Posts Tagged physicians
Posted by torontoemerg in Before I Start Throwing Things, I'd Better Write This Down on Thursday 04 November 2010
I’ve written before how labelling patients — humorously or not — demeans and devalues those look after, and sometimes has consequences harmful to patient and practitioner alike. Now we have an article in the medical literature which seems to legitimize the practice. Via FiercePracticeManagement:
The debut issue of Neurology: Clinical Practice, launched Nov. 2, takes a deep look at the complexities of difficult interactions between neurologists. Although the neuropsychiatric problems often seen in this specialty may make for more intense situations than might be seen in your practice, the four main types of patient “maladaptive coping styles” identified by the article may ring all too familiar.
Consider whether any of your needy or demanding patients fit into any of these categories and how the following insights might help you respond more effectively:
1. Dependent clingers. Early in the medical relationship, these are the patients who pour on the praise. .
2. The entitled demander. This type of patient likes to tell you what types of tests to order and medications to prescribe–and may threaten legal action if denied. . .
3. The manipulative help-rejecting complainer. This type of patient drags physicians through an endless cycles of help-seeking and help-rejecting. . .
4. The self-destructive denier. This is the patient that knowingly continues behaviors that are dangerous to their health. . .
[The original article can be found here.]
I don’t think this represents an advance in providing patient-centred care. None of us in health care, in the end, treat “maladaptive coping styles” or even disease and certainly, we don’t treat labels: we treat patients, individuals with their own particular, complex histories and needs. Patients don’t need the condescension of being labelled — and being called an “entitled demander” is about as condescending as it gets.
And yes, labelling patients creates its own problems. It allows practitioners to ignore what might be legitimate concerns from patients about their care. Furthermore, I’m pretty sure documenting a patient as a “dependent clinger” or a “manipulative complainer” will not work to a clinician’s advantage if the treatment of the patient is ever called into question. More seriously, labelling causes both nurses and physicians to generalize to the extent of missing valuable pieces of information necessary to treat and provide care, sometimes with catastrophic results. So is it good practice? From my point of view, it’s a fail.
When I was young and worked at Sticksville General Emerg, we had exactly one dental surgeon on call. I secretly called him Dr. Fabulous, because in his esteemed and respected opinion, he was fabulous. He was fabulously good-looking, and lived in a fabulous house with fabulous wife and children; his practice was fabulous, and of course, his ego was fabulously huge.
As I’ve mentioned before, Sticksville Gen was somewhat reactionary in attitude: the physicians were all men and the real leaders and heroes, and the nurses followed them like meek lost puppies. We had one nurse — Suzanne — however, who didn’t quite fit the mold: she was, truth be told, dangerously mouthy.
One day, Dr. Fabulous made his triumphal entrance, all pomp and self-regard, into the emergency department to look at the smashed mandible of an 18 year-old hockey player.
“Jim,” said Suzanne, “Your patient is in Minor Trauma.”
Dr. Fabulous screwed up his eyes and made a great show of looking at Suzanne’s name tag.
“Suzie,” he said, “You will please address me as Dr. Fabulous!”
Without missing a beat Suzanne screwed up her eyes and looked at Dr. Fabulous’s name tag.
“In that case, Jimmy,” she said, “You may call me Nurse Assertive or Mrs. Assertive. Only the people I like get to call me Suzie!”
I was reminded of this story when I saw this article: Doctorate in nursing causes confusion, resentment.
Shirato, a nurse practitioner, just got her doctor of nursing practice degree at Thomas Jefferson University.
Most newly graduating physical therapists now have doctorates, too. Pharmacists and psychologists already made that move. Audiologists, physician assistants, and occupational therapists can also get doctorates.
As nonphysicians with doctorates proliferate, the potential for confusion has grown, and physicians aren’t happy about it. A 2008 survey by the American Medical Association found that 38 percent of patients believed that nurses with doctorates were medical doctors.
The American Medial Association has produced model “truth in advertising” legislation that requires health professionals, including physicians, to wear badges that clearly spell out their credentials.
Yeah, well, yawn. Just do normal practice and identify yourself when you meet the patient. In any case, I’ve come around to the opinion that titles of any sort are antiquated expressions of professional authority. Physicians acquired the title “doctor” — and remember it was originally, and still is, an academic title — over the course of the 18th Century to establish their credentials on par with the traditional professions (and gain entrance to the middle-class). They then spent a good part 19th Century trying to deny the same title to surgeons who were, in their opinion, “mere barbers.”
Titles, in short, are about establishing status and power. Why else worry about them? They are utterly irrelevant to actual patient care and one’s ability to do the job. Insisting on their use can create an atmosphere of professional intimidation that suppresses the free exchange of information. Health care professionals expressing power over patients is definitely not a good way to create therapeutic relationships. Implicitly saying (or believing) the title makes you a better person or supplies you with definitive or superior knowledge about patient care is dangerous as well as destructive to collaborative relationships with other health care professionals. In the end, it results in bad care of our patients, and of each other.
Some physicians really resent the loss of power. Don’t believe me? Check out why the defensiveness of this physician.
