Tuesday, May 02, 2006

Perception vs. Reality

From today's New York Times:
Patterns: Making Patients Happy Doesn't Make Them Well

Eric Nagourney writes, "Researchers reported yesterday that when it came to medical treatment, the satisfaction expressed by a group of elderly patients had little correlation with the quality of care they had received based on a review of their medical records."

We all know the type: the guy who works a million hours, puts in overtime, sleeps in his office on weekends, yet still seems to be always drowning. And while yes, he does work a million hours, all anyone really notices is that he's consistantly late in the mornings, or takes a few too many days off for perpetual emergencies. We also know the other guy, the one who is calm, unrushed, in at 9, out by 5, and somehow creates an image that keeps you from asking if all his work is really done, we just assume he's efficient and no one opens his drawers.

A lot of life-- and a lot of doctoring-- is about perception.

Here's a story. Years ago, an acquaintance had an awful accident with a severe vertebral injury resulting in paralysis at the scene. He was transported to a local hospital where a scan showed bone fragments in the spinal canal. The patient was then brought by helicopter to a major academic center where a renowned spinal surgeon (the only one in a multi-state region deemed capable) operated. It was a long recovery period, but the patient was able to return to work within a few months, and was eventually able to resume skiing-- by anyone's measure, his recovery was remarkable. The family, however, walked away with nothing but venom for the surgeon-- apparently he was callous with a cavalier bedside manner. To hear their tales, I had to wonder if, in their minds (though not in the patient's ambulating legs!) all the good he had done wasn't erased, or at least discredited, because of some intangible personality flaw or insensitive word.

The first time I see a new patient, I ask a lot of questions. I start by asking for permission to take notes ("just for the first session, I know it's a little disconcerting to talk to someone who is writing, but it's helpful to me") and I end the 90 minutes of interview with a single final question: "Do you have any questions for me?" I ask. I end this way so the patient won't walk feeling rattled by what might amount to an interrogation. Does it work, does it create a sense that I am approachable, that our efforts need to be teamwork, that perhaps I have some answers? I've no clue (most people come back...) but it leaves me with the perception that I tried!

1 comment:

Anonymous said...

Interesting comments. I mostly do consultations to med-surg patients in general hospitals. I've noticed that my approach to a new patient varies depending on the nature of the consult. Almost universally, though, I do several things that are disarming:

-shake the patient's hand

-introduce myself by name (I tend to save the 'I'm a psychiatrist' piece until there is a little engagement, otherwise some will dismiss me outright..."I'm not crazy"...but if they ask, I tell them...I do say why I'm there, so I don't see it as misleading)

-sit down at eye level. This is MOST important. In the ER, if they are sitting on the floor, I sit on the floor.

If there is dementia or delirium, I will approach with a definite smile on my face. If you are confused, you look for environmental cues to orient yourself. If a stranger is coming at you with hand outstretched and a smile, most folks immediately go into a disarmed mode. (Of course, if they are paranoid, they wonder what I'm up to, smiling like that.)

I note that my verbal pace picks up with manic patients (they get impatient with speech that is "too slow"), and it slows down with depressed patients.

It would be an interesting observational study to assess how one approaches different patient types.