A hospital stay provides new insights into the patient experience

Communication is critical to success in medicine.  Our patients depend on us to help them understand their disease and the risks that it may pose.  In previous blogs I have commented on how vital effective communication can be in determining outcome — much of my writing has focused on the success associated with outpatient doctor-patient relationships. We now know that when doctors and patients engage, patients become invested in their own health care and are more likely to comply with lifestyle modifications and take medications as prescribed.

However, when a patient is ill and hospitalized, a entirely new level of complexity is added to the communication mix. The role of patient places one in a difficult position — you lose control, you lose your individuality and you may often become frightened due to the uncertainty of the clinical outcome.  The dynamic of communication in the acute hospital setting may be quite different in that the patient may be interacting with a new team of health care providers that they have no previous relationship with.

In addition, disease related factors such as pain, fever, and sedation may play a role in a patient’s ability to comprehend what is being said to them at any given moment in the hospital setting.  I can now speak to this from personal experience — this last week I became an unexpected patient.  I spent several days navigating illness and a complex yet compassionate hospital system.  My experience as a patient has inspired this particular blog — and has inspired me to become a more effective communicator in my practice.

Recently in the New York Times, two articles were published that discussed different aspects of physician communication with patients.  Both pieces are important and should be read and carefully digested by both patients and physicians (as well as any other health care provider).

In the first article, author Theresa Brown discusses the discussions that physicians and other health care providers commonly have with patients during a time of illness.  Particularly in the hospital, teams of providers at all levels enter a patient’s room and discuss all aspects of the case (both with the patient and amongst one another.)  It is interesting to realize just how much of what is said during these encounters is “lost in translation.”  During periods of illness, even the most educated and medically sophisticated patient can have difficulty comprehending exactly what the medical team is trying to convey.  Pain, worry, and emotional fatigue may all play a role in a patient’s inability to comprehend the clinical situation, the possible diagnoses, the testing required and the treatment plan.

In a separate article, authors Gilligan and Sekeres explore whether or not there are effective ways in which we may be able to teach better communication skills to physicians in training.  Several studies have demonstrated that no amount of training will convert an introvert to an extrovert communicator — however, communication training may open a health care provider’s eyes to the profound impact that their interaction with patients may have on outcome.  Once a provider is aware of the impact communication may have, they are more likely to be able to better engage patients and engage in a more effective way.

During my unexpected role as a patient this week, I often did not understand what to expect — even with my years of medical training and experience.  I could only focus on my symptoms and my fear of the worst possible outcome scenarios.  During my patient experience, I interacted with many physicians, nurses and other team members — ER doctors, specialists, imaging technicians, transporters, etc.  My particular providers were very compassionate and spent a great deal of time attending to my needs and explaining their thought processes, differential diagnosis and treatment plans.

However, I was unable to process most of what was said.  I was often distracted by pain and my ability to assimilate and comprehend information was limited by the sedation I had been appropriately given.  Ultimately, emotion and fear would come to the forefront and dominate my thoughts, further limiting my ability to actively and effectively communicate with the medical team managing my hospital care.  My caregivers were dedicated and wanted only the best outcome for me and my family.

I was often confronted with large amounts of clinical information and I began to hear only pieces — I would latch on to particular words such as surgery and potential complications and would lose focus — no longer able to follow the conversation.  My ability to think rationally and effectively process clinical information (as I would as a physician)  was severely impaired.  I can only imagine what the experience would have been like for a non medically sophisticated person.

Fortunately, as the week progressed, my condition improved and I was ultimately discharged from the hospital.  My physicians and nurses spent time later in the week making sure that I understood what had happened to me and what the next steps would be.  My hospital stay and treatment provided me with new insights into the patient experience.   I now am able to envision ways in which I can improve my own interpersonal skills with my hospitalized patients — by actively taking time to make sure that each patient understands and truly hears what is being said to them.

From my experience, one of the keys to promoting  understanding is to provide time for questions — from both patient and family — during the inpatient hospital visit.  My caregivers did this often and it did provide comfort and some semblance of control (as much as one can have in an ill fitting hospital gown.)

In addition, providing small, easily digestible bits of clinical information at several points throughout the day seemed to improve a patient’s ability to process and comprehend their condition, treatment and prognosis (at least it did in my case).  Although is is not practical for the physician to make multiple stops to the patient room throughout the day, phone calls for updates by the treating physician and visits by other providers such as nurses, PAs and NPs can make a difference in patient understanding and comprehension.

