One concern some have about the hospitalist model has been that it may contribute to depersonalization in healthcare. And yet, the way the Japanese people responded to the 2011 earthquake and tsunami illustrates how healthcare workers without existing patient relationships can still care deeply for patients and earn their trust.
On March 11, 2011, an earthquake of 9.0 magnitude hit northeast Japan. It was followed by a tsunami more than 45 feet tall. The world was horrified by the images of waves swallowing the coast of Japan, throwing boats and cars about like toys. As of March 2012:
- 15,854 deaths had been attributed to the earthquake;
- 3,155 people were still missing;
- More than 2.5 million houses were destroyed and
- 344,290 evacuees were still homeless.
A meltdown of nuclear reactors at the Fukushima Daiichi Nuclear Power Plant is now under way, and the country still struggles to minimize the impact of radiation contamination.
As government officials and representatives of Tokyo Electric Power Company (TEPCO), operator of the Fukushima nuclear facility, lamented they were “prepared for a tsunami 20 feet tall, but not 45 feet,” I could not help but recall a similar conversation I had years ago with one of my patients.
Working at my primary-care clinic, I was taking care of a woman who was in her fifties who had hypertension, diabetes, and hyperlipidemia. She was adherent to all of her medications and diet; she had just started swimming at the YWCA; she was a model patient whose numbers were all pristine. We did everything we could and all indications were that she was going to do very well. Yet, one day, she suffered a major stroke. “This is so unexpected,” I lamented when I saw her in the hospital.
Adversity can bring out both the best and the worst of human nature. The world witnessed diligence, solidarity, and fortitude by the Japanese following the 2011 disaster. Viewers around the world were surprised by media coverage of the affected areas, as reports showed hardly any evidence of violence or looting. Hundreds of evacuees living in a school gymnasium were engaging in morning stretches together. At mealtime, the evacuees lined up quietly, waiting for rations of food and water. They politely took turns using portable toilets and showers. Some women were taking care of the elderly while their husbands searched for missing neighbors. There was a strong sense of “we are all in this together.”
Japanese victims were able to remain resilient because they trusted in each other and in the help that ultimately arrived. For example, many people were touched by the dedication of healthcare workers who volunteered in rescue missions. According to a widely read blog posted by a nurse who participated in a mission to Rikuzen Takata, one of the most devastated areas, her team leader had warned her not to expect to eat, drink, sleep, or even use the bathroom. She had also been cautioned not to cry: “The victims are asking for our help, not sympathy.”
The nurse took care of several hundred evacuees on her first day, literally without eating, drinking, or using the bathroom. Amid her incredibly hectic day, she found comfort in making a new friend, a cute 9-year-old girl who followed her everywhere. They talked about boys and laughed together. When the nurse later discovered that the girl was following her because she had just lost her mother and her home, she could no longer endure. She cried in secret. Masking her own distress, she remained dedicated and selfless until the end, bolstering the victims with her smiles instead of tears. (Read more of the blog in English at jkts-english.blogspot.com, or read in Japanese at blog.goo.ne.jp/flower-wing.)
Such a courageous story is in stark contrast to how the government and TEPCO responded to the nuclear crisis in Fukushima. Their combined lack of leadership and inadequate disclosure of information on the risk of radiation contamination deprived them of trust from both the Japanese public and the global community, creating chaos and confusion.
Again, I was reminded of my clinic patient. After she had suffered the stroke, I was fearful that it could disrupt our therapeutic relationship. I thought I might have lost her trust. I expected her to stop listening to my recommendations. I even thought she would fire me.
To my surprise, however, she not only kept me as her physician, but also recruited her husband to become my patient. She continued to take her medications and follow a diet that I recommended. She said she liked how I continued to visit her in the hospital during her worst times. I was sincerely relieved to hear that, because it took a great deal of nerves to see her in the hospital after what had happened. Fortunately, her weakness improved significantly as she went through rehabilitation and, eventually, she recovered to the point where I could no longer tell if she had ever suffered a stroke. I believe that the trust she had in our healthcare system saved her.
In both cases, trust played an essential role. Trust can make people resilient at critical junctures because it gives them hope. The question for hospitalists then becomes how to build trust. More simply said than done, I believe that some form of personal sacrifice is necessary. This might mean that we may need to spend more time at our patients’ bedside, but it might mean that we have to make ourselves emotionally available to patients’ needs and remain compassionate.
A few years ago, I worked with an intern who spent a couple of hours with his patient during his call on a Saturday night. He was talking to an anxious patient who had just been diagnosed with advanced cancer and wanted to give up. After that night, the patient decided to stay and undergo treatment. The intern provided the patient with hope, and the patient trusted the intern. The patient is doing well today and, whenever I run into him in the hospital, he always asks about the intern.
Another intern I worked with exhibited outstanding bedside manners. She always sat down and held her patients’ hands as she explained her plans. She was kind and caring. One of her patients appreciated her and trusted her so much that he insisted on finding her a husband. We all laughed, mirthfully. Even though we could not do anything about the terminal cancer he was diagnosed with, he still left the hospital smiling.
In hospitals, we witness disasters and devastations daily. They might not be as visible as the images of earthquakes or tsunamis, but we know the impact of disease or injury is challenging. As responders to personal catastrophes, hospitalists must strive to allow our patients to trust us, trust our healthcare, and, above all, trust themselves. We have to constantly remind ourselves that the very existence of hospitalists came out of the necessity to have a readily available presence of physicians in the hospitals. We can help our patients by rededicating ourselves to the values at the heart of our profession.
Ryotaro Kato, MD, JD, is chief hospitalist at the Department of Veterans Affairs Medical Center at the Washington University School of Medicine, St. Louis.