Dr. B is DAVID BRECHTELSBAUER of the department of family medicine at the University of South Dakota Sanford School of Medicine, Sioux Falls. He also is associate director of the Sioux Falls Family Medicine Residency Program at the Center for Family Medicine and the medical adviser for this publication. To submit a question for possible discussion in this column, e-mail us at caring@elsevier.com.
Dear Dr. B.: As a nursing home social worker, I often find myself interacting with family members, and staff members, who are confused about the patient's prognosis and medical treatment. Many physicians seem unwilling or unable to discuss family and staff concerns. Why are doctors like that?
—B.K., Sioux City, Iowa
Dr. B responds: There may be as many answers to this question as there are physicians. But for the sake of doctor-patient-social worker communication, I'll try to provide a useful response.
First of all, it may be helpful to consider the educational process that shapes a physician. Most will have spent 4 undergraduate years in pursuit of excellent grades, while majoring in one of the biological sciences with other premed overachievers, in an effort become a strong candidate for admission to medical school.
A competitive spirit is more sharply honed during 4 years of medical school, as medical students vie with one another for coveted positions for residency training. Then 3 or more years of residency training still doesn't produce a practicing physician. With the increasing frequency of subspecialization, these young doctors compete for desirable fellowship slots and 1–6 years of additional training.
The physician's formal training is therefore generally not conducive to collaboration. The culture of the medical profession promotes self-sacrifice, personal responsibility, and academic and technical excellence, but shared responsibility is a foreign concept for many physicians. The medicolegal environment reinforces the sense of ultimate responsibility that discourages collaboration.
Physician training provides few opportunities to get to know much about the people pursuing other careers in health care, or about their training. Therefore one begins life as a physician ill-prepared to work comfortably and skillfully with social workers, nurses, and other professionals of interdisciplinary teams.
Medical education generally does a good job teaching doctors about communicating with patients, but less about working with a patient's or resident's family. Given the prevalence of advanced dementia in the long-term care setting, communicating directly with the patient is often not sufficient. This, of course, creates the need to communicate with families, a task many physicians may want to avoid because they just don't have the skills to do this very effectively. Most of us don't enjoy being asked to do things for which we have not been trained.
Difficult but Doable
Beyond the influence of the rigorous educational process that molds a physician, the current practice of medicine has been dramatically altered by the commercialization of health care. The professional autonomy the doctor aspired to has been replaced by productivity targets and concerns about making a profit for investors in for-profit health care organizations. The business model, as opposed to the service-professional model, of health care has also dramatically influenced the not-for-profit sector of health care.
You may recall this issue being eloquently discussed by Arnold S. Relman, MD, is his guest editorial in CARING FOR THE AGES in January, “Ownership Issue Can Compromise Patient Care.” In the April issue, columnist Janet K. Feldkamp, JD, RN, LNHA, addressed some of the medicolegal factors that are undermining physician behavior and satisfaction in her report “Are Medical Errors Being Increasingly Criminalized?”
Before you give up on effective physician communication with patients and families and collaboration with the interdisciplinary team, let me assure you there is still hope. Some physicians have escaped the dehumanizing aspects of medical education and found ways to accommodate the demands of the business model of medicine. Through experience, continuing education, and the guidance of mentors, these physicians have developed a sense of service and professionalism—and new skills—in working with families struggling with the many issues of long-term care.
Physicians who complete AMDA's Core Curriculum get an intense week-long experience that teaches them about working with families and being a productive team member. The Core Curriculum is an experience that includes didactic, role-playing, and small-group experiences, all honoring the principles of adult learning. Feedback from participants in the Core Curriculum and from the facilities they serve suggests that part of the solution to your problem could be to encourage your medical director to attend this training program.
Another formal educational opportunity for physicians is through the Northwestern University-based “EPEC” (Education for Physicians on End of Life Care) Project, which includes extensive training on how to break bad news to a patient, deal with families in difficult situations, and work with other professionals.
