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Sunday, April 14, 2013

Where is Your Center ??

 

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The patient is the center of our universe. Although pundits and bureaucrats emphasize this,  many of their edicts and actions run counter to this proposal.

I remember an event in residency when after a long night on call, one of my junior residents was complaining how tired and angry he was with patients calling in during the early morning hours with what he thought were ‘spurious’ and unnecessary calls.  Granted he and many of us were doing every other night call and working over 100  hours/week. (back in 1977).  

As it turned out the head of our department overheard his complaints about “foolish calls’ from patients.

It was as I like to call it ….a Bob Hope Moment’  as written in The Laugh Makers.

Our chief came back with his one liner, “That is why you have a job !”

For my junior resident it was probably a scary moment to be caught in the act of disparaging a patient in need.  For me it was a poignant moment in training which has  stayed with me for over 30 years of medicine.

It was my introduction to ‘Person-Centered Healthcare’, in 1976 long before the current shift from disease centered management to patient centric healthcare.

In an outpatient environment it is easier to maintain patient centered care and management.  In an inpatient setting it is far more difficult.  In the hospital environment compressing activities into a limited time frame is mandatory. Patients cannot just drop in for an MRI, lab work, or surgery.  Medical emergencies occur more often in hospital and the most critically ill patients are placed in an ICU so that their level of intense care is isolated and does not impact more routine hospital care.

Medicare and payers limit hospital length of stay according to diagnosis and/or procedures. Inpatient stays that are in excess of a standard length are not reimbursed, and require additional paper work for authorization and payment.

The centricity of patient care in the hospital requires some additional steps for providers, and their extenders (nurses, therapists, administrative clerks and others who have contact with a patient.  Many of these requirements apply to other businesses, and in many cases hospitals have adopted these subtle techniques.

Patients by and large are very unfamiliar and anxious about hospital admissions.  Anxiety can affect outcomes, if excessive.   Frequently patients may exhibit the worst of their personalities under this stress, requiring additional time on  the part of staff.

It helps me to remember

1. No one wants to be ill (even addicted drug dependent patients).

2. No one wants to go into a hospital, except perhaps to give birth, and then there is anxiety about pain, and a healthy newborn.

3. Illness brings out strange behavior in patients, that can only be measured in relation to the perceived threat by the patient.

4. I would be out of my job were it not for ill people. 

5. Few people will pay to stay well even though most of preventive medicine is relatively inexpensive. 

       a. Good nutrition, balanced diet, special attention to nutritional   

       requirement of some diseases, ie diabetes, hypertension, cystic

       fibrosis.

       b. Routine exercise programs, with special attention to

           physical challenges

       c. Risk evaluation for a patient related to family history, genetic    

           profile, and past medical history.

       d. Emotionally balanced life style.

6. The realization that Most of my stressors  are not driven by patient demands, but from bureaucrats, and payers. In other words it is not the patients’ actions causing difficulty.

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