Recent Posts


July 26th, 2017

When a Child Receives Care at a non-Children’s Hospital

Emily F. Moore, RN, MSN, CPNP-PC, CCRN practices pediatric cardiovascular care across the Pacific Northwest.

In a recent post, I wrote about my niece’s episode of appendicitis. Another part of that story relates to her post-op course. When my sister first called asking my advice on whether or not her daughter needed to be treated, I didn’t specify where she should take her. She ended up going to a general hospital with a pediatrics unit. There, my niece was treated by surgeons and other clinicians who primarily see adults. Here’s what happened.

Less than 24 hours after surgery, I arrived at the hospital to find her slumped over in bed with visible retractions and oxygen saturations around 88%. When I asked about pulmonary toileting and basic nursing care, such as ambulation, positioning, and rolling over in bed, I was told, “We aren’t bullies; we don’t make our kids do that.” When I asked how making a child deep-breathe and walk to prevent nosocomial complications like pneumonia was bullying, I was dismissed. Never one to let things lie, I kept asking questions, and I soon concluded that the institution itself was not familiar with basic pediatric care. Despite being only 8 years old, my niece still needed to sit up, walk, and use an incentive spirometer. (And since when is an oxygen saturation of 88% okay for anyone, assuming there are no signs of cardiopulmonary disease?)

Photo by ccmackay at

My niece spent close to a week in the hospital and was sent home despite my sister’s concerns regarding things “just being off.” When my sister told the staff that she didn’t think my niece was eating well, she was reassured that this was normal and that discharge was the next step. At home, things continued to worsen, and two days later they returned to the emergency department for continued abdominal pain, diarrhea, and low-grade fevers. Once again, my sister’s concerns were dismissed, and after urine was dipped and “clear,” she was sent home, after being told that my niece was recovering and everything was okay. I was quite surprised that in the setting of postoperative pain and fever, an abdominal imaging was not done and labs were not sent. Two days later, my niece’s symptoms worsened, and I advised my sister to go to a children’s hospital.

Initially annoyed at me for suggesting another institution, my sister immediately saw why she needed to be there. From the animals on the walls to the different colors on the floor, it was clear to her the moment she walked in the door that the care would be more geared towards children. And from the moment they saw a physician, there was no question that the expertise had shifted from an adult provider who sees children to a pediatrics-focused specialist. When my sister first explained the course of events, she was listened to. The physician said, ‘I am sorry this has happened to you; not only is your daughter’s care our concern, but your comfort with her care is as well.” My sister was instantly put at ease and felt that they were in good hands. She thanked me for insisting that they drive the extra miles for my niece to be treated there.

My niece was diagnosed to have three bowel abscesses and a bowel fistula. She ended up being started on total parenteral nutrition and was hospitalized for an additional nine days. Her care team made sure that both my niece and my sister were ready when it came time to go home. Thankfully, this story has ended well for my niece, who is now active and healthy again.

Working at a children’s hospital myself, I sometimes forget how different the worlds of pediatric and adult health care can be. I often go out into the community to educate first responders about pediatric heart disease, and I have realized that while treating kids is normal for me, many of them are uncomfortable with it. (The opposite is true for me… give me a kid any day! Adult-sized patients make me incredibly nervous and uncomfortable.) Also, as demonstrated in this case, a common theme in pediatrics is to treat the family, not just the patient. If a parent has a concern about his or her child, it is addressed. So, when this doesn’t happen in a clinical care setting, I am often surprised and taken aback. I strongly believe that parents know their children best. From my perspective as a pediatric care provider, if you are telling me that your child isn’t back to normal and just seems off, then we should probably take a step back and reevaluate the situation.

My niece’s limited care was likely related to the institution’s focus on adults rather than pediatrics. I know that there are many general hospitals with above-average pediatric units. However, this whole situation made me think, should there be more standard practices in place to ensure that children are well cared for everywhere? Should pediatric hospitalists be present at general hospitals? Or should more pediatrics training be conducted at these hospitals? Presumably more trainings and simulations would help ensure a high quality of care for children regardless of where they receive it.


Register Now for more NEJM Journal Watch Content

July 20th, 2017

Needing a Vacation after your Vacation? Primary Care Providers Feel the Same!

