A Personal Book Review

  

      

     In his book How Doctors Think the author Jerome Groopman, MD presents an interesting perspective of human nature and clinical practice. He candidly discusses the causes of Medical Errors. In his own experience after much personal and professional reflection throughout his long career, he concludes that besides poor listening skills, detached clinical involvement, and lack of crystal-clear communication among patients and providers, “Diagnosis Momentum” is one of several derailers leading clinicians astray in their medical decision-making process.

 

        He also believed that many clinicians closed the diagnostic process loop prematurely. Thus, failing to begin a new diagnostic process on those patients with “difficult or elusive diagnoses”. This flawed approach or significant diagnostic short-sightedness is compounded because the clinician feels that all venues have been exhausted and there are no other differential diagnoses to consider given the fact that other providers sinched the most common presumptive dx, albeit wrongfully diagnostically speaking. Or our own clinical prejudices take us down the same path that others have ventured erroneously, therefore, failing to prove or uncover a disease state of the patient. 

        He also draws heavily from his colleagues & what he had learned from his colleagues (referrals) also seems to confirm his belief that whenever a misdiagnosis was involved in a negative outcome, it was always due to the rationalization that it was all due to psychosocial issues rather than organic issues. He also felt that many became less humane but more prone to stereotyping their patients.

        Dr. Groopman states clearly his thesis in the book introduction. Here he claims that a lack of inquisitiveness can increase clinical nearsightedness in any clinician.

 

        Fortunately, is not all doom and gloom, since medical error awareness has taken center stage in our industry. Systemic errors are increasingly recognized as many of the underlying factors contributing to medical misadventures.

 

         By understanding cognitively our shortcomings and negative attitudes, then we can begin improving healthcare delivery safety. But more so, by discarding those bad habits and incorporating our newly found knowledge and ethos can improve diagnostic reasoning.

 

So, yet another painful lesson can be learned from our practices. We need to maintain our patient advocacy call and vigilance up at all times and not let our professional guard down. We can no longer afford to be paternalistic nor disengaged or indifferent to the plight of our patients if we are to discard risky clinical outmoded practices. We can do better…we must do better. Without a doubt a great read for any clinician whether you're a novice or a seasoned veteran.

 

 

Strained Interprofessional Relationships: When PAs are ( unfairly) Scapegoated by Disingenuous Employers.

             Let me be direct and possibly blunt: The business world is rife with contempt, unpredictability, and unfairness. And so does the employing marketplace, especially when hearing or reading about uncertain revenue trends, increased regulatory burdens, and/or inconsistent or challenging reimbursement models seen across the Healthcare industry. Naturally many healthcare executive leaders or administrators are quick to point out & “vent about their financial organizational hardships” and how imperative is for every organizational employee to be fiscally responsible if they are to survive the current & continuous economic turmoil faced every day.

            Unfortunately, given these financial stressors & “reality” to most healthcare organizations, frayed relationships are beginning to rise & impact PA’s relationships with their CEOs & other deep-pocketed healthcare executives. Mostly due to deceitful dishonest corporate mandates or strategies used to curtail, eliminate or streamline salary-benefits packages of Advance Practice Providers ( APPs ). These alleged “financial woes” as given & used on many CEO-employee forums ring untrue and are very hard to stomach when there’s a deceitful agenda behind them; particularly if the company is thriving otherwise 

            Many clinicians fear and stand to reason this compensational “imbalance” has increased the divide and added to the frustrating rage an element of distrust especially when these executives make their obscene year-end “bonuses”. And since most APPs are not union members or hired as sub-contractual if hires we tend to be the “sacrificial lambs first”; after all, & often times we don’t have a voice nor representation as other company employees do.

            However, we do not need to see ourselves as the perennial sacrificial lambs as they would like us to. Our professional interdependence is not a parasitic one but rather a symbiotic one, technically that’s what we need to remind ourselves. We must not succumb to believing their “dualistic message” is the final word or amended dictated reality.

We are in the driver’s seat sort of speak; both directly and indirectly we can exert a profound influence on “advertising” and let’s not forget “public relations”—vital core issues for any business enterprise.

            Yet, keeping in mind that the business world is not regular, nor that industry forces are predictable, it’s best if collectively we remain flexible and adaptive in our transactional dealings with administrative executives.

