Tuesday, October 19, 2010

Top 10 Qualities of a Great Physician...A Mother's Perspective

It’s no secret that I spend a lot of time in hospitals. Dear Son has endured some sixty plus hospitalizations and I’ve been there for every one. Over 90% of these hospitalizations have been at a teaching hospital or major academic medical center so I’ve encountered physicians at all stages of their careers. I’ve met residents, fellows and attendings and what is most interesting is that the standout physicians are standouts from the beginning. So let’s imagine for a minute that I am sitting in a patient room at a hospital with Dear Son. Here are my thoughts on what makes a great physician from a mother/caregiver’s perspective.

1) They are always prepared. Much of the work is done before the physician even steps through the hospital door. Good doctors will know three things: the patient’s name and baseline, diagnosis/medical history and finally, what brought him into the hospital this admission. Most attendings do this however many residents don’t.

In a good situation, a doctor will know that Dear Son has a history of seizures from birth, is severely developmentally delayed, is non-verbal, non-ambulatory, on a feeding tube, can’t clear his airways with the risks being seizures, aspiration and respiratory depression and what brought him in this admission.

Residents who are unprepared, rush in the room, don’t read the patient’s medical history, then ask if his appetite is poor now that he’s sick or if he’s weaker than normal and not walking as much. They’ll want a quick update as to how he’s doing so they can update the attending. Their goal is to get the information as soon as possible. They often won’t identify themselves so I am at a loss to know what speciality they are from (Peds, Neurology, GI, etc.) which would help me better frame my answers. I can tell by their questions, asking me if he eating less by mouth, that they’ve never even read the medical history since Dear Son eats nothing by mouth and eats via a gtube. When it’s that obvious, I’ll ask that they take a minute to read the history and then come back and I’ll be glad to answer their questions. Of course, it’s not just one resident that comes in the room, but multiple residents, from multiple shifts, from multiple specialities, and that can all be in just one day.

Being prepared is about respect. I would never dream of walking into a client’s office and meeting with a CIO or anyone in the organization without having done my homework. I would know who they were, the history, their history with my company, customer support issues and as much as I could, as well as reading through their entire contracts so I would not be surprised by anything. Translated, it means being prepared. Now I do understand time constraints in a hospital setting, however if you are involved in the decision making process with patients, you have to take a minute or two to get the basics which include the baseline, medical history and the purpose of the admission. I think residents forget that patients are their clients. Residents shouldn’t demand respect, they should command respect by their actions. Being prepared commands respect.

For Attending Physicians, I most often see this step omitted in new patient histories. For example, sometimes if I make a visit for Dear Son with a new physician, the office will send out a packet to be filled out with the patient’s medical history. It might take three hours or so for me to complete this packet of information and the physician will not even look at it prior to seeing Dear Son. If you ask for information, then read it prior to the office visit, even if it’s five minutes prior to walking in the room. I don’t want to spend three hours assembling information for you and then repeat every detail once I am in the office. If you want to discuss it in the office visit, then don’t send out the packet. My time is important too. I don’t have time to do this twice and I don’t want to spend two hours at an office visit.

2) They always introduce themselves. When meeting someone for the first time, we all value a proper introduction. It’s good to know the other person’s name, their title and a little bit about them. When a person walks into the hospital room, I want to know three things: who they are, their specialty, the purpose for their visit.

A great introduction goes like this: The Fellow walks into the room, standing tall and appears calm and not rushed. He smiles, says hello and asks if it’s Dear Son, introduces himself by saying his name and specialty, then shakes my hand. He asks for my name. He then says a sentence or two letting me know he’s read the patient history, then asks me how he’s doing and asks for information.

