Context and History
Hawgood reminds hospitalists that families often come into hospitals with past histories of things gone wrong.
“The whole healthcare system is so volatile now,” she observes. “People feel rushed, they feel [they are being] rushed out of hospital. They don’t have adequate healthcare insurance; they don’t have adequate care in the community. We send people out with trachs, tube feeds, open wounds, and pain issues. People are dealing with limited money, trying to juggle work, children, and elderly parents. So they have reasons to be angry.”
Families feel frustrated when their loved one is sick, agrees Dr. Baudendistel. “It may be that your role is to just let them vent their frustration.”
Says Hawgood, “I tell the people I train that I have nothing to lose. The patients and their families have everything to lose. So, even if I get off on the wrong foot, I’ll go back and ask, ‘could I start again?’ And usually, people will say, ‘yes.’ It’s up to me to make it work.”
Dr. Weber recalls one family at ANMC with a special needs child who had been in a Seattle hospital, and was readmitted to their facility with kidney stones. He was not getting better and the physicians recommended that the family travel back to Seattle, where a pediatric urologist could remove the stones. The parents were uncomfortable with the recommendation that their son return to Seattle.
“We did need to bring in a mediator, and have several family care conferences with the parents, with social workers and discharge planners, and all involved providers,” says Dr. Weber.
In the course of the conferences, the family revealed that their child’s disabilities were due to a missed diagnosis of meningitis when he was a baby. “They harbored a lot of resentment toward the medical profession in general,” says Dr. Weber. “It was hard to work through that. They couldn’t let it go—and I don’t blame them—and it caused them to always question our motives and our intentions.”
During the care conferences, the team let the family tell their story of the meningitis case again. Just by listening to the family’s history with that event, the team was able to validate the family’s concerns. The parents agreed to take their son to Seattle for the procedure, and later sent a thank you card to the pediatric team at ANMC that had treated him.
Don’t Make Assumptions
Hawgood always cautions physicians to enter the patient’s room with an open mind and to be open to cues and clues about the family’s situation. She praises the UCSF hospitalists’ training of young residents.
“They let them take the lead in patient interviews, then we all discuss how that interview went, and how things could have been done better,” says Hawgood. For instance, she recommends that hospitalists “allow for some silence in the room. You don’t have to fill up every minute with conversation. Look for the non-verbal cues, the things that weren’t said.”
In Dr. Weber’s hospital, pediatric patients come from all over state. It is not unusual for a baby to be in the neonatal intensive care unit for a while before the parents come back to visit. It would be easy to question, she says, whether these people are going to be good parents. “But until you know their social situation, you really have no place saying that,” says Dr. Weber. “You may find that they have six other children at home and cannot be here because they have no other caregivers for their children, and their village is 200 miles away.”