            We must realize that we are worthy professionals. Also, we’re not doomed to be a submissive, subservient class because of protectionist views or activities exercised by other kindred groups in the industry. Our social reality is one of evolutionary progress as seen through the last few decades. Fallacious arguments and empty rhetoric must be scrutinized so we can think more rationally & proactively while not being fooled by half-truths, and misleading corporate metrics when sitting at the negotiating table with deceitful greedy employers. This day and age calls for a new negotiating perspective for all PAs. One of a “healthy mistrust of authority”. One that emphasizes searching for unbiased facts, probabilities, and objectivity to all stakeholders involved when seeking to find common grounds & simplify these discussions. In addition, we must learn to live comfortably with the uncertainties of the business world. The truth is there’s no single guarantee of legitimacy or truth when it comes to the information age, only skewed information lacking indicators of legitimacy. So try not to put all your eggs in one basket when trying to make an informed wise decision, but at the same time don’t victimize yourself by procrastinating due to paralysis analysis… especially when debunking some questionable corporate fabrications.

            Yet, time after time, whether privately employed or hospital employed, many APPs have found when they attempt to establish some form of dialogue to correct this disparity, or at the very least level the playing field then it becomes rather obvious to them we are always to blame even though we’re steadfast big revenue producers. How wrong is this? Don’t they realize that truthfulness goes a long way rather than obfuscation? Quite frankly, I would think this is not the role nor the message any transparent (ethical) healthcare organizations or employers would like to send to their internal/external constituents when portraying themselves as solid patient-centric community partners.

            Am I wrong? (think of Enron,& Wells Fargo corporate sins) – not exactly the pristine corporate behavior per se that they would like us to believe…right?

            You [we] have a choice; our career transactions are not always fated. The days of skepticism, pessimism, & illusionism are behind us. Moreover, we should be redefining this reality with optimism and a deeply rooted sense of PA pride.  

Biased Tell-tale PA Faculty Hiring Practices

        For all my colleagues who are considering transitioning into teaching, one word of advice: you must do it before you're older than 40 years of age. Otherwise, you could be considered past your teaching prime...regardless of how experienced or accomplished you have been in your PA career or professional journey.

        How do I know? What makes me an expert? Simple –I have lived it, so I am speaking from my very own firsthand experience. Sadly, implicit and explicit ageism exists even to this day in PA faculty hiring and retention practices. 

        And what I am about to say/share with you in this post, I suspect most likely will not be embraced by some if not by most of my peers.  Moreover, I am very aware & very prepared for the barrage. Yet, I feel it is my duty to be truthful and transparent on a few PA taboo issues such as this one– the huge Elephant in the room, sort-of-speak and everyone tends to be oblivious to it. 

        In all fairness to PA faculty recruitment practices, I will be the first one to admit that these faculty search committees often times strive for hiring fairness. Fair, perhaps, but in many instances not even close; sadly to say even as holistic their candidate selection criteria is advertised on their job postings.

        Why?  Because even with all the talk of practicing hiring inclusivity and aiming for diverse faculty retentive practices, etc., the reality is a very different one in academia when it comes to PA faculty selection. Unfortunately, there remains and unexplained gap; a dissonant one seen in many instances.  

        For example, while earning & shortly after obtaining my master's degree and working full-time as an EMPA, I was able to be a PA adjunct faculty member in one program and a guest lecturer at another one in the state. All while receiving excellent evaluations from my PA and non-PA undergraduate students from another local university. Doesn't my decade long teaching track record account for anything?  

         To date, after applying for several local PA programs within the past 4 years, having published over 95 non-clinical articles & commentaries in various PA Journals, spoken at various state yearly conferences, & served as an advocate at the state level for my profession through the years, all I have received has been only 2 phone interviews, but no invitations for a face-to-face interview.  

        If we (they) are as serious as they say they are in hiring qualified diverse faculty members, then they may have to rethink their hiring policies or protocols when hiring younger & much less experienced peers over older/senior seasoned colleagues. Because ageism (the unspoken practice) is still alive and practiced in many subtle ways is detrimental to potential experienced PAs by sidelining and disallowing them to be enriching contributing faculty members to the next generation of PAs. 

