Professionalism & Communication Taking Care of Patients Taking care of Each Other Taking Care of Yourselves

A series of vignettes…with audience participation Dominick Tammaro, MD Internal Medicine June 2010

Before we start….

    Newport Folk Festival Newport Jazz Festival Rhythm & Roots Festival Waterfire July 30-Aug 1 August 6-8 Sept 3-5 Saturday, June 26 Saturday, July 17 Saturday, Aug. 14 Saturday, Aug. 28  www.projo.com

for calendar

The six general competencies are:

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Patient Care

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Medical Knowledge

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Professionalism

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Systems-based Practice

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Practice-based Learning and Improvement

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Interpersonal and Communication Skills

Competency 5: Professionalism

Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population.

Residents are expected to:



demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development



demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices



demonstrate sensitivity and responsiveness to patients’ culture, age, gender, and disabilities

Professionalism - Vignette 1 Student on Rounds

 You are on rounds with your attending, and one of the medical students is presenting. The student has been working very hard and doing a good job. The attending asks the student about the results of a laboratory test that the student was to have checked on. You know that the student did not have an opportunity to get the results, but the student responds by saying that the test was normal.

 Points to consider during discussion:    What would you do as the senior resident; as the medical student? What are the consequences of ignoring the student's comments? What are the advantages/disadvantages of saying something immediately during rounds?

Professionalism - Vignette 2 “Drug Seeking”

 A patient with a history of injection drug use is admitted to the hospital with a leg abscess at the site of an injection.

 The intern does not order adequate analgesia because the patient has been in several times before and is felt by others to be “drug seeking”

Professionalism - Vignette 3 Covering for a Colleague

      Intern called in to cover for co-intern who is out sick Very busy night in MICU Several calls to intern to evaluate patient who is dyspneic Intern goes to see patient, after 2 nd delay in response.

call from RN and Intern very abrupt with patient, no introduction, no discussion of intern’s impressions or treatment plans.

Patient calls nurse and asks to call his doctor “clearly doesn’t want to take care of me...” – patient afraid of being cared for by angry MD who

Professionalism - Vignette 4 Chest Pain in the ED

  48 yo male with chest pain and cardiac risk factors Seen in ER and felt to require admission to either CCU or Cardiac Intermediate Care Area      CCU team comes to ER to evaluate patient Patient admitted to CCU. MI ruled out but patient felt to have unstable coronary syndrome based on history and ECG.

Cath - critical single vessel disease PTCA/Stent - good outcome Patient Discharged

Professionalism - Vignette 4 (cont’d)

 IM Program Director gets call from patient’s mother-in-law, who was present, along with the patient’s wife (her daughter).

 Mother-in-law works at RIH in a capacity that involves working with residents on a daily basis.

 Feedback given.

 

Professionalism - Vignette 4

(cont’d)

ER:  Family overhears conversation between ER and CCU/ICCU: “I don’t care where you put him, but someone has to take this guy!” CCU Team:      No introduction or explanation of role by either resident or intern Once asked, resident replied “We’re from the CCU”. No mention of level (intern, resident, fellow, attending., PA) or specialty (IM, Cardiology). No ID badges.

“We’ll try to get in touch with the fellow to see if he wants to take you.” Resident left to return to CCU and intern introduced self and continued exam.

No mention of what their assessment was or what they felt the possible next step scenarios could be.

Professionalism - Vignette 4

(cont’d)

 Family Conclusions      We don’t know what’s going on We think it’s bad because they want to admit us to the CCU We don’t know what the next steps are We don’t know what the doctors who assessed the patient think We don’t know who our doctors are  Whomever they are - they’re not that excited about taking me onto their service.

