs, we should start by recognizing that by paying for more medical personnel who slow down and speak in plain English – to make sure that patients are hearing what was said – will save more money than we will through technology and efficient networks.
It also supports the model we have developed at Accolade. At Accolade, our clients have their own Accolade Health Assistant® who is skilled at purposeful, understandable communication and relationship-building in order to foster the type of two-way communication that is critical to good, truly efficient care. The clients also often have a Clinical Health Assistant, a nurse, who works with the Health Assistant to offer the medical knowledge (and translation) that is also critical to good, efficient care. With that team approach, the resources for proper, care and two-way communications are in place. The result is better care and lower costs.

The lesson learned for health care more broadly from our experience is the lesson of communication and trust as modalities every bit as important, and perhaps even more important, than the pure science that is integral to good medicine.