Embed Size (px)
Citation preview
3/17/2014
1
Ronald J. Vender, MD, FACG
Professor of Internal Medicine Associate Dean for Clinical Affairs, Yale School of Medicine
Chief Medical Officer, Yale Medical Group
3/17/2014
2
Solves complex problems
Performs difficult procedures
Ensures patient satisfaction
Quality/safety metrics
Cost-effective care
Number of referrals
Productivity
Local or national reputation
Income
Lifestyle
Personal fulfillment
Work-life balance
Treating differs from healing. The former deals with a malfunctioning organ system, the latter with a distressed human being.
Lown, The Lost Art of Healing, 1999
3/17/2014
3
The impact of sickness upon a person is always multifocal, and the effects highly complex, involving as they do the whole person, with his spiritual, intellectual, emotional, social, and economic components.
Tumulty, The Effective Clinician, 1973
You are surely aware that physicians are not now as highly esteemed by the general public as formerly. It seems unlikely that the public, so easily impressed by what appears to be scientific, resent the fact that physicians nowadays have become more scientific in their education and methods. Actually, what many patients miss and resent today is their inability to communicate with their physician in a meaningful manner.
Tumulty, The Effective Clinician, 1973
3/17/2014
4
ACGME
Professionalism
Humanism
Patient-Centered Care
Patient-Clinician Communication
Quality & Safety Standards
Value-based Care
Patient care
Medical knowledge
Practice-based learning and improvement
Interpersonal skills and communication
Systems-based practice
Professionalism
3/17/2014
5
Professional competence
Honesty with patients
Patient confidentiality
Maintaining appropriate relations with patients
Improving quality of care
Improving access of care
Just distribution of resources
Scientific knowledge
Maintaining trust by managing conflict of interest
Professional responsibilities
Based on the principles of the primacy of patient welfare, patient autonomy, and social justice:
ABIM, 2002
Dimensions of patient centeredness include respect for patient values, preferences and expressed needs along with a focus on information, communication, and education of patients in clear terms.
Crossing the Quality Chasm, IOM, 2001
3/17/2014
6
Providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.
Krumholz, JAMA, 1190-1, 2010
3/17/2014
7
A 68 year old male “GI bleeder” had an episode of hematemesis earlier in the morning. He reported mild anorexia and a two pound weight loss over the past two weeks, but otherwise feels well.
PH: Coronary artery disease
FH: Not contributory
Meds: 81 mg Aspirin and 20 mg Lipitor
PE: BP= 130/80 Pulse=85 Rectal=Black, Heme + stool
Lab: Hct=34 MCV=80 PT, PTT, Platelets are normal
Is this a significant GI bleed?
Do you need to see the patient tonight?
Will he require endoscopy tonight?
What would YOU do?
3/17/2014
8
Patient
Patient
You
3/17/2014
9
Patient GI Section
MCIC
YSM YMG
Hospital
Family
Referring Physician
You
ED
3/17/2014
10
Am I going to die?
Do I have cancer?
Can my heart take this stress?
Is my wife ok?
What should we tell the kids?
Can I get back to work this week?
When can I eat?
When will I get out of this loud crowded ED?
Will we still be able to take our vacation in 3 weeks?
3/17/2014
11
Is my husband going to die?
Does he have cancer?
I don’t want to go to an empty house without my husband.
What do we tell the kids?
How will I get home tonight?
I’m hungry, but don’t want to go to the cafeteria in case the doctor comes by.
When can we get to a quieter room?
Who is the doctor who was called to see my husband? Is he good? Should we get someone else to see my husband?
3/17/2014
12
I don’t come to the hospital anymore, so please take care of my patient.
Did I miss something on his physical exam last month? Does he have cancer? Will he be angry with me?
Please don’t make me look bad in front of the patient.
Be nice to this fellow. He’s one of my long-standing patients.
Call me if there are any surprises, and remember to call me when he leaves the hospital so I know what is going on.
I’m sure you will figure out what is going on and get my patient better.
I have 8 patients waiting to be seen, so I don’t want to have to worry about this one anymore.
It took me six hours to see this man, and now I’m worried we waited too long.
