Language Choice in Health Care

Recently I read a fantastic blog post by @RenzaS, a writer with Diabetes who shares her perspectives on the patient experience and is a patient advocate. You should first read her post here on “Difficult Patients” to get background on this discussion.

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How we say things matters as much as what we say.

As a physician, an avid reader, and an unrefined, unexperienced writer, I understand the importance of our language and word choice. In my line of work, daily, I must pick my words carefully to help explain complex medical problems in a way my patients and their loved ones and caregivers can understand. I feel one of the services I provide my patients is actually translation – I translate the complex medical problems, treatments, and research I am tasked with understanding into terms my patients can understand.

That being said, I have to say that many health care professionals, in my experience, use language and terms that can be construed as offensive and derogatory. I bring up the issue because I want to encourage readers who are physicians, nurses, physician assistants, nurse practitioners, technicians, paramedics, etc, to consider changing the way they discuss patients and their care.

Below are some examples of terminology I have heard over the past 13 years which makes me uncomfortable. When I hear these terms, I cringe. I refuse to use them myself.

  • Patients in rooms or beds referred to by their room number, not their name, or even worse, by their disease or chief complaint.
    • Example 1: “Dr. Smith, the chest pain in 1…”
    • Example 2: “Dr. Lee, room 1 needs…”
  • Patients referred to by their disease process in a made up, often derogatory phrase.
  • Patients referred to as “difficult”

These are just some of the examples I have heard. Now keep in mind, I myself refuse to use these terms, or refer to patients in this way. The reasons why should be obvious. It is offensive and unprofessional! I know there may be those who disagree with me, and they might claim that how they discuss patients in private conversation is up to them. I have heard all to many times that in 2016, we worry too much about being “politically correct.” However, this is not about being politically correct.

This is about changing the current culture of health care which finds as many ways as possible to make the patient experience matter as little as possible, and which places the power in the physician-provider and patient relationship squarely in the hands of the physician-provider instead of in the hands of the patient, the most important person in health care!

So, the only term I have seen used that is quite frequently used is “difficult patient.” Healthcare providers often use the term “difficult” to refer to patients who are in distress of some kind which affects their decision making capacity. For example, a patient who is under the influence of mind altering substances like alcohol or PCP. Healthcare providers also use the phrase “difficult patient” to refer to patients who are angry, hostile, combative, or physically abusive. Especially in the Emergency Department, we often take care of patients who present via law enforcement or EMS because they are psychologically unstable, who may have diagnosed psychiatric illness, and are making it hard for us to care for them. Lastly, some healthcare providers use “difficult patient” to refer to patients who have many questions about their care or who question decisions made by the healthcare team.

All of these situations are different, but what I can honestly say in all of them, is that there is no need to use the term “difficult patient,” ever. It’s ambiguous and open to interpretation. I venture a guess that most patients actually take that phrase to refer to the last scenario above, referring to a patient who has many questions or concerns about their treatment. This term has a negative connotation and perpetuates a culture where the patient’s voice is less important or implied to be irrelevant, when in reality, the patient’s voice should be the loudest, and we healthcare providers should be working to augment their voices.

Renza recommended in her article here that we use the phrases “empowered” or “assertive.” I thoroughly agree with her, because these terms have positive connotations, and elevate the patient to the center of the healthcare provider-patient relationship. Renza also referred to @annareisman who wrote a wonderful article covering the inappropriate use of the term “difficult patient” and she emphasizes that patients who asks questions are excellent teachers. She stated, “Don’t dread patients bearing questions, I told my students. Welcome them. They’re some of the best teachers you’ll encounter.”

At the end of the day, patients are simply trying to receive care for their medical problems. As healthcare providers, it falls on our shoulders, based upon our years of training and commitments to our patients, to always do what is right for them. This doesn’t stop at our medical decision making. It absolutely includes our communication, because how you say things matters just as much as what you say!

