Both Sides Now – Part II

The art of facilitating without getting in the way

The 95-year-old lady was accompanied by her two elderly daughters, who regarded their mom with a mixture of respect and fear. Her chest x-ray showed lobar pneumonia, and her sputum gram stain (yes, we used to do this) showed gram-positive cocci in pairs and chains, confirming her ill hypoxic tachycardic presentation to be due to pneumococcal pneumonia, a common, painless, often fatal illness for elderly patients.

The intern launched into a 30-minute discussion of code status, graphically explaining intubation, fractured ribs, poor prognosis, and the alternative of focusing on comfort. He was careful to remain neutral and not overly influence their decision.

The utter failure of that conversation was enhanced by the fact that the patient spoke only Italian, and the translators were her increasingly distraught daughters. The ladies just stared at him. There was no connection. He left with an upset patient and family and an unsigned DNR form.

The lady survived the night. Daylight brought the usual post-call clarity. The intern expressed his frustration with Dr. Z, the patient's attending physician. Dr. Z. invited the young doctor to accompany her to visit the patient.

After a warm greeting (including a hug), the internist sat beside the bed.  “Mrs. S, you have a very serious illness. Dr. X here did an excellent job caring for you last night, and I think you will be OK, but if your heart stops or you are unable to breathe on your own, we will let you die naturally. Given your age and health, I think that is the correct way to proceed. Is that alright? Do you have any questions?”

Watching the patient and family’s relief as they nodded and thanked their doctor, this intern remembered thinking, 'Wait! What just happened? She’s not supposed to tell the patient what to do. Is this even legal? Is it ethical?’

He thought about the dozens of lectures on medical ethics he had attended, the warnings against paternalism, and the need for shared decision-making in which the doctor outlines what medical care can achieve, and the patient articulates their values.

The conversation he had just heard was an ethics textbook coming to life. He had tried to present facts and demand that the patient incorporate these facts with her values and tell him how to care for her.

Only with time did the intern understand what he had witnessed. Dr. Z knew her patient well. She knew the right thing to do medically and what her patient wanted - not only what kind of care she did (and did not) want, but also what kind of doctor she wanted.

Medical facts are seldom facts. They are likelihoods, often drawn from flawed data, applied to the infinite variety of patients and situations. Patients often require assistance in articulating and applying their values and wishes to a complex situation. A successful collaborative plan of care incorporates medical realities, uncertainties, and patient preferences. It goes down most easily when the one offering guidance is invested in the results, particularly in a relationship of trust.

Dr. Adam Cifu introduced a new term, “Parentalism.” It isn’t a real word. While it sounds like paternalism, a red line appears underneath each time I use it. Dr. Cifu intended parentalism to mean giving clear guidance based on knowledge, beneficence, and respect for the patient's values and expectations.

Parentalism in medicine differs from parenting. The patient can choose whether to comply, whereas the child does not have the same option. Both the provider and patient have the option to decide whether to continue the relationship. Parents and children don’t have this choice. What should be shared in both is an emotional investment in the outcome.

Paternalism implies a condescending or patronizing egotistic effect where a power imbalance exists between the provider and the patient. Shared decision-making has merit, but it offers doctors a way out. In shared decision-making, doctors can often get away with not knowing enough to provide strong guidance, not being decisive enough to offer genuine recommendations, and not being brave enough to take responsibility. To walk home free of blame for the results.

This concept can be applied to healthcare management.

The level of complexity in healthcare has grown exponentially, driven by skyrocketing regulatory requirements, metrics imposed by outside parties, and compliance concerns within corporate structures.  Often, it is not healthcare itself that is so difficult, but the system controlling its delivery.

Administrators are experts in some aspects of that system. They can either use their skills to facilitate or impede the mission. It is a choice. There is no cure for “don’t care.” There is no remedy for valuing compliance and career over results and execution. Nothing good will occur when the job becomes disconnected from the reason the institution exists in the first place.

The best managers protect workers from distractions that impair performance, facilitate the process and quality, and, most importantly, they have an emotional investment in the outcome. They know enough to give advice and care enough to acknowledge when their input isn’t helpful. They manage relationships more than just work.

Consider technology. Most physicians feel overwhelmed by information. Technology should alleviate stress, not add to it. Access to information is not enough. What is critical to enhancing care is surfacing relevant information- clearly, and in the moment, it matters.

Interoperability – the ability for systems and organizations to securely exchange and use health information is foundational to a simpler, more connected healthcare experience. When IT support is outsourced, often to locations on the other side of the world, an essential level of connectivity is lost.  

When decisions are controlled remotely, the mission itself loses meaning. While top healthcare administrators often speak of the mission, they would struggle to articulate how their function contributes to achieving it.

On the other hand, frontline workers and providers can mistakenly attribute their personal experiences to systemic dysfunction. This error is as serious as the administrator who makes the job about himself. Management’s task is to look at the delivery system at both micro and macro levels. That view may be lost up close.

As with our physician–patient illustration, a successful collaboration between management and provider incorporates realities, uncertainties, and preferences. It goes down most easily when the one offering guidance is invested in the results and has built a relationship of trust.

With so many components to our health care delivery, fragmented systems and mistrust of others’ priorities will always exist. A clear articulation of the mission and the nurturing of a shared culture are the only hopes of building a bridge.

I have little hope that this will occur within corporate medicine managed by large systems, where neither the mission nor the culture is shared, and trust was lost long ago. I have faith we can preserve this within Evergreen Family Medicine. We must. Our own integrity, purpose, and success in addressing the needs of our community depend on it.

Tim Powell MD