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Curbside Consult with Dr. Jayne 7/1/13

July 1, 2013 Dr. Jayne 6 Comments

It’s been a busy couple of days for me with a lot going on outside of work. Unfortunately, it was all healthcare related and not in a good way. As I was leaving the office Friday, I received a call from an elderly relative. I wasn’t surprised to hear from her since her daughter had e-mailed me earlier in the week for advice.

It started out last Monday as as a classic tale of the things that can go wrong in a medical office – phone messages not making it to the physician in a timely manner, test results being misplaced, and more. Surprisingly, this was happening in the flagship office of a hospital’s employed medical group that had been on EHR for years. There was no excuse for lost messages, missing results, or delayed callbacks, especially with a frail patient. It was bad enough that she was considering a change of physicians after nearly 20 years at the same practice.

Unfortunately the best advice I could offer based on the information available (and it being Friday after 5 p.m.) was a recommendation to go to the emergency department since the likelihood that she would get a call from the physician was low. I offered to pick her up rather than wait for her daughter to drive over. After all, when you can take a spare physician to the ED with you to make sure you stay safe, you might as well.

The facility wasn’t very busy, but the registration experience left something to be desired. She was in a wheelchair and couldn’t see the “Guest Relations Specialist” over the tall counter. I put that title in quotes because I’m not sure what she was really there to do. She wasn’t performing registration (and in fact refused the insurance cards that were offered) or doing triage. Basically she just found the name in the computer and went back to chatting with her co-worker, which she did for most of the time we were in front of her.

After some time, we met with a triage nurse, who clearly had already reviewed the patient’s records in the EHR was able to ask targeted questions in addition to the required screenings and assessments. We moved quickly to an exam room, where the actual registrar came in and took care of the insurance paperwork. She also corrected a phone number that was at least six or seven years out of date despite several recent visits to the health system.

As sometimes happens in the ED, we saw the physician before the nurse came in. I was pleased to see that the nurse had already reviewed the chart when he arrived. He specifically mentioned that he had looked at her information and would try not to ask the same things as the doctor, which was much appreciated. Although a long-time employee of the health system, he was new to the facility. We sympathized about the EHR and getting used to it. He apologized for being slow on the system and we appreciated his honesty.

I can’t say we appreciated the nurse that was mentoring him, though. She would come into the exam room from time to time and tell him he needed to do things differently in the computer. She never introduced herself or acknowledged the fact that there was a patient or a family member in the room. She barked instructions at him and then left. I could tell he was embarrassed by her behavior. I appreciated his attempts to make up for it.

We finally received the radiology results more than three hours after the tests were performed. After five hours in the ED, she was admitted, which took another 90 minutes. There was little communication about what was going on and why it was taking so long. I know it was frustrating for her as a patient and it was even more frustrating for me as a support person and especially as an ED physician who knows we can do better.

The fantastic nurse wrapped our sweet nonagenarian in heated blankets for the trip to the med/surg unit. He was rolling her out the door when his mentor stopped us to complain about his data entry skills and to make him fix the entries before he left the ED. She had absolutely no compassion for the patient and didn’t even apologize for leaving the gurney half hanging out in the hallway while she complained about the documentation.

We finally made it to the floor, only to experience another bit of silliness. Although the patient was asked at triage whether she was suicidal, whether she felt safe in her home, and the level of her pain, she was never asked her preferred name even though I know there’s a field for that in the system. She goes by her middle name rather than her first, so asking might have been courteous. The nurses immediately called her by her first name and that’s what they had on the white board in her room as her preferred name. Regardless of whether she uses her first or middle, as a healthcare professional, I would never dream of calling a non-pediatric patient (especially one in her 90s!) by anything other than Mrs. or Ms. and her last name.

By now it was nearly 2 a.m. and I helped the nurse get her settled. I’m not sure why we had to go through the instructions for the touchscreen meal ordering system or how to operate the television at that hour, but we did, along with a stack of paperwork that I’m fairly sure she would not have understood without my help. She was finally allowed to rest. Since then her hospitalization has been uneventful, but she has savvy family members that are keeping up with her treatments and medications and making sure to minimize the risk of medical misadventures.

In thinking back about all of it though, it makes me sad. I think we’ve lost the care in healthcare. We’re so busy meeting the letter of the law and checking the boxes that we can’t deliver what we hoped to when we were called to the healing professions. Those making the rules forget that patients are seeing and hearing everything we do and are recognizing that our focus is not on them.

As colleagues in healthcare IT, let’s promise to do our best to turn it around. How do you think we can make a difference? E-mail me.

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Currently there are "6 comments" on this Article:

  1. Oh Dr Jayne this makes me sad. This is not an uncommon experience. Change starts with setting a leadership vision that values the focus on customer service with clear behavioral expectations for physicians, clinicians and all organizational wide staff

  2. Who ever thought we’d ever say today’s hospitals are dangerous places to be?? I hear about re-instituting hourly patient rounds – that was the standard of care 30 years ago. When did it stop? Mentoring nurses are still eating their young – why? Calling patients by their first or preferred name without asking is rude! When I realized I could no longer giver the type of patient care I wanted I got out of clinical nursing and never let my family members be a hospital patient without me there as an advocate and to make sure they are safe.