Elizabeth Donahue, RN, MSN, NP-C, practices adult primary care medicine in Boston, MA.

I just finished a week of vacation and, truth be told, I’m seated at a bar on this particular Sunday night seriously considering early retirement. Small problem being, at the tender age of 34, it’s probably a little too soon for this to be a feasible option. I’m trying to figure out how to make retirement work because I’m seated at this bar because of its excellent internet connectivity and not because of the attractive cocktail list. I have a salad and a glass of water and my laptop before me. I’m checking messages, prescription requests, and lab results from the last week — preparing to return to work tomorrow, hoping to reduce the to-do list before I’m physically back in action and actively adding to it.

I know that I’m not alone in this experience. A physician colleague returned from her own vacation about two weeks ago and since we she was in Europe (where she was less able to dock in remotely), she was completely overwhelmed on her first day back in the office. A full clinic day scheduled, with the backlog of messages and requests, and just one really sick patient to manage can leave even the most competent and experienced provider flummoxed. And all of this occurs despite having in-office coverage by a colleague for “urgent” requests and likely several hours of advance work put in by the provider in the week before vacation. It’s leading me to be a little more inquisitive about vacation practices in healthcare settings.

A photo from my recent vacation in Burlington, Vermont (Lake Champlain in background)

How much vacation do most providers take? Are there specialties that find it easier to take a vacation than others (perhaps some that have less continuity of care burden)? What is the impact of all of the technology we have in 2017? Electronic health records make accessing messages and records outside the office quite easy, smartphones connect our work email instantly, almost unavoidably keeping us tied to work? Why do providers struggle with completely “signing out,” and are patients willing to accept that providers need time off too?

A quick internet search shows that general vacation policies in the U.S. are widely varied. Ours is one of the only developed countries that does not have labor laws dictating that employers MUST provide paid vacation time to employees. Other developed countries are required to give employees an average of 2 to 4 weeks of vacation per year. Small U.S. employers are unlikely to give any paid vacation while other companies have recently begun to provide unlimited vacation time (most are startups and technology companies but this has also been seen with more traditional companies like Grant Thornton and General Electric). I’m not sure unlimited vacation time would get any legs here in the healthcare industry! Like U.S. vacation policies and practices in general, those among healthcare providers also seem to vary; one survey in 2012 showed that anesthesiologists and radiologists reported taking nearly twice as much vacation time as their colleagues in family and internal medicine.

Wareham, MA

How do you manage your vacation time? How often do you find yourself checking in when you’re not in the office, and how do you support your colleagues when they are on vacation? I’d love to hear about your experiences.

All early (OK, really early) retirement dreams aside, I will likely work until the average primary care provider retirement age of 65. Until then (actually, until my next vacation), back to that to-do list!”


Register Now for more NEJM Journal Watch Content

July 12th, 2017

You Might Be an American Physician Assistant in the U.K. if …

Megan Tetlow, PA-C

Megan Tetlow, PA-C, is from Fort Myers, Florida, now working in Sheffield, England, as part of the National Physician Associate Expansion Program.

Somewhere between figuring out what foods classify as puddings* and learning how to make the physician assistant (PA) role work within the National Health Service, my colleagues and I find that we have arrived at our 1-year anniversary of working in the U.K. As I reflect on both the successes and struggles of adapting to life here, my overall thought is how far we’ve come and how much we’ve grown, both professionally and personally. I would like to look back at some of my own growing pains with a segment I’ll call:

“You might be an American PA in the U.K. if …”

  1. … you never call anyone by the correct title.

Megan, Miss Fiona Kew & the robotic surgery team

I had heard before coming to the U.K. that (male) surgeons historically styled themselves as “Mr.” and not “Dr.” The use of this title dates back to the 1700s and earlier, when surgeons wielded a knife but did not necessarily have formal medical training in the form of an M.D. Fast forward many years, and surgeons are M.D.s and are admitted into the Royal College of Physicians, but they’ve kept the “Mr.” title as a point of professional pride. Knowing this, I was still surprised by the array of titles. For example, I work for four surgeons in the gynecologic oncology department. They are professionally titled, “Mr.,” “Dr.,” “Miss,” and “Professor.” “Miss” does not indicate marital status. “Dr.” can also be a surgeon. I am still not completely clear how the “Professor” title works. Beyond doctors, head nurses are “Sisters” and the senior head nurse is titled “Matron.” These titles do not indicate gender. While I’m on the topic of titles, the CEO of my hospital has been knighted and therefore is a “Sir.” I had the pleasure of meeting him, and he introduced himself by his first name, which I respectfully ignored in favor of saying “Sir Andrew” — because how many times does an American girl meet a knight?