I hope that at least a few of your attending physicians are specialists in geriatric medicine. Physicians with specialty training in this area are likely to bring expertise in caring for common problems among residents in your facility and expertise in working as part of a team. Furthermore, such physicians may bring a level of contentment that many others seem to lack: Several studies have shown that these physicians are more satisfied with their choice of specialty than any others (Arch. Intern. Med. 2002;162:1577–84).
Back to You
Now let me turn your question around and ask what you and your facility can do to promote successful physician participation in the care of nursing home residents and their families.
Recognize that efficiency is probably an acute concern for the physicians with which you interact. Most physicians working in nursing homes are there only for a short period each time they round. Getting the most out of that time is important for the facility and the physician. If there is a question that needs to be addressed, provide as clear a statement of the problem as possible. Communicate what has been tried to address the problem before you decided to seek the physician's involvement, and explain why earlier efforts weren't entirely successful.
Anticipate what information may be needed for the physician to logically address the question and try to have that information available. For example, if the issue is a resident's problematic behavior, have available the behavior log, records of any prior behavioral plan and psychotropic medication use (with start and stop dates), and a report of other contributory factors (such as a room or roommate change).
Sometimes, your staff might be asking a physician to get involved in problems that are not medical. Not surprisingly, the doctor tends not to be very helpful. If the nursing home staff are not sure whether the problem is a medical problem, you should discuss that doubt before convening the interdisciplinary team or urging a physician-family meeting. There may be more appropriate methods to address the problem.
If it's appropriate for the physician to meet with the family, try to reserve a private area large enough to accommodate the family and any additional team members who need to be present. Determine whether the resident needs to be present. Generally that's necessary and appropriate, to allow this person to contribute to the decision-making process. Know that the physician will not be reimbursed for his or her time if the patient is not seen face-to-face, another incentive to have the resident at the meeting.
There may be circumstances in which the physician can more effectively conduct a family meeting at his or her office. In this case, it may be helpful, if possible, to have a representative of the nursing home's interdisciplinary team present in person or by speaker phone. If the physician is not aware (has never been taught) the rules of a family meeting, either provide instructions or offer to moderate the meeting and teach by example.
Physicians are accustomed to providing “orders,” a word that is disconcerting at times for other team members who do not have the power to give orders. Remember, for many processes in the health care system to function, physicians need to provide orders. Physicians are also taught to assess and treat problems as quickly as possible, a trait that often has to be put aside during family meetings, where hearing from everyone is an important part of the process.
Complicating Factors
Back in the nursing home, physician expectations of other team members are likely to be colored by the physician's experience in acute care settings. A gentle reminder of the differences between acute care and long-term care staffing ratios may be necessary in order for the physician to have appropriate expectations of nursing facility staff.
Personality issues cannot be ignored. While people highly skilled at being part of interdisciplinary can function effectively within a team populated by persons they personally do not like, the efficiency and likelihood for success is greater if there are opportunities to get to know and like team members personally and professionally. This takes time, and definitely should not be a formal part of a team meeting. Seek opportunities to get to know the physician when there isn't a crisis to be dealt with. Ask about his or her training experience, other parts of the physician's professional life, or just how the day is going. This should stimulate similar questions in return, and relationships can gradually build.
In my experience, team and family concerns often center on the question of prognosis. While predicting a patient's course is something physicians are taught to do in medical school and residency, it is still an inexact science. Sometimes, vague and inexact statements are the only ones possible. The patient and family, the nursing home team, and the physician must deal with the stress of going forward in the face of uncertainty.
Don't let anyone tell you this is not difficult work. Sometimes, the unskilled or uncooperative physician may be what makes things difficult, but more often it's the multiple medical, psychosocial, and functional problems faced by the frail elders we care for. Good luck in meeting this challenge in your facility, and in your occasionally necessary efforts to develop the geriatric and long-term care skills of your attending physicians.
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