Nothing brings out the mama lioness in me more than seeing one of my cubs not being treated as well as I think it should be.
Recently I had the unusual experience of accompanying my oldest daughter into an unfamiliar hospital for a minor surgical procedure. Now this daughter isn’t exactly a cub — she’s a full-fledged adult, with a master’s degree in health care administration, a husband, and two small boys of her own.
But as I watched the OR team prepare her for surgery, I started to feel like an odd combination of a mama lioness and a secret shopper. To the staff members who came in and out of the hospital’s preoperative area, it was clear that I was simply the family member in the corner, and they probably figured I had little clue about what was transpiring. Meanwhile, I was taking in every detail. Some tasks were performed excellently — others, not so much.
The hospital where her surgery took place is a small community hospital on Long Island. It enjoys a location where Jerry Seinfeld, Christie Brinkley, and other wealthy New Yorkers maintain lavish homes for weekend and summer holidays.
My daughter was instructed to arrive at 6:30 a.m. Her procedure involved an initial stop in radiology, to be followed by the actual surgery. As a veteran of hospital life, I questioned whether radiology even opened that early, but we had no way of checking. So we left her house at 5:25, driving carefully on dark, icy roads with fresh snow, and lining up for a 5:40 a.m. ferry ride from her home town so that we could arrive at the hospital by 6:30.
The good news — a valet met us at the hospital door and whisked away the car, so we had only a moment to savor the 20-degree weather and the harsh wind that made it feel colder. My daughter was promptly escorted to a private room to change clothes.
Hurry up and wait
A nurse gave her an insulated paper gown with two openings to connect it to a wall-mounted forced air warming unit. This, I thought, was a wonderful thing. Where I’ve worked, we had forced air warming blankets in the ORs but the hospital wouldn’t spend the money to put them in the preoperative areas. I thought of Tina Fey, playing an immigrant from Albania in a Saturday Night Live spoof of the HBO series “Girls”, and imagined her saying, “In my country, we do not have such things.” Within minutes, my daughter’s gown was hooked up to the warmer and she was feeling much cozier.
Then we waited.
The nurse started her IV and we had a nice chat.
After 45 minutes, the door opened and a man in a white coat and scrubs came in, pushing a “cow” — a computer on wheels. He introduced himself as the anesthesiologist. He parked the “cow” at the foot of the stretcher, facing the window, at a right angle to his patient. He proceeded to ask her all the usual pre-anesthesia questions about oral intake, medications, and prior surgery, all the while typing busily on the keyboard and occasionally turning his head to look at my daughter.
This is the sort of behavior that gives physicians and the electronic health record (EHR) a bad name. We had already been told that the operating rooms weren’t terribly busy that morning, so time pressure wasn’t an excuse. My daughter is perfectly healthy — a nonsmoker, normal weight, on no medications, and definitely not pregnant. She’s the definition of an ASA I patient. So there wasn’t much the anesthesiologist would need to do except check off a lot of “No” boxes on the pre-anesthesia assessment form. Why wouldn’t he talk to her face-to-face first, and then check off the boxes?
At least he took the time to listen to her lungs with an actual stethoscope, something I have trouble convincing my residents and fellows to do even on major thoracic cases.
Then he went back to the computer and typed some more. Still looking mostly at the screen, he gave my daughter a rote explanation of what was about to happen, including placement of an “airway device” in the back of her throat, and informing her that a nurse anesthetist would also be taking care of her. He asked if she had any questions, which she didn’t, and he left. My daughter looked perfectly satisfied with this interaction, so I kept my thoughts to myself.
By 8 a.m., the radiology team finally arrived and took my daughter for the first portion of her procedure, which took about an hour. When she came back, the OR circulating nurse arrived to interview her.
“Any allergies?” she asked.
“ChloraPrep,” my daughter replied, for the umpteenth time that morning.
The nursed paused in her review of the chart. “ChloraPrep? Really?” she asked.
The tone of disbelief in the “Really?” was the same tone I imagine she might use with a narcotic-abusing patient who claimed to be allergic to ketorolac and Tylenol. I could feel my mama lioness hackles rising.
My daughter, who is a nicer and more tolerant person than I’ll ever be, explained patiently that during a prior C-section, she had developed a bright red rash in a perfect square on her lower abdomen, exactly where her skin had been painted with ChloraPrep. The rash was severe enough that it required topical steroid treatment. Her obstetrician advised her to avoid ChloraPrep in the future.