There are patients in the hallways waiting to be seen, so get here soon.
3/17/2014
13
Fill the beds with insured patients
Provide high quality care with good outcomes
Avoid complications
Short length of stay
Keep costs under control
Document everything
Don’t call in an on-call team unless necessary
Keep patient satisfaction high
Obtain and document informed consent
Follow Joint Commission and DPH standards
Report adverse events to Legal and Risk Management office
Maintain the reputation of the group
Keep the referring doctor happy
Do your work
Be productive
Bill and code properly
Don’t dump your work on others
3/17/2014
14
Provide outstanding expert care
Represent the organization well
Patient satisfaction
Document carefully
Bill and code properly
Maintain confidentiality
Know when to seek assistance
Refer to your medical practice colleagues
Obtain and document informed consent
Careful attention to hand-offs
Disclose conflict of interest when relevant
3/17/2014
15
Establish good relationship with patient and family
Document carefully and accurately
Avoid conjecture in your notes
Don’t criticize others in chart
Call Legal and Risk Management offices for any unanticipated adverse events
Proper disclosure of adverse events
Careful handoffs
Patient
You
3/17/2014
16
A 68 year old male “GI bleeder” had an episode of hematemesis earlier in the morning. He reported mild anorexia and a two pound weight loss over the past two weeks, but otherwise feels well.
PH: Coronary artery disease
FH: Not contributory
Meds: 81 mg Aspirin and 20 mg Lipitor
PE: BP= 130/80 Pulse=85 Rectal=Black, Heme + stool
Lab: Hct=34 MCV=80 PT, PTT, Platelets are normal
It is 4 pm, you were on call last night, you are tired, and you still have a number of follow- up patients to see.
You plan to attend your daughter’s school concert tonight.
You receive a page from a doctor in the ED whose attitude and judgment you have not always appreciated.
He tells you there is a GI bleeder whose private doctor requested you as the consultant.
3/17/2014
17
I hate dealing with that guy in the ED.
Why did the primary care doctor refer this patient to me? He usually calls someone else. I bet the patient has no insurance.
Should I have the fellow see the patient tonight, and I will see him in the endoscopy suite in the morning?
I wonder if I will be able to get an add-on in the morning?
I wonder if my partner has time for an add-on case tomorrow?
I can’t believe how tired I am. Now I have to see a bleeder in addition to the follow-ups.
Maybe I will have the patient admitted to the Hospitalist service instead of mine.
Will my daughter be upset if I don’t make it for her concert? I hate disappointing her.
I wonder if I should call my on-call partner and ask for help?
3/17/2014
18
Few of us realize how strongly a physician’s mood and temperament influence his medical judgment.
Groopman, How Doctors Think, 2008
A physician must not lose sight of the fact that what would seem mundane to the doctor can strike the patient as tragic.
Groopman, How Doctors Think, 2008
3/17/2014
19
Most errors are mistakes in thinking. And part of what causes cognitive errors is our inner feeling, feelings we do not readily admit to and often don’t even recognize.
