Shoe/Foot (other)

I wish I'd had a tape-recorder. I'd have gotten it all and sent a copy to the doctors and the nurses. If I were nasty, I'd have sent it to the hospital administrator...

Having had a number of people close to me in the hospital lately, I've spent plenty of time at the bedside. It leads me to conclude that if every doctor and nurse did the same, without letting on that they were "medical," they'd change their behavior overnight. I was a visitor in a hospital just this morning, in a two person room. The roommate was a nice lady, fresh from surgical repair of a broken leg. A few months ago, she'd had breast cancer. A doctor came to see her: thin, dressed in a crispy thigh-length white coat, dark slacks, academically correct glasses. Medical guy, clearly.

"Hello," he said. "How are you feeling?"
"Hi. I'm ok, I ...."
"I saw your scan. It doesn't show the cancer. Does it hurt when I press here on your liver?"
"That doesn't hurt, but..."
"Are you feeling better than yesterday? Does your liver hurt when I push here?"
"A little, maybe..."
"OK." Exits.

Seriously. That was the exact interaction.

Meanwhile, the lady had called the nurse because her drain had come apart, leaking into her bed. As the nurse checked it out, she noticed what was evidently more than the usual amount of swelling in the lady's leg. "Oh, this is pretty swollen. Is it bigger than yesterday?"
"I don't know. I guess so, looking at it..."
"I'm going to call your doctor." Exits. Returns with another nurse in a couple of minutes. "Does this look swollen to you?"
"Yes, and it feels tight."

Someone sticks her head in the door. "You page Dr Ortho?"
"Yes, I'll get it." Exits, returns in a couple of minutes. "He said not to call him urgently, it scared him. He's coming." Rustling around, passing back and forth in front of me and the person I'm visiting, urgent, but no eye contact our way.

Dr. Ortho shows up in about five minutes. "Let's have a look... You have some bleeding into the muscle. It happens. We cut apart the muscle to fix the bone. And you're on blood thinners. You need to be on them, but when they cause problems, we have to stop them. We'll take out the drain. Try to lie right on the leg. The pressure will help."
"Thank you, Doctor."
"You're welcome. Goodbye."

Nurses return to patient, and talk while changing the bandages: "He acted like it wasn't important, like I didn't need to call him. I think it was important."
"So do I. It's a problem."
"Well he sure acted like it isn't."
"It is."

No point in listing the issues: I assume they're obvious, and that if the people were to see or hear a playback, they'd feel bad. Nor did I say anything, because I wasn't part of it. Last time I was, I did.

When my dad was admitted for what turns out to have been his final hospitalization a couple of years ago, it was first to a room on the medical floor. (I arrived a few hours after admission, to find him working quite hard to breathe, and asked the nurse how long it'd been since his oxygen level had been checked. "It was fine when he came in, but I'll check again.... 75%. That can't be right...." But that's another story, maybe for another day.) The point was that while we were awaiting the arrival of his physician, some attending came in leading an audience of admirers, consisting of a resident, an intern, and a student. Never acknowledging my mother, who was sitting by my dad with her fear and concern as obvious as if she were on fire, the attending told my dad he was going to listen to his lungs, and did so. No introduction, no preamble. Without another word to my dad, he asked his charges to do the same, which they did, wordlessly, after which he began to talk to them about it as they exited the room. The student turned and (uncomfortable, I'd like to think, at the absence of humanity) said "thank you" as he left. "I'll be right back," I said to my folks, launching from my chair with the fury of righteous indignation thrusting me like a bottle rocket.

"Excuse me, I'm Dr Schwab, and those were my parents," I intruded into the gaggle outside the room, ignoring entirely the attending and looking only at the student. "I've been in practice over twenty-five years, and I've never seen a worse example of how to behave in front of patients and family. I hope you took notes, because it's really important, more important than whatever you heard in my dad's chest. No one introduced himself, no one explained why they were there, what was going on. If you couldn't tell my mother was scared to death, you're all blind. Yet no one acknowledged her at all. No one even turned her way. She didn't exist to those people. That was the most egregious behavior I've ever seen.... and I'm a damn SURGEON!! Maybe you can learn from this -- (still looking at the student and paying no attention to the doctors) -- I'm guessing the rest couldn't care less." As I walked back into the room, I noticed the eyes of a couple of nearby docs aimed in my direction. I don't know what they were thinking.

Docs, nurses, students: when someone you know is in a hospital where you aren't known, make it a point to visit. Watch and listen. It'll be better for you than a dozen sensitivity classes. Way better. Acknowledgment, explanations. Listening. In that first case, about twenty extra words from the docs, and twenty fewer from those nurses would have made all the difference. For all of 'em: empathy. It's all about empathy. The absence is about 90% of what's wrong with medical care. And you know what? I'll say it. I'll take a chance on sounding like a pain in the ass: I know I was never perfect. I don't have the fastest hands nor the deepest knowledge on the planet; I've made mistakes in technique and in judgment. But I always had empathy. I treated my patients as I'd have wanted my parents to have been treated. I never acted like any of those idiots. (Not to patients, anyway.) And I'm still pissed.

Age of Consent

"Whatever you say, doc." "Just tell me what you're going to do, and forget about all the rest." Once in a while, you still hear that sort of thing. There are times when "informed consent" isn't all it's cracked up to be.

Don't get me wrong (not that no one ever would, or could, or has!): I believe in full disclosure, think an informed patient is a good patient, and in fact I always took pride in my ability (and willingness!) to take plenty of time to explain things clearly. And yet... I also think instilling confidence and a positive attitude facilitates smooth recovery. Nurses regularly told me that my patients always seemed calm and confident when they were admitted, and I considered that a very good thing, and high praise indeed. So I hated, at the end of a conference with a patient and family wherein I explained the plan and tried to alleviate fear, to whip out a consent form and ask them to put their name on a shopping list of horrors. It made me feel like Snidely Whiplash. Which is why I generally didn't.

What I liked to do, rather than list all the things that can go wrong, is to enumerate the steps I planned to take to make it go right. It's better, to my way of thinking, to say "putting you on a liquid diet and giving a dose of antibiotic lowers the chance of infection or leakage to less than one percent" than to intone "the suture line could leak and give you a serious infection or kill you." That there is danger is implicit; yet the emphasis is on safety. "To protect your lungs and prevent clots, we'll get you up right after surgery and walk you around, and we'll give you a mild blood-thinner" sounds better and is more positive than "you could get pneumonia or drop dead from a blood clot."

With regularity, I was regaled with the latest consent form generated by lawyers and insurance execs, each more detailed, cold, and frightening than the last; always with the admonition to use that form or suffer unspeakable consequences. Cover your ass above all, they'd say: forget about the patients' peace of mind. I never did. My office notes included what I'd said and how I'd said it. For most operations, I gave handouts or booklets that I'd written myself, and I referred to that in my notes as well. I solicited questions, asked if there were things they were worried about, and I noted that, too. But I wanted my patients to leave my office feeling OK about what they were facing, and I worked hard at it. Foisting a frightening form full in the face after all that is sort of a spell-breaker. So I left the consent signing to the hospital, when they got there. No one ever called me on it, and I never had a reason to regret it. I'm not sure I could get away with it today.