At Bay Area Medical Center in Marinette, Wis., the time had come to start talking about an elderly woman’s end-of-life care.
Her hospitalist thought that those discussions should take place with the patient present, but the woman’s family felt otherwise and made this known to the hospitalist, who stood his ground.
Eventually, the family told a nurse that they wanted to fire the physician. But the only other hospitalist on shift didn’t want to take the patient.
As case managers and hospital administrators tried to wrap their heads around the situation, it became clear: They didn’t really know what to do.
Could the patient fire a physician? Was the second physician obligated to take what he knew from the outset would be a difficult case? What if nobody wanted to take care of this patient?
“There was no black-and-white to this,” says Robin Dequaine, director of medical staff services at the hospital, who was involved in the case.
Some “difficult patient” scenarios are fairly straightforward. A patient is violent? Enact your security measures. An addict wants narcotics? Don’t give them.
But there are other situations that enter murkier territory: What if a patient makes inappropriate or abusive remarks? How much should a hospitalist put up with? What if a patient’s request for treatment might not be the hospitalist’s first choice but could be seen as reasonable? Is the patient’s request accommodated? And what about those firings?
Hospitalists, administrators, and patient advocates say these tense situations with patients involving firings, or would-be firings, while not a daily occurrence, are actually fairly common.1 Getting to the root of the problem is essential. And as with so much in healthcare, good communication is the absolute crux of it all, they say.
“These are almost all communication issues,” says John Bulger, DO, MBA, FACP, SFHM, chief medical officer at Geisinger Health Plan in Danville, Pa., who has had a long career as a hospitalist and administrator handling and trying to resolve these situations. “They’re all [about] the way the hospitalist and the team is relating to the patient.”
Jackie O’Doherty, a private patient advocate who practices in New Jersey and New York across a gamut of hospital types, has a similar view.
“For me, the biggest problem, period, against hospitalists, doctors, everybody in the hospital, is communication—the lack of it,” she says. “Their communication skills are really poor.”
Patients accustomed to choice in the outpatient setting might not handle it well when they don’t have an established relationship with their hospitalist, says John Vazquez, MD, associate director for the Emory University School of Medicine’s Division of Hospital Medicine in Atlanta.
But the system, he says, “does not allow for, unfortunately, that much patient choice.”
End-of-life Discussion at a Small Hospital
Dequaine says the staff at Bay Area Medical Center was caught flat-footed with the case of the family not wanting end-of-life care discussed with their elderly mother.
“The doctor felt very confident that he was in a position that he could have that discussion in front of the patient,” she says.
At the 99-bed center, there were just two hospitalists, who were also employees of the hospital, on shift. And the communication channels involving the medical director of hospital medicine, a case manager, and the chief nursing executive were not well-controlled, Dequaine says.
“It didn’t go up the ladder correctly,” she says. “Too many people got involved, not knowing that somebody else was already involved.”
The second hospitalist at first said he would take the case, but later Dequaine learned that he changed his mind.
“He knew his care would be no different, and we were very, very busy, so they both had a high census already,” Dequaine says.
A third physician reluctantly took over until the issue subsided. And the family still brings the patient to the hospital for care.
Ultimately, the center adopted a new policy that doesn’t guarantee a patient a new doctor, only that the hospital will have frank discussions to try to resolve the issue and then try to arrange for a transfer if the situation can’t be resolved.
“The goal is not to get rid of the patient or to force them to keep the provider,” Dequaine says. “The goal is to resolve it in a mutually satisfactory way.”
A Patient Demands a Contraindicated Medication
A middle-aged woman with Crohn’s disease was hospitalized at Emory with an infection. The woman, worried about her disease flaring, wanted to keep getting her immunosuppressant, but the hospitalist suspended it because she needed to fight off the infection. The patient became upset. At a point when the hospitalist wasn’t in the room, the woman insisted to a nurse that she get her medication. The nurse called a doctor who was on call, but that doctor wouldn’t give the immunosuppressant either.
The patient began to think she wasn’t being listened to. Dr. Vazquez went in to see the patient and apologized for the misunderstanding.
“I went back into the room and explained here’s why I’m doing it: ‘I totally understand where you’re coming from; you don’t want your disease to be out of control. I appreciate that. What I’m worried about is killing you if we give you an immunosuppressant at the wrong time,’” Dr. Vazquez says.
Dr. Vazquez has underscored at his center how important it is for the physicians to be consulted and go back into the room when patients want to fire them, even though the expedient step might be to just bring in a new doctor. At previous centers, he says, it wouldn’t be unusual for the director to get a call from a nurse, who would say, “Yeah, they want to fire this physician, so let me know who’s going to see the patient.”