Groopman, How Doctors Think, 2008
Slow to arrive in ED
Hurried history and exam
Little explanation
Fails to meet the family
Does not offer reassurance and understanding
3/17/2014
20
Determine the question and respond to it
Establish the urgency of the consultation and provide a timely response
“look for yourself”; confirm the history and physical exam and check test results
Goldman, Lee and Rudd; Arch Int Med, 1753-1756, 1983 Salerno et al, Arch Int Med, 271-275, 2007
Cohen and Macpherson, UpToDate, version 19.3, Sept 2011
Be as brief as appropriate; be definitive and limit the number of recommendations
Be specific, including medication details
Provide contingency plans; anticipate potential problems and questions
Goldman, Lee and Rudd; Arch Int Med, 1753-1756, 1983 Salerno et al, Arch Int Med, 271-275, 2007
Cohen and Macpherson, UpToDate, version 19.3, Sept 2011
3/17/2014
21
Honor thy turf; don’t steal other physician’s patients
Teach with tact; consult, don’t insult
Talk is cheap and effective; direct verbal communication is crucial
Follow-up to ensure that recommendations are followed
Goldman, Lee and Rudd; Arch Int Med, 1753-1756, 1983 Salerno et al, Arch Int Med, 271-275, 2007
Cohen and Macpherson, UpToDate, version 19.3, Sept 2011
Decide if you have the time to provide adequate care to the patients waiting to be seen, in addition to the patient in the ED
Determine if you are too tired to handle the responsibility
Determine the impact that this will have on your family and your personal well-being----(should be determined in advance of such situations)
Call a colleague to request assistance if appropriate
See the patient in the ED
3/17/2014
22
Patient GI Section
MCIC
YSM YMG
Hospital
Family
Referring Physician
You
ED
3/17/2014
23
Calm Certainty Committed Communication
Compassionate Courage Creative Curious
Dynamic Efficient Emotional Intelligence Endurance
Energy Healer Humility Integrity
Intelligence Judgment Kindness Leader
Listening Skills Manager Organizer Patience
Persistence Resilient Responsible Self-aware
Sincere Skilled Stamina Thoughtful
Warm Wise
Attribute
P1 P2 P3 P4 P5 P6 P7 P8 P9 P10 P11 P12
Service
Nice
Skilled
Dedicated
Devoted to improving
Leadership
Communication skills
Respect for colleagues
Modesty
Passion for medical career
Kindnes
Warmth
Total Score
Ranking
3/17/2014
24
Attribute
P1 P2 P3 P4 P5 P6 P7 P8 P9 P10 P11 P12
Service 10 10 9 9 10 8 10 10 10 10 10 10
Nice 8 6 7 6 10 8 6 10 9 10 10 8
Skilled 10 10 10 10 9 9 10 10 10 10 10 10
Dedicated 10 9 10 9 10 10 10 10 10 10 10 10
Devoted to improving 10 10 9 9 6 7 8 8 8 10 9 10
Leadership 8 6 7 5 7 10 7 5 10 8 10 10
Communication skills 8 7 7 6 10 9 7 10 10 10 10 9
Respect for colleagues 10 8 10 8 10 8 8 10 10 10 10 10
Modesty 10 3 9 9 9 3 3 9 9 10 10 10
Passion for medical career 10 10 9 9 8 10 10 10 8 10 10 10
Kindnes 8 6 9 6 9 7 3 9 9 9 8 7
Warmth 7 6 7 5 10 8 3 8 8 9 10 7
Total Score 109 91 103 91 108 97 85 109 111 116 117 111
Ranking
Attribute
P1 P2 P3 P4 P5 P6 P7 P8 P9 P10 P11 P12 Total
Service 10 10 9 9 10 8 10 10 10 10 10 10 116
Nice 8 6 7 6 10 8 6 10 9 10 10 8 98
Skilled 10 10 10 10 9 9 10 10 10 10 10 10 118
Dedicated 10 9 10 9 10 10 10 10 10 10 10 10 118
Devoted to improving 10 10 9 9 6 7 8 8 8 10 9 10 104
Leadership 8 6 7 5 7 10 7 5 10 8 10 10 93
Communication skills 8 7 7 6 10 9 7 10 10 10 10 9 103
Respect for colleagues 10 8 10 8 10 8 8 10 10 10 10 10 112
Modesty 10 3 9 9 9 3 3 9 9 10 10 10 94
Passion for medical career 10 10 9 9 8 10 10 10 8 10 10 10 114
Kindnes 8 6 9 6 9 7 3 9 9 9 8 7 90
Warmth 7 6 7 5 10 8 3 8 8 9 10 7 88
Total Score 109 91 103 91 108 97 85 109 111 116 117 111
Ranking
3/17/2014
25
They were passionate about being a doctor
Dedication to career
Respect for their colleagues
They were highly skilled
Most were modest
They were committed to continuous improvement
In general, they were good at communication
A doctor establishes credentials as a caring practitioner during the very first visit by listening attentively. This, requiring engagement of all sensibilities, is the most powerful diagnostic device in the doctor’s armamentarium. In fact, a doctor who takes a careful history reaches a correct diagnosis in 70 percent of cases.
Lown, The Lost Art of Healing, 1999
3/17/2014
26
Listening well is the key to effective communication. Much of communication is non-verbal.
