Plenary 2. Vincent Lam - Narrative in Health Care - Telling The Story of Quality Patient Care
Transcript of Plenary 2. Vincent Lam - Narrative in Health Care - Telling The Story of Quality Patient Care
Narrative in Health Care – Telling
The Story of Quality Patient Care
Dr. Vincent Lam, CCFP
Emergency Physician, Toronto East General Hospital, Lecturer, University
of Toronto
Case 1: “Just can’t sleep”
• Patient: 81 year old South Asian woman
• History Present Illness: Unable to sleep, felt panicked last night, unwell this AM, no pain
• Other Stuff We Know: 3 months history exertional chest pain, suggestive of coronary artery disease, diabetes, hypertension, hyperlipidemia
• unable to meet target heart rate on recent stress test due to mobility issues, scheduled for Persantine scan (today!)
What’s The Story?
• Third visit to ER in similar scenario – ie:
unable to sleep prior to Persantine
• Son says: “The cardiologist says she must
have the test.”
• Daughter says: “This is the third time the
Persantine has been booked.”
• Patient says: “I’m scared of the test.”
Quality Options:
• A) ‘Standard of Care’: Tell patient there
she will have to do what her cardiologist
says.
• B) ‘Best Quality Health Care in World!’:
patient must not travel to India.
• C) ‘Quality Communication’: to weigh
options.
“Statistics cannot substitute for the human
being before you, statistics embody
averages, not individuals.”
Jerome Groopman,
How Doctors Think
Case 2: “It’s just a little cut”
• Patient: 18 month old boy
• History Present Illness: ran into coffee
table, smashed glass top, cut near eye
• Other Stuff We Know: waiting in ER for 6
hours, holding bag of cheesies, has
destroyed play room, WAY past bedtime
(11 PM)
What’s The Story?
• Mom: “Is this an emergency department? It’s
your fault! I’ve been waiting for hours! No one
told me not to feed her! you expect me not to
feed my child? I’m raising her on my own, do
you know how tough that is? I haven’t had a
good night’s sleep in months! You don’t
understand! You are an *%&hole! WHAT am I
supposed to do for three hours?”
• Patient: laughing hysterically, uncontrollable
The Story Continues…
• “You #*^%head, you @*&%ing (insert
racial slur), you can’t make me wait
around, I’m getting out of this @)(&hole!”
• Mother leaves with child.
• Observant nurse: “That’s a mom on the
edge.”
• Physician colleague: “Nicely done!”
Quality Options:
• A) ‘Duty of Care’, ‘Standard of Care’: Call Children’s Aid Services.
• B) ‘Mom-centered care’: Let the kid have a scar.
• C) ‘Quality Companionship’: Ask my supportive colleague for advice, then document his advice clearly in the chart, so that we can keep each other company in court.
Case 3: “She said she never
wanted life support…”
• Patient: 67 year old female
• History Present Illness: Unsteady on her
feet for several weeks, not seen several
days, found today unresponsive, in ER
with agonal respirations
• Other Stuff We Know: Living in basement
of relative’s home, husband died of
metastatic lung cancer within past year,
What’s The Story?
• Medical assessment: Critically ill, stroke,
pneumonia, needs intubation, aggressive
resuscitation for any chance at survival
• Family says: “She saw what her husband
went through. She said she never wanted
life support…”
• Meanwhile, in the overloaded emergency
department, “phew!”
The Story Continues…
• Sister: “It’s time.”
• Family, lots of family, “Come to say
goodbye to auntie.”
• Excellent internist: “Vincent, I just want to
see what you think about something…”
“Vincent, I just want to see what
you think about something…” • The words: I don’t know what’s going on here,
and I’d like your opinion.
• The subtext: You totally missed the boat, and I’d like to point that out in the nicest possible way.
• The upshot: This is going to be tricky…
• Medically: Intubation? Or…
• BIPAP? Chest tube? Is this life support?
Quality Options
• A) ‘Stick to Advance Care Directives’: No
further aggressive measures, because the
patient didn’t want life support anyways.
• B) ‘Highest Technical Quality’: Aggressive
resuscitation because we might save this
patient’s life.
• C) Is there a bio-ethicist on call?
???
“The practice of medicine is an art, not a
trade; a calling, not a business; a calling in
which your heart will be exercised equally
with your head. Often the best part of your
work will have nothing to do with potions and
powders.”
Sir William Osler