Tag Archives: doctor-patient relationship

Blog: Rural Mississippi—Aftermath of Hurricane Katrina

–Shailendra Prasad

August 2005. I planned on flying back to New Orleans after a conference in Arizona. My wife and son had accompanied me. We watched Katrina grow like a weird reality show—a petulant child gaining weight, becoming unruly. There was talk about this being bigger than Ivan from the year before, even bigger than Camille from 1969. “No,” my friends and patients in Mississippi told me, “nothing gets bigger than Camille.”

Our flights home were canceled. Then we learned our neighborhood was under mandatory evacuation. Evacuation was not foreign to us. We’d participated in four drills during our seven years in Mississippi. “Hurricane parties,” we called them. We’d lock the shutters on the house, secure the garage door, and remove the yard implements that could become missiles in the sixty plus mile-per-hour winds. Then along with our two satchels filled with a change of clothes, our son’s favorite toys, and copies of our important documents we would drive to a safe home, a friend whose home was not in the path of the storm. We’d spend the night playing cards, talking, and waiting out the squall. Usually we could go home the following morning.

We hoped this, too, would pass and called a friend who had a spare key to our house.

“Sounds like a bad one,” our friend said.

“Can you get our hurricane satchels? There are two of them, in the closet in the master bedroom.”

“Sure. I’ll lock up the house too. Anything else?”

“Yeah, put the birdfeeders in the garage. The birdbath too.”

“Of course. Be safe. I’ll be in touch.”

That night in Phoenix I watched the television. Reporters talked about the rain and wind in surrounding areas. Counties in both Mississippi and Louisiana were evacuated. I called every number in my cell phone. No answer at the hospital, the clinic. My practice partner did not respond at his home phone or cell. I could not reach our neighbors or local friends.

Our county, Pearl River, and our town, Picayune, were orange on the weather map. The Internet news pages said nothing more. I could not eat dinner. I continued to make calls. I phoned my dozen sickest patients whose numbers I kept just in case they needed me. No one answered. I worried about my three-year old patient waiting for a renal transplant at Tulane. He’d just gotten a match.

What would happen now? No answer. And there was complicated Mr. Shirley who I just referred to the neurologic unit in Birmingham, Alabama. Would he get there for his appointment? When was that appointment? No answer. Then there was my dialysis patient. Where would she go? No answer. Feeling restless and helpless I walked down to the business center and opened this blog:

Pearl River County Katrina Survivors

This is my attempt to help in the aftermath of Katrina. I work in the Picayune area and have very dear friends in the area. The only precondition to this blog is this—respect your fellow bloggers.

Please blog away to add on to the information on Picayune/Pearl River County,Mississippi.

posted by sprasad @ 8/30/2005 07:54:00PM

By midnight there were thirty posts. I am looking for . . . I am trying to reach. . . does anyone have any information on . . .

 (Excerpted and used with the permission of the author, published in The Country Doctor Revisited, KSU, 2010)

Dr. Prasad felt an obligation to his patients during Hurricane Katrina. Medicine is rarely something you can walk away from when you leave the hospital or office. Often you carry patients with you – think about them, worry about them, pray for them. In a small town you often see  patients as you run errands at the hardware or grocery stores. This raises the issue about how one sets boundaries. How one cares for his/herself.

Talk with your preceptors and other staff in you clinical setting and see how they manage these challenges. 

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Disconnected US health care–Part 2

The Dressing Change – Part 2

–Tara Frerks

As I worked, I listened as Mr. Friedrikson repeated some of the particulars of their story. It was clear that he was angrier than his wife, maybe feeling some guilt. He clearly had taken the lead in trying to secure help.

I washed off the remaining betadine and dried blood, then patted the patient’s hand dry, careful not to hurt her. “Want to take a look before I wrap your hand?” I asked.

Mrs. Friedrikson emphatically shook her head.

Using supplies from their bag, I carefully placed Telfa (no-stick gauze) over the healing lacerations, then wound gauze around the fingers and thumb, wrapping the thumb separately and keeping the fingers visible to just below the nails. I’d watched many dressing changes, but this was the first I’d done on my own. I gained confidence as I worked.

