Patient Education and Counseling 98 (2015) 1164–1166
Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Reflective Practice
One good hand§ Kavitha Kolappa a, David E. Kern b,* a b
Massachusetts General Hospital, USA Johns Hopkins University School of Medicine, Division of General Internal Medicine, Johns Hopkins Bayview Medical Center, USA
A R T I C L E I N F O
Article history: Received 25 August 2014 Received in revised form 6 April 2015 Accepted 15 June 2015 Keywords: Narrative medicine Patient-centered care Medical education Physician–patient relations Patient compliance Empathy Holistic health Cost-effectiveness Healthcare delivery Career choice
If you had been a few feet away, you would have never guessed she was nearly 50 years old. She looked more like a child, her tiny silhouette hiding beneath the bleached-white hospital sheets. A brightly colored cloth wrapped her hair, further concealing her years. Only temporal wasting and paper-like tightening of the caramel-colored skin over her cheekbones betrayed her age and illness. I met Ms. Lana1 as I would come to call her, while on-call as a medical student. As a third-year medical student, you are always hoping to get the ‘‘perfect patient’’ . . . the one who gives you a clear, concise history, the one who makes you look good in front of your team, and the one who does not mind you rudely waking them for morning rounds. At first Ms. Lana seemed anything but the ‘‘perfect patient.’’ When I entered her room for the admission interview, she could not have seemed less interested. She did not
§ For more information on the Reflective Practice section please see: Hatem D, Rider EA. Sharing stories: narrative medicine in an evidence-based world. Patient Education and Counseling 2004; 54: 251–253. * Corresponding author at: Division of General Internal Medicine, Johns Hopkins Bayview Medical Center, MFL Center Tower, Suite 2300, 5200 Eastern Avenue, Baltimore, MD 21224, USA. Tel.: +1 410 550 1828; fax: +1 41 550 3403. E-mail address: [email protected] (D.E. Kern). 1 The patient’s name has been changed to protect confidentiality.
http://dx.doi.org/10.1016/j.pec.2015.06.010 0738-3991/ß 2015 Elsevier Ireland Ltd. All rights reserved.
open her eyes throughout the encounter; she mumbled faint responses laced with irritation to only a sporadic selection of my questions. Most of what I knew about Ms. Lana that first day I gleaned from her extensive hospital records. She had been admitted to our health system 12 times over the previous 5 years, the past 10 admissions being for recurrent abdominal pain and nausea secondary to diabetic gastroparesis. She had had 13 abdominal/ pelvic CT scans with contrast and four ultrasounds of the abdomen. All imaging tests had been negative except imaging years ago that had shown gall stone pancreatitis and cholecystectomy. Multiple X-rays of her abdomen, an upper gastrointestinal series, a small bowel follow-through, an upper endoscopy and a colonoscopy – all had been unrevealing. Two gastric emptying studies showed mild gastroparesis, Ms. Lana had been non-adherent with the promotility agent that had been repeatedly prescribed, and had over the course of several hospitalizations become dependent on oxycodone, which would exacerbate her motility issues. Her illness was further complicated by HIV, hepatitis C, depression, alcohol abuse, and intermittent cocaine use. Our attending had actually taken care of Ms. Lana twice before. Her abdominal pain and nausea would be controlled at each admission, and after discharge she would not take her pro-motility agents or follow through with HIV and substance use care. At first,
K. Kolappa, D.E. Kern / Patient Education and Counseling 98 (2015) 1164–1166
this admission seemed no different. She was emaciated at 70 lbs, down 38 lbs from when our attending had seen her last. Her urine was positive for cocaine, though she denied using it, and she was requesting narcotics to manage her abdominal pain. The morning after admission our team considered the sensitive issues Ms. Lana faced and debated whether we should present her case at the bedside, as was our custom on rounds. Our medicine team that month was part of the Aliki Initiative, a novel pilot project at Johns Hopkins Bayview Medical Center. The case load for our team was halved, with the directive that we get to know our patients better and address their often complex social needs during and after their hospital stay. I knew that counseling would be invaluable to Ms. Lana’s care, but I was not confident in my own ability to traverse the fine line between acceptance and gentle confrontation in addressing her medication non-adherence, cocaine use, and narcotic dependence. I tried to talk my way out of presenting at the bedside, but my resident and