A poor introduction goes like this: Resident rushes into the room and wants a quickie update. They look frazzled, are hurried and demand answers, regardless of what you are doing. They ask questions that indicate they haven’t read any patient history and when you ask them if they’ve read it, they get annoyed and still ask the same questions. They waste your time and theirs. The reason a poor introduction is bad is not only because it sets things off on the wrong foot but because it does not allow them to get good information about the patient to make good decisions. If I don’t know who you are, or your specialty, I can’t answer questions well. The worse introductions in my experience are always “pediatric” specialities. They rarely introduce themselves, rarely read the medical history, always appear hurried/rushed and do a lot of unnecessary work. More often than not, they don’t spend their time wisely. This is just my experience at this hospital and certainly does not cover all residents.

The best introductions in my experience over the last twenty years are pediatric neurology fellows. They are smart, cool, calm and collected. They have great manners, are very bright and when you talk to them about their specialty, they just glow.

3) They are good listeners. Having read the medical history, good doctors ask good questions and listen to what is said and what is not said. They read between the lines. They know what information is important to the decision making process and what information is important in caring for the person. A good doctor knows both.

4) They look you in the eyes. I probably wouldn’t mention this had it not been for the electronic records. Electronic records are just that, electronic. Take the time to look at the patient when you are speaking to them. I had one visit where the entire time the Attending Doctor sat with his back to me as he asked the questions, entered the information into the pc, then edited the information in the pc, then re-edited it again. If you want to have a conversation, have a conversation. If I have a situation that is uncomfortable for me to ask you about, I’ll never ask that with your back to me. And that may be the one piece of information you need to make the right diagnosis.

5) They treat everyone well/equally. This is a symbol of class and but something that is so closely aligned with being a great doctor, that I had to mention it. Great doctors are liked by everyone, not just the patient’s, the patient’s mother or by the caregivers. They treat everyone well and I’ll always hear the hospital workers sing their praises as they are cleaning the room or doing whatever task is at hand. When a physician is really good, I’ll hear that from every level of the hospital staff.

6) They allow enough time to address your concerns. The best example of what to do is by talking about what not to do. A poor Attending will come into the patient’s room, say hello, ask how the patient’s doing, get a page, take the page, then say the visit is done and go take the page. I haven’t had a moment to ask any questions and I’ve waited all day to see them. The bill comes in the mail with a charge of $765.00 for that visit.

7) They are good communicators. Good doctors communicate well. They tell you not only what they know, and what to do but what to watch for or what you should be concerned about. In communicating well, they help define the parameters around knowing when it’s an emergency or when to seek medical care. That saves their time and mine.

8) They are kind. There is something about kindness that shows through. You can make a right decision or you can make a right decision for that patient. If you get lucky, they are the same.

9) They always take time to see you when you are in the hospital. This is huge. After all, when you are the sickest, isn’t that the time when you want to see the doctor the most? A good doctor doesn’t always have the time but he always makes the time. That’s the difference. Dear Son has been in the hospital a lot. His medical condition is complex and he’s been in many life threatening situations over the past few years. We’ve spent a lot of time in the ICU, he’s been on ventilators a few times, he’s had a transfusion and we’ve had a few admissions where they didn’t know what was going on. As a result, we’ve had a lot of different physicians that have cared for Dear Son. In times of crisis, it can be challenging as a mother when you hear different physicians talk about what they should do for Dear Son and sometimes I’ll admit that I am not sure who to trust so to speak. It always puts me at ease though when his physician walks in because I know that he knows Dear Son the best and because I know that he’s overseeing or working with the physicians with regards to Dear Son. Sometimes, when you are in a medical crisis, it helps to have a physician that knows the patient very well involved in order to overcome the medical crisis. We have been very fortunate to have a doctor who always makes the time to see us.