  1. … menial tasks all of a sudden are incomprehensibly difficult.

Like opening doors. One of three buttons needs to be pressed before you can open it. Pro tip — it’s not the green one. That is an emergency switch. I may or may not be speaking from experience. I’m also remembering my first attempt at dialing a number on a U.K. telephone. “Do I just type these numbers?” I asked. “Like, all of them??” My mobile number has 11 digits, 13 with the country code. “Is that a busy signal or is it off the hook?” And you’ll need either a manual or an incredibly patient work colleague the first time you have to bleep (that is, page) someone.

  1. … you are suddenly a terrible speller.

I knew that in the U.K., some words were spelled with an added “u” that we don’t use in the states — colour, favourite, humour, etc. I was not prepared for all the other added letters. For instance, the “o”s — oestrogen, oesophagus, diarrhoea (the “o”s are silent, by the way), and the “a”s — gynaecology, orthopaedics, anaemia (“a”s also silent). Then there are the “s”s instead of “z”s — modernise, realise, organisation. Maths is plural. Sport is not. Probably easier to just accept that you are going to confuse all of these and often use American spellings in British patient charts, and British spellings when you email American friends, and everyone is going to think you are a really bad speller. Which now you are. Welcome to life as an expat healthcare provider.

*Answer: Puddings = desserts, in general. Except if you are talking about a Yorkshire pudding, which is a type of puffed pastry served with Sunday roast. Or if you are talking about black pudding, which is blood sausage that is usually served with a Full English breakfast. None of which are American pudding.



Register Now for more NEJM Journal Watch Content

June 27th, 2017

Bring Back the Letter of Condolence

Harrison Reed, PA-C, practices critical care medicine in Baltimore, MD.

I don’t remember the first time I watched someone die. I don’t remember the second or third time either. But I know it happened when I was 24 years old, and I know that, afterward, I went home, ate dinner, and went to sleep. The next morning I woke up, put on a clean pair of scrubs, and did it all over again.

Before I could even grow the scruffy hint of a beard, death had become a constant companion. But that didn’t mean participating in someone’s death ever felt routine, or that I grew numb to its significance. If anything, the effect was the opposite.

The more I encountered death, the more I saw it as an important chapter of life. And I made it my duty to ensure that my patients and their families navigated this often-saddening event surrounded by as many positive experiences as possible.

But as a brand new physician assistant in the intensive care unit of a mega-hospital, that desire was no easy accomplishment. A medical ICU at an academic center invites the intersection of two conflicting concepts: the close bonds that can form between clinicians and patients (or their families) over a prolonged hospitalization, and the factory-style shift work that keeps the entire process functioning.

That concoction produces the same scenario time and time again: we meet people with their every vulnerability flayed open to the world, guide them through their personal hells, and tear ourselves away at the end of their lifespans or the end of our work week, whichever comes first.

For patients and families, it must feel cruel. On the other side of that hospital bed, they may have found a friend in the most unexpected way, only to have that person vanish at the worst time. Then a new stranger appears, ready to restart the process.

That level of interchangeability clashes with the intimacy of death. At this most significant time in their lives, we pummel our patients’ families with a barrage of white coats.

The idea of dehumanizing medicine, especially at the end of life, began to bother me so much that I wondered if critical care was the right field for me. In my search for consolation, I found an article written by Dr. Gregory Kane. In it, he described a bygone tradition once commonplace in medicine: the letter of condolence.

By writing a letter to deceased patients’ next of kin, Dr. Kane argued, clinicians can offer families an irreplaceable level of support. We can reassure them that their loved one’s life was significant and that he or she mattered to the medical team not just as a patient, but also as a person.