Two hours after entering the clinic, I sent the couple on their way. They left with a neatly applied dressing and two hours of telling their story. Now more confident in my wound care, I realized that today I’d made a valuable contribution to Dr. Brown and the clinic team. As a medical student I had the luxury of spending time with patients, listening and talking and hearing every detail of their nightmare in a way that Dr. Brown could not. Now, my challenge over the next years of training is to learn how to demonstrate the same humanistic care in a more compact interval. And maybe with advocacy on my part, I might see a saner health care insurance system during my career.

(Excerpted and used with the permission of the author, published in The Country Doctor Revisited, KSU, 2010)

We’ve talked before on these pages about the student’s luxury of time, what a gift that is for the patient and the clinic. Pay attention to what you can learn because of the time you have to spend with patients. You’ll gain not only techniques and skills, but a wealth of information about health and healing and  the resiliency of the human body and spirit.

 

A Psychiatrist Waits for His Ten O’clock Patient and Imagines He Is Han Shan

 

–Richard M. Berlin

Daughter gone,

hair gone, my father

dead for half my life.

Patients I saved from suicide

lived until old age,

died from cancer instead!

Twenty years of hospital work.

Twenty years pruning apple trees

on the west flank of Cold Mountain.

Once they were sticks.

Now the branches bow with ripe fruit.

A faint wind stirs them.

I’ll share a bushel with the crows,

another with the worms!

 

 (Excerpted and used with the permission of the author, published in The Country Doctor Revisited, KSU, 2010)

Dr. Berlin, a psychiatirst and poet whose poems we've shared in other blog entries, reflects on life's rhythms and transience mimicking the Chinese poet Han Shan. Han Shan referred to himself as Cold Mountain. Dr. Berlin lives on Cold Moutain. Han Shan was a cynic and a hermit who liked to poke fun at the self-importance of the other monks. Enjoy this brief reflection on all we try to do and hope to do as healers/physicians and what it all amounts too.

Spring Planting

—Richard M. Berlin
                 For Julianna A. Luntz Van Raan, 1950–1998
A morning call wakes me:
something hard and fibrous in her leg
growing fast and uncontrolled
that can’t be weeded out.
Through my bedroom window
I study winter rye in April
swinging on strong stems.
I wish I could plant Julie’s leg
in a warm tangle of earth,
turn her face toward the sun,
and let her nurse on spring rain
like the dandelions waiting
to fill the meadow with stars.

Reprinted from The Country Doctor Revisited (KSU, 2010) with permission.

Dr. Berlin celebrates Spring and reflects on his wishes for his patient who is dying of cancer.  We grow attached to our patients. Their losses can become our losses. Although we need to maintain a certain professional distance so that we can contiue to care for them, we can still feel sad and should make the time and space to feel our own grief.

When you grieved the loss of a patient for whom you cared, did you talk with someone about it? Did you cry? Write a poem or story? Go for a run or a walk? We may be scientists, but we have hearts and we are human.

Sometimes patients repulse us…

— Lorence Gutterman

I knock, enter the room, and introduce myself. Carter rolls over to look at me, a grimace on his face. I step back as the musty air of his room reaches me, reminding me of my high school gym locker room. I brace myself and ask him why he became a rodeo rider.

“My uncle and older brother rode. I wanted to be like ’em. Doc, you want to try it?” He laughs through his obvious misery as he pushes himself into a sitting position, his reedy legs now dangling beneath the flimsy, gray-checkered hospital gown.

“I’m too chicken to sit on a bucking horse,” I say and place my chair a safe distance from him. Not so far away to be rude, but I need some space.

“Man, what are ya’ afraid of? Thought Docs could do everythin’.” His grin changes to a frown as he crosses his legs.

“Believe it or not, doctors get scared.” What would my colleagues think of me, admitting vulnerability?

Carter shuts his eyes and rubs them. He clenches his jaw. “Can you give me something for pain? I hurt like hell.”

