“Listen
to the patient and he will tell you the diagnosis.”
--
Sir William Osler
I was
reminded this week that listening to the patient will also tell you what we do
and do not do well in delivering the care that patients need. It baffles many physicians, I think, to see survey
reports from the federal Hospital Consumer Assessment of Providers, Hospitals
and Systems (HCAPHS) and in particular their results on the following question: How often did doctors treat you with courtesy
and respect? Respondents can answer always, usually, sometimes or never, and to our collective dismay they
don’t always say “Always.” And yet, when
do we approach the bedside with the intention to treat our patient any other
way? We are failing without meaning to
or even knowing it.
Once a week
I visit patients on “leadership rounds,” often with our Director of Patient and
Family Centered Care. We find patients
and families facing many different circumstances: one is preparing to leave the
hospital as we enter her room, another was just admitted, one is thirty five
and homeless, and many, many patients are elderly, often too ill or tired or
demented to converse. On these rounds,
as the primary caregiver team must, we improvise and we adapt.
One of our
visits was to Mrs. Cunningham (not her real name, of course), an octogenarian
with thick, large glasses. Her calm face was pallid and creased, but with strong
bone structure, just a few age spots, and white, wavy hair that I thought was
surprisingly thick. She regarded us
mildly as we explained carefully why we were there. It was hard to know, at first, whether she
understood a word of it. My associate
came closer, held her hand and looked into her eyes. Our patient’s voice was thin and her speech
was halting. One needed to adapt to it
as one would to a person with a foreign accent.
But she was very clear indeed.
Why was she here? “Because I have
health problems and need them taken care of…That’s enough detail for me! Oh
yes, the nurses answer the call bell fast enough. But they are very busy, you know.”
Did you work in healthcare?
I worked for
the air force for many years, in Finance.
Do you have family?
Just a
relative in Florida and a friend who visits once a week or so. These days my home is at ________ Assisted
Living. It’s nice enough.
What about the residents? Do you have friends
there? Well, most of them are, you
know…they have Alzheimer’s. It’s sad;
their minds are just gone. I like to
read the news, but there’s really no one to discuss it with. Of course with what is going on in the world
right now, maybe it’s better not to know what’s going on, you know?
We chatted,
and Cheryl asked Mrs. Cunningham if we could get her some books from our Gift
Shop. She declined politely. At a
certain point I returned to our mental checklist…Who is your doctor here? Is he keeping you informed of what is
happening with your treatment?
“Not so
much,” she answered, with a degree of equanimity that I found surprising. “I guess it’s to be expected,” she
added. When pressed to explain, she
did. “Well, the doctors come in together
and mostly talk to each other.”
So this is
what it looks like to fall short. How
natural it is to assume that every placid senior is demented. It
takes skill and discipline not to give in to the pressure to move on, to take
the time to engage every patient, knowing that the results will be variable.
How often do we overlook persons like Mrs. Cunningham without even knowing it? It matters, of course, because educating our
patients is important, because one in five elders is readmitted within a month,
because HCAPHS results are publicly reported and drive hospital reimbursement,
and because listening to our patients is just what we do. It is what makes us physicians.
“During this
hospital stay, how often did doctors treat you with courtesy and respect? Circle one…”
