DocCom Module 2

Your new admission is a 90 year old man in renal failure who has not much longer to live, and there is little you can offer medically at this point. You communicated this to the family who has assembled around his bed. As you leave the room you are disturbed by the feeling that you did so little for him. What can you contemplate to maximize your future impact in this and similar situations, for your patients as well as for yourself? A. What would I want and need from my physician, if I were dying? B. He seems to have a loving family - I wonder if he understands how lucky he is? C. Perhaps I should spend more time with the many patients for whom I can actually make a difference? D. Should I ask to be transferred to a unit where I can have more impact on my patients' health? E. After all, the reality is that I can't do any more for him-shouldn't I just move on?

A is correct because a better understanding of both the patient and yourself may emerge from this reflection, allowing you to move past your disruptive feelings. After you take time to explore this, accepting the reality and moving on (E) is a reasonable next step.

One of your colleagues made a serious mistake and administered the wrong antibiotic to a patient. Now it is 3am and you are trying to stabilize the patient, with mixed results so far. In the light of day you will have to talk with the family and reveal the error to them. Which of the following questions are most important to contemplate to make that encounter more successful, for yourself and for the patient's family? A. What are my beliefs about such mistakes? B. How can I provide support to the family? C. What would the risk management department advise? D. How soon after telling the family am I able to go off duty? E. How can I protect my colleague?

A. is correct because it helps to first be aware of all thoughts and feelings generated by the incident. With such self-awareness it will be easier to provide an optimal response to the patient and his family. Rehearsing what to say and how to say it should be the next step to make this difficult situation more manageable (see Module 35).

Your first patient is new and you are trying to establish a rapport with her. As you are ready to examine her ears, you notice that the otoscope specula are once again missing. Clearly the exam rooms were not adequately restocked. This makes you angry because you have complained about this problem to the clinic administrator without results. The nursing aide responsible for restocking either is incompetent or lazy. This clinic should be able to hire better support staff. What could you contemplate during the clinical encounter to reduce your frustration and stay focused on the patient? A. How can I talk to the administrator more forcefully? This has to end. B. What successful strategies have I employed in the past to reduce stress? C. I'll save this routine ear exam for the next visit so that the patient won't be alarmed about disorganization. D. I can't be expected to restock the rooms myself. If it happens again I'll refuse to see patients until the problem is corrected. E. Maybe I can stock up the cabinets before I leave tonight.

B. is correct because being aware of one's coping strategies can lead to a more effective approach when dealing with stressful situations. Although some of the other issues may be worthwhile contemplating too (e.g., how to fix this systems problem), they are more likely to interfere with your care of this patient.

It's late on a Friday afternoon and you are tired. Your 15th and last patient, a 62 year old recent widower, is particularly challenging because he has come in frequently during the last three months, each time complaining of a new ache or pain. You have been unable to find a physical cause for his complaints, and come to the conclusion that his symptoms are part of his grieving process. Your offers to refer him to a support group were rejected, and he seems to have no insight at all. Which of the following questions represents mindfulness, and is most important to contemplate in order to make this encounter more successful, for you and for the patient? A. How do I feel about patients with psychosomatic illness? B. To whom can I refer this patient? C. How do I feel about the fact that he has rejected my efforts to help him with his real problem, the recent loss of his wife? D. Can I help him see that his problem is not simply physical and that he needs psychological care? E. How can I prevent him from coming back next week with another complaint?

C. is correct because it explores the clinician's own emotions at a specific point in time. Mindfulness is always a useful strategy when you seem stuck with a patient. A (an example of self-awareness) might also be useful since it addresses general beliefs regarding patients who suffer from psychosomatic conditions. Options B and E may provide temporary relief, but will not help you work with similar patients who will inevitably appear in the future (and B and E could even diminish both your effectiveness and your well-being in the future!)

You just saw a patient whom you have known for many years- one of the first in your practice. You found her breast cancer during a routine check, and supported her throughout her treatment. For 8 years she was in remission but now the cancer has recurred and you had to give her the sad news. First she was shocked and then she cried. You reassured her that you would continue to support her, and made arrangements to start treatment. Even though you have to give such bad news two to three times a week, you felt quite sad and discouraged after she left. Which of the following considerations is most important to contemplate in order to optimize future encounters for yourself as well as for the patient? A. She got over this once before, chances are the treatment will work again. B. Maybe I should look into some possible drug trials. C. I give bad news quite frequently, so what is it about this patient that makes me feel so discouraged? D. How can I be more upbeat with her? E. This patient clearly needs a lot of support right now. Where can I find a support group that would be suitable for her?

C. is correct because when you reacts to a common situation in an atypical way it helps to reflect on your own thoughts and feelings. Exploring unexpected feelings first will optimize further problem solving. Other options may be good second steps; E addresses the patient's need for extra support, and it would be reasonable to refer her to a support group.

