Problem Solving & Patient Discussions

Girl Thinking

By Sarah Riley-Burnett

A member of my family recently spent two weeks in the hospital after a difficult abdominal surgery. She had a complicated post-operative course and at one point required a nasogastric tube placed due to increased vomiting. This had infuriated her because she maintained that it was “sprung upon her” without discussion with the doctor. I imagined that her physician had recognized the seriousness of repeated vomiting after an abdominal surgery and that a nasogastric tube would decompress the stomach, relieve symptoms in the event of small bowel obstruction and to also allow for feeding should she not be able to tolerate a diet. I likely would have made the same decision if she had been my patient. Yet the physician who ordered the tube to be placed had not spoken to her or her husband. He had solved a problem but had not explained his reasoning to my family member, nor had he spent any time to listen to her concerns.

Would my family member have been so furious, had the physician spent some time in the room with her? Is it more important to solve a problem or to talk to a patient? The opportunity to see a patient as human and not as a disease, a symptom, or a lab value to correct, is often difficult to do when more time is spent in front of a computer charting. Time spent with patients is increasingly shrinking and we are rewarded for efficiency, finishing notes, putting in orders, following up on lab tests. I often spend more time in front of a computer screen rather than in front of a patient. Recently I’ve been told that I should spend no more than four minutes in a patient’s room in the morning pre-rounding with the intent of returning later to discuss the plan of care with the patient. One of the skills I have yet to learn is how to quickly assess a patient, get just enough history to come up with a plan, and graciously exit the room.  I have found that sometimes returning to the patient’s room for discussion can be difficult with new admissions or discharge paperwork or sudden complications to attend to, etc. It can be impossible to maintain a schedule in an unpredictable environment.  So when I see a patient, I want it to count.

Recently, I was rounding on a patient that was completely new to me. She had just come into the hospital overnight with chest pain, we were ruling out a heart attack in her situation. As I was in the room, I happened to remark that she appeared sad and asked if she felt this way. She admitted to feeling extremely depressed and between sobs told me that her daughter had recently committed suicide, how she had lost her mother, and her son had died in a car accident. I sat for a while as she spoke about her feelings of guilt and lack of friends to talk to. I spent longer than four minutes in the room with her.  Another patient of mine with severe pancreatitis, was delirious and in pain. He was mumbling one morning while I was examining him. He was mostly incomprehensible but I heard him mention God and how he wanted a pastor and begging me, “please, please, a prayer.”  I am not religious, but I took the patient’s hand and said a prayer for his health to return and for the patient to have more time with his wife and son. The patient became extremely quiet and still, I wasn’t sure if he’d fallen off to sleep until he mumbled, “amen”. I spent longer than four minutes with this patient. There was another patient that was being treated for cellulitis and was incidentally found to also have diabetes. I sat with the patient and answered questions regarding his diagnosis and the importance of follow up and lifestyle change. Again, I spent longer than four minutes.

I am not trying to say that I am perfect. I have a lot of medicine to learn and I am still developing my style as a new physician. There have been plenty of occasions where I have made a patient care decision without discussing it with the patient first. There is a lot of unpredictability in medicine, which can frighten a patient and their families. A nurse once told me that the number one complaint from patients in the hospital is not knowing the plan of care. Sometimes there just is not enough time to explain everything, the patient is too sick, the test results are still pending, a diagnosis has changed or is still unknown. Patients come to the hospital when they have a problem to be solved, but I believe that they also want to feel cared for. As a physician working in a hospital, it is easy to focus patient care on correcting a lab value, ordering medications or imaging, performing a procedure. In these ways we are focused more on the disease, than the human with the illness/disease.  As much as possible, I will try to spend a few extra minutes face to face with my patients so that I can help them feel cared for.

sarah_riley-burnett_wht

Sarah Riley-Burnett, DO is a Second Year Family Medicine Resident in the Department of Family & Preventive Medicine at the University of Utah School of Medicine.

 

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One thought on “Problem Solving & Patient Discussions

  1. Thank you, Sarah, for being sensitive to the needs of your patients. So many times I have felt the doctor was not listening or was just insensitive. I know you will be a wonderful doctor.

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