James Goodyear, a Lansdale, Pa., general surgeon and president of the Pennsylvania Medical Society, said health care workers who are not physicians should immediately tell patients what they do.
“I am a physician. They are not,” he said. “They trained for hundreds of hours. We trained for thousands of hours.”
And, he said, physicians should still be in charge. “We think that those in the allied health fields that get a doctorate such as in nursing are a very, very important component of a physician-directed … team,” he said. [Emphasis mine.]
Not about power and status? Fer sure. When this guy says, “I am physician” you can almost hear the sub-vocal “I am God”.
Oh, and thanks for the condescension too.
Posted by torontoemerg in Before I Start Throwing Things, I'd Better Write This Down, Health Care Policy That Matters to Nursing on Thursday 05 August 2010
Torture is a health care issue. Especially when physicians are complicit, as they evidently were during the Bush administration, in the CIA’s Office of Medical Services, where they facilitated torture of prisoners: [via The Daily Dish: the original JAMA article is behind a paywall.]
An important new study came out today. It’s from the Journal of the American Medical Association about the deep and unethical involvement of CIA doctors and psychiatrists in pioneering torture techniques for the Bush-Cheney administration. . .
The CIA Office of Medical Services
- purported to subject some techniques to “medical limitations,” but those claimed limitations imposed no constraint on use of torture, e.g., allowing weight loss up to serious malnutrition, noise up to level of permanent hearing damage, exposure to cold water right up to development of hypothermia, shackling in upright sitting or horizontal position for 48 hours (and longer with medical monitoring);
- placed no medical limitations at all on the use of isolation, hooding, walling, cramped confinement or stress positions except in some cases avoidance of aggravation of pre-existing injury;
- ignored medical and other literature on effects of these forms of torture, and instead cited sources like NIH web site, wilderness manuals and WHO guidelines.
- recognized dangers of certain enhanced methods but nevertheless approved them, e.g., that waterboarding risks drowning, aspiration pneumonia, and laryngospasm; sleep deprivation can degrade cognitive performance, lead to visual disturbances and reduce immune competence acutely; prolonged standing can induce dependent edeme, increased risk for DVT, cellulitis.
I spent a considerable amount of time yesterday trying to imagine circumstances where health care professionals in a supposedly free society could justify their participation in torture of their patients. Because there is no way around this bald fact: those being tortured were patients of these physicians. They assumed care; they took up responsibility for their treatment and well-being.
I came up empty. I suppose one could make the argument that physician participation mitigates the worst effects of torture, as if having waterboarding (for example) supervised by medical personnel somehow minimizes poor outcomes and creates and justifies acceptable practice. In short, it’s all routinization and normalization: torture as a medically prescribed treatment. But do we really want torture to be medically “administered” to ensure acceptable outcomes?
There are certain ethical touchstones all health care professionals must abide by: beneficence, non-maleficence, autonomy and justice. We must work for the patient’s good. We must not do harm. We must respect the patient’s choices in accepting or rejecting treatment. We must ensure patients are treated equally without regard to externalities. It’s hard to see which of these principles isn’t grossly violated.
“Conduct disgraceful and dishonourable to the profession” is the traditional formulation when health care professionals are found guilty of misconduct. I guess it would apply here.
This study (PDF here) from an outfit called The Physician Executive Journal of Medical Management tells us what we all know too well: poisoned relations between nurses and physicians, specifically and mostly consisting of the latter abusing the former, but also sometimes the other way around, is bad for patients.
What was the most common complaint? Degrading comments and insults that nearly 85 percent of participants reported experiencing at their organizations. Yelling was second, with 73 percent. Other typical problems included cursing, inappropriate joking and refusing to work with one another.
Some of described behavior is criminal, and would appear to meet the criteria for an assault charge, such as throwing scalpels or squirting a used syringe in a co-worker’s face. But according to some survey participants, it’s the day-to-day putdowns and slights that can be the most harmful.
“The worst behavior problem is not the most egregious,” wrote one participant. “It’s the everyday lack of respect and communication that most adversely affects patient care and staff morale.”
Another float in the Parade of the Blindingly Obvious. But now — hurray! — we have a study, instead of the avalanche of nursing anecdotes we all have been repeating to ourselves since Flo was emptying bedpans, but all ignored because, you know, we’re just a bunch of whiny nurses.
A few things caught my eye. The cases of physical assault were striking. Having scapels thrown at you, or getting your head stuffed down a garbage can by a physician is, as the study points out, actual criminal assault. Don’t care if Dr. Obnoxious was having a bad day, or his wife left him, or his last three patients developed post-op nosocomial infections — things which another article in the same issue charmingly and evasively calls “acute stressors.” I would be curious if any of these physicians were ever charged with assault, and if not, why. I think the answers would be revealing.
Alas, the study — nor the related articles in the same issue — doesn’t quite address the underlying causes of abusive behaviour. Well, almost. From the same study, here’s a clue:
So in other words, though physicians account for the most instances of bad behaviour, nurses are the ones that get in in the neck.
Speaks volumes about the power differentials in your average health care setting, doesn’t it? And just maybe, there’s an unexamined relationship between power and abusive behaviour?