6.1: Consistently demonstrate compassion, respect, honesty, integrity, accountability, altruism, prudence, social justice, and commitment to excellence in all professional and personal responsibilities.
During medical school, I have thought often about how to make the best of a situation with little hope for improvement. These hard times can make you frustrated at the situation, the system, and even the patient for reasons beyond your control. Early in medical school, I wrote about a patient at the VA who was refusing to take the needed actions to safely monitor the apixaban he was taking following a PE, most likely due to his anxiety or his social situation.
Reflecting on this case now, it is easy to see themes that would reappear often these last four years, and it posed that central question of “what to do in these situations?” that I would see answered in many nuanced ways by many different mentors and colleagues. This patient was not beyond help scientifically, but his mental health and social situation seemed to make him feel that he was. Was there something that I could say or do that would change the outcome? At the time, I think I leaned toward believing that there was. Now with more experience, I know that some of these situations are probably insoluble, but you never know which ones are until you do everything that you can.
During my third year hospital pediatrics rotation at Nationwide Childrens, I saw what I have seen since then as the gold standard of doing everything in a hard psychosocial situation. There was an 18 year old boy from Cleveland who was reportedly having seizure like events. His family were disagreeable and would frequently threaten litigation, despite repeatedly breaking ground rules they had previously agreed to, like not taking the patient outside to smoke. They were the only people that had ever seen these seizures, despite repeated hospitalizations at NCH and Rainbow Babies in Cleveland, which perhaps suggested malingering. The patient was on the spectrum and had some sensory and behavioral issues, and would act aggressively if something was not to his liking. These factors made it impossible to continuously observe him in a room with a camera or to get a cEEG. All of the floor staff were frustrated, and I wrote about some of the poor coping mechanisms people deployed in a previous portfolio entry.
The attendings response to these challenges is something I will always remember. She had an afternoon long conference with the family to get an extremely deep history, and to attempt to establish a more durable path forward instead of bouncing between institutions. She spent all night doing a deep dive into the patients chart and writing the most comprehensive note I have seen. She did get them to agree to go back to a specialist they had significant history with at Rainbow Babies, after hearing from them that they felt like their concerns weren’t addressed up there and telling them that they were going to get similar answers elsewhere and that they needed to do their part as well. I think that the amount of time and energy she spent on them was not lost on them, and they started to trust her enough to give the neurologist another try. At the time, I was focused on how team members reacted to this frustrating situation behind closed doors, but the longer I get from this encounter, the more I appreciate what the attending actually did, and that it seemed to actually get through to them. Even if it was a frustrating encounter for everybody, they deserved the best care possible, and I think that is what they received at Nationwide that week, even if staff weren’t as kind behind closed doors as they should have been.
When bad outcomes happen, they usually don’t happen because of bad intentions, but because of systematic incentives. While this kid and his family had a good outcome this time, thanks to an extraordinary provider, their care took up most of the care teams time during that week, and there were about ten other patients assigned to that service. If those patients had been sicker or more complex, there would not have been the time in the day for the kid to receive the intensely focused care that he did. If that were the situation, would the attending be at fault if the family had decided to leave again after an insufficient attempt at trust building cut short for time? I do not think so, because I don’t think it is a breach of professionalism to be at the mercy of staffing ratios and things outside of your control in medicine. More families like that would likely receive better care if there were smaller patient to provider staffing ratios, as there would be more hours in the day for time consuming trust building and history taking opportunities. But harsh circumstance does not excuse you from the responsibility of doing everything that can be done for the patient, and I think that “everything” means working in the moment, and later, to change the systemic incentives that lead to these outcomes. So, I want to make both of these ideas core to my practice in the future: I’ll do everything for my patients individually, and seek to change what I can systemically. I would be in breach of professionalism if I did not do these things.
- Take a leadership role on a QI project during my intern year.
- Schedule time once a month for a personal reflection time regarding times during the previous month when I felt like I was not doing my best.