attending would not let me off the hook. Our team decided that given Ms. Lana’s recidivism, it would be best to discuss all of these issues with her as openly, honestly, supportively, and inclusively as possible, which could be done privately with her in her single room. While presenting Ms. Lana’s case, I could not be sure if she was hearing me, as her eyes were initially closed. I leaned over the plastic bedrail and held her hand, while the rest of the team, who had also met with her the previous evening, formed a circle around her. At one point Ms. Lana’s eyes opened and looked at me. We talked about gastroparesis and explained our rationale for dietary adjustments and pro-motility agents like metoclopramide. We talked about how oxycodone, which she had come to depend on, was actually making her stomach troubles worse. We talked about cocaine and how it would also affect her appetite. We talked about HIV and how there were medications that she could take to keep her immune system strong. Her right hand, which had previously been limp, squeezed mine, signaling that she was hearing and connecting with us. Our attending looked at Ms. Lana and said, ‘‘We know that life has not been fair to you. You’ve been dealt a bad hand of cards. We’re just going to try to deal you one good hand.’’ I think that made all the difference. With this simple, yet empathic statement, our attending set the tone for the many conversations that would follow with Ms. Lana. And for me personally, he modeled our responsibility as healthcare providers to discard preconceived ideas, seek understanding, and offer acceptance and support. We went on to lay out a plan for the hospitalization with Ms. Lana’s full involvement. What followed surprised us all. Over the coming days, we learned more about Ms. Lana’s life. We learned that she lost both of her parents at age 7 and had been raised in a series of foster homes. Whenever I came into her room, Ms. Lana insisted that I sit down and watch television with her. We watched segments of the Godfather and lamented together Fredo’s betrayal of Michael Corleone. Ms. Lana told me that she had seen the trilogy 25 times. We learned that her best friend was a cat named Samson and that she lived in a difficult neighborhood with acquaintances who pushed drugs on her. Ms. Lana’s abdominal pain and nausea improved quickly over the next few days. She transitioned from intravenous fluids to a liquid diet to semi-solid foods, and ultimately to a normal diet. We supplemented her oral intake with nutrient drinks; strawberry-flavored Ensure was her favorite. We weaned Ms. Lana off oxycodone and started her on non-narcotic analgesics, which seemed to control her pain. She would never again ask for narcotics. On the Friday morning planned for discharge, Ms. Lana confessed to the team that she would be evicted soon from the apartment where she was staying. She asked to be kept in the
1165
hospital over the weekend so that she could be directly transferred to a group home. Additionally, she was afraid of returning to an environment in which drug use was encouraged. Although the team faced pressures for discharge, our attending made the courageous choice to keep Ms. Lana in the hospital over the weekend. That afternoon I went in to see Ms. Lana and apparently looked concerned because she asked me what was wrong. I felt my eyes well up and expressed that I was worried about her. She responded with, ‘‘I’m going to be alright. Y’all are going to take care of me.’’ The following week, we arranged for transfer to a group home for HIV positive women. We personally spoke with the case manager who would follow Ms. Lana at her primary care clinic to ensure a smooth discharge. We had the privilege of speaking and visiting with Ms. Lana several times after discharge. A few days after discharge, the whole team visited her at her new group home as part of the ‘‘Aliki experience.’’ When our resident asked Ms. Lana what we could have done differently during her hospitalization, she replied ‘‘Y’ all already done everything different’’. Several months later I found Ms. Lana at another group home on the outskirts of Baltimore. She was settled in with several friends at the home. She was in good spirits, was taking all of her medication (including her HIV medicines), and now had a new kitten named Socks. One of her caretakers in the house pulled me aside and said, ‘‘I didn’t want to say this in front of the other boarders, but Ms. Lana . . . that woman is about to die and is the cheeriest person in the world. Everyone knows she’s going to die, but she is just so happy and grateful. And if she’s that grateful, then we all better be.’’ Two and a half years after discharge from our service, Ms. Lana was alive and well, and in her own apartment. Yes, Ms. Lana was doing well, and in her own words ‘‘fat as a butterball.’’ We met her in her very tidy apartment cooking fried chicken, which impressively she could now eat. She had been off cocaine and all narcotics for over 2 years, was attending NA (Narcotics Anonymous) and AA (Alcoholics Anonymous) meetings, saw her health care providers regularly, and was managing all of her medications on her own, including insulin. She also had a boyfriend and went dancing on Friday nights in a nearby church basement. She was delighted to see us and felt proud to report that she was on ‘‘cloud nine’’. A follow-up phone call five years after discharge revealed that Ms. Lana was still doing well, living independently, and had had only one hospitalization since we cared for her. We provided Ms. Lana with patient-centered, personalized care. We also delayed discharge until we knew she had a safe place to stay and communicated personally with individuals who would provide care for her going forward. We may not have had the time or capacity to provide this kind of care and follow-up had the Aliki service not reduced our caseload. Was Ms. Lana’s care costeffective? We believe so. She gained a much improved health status and happiness. Her recidivism rate was markedly reduced, and she became successful at managing several chronic illnesses and a complex medication regimen. Getting to know Ms. Lana was not only a privilege; she was my ultimate teacher, better than the ‘‘perfect patient.’’ She taught me, as an impressionable thirdyear medical student, what kind of doctor I wanted to be and ultimately led me to pursue a path in psychiatry, where getting to know patients is paramount. All of us who worked with Ms. Lana learned something about our own humanity. We felt really good about being physicians. Acknowledgments We would like to thank Mrs. Aliki Perroti, whose contributions made possible the founding and initial years of the Aliki Service.
1166
K. Kolappa, D.E. Kern / Patient Education and Counseling 98 (2015) 1164–1166
Based upon patient satisfaction, physician satisfaction, and hospitalization readmission data, the hospital decided to continue the practice of a lower case load after cessation of external funding, not only on the Aliki Service but also on the other house staff inpatient internal medicine services. Expansion of our hospitalist
service, funded by the hospital, made this possible. We would also like to thank Dr. David Hellmann, Chair, Department of Medicine, Johns Hopkins Bayview Medical Center and Vice Dean, Johns Hopkins Bayview Campus, for his vision in creating the Aliki Service.
Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Reflective Practice
One good hand§ Kavitha Kolappa a, David E. Kern b,* a b
Massachusetts General Hospital, USA Johns Hopkins University School of Medicine, Division of General Internal Medicine, Johns Hopkins Bayview Medical Center, USA
A R T I C L E I N F O
Article history: Received 25 August 2014 Received in revised form 6 April 2015 Accepted 15 June 2015 Keywords: Narrative medicine Patient-centered care Medical education Physician–patient relations Patient compliance Empathy Holistic health Cost-effectiveness Healthcare delivery Career choice
If you had been a few feet away, you would have never guessed she was nearly 50 years old. She looked more like a child, her tiny silhouette hiding beneath the bleached-white hospital sheets. A brightly colored cloth wrapped her hair, further concealing her years. Only temporal wasting and paper-like tightening of the caramel-colored skin over her cheekbones betrayed her age and illness. I met Ms. Lana1 as I would come to call her, while on-call as a medical student. As a third-year medical student, you are always hoping to get the ‘‘perfect patient’’ . . . the one who gives you a clear, concise history, the one who makes you look good in front of your team, and the one who does not mind you rudely waking them for morning rounds. At first Ms. Lana seemed anything but the ‘‘perfect patient.’’ When I entered her room for the admission interview, she could not have seemed less interested. She did not
§ For more information on the Reflective Practice section please see: Hatem D, Rider EA. Sharing stories: narrative medicine in an evidence-based world. Patient Education and Counseling 2004; 54: 251–253. * Corresponding author at: Division of General Internal Medicine, Johns Hopkins Bayview Medical Center, MFL Center Tower, Suite 2300, 5200 Eastern Avenue, Baltimore, MD 21224, USA. Tel.: +1 410 550 1828; fax: +1 41 550 3403. E-mail address: [email protected] (D.E. Kern). 1 The patient’s name has been changed to protect confidentiality.
http://dx.doi.org/10.1016/j.pec.2015.06.010 0738-3991/ß 2015 Elsevier Ireland Ltd. All rights reserved.
