RP101 – Implications: A Tactical Approach (SOM – Sept 2017)



Session Readings

 

Background:

In the first session of Reflective Practice, we identified our reactions to patient encounters, the impact of those reactions on how we interacted with our patients, their family members, and colleagues, and, to an extent, the sources of those reactions (our personal context).  Personal context may be best described as, “the interwoven fabric of one’s unique and diverse life experiences.” As a consequence of the fact that we continue to accrue new experiences throughout our lives, our personal context is dynamic and ever-evolving.  Some of this reflection may be easiest to reflect on as you are moving through this transitional state between being a student/enlisted member/nurse/general member of society and what you hope to become as a military physician.

One of the trickier things to do, after identifying first what your reaction is and then what your context for that reaction is,  is to then figure out what the positive and negative implications are to your patient care.  As an example, why does it matter if you feel strongly about someone’s weight issue? How could your ability to empathize (or not) impact your delivery of patient care.  It may mean the difference between a therapeutic and non-therapeutic patient-provider relationship.  Another example:  consider a 57 year old patient who smokes 2 packs per day, has poorly controlled diabetes, and is not interested in changing her smoking or lifestyle habits.  A provider who labels this patient as someone who will “never change their ways” is demonstrating an erroneous belief in a static personal context.  By contrast, a provider who recognizes that same patient as someone who is not ready to make a lifestyle change at that moment, during that encounter, connected to that engagement, with that provider, but who very well may be interested in said change at another point in time, environment, social circumstance, etc. demonstrates recognition that personal context is dynamic and is much more likely to effectively help that patient.

The IMPLICATION of being frustrated with a patient who seems unwilling to change their ways, in the example above, may be that you will be less likely to address opportunities for harm reduction or other smaller ways to manage lifestyle changes. A positive implication might be that you work on your motivational interviewing skill in order to assess their stages of change and work to build rapport to get past your frustration.

The next challenge is to think about those implications and figure out what your PLAN (your tactical approach!) might be for dealing with them – do you need more exposure to patients with this issue? Do you need a little more edification about a certain topic or perspective – through journal articles, podcasts, conversations or something else? What are the concrete steps you think you could take in getting to the goal of being an open-minded, empathetic physician?

YOUR PAPERS ARE DUE BY FRIDAY SEPT 22. THEY CAN BE BASED ON ANY CLINICAL SCENARIO YOU’VE HAD TO THIS POINT. As a reminder, they are confidential and will only be read by your facilitator or me, as the course director, if there is some need for remediation.

As an opener for this particular topic, on the day of the small groups, we will have a special speaker to talk briefly about a time when, as a physician, he entered a patient experience with one notion and having taken a moment to consider further options, actually identified the real issue. It’s a reminder that we ALL have reactions and biases that will impact our patient care – the important thing is to recognize them and work to mitigate the negative implications and emphasize the positive.


Note: On all papers in Reflective Practice, please:

  1. submit to Sakai in Word format
  2. include your email address in the header, and 
  3. include your last name in the file name 

Assignment:

Identify a patient encounter in which you had a reaction to the patient or the situation. This may be a patient encounter you had prior to starting school at USU, or a patient encounter you had or observed as part of your interviewing class.  If this is a recent encounter, consider whether this reaction is one you think you would have had prior to starting school at USU; if this is an encounter in the past, consider in what ways your reaction to this situation would likely be similar and different now that you are in the process of becoming a physician.  Using this as the stimulus, compose a reflective essay, using the R.S.I.P. (Reactions, Sources, Implications, Plans) format. Use the titles: “Reactions, Sources, Implications, and Plans” as headers for each section of your paper.  Please follow the detailed instructions for each section as follows:

