When doctors and other health care personnel care for patients, it is important to establish a relationship in which the patient feels comfortable in opening up about his/her health. This can include sensitive discussions, such as the sexual history, the use of illegal substances, and mental health issues.
When certain conditions are due to patient’s “lifestyle”, then it is the doctor’s duty to discuss lifestyle modification. This may include, for example, counseling on smoking cessation, eating a healthy diet, exercise, practicing safe sex, refraining from harmful substances such as cocaine, and other discussions. The medical professional may use motivational interviewing as one method to deliver these difficult conversations.
How far do we need to go, though? For patients with peripheral vascular disease who continue to smoke, when we know that the ONE thing that will help the patient as much as any other intervention is smoking cessation, what are we obligated to tell our patients, and how do we say it without alienating the patient? Do we discuss how much personal responsibility the patients need to take?
The same concepts are true when we are working with learners who are struggling in some dimension of their training. Sometimes it is a medical student who is chronically late for clinic, but we know who is otherwise excellent with regards to patient communication, and spends that extra time so many patients crave. How do we say that the student needs to be on time, when we know that she is probably taking time with other patients in a different setting? Which patient is “more important” and how do we relay that to the learner?
What do we say to the resident who never completes his administrative duties, such as completing duty hour forms, logging their required number of patients, or turning in vacation requests on time? What is the tough love there? I have found that those same residents who struggle with “administrative professionalism” are also the ones who, after they graduate, will then suddenly call, email, or even page me, needing credentialing papers done immediately, “because if you don’t do them by the end of today, then I can’t start working”. Is there a version of tough love for those discussions?
I am a firm believer that what is “most important” is the care of the patient. I know that Francis Peabody, who stated “The secret of the care of the patient is in caring for the patient”, never had to deal with EMRs, competencies, clinical documentation improvement programs, credentialing papers, milestone documentation, RRC site visits, or other administrative duties which come part and parcel with being a medical educator. But the times have changed.
With this piece, I realize that I raise more questions than answers. What are your thoughts on this topic?
The clinical nurse ethicist at Riley had a great discussion about this when I used to work with the Ethics Committee (at least the patient part.) We as doctors, especially pediatricians, feel like we want to/must control everything in the patient's life. We even put it on us when bad things happen to the patient because of bad choices that either they or the parents make. But in the end, we cannot control what people do outside of our office. Sure, we could file with CPS every time a parent makes a decision we don't like, but at what point do we then give control back?
ReplyDeleteAs for the med ed part, my favorite quote (which I might have made up, or I might have heard somewhere, but forgot the source) is "A program shows what it values by what it enforces." My question to you then is, what do we value?
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