Helping our patients get the help they need when their senses fail

May 13, 2010 by  
Filed under For Healthcare Professionals

The American Speech-Language-Hearing Association (ASHA)

It is so important to make sure that your senior patients get check ups for both hearing and seeing. Don’t assume that the mental changes you are seeing mean there is a brain or psychological issue. Sometimes it is a senses issue. And your patient may or may not know it is happening since it changes happen slowly over time. I didn’t realize that my dad had such poor vision until I sat with him during his eye appointment. Then I understood how much he was missing and how I needed to make sure we modified his space to help him with his visual limitations. I wish the doctor had taken a more proactive approach to helping me with my dad. Instead, he just documented what was happening and moved on to the next patient. I sure could have used his advice and guidance about what this vision loss meant to my dad and how I could help.

Language barriers also create an obstacle to getting what one needs. Unfortunately, I see healthcare professionals discount or ignore someone with speech limitations and turn to the family member instead. I know we are all rushed in medicine but we have to take a stand and say no, I am not going to rush this person through because my patient needs me. It also happens in our day-to-day life when we want someone in front of us in line to hurry up but they can’t because it takes them longer to speak.

Just because people can’t speak well or speak fast, doesn’t mean they shouldn’t have a voice in their lives. There are other ways to communicate. People can write, type, point to words or pictures on a board or sign. Many times it is just about having patience. Having the patience to sit still while the other person finds the words. And what I have found with my hospice work is that people communicate even when they can’t say a word. So, sit still and listen. You make a difference when you do.

Have a kind and respectful day.

Speaker phone, conference call or webcam your patient’s condition to their family.

March 30, 2010 by  
Filed under For Healthcare Professionals

Are you frustrated when the patient goes home and doesn’t follow your instructions or when the family member calls you and wants you to repeat everything you said to the patient?

A great way to solve this is to use technology. And I don’t mean fancy technology, but using either the speaker function and/or conference call feature on everybody’s cell phone. Then the loved ones can give you more information, ask questions and can listen to your update about the patient’s health and treatment plan. This is also an opportunity for you to build a relationship with the family in case the patient can’t speak for him- or herself in the future.

Using technology can be especially important in the hospital. For those who can not travel, use a laptop with a webcam to help the family see how their loved one is doing. There is nothing like seeing the person with their own eyes to help them picture what you are talking about. An image, either by webcam or cell phone picture can give the family understanding of the condition of the patient and how his or her health has changed.

Have a kind and respectful day.

Improving the Medical Experience of the Person struggling with Alzheimer’s or other memory loss

January 17, 2010 by  
Filed under For Healthcare Professionals

When a person with Alzheimer’s or dementia is going to have a medical test or procedure, how can we help the person to feel less frightened and to minimize any suffering? If the patient is struggling to understand what will be happening to them, do a practice run-through and show the person the room where the test will happen. Or find a book with pictures that will help him understand what you are talking about. If the person with diminished capacity is afraid of being alone, you may want to introduce him to the nurses who will be working that day. For my dad, we tape-recorded the doctor’s explanations so he could listen to the information over and over again until he felt more comfortable.

Another thing to keep in mind is that the patient may be experiencing symptoms that affect his or her participation. These symptoms could be pain, side effects of medications, loss of hearing or sight, lack of sleep, an undiagnosed illness and grief, to name a few. Find out what can be done to relieve these symptoms to make it easier for the individual to participate in the process. Ultimately, our goal is to think about the quality-of-life questions from the person’s perspective as he or she will experience the consequences of our decisions.

Have a kind and respectful day.

Teaching your Patients How to be Good Patients

January 7, 2010 by  
Filed under For Healthcare Professionals

getmostfromdrTime is limited and the patient keeps talking and talking. What can you do? I realize that patients aren’t taught how to be good patients. So it is up to us to teach them. I have three recommendations for you.

