Developing bedside manner comes from understanding who the patient is

Great article on how to develop a great bedside manner remember always a work in progress, filled with fluid situations.  Not at all different from my project management experience with “change Management”  Lisa Marie Blaskie

Over the years I have strived to develop my bedside manner.  On rounds many learners comment on this aspect of my doctoring, and these comments have led to much self reflection.  This commentary may convince some readers that I have the answers, but I do not.  Sometimes I do very well, but sometimes my skills fall short.  I do try to connect with patients and families, and give them confidence, hope and realistic expectations.

Being the product of a liberal arts education (psychology major at the University of Virginia) and being a life long reader, music lover, as well as going to movies and watching some selected TV shows, gives me a broader understanding of the human condition.  The first thing (and perhaps most important thing) in developing one’s bedside manner comes from understanding who the patient is.  Observers since Osler have quoted him often. Particularly like this quote: “It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.”  When you understand patients, then you can talk with them on their terms.

We must work at understanding our patients and how to connect with those patients.  When physicians first walk into the room, the patients usually view us positively.  Our job is to earn that trust, and help the patient understand what we think and what we plan to do.

It helps to like most people.  It helps to empathize, imagine their situation and understand their expectations.  Some patients want detailed sophisticated explanations.  Some patients want to research and control the decision making.  Many patients are just scared and want someone to tell them what to do (channel this common comment: “You’re the doctor.”)  Some patients have great medical sophistication, while others have just fear and virtually no understanding.  In my corner of the world, patients seem to speak multiple varieties of English: urban poor, urban sophisticate, rural poor, rural sophisticate, immigrant English, no English, drug user English, etc.  We have to have a sense of all these languages.

Despite the differences in patient types, all patients want a physician who listens and explains.  All patients value a physician who sits down at the bedside.  Sitting makes the patient understand that we have time to talk.  Touching the patient develops a sense of connection.  Caring becomes evident in our faces, our words and our touch.

Walking In The City

Autumn is my favorite time to walk around my city. The swirling skies, the cool weather, the breeze, the crunchy leaves—it’s dynamic, and, best of all, I don’t sweat as much.

In Wanderlust: A History of WalkingRebecca Solnit writes, “Walkers are ‘practitioners of the city,’ for the city is made to be walked. A city is a language, a repository of possibilities, and walking is the act of speaking that language, of selecting from those possibilities. Just as language limits what can be said, architecture limits where one can walk, but the walker invents other ways to go.”

I love this quote. Despite the fear I feel sometimes as a woman walking alone, walking places gives me a sense of control. I’m not at the mercy of someone else’s schedule. I can take a new, weird route or linger by the Canadian geese in a recently renovated lake. In the following essays, Antonia Malachik discusses the cultural implications of our aversion to walking; Garnette Cadogan relates how his walks are coded by his skin color, depending on where in the world he is; Adee Braun praises the New York eat-and-walk—and that’s not all. You can read these on the move. Just don’t trip, okay?

1. “The End of Walking.” (Antonia Malachik, Aeon, August 2015)

We’ve featured Antonia Malachik’s article on Longreads before, but it fits this week’s theme too perfectly to ignore:

“In many parts of the US, pedestrianism is seen as a dubiously counter-culture activity. Gated communities are only the most recent incarnation of the narrow-eyed suspicion with which we view unleashed strangers venturing outside on foot, much less anywhere near our homes. A friend of mine told me recently that a few years ago, when she lived in Mississippi, she was stopped by police constantly simply because she preferred to walk to work. Twice they insisted on driving her home, ‘so I could prove I wasn’t homeless or a prostitute. Because who else would be out walking?’”

2. “A Walking Tour of the Places Where I Hit Rock Bottom.” (Michelle Tea, BuzzFeed News Reader, October 2016)

Author and activist Michelle Tea takes us to four of her old haunts: a clown-themed strip club, a bar, her old apartment, and an on-ramp.

