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Archive for the ‘Communication’ Category

Clinical Guide to Delivering Death Notification

Posted by medliorator on August 18, 2008

Excerpts from The Last Hours of Living: Practical Advice for Clinicians by Linda Emanuel, MD, PhD et al.

1. Get the setting right
Find a quiet or private area with a telephone. Identify yourself and ask the identity of the person to whom you are talking and their relationship to the patient. Ask to speak to the person closest to the patient (ideally, the healthcare proxy or the contact person indicated in the chart). Avoid responding to direct questions until you have verified the identity of the person to whom you are speaking. Ask whether the contact person is alone. Do not give death notification to minor children.

2. Ask what the person understands
Ask what the person understands about the patient’s condition with a phrase like, “What have you been told about M’s condition?”

3. Provide a “warning shot”
One approach may be to begin with a sentence such as “I’m afraid I have some bad news.”

4. Tell the news
Use clear, direct language without jargon. For example, you could say, “I’m sorry to have to give you this news, but M just died.” Avoid words like “expired,” “passed away,” and “passed on.” They are easily misinterpreted.

5. Respond to emotions with empathy
Most importantly, listen quietly to the person and allow enough time for the information to sink in. Elicit questions with a phrase like, “What questions do you have?” Ascertain what support the person has. Ask if you can contact anyone for them. Consider other support through the person’s church, Red Cross, local police, or other service agencies if it is needed.

6. Conclude with a plan
f the family chooses to come to see the body, arrange to meet them personally. Provide contact information for the physician, nurse, or other professional who can meet with them and/or make arrangements.

Introduction to the Last Hours of Living [Medscape]

Correlate: How to Give Bad News (Randy Pausch)

Correlate: Discussing End-of-Life Care

Correlate: Delivering Bad News & Crying

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Facebook for Medical Students

Posted by medliorator on August 9, 2008

researchers looked up more than 800 medical students by name on Facebook, finding that 44 percent of them (for a total of 362) had profiles on the social networking service. Only 37 percent of those students had made their Facebook entries private …students were looser with lifestyle information including sexual orientation (revealed by more than half of Facebook-using students), relationship status (revealed by 58 percent of students) and political opinions or positions (revealed by half of students).

Seven of 10 [randomly selected profiles] included photographs in which the subject was drinking alcohol, and some form of excessive or hazardous drinking was implied in as many as half of those photos… Three of the 10 students in the sample had joined groups that could be interpreted as sexist (“Physicians looking for trophy wives in training”) or racially charged

Three of the 10 students in the sample had joined groups that could be interpreted as sexist (“Physicians looking for trophy wives in training”) or racially charged (“I should have gone to a blacker college”).

“I’m not sure I would want to have a permanent, public record of everything I did 10 years ago, but many of our students are creating just such a record, and they need to understand the problems this may cause.”

Future doctors share too much on Facebook, UF researchers say [University of Florida News]

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How to Ease Anxiety in the ER (Randy Pausch)

Posted by medliorator on July 28, 2008

As Jai was being rushed into surgery for an emergency C-section, she said to the doctor, “This is bad, isn’t it?”

I admired the doctor’s response.  It was the perfect answer for our times: “If we were really in a panic, we wouldn’t have had you sign all the insurance forms, would we?” she said to Jai.  “We wouldn’t have taken the time.”  The doctor had a point.  I wondered how often she used her “hospital paperwork” riff to ease patients’ anxieties.

A New Year’s Story [The Last Lecture by Randy Pausch]

Correlate: How to Give Bad News (Randy Pausch)

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Confronting Unscientific Beliefs

Posted by medliorator on July 24, 2008

by Steven Novella:

It is not the place of the physician to validate or refute personal religious beliefs.
Non-religious ideological beliefs are the same. The point is that the physician cannot impose their value system onto their patient.

Most experienced clinicians already know to avoid dismissive, insulting, or judgmental statements. In confronting unscientific medical beliefs, it is easy to do so. Simply confine your opinions to the scientific evidence. For example, if a patient asks me about acupuncture for migraine headaches I simply tell them that I have reviewed the published literature which does not support the use of acupuncture for migraines. I therefore do not recommend it. I am then happy to discuss the evidence with the patient as much as they desire. But almost always patients appreciate the fact that I have taken the time to actually read the literature and they respect my opinion.

Sometimes patients ask me about treatments that I believe to be fraudulent and exploitive – for example I am frequently asked about whether or not it is worth it to fly to China to get stem-cell therapy. In these cases I tell my patients, in a very factual and dry manner, that such clinics are fraudulent. What evidence we have shows that their treatments are not safe and that they do not work. In my opinion the people operating the clinic are committing fraud to steal money away from desperate patients. To do anything less is to fail to properly inform a patient.

It is profoundly misguided and harmful to fail to confront pseudoscience or bad science in medicine out of fear of offending a patient.
Given the medical environment today, clinicians are obligated to have a working knowledge not only of science-based medicine but of the unscientific practices and claims with which their patients may be faced. We are obligated, as part of good practice, to know the literature and the nature of unscientific claims and to help our patients navigate through them.

A Guide for Confronting Patients [Science-Based Medicine]

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How to Give Bad News (Randy Pausch)

Posted by medliorator on July 21, 2008

The horrible exchange was surreal for me.  Yes, I felt stunned and bereft for myself and especially for Jai, who couldn’t stop crying.  But a strong part of me remained in Randy Scientist Mode, collecting facts and quizzing the doctor about options.  At the same time, there was another part of me that was utterly engaged in the theater of the moment.  I felt incredibly impressed – awed really – by the way Dr. Wolff was giving the news to Jai.  I thought to myself: “Look at how he’s doing this.  He’s obviously done this so many times before, and he’s good at it.  He’s carefully rehearsed, and yet everything is still so heartfelt and spontansous.”

I took note of how the doctor rocked back in his chair and closed his eyes before answering a question, almost as if that was helping him think harder.  I watched the doctor’s body posture, the way he sat next to Jai.  I found myself almost detached from it all, thinking: “He isn’t putting his arm around her shoulder.  I understand why.  That would be too presumptuous.  But he’s leaning in, his hand on her knee.  Boy, he’s good at this.”

I wished every medical student considering oncology could see what I was seeing.  I watched Dr. Wolff use semantics to phrase whatever he could in a positive light.  When we asked, “How long before I die?” he answered, “You probably have three to six months of good health.”  That reminded me of my time at Disney.  Ask Disney World workers: “What time does the park close?” They’re supposed to answer: “The park is open until 8 p.m.”

The Park Is Open Until 8 p.m. [The Last Lecture by Randy Pausch]

Correlate: Delivering Bad News & Crying

Correlate: How to Communicate with Cancer Patients

Correlate: Discussing End-of-Life Care

Posted in Communication, How-To, Oncology | 2 Comments »

How to Communicate with Cancer Patients

Posted by medliorator on July 8, 2008

She recommended starting out with some tenderness. “This is a tender time,” she said. “It can be, ‘Hey, you know you’re great. I care about you. I love you and I’m here for you.’ ”

Healy said it is important to offer plenty of encouragement either in person or in a letter. “I know you can do this. Having cancer isn’t fun. You’re going to face some difficult times, but I know you can do this. You’re strong.”

“One thing you don’t want to do is instantly assume it’s terminal. … Often there is a feeling that people are going to write them off, or they’re going to count them out.”

In her book, Healy wrote, “Banish the following from your vocabulary: terminal, incurable, hopeless and salvage.”

She said she prefers positive conversations. “I liked hearing that I seemed like myself again. It meant that I was in control, and I was able to believe it,”

Finding the right words to comfort cancer patients [CNN]

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One Patient’s Advice

Posted by medliorator on July 3, 2008

Don’t call patients by their first names unless they ask you to do so… That goes for the doctor, too. When he and I have been dealing with each other for a length of time, I’ll permit him to call me Larry and I’ll naturally call him Frank. Otherwise, I would prefer that he call me Mister until asked to do otherwise

Tell the doctor to slow down. Why should I be scuffled from the waiting room to an inside cubicle designed so that the doctor need not sit down? If he doesn’t sit, there is no reason for him to tarry while answering my questions.

A patient’s advice to hospital communicators [ragan.com]

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Discussing End-of-Life Care

Posted by medliorator on June 16, 2008

Only one-third of terminally ill cancer patients in a new, federally funded study said their doctors had discussed end-of-life care

…people crave these conversations, because without a full and candid discussion of what they’re up against and what their options are, they feel abandoned and forlorn, as though they have to face this alone. No one is willing to talk about it

The new study… involved 603 people in Massachusetts, New Hampshire, Connecticut and Texas. All had failed chemotherapy for advanced cancer and had life expectancies of less than a year. They were interviewed at the start of the study and are being followed until their deaths. Records were used to document their care.

Of the 323 who have died so far, those who had end-of-life talks were three times less likely to spend their final week in intensive care, four times less likely to be on breathing machines, and six times less likely to be resuscitated.

About 7 percent of all patients in the study developed depression. Feeling nervous or worried was no more common among those who had end-of-life talks than those who did not.

Cancer doctors dodge the death talk [CNN]

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Delivering Bad News & Crying

Posted by medliorator on April 29, 2008

Delivering bad news is painful. Before each session I prepare myself using a self visualization technique. I have learned over the years the art of these conversations. Each one drains me both because I empathize and I care. However, crying would detract from my ability to do the complete job of helping the patient.

I believe that my patients’ deserve my empathy, and also careful explanation. When I tell someone they have cancer, I then spend a significant amount of time explaining what it means. I then explain it again the next day, because patients often do not grasp all of my words after I say the C word.

My students and residents have told me that I do a good job of this necessary and painful task. I take the time to sit down and explore the patient’s understanding and help the patient develop a “game plan.” If I let me emotions take over, then I believe my effectiveness will diminish.

Even with the worst news I try to provide hope and support. We can always do something to help the patient. Our toolbox includes palliation and emotional support.

I once had a colleague who stressed the importance of maintaining composure when everything seems to be failing. Patients deserve composure, empathy and a well developed plan. Maybe they also deserve my crying with them, but I really do not think so.

Appropriate bedside manner [DB’s Medical Rants]

Correlate: Should Doctors Hug Patients?

Posted in Communication, Professionalism | 1 Comment »

When & How to Disclose your Specialty Preference

Posted by medliorator on April 28, 2008

Thomas Robey at Medscape…

The purpose of rotating in all the major fields is to educate students in the basic principles of medicine. A secondary goal is to assist future doctors in knowing when to refer their patients for specialty care. The third objective is to help students decide which residency to apply to.

the observant student will recognize that it might not be a good idea to disclose her chosen profession to those evaluating her.

As it gets later in the year, the legitimacy of an “I don’t know” answer decreases. You’ve scheduled the fourth year to cater to your next step and you’re already thinking about residency programs. Hopefully, you’re pondering what will go into your personal statement. Even if you’re considering three fields, at least that’s down from the “everything seems interesting” non-answer

be confident in your ability to identify what you are best at, what you enjoy the most, and what career will contribute to a happy and meaningful life. When you’re on a team with docs who don’t understand your view, that’s okay. In whatever clerkship you are in, you’ll be best served by working hard and studying. In the end, that will affect your grade more than your professional choices. And when you’re out on the field with your own practice, don’t forget the value of teamwork. I can’t think of any way that trash talk benefits patient care.

Coming Out of the Closet [Medscape]

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