 

An Ode to You, ED Nurse

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There are many people who work in health care. There are patient care technicians, physician assistants, custodial and housekeeping staff, dietary, patient transporters, nurse practitioners, and yes, doctors too. However there is truly, in my humble opinion, one individual in the hospital who does the majority of actual medical care. Yes, physicians, nurse practitioners, physician assistants, technicians, they all contribute important activities for patient care. Physicians, and their teams, intubate, place central lines, deal with complex medial situations and make decisions that change the course of their patients’ lives.

You may have guessed it by now. Yes, this is going to be about nurses.

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Nurses are the heroes of healthcare. No ifs, ands, or buts about it. Anyone who tells you otherwise is in denial. My purpose in sharing my opinions on nurses is simple: they are never, ever recognized enough for their tireless, selfless, genuinely caring efforts.

Don’t get me wrong! I am not saying that all those who work in healthcare don’t deserve accolades. They absolutely do! But truthfully, I have never been able to thank the nurses I work with for their hard work and efforts enough, and this is my attempt.

A wise nurse I worked with at the Baltimore VA ED taught me last July, when I was a brand new intern, that patients don’t go to hospitals to see doctors – they go to receive nursing care. It was profound, and true. Doctors get the glory for good outcomes, but though they are essential in the delivery of healthcare, most doctors are pretty useless without the nurses they work with to deliver actual medical care.

Look around the hospital. Who is giving patient’s their medication? Who cleans patients when they soil themselves? Who dresses a patient’s wounds? Who takes the patient’s vital signs? Who assesses patient’s more frequently than anyone else in the hospital – universally? Who deals with problems with patient care as they arise more often than anyone? If you answered anything else but nurses, you’re wrong.

All nurses, wherever they work, whatever their area of expertise, deserve recognition for their tremendous efforts. I thank the nurses I work with each and every day. I have learned from my mentors that whenever I leave a shift in the ED, before I leave for the day, to share gratitude with the nurses and other staff that helped deliver care that day (including housekeeping, administrative assistants, transporters, literally everyone!) It sounds silly, but don’t be mistaken, it’s so important to recognize those around you for their hard work.

That all being said, there is one kind of nurse that I have tremendous respect and admiration of. If I had to be stranded on an island and needed medical attention, I would want this type of nurse there to care for me – an ED nurse!

ED nurses work in a chaotic, stressful, and unpredictable environment, day in, and day out. They never know what they will deal with. They are often the first people in the hospital to see the sickest, most helpless patients – even before the ED physicians! ED nurses are tasked with the often challenging and sometimes impossible – take care of everyone, address all of their problems, with what resources you may have.

Do you have too many patients to take care of? Did your patient tech call out sick? Is the nursing staff short for the shift? Do you get to call for help, or ask administrators to reassign nurses from other departments? Nope. The answer is a resounding, “Deal with it, friend.”

The CDC states that in 2011, there were 136,000,000 ED visits in the United States. Each of these patients were cared for by at least one, often multiple ED nurses. That means more than 1/3 of the entire country’s population has essentially been cared for by an ED nurse. Not all ED visits result in admissions, so you must accept that ED nurses are the most seen nurses in the entire field. Let that sink in. (I may be wrong on that, and if I am, please let me know. I just don’t see it being any other way.)

I have witnessed, since I first set foot in a hospital as an Emergency Department volunteer clerk back in 2003, ED nurses exhibit such unwavering dedication and commitments to their work. They are cursed at, spit on, yelled at, and sometimes even physically attacked by their patients. They are responsible for taking care of multiple undifferentiated patients with often uncertain medical diagnoses all at once. Furthermore, if we as physicians have any issues with patients, their care, or anything related, we frequently rely on nurses to help guide us to the next resource we need.

The best physician advocates for a patient in the hospital are frequently ED physicians, because they see the patients earliest, and are tasked with deciding what the ultimate plan for a particular patient is. However, the ED nurses who work with those ED physicians are even stronger advocates for their patients, because they are the first to bring up issues with the physicians they work with. I’ve lost track of the instances when nurses were concerned about a patient’s condition, whether it was because they were complaining of worsening pain, their breathing was becoming too rapid, they had abnormal changes in their vital signs, or some other reason, and they brought up their concerns with the physicians they work with. Most of the time, in a good ED, the physicians will learn to respect the ED nurse’s assessment. Good ED physicians know they should trust and rely on the ED nurse colleagues for their clinical gestalt, or “gut feeling.”