3. “Walking While Black.” (Garnette Cadogan, LitHub, July 2016)

In an essay that remains sadly, horrifically relevant, Garnette Cadogan describes his risk-tainted wanders through Kingston, Jamaica; New York City; and New Orleans:

“Walking while black restricts the experience of walking, renders inaccessible the classic Romantic experience of walking alone. It forces me to be in constant relationship with others, unable to join the New York flaneurs I had read about and hoped to join…Walking as a black man has made me feel simultaneously more removed from the city, in my awareness that I am perceived as suspect, and more closely connected to it, in the full attentiveness demanded by my vigilance.”

4. “Mastering the Art of the New York Eat-and-Walk.”(Adee Braun, Narratively, September 2014)

My friends and I paused on a classic Manhattan street corner so we could purchase hot dogs on our ill-fated attempt to catch our bus back to Maryland. Certain denizens of the Mid-Atlantic are familiar with the Day Trip to New York City: You wake up earlier than is reasonable in order to board a stale, at-capacity charter bus full of crabby Marylanders (or wherever), and a few restless hours later, you’re deposited somewhere outside Times Square or Chinatown or the Javits Center. Then, you see a show (anecdotally, the most common reason for these jaunts), or go to the Strand bookstore (guilty), or something else. After we saw our show of choice (cliche, I know, but it was a one-weekend remount), we partook in that hallowed New York tradition: the eat-and-walk.

At Narratively, Adee Braun has written a love letter to the eat-and-walk, a lesser-known American export and beloved regional pastime.

5. “Ghosts and Empties.” (Lauren Groff, The New Yorker, July 2015)

Lauren Groff’s command of language will entrance you in this short story about an on-edge mom who takes evening walks in her North Florida neighborhood.

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Medication Creep Is A Big Problem

Patients are often the victims of medication creep

As nurse case managers we all too often see these issues when performing nursing assessments.  Children of senior parents need to review medications with their loved ones.  This a great post from Kevin MD on what to do when these issues arise.

ANDI SHAHU AND ERICA SPATZ, MD, MHS | MEDS | OCTOBER 24, 2016

Martha arrives for an appointment with her new primary care provider. She hesitantly hands over her pill boxes at the nurse’s request; it seems to take forever to enter them all into the computer.

“You are taking a lot of blood pressure pills,” he comments. The doctor comes in and after a brief introduction, notes that she is taking five medications for her blood pressure.

“Five?” Martha exclaims in disbelief. She hadn’t realized it was that many.

Martha recently retired after 40 years as a business consultant. She was successful in her career – detail-oriented and good with numbers. But over the years, with all the travel, dinners out and stress, she gained weight, and her blood pressure remained high. She saw different doctors at her employer’s health clinic, all of whom had different ideas about how to better control her blood pressure. She followed their advice as best as she could, but was sometimes confused by conflicting advice and didn’t have time to get more involved in her care.

At the appointment, the doctor systematically goes through each medication, seeking to establish a timeline for when it was prescribed and whether it had any effect on her blood pressure. Martha is uncertain about the timeline; now that she is on so many medications, it’s hard to keep them straight.

“Have you had any side effects?” the doctor asks. Martha had some ankle swelling and dizziness a few years ago but is not sure which medications caused it. She now wonders whether it is worth mentioning. The doctor asks, “Have you been able to take your pills as prescribed, or do you miss doses?” Feeling deflated, Martha admits that she forgets to take them once in a while. The doctor then takes her blood pressure. It is 160/95 mmHg.

How did we get to this point?

Unfortunately, when it comes to managing chronic conditions, patients are often the victims of medication creep. In an attempt to reach target numbers, there is a natural tendency to escalate doses and add medications. Often, we as clinicians fail to evaluate whether a prior therapy was effective, and to stop it if it isn’t. We frequently do not assess other factors, like stress, side effects from other medications, and adherence challenges, which may contribute to uncontrolled levels.