Recommendation #1 Have them write out what they want to talk about before their appointment. Now I am sure you have heard this before, but the part that most doctors miss is to get them to prioritize their questions. I tell them to circle the most important 2 questions they want to discuss with you. Otherwise you just get a long list of random questions without any sense of what they truly want you to focus on. Patients understand that you can’t answer all of their questions but they will be satisfied if you take care of the most urgent issues. I have a questionnaire form, Viki Kind’s Office Form that you can download to help you help the patient. I encourage you to give copies to your patients to keep at home so they can fill them out before their appointment. If they haven’t filled one out before they arrive, then have them work on it while they are in your waiting room. In the medical practice I used to manage, we had a clipboard and form all ready for the patient when they checked. This is an easy way to be more efficient and to increase patient satisfaction.

Now some of you might be thinking, “Good, I don’t have to spend time listening, I can just read their list.” Well, you can if you want but your patient will be angry and non-compliant. If your patient doesn’t trust you or trust that you care about them, they won’t heal as fast or follow your instructions.

Here is Recommendation #2. It is up to you to build a caring relationship with them and you do that through compassionate dialogue, not a monologue. The act of listening has its own healing properties.

Recommendation #3 The other thing you need to educate patients about is to stop asking you the, “Oh by the way…” question as you are about to walk out the door. You need to tell them up front to ask you the most important questions at the beginning of the appointment or else you won’t have to time to address their concerns. Of course, this is a hard habit to break for patients and you will have to give them time to learn to be more direct with you.

Bonus Information: Unfortunately, some of these techniques will not work with certain cultures as they use a form of indirect communication which dances around the topic and takes longer as the only way they know how to communicate. But for most of your patients, these techniques will help you manage your time while caring for your patients.

Have a kind and respectful day.

Having patience with your senior patients

November 19, 2009 by  
Filed under For Healthcare Professionals

I understand that it isn’t easy to have patience with a patient that is aging or has a physical or mental limitation. I know that I have tried to hurry patients along with little success. But it is important to understand that our senior patients aren’t doing this to annoy us. They are just at a different stage of life. As a people age, the need to be in a rush and to get a lot done changes. Older seniors have more important things to focus on, the work of aging. There are two main tasks that need to be accomplished: Keeping control over as much of their life as possible and legacy work. The need to keep a sense of control and power over one’s life is necessary as the seniors begin to experience significant losses. Seniors are losing their health, their abilities and those around them begin to die. As people come to terms with what they are losing, the need to hold on to what power they can becomes even more important.

This is why when you come in and tell the senior that they should do what you are telling them, you are not being seen as a trusted healer but as someone who is trying to boss them around. Yes you are in a hurry and yes the senior patient takes longer, but that is not the senior’s fault. The need to rush and get things scheduled is our agenda, not theirs. It is important to remember that the senior is not in a rush. He or she is trying to enjoy and appreciate the time remaining. If you can, allow the senior patient the time to think about the options. Ask your senior patients to tell you what is important to them and what they think of the options you have presented. Perhaps it would be best if you let them go home to consider what is best for their lives, then have them come back in or call you with their answers. Just because you think this is the right treatment plan for them, doesn’t mean that they agree.

One other thing to be aware of is that the senior is also doing legacy work. This is when the aging are trying to make sense of and to make peace with how their lives have gone. They want to be remembered. They want to be able to tell their story and to know that someone is listening. When seniors repeat a story, it serves many purposes. They need to make sure our families will remember our history so they can share it with future generations and the need to re-tell the story themselves so they can make sense of what has gone before. If you can, take the time to hear your senior patients and connect with the person they are, not the disease they represent.

For more information about how to communicate in a way that respects the journey of the senior, read David L. Solie’s book, How To Say It To Seniors.

Have a kind and respectful day.

Stopping the “Third Party Patient” problem.

