He had just had a tumor removed from his back and his lung. He was in the hospital bed with a chest tube, an IJ, and a foley. He had been intermittently confused, as expected, and was in no condition to sign the consent.
That left his wife, who was about to sign. What else could she do? There was probably no choice. My wife, Michele, a physician herself, interceded to ask the nurse why he was getting transfused. “The doctor ordered it,” the nurse answered, slightly annoyed at the challenge.
Michele was appalled that the ordering physician never mentioned this to the patient, his wife or his physician daughter, all who had been at his bedside for every moment since the operation.
She knew that transfusions are rarely automatic. Her father had stable vital signs, was not dizzy and had expressed concern before the operation about receiving someone else’s blood.
The point wasn’t whether the transfusion was appropriate, but whether its risks and benefits had ever been discussed with the patient, or his family.
Lack of communication
A recent study in Annals of Emergency Medicine reviewed audiotapes of 477 discharge encounters. It found that “the expected course of the disease” was explained adequately only 24% of the time.
This means that most patients have an incomplete understanding of the nature of their disease, what could happen, what to expect and what to do when the unexpected happens.
The total time spent on the discharge instructions was under 4 minutes, according to the tapes. This means that doctors are spending more time charting than speaking with the patients.
My group struggles with this issue as well. Our peer review process and WebQI chart reviews allow us to review our care after the fact. They show that many times physicians offer admission to the hospital but the patient refuses. Other times patients are instructed to follow up with their physician in a few days – but that doesn’t always happen, despite the fact that the importance of follow-ups can run the range from truly urgent to merely cautionary.
Instances like these should prompt the question: are we truly, appropriately educating our patients?
Not just clinicians
My father in law had been in the hospital for a week post op. I asked his wife when he would be going home. Were the doctors happy with the results? She wasn’t sure. All they wanted to know was what the doctor thought about the result of the surgery.
Patients need us to be more than clinicians. They need us to be communicators and educators. What are we thinking? What are we ordering and why? When can they go home? What are the next steps and why? We are here to help our patients learn about themselves, about their illnesses and teach them how to lead healthier happier lives.
Consider the words of educator and philosopher Parker Palmer:
Good teaching isn’t about technique. I’ve asked students around the country to describe their good teachers to me. Some of them describe people who lecture all the time, some of them describe people who do little other than facilitate group process, and others describe everything in between. But all of them describe people who have some sort of connective capacity, who connect themselves to their students, their students to each other, and everyone to the subject being studied.
ER doctors need that connective capacity, just as teachers do.