The problem worsens when multiple providers make changes in response to a singular abnormal blood pressure reading. At best, we land on the right combination. At worst, we subject our patients to the medication creep — in which more and more medications are added, and neither the doctor nor the patient know what is working. Too often, we have lost sight of the intended goals of therapy. The medication creep takes its toll on patients, increasing the number of pills to swallow, out-of-pocket monthly prescription costs, and the likelihood of drug-drug interactions and side effects.

Missing the milestones

In shared decision making, patients participate in decisions about their care. Providers describe the risks and benefits of different options, and patients consider what matters most to them. Yet shared decision making is largely built around “milestone” decisions: Whether to proceed with a surgery, or whether to undergo a certain medical intervention. In chronic disease management, we often miss the milestones for shared decision making, including decisions to escalate or de-escalate therapy. We fail to assess the utility of each medication, including its efficacy, cost, side effects and burden to patients. It is easier to make decisions based on numerical targets rather than the unique biological and social context of the condition, treatment response, or preferences, values and goals of management.

How to prevent medication creep and stay goal-oriented

  • Identify medication creep when it occurs.
  • Redesign chronic disease management to engage patients in their care.
  • Work with patients and their familes to create short and long-term treatment goals.
  • Develop dashboards from electronic medical records that document the disease course and chronologically organize when medications are added or subtracted and the associated impact on short and long-term goals.
  • Give patients access to their medical records so that they can contribute to and correct the story line.
  • Utilize technology to enable transportability of medical records so that new providers can easily analyze a patient’s chronological history.

Simplify and clarify to empower patients 

At the end of the visit, the doctor and Martha establish that the main goals are to get her blood pressure under control to avert heart attack and stroke – both of which run in Martha’s family. “In order to figure out which medications to continue and which to stop, I need your help. What matters most to you?” the doctor asks Martha.

Martha becomes tearful. “I wish I didn’t have to take so many pills. I actually have trouble swallowing them.”

Suspecting that Martha does not need all five medications, the doctor simplifies the regimen to three medications, eliminating the two that needed to be taken twice daily. The doctor asks Martha to document her daily symptoms and blood pressure readings so they can discuss them at a 2-week follow-up appointment. On her way out, the doctor gently rests her hand on Martha’s shoulder and says, “Just remember, you are not alone; we’ll get there together.”

Andi Shahu is a medical student. Erica Spatz is a cardiologist.  This article originally appeared in Emmi Solutions.

Image credit: Shutterstock.com

Extravert, Introvert or Ambivert

 I’m in the center. I do communicate for my job, so that is pure extroversion, but before and after the ‘show’ I NEED time alone. I don’t like to talk to anyone.
Some days, I walk around the grocery store with a smile and an open heart. Other days, I’m wearing my headphones hoping nobody speaks to me.
For me, it all depends on how much alone time I get. When I’m alone, I meditate. I relax. I’m calm. I’m never stressed out when I’m alone, but I’m not a true introvert because the right energy from others motivates me.
I love going out. I love meeting new people. Some days, I’ll call people, text, and engage in conversation all day because it feeds me. Other days, like today, my iPhone is on moon mode because I don’t want humans to contact me.

That’s a little insight on me. Think about yourself.  Connect on a deeper level. Tag someone who will enjoy this writing.

Signs that you’re an Ambivert:
1. You can go out and be the life of the party but suddenly your energy drops and you want to go home
2. Small talk all annoys you. In fact, it bores you.
3. Some weekends you want to party. Some you want to be alone.
4. Too much time alone makes you sad or puts you at a low vibrational frequency.
5. You literally balance out whoever you’re with. You become more extroverted around introverts and more introverted around extroverts.
6. You’re usually observing what’s going on around you.
7. You love attention but don’t want it for too long.

 

First blog post

This is our very first post. the posts you will see going forward will be about our line of Supplements including Brand wholesale and Private Label products  Our first Private Label offering is Resveratrol; our very first and the most powerful Resveratrol supplement.

If you haven’t heard about this product be prepared it’s been around for decades and the heart of the product is the grape seed extract.  We will start a series of post about this awesome supplement in the coming weeks