Just to be clear, as well, ED nurses have an awe-inspiring ability for versatility and resilience. They often deal with the sickest patients before we know exactly what’s going on. They take care of patients that should be in an ICU, where the nurse to patient ratio is often 1 nurse for 3 patients or even 1 nurse for 2 patients, BUT, often carry 1 or 2 ICU level patients AND 2 or more patients. ED nurses are efficient, quick thinking, and a TON of fun to work with. They are smart, they are compassionate, and they are incredibly fun. I am so lucky that in the ED where I spend most of my time, not a shift goes by when I don’t laugh with the nurses I work with, and they have made me feel better about difficult patient encounters or helped me deal with suffering I have witnessed more than I can ever thank them for.

This is why, for the rest of my career, I will be sure to show my gratitude for and advocate for ED nurses everywhere.

I thank you, ED nurse, for the tremendous work you perform.

I thank you, ED nurse, for the role you play in public health and wellness through your role in the ED.

I thank you, ED nurse, for the sacrifices you make to take care of the entire country.

I thank you, ED nurse, for being the ultimate troubleshooter, the “MacGyver” of all nurses.

I thank you, ED nurse, for putting up with me, my colleagues, and aiding us in taking care of our patients.

I thank you, ED nurse, for somehow finding a way to get it all done, while maintaining a smile on your face, and keeping me laughing too.

I thank you, ED nurse, for coming back day, after day, after day, after day, to see so much hardship and suffering, often in a broken and dilapidated healthcare system that makes it harder and harder for you to do your work.

Never, ever change!

To everyone else, #thanknurses! I encourage you all to share gratitude with nurses you work with. Let’s use the hashtag #thanknurses to let them know we appreciate them. Spread the word, get your colleagues in on it, and share the love!

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Why Physicians Benefit from Social Media

As a teenager I grew up using social media platforms such as FaceBook. It was mostly used to keep in touch with friends and family and waste time. Those days of aimlessly browsing news feeds and playing FB games are gone. I also had a Twitter account I hardly used and mostly because I never knew how to actually use it. By the time I reached my second year of medical school, I had lost any interest in social media and my FB has been deactivated almost all the time for the past few years. My old Twitter account was deleted. I enjoyed focusing more on my day to day life and went about my routine.

Eeventually I reconnected with my now wife, graduated from medical school, and began residency. As a fourth year medical student, I learned about the phenomenon know in the social media world as Free Open Access Medical Education, abbreviated #FOAMed. See this fantastic post by Dr. Chris Nickson (@precordialthump) on the concept and how all kinds of medical personnel (nurses, technicians, paramedics, researchers, including doctors). I loved the entire thing!

What could be better for all stakeholders in healthcare than getting together on a shared platform, discussing new ideas about medical care, medical education and training, research, and all sorts of highly relevant and important issues affecting people that deliver emergency healthcare worldwide?

It got better and better as time went on. I became an avid consumer of #FOAMed. I connected with not only globally known clinicians famous for their ability to educate and spread wisdom in medicine, but have gotten to know literally thousands of people I have never met or even spoken to who I now regularly keep in touch with using social media.

As I enjoyed exploring Twitter as a doctor, it occurred to me that most physicians think one of two things when it comes to social media:

  1. I can use social media to make money by publicizing myself and driving potential customers to my website and ultimately medical practice.
  2. Social Media is a black hole where doctors go to get sued and lose their licenses and there is never a time for a physician to be involved on social media.

I lesrned to to shy away from those physicians who believed in number 1, and I was utterly shocked and confused by those in number 2.

However, as time went by, I identified that physicians are perpetually claiming they have no time for personal lives, with families, to keep up with their medical work, that for the vast majority of them, learning how to get active on social media in a climate which makes physicians in America worry that they will get sued for simply looking at their patients the wrong way is not ideal.

Physicians are value based individuals. They are trained to look at pros and cons, and weigh options, because they advise their  patients to navigate those situations on a daily basis as their career. This is my attempt to share the value.