  3. This saddens me, and worse, does not surprise me. Having made several ED trips with several family members over the past few years, it never ceases to amaze me that things really haven’t changed.
    With a couple of name changes in the above story, this could easily have been told by me (except I’m not a doctor, but have spent my entire career in healthcare). You find a couple of people that shine, and are embarrassed by the behavior around them.
    You also find processes that in no way take the patient or family into consideration, and with all the QI/PI projects you hear about, you still see extended wait times and situations where one hand has seemingly no idea what the other is doing.
    I know my way around the healthcare system, I am not afraid to speak up and ask questions, I understand the language and often why certain things are being done in the order they are being done, and I know what to look for. Even with all that, things can go terribly wrong.
    I feel for those patients that end up in these situations alone, or with family or friends for whom this is a foreign land.
    Thanks for continuing to tell these stories…
    Is anyone listening?

  4. I have been doing patient care for over 30 years, the first 20 as an ED Physician and the last 10+ as a Hospitalist. I have also worked in HIT and participate as Physician Champion on HIT projects at our institution. I currently practice at a large inner city teaching hospital. I am doing my best not to be defensive about the criticism raised in the experience of your relative, but I feel I must reply. After all, you did request feedback.

    From your description the outpatient care was sloppy; probably equal parts poor office practice operations and partly poor EMR patient tracking performance. (Full disclosure: I did 6 months primary care internal medicine and I was completely uncomfortable in that realm…I have no idea how a practice can keep tabs on all the balls in the air and all the different work ups in different stages of completion…I suppose a workable software solution is theoretically possible but I cant really comment any more than that on the out patient aspect of your experience).

    As for the ED/Inpatient care I am not sure what your expectations are. The patient experience you describe is absolutely prototypical. Certainly all patient facing personnel are obliged to be civil and professional. Certainly a patient’s physical comfort should be attended to as much as possible. Certainly any trivial catfighting amongst personnel should be done out of sight and sound of patients. Certainly duplication of patient interviewing should be kept to a minimum; but keep in mind redundant interviewing is a safety feature (consistency and confirmation) as well as an clinically useful (multiple clinicians need to get information that is in part unique to their roles), not to mention that historical information has a tendency to change and evolve in important ways as a patient recalls his/her story. Most importantly, competent care is expected. To me, anything beyond civility, professionalism and competence is concierge care…and though available for a premium, that is not included in the basic health care package. It seems to me your relative received civil, professional and competent care.

    Next is the complaint that a scan took several hours from order, to performance, to interpretation to action. As the patient was admitted to a med surg floor I will deduce that the study was not truly emergent (ie no surgery, no procedure, no ICU) and this time frame seems very reasonable…I dare say some facilities would envy this turnaround time.

    Then there is the issue or relativity. Any developing or undeveloped world patient would be ecstatic to receive such care as has been rendered here. Just saying.

    But the biggest reaction this generates in me is the expectation that patients can expect both high tech and high touch. I simply dont believe that is possible, or even desirable, in the modern medical world. Perhaps a frail nonagenarian (your description) should be receiving palliative care and not full on acute tertiary care? Maybe as a citizenry, we need to accept that the medical resources (both people and technology) of the world are limited and suffering, morbidity and mortality are inevitable?

    I am sorry if this seems unsympathetic or personal…it is not meant to be. I appreciate the opportunity to vent some of my own frustrations with the state of medicine in america, such as you have. I wish your relative a peaceful recovery.

  5. DZA,
    I share 30+ year career as RN @ bedside then IT – why not strive for high tech, high touch care? (Don’t see a lot of “touch” in generation raised on texting/tweeting. And compassion in short supply, in general.)

    Generally, IT sees IT as “be all”. Clinicians dismiss it’s potential (partially due to poor solutions). People generally focus on what’s managed/rewarded – KPIs and box checking is how hospital (and staff) get paid.

    Hear “let old ones die” before diagnosis or further info. We saw 30 year olds in ED dissipated, with shorter life expectancy than some 90 year olds. As oncology and then ED/CC RN, I promoted palliative care and fought against profit driven end of life procedures. But balk at age as arbitrary factor. Hear 25ish interns write off 60 year olds as “too old” for reasonable treatment of curable problem.

    3 hr. TAT on diagnostic study as not OK even if the norm – couldn’t someone simply inform person and family in agony worrying. Public needs to be reasonable.. but is that really too much to ask? Even with stress and understaffing, civility should not be standard. I hear others argue that “we don’t get paid for compassion”.

    Computers should be enabling tools, they sadly became an obstacle -now I see them scapegoated for deeper societal and healthcare cultural issues.

  6. “To me, anything beyond civility, professionalism and competence is concierge care…and though available for a premium, that is not included in the basic health care package. It seems to me your relative received civil, professional and competent care. “…..I’m sorry DZA, MD but if you set the expectations for care this low, I’d like to know where you work so that I’m sure not to visit that facility. I have found in my years of managing medical offices and working with hundreds of clients who are implementing medical software that people will inevitably meet the expectations that are set for them with regard to patient care. Set the bar low and that’s what is acceptable for your staff. I don’t believe that this lady received even what you describe as basic health care, either from her primary care physicians office or from the ED. While it is important to correctly and completely document a patient’s care, there is no reason that patient care needs to adversely affected by the use of an electronic EMR.







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