As Ms. Brown rightly states in her Times piece, hospitals and medical care are well focused machines — most providing efficient, quality life saving care.  We must remember, however, that we are treating patients — human beings with emotion and fear that can certainly impact a disease process.  We must take time to ensure that we not only provide the high quality efficient care but we also are able to care for the human being lying in the bed in the awkwardly draped hospital gown.

I am glad to be home from the hospital.  I am grateful for the wonderful care and compassion that me (and my family) received from many over the last week.  I am happy to be sitting outside in the sun writing this blog today.  I am excited about the opportunity my experience as a patient has afforded me.  I will take what I have learned and apply it to my practice — I hope to work every day to improve my communication with all of my ill and hospitalized patients.

Most of all, my experience has reminded me that although medicine is the application of science to the treatment of ailments suffered by human organisms, it is the human that really matters.  Our patients are people — they are often alone, frightened, emotionally exhausted and suffering.  We must all engage them in a way that best facilitates their understanding of their situation and focus equally on both treating a disease and treating a frightened person lying in the bed before us.

Kevin R. Campbell is a cardiac electrophysiologist who blogs at his self-titled site, Dr. Kevin R. Campbell, MD.

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  • Dr. Drake Ramoray

    You are correct. Unfortunately with the way medicine is headed hospitals are buying up outpatient practices all over the country and adding their fees and your just a number level of customer service as the norm for office medicine now too.

    http://www.publicintegrity.org/2012/12/20/11978/hospital-facility-fees-boosting-medical-bills-and-not-just-hospital-care

  • Patient Kit

    There really is nothing like walking in another person’s boots — or non-slip hospital socks — to gain a whole new depth of knowledge about their experience. I hope you’re well now and that your experience as a hospital patient stays with you long and informs how you interact with your patients. It’s great to get something so good out of something as bad as being hospitalized.

  • http://www.myheartsisters.org/ Carolyn Thomas

    News flash: “We must remember, however, that we are treating patients — human beings…” Why on God’s green earth should it take hospitalization for intelligent, educated doctors to grasp what should be considered the bleedin’ obvious: that those people wearing the drafty hospital gowns and matching booties are actually human beings? Are med schools missing this important bit of classroom teaching?

    Sigh….

    • rbthe4th2

      Yes. In studies, once 3rd year is around, they start losing empathy. Sad to say but the business of medicine is such that no one of us rank and file – both patients and doctors/PA/NP’s are happy.

      • http://www.myheartsisters.org/ Carolyn Thomas

        Yes, I’ve read something similar. Yet I’m not referring to overall “happiness” here – just this basic yet apparently surprising awareness that one’s patients are indeed human beings. I can’t help but notice that this newfound awareness seems to strike doctors-turned-patients with a “Eureka!” thunderbolt as if they have never actually realized it UNTIL they are hospitalized themselves. It’s also why doctors must stop saying nonsensical things like: “We are all patients…” (No. You’re not!)

        I wrote about this in the BMJ on what happens when docs become patients: “… They announce to their colleagues that hospitals are demoralizing, medical procedures frightening, lack of dignity embarrassing, symptoms distressing, dependence humiliating, the simplest
        of tasks exhausting, anxiety relentless, their past as a healthy person
        but a dim memory, and a future looming bleak and uncertain. Who knew?” – http://blogs.bmj.com/bmj/2014/01/14/carolyn-thomas-why-physicians-must-stop-saying-we-are-all-patients/

        • rbthe4th2

          Oh yes, we’ve seen it. “http://www.propublica.org/article/qa-marty-makary-m.d.-author-of-unaccountable
          Complacency and blind trust are the greatest barriers. The complacency is embodied in the traditions of medicine. Medicine has its own culture, values, vocabulary and justice system. Part of that culture is that we only listen to ourselves. … But the treatment is too often based on that individual’s practice rather than what’s the best evidence.”

  • Deborah Shlian, MD,

    I couldn’t agree more with Dr. Campbell. Communication between doctors caring for an individual patient and communication between those doctors and the patient are key to quality. That should be a no-brainer. Yet despite all the time and money spent on developing electronic medical records and the hoards of consultants emerging with new patient centered models and various technologies promising improved communication among all those involved in a patient’s treatment, a cultural barrier exists within our healthcare system that often derails an organization’s best-laid plans.

    I’m a newly retired physician and a recent patient in a hospital in Santiago, Chile where I experienced a system in which communication between all levels of staff made all the difference in the outcome of my admission.

    I’d been on a South America Holiday cruise. Sometime mid-trip I picked up a bug that caused a spasmodic cough, extreme fatigue and significant shortness of breath. By the time the ship docked in Valpariso, the symptoms were serious enough to seek out medical help.