On the flip side, we had an incident last year with an attending physician who also happened to be the department head. This particular physician had only seen Dear Son once in the hospital and had let the fellows/residents see him. In this case, Dear Son was seriously ill and it was life threatening. I had many questions and this particular specialty was new to me so I didn’t have much experience in terms of what to expect. It was a stressful time for me. During this time, there was a week where this doctor had never come into see Dear Son or talk to me. At the follow up office visit, I sat down with the doc to address this. I explained the situation in the hospital and said that I would need them to come by more often in the hospital settings since I would have questions and that I would need them to come by more often than once a week. I explained that this was a new specialty to me and that I would have questions and would want to get answers from them versus getting these answers from fellows or residents that did not have their experience. The Attending Physician became very angry and then read me out for about five minutes telling me that they were every busy with clinic and all of the demands and that they didn’t have time to do this. I remained calm and said that was fine, but if that Dear Son didn’t fit into their practice, I would have to find another doctor. I explained that I need a physician the most when Dear Son’s in the hospital, not when he’s in clinic so to speak and that if they don’t have time to see us in the hospital, then they weren’t the right physician for us. Notice, I didn’t say they weren’t a good physician but only that they weren’t the right fit for us. After they went on again, they calmed down and the office visit went fine. It’s not always easy to have these conversations but sometimes you have to have them. I always like to give someone an opportunity to respond to an issue before moving on.

Some months later, we had another crisis and I had to page this Attending Doctor. The Attending was leaving on vacation on a road trip within the hour and couldn’t have been nicer. They addressed the crisis, mapped out a plan, saw us in the hospital and did a great job at our follow up visit. Addressing the situation in clinic made all of the difference. I also made sure to thank them at our follow up visit.

10) They admit it when they make a mistake. This is also important. Everyone makes mistakes and physicians are no exception. It’s o.k. to acknowledge a mistake, apologize and move on. It’s not o.k. to ignore it. Ignoring it sends the message that they don’t care, it wasn’t their fault and the patient isn’t important.

For example, I had a situation where a well liked and well known physician made a medical error that nearly caused Dear Son’s death. It was more than likely a bad judgment call but how they handled the situation was more than disappointing, it was enraging. The mistake occurred and Dear Son nearly died. The doctor came to see Dear Son after the ICU docs and docs involved in Dear Son’s care strongly urged him to see Dear Son. He walked in the room and said Dear Son wasn’t as bad as they said. He got a page, left the room and never said a word. He charged me for the visit. During the hospitalization which lasted several weeks, he refused to see Dear Son. He never came by. I asked to see him now that Dear Son had transitioned to a regular floor and off the ICU floor. He refused to stop by. I spoke with the Peds Attending, whom I knew from the other hospitalizations and explained the situation privately to him and asked him if he could help arrange a visit. The doctor still never showed. We tried to see him for a follow up office visit (while we were still in the hospital) and he still refused to see us.

In the meantime, I went online while I was in the hospital with Dear Son and researched the largest medical malpractice firm in our state. They had only lost one case in their career. I was prepared to call them when I left the hospital. Finally, the Attending Doctor arrived and said he heard that I wanted to speak with him. I explained in very terse terms that I had some concerns I had around the surgical procedure and the fact that I made multiple attempts to see him however his behavior was unacceptable and that I didn’t appreciate that behavior. I said that I wasn’t going to beg to see him and that if he didn’t want to take the time to talk to me that we could talk through our attorneys. It got his attention, he sat down and answered all of my questions. I won’t go into detail however this entire situation could have been avoided had he simply spent five minutes with me in the hospital room in the ICU. I went above and beyond the call of duty to attempt to meet with this physician to discuss this situation and I’ll never do that again. In the future, if they don’t want to meet, I’ll just proceed as I need to. I can accept a bad decision; I can’t accept it when they ignore me. This issue came many years after a previous medical error by a surgical nurse caused over $500,000 in multiple hospitalizations and my son never walked again. Medical errors are serious business.

In summary, I’ve learned a lot about physicians over the years. We’ve been fortunate to have some wonderful physicians that take excellent care of Dear Son. Our Pediatrician did a wonderful job for many years taking care of Dear Son. Our Pediatric Neurologist has done a wonderful job over the past twenty years in caring for Dear Son. I often am at a loss to know how he manages to give such exemplary service over such a long period of time. In the end, it’s not a hospital that makes a facility great, it’s the doctors that make a hospital great. And when you or a loved one are sick, the person you want to see the most will always be “your” doctor, not another Attending, not another Resident, not a Hospitalist or anyone else.