open her eyes throughout the encounter; she mumbled faint responses laced with irritation to only a sporadic selection of my questions. Most of what I knew about Ms. Lana that first day I gleaned from her extensive hospital records. She had been admitted to our health system 12 times over the previous 5 years, the past 10 admissions being for recurrent abdominal pain and nausea secondary to diabetic gastroparesis. She had had 13 abdominal/ pelvic CT scans with contrast and four ultrasounds of the abdomen. All imaging tests had been negative except imaging years ago that had shown gall stone pancreatitis and cholecystectomy. Multiple X-rays of her abdomen, an upper gastrointestinal series, a small bowel follow-through, an upper endoscopy and a colonoscopy – all had been unrevealing. Two gastric emptying studies showed mild gastroparesis, Ms. Lana had been non-adherent with the promotility agent that had been repeatedly prescribed, and had over the course of several hospitalizations become dependent on oxycodone, which would exacerbate her motility issues. Her illness was further complicated by HIV, hepatitis C, depression, alcohol abuse, and intermittent cocaine use. Our attending had actually taken care of Ms. Lana twice before. Her abdominal pain and nausea would be controlled at each admission, and after discharge she would not take her pro-motility agents or follow through with HIV and substance use care. At first,
K. Kolappa, D.E. Kern / Patient Education and Counseling 98 (2015) 1164–1166
this admission seemed no different. She was emaciated at 70 lbs, down 38 lbs from when our attending had seen her last. Her urine was positive for cocaine, though she denied using it, and she was requesting narcotics to manage her abdominal pain. The morning after admission our team considered the sensitive issues Ms. Lana faced and debated whether we should present her case at the bedside, as was our custom on rounds. Our medicine team that month was part of the Aliki Initiative, a novel pilot project at Johns Hopkins Bayview Medical Center. The case load for our team was halved, with the directive that we get to know our patients better and address their often complex social needs during and after their hospital stay. I knew that counseling would be invaluable to Ms. Lana’s care, but I was not confident in my own ability to traverse the fine line between acceptance and gentle confrontation in addressing her medication non-adherence, cocaine use, and narcotic dependence. I tried to talk my way out of presenting at the bedside, but my resident and attending would not let me off the hook. Our team decided that given Ms. Lana’s recidivism, it would be best to discuss all of these issues with her as openly, honestly, supportively, and inclusively as possible, which could be done privately with her in her single room. While presenting Ms. Lana’s case, I could not be sure if she was hearing me, as her eyes were initially closed. I leaned over the plastic bedrail and held her hand, while the rest of the team, who had also met with her the previous evening, formed a circle around her. At one point Ms. Lana’s eyes opened and looked at me. We talked about gastroparesis and explained our rationale for dietary adjustments and pro-motility agents like metoclopramide. We talked about how oxycodone, which she had come to depend on, was actually making her stomach troubles worse. We talked about cocaine and how it would also affect her appetite. We talked about HIV and how there were medications that she could take to keep her immune system strong. Her right hand, which had previously been limp, squeezed mine, signaling that she was hearing and connecting with us. Our attending looked at Ms. Lana and said, ‘‘We know that life has not been fair to you. You’ve been dealt a bad hand of cards. We’re just going to try to deal you one good hand.’’ I think that made all the difference. With this simple, yet empathic statement, our attending set the tone for the many conversations that would follow with Ms. Lana. And for me personally, he modeled our responsibility as healthcare providers to discard preconceived ideas, seek understanding, and offer acceptance and support. We went on to lay out a plan for the hospitalization with Ms. Lana’s full involvement. What followed surprised us all. Over the coming days, we learned more about Ms. Lana’s life. We learned that she lost both of her parents at age 7 and had been raised in a series of foster homes. Whenever I came into her room, Ms. Lana insisted that I sit down and watch television with her. We watched segments of the Godfather and lamented together Fredo’s betrayal of Michael Corleone. Ms. Lana told me that she had seen the trilogy 25 times. We learned that her best friend was a cat named Samson and that she lived in a difficult neighborhood with acquaintances who pushed drugs on her. Ms. Lana’s abdominal pain and nausea improved quickly over the next few days. She transitioned from intravenous fluids to a liquid diet to semi-solid foods, and ultimately to a normal diet. We supplemented her oral intake with nutrient drinks; strawberry-flavored Ensure was her favorite. We weaned Ms. Lana off oxycodone and started her on non-narcotic analgesics, which seemed to control her pain. She would never again ask for narcotics. On the Friday morning planned for discharge, Ms. Lana confessed to the team that she would be evicted soon from the apartment where she was staying. She asked to be kept in the