Soon after I read Dr. Kane’s article, I faced a particularly difficult experience saying goodbye to a patient and her family. It was the first time I had considered writing a letter of condolence, but it seemed more appropriate than ever. I later detailed the entire experience in my essay “The Letter.”

To many people, this act probably sounds overly sentimental. Any kind of attachment might be unwise, or it might be seen as a sign of weakness. Despite the occasional lip service, our medical culture doesn’t place a premium on emotional sensitivity. Besides, isn’t letter writing out of fashion?

As those doubts grew, I decided to write a second letter. This one was to Dr. Kane. I told him how much I appreciated his advocacy for the letter of condolence and how writing one myself had convinced me of its value. I also said that I hoped the idea would see a resurgence, that it might catch on with a new generation of medical providers, but I worried I couldn’t convince others to spend precious time and energy on such a task.

His response was, unsurprisingly, wise.

Just share your experience with anyone who will listen, he said. “That will say it all.”

And now I have.


Register Now for more NEJM Journal Watch Content

June 20th, 2017

Mending Broken Hearts: A Profile of a Heart Surgeon

Alexandra Godfrey, BSc PT, MS PA-C

Alexandra Godfrey, PA-C, practices emergency medicine in North Carolina.

“Resilience makes space for feelings. It’s different from depersonalization—something that we see in medicine today. The depersonalized response to tragedy is ‘too bad, so sad, get on with it.’ Depersonalized physicians believe feelings are too risky and painful, so they can’t imagine that feelings exist in others.”—Ross Ungerleider, MD

Ross Ungerleider, pediatric cardiothoracic surgeon at Driscoll Children’s Hospital in Corpus Christi, Texas, is ranked in the top one percent of his specialty and has for the past twelve years been listed as one of America’s best doctors. Over the course of his 40-year career, he has repaired the hearts of more than 6,000 children.

Ungerleider’s office is a shrine to children with congenital heart defects. Children’s cards and paintings cover the walls, leaving his awards stacked along the baseboards. Textbooks he’s written sit beside a model heart, and a box filled with artificial valves occupies the coffee table.

I ask, “How many heart surgeries are too many?”

He looks me in the eye. “Every single one.”

Ungerleider’s journey began when his mother took him as a child to the Chicago Roosevelt Museum (now the Museum of Science and Industry). There he saw an enormous model of the human heart with patches and valves lowered into it on strings like a complicated marionette.

His fascination was not just scientific. His parents were divorcing, and he was trying to understand the collapse of his family.

“I was amazed by how orderly and precise it all looked,” he says.

Dr. Ungerleider as a child

For ten-year-old Ross, the model made sense of broken hearts.

Years later, the summer before he left for college at Wesleyan University, his stepfather was killed in a tragic accident. “A divorce is devastating,” he says. “It makes it harder to relate to the people you love because they’re not in the same place and may say awful things about each other. But they’re still there. I understand the permanence of death. I never take lightly the fear of the parents of the children I operate on.”

On the day that his mother drove him to college, they heard a song on the radio — Tony Bennett’s hauntingly beautiful “Who Can I Turn To?” His mother looked into his grieving eyes and said, “I’ll find that record and send it to you.”

On a crisp New England morning a month into his undergraduate studies, he received a call telling him that his mother had unexpectedly died. Stunned and numb, he went home for the funeral. When he returned to campus, “I was walking across the football field, looking at the stars and wondering, what would become of me? How was I going to make it? “

The next morning, he received a package in the mail — “Who Can I Turn To?” Mailing that record had been one of the last things his mother ever did.

Ungerleider now believes that his mother died of Broken Heart Syndrome. Shortly after her death, his English professor read out loud an excerpt from the Yeats poem, “The Circus Animals’ Desertion.” As he read, “I must lie down…in the foul rag and bone shop of the heart,” the professor went to the window, raised it to take a deep breath, and said, “You are all too young to understand.”

But Ungerleider understood.

He graduated from Wesleyan University with a major in English, a thesis in biology, and highest honors. It was 1970. The Vietnam War was raging, and the draft caused a surge in applications to medical school, making admissions far more competitive. Like his peers, he