      Furthermore, practice what you preach w/o exceptions if you're a social justice advocate and authenticity & credibility is a core value of your system. Better yet, actively combat this myopic hiring practice. Lastly, who gets to be your faculty is just as important as who gets to be your PA student.

PAstroika: Metric or just a trendy Buzz word?

In recent years we have seen trendy terms & concepts come and go. However, when “transparency” became entrenched in our day-to-day vocabulary, our day-to-day expectations and/or dealings with all businesses, it kind of felt different. It truly began feeling right, not to mention it felt hopeful when it came to any type of transactional accountability expectations between two parties.

Used in a transactional and transformative business new paradigm context, it seemed like we were moving in the right direction—one leveling the playing field. For a moment, it seemed transparency represented a new higher standard of corporate behavior sought, expected or even aspired by all parties involved—external and internal customers included. Particularly when seeking to build mature & respectful relationships among both stakeholders.

But in recent years, we the PA community have disappointingly witnessed 1st hand how difficult this process has been for some companies to engage in it, and adhere through their public promise to embrace transparency and reform. 

The offending TV Networks

Unfortunately, I can not think of a more hypocritical & unprofessional  example of this issue than the unflattering portrayal of the PA profession through the TV major Networks. For instance, one of the most recent derogatory media references was when our profession, was  ridiculed in a satiric comedy show titled “Night life” aired on Feb 23rd, 2015. Essentially in this particular episode our education & training was utterly mischaracterized and trivialized as nothing more than “scut monkeys” pushing paperwork while trying to become physicians. 

As if that wasn’t enough, on March 4th,2014 the PA profession was again disparaged on prime time TV on the O’Reilly Factor broadcast. 

Similarly, he [ O’Reilly ] basically grossly misrepresented our rigorous PA training and the quality of our care-giving services by stating that we were akin to “Lenny”— a fictional community college graduate metaphor he used to compare our background against physicians. Contextually through his commentaries that night he implied the American healthcare consumer receives subpar care when care-giving services are provided by the Physician Assistants’ community.  

To this author and the PA community this Fox News report was extremely offensive, denigrating if not to mention unfair and unbalanced. It makes one wonder what ever happened to fact checking when reporting not only on a professional group, but anything else too. Almost a la “Rolling Stone” magazine "Faux pas" before the days of cancel culture. 

Along the same vein, even ousted Nancy Snydeman, MD former NBC New’s Chief Medical Editor misspoke about our background/role and our limited prescriptive abilities when caring for patients in a segment aired March 11th 2011.  In her defense and unlike the other TV show producers, she later, tried to correct her statements on her Facebook page the next day. Somehow, it felt insincere.

        So how did they slipped into these non-transparent behaviors? 

Essentially, at the core of their mischaracterized broadcasted reports was the fact they did not bother to research nor present factually the issues. Instead, would have they sought a more balanced reporting, these probably would have shown/depicted a very  more balanced group of highly schooled and skilled healthcare professionals: namely Physician Assistants community

        Unfortunately, journalistic integrity is dead & all three networks choose to forego their journalistic responsibility and the end result was the grossly and inaccurately misrepresentation of a highly validated & well-respected, cost-effective care-givers professionals to the healthcare consumer. 

Sadly, these examples illustrate the inherent egregious blunders each TV network committed and failed to apologize for their offensive and insulting aired transgressions. Generally speaking, these dismissive organizations not only lost value in the eyes of the PA community, but credibility as well tto this author. Clearly, not correcting the error will resonate negatively in our minds when it comes to TV network transparency. Thus, allowing their overt corporate arrogance to alienate us. 

Isn’t “transparency” bi-directional? 

If we as clinicians, are urged and expected to talk openly about our mistakes, foibles, and disclose harm done to patients and apologize promptly and sincerely, shouldn’t we expect the same from the business/TV industry? I /we would think so.

Therefore, doesn’t the PA profession deserve the same degree of respect, transparency in return?

         So far, it does appear that being transparent to the healthcare consumer is not nearly as important as garnishing high TV ratings, even if it’s disparaging a venerable profession. Frankly, these examples illustrate the inherent egregious distasteful blunders each network committed while failing to apologize for their offensive and insulting transactional transgressions.

These transparency Faux Pas certainly open the doors to speculation and debate on some companies understanding of this expected new transactional behavioral accountability. In short, transparent relationships do matter if you expect to have a trusted engaged readership, and/or viewership in these cases.  