  

Professionalism - Vignette 5 Worried about Cholangitis

 60 yo patient admitted with      LUQ pain, 4/10 Total Bilirubin 2.7, mostly conjugated Dilated common bile duct on RUQ US Afebrile Stable Vital signs Team concerned for cholangitis; Rx Abx GI Consult concurs – plan ERCP in AM Intern worried about signing patient out that night; aware that patients with cholangitis can undergo rapid clinical deterioration

 

Professionalism - Vignette 5 Worried about Cholangitis

   Intern goes back to re-evaluate patient Patient feels “warm” – intern writes “101.5” on RN vital sign sheet Calls GI that evening – I am worried about this patient – she is now febrile. I think we should decompress biliary tree tonight.

 GI concurs – comes in at 9PM, ERCP shows biliary tree stones and pus LUQ pain resolves, as do LFT abnormailities Patient discharged

Vignette 6 Back Pain

   38 yo healthy male with back pain.

Went to TMH, xrays negative, felt to be non-traumatic, discharged with pain meds and follow-up with his PMD.

That morning, awoke at 3AM “crying with pain” – wife called ambulance who brought him to RIH.

Vignette 6

 Day 1   Waiting in ED for 10 hours Family “begged” for imaging  MRI: Bulging disc  Rx with narcotics with incomplete relief  Doctors: • Psych intern on Internal Medicine rotation • IM resident and attending

Vignette 6

 Day 2  Plan: Pain Rx, physical therapy  Physical Therapy came once, demonstrated exercises  Family raised concern about walking up stairs to home  Pain better but still not entirely controlled  Attending confirms assessment and plan

Vignette 6

 Day 3  Plan: Intern plans on discharge today; attending confirms – plans to have PT see patient once more that day.

  Discharge discussed on rounds with patient No activity until 4PM (patient already dressed) • PT comes back, walks patient on stairs, gets cane • Patient wants to see the attending • Intern returns from seeing many sick patients which kept her from returning earlier – “he’ll just tell you the same thing – we’ve already discussed the plan for you...” • Patient states he is uncomfortable going home that night.

Vignette 6

 Day 3    6PM – Prescriptions given, discharge order written.

Nurse sees Rx for oxycontin & appreciates that not all pharmacies carry this in stock Nurse calls pharmacy – no where to pick up tonight so patient has to wait until next day to get meds    Nurse calls intern, changes prescription, patient leaves (has not eaten since was anticipating departure around lunchtime and wanted to eat at home) No parking vouchers – pays to park Patient satisfaction survey completed

Vignette 7 MICU Patient Drug OD

   Complaint submitted by mother of MICU patient Patient admitted to ICU following drug overdose Family has been struggling with their daughter’s depression and is appropriately worried about her health and future.

 Social worker (whom the family describes as “wonderful”) assures the family that they are working on an after-hospital plan

Vignette 7

   Patient discharged to home one evening with cab voucher  MICU staff felt patient safe to go back to her home alone Family worried Family involved throughout the patient’s MICU stay...not notified on discharge.

“Now is not the time for verbal Swordplay…Now is the Time for simplicity …kindness…tenderness”

Vivian Bearing, PhD from

Wit

, a play by Margaret Edson

The End

Physician’s Health

Vignette 1

 Program Director called by Pharmacy with concern that a resident is writing prescriptions for large quantities of a narcotic with frequency......

for another resident

  

Vignette 1

Concerned Program Director thanks pharmacy for their heads up and asks them to fax the prescription to his office.

Program Director reviews the faxed Rx and confirms that both names are residents in his program.

Meetings are called...

  with the “prescriber”, out of concern for unprofessional conduct – prescribing for a non-patient.

with the “patient”, out of concern for addiction



Vignette 1

Meeting with “Prescriber”  That’s not my signature!

 I wrote a prescription once for the “prescribee” for a brief course of percoset for a sprained ankle after a fall while biking, but I swear, only once.



Vignette 1

Meeting with “Prescribee”  Forging the other resident’s signature  Narcotic addiction for >1 year  Begun while in residency  Past excessive alcohol use  Referral to Physician’s Health Committee



Vignette 1

Referral to Physician’s Health Committee  Immediate withdrawal from patient care activities • Not as punishment...consider the legal implications of a medical error while under the influence of narcotics...