September 21, 2009 by  
Filed under For Healthcare Professionals

When a person with diminished capacity comes in for an office visit, do you remember to include the person in the conversation or do you take the easy way and just talk to the patient’s family or caregiver? Unfortunately, sometimes we forget that patient is still there and allow the caregiver to speak for them. This is what is called, “Making the person a third party patient.” The patient losses his or her own voice and becomes invisible to the healthcare professional and the caregiver.

I know this has happened in my family. Many times, my dad’s doctor would ask me in front of my dad, “How is your dad feeling today?” Then I would say, “I don’t know, ask him.” Or when I would take my aunt, who was in a wheelchair, out for lunch, people would say to me, “What would your aunt like to eat?” And once again I would say, “I don’t know, ask her.” We have to remind people that our loved one is still here. Even if the person has lost some of their ability to think and communicate, that doesn’t mean that he or she shouldn’t be included. Yes, the person with diminished capacity will not be making the final decisions about medical treatment choices, but the individual can still voice his or her opinion.

I know that it may not be easy and it may take more time, but we need to keep the person included. The person deserves our attention and our effort. Face the patient, ask the person questions and be patient when waiting for the answer. Explain to the person what will be happening to him or her in language that can be understood. It is important to include the person for as long as possible and when it is safe to have them have a voice in the decisions.

Have a kind and respectful day.

An healthcare insider’s look at the healthcare debate from a money point of view.

September 6, 2009 by  
Filed under For Healthcare Professionals

Someone recently asked me what I think about the national healthcare debate. I don’t usually talk politics but I have decided to voice my opinion and to give you a healthcare insider’s view of the issue.

Part 1:
I am very angry about the death panel comments. Finally, Medicare was going to pay doctors to spend time listening to and respecting the patient’s end-of-life wishes. (Not telling seniors what to do, but listening and respecting.) These conversations already take place, but the doctor hasn’t been able to get paid for that longer appointment time. If a plumber spends 1 hour or 5 hours at your house, they can charge you appropriately. But the doctor can’t because if there isn’t a billing code for the service, the service can’t be billed. Now the doctors will continue to not be paid to listen to your wishes while they already are sacrificing not going home to their own family on time. This will be one more reason that doctors will leave the practice of medicine. You can only mess with someone so long before they say, “I am out of here.”

The idea of a death panel goes against everything in medicine. The last thing doctors want to do is to kill people. They went into medicine to heal and save. Doctors won’t participate in making sure the prisoner doesn’t feel any pain with lethal injections because doctors won’t agree to be a participant in a death. Doctors are very opposed to physician assisted suicide, even when the patient is in out of control pain and is begging for help with dying. (About 5% of the time, pain can not be managed no matter what medication is used.) These are the types of things that politicians can’t understand. The rules of medicine are deeply embedded in the culture of medicine.

Here is what I am also angry about. The healthcare debate has become a battle of political posturing and propaganda instead of trying to come up with a really great plan. I am angry that the politicians are designing the national healthcare program. Hospitals, doctors, nurses, economic experts, healthcare and public health experts etc. should be designing the government program. It would be like an electrician trying to teach your child in school. They are not trained to do that job and are not qualified. I am also angry with the politicians because they are forgetting or are ignorant to the rules of medicine. They can’t ask the doctors to jump through these new hoops to provide adequate care and still hold them to the malpractice standards in place. You can’t tie someone’s hands and then punish them when they couldn’t do everything they wanted to do.

Here are a few other insider perspectives.

Part 2:
1. We already have 3 large government run programs: Medicare, Medicaid and the Veterans Administrations. While those aren’t perfect, they are already a form of socialized medicine. If someone is against a government run program, then I suggest they turn in their Medicare card and go buy their own insurance. The doctors are already relying on the government (Medicare and Medicaid) to pay their bills because the other insurance companies are paying the doctors less and less after they provide services. The government part of healthcare is keeping hospitals and doctors in business.