  • Set the stage briefly. Jot down a few lines to set the stage for the encounter you are discussing so that others will understand the situation.  As an example: Ms. M. is a 22 year old patient who was admitted to the ward with complaints of paresthesias and diplopia for the past 3 weeks. She was very anxious and worried about what this might mean. Her MRI, done on admission, showed changes consistent with Multiple Sclerosis and when I met her, she had heard this being discussed, but hadn’t had the chance to talk to anyone about it, so I was the first one to start explaining what this meant.
  • Reactions – Identify at least two reactions you had to a given patient care experience. This may include your reaction to the way the patient looked, how they spoke, their physical characteristics, the chief complaint, their healthcare problems, etc. Identify each reaction in bullet format with 1-2 sentences afterwards that describe the reaction more fully. As an example:
    • Frustrated – I found myself becoming very angry when I learned that our 22 year old patient had Multiple sclerosis. The situation seemed very unfair to me and I was unable to reconcile her reality with the world as I view it. 
    • Overwhelmed – When I realized that she had Multiple Sclerosis and that this is a lifelong illness, I felt completely overwhelmed and didn’t know what to do or say.
  • Sources – Examine the sources of these reactions (your personal context).  If this was a past patient care experience, consider in what ways you think you would react differently to that situation today. If this is a recent patient care experience, consider in what ways you think you would have reacted differently to that situation in the past. The below example describes the sources for one of the above reactions.  In your paper, identify the sources for each reaction.
    • Growing in Iowa with my mom, dad and the 5 of us boys meant a lot of rough housing and wrestling matches. Being the youngest of the bunch, you might assume that I was the rag doll who would get pummeled on a regular basis. As it turns out, that did happen from time to time but not as often as you might think. I was saved by our parents’ belief in a “level playing field” which they frequently referred to as “fair play”. In terms of the basement wrestling matches, this meant that when one brother was more than 2 years older than another and we wrestled the older one could only use one arm. I don’t recall my parents putting this rule into place – we just made it up on our own, something I attribute to the five of us understanding and accepting fairness as an important value. The importance of the value of “fairness” impacted my experiences in our community as well. An example is when I was in a playoff game for 7 vs. 7 pop-warner football. While warming up, we realized the other team only had 6 players, a clear advantage for us, not only because they would have to play one person short but because they would be exhausted by the end of the game without subs. We were all grins and smiles, until our coach called the 13 of us over to the bench and had us put out one or two fingers on the count of three. We were bewildered, but he was the coach and this was farm country in Iowa – we did what he asked. Seven of us put out 1 finger and six of us put out 2. I remember sitting there with my one finger out, as he explained that the 6 boys with 2 fingers held out would play and the rest of us would sit on the bench and not play at all. As he explained it, it was the only way to make the game truly fair. I remember having mixed emotions that day – frustrated that I couldn’t play (which ironically didn’t seem fair to me even if it was fair to the other team) and also proud that I had a coach whose actions demonstrated the principles he preached. I think it was also easier to understand coming from the family in which I was raised.I think this is why I was so upset when we saw Ms. M. My belief in a sense of fair play was demolished. Here she was, a healthy, physically fit 22 year old, who had taken care of herself, and we were handing her a diagnosis of Multiple Sclerosis. Where’s the fairness in that?I don’t think that my reaction now differs all that much from how I would have reacted in the past. Fairness has, and continues to be, important to me.  At the same time, even with only a few weeks of school under my belt, I see how my personal context and perspective is changing.  While I want the world to be a fair place, my experiences on the wards have shown me that when it comes to health, the idea that one’s health is in any way associated with “fairness” is rather absurd.  Prior to starting at USU, I lacked many personal experiences with patients. From this distanced vantage point, I used to believe that people became ill for a reason – usually related to their not caring for themselves and being lazy about their diet, exercise, etc.  Meeting my 22 year-old patient, who lived a healthy lifestyle made me question this, as have a number of other experiences.
  • Implications – Analyze the positive and negative implications of your reactions for patients care.
    • As noted above, I am coming to realize that life, and especially one’s health or lack thereof  is not always an issue of “fairness” but that doesn’t make it any less frustrating for me.  I worry that when I talk with patients who are experiencing illnesses or injuries that don’t seem fair, my frustration may distract me from being “present” at the visit – a concept I have heard referred to before as “mindfulness” – and as a result of my distraction, I might not listen fully to their concerns, which would inhibit my ability to care for them as best as I could.  In addition, I worry that my frustration with the lack of “fairness” will be evident in my non-verbal communication and could be interpreted by them as frustration with them and not frustration with the situation. At the same time, my frustration may have beneficial implications if I can channel that energy into working more diligently to read about my patients’ medical problems, new treatments, and to do everything I can to help them.
  • Plan – As you summarize the situation, describe a realistic plan that you can implement today to help you mitigate the negative and enhance the positive implications of your reactions. The idea is not just to say “I want to make a cake” or ” I will be a more empathetic physician” — those are both goals. A plan would be “I will gather the appropriate ingredients (flour, sugar, baking soda, etc), turn the oven on to 400F, etc.”
    • Continuing to see more and more patients is likely to help me to become more comfortable with the lack of “fairness” that exists in healthcare and decrease the frustration I feel.  At the same time, I suppose that if I were to work in a field in which I felt that someone’s choices were usually the cause of their illnesses, such as a sleep apnea clinic where most patients were overweight or obese, this might exacerbate my frustration.  Early in my career, in a given encounter where I am getting frustrated with the situation, I think it will be important for me to name my frustration so that my patients will know that I am frustrated with the situation and not with them.  I also think that I can say this in an empathic way and that such a statement is likely to help build rapport. I will need to be careful to not assume, and in what I say imply, that they are also frustrated. One phrase I plan to try remembering to say is,  “That situations sounds very frustrating – how are you doing with it?”   On the flip side, I plan to use my frustration as a motivator for me to research treatments for my patients when I otherwise might feel too tired to do so.   I’ve never thought much about mindfulness until getting to USU, but I heard that there is a group called “Mindful Warriors” that holds sessions on campus – I think I will check that out and see what I learn from it.  

