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A Clinical Heart

Discussion in 'Weblogs' started by Second chance, Oct 10, 2012.

  1. Second chance

    Second chance New Member

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    Hey everyone,

    I am starting a new blog from the perspective of a new, third year medical student. It's going to look at some of the issues that medical students need to deal with in their clinical years, with a focus on how to maintain an empathetic relationship with the patients you may encounter along the way. The link is...

    A clinical heart

    And here's the latest post!

    October 10, 2012
    The brisk consultant


    I feel that in my medical school we’ve had quite good teaching about how to address patient ICEs (ideas, concerns and expectations). It’s only when I’ve come into hospital that I’ve realized how these are sometimes the most importants aspects of taking a patient history. So many things seem to come up when you ask at the end, ‘so, what is it that you’re worried about?’

    I tell this anecdote because of the kind of ward rounds I attend with a senior consultant who seems not to really be aware of what the patient is really worried about. It is difficult to watch a 3 minute encounter during a ward round where the patient, who’s probably been waiting for this meeting with a senior doctor, has a brief check up and a plan is decided. The concept of patient concerns, or worries, is rarely brought up as these ward rounds are typically a matter of making sure that nobody is suddenly or severly unwell or not being followed up for blood tests, rather than a check up of ‘how are you doing today?’

    Someone said to us a few weeks ago, ‘Never treat patients like a piece of meat’ It’s wise advice, a bit brutal but speaks to the kind of doctor who will go in, do a procedure and not treat a patient as a person or a real human being. Getting an idea of a patient’s concerns is such a good way of eliciting their real feelings and worries about what they are experiencing that I feel it’s not only polite, and human, but good clinical practice. So for those consultants who come breezing in and listen to heart sounds/check obs/rush off again, I would encourange them to just listen for a bit longer to what their patient has to say, as I think that is where the fundamental issue may actually lie. It’s not always in the clinical signs.
     
  2. Second chance

    Second chance New Member

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    The doctor/patient relationship is an odd one. It's not quite balanced, and inherently involves some sort of power imbalance (or so I believe). Even as medical students we have some sort of 'power' or abililty to take up patient's time where they feel perhaps beholden to us or as if they should play a patient's role towards us.

    I was wondering earlier today what the GMC says about doctor and patient relatioships. I pulled this straight out of the GMC Good Medical Practice handbook relating to the doctor/patient relationship:

    The doctor-patient partnership:
    20 Relationships based on openness, trust and good communication as these will enable you to work in partnership with your patients to address their individual needs.
    21 To fulfil your role in the doctor-patient partnership you must:
    (a) be polite, considerate and honest
    (b) treat patients with dignity
    (c) treat each patient as an individual
    (d) respect patients’ privacy and right to confidentiality
    (e) support patients in caring for themselves to improve and maintain their health
    (f) encourage patients who have knowledge about their condition to use this when they are making decisions about their care.

    In ny own turn of phrase, I would say in response to the above...'Dude! It's all there! Why aren't we doing this all the time?!' I know that the majority of clinicians do treat patients with dignity and I don't doubt that, but the bits about sharing knowledge to make decisions, or to build relationships based on trust and communication, don't come easily especially in an acute care setting. So what ends up happening relates back to what I was saying about a power imbalance. If patients don't feel that they have adequate knowledge or information to make decisions about their own health care, they will rely on their clinicians to make the best decisions on their behalf. I feel that I constantly observe situations where patients haven't had the right, or best information to make decisions about their own health care and someone else ends up making that call for them. Could we change that? Would it take too long to make people informed consumer about their own health?
     
  3. Second chance

    Second chance New Member

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    Sometimes, you come across cases where things seem quite straightforward. You see an ECG change, or an abnormal blood result, and come to some kind of differential diagnosis to explain what is happening to a patient.


    Other times, things can be less clear-cut, and possibly there is no immediate explanation for what's happening to a patient. Today, in A&E, a woman came in complaining of severe upper abdominal pain. I won't go into the details, but she was investigated quite thoroughly with blood tests, CTs, a review of her past medical history. The tests didn't bring anything up, and the conclusion from the consultant was to send her home, with pain relief, under the care of her GP.


    When one of the nurses was asked to come and take her cannula out, the patient started weeping and told the nurse that she couldn't bear to go home with the pain she was experiencing. The nurse spoke to me and the senior ward nurse, and said that she needed to act on behalf of the patient and didn't feel it was appropriate to send the patient home in so much pain. The ward nurse agreed.