Note: Dear Son is eighteen years old and suffers from seizures, dystonia and severe developmental delay as a result of a random mutation of the ARX gene. He also has a progressive neurological disorder and is in the later stages of the disease.


MB said...

Sue, this article should be required reading at med school. Maybe you can get it submitted to some sort of magazine or other venue for wider readership. It is excellent.

SalicosFamilyBlog said...

I'm a nurse that has worked at a teaching hospital for many year. I've seen the transition from a 1st year resident to a Fellow. If they could learn the different between confidence and arrogance. If they center themselves before entering the room and being FULLY PRESENT - that makes all the difference in the world!
Think I'll print your post and put it at the nurses station :)

deb said...

Outstanding post, Dream Mom. I agree with MB, it should absolutely be required reading in med school. It should also be printed and handed out to parents of medically fragile children, especially the ones who are just beginning this journey, when it is so terrifying and overwhelming.
I had a Doc say to me years ago, not long after Chris' sustained his Brain injury, the NO ONE knows my son as well as I do. He was listening. Very wise Doc! (One of the good ones...also at a Big Academic Medical Center..not far from yours!)
Again, outstanding post.
All the best-

deb said...

I forgot to mention that Very Wise Doc, who made the comment about no one knowing my son better than me, did so in front of a gaggle of residents and med students. (Who of course were all nodding in agreement like good little soldiers)
We can only hope that it sunk in to a few of them!

Anonymous said...

The bill comes in the mail with a charge of $765.00 for that visit.

I am in shock. Be assured, the physician is not seeing that money.

About introducing by "rank" - just know that most people don't know what a resident, fellow, attending even is. My parents, after following me through med school and training still don't quite get it. Most patients have never heard of these things. I guess we need to be aware that people who have a lot of contact with the medical system do understand and appreciate the difference.

Dream Mom said...

Thanks, everyone. I appreciate your comments.

Anon-The charge was the "billed charges" which is prior to the discounted amount, which is typically 30% less depending on the PPO plan/contract, but that is how it's billed. Some physician fees are higher.

I don't object to fees per se, and as a matter of fact, most of the time, I think docs aren't paid enough! I only object to fees when they haven't done a proper visit, meaning no information was exchanged.

I realize that everyone may not know the difference between residents, fellows and attendings however I felt that these examples better illustrated my point.

Anonymous said...

Dream Mom, You are so right about all these things .... I just wanted to comment that I also am maddened by all the repetition, having to recite the same history over and over while knowing that all of this is in the chart, has been written down repeatedly. Why is there a chart if the doctor is going to get all huffy at the notion that he or she should have looked at it? Also this is at times frightening, what if this one time I leave out an essential nugget, or say in too soft a voice something vital?

Gloria (The Little Red House with the White Porch) said...

Hi, Dream Mom -- what a wonderful post. I agree with others in that this should be given to medical students! If nothing else, it might 'scare' them into doing the right thing so they don't get into trouble! You know how people are: they will adhere to things if they think people will call them on it. Anyway, great post and I agree with everything you said about doctors and good for you for being such a fabulous advocate for your dear son. Take care.
Best regards,

Dream Mom said...

Anon711-I agree with you on the history!


Sarai said...

I found your post about med errors interesting. After our baby girl died from a medical error, it was alarming to see how poorly we were treated, like we had suddenly become poisonous. Its a story that has probably been told a thousand times, but when they refused to acknowledge us, and started treating us like WE had done something wrong, we did, indeed "talk through our attorneys" from which the hospital did not fair well.....it still hurts how we were abandoned when we were needed the most.

Dream Mom said...

Sarai-I am sorry for your loss. I can totally relate to what you are saying. The abandoment really hurts. I think there is also disappointment too because I expected them to have better character. I can't imagine losing a child and then having that issue on top of that. And yes, they do make you feel like it's something "you" did. Take care. Thanks for sharing. There aren't many people who understand this kind of thing.

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