“Oh,” said the nurse, apparently surprised at receiving a calm and rational explanation. She still looked dubious, and I’m not sure she believed my daughter, but at least it seemed likely that ChloraPrep wouldn’t be used.
By 9:30, three hours after we arrived at the hospital, my daughter finally left for the OR. I left to take over the care of their two little boys so that her husband could be there when she woke up, have the opportunity to speak with the surgeon, and bring her home.
You always remember the negatives
In fairness, everyone else who looked after my daughter was perfectly nice. She had an uneventful anesthetic and surgical procedure, and is doing just fine. She is quite content with the care she received, and her only real complaint afterward was unexpected soreness in her forearms that was probably the temporary result of having her arms abducted during the procedure.
Clearly, I’ll remember how annoyed I was with the anesthesiologist and the OR nurse much longer than anyone else will. But the point I would make here is that many other family members of surgical patients probably remember these interactions more clearly than the patient does. After all, the patient’s attention is focused on the upcoming operation, and patients often lose recall after receiving a premedication such as midazolam.
Points worth remembering:
The EHR is often the enemy of good clinician-patient interaction.
The family member in the corner may be paying more attention than we think.
I’m glad all went well for your daughter and that she is recovering. If I had the choice of who would be by my side in such a medical situation, it would be you. Let me share just one instance when I was the patient, and my daughter was the lioness. After removing my clothing and putting on a paper gown, we waited for almost an hour in a freezing room. The warm up thing must be new. I also wished to have either you or my daughter with me on other occasions when the doctor neither used a “cow” to take down replies to his questions, nor did he ask any questions.
Clearly, the EHR is the latest obstacle in the way of the doctor-patient relationship. All those boxes have to be filled in or the chart is incomplete, and most of us are not touch typists, so we have to look at the keys and that takes us further from the patient. The nurses have the same problem as they make their rounds of the inpatients. I could see that clearly, having been one of those inpatients on a few occasions. The EHR is wonderful for storage and retrieval. but it may require that each of us has his own scribe to do data entry as we interact with the patient.
Nice article Karen. Did you identify yourself as an anesthesiologist to your daughter’s doctor? I wonder if the interaction would have been more “professional”. In my tenure as a Chief of Staff of a large medical center, I learned that there are many different personality types, levels of empathy, production pressures, personal difficulties, system obstacles (such as the electronic health record), rules and regulations, performance metrics, and many other things that make out lives as physicians more difficult. But the bottom line is that patients deserve better from all of us. Being an attentive listener is easy if you try and empathetic discussion with your eyes focused on the patient takes very little time and means so much to those who are frightened by their current situation. We should all treat patients like we want to be treated. We’d have a much better health system, despite the artificial bureaucratic obstacles thrown in our way. And the observer in the corner might see things differently.
Dear Dr. Boudreaux,
Thank you for writing! No, I didn’t introduce my self as an anesthesiologist. It seemed to me that would have been a bit obnoxious, and I didn’t want either to make anyone nervous or to look as though I was demanding special treatment in any way. I have used an EHR for a couple of years now, and see no need to type and interview at the same time. In fact, I feel as though I do a better job of listening to the patient if I don’t multitask.
All the best,
If we’re honest, many of us are guilty of “rushing” through the pre-op interview. Some times more than others. Although, I’m usually in trouble for taking “too long.”
Add EHR and you’re fried. Still no excuse.
I make a point of finding out my patient’s occupation, but must confess, I don’t inquire about that of the “family member in the corner.”
If I know their occupation, I won’t change what I do, but I will adapt my vocabulary, especially if they’re in the medical field.
Perhaps, it’s not a bad idea to introduce yourself with your occupation, even as a family member. Can’t do harm.
Still, there’s no excuse for lack of eye contact and “proper” communication!
Karen: Wait until you are actually the patient, as I have been frequently in recent years. “Modern Medicine” is terrifying for someone who actually knows a better time – far closer to the quality offered by Lucy in Peanuts than that taught by Sir William Osler!(Except the charges are more like Tiffany than like even Sir William’s charges.) It’s already too late to fix it, Karen! Which gives rise to the question: “Is it better to be like your daughter and not to know how bad the care is, or as we do, remember a better way?”
I’m glad that some parts to that day were positive – i.e. quick out of the cold due to the valet, the warming unit, and that the surgery went well. I had surgery in December and they gave me one of those warming units to use in pre-op – it was wonderful. I have had interactions with a few medical professionals in my lifetime in which I have had similar experiences. I have never figured out if they were just having a rough day or if they just had a horrible bedside manner.