2. The biggest problem is that there are too many stakeholders involved. Your employer buys your insurance, the insurance manages your healthcare dollar while taking a big cut for themselves, the doctors and hospitals take whatever they can get and eventually you get service. You are so separated from your healthcare dollars, that you can’t understand the true cost and value of what you are getting. If you buy a Chevy or a Rolls Royce, you understand why it costs what it costs because you are writing the check. But you don’t know what you are getting or what the actual costs are when you get medical care. Would you be willing to pay for the services if it was coming directly out of your pocket?

Next, if the insurance company wasn’t taking their cut, there would be plenty of money to care for even the uninsured. And if you are paying for healthcare, you need to realize that you are already paying for the uninsured. That cost is added to part of the charges the hospitals and doctors are billing your insurance company. Removing the insurance company as a middle man would really reduce your costs.

3. Doctors are fleeing the profession. I know doctors that can’t cover the costs of staying in business. One group of Ear Nose and Throat doctors haven’t been paid a salary for 6 months. They just cover the cost of running their practice and that is it. Would you be willing to work for 6 months without a paycheck? No. But doctors are so devoted to their work that they are enduring terrible hardships. But this won’t last. They can’t do this forever. We are losing the good doctors in record number. This is not a joke. Eventually we will have to recruit foreign doctors to fill our vacancies.

4. We don’t have enough emergency rooms still open. In Los Angeles, a large number of hospitals are still open but are no longer providing emergency services. Because of EMTALA, which mandates that anybody who comes to the emergency room must be treated, it is a tremendous financial burden to these institutions. The only choice they have is to close the ER or they will have to close the hospital. There is no emergency room near me.

5. You can not expect people to keep businesses open when they are losing money. And healthcare is a business that is bankrupt. The time is now to put a new plan in place that is fiscally responsible and can meet the needs of our growing and aging population. I am not the expert but there are experts out there that should be designing this plan for us. Stop the political bickering and get down to creating a viable healthcare system.

See this article for more discussion about our role in the healthcare debate.

Have a kind and respectful day.

Improving Bedside Manner While Managing Your Time

September 3, 2009 by  
Filed under For Healthcare Professionals

Your bedside manner will affect the medical outcome of the patient. Here are some easy tips you can do in your office. The first thing you want to do is to briefly review the chart before you walk in the room. Usually physicians will start looking at the chart once they’ve entered the room and will be so busy reading the chart, that they missed the opportunity for a warm greeting and good eye contact. So while you’re in the hallway, before you open the door, do two things. Review the chart quickly and check in with yourself. You want to check in with yourself that you’re ready to go in and be present with this particular patient. Even if your mind has been thinking about other patients in the office or the hospital, or if you’re thinking about your kid’s soccer game, stop and redirect your focus. Then when you walk in the room, the patient will feel like you are there for them and that you are paying attention. As you walk, greet the patient warmly and use culturally appropriate nonverbal skills. Don’t assume that the patient hasn’t minded waiting for you, they do mind. Apologize if you are late.

Please don’t sit behind a desk. The desk can be cold and distancing. The patient will feel more comfortable if you sit with them in the exam room. If you can, please talk to patients with their clothes on as patients can be very uncomfortable sitting in a small gown or with just a drape covering them up. If you’re using electronic medical records and are just now getting used to doing the patient interview in front of a computer screen, please remember to look up from the screen and to make sure you stay connected to the patient. I know the new technology takes some getting used to, but you can’t afford to have the patient feel like you don’t care. You also want to make sure that you don’t make the patient a third-party patient. This is when you talk to their caregiver and ignore the patient. Even if the patient doesn’t have full capacity, keep them included in the conversation.

Remember that the conversation should be a dialogue, not a monologue. Leave plenty of time for listening, especially at the beginning of the conversation. If you do want to connect with the patient on a personal level, don’t make the mistake that many doctors do. Doctors will begin to tell the patient about their own hobbies or interests. Don’t tell the patient more about you, instead you want to listen more to discover things about them. You also want to look for moments of caring where you can reach out and give the patient and family the needed reassurance. Don’t just focus on the symptoms the patient is reporting. Make sure you ask the important questions about how their lifestyle or culture may be contributing to their illness.