I posit that many physicians deal with burnout and poor job satisfaction because they lack a support group of peers who they can discuss their concerns, experiences, and hardships with.

I hypothesize that physicians struggle to identify what information is relevant for them to know.

I believe that healthcare social media, or networks and communities of people that are passionate about not just delivering healthcare but shaping its future, is the BEST place for an engaged physician to be.

  1. My involvement on Twitter has allowed me to connect with other individuals excited and passionate about delivering quality patient care.
  2. My involvement on Twitter has opened my world to entire fields related to healthcare that I never even knew existed such as healthcare design and patient experience design.
  3. My involvement on Twitter provides me with an added layer of support beyond my family and friends who work in the same settings, devote their lives for better or worse to guiding patients & their families through suffering and pain on a daily basis.
  4. My involvement on Twitter especially chat groups such as Healthcare Social Media, Healthcare Social Media Philippines, Healthcare Social Media Canada, Bioethics Chat, Medical Education chat, and Patient Advocacy Chat.
  5. My involvement on Twitter has taken me not only to the most fun, knowledgeable, and influential people in Emergency Medicine, which is my field of medicine, but it has taken me to the patients and their advocates who are working tirelessly day in, day out, to make sure that patients are at the center of health care today and tomorrow. For examples, you must get to know @NatriceR, @CancerGeek, @Colin_Hung, and @Colleen_Young.

Why should physicians be active and involved in social media? 

In 2016, we have finally reached a point where physicians can engage in social media in a professional way, without compromising patient confidentially or laws such as HIPAA. Furthermore, the entire medical field is encumbered by physicians and other healthcare providers who are exhausted, stressed out, and struggling to deliver quality care while maintaining their own personal lives.

Examples I have myself experienced:

  1. I have  met wise educators in Emergency Medicine and have had new opportunities come to me just because I am enthusiastic, involved, and willing to try new things.
  2. I have connected with countless patients, patient advocates, healthcare designers, and read their blogs and ideas, and have become a more innovative, creative, and open minded member of the healthcare world now.
  3. I have found much needed support from colleagues and other individuals who deliver medical care when I have been dealing with depression and emotional anguish related to work.

I never once thought that when I started @S_P_MD, that I would be so positively impacted by it. Now I cannot imagine a life in which I do not use #FOAMed or Healthcare Social Media (#hcsm). The time has never been better for physicians to get active on #hcsm! Share this with a colleague who is skeptical and connect them with resources to help them get online!

10 Commandments for Intern Year

I’ve been inspired by the #TipsForNewDoctors trend on social media. I’ve decided to start posting some thoughts and advice based on what I have gone through on my blog.

These are simply recommendations I can make for any first year residents based on my own experiences and observations over the past 8 months of intern year. I don’t have any evidence to support my words, though I hope they might help others.

1) Thou shalt be a team player.

You should make it your priority to be courteous and respectful to everyone you encounter. This isn’t limited to your immediate resident colleagues, medical students, or attendings, but includes custodial staff, administrative assistants, patient care techs, transport staff, literally anyone. Make it a goal to get to know as many names as possible. Many of my heroes like Dr. Amal Mattu and Dr. Michael Winters have emphasized that learning names positions you to be a leader.

2) Thou shalt take care of thyself.

If you are chronically sleep deprived, sick, or emotionally unstable, you not only put yourself at risk of burnout and further health problems, but you put the lives of your patients in danger. Imagine when you are on call in the ICU, in many hospitals making critical decisions for your patients without direct oversight at times. Seek help early if you start to find you are struggling. Every residency program must guarantee resources for physical and mental wellness.

3) Thou shalt read daily.

This is a tough one for me to do myself, but I guarantee you that if you can keep this one up, you will excel. Success as a resident, attending, and beyond does not require marathon study sessions in the library. Leave that in medical school where it belongs. Read about 1 patient you care for daily. It can be FOAMed, a review paper, or even discussion with a colleague. Something. Every day!

4) Thou shalt not incur debts.