In the world of the competitive diminishing market share & good customer relationship management, one thing is (and should be) key--transparency must be at the top of the list; anything less than that would be a problematic agenda for a TV producer and/or reporter…don’t you think?

Ten Verbal Blunders: Credibility liability in our practices.

Through the years I have seen some of the best clinicians instantly loose all credibility when letting a verbal blunder slip into the verbal interaction @ hand. At a glance what appears to be an honest assertion or an insignificant remark to us, it might not be so to a patient.  Moreover, these tongue slip-ups can rob you of your credibility if not great trusting rapport that you have enjoyed for years.

The following statements or phrases are those culprits alluded too:

1. “It’s not a big deal”: While the single closure of a wound might have not been your very best that day after countless other ones through the years, for the patient  this statement  would be received as you didn’t take the time or cared for the cosmetic outcome. Your careless statement basically discounted their trust.

2. “It’s a slam dunk”:  Sure, easy for you to say since you’re not the recipient  of an unfamiliar procedure or intervention for an anxious or distrusting individual of the medical industry. Patients like to be informed of all attendant risks…not some or partially. 

3.”You’re making this more difficult than it really is”: Your empathy just went out the window with that negative reassuring comment –if you thought it was one. Best practice would be to say, “I will do my very best to minimize any pain or discomfort or possible complications”. ‘I/we will get you through this together”.

4.“Bee sting” : The sight of a needle is anxiety provoking even in the “toughest folks” or “weekend warriors”. Downplaying the discomfort even with the best of techniques doesn’t help anyone under these circumstances. Pain or discomfort should never be “embellished”—just be truthful from the outset. Is best if you tell them you will be as gentle as you can be. Again, never say  ”this won’t hurt you”.

5.”There’s nothing wrong with...” This dismissive statement simply translates into the patient’s mind that you doubt his/her concern or complaint being legitimate. 

Before closing the door diagnostically speaking it might behoove you to do some preliminary testing or investigation. Avoid early diagnostic closure, ( aka Anchoring—a medical heuristic ) especially if there’s a unexpected or bad medical outcome.

6.”Guaranteed, this will...” get better and/or resolve in 2 days…2 weeks… 2 months. Assurances are best to leave out of discussions, rephrase outcomes or your expectations in terms of probabilities instead. For instance:..”my best guess is…” by using this statement,  the patient will be less disappointed if the course of the illness or ailment takes longer to resolve or improve.. Early resolution, and you are a hero—simple as that.

7.”Sorry for the delay, we’re busy today.”  Patient’s view their time just as important as yours. If there’s a delay notify them @ once and explain that you will be late. They will be appreciative if you can re-schedule or give an approximate time of seeing them. Saying you’re busy is not as good as saying an impromptu situation caused the delay thus requiring your immediate attention before seeing the patient. Always close or state you appreciate their patience & understanding.

8.”Oopsie”: Not something you want to say when a mishap or an error happens. This word does not mitigate the bad outcome or the unintended consequence even though you might think so. Be honest and use a direct approach when explaining what went wrong or possibly caused the departure. Stick to honesty.

9. “I’m the best @ this”:  Based on whose opinion—Consumer’s report? They think not. Perhaps stating how many X-Y-Z procedures you have done with safe outcomes might be more prudent and less arrogant-sounding to their ears. Moreover, it would be best if your supervising attending physician or colleague would endorse you by saying or praising your accolades even though there’s nothing wrong feeling you’re the right person for the job or task at hand.

10. “I have nothing ‘ else’ for you…I wished“: Short of a terminal illness which you can always consider palliative or hospice care, you must consider exhausting all medical resources and/or venues before uttering this “I/we’re give up” on you. We must keep a balanced perspective (naturally) and accept that we are not to engaged in practicing futile medicine, but we must not abandon ship to soon if there’s some significant statistical chance of medical recovery. 

Sometimes another medical perspective is reasonable and needed. Remember, each and one of these statements, words or phrases could easily undermine your patient’s trust. Place yourself in your patient’s shoes if your to be the recipient of these verbal faux pas. You would feel resentful or upset at the very least. Don’t you think?   

So, before you engage your tongue …you must engage your brain to avoid these verbal blunders be part of your day-to-day communication.