You have good rapport with a 70 year old woman with diabetes whom you've known for a long time. Sometimes her daughter brings her to the office, worried that she seems to be forgetful. She also mentioned some safety issues- namely burning food and serving spoiled food. You wonder how meaningful the daughter's concerns could be, since your patient always seems well put together and so much in charge of her own life. Her diabetes is a bit less under control at the moment, but she has been abroad visiting relatives and thus you thought that her diabetes self-care may have suffered in the process. What can you contemplate to make sure that you are not overlooking the onset of dementia? A. Should I refer her for testing? B. Are the patient's children overreacting to normal aging processes? C. Does the patient remind me of my own parents and their struggle to lead an independent life? D. What does it men that my real Alzheimer's patients don't look as well put together as she does? E. OK her performance on the Mini-Mental Status exam was borderline, but then she just returned from overseas and probably still has jetlag.

C. is correct. It is helpful to be aware of the impact our significant others have on patient care. If you do not acknowledge this impact, you may be unable to have a reality-based approach to some patients. Referring her for more objective testing (A.) may be the next step.

For some years you've seen each in a couple for preventive care and minor health care problems. Today you had to tell the wife that she has gonorrhea, who assures she only has sex with her husband. After the initial shock she besieged you with questions about her partner's status and the possibility of him having affairs. You are aware that the husband has had affairs, and know that you must respect his privacy, but on the other hand you feel sympathy for the wife. What could you contemplate that might help you balance your feelings towards the wife with upholding the ethical principles? A. Doesn't she in her heart know that it must have been him who gave her the STD, so I don't really need to tell her? B. I'm glad I'm not in her shoes, I would be furious if this happened to me. C. How can I help her accept that I can't tell her anything about her husband? D. Do I experience a similar type of helplessness and frustration as she does? E. Won't she feel a lot better when I tell her it is a simple infection and that treatment will cure her?

D. is correct because it explores your own feelings in connection with the patient's. Being aware of one's own emotions can often provide clues to the patient's experience, and can help the clinician get "unstuck" faster. Other options are less likely to help resolve the current dilemma.

Right now you are way behind in your schedule. Three patients are waiting to talk to you, you are late for rounds, and you promised the social worker to call a nursing home on behalf of a patient. Your boss interrupts to tell you that for the second time you are passed over during the search for an Associate Unit Director. This seems very unfair and you suspect that your race and gender had something to do with it. It annoys you even more because you have been putting a lot of effort into your job, and have sacrificed valuable time that you could have spent with your family. What should you contemplate to reduce your frustration and get ready for seeing the patients and catching up with the other tasks? A. Maybe I should launch an official discrimination complaint. B. It happened the second time, maybe I'm just not right for this administrative position. C. They just don't appreciate my work ethic. From now on I'm going to do less. D. I'm so mad. I should call my spouse, even if the patients have to wait a bit longer. E. I've been putting work first for a very long time, and without results. I need a vacation.

D. is correct because it is an attempt to deal with personal issues in order to be able to fully listen to patients' concerns. Being mindful may mean taking time for yourself which could inconvenience patients in the short run. However, in the long run, you will be able to provide better care.

Your department chair asked you to take over the establishment of a new pain center, and this means that you will need to cut down on your patient load. You'll need to transfer to colleagues some patients with whom you have long-standing relationships. What can you contemplate to prepare yourself for informing your patients about the upcoming transfers and changes. A. Will these patients who count on me feel that I'm deserting them? B. Without doubt, the administrative responsibility will diminish over time, so could I tell patients that this is a temporary situation? C. Could I develop strategies that would allow me to take on the pain center and also care for the patients? D. I know I'll get over this hump, haven't I managed more stressful situations in the past? E. What are my feelings about saying good-bye to these patients?

E is correct because exploring the feelings engendered by saying good-bye to longstanding intimate relationships will likely make you more effective at acknowledging the patients' feelings. (See Module 36) Showing respect for their feelings engenders trust and helps them begin their new relationships effectively. B, C and D could enhance your coping but invite you to suppress feelings that connect you with yourself and with other people- patients, friends, family and colleagues.

You are following up with Mrs. Gonzales, who has persistent headaches. You've talked with her at length and done all the exams that seem appropriate but you can't arrive at a specific diagnosis. She is about to walk in. What could you contemplate (in the spirit of mindfulness) to improve the situation for yourself and for Mrs. Gonzales? A. Headaches are frequently puzzling; I wonder which specialist would be best for her?. B. I wish I had heard the recent grand rounds on headaches, it might have given me some new ideas. C. Without a clear diagnosis, is it more likely that there is a psychosomatic cause? D. The patient will be frustrated that I don't know what it is. Should I just tell her that we might gain more clarity over time? E. Am I assuming something about this patient that might not be true?

E. is correct because examining your assumptions is always a useful strategy when you feel stuck. It is quite possible that the patient suffers from a psychosomatic ailment (C.), but it is important to not come to a premature closure.