    I still hang on to the notion that the American healthcare system is the best in the world – so when I walked into the Alemana Clinica ER last Saturday asking for an X-ray “just to be sure I [don’t] have pneumonia”, I was not expecting a world class facility and certainly not physicians of the caliber of my colleagues at home. Luckily I was wrong on both counts.

    I don’t speak Spanish and most of the Alemana Clinica staff does not speak English. However, the hospital made sure that all the physicians who saw me spoke at least some English.

    From the moment Dr. Rosas came in to examine me in the ER- and by the way, he made a point of first introducing himself and showing me his ID so I could write down his name – it was clear that he knew his stuff. He took a careful history (a critical part of the work-up that is often missing these days in the US), did a thorough physical exam and then reviewed with me the tests he felt were important.

    In less than two hours, Dr. Rosas had determined that I had double pneumonia with a critically low oxygen saturation level, requiring admission to the ICU. Dr. Descalsi, a pulmonologist was called down to the ER to see me and to let me know that he would be my doctor during my entire admission. He actually took my hand to reassure me that I would be OK!

    I’m used to doctors flying in and out of hospital rooms as they rush through rounds, so I was shocked that indeed Dr. Descalzi was there everyday, patiently examining me and reviewing how I was doing.

    Terrified that I would be all alone in a foreign hospital where I didn’t speak the language, I asked if my husband could stay with me. Without hesitation, the doctor said “of course”. My husband slept on a reclining chair by my bed for 4 nights. I know it wasn’t optimally comfortable for him, but his being there reduced my stress significantly. It’s hard to know why so many American hospitals simply refuse to allow family members to stay with the patient. As Dr. Campbell points out, even the most medically literate can’t always process everything explained to them while they are patients. Having an advocate should not be regarded as a nuisance, but rather a way to enhance communication and decision making.

    Being a patient is really scary. No matter how empathetic a physician you believe you are (and I’ve been told that I am), it’s still hard to fully grasp the experience of being a patient until you become one. There is almost no other comparable situation in which one feels so vulnerable, so out of control- tethered to IVs and oxygen, wearing a skimpy toga-like gown that leaves little to the imagination (there Alemana could do better) and in my case, stuck in a setting in which I had to communicate with most of the nurses using an APP I found called iTranslate.

    Always looking at how things can be improved, I found myself critiquing my care along the way. Now that I am recuperating at home, I have to say that the folks at Alemana did just about everything right medically and even more on the caring side. We in the US could learn from some of what might at first seem like small issues, but make all the difference in quality of patient care- and they all fall under the rubric of “communication”.

    First, everyone from cleaning ladies to folks delivering meals, to the nurses’ aides to the nurses and doctors- everyone introduced themselves when they entered my room. They never failed to ask how I was feeling; many squeezed my hand in reassurance; one or two even gave me a hug. Oh and I never caught anyone not washing their hands as they came through the door.

    Second, when shifts changed, the person leaving brought her replacement to let me know who would be caring for me that morning or evening.

    Third, the moment I pushed the button for the nurse (needed help with bathroom, my IV was infiltrated, etc), someone was in my room within moments.

    Finally, with each shift change, the doctor on call would come into the room, introduce him/herself, review my history, examine me and share the up-to-date lab results.

    For the past 12 years I have helped care for my elderly parents (they have both passed), so I’ve watched their care as a family member whenever they were admitted to a hospital. Frankly, even in the “best” facilities (by HealthGrades ratings, etc), there was always a huge gap between medical care and “caring”. Had I not been there as my parent’s advocate, the lack of adequate communication would likely have led to more than one serious medical error.

    Some might take this as an indictment of every physician, nurse and hospital in the US. On the contrary. There are many many wonderful medical providers and facilities in this country. Obviously Dr. Campbell was lucky enough to be a patient in a great facility with excellent, caring providers. The problem is the system. A trusting relationship with patients and their families is built on open, honest communication. Unfortunately, today’s health care environment makes good communication among patients, families, and caregivers harder and harder to achieve. Hospital stays are shorter, medical care is more technologically complex, and resources are increasingly constrained.

    US hospitals are increasingly tracking satisfaction ratings- unfortunately not because most hospital executives really believe that “touchy-feely” indicators are critical to improved clinical outcomes, but because they are finally being tied to hospital reimbursement. The problem is that unless there is a true patient-centered culture of communication, compassion, transparency and shared decision making, however the information is captured will be meaningless.

    I know we can do better in the US.