    What was the right course of action in this case? The consultant in charge was keen to get the woman out of A&E within a 4 hour time limit, and was aware that surgery wouldn't be interested in a transfer (she wasn't a surgical case) and there wasn't much else that the medical team could do. The patient was prescribed strong pain relief both in A&E and to go home with, but didn't feel it was sufficient. One of the F1's wondered if perhaps she could be admitted by the medics on the basis of pain relief, but under the proviso that there was nothing 'medically wrong' with her to warrant a hospital admission for further tests. So, in the end, the patient ended up hanging about in A&E getting more pain relief while the nurses battled out their difference of opinion with the consultant responsible for the case. I'm not sure what happened in the end, as I left A&E about 6 hours after she was admitted. It did make me wonder, though, what happens to the patient in pain where there is no immediate medical explanation for the symptoms? Should they go home if any emergency reasons for their pain have been excluded? Do they need to stay in hospital? And if they do stay in, at what threshold of pain is the patient deemed to be in 'too much' pain to get home?
     
  4. Second chance

    Second chance New Member

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    Non-attenders in a serious medical condition

    http://clinicalheart.wordpress.com/2012/10/26/non-attenders-with-a-serious-clinical-condition/

    Today, in the lung MDM, we discussed a case relating to a woman with probable breast cancer and mets to her spine and lungs. She'd lost about a stone in weight in the last few months, wasn't eating well and required urgent staging/treatment where possible. However, she was a known paranoid schizophrenic, with a severe fear of hospitals and hospital stays.

    The problem, from a clinical perspective, was that she was a frequent non-attender to any hospital clinic. Her fear of hospitals translated into her not wanting to come to hospital unless it was via hospital transport, which was often difficult to arrange for any tests (i.e. chest x-rays, scans etc) or clinic appointments. Her GP was well aware of her probable diagnosis and symptoms, and had literally referred her to every single rapid access clinic in the hospital due to the nature of the cancer mets. Unfortunately, she had not attended the first or second appointment for any of these clinic visits, and had been discharged and dropped off the lists for each clinic/specialty care team.

    The interesting discussion during the MDM was...do we have an obligation of care to get this woman into hospital to have her repeat scans and for treatment, and what do we need to do to make that happen? One clinician raised the issue of capacity...if she was unable to make a decision based on her psychiatric history should she be sectioned in order to get her into hospital? This avenue was dismissed as we decided it was unethical to get someone sectioned and forced to have care for a condition unrelated to their mental illness.

    Often, when people have capacity and are very aware of their condition, but are unwilling to seek further testing or care, I often think, 'well, that's their decision'. But what happens in this kind of case? On one hand, the woman may have impaired capacity to make decisions about hospital care due to her paranoid delusions. And, this is probably limiting her care. On the other hand, if the disease is as far advanced as thought, is there any point in pushing this forward in any way...knowing that the patient is unwilling to attend any hospital appointments? It's a tricky one. With limited resources, i.e. point of care testing in GP surgeries, and a lack of patient transport facilities, patients like this will struggle to get any sort of medical care. Whether or not she really wants any treatment or not is a different matter altogether I suppose....
     
    #4 Second chance, Oct 26, 2012
    Last edited: Oct 26, 2012
  5. Second chance

    Second chance New Member

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    What is it that's really brought you in here today?

    What is it that’s really brought you here today? « A clinical heart

    Sometimes, as medics, we can miss the woods for the trees and focus on the medical issue when the real issue might be a social problem. I have noticed that I can take a lengthy and detailed clinical history focussing on the presenting complaint, past medical history, medications etc etc, but it’s only when I ask at the end, ‘so, what is it that’s worrying you’, or ‘what is it that you expect from your stay here’, that the underlying reason for a patient’s admission into hospital comes to light.

    A recent example of this was an elderly lady who came into A&E with a 2 day history of severe, watery diarrhoea. She had been having problems with her bowel movements for weeks and perhaps even months, but things had become acutely worse over the past few days. She was anaemic, with recent weight loss, and with her change in bowel habits had been under investigation by her GP, who had referred her to the gastro team at the hospital for a more detailed assessment. Her next appointment with the outpatient gastro team was two days from her A&E admission, and she’d been to see her GP the previous day about her acute episode of diarrhoea, which had been investigated for an infective cause.

    Because there was a suggestion of melaena and due to her other symptoms, she was investigated in A&E for a possible upper GI bleed. However, the investigations we carried out suggested that this was unlikely, and we went back to speak to her, and her elderly husband, to tell them we were happy to discharge her from A&E and that she could probably discuss her symptoms at her gastro outpatients appointment in a few days time.