Maintain the focus on the needs of the person seeking your help, and keep one’s own judgments and emotions concealed.
Project compassion to every patient, even on days you would rather be doing something else, or when you are potentially distracted by your personal worries.
Mutual respect
Harmonized goals
A supportive environment
Appropriate decision partner
The right information
Transparency and full disclosure
Continuous learning
IOM, June 2011
3/17/2014
27
Compassionate Communication
Access
Respect
Empathy
Skill
3/17/2014
28
I have come to realize that caring without science is well intentioned kindness, but not medicine. On the other hand, science without caring empties medicine of healing, and negates the great potential of an ancient profession. The two compliment and are essential to the art of doctoring.
Lown, The Lost Art of Healing, 1999
Excellent medical care combines sophistication in scientific knowledge with equally sophisticated communication skills to understand the needs of the individual patient, to address his/her feelings and concerns with sensitivity and compassion, and to educate patients about their choices in care.
Levinson and Pizzo, JAMA, 1802-3, 2011
3/17/2014
29
Well trained
Up to date knowledge
Quality
Safety
Value
Innovation
Cutting edge
Persistent
Human connection
Caring
Kindness
Humanism
Emotional intelligence
3/17/2014
30
Courteous
On-time
Wash your hands
Use of proper name
Attention to modesty
Listen carefully
Shared decision making
Informed consent
Confidentiality
Conflict of interest
Patience
Available for appointments
Return test results
Return phone calls
Available for urgent issues
Communicate with referring physician
Answer pages promptly
3/17/2014
31
Listen
Explain
Reassure
Offer hope
Avoid insensitive or hurtful words
Avoid distraction during visit
Inform
Shared decision making
Compassionate communication
Access
Respect
Empathy
Skill
3/17/2014
32
ompassionate communication
ccess
espect
mpathy
kill
3/17/2014
33
Decreasing reimbursement
Increasing expenses
HIPAA
EMTALA
TJC
P4P
EMR
Financially troubled hospitals
Night call
Sleep disturbances
Liability risks
Malpractice suits
3/17/2014
34
Time
Energy
Personal commitments (e.g., family, health)
Professional commitments (e.g. teaching, leadership, research, administration)
Working with sick and anxious people daily
Unachievable demand for perfection
Need to place profession ahead of your family and yourself
Financial debt from education
3/17/2014
35
More work (e.g., more patients, shorter visits, longer hours)
Less pay
More emphasis on efficiency and productivity
More attention to the financial aspect of medicine
Less time for family and self
Change has become a constant
Uncertain future
Less job satisfaction
Less fulfillment
Less happiness
More stress
Compassion fatigue
Burnout
Depression
Impairment
3/17/2014
36
Have realistic expectations
Don’t sweat the small stuff
Establish your priorities
Be self-aware, and recalibrate regularly
Develop fulfilling personal relationships
Take care of your personal well-being
Focus on what you can truly control or influence
Develop systems to make your life easier
Conserve your energy (you can’t do it all!)
Make your family a priority
Seek help when appropriate
3/17/2014
37
Exercise
Meditation
Yoga
Journaling
Hobbies
Eat well
Sleep enough
Avoid excess alcohol
Don’t self-medicate
Practice gratitude
Learn to forgive
Spend time with friends and family
Spirituality
Positive psychology
Therapy
Stay in touch with your passion for being a doctor
Remind yourself that it is a privilege to share a person’s most intimate and vulnerable experiences, and to bring healing to another human being
3/17/2014
38
Illness is more than a physical ailment. It impacts the patient emotionally, spiritually, socially, intellectually, and economically.
There are many involved parties in the care of a patient, including their family, other doctors, the hospital, your partners, your insurance carrier, you and your family.
3/17/2014
39
Doctors are human beings who struggle with the same challenges as all people, as well as some that are unique to our profession.
A successful career in medicine requires lifelong dedication, endurance, resilience, and a commitment to continued improvement.
The effective clinician is highly skilled but also understands human behavior, listens carefully, communicates well, and cares for others.
The effective clinician understands that people want more than treatment. They want healing.
You have an obligation, and a right, to take care of your own well being.
3/17/2014
40