These are just a few tips I teach doctors when we talk about bedside manners and how to improve medical outcomes.

Have a kind and respectful day.

A Good Death – The Patient Gets to Decide

August 6, 2009 by  
Filed under For Healthcare Professionals


A good death is what the patient tells us it should be. No one can define what would make a good death for another person. We have to ask.

There is a famous bioethics case of a lady who needed to have her leg amputated. She didn’t want to have her leg cut off even though it meant she would die. The doctor argued with her again and again. He would ask, “Don’t you want to be alive to see your grandkids grow up? Don’t you want to spend time with them?” Finally the woman said to the doctor, “I hate my grandkids.” He was shocked. But she went on to explain that the only thing that brought her joy was working in her garden. And if her leg was cut off, then she couldn’t do that anymore. The doctor had thought that what would be valuable for him would be valuable for her. He was mistaken.

We have to ask the patient what they would want and then respect their answers. We have to respect the person. It is their life and their death.

I know it is difficult to accept when people want things we don’t understand. For instance, for some people suffering has meaning. If I understand this, I can understand when the patient doesn’t want to take their pain pills. Or if they want to trade a little bit of pain control for increased consciousness, then I will understand if the patient will only take a little of their pain meds. It is their death. We need to listen to them.

When I work as a hospice volunteer, I have lots of ideas for things people might want to do to create a legacy for their family but that is only if the person wants to. But I don’t assume that what other people want is what I would want. I ask. If someone wants to record their life history on an audio or a video tape, I will help them. Or perhaps they will want to write love letters for their family to open after they are gone. And some people want to write an “ethical will” outlining what values and beliefs they would like to pass on. Or if they would rather avoid thinking about dying, then I honor that. It is their decision to make. They get to choose what makes a good death for them, so I listen.

Have a kind and respectful day.

When you have to say, “There is nothing more we can do”, there’s a better way to do it.

July 13, 2009 by  
Filed under For Healthcare Professionals

Unfortunately, there comes a time in a patient’s life where you have to say to the patient or their family, “I’m sorry, there’s nothing more we can do.” This is the wrong thing to say and let me explain why. I know what you’re trying to say is, “there is nothing more we can do to cure your disease” but what the patient or loved one hears is, “I’m giving up and walking out this door and never coming back.” I know that’s irrational and that’s not what you meant to say but unfortunately these words sound like abandonment to the patient or family.

I believe it’s important to tell the truth about prognosis (if the patient wants to hear it), even if you can’t give them an exact time give them an estimate. You can say days to weeks, weeks to months, months to years. People deserve the opportunity and time to clean up their lives. So, when you have to say that there really is nothing more you can do, you may be missing a really important piece to this conversation. Here is how to solve this. Go ahead and tell them that there’s nothing more you can do to cure the disease, and then continue on and say, “But there’s lots more I can do. I can do plenty to keep your loved one comfortable, out of pain, minimize their suffering, refer them to hospice, get your religious leader in here to pray and help provide a peaceful and dignified death.” Helping someone to have a pain-free and dignified death is substantial. I don’t know if you realize this but palliative care specialists have the highest satisfaction rate of all medical specialties. And why is this? It’s because this is profound and meaningful work. You really matter to the patient and the family on those last days of life. It is wonderful if you can say to the patient that you’re going to walk on this journey with them no matter where it takes you. Then they won’t feel abandoned and alone. You will still be the healer, but now the focus of your healing is to heal suffering, not the disease.

The other reason this technique works is because whenever you have to say no to a patient, it is always important to offer them something else in exchange. I don’t know if you’ve had this experience with young children when trying to take a breakable item out of their hands. A smart parent grabs their favorite toy and exchanges it with them or distracts them toward something else. The same thing can happen in medicine. If you have to say no to a patient then offer something that you can say yes to. Even if all it is good pain management or the hope for a peaceful death.

Have a kind and respectful day.

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