Objectives: By the end of the session “Implications: a tactical approach”, students, through written and verbal expression will demonstrate:

  1. The ability to identify reactions they have had in the context of patient care experiences.
  2. The ability to examine the sources of those reactions and how one’s reactions and perspective can change over time as a result of the fluidity of one’s personal context.
  3. The ability to analyze the implications (both positive and negative) of one’s reactions for patient care
  4. The ability to create a realistic, concrete plan to mitigate the negative and enhance the positive implications of one’s identified reactions.
Kevin MDWhen a patient evokes an emotional reaction from a physician by Brian Goldman, MD Some patients are “difficult” not because of their pathology, but because they evoke reactions in their providers.
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New York TimesAt the Bedside: Stay Stoic, or Display Emotion, by Barron H. Lerner, MD For years, students were taught to avoid demonstrating emotion to patients, without consideration of the individual provider-patient relationship. While many still argue for emotional distance in the name of objectivity, newer research questions this approach.
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MedscapeWeight Stigma: Doctors Guilty of Prejudice Against Obese, Too by Lisa Nainggolan Healthcare workers, even those who work at hospitals dedicated to research and treatment of obesity, are biased against those who are obese. The healthcare implications are obvious…and worrisome.
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Liminal ThinkingLiminal Thinking - The Pyramid of Belief by Dave Gray In this sketch video, Dave Gray postulates that each of us has own reality based upon our individual pyramid of belief. Recognizing that these pyramids are built upon our life experiences and put us at risk of becoming blind to our assumptions and biases is a particularly resonant message for healthcare professionals whose assumptions and biases can have grave implications.
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YouTubeEmpathy: The Human Connection to Patient Care If you could put your feet into your patient's shoes--see what they see, hear what they hear, and feel what they feel--would you treat them differently?
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Session originally created by: Adam Saperstein | SOM/GSN, Uniformed Services University | Director, Reflective Practice | Family Medicine