1165
hospital over the weekend so that she could be directly transferred to a group home. Additionally, she was afraid of returning to an environment in which drug use was encouraged. Although the team faced pressures for discharge, our attending made the courageous choice to keep Ms. Lana in the hospital over the weekend. That afternoon I went in to see Ms. Lana and apparently looked concerned because she asked me what was wrong. I felt my eyes well up and expressed that I was worried about her. She responded with, ‘‘I’m going to be alright. Y’all are going to take care of me.’’ The following week, we arranged for transfer to a group home for HIV positive women. We personally spoke with the case manager who would follow Ms. Lana at her primary care clinic to ensure a smooth discharge. We had the privilege of speaking and visiting with Ms. Lana several times after discharge. A few days after discharge, the whole team visited her at her new group home as part of the ‘‘Aliki experience.’’ When our resident asked Ms. Lana what we could have done differently during her hospitalization, she replied ‘‘Y’ all already done everything different’’. Several months later I found Ms. Lana at another group home on the outskirts of Baltimore. She was settled in with several friends at the home. She was in good spirits, was taking all of her medication (including her HIV medicines), and now had a new kitten named Socks. One of her caretakers in the house pulled me aside and said, ‘‘I didn’t want to say this in front of the other boarders, but Ms. Lana . . . that woman is about to die and is the cheeriest person in the world. Everyone knows she’s going to die, but she is just so happy and grateful. And if she’s that grateful, then we all better be.’’ Two and a half years after discharge from our service, Ms. Lana was alive and well, and in her own apartment. Yes, Ms. Lana was doing well, and in her own words ‘‘fat as a butterball.’’ We met her in her very tidy apartment cooking fried chicken, which impressively she could now eat. She had been off cocaine and all narcotics for over 2 years, was attending NA (Narcotics Anonymous) and AA (Alcoholics Anonymous) meetings, saw her health care providers regularly, and was managing all of her medications on her own, including insulin. She also had a boyfriend and went dancing on Friday nights in a nearby church basement. She was delighted to see us and felt proud to report that she was on ‘‘cloud nine’’. A follow-up phone call five years after discharge revealed that Ms. Lana was still doing well, living independently, and had had only one hospitalization since we cared for her. We provided Ms. Lana with patient-centered, personalized care. We also delayed discharge until we knew she had a safe place to stay and communicated personally with individuals who would provide care for her going forward. We may not have had the time or capacity to provide this kind of care and follow-up had the Aliki service not reduced our caseload. Was Ms. Lana’s care costeffective? We believe so. She gained a much improved health status and happiness. Her recidivism rate was markedly reduced, and she became successful at managing several chronic illnesses and a complex medication regimen. Getting to know Ms. Lana was not only a privilege; she was my ultimate teacher, better than the ‘‘perfect patient.’’ She taught me, as an impressionable thirdyear medical student, what kind of doctor I wanted to be and ultimately led me to pursue a path in psychiatry, where getting to know patients is paramount. All of us who worked with Ms. Lana learned something about our own humanity. We felt really good about being physicians. Acknowledgments We would like to thank Mrs. Aliki Perroti, whose contributions made possible the founding and initial years of the Aliki Service.
1166
K. Kolappa, D.E. Kern / Patient Education and Counseling 98 (2015) 1164–1166
Based upon patient satisfaction, physician satisfaction, and hospitalization readmission data, the hospital decided to continue the practice of a lower case load after cessation of external funding, not only on the Aliki Service but also on the other house staff inpatient internal medicine services. Expansion of our hospitalist
service, funded by the hospital, made this possible. We would also like to thank Dr. David Hellmann, Chair, Department of Medicine, Johns Hopkins Bayview Medical Center and Vice Dean, Johns Hopkins Bayview Campus, for his vision in creating the Aliki Service.
