Medicolegal Issues

Communication King


 

When Kenneth Patrick, MD, joined Chestnut Hill Hospital in Philadelphia in 1982, he was known simply as a physician who practiced HM. It wasn’t until 14 years later that the term “hospitalist” appeared for the first time in a New England Journal of Medicine article.

As Dr. Patrick’s job title changed, so did his outlook on the future of the profession. “My practice was exceedingly unique and, for many years, people didn’t understand that a physician could practice exclusively in a hospital,” says Dr. Patrick, now the ICU director at Chestnut Hill. “But when I first heard the word ‘hospitalist,’ I was surprised. I remember thinking, ‘Hey, I’m one of them.’ ”

He also knew that if other physicians were recognizing the specialty, more and more physicians were going to jump on the HM bandwagon. “I knew it wasn’t just a short-lived thing,” he says.

With three decades of HM experience in the bank, Dr. Patrick offers his take on the evolution of HM, changes to the delivery of care, and the importance of communicating with patients.

Question: What drew you into the medical field?

Answer: I earned an undergraduate degree in mechanical engineering [from Drexel University]. The country was going through a recession and there weren’t many job offers, so when I was a junior, I decided to switch careers. I went into medicine.

Q: Have you found any similarities between engineering and HM?

A: Very much so, particularly in the intensive-care unit (ICU). That’s what drew me to critical care and HM. You have to be very detail-oriented. You have to go through your thinking process in a very organized fashion, and you have to be prepared to solve problems that aren’t apparent when you first start caring for a patient. That’s the basis of engineering.

Communicate with patients and their families. … Be open to suggestions, because you don’t know everything. I still feel that way after 26 years. Be optimistic and enjoy what you do.

—Kenneth Patrick, MD, Chestnut Hill Hospital, Philadelphia

Q: Did you face challenges in 1982 that new hospitalists won’t face today because the field is more established?

A: No, I would say it’s the other way around, particularly in terms of regulation and monitoring. The Joint Commission existed then, but the standards of hospital care, pressures from insurers, and things like length of stay were not so much of an issue. The challenge to get people evaluated and discharged exceedingly quickly did not exist back then.

Q: How has your role as a hospitalist changed in 26 years?

A: The most significant change is speed. I remember during residency caring for a patient with an infection of the heart valves. That patient stayed in the hospital for 28 days getting antibiotics, and I went to see the person every day to listen to the heart. … Today, that patient would be in the hospital two or, at most, three days. They’d be discharged either to home on IV antibiotics or to a skilled nursing facility. They’d no longer stay in the hospital for a prolonged period of time.

Q: How has that changed the delivery of care?

A: Our job as hospitalists is to see someone who is sick enough to be in the hospital, evaluate and diagnose them exceedingly quickly, get them started on treatment exceedingly quickly, and, as soon as they start improving, the regulators or insurers say they no longer need to be in the hospital. We don’t get to follow them through their entire illness.

I think that is something that is lacking for young hospitalists and residents during training. They don’t see the illness from start to finish. They see it from the start until the moment the patient begins to improve and is discharged.

Q: What is the consequence of that shift?

A: Less-experienced physicians, in terms of management of a patient from the beginning to end, unless there is good communication between hospital physicians and outpatient physicians. And I just think younger physicians are less well prepared for the complications that may ensue from a given illness because they only see the illness for such a short period of time.

Q: What’s the biggest reward of being a hospitalist?

A: Making patients better, if that can be done, and helping them through illnesses that can’t be made better. The outcome may be death, permanent disability, or something tragic, but patients and their families still feel thankful if they feel you’ve been a caring physician. Without the patient and the family being satisfied, I wouldn’t have many rewards.

Q: After 26 years as a hospitalist, what’s the best advice you could offer to someone new in the field?

A: Don’t cut corners. Be as complete and as thorough as you need to be. Communicate with patients and their families, which is crucial. Be open to suggestions, because you don’t know everything. I still feel that way after 26 years. Be optimistic and enjoy what you do. And it’s very important for busy, high-pressure physician specialists to keep their mind on their family and their outside-the-hospital relationships. Don’t forget your kids are going to grow up.

Q: You often emphasize the importance of physicians communicating with patients and their families. What’s the biggest barrier to communication?

A: First, reimbursement isn’t there for explanations and counseling. You get reimbursed for the evaluation, the diagnosis, and the management of the illness. No. 2, it takes time—sometimes an inordinate amount of time. If a patient is critically ill, I can spend 30 to 90 minutes with a family, not treating the patient, but explaining what’s the matter with the patient and what the treatment options are. During that time, you’re giving up other patient-care responsibilities.

And I don’t think physicians have been well trained to communicate with someone and explain the details of an illness and the treatment options nonmedically. I’ve seen doctors try to explain to families that a patient is dead and the family didn’t know what the doctor meant. I teach residents to speak English to patients and their families, not speak medical.

Q: Should there be a greater emphasis on communication during education and residency?

A: Absolutely. I tell residents they need this training as much as they need to know what antibiotic to use for pneumonia. … My experience over the years is patients think they’re getting better care from average doctors who communicate well than doctors who are brilliant and can’t communicate.

Q: What has kept you at Chestnut Hill Hospital for 26 years?

A: Some of it is inertia. When my children were young, it was the community in which I lived. And I like working in a small, community hospital because of the personal relationships I’ve developed with the other professionals, everyone from medical records to the secretarial staff.

Q: What’s next for you?

A: As I’ve gotten older, being woken up in the middle of the night gets harder and harder, so I’ve thought of doing something where the hours are more fixed and I have a little more time. I have thought about starting satellite practices in other community hospitals that are looking to start hospitalist programs, being more of an administrator and delivering less patient care. But I still like what I’m doing, and that’s why I keep doing it. TH

Mark Leiser is a freelance writer based in New Jersey.

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