    One of the things we were thinking as we went through the history, and the investigations, was, ‘what made this acute episode so serious that this lady felt she needed to come into A&E’? Her immediate care plan seemed to be in place, and she was under the care of both her GP and the gastro team. She was quite dehydrated, and probably benefitted from the IV fluids she got during her short stay in acute care. Both me and the more senior doctor, however, suspected there may be social reasons at home.
    When we spoke to the woman about discharge back to home, we asked her husband, ‘what’s concerning you if we let her go home now?’ At this stage, her husband admitted that he was struggling to maintain care for his wife. The toilet in their house was about 20 steps from their bed, and her acute diarrhoea meant she was severely incontinent upon standing and often had an accident trying to get to the toilet from her bed. He had been spending much of the day scrubbing carpets, and trying to carry and lift his wife in and out of the bath to try and keep her clean. He himself was dealing with dementia and arthritis, and I think had just come to the end of his abilities to care for his wife. The main reason for bringing her into hospital was that he thought she would get better care if she was admitted in for a few days while her infective and acute diarrhoea resolved, and he would be able to cope better himself. All he needed to make things better if she was sent home, he said, was a commode to keep beside the bed, so that she could get to the toilet immediately without having to stand. And that could be easily arranged.

    Making the time to try and figure out the real social issues behind what’s going on, and having an easy and open rapport with the patient and the family, makes it easier to communicate about these issues. Her husband was reluctant to admit that he couldn’t cope at home perhaps due to a sense of duty towards his wife. But he was able to cope…all he needed was the right tools to make it easier for both of them.

    It might seem like a trivial question, but asking at the end, ‘what’s really bothering you?’ may help answer that key question of ‘why are you really here?’
     
  6. Second chance

    Second chance New Member

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    Patients who don't want to leave hospital at all

    The flipside…patients who don’t want to leave hospital « A clinical heart

    Following a rather optimistically minded post yesterday about looking for social reasons why patients might come into hospital, I was reminded of the flipside of medicine today while doing ward rounds in the respiratory ward this morning.

    I have noticed a strong correlation between respiratory and psychiatric illness amongst inpatients. I wondered if it was that respiratory patients might feel constantly a bit panicked as they are struggling to breathe, but one of the consultants suggested it might be the other way around – patients with psychiatric illnesses develop or present with chronic respiratory illnesses.

    I’m placed at a hospital where all the consultants switch between wards/clinic care every few months. This means that some patients have been admitted, and cared for on the wards for months at a time under one consultant, but when the switch-over happens, the new consultant re-assesses the case and may have a very different viewpoint on the patient’s care. What has happened in the respiratory ward in this hospital is that there were a few patients admitted with shortness of breath, cough…and just kept on the ward for up to 2 months for a number of ongoing issues.

    So, while yesterday I wondered what brought patients IN to hospital, today I wonder, what keeps patients IN hospital? My theories:

    1. Consultants don’t want to send patients home if there is a high risk of an acute illness

    2. Consultants don’t want to send patients home if there’s a high risk they’re going to come straight back again in a few days

    3. Consultants don’t want to be tough with long-term patients and cut them off of a hospital inpatient care plan

    4. Patients get institutionalised and used to the hospital environment

    5. Patients are scared about their chronic conditions and are worried about managing them at home, themselves

    The new consultant on the ward today went through and discharged 3 long-term patients who’d been on the wards for weeks, months etc. His reasoning was that they were all medically fit (which they were, and numerous teams/consultants/nurses had confirmed this in each case) and that they were not acutely ill enough to require hospital care. He discussed his reasoning with the patients, 2 of whom became quite upset, whereas 1 just wanted to go home if adequate transport was arranged.

    I get the feeling that sometimes, there is a ‘good cop, bad cop’ mentality on the wards. There is the good cop consultant who admits chronically ill and chronically admitted patients into hospital, and declines to discharge because it’s tough to have that conversation with the patient. Then, there’s the bad cop consultant who is acting with patient safety in mind (i.e. they are medically fit) but wanting to free up an acute bed in a busy hospital.

    For reasons 3 and 4 above, consultants need to get on with getting patients home, and patients need to get used to the idea of going home and resuming their normal lives. Point 5…it’s natural for people to be scared about management of their conditions, and perhaps this is where the care plan fails. And these are the patients who tend to ring up paramedics and come in, perhaps a few months later, with the same problems, when the team has switched again, and the ‘good cop’ consultant is back on ward round rota and will admit them for long-term care. And….the cycle continues on.
     
  7. Rachel Moron

    Rachel Moron New Member

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    First day of placement is never easy rather I'd say it is difficult to cop up, with full nervousness from the moment of stepped into a ward. Generally most of the medical schools run a full four years program. Where the first two years of which you'll continue to spend much of your time in the classroom and the lab. The courses you'll take are the ones that will give you all the fundamentals you need to start learning the art of medicine and patient care. They will also prep you for the first of your licensing exams, which you must pass to move on to the third and fourth years of medical school. My first clinical experience was good and would be an immense understatement. It truly was one my favourite parts of the clinical program. I had the privilege of working alongside care aids and nurses who have been in the field for over 10-20 years. I learned all their tricks of the trade as well as different techniques for providing care that you can’t learn from a text book. It was amazing to finally be out in the field getting hands-on training and experience.
     

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