“Of course. I’ll talk with your nurse.” I quickly leave the room to find his nurse who is counting tablets and putting them into a tiny paper cup. I ask her to increase Carter’s dose of morphine. I reenter Carter’s room. The odors have not changed. I return to my chair, the cracked vinyl squeaks.

“Hey Doc, ya gonna get me feelin’ better?” He has returned to lying down.

“I’ll try. Can’t promise you though. Could you control the bronco the first time you sat on it?”

He tries to prop himself up on his right elbow. “Doc, ya never can control that animal.”

“Kind of like your fever, until I know more about you,” I say fidgeting with his chart.

“Those shakes last night, damn! Bounced me around more than any bronc.”

“Fever caused your shakes.” I stare at the plastic bag filled with clear liquid hanging on a metal pole on the corner of his bed. Its slow drip is hypnotizing, calming. I decide to get to know him before I start quizzing him about risks for AIDS. Taking a sexual history has never been a comfortable task for me.

(Excerpted from Hanging on for Your Life and used with the permission of the author, published in The Country Doctor Revisited, KSU, 2010)

In this selection the author appears repulsed by this patient. It may be the patient’s profession, it may be the smells of illness, it may be the patient’s personality. We are human, we all have reactions to patients. My toughest patients are those who are morbidly obese and come in with complaints related to their excess weight. Obese patients are hard to examine. My feelings are real, I can’t get rid of them. The important thing to remember is that I cannot act on my feelings. I need to recognize them, then set them aside and figure out how to meet the patient where he or she is. Likely the obese patient is embarrased about their weight and has been the recipeint of cruel comments. I try to find some empathy for that patient.  Partnering with a patient demands figuring out what if feels like to walk in their shoes–that saying may be cliche, but its a good place to start. Empathy can help me put my repulsion aside. This is part of professionalism. We may have unsavory feelings, but we don’t act on them.

Sometimes to let off steam, we may joke with colleagues and co-workers about a patient or the situation. Be careful about this. You never want to do that in a location where the patient or his/her family/friends might over hear you. Humor helps us to cope, but eventually you need to set it aside and return to a position of empathy.

The author also talks about being scared. Feelings of fear are human too. Sometimes we are afraid and we need to ask for help. However, sometimes we need to set our fear aside and do what needs to be done.

As you spend time in clinic and the hospital you will see health professionals who are empathetic and kind to some of the most difficult and repulsive patients. Watch them, ask them how they do it.

Thank God for My Ass

–Therese Zink

I am not referring to my backside, although I do have a well developed gluteus
maximus due to my stocky German build and fifteen miles of running every week. My ass is Jimmy, a shy miniature donkey (think Shrek’s pal) who has been the companion of my horse, Indy, on my twenty-acre farm for almost four years. Recently Jimmy saved my ass. Please pardon my crass language, but it is the truth.

At about eight one evening, my cell phone chimed as I was driving home.
The local nursing home needed help with an elderly gentleman who had been
admitted three days earlier. My partner had given him some furosemide late
that afternoon for congestive heart failure, but Mr. Olson was still edematous
and very short of breath. “The family is upset and wants me to do something,”
the nurse reported. “His hemoglobin is four and his potassium is six. Will you
talk with the daughter?”

A hemoglobin this low would require a transfusion of several units of blood,
and the potassium suggested kidney failure. “Sure,” I responded. Not wanting
to be the student who lost her homework, I said, “But I don’t know him. Please
read me his diagnoses and tell me what meds he’s on.”

It took the nurse several minutes to tick off the list, which included some
dementia and repair of a thoracic aneurysm seven years ago.

“How old is he?” I asked wishing I was not the one on call.

“Eighty-eight,” she informed me. “He’s very sick. DNR-DNI. The family is
pushing me to do something. The daughter is really upset.”

As I drove in the darkness toward home, I took a deep breath and readjusted the
phone next to my ear. My new challenge flashed like a neon sign—the distressed
family of a new patient who I didn’t know. “Any thoughts?” I asked the nurse.

“The daughter is a handful. Good luck.”

“Put the daughter on,” I said and prayed for inspiration.