 Extensive history  Medical Evaluation  Inpatient detox & rehab for 2 months.



Vignette 1

Referral to Physician’s Health Committee     No report to Board of Licensure as long as resident complies with treatment and monitoring (urine screen, meetings, counselling) Both residents graduated and are successful in practice.

Resident with addiction reports his ordeal on application to Board of Licensure. Board requests letter from PHC, which states that he has successfully completed rehab and is 100% compliant with treatment and monitoring program (5-10 years) Resident with addiction remains sober for >10 years.

Successful Career 

Vignette 2

    Program Director receives phone call from chief resident. A resident had an episode of slurred speech/syncope at home and was being brought to the ED by friends. Symptoms resolve spontaneously.

ED work-up negative for etiology. Patient begun on dilantin and referred to neurology outpatient evaluation.

Program Director gets reassuring call from ED Physician.

No EtOH involved per friend history. Tox screen not done.

Vignette 2

 Program Director approached by a resident who indicates feeling “guilty” at having prescribed med with addiction potential for this resident.

 Feedback given to prescriber re unprofessional conduct (No Rx unless you keep a medical record on the patient)  Meeting with resident is set up

Vignette 2

Next day, another resident admits to writing a prescription for this individual

Vignette 2

Next day, same story...yet another resident admits to writing a prescription for this individual

Vignette 2

   Resident admits to excessive use of medication and history strongly suggestive of impairment.

Referral to Physician’s Health Committee History reveals longstanding addiction with pattern of prescribing by friends and faculty.

   Inpatient rehab for 2 months – gradual resumption of clinical responsibilities Relapse – repeat inpatient rehab for 2 months.

Non compliance with monitoring - termination

      

Vignette 2

AOA graduate from a respected school USMLE 1 - 256 USMLE 2 - 260 Four publications in peer-reviewed journals (1 in which he was lead author) Volunteer activities Described in Dean’s letter as “one of the best in his class” Strong performance in intern year (concerns in retrospect?)

Vignette 3

   Intern with excellent medical school record begins internship. She is felt to be a solid intern, hard-working but slow and somewhat lacking in organization.

After a period of improvement, her performance begins to falter. She stays in the hospital late and seems unable to complete tasks in a reasonable amount of time. Notes lacking in pertinent content. Sign out reflects inadequate understanding of patient conditions.

Nurses complain that she does not reply to pages in a timely manner, sometimes not at all. They begin to call her resident instead.

Vignette 3

 Chief residents become concerned that she has called in sick more than is usually expected.

 Meeting with PD reveals tearful, embarrassed intern who is questioning her ability to succeed in medicine. PD and intern agree that she should seek counseling.

 Referral to psychologist

Vignette 3

      Diagnosis – major depression Referral to psychiatry for SSRI Rx Medical leave for 6 weeks Returns with re-acclimation schedule Improved performance to excellent level Praise from peers and nurses

Vignette 3

 Substitute Diagnoses:  Hypothyroidism  Divorce  Chronic neurologic disease  Any medical, psychiatric, or other condition may result in transient impairment

Issues

   Common It can’t happen to me   It only happens to the weak or to those who do poorly in med school  Episodic shift schedule may diminish sensitivity of those in a position to pick up clues.

High performance at baseline Industrial strength denial and dishonesty like you have never seen in your lives

Physicians Health Committee

   Rhode Island Medical Society Physician (including resident) members Confidentiality guaranteed   Each client seen by one MD and director Referred to as case number in committee   Physician advocacy – on our side Board of licensure is satisfied by PHC attestation that someone is fit for practice  Big stick

Physicians Health Committee

Director of the Physicians Health Program is

Rosemary H. Maher, ACSW, LICSW

401 528-3287 [email protected]  Committee Membership includes faculty and residents   Contact with PD limited Can be best testimony of sobriety for future licensure