While it may seem pointless to be fiscally responsible if you have hundreds of thousands of dollars in debt like me, do not be fooled. You will have limited month to month cashflow, and any extra debts you incur, especially for purchases you don’t need, will cause you unneeded stress when bills are due. Every penny you don’t spend is going to make a difference as a resident. Be wise with your money and you will be glad in the end.

5) Thou shalt put the patient first.

It may seem silly to emphasize this point, but entitlement and privilege are pervasive among medical students and physicians. Because of the hard work and sacrifices we all endure, the bumps along the way can be tough to deal with. Avoid giving into the urge to make everything about you. The day you became a medical student, and especially the day you start residency, you are truly making the rest of your life about your patient. You had many years to make up your mind about being here, but your patient, especially when they are sick, did not ask to be in the hospital. Maintain compassion for your patients and their families. We sometimes take health and healthcare for granted because we see it from the physician perspective. Try to see the situation through your patient’s eyes and you will understand it can be frightening and overwhelming to navigate the system.

6) Thou shalt not sign out loose ends.

Trust me, if you don’t know what I’m talking about, you will know soon enough. Do not be that resident in your program who develops a reputation for awful sign outs. Sometimes you have to stay late past your shift or call night to close the loop. Resist the tendency to think of it as doing procedures or examinations you don’t want to do; instead think of it as better for patient care. Nothing is worse for your patients than poor quality sign outs. If you need to call a consultant, perform a procedure, complete an examination, or finish a discharge or admission, be the resident that stays to take care of it. It’s not just a good habit to develop. It’s better for patient care, and that’s ultimately your first priority.

7) Thou shalt be professional with everyone.

This is a huge one. There are going to be times when you have a sick patient and you might feel like staff around you are not helping you with their care. There will be moments when you need help from a consultant or colleague in a different specialty or field and that physician may disagree with your plan or concerns. There are frequently situations when you will feel unsupported and like you are the only person who wants to care for your patient. You are not alone, and it is never, ever acceptable to be rude, discourteous, or nasty to others. It is never okay to raise your voice, swear, speak profanity, or speak rudely to another person. It doesn’t matter who that person is, whether a colleague, staff member, patient, or other human being. You are now held to a higher standard, and you must accept that, or you will flounder.

8) Thou shalt be early.

I must admit, this one is challenging for me even to this day, because I have trouble being organized. I am working on it though. That being said, it doesn’t matter what kind of residency you are starting, being early is the new “on time.” Showing up on time demonstrates work ethic and everyone remembers if you are late. If you develop a reputation for being late, it can be hard to overcome this moving forward. It sends the wrong signal, which is that you don’t care about your work. You most definitely do care about your work, and you have worked hard to get to this point. Don’t screw it up by being late.

9) Thou shalt surround thyself with positive influences.

Wise people rarely become wise by their own virtue. They simply understand that they are influences by those around them. If you seek out uplifting, motivated, and success oriented individuals to spend time with, get advice from, and learn with, you will 100% benefit from this. As you move forward, understand that not all health care providers are created equally. Some of them ended up where they are by mistake, are unhappy, and will try to get you to join their complaint corner. I say, find a senior resident or attending you admire early on, and reflect on what makes them so good at what they do. What qualities do you appreciate about them? What about their personality or professional life do you wish to emulate? Then, go one step further and identify where they may be able to improve. Write all of this down, and you have your road map for your own growth and development.

10) Thou shalt remember you are human.

At the end of each day, you need to take a deep breath. Being a physician, nurse, physician assistant, nurse practitioner, patient care technician, EMT, paramedic, or any other staff member that cares for patients, will be hard on your mind, body, and soul. You are not perfect. You have limitations. You should aspire to be your best but accept that you will have some bad days. Perhaps many bad days. Learn to laugh at yourself. Develop a tough skin to receive criticism and use it as an opportunity to improve. When you see patients and their families suffer, allow yourself to feel their pain and empathize with them. Humanism is sorely lacking in healthcare today. Patients, doctors, and everyone around can tell. Bring humanism back to medicine.

If you have any feedback, suggestions, comments, criticisms, or advice, or if you want to add your own commandments to this list, please comment or reach me at sspatel@umem.org or @S_P_MD!