But simply switching doctors, he cautions, is like saying, “I agree with you we have incompetent doctors here, so we’re going to remove that doctor and I’m going to put a doctor on who actually knows what they’re doing.”
When doctors try to resolve the issues, good things tend to happen, Dr. Vazquez says.
“There’s generally a large amount of appreciation that someone comes back into the room and says, ‘We want to do this right.’”
Of course, there are times when, if tension remains after such discussions, patient care might be better served by a swap. At large centers, that might be possible, Dr. Bulger of Geisinger says.
“If the patient doesn’t tell the doctor something because he or she doesn’t like the doctor, then the doctor’s decisions are made on partial information—that’s the issue,” he says.
O’Doherty, the patient advocate, says that if patients frustrated with poor communication actually fired physicians as often as they would like, there would be more firings.
“Patients don’t like firing the doctors because they don’t want to be the patient who everybody doesn’t like,” she says. “They’re afraid that if they argue or disagree or ask too many questions, that they’re not going to get the care they need. And the family is afraid of that as well, especially in the older population. They think doctors are like God, they hold your life in their hands. So they don’t want to really question doctors.”
She says patients don’t necessarily need a particular finesse or expert bedside manner. In many cases, she says, it’s “just giving the information.”
A Patient Demands Pain Medication
Martin Austin, MD, SFHM, recently cared for a patient with chronic headaches. The patient asked for higher doses of pain medication, insinuating that she might turn to heroin if denied.
“I was trying to make the argument that I kind of disagreed with that but, ‘I respect your opinion,’” says Dr. Austin, medical director at the Gwinnett Medical Center Inpatient Medical Group in Georgia. “We came to a negotiation about how long we would use narcotics acutely until her other acute issues were over, but then we would try to get her away from narcotics.”
A good approach, he says, is to “outline to the patient why you’re doing what you’re doing. We try not to pick battles and give the patient some degree of control if it’s not contraindicated.”
But sometimes there can be no negotiating these kinds of requests, he says.
“Sometimes we’ll just say, ‘Look, it’s not a good thing for you to continue on this medication. You’re showing side effects, you’re sedated. … We think that the risk outweighs the benefit in this case,” he says.
A Patient Feels Left in the Dark
One patient at Emory wanted to fire his hospitalist because he wouldn’t tell him what was on his CT scan.
Dr. Vazquez held a discussion between the patient and the doctor. If not for the seriousness of the patient’s condition (he had tremors and neurological concerns), it would have been almost comical.
The patient had asked, “What’s on my scan?” The patient interpreted the doctor’s response, “It’s negative,” to mean that he wasn’t being told something about the scan.
Dr. Vazquez realized that the patient had felt dismissed.
“He was a sick gentleman,” Dr. Vazquez says. “And what he wanted to hear was, ‘Look, the great news is your CT scan looks good. There’s not an anatomical abnormality. It’s not a tumor. It’s not a big bleed. … That’s great news, but I, as a physician, I am concerned about you. You’re sick. We’ve got to really figure out what’s going on with you.’… He wanted a pat on the back, and that’s all it took.”
After that, the patient no longer wanted to fire the hospitalist.
One case at Gwinnett involves a hospitalist who was quite shy and easily intimidated and was not comfortable with a patient.
“They were struggling with a patient who was very difficult and very angry and a little abusive,” Dr. Austin says. “This doctor was really suffering psychically from this whole thing, and we switched.” Another doctor, who would not be thrown by the situation, took over the case. And Dr. Austin says he had great respect for the first doctor’s request to hand over the case.
“They needed a different personality,” he says. “It worked out beautifully. The patient and the doctor got along much better. The doctor was firm with the patient but respectful, and the other doctor felt relieved. And the [original] doctor is great with patients who need a lot of emotional support, probably better than the other doctor. So that worked out really well.”
It might be a challenge during a busy day, but it’s helpful to step back and see the situation as a whole, Dr. Bulger says. Sometimes, hospitalists can get flustered when patients are not acting rationally. But there’s usually a good reason they’re acting that way, he says.
“The patient is sick. And if it’s the patient’s family, they’re stressed by the fact that the patient’s sick. So you really need to take a step back and understand that.” TH
Thomas R. Collins is a freelance writer based in West Palm Beach, Fla.
- Centor R. Can I fire my hospitalist? SGIM Forum. 32(5):112-13.