“This is Janet,” the voice said. “You know me. My husband and I borrowed
your donkey for our church’s Christmas nativity pageant.”

I thanked God for the connection, some place to start this conversation. “Of
course, Jimmy. That was a cold day.” I said and remembered that the shepherds,
kings, even Mary and Joseph, wore snowmobile suits under their cloth costumes. Thick Sorel boots peeked out beneath their flowing robes. Jimmy was insecure without his buddy, Indy. So this manger scene had had a horse and a donkey. Janet and her husband had given me the digital photos that I had cut and pasted into my Christmas letter to family and friends. “I am glad to talk with you again, but I am sorry about the circumstances. Tell me your understanding of what’s going on with your Dad?”

Janet cleared her throat. “My mom cared for him at home for six years. He
started having trouble walking two weeks ago, so I started coming every day
to help her. We decided he needed more than we could do and looked for a
nursing home. There was an opening here, so we moved him last Friday. He’s
gone downhill since.”
I heard the frustration and recrimination in her voice: Why was he doing
worse, not better at the nursing home? “The nurses tell me he has a lot of fluid in his lungs,” I said. “We can help him breathe easier.”
“Can you help him get better?” Janet asked.
Read the rest of the story

First published in JAMA,299:16 (2008):1879–80, used with permission in The Country Doctor Revisited (Kent State University Press, 2010)

Building trust is an important ingredient to the doctor-patient relationship. In the 4 habits model, Dr. Frankel ARTICLE  presents a very practical model for thinking about how to approach the patient. Sometimes trust must be built rapidly, such as in an emergency or crisis. In this story, I was faced with the angry daughter of a patient I did not know. Luckily my miniature donkey gave us a place to start the conversation. If you are on a rural rotation, what have you observed about how doctors and nurses build trust with patients?

Home Visit

As a medical student in North Carolina, Dr. Fleg did a home visit with his preceptor and received a gift for his heart.

 The Sisters

–Written in Love

by Anthony Fleg

My watch said it was time to go,

But my heart spoke otherwise,

Fortunately, I listened to the latter

And went with Dr. Stuart to see

The Sisters

Miss Minnie and Miss Viola

Hailing from Georgia,

With ten scores of wisdom between them,

They spoke first, without words

Perfuming the room as we entered.

They began to tell of their aches and pains,

Joking about whether Dr. Stuart or I would be their “catch” for the day

When asked about the key to their longevity,

Viola answered, “God has been good to us,”

While their relative with them offered, “It is because they were good to their momma.”

Which caused me to pause,

Trying to shut off that medicalized, left-brain-oriented way of hearing that afflicts many of us in medicine,

They spoke not on the recipe for reaching the holy feat of triple digits,

But instead on the way to appreciate each and every day whole-ly,

as something holy,

They teach that the goal is not to reach an old age

But instead is about how to be on your way there

They remind us that the goal is not to avoid death

But to fully embrace life

I am thankful,

I am refreshed,

Dr. Stuart and I leave smiling with our minds and hearts

If someone asks me why I am late

I’ll simply say, “My teachers had something I needed to hear.”

(used with permission and published in The Country Doctor Revisited, KSU, 2010)

Many patients have lots to teach us, especially older patients, who know their bodies and themselves pretty well. One of my favorite elderly patients, a retired farmer, cannot do much on the farm now that he’s reached 90, but he takes great pride in growing tomatoes. He’s given me many pointers and improved my green thumb. Despite the pressure of seeing lots of patients, Dr. Fleg reminds us that we need to take the time to listen and connect with patients on topics beyond their health and diseases. These kinds of connections nourish us and are the rewards that come from taking care of people. If we don’t take time to bask in these, we will get burned out and cynical. What are some of the treasures you’ve heard and witnessed on your rural rotation? What wisdom will you carry with you for a while? Urban patients have many treasures to share as well. Urban or rural, have you seen interactions between your teacher and a patient that remind you of Dr. Fleg’s. Sometimes you are working with teachers who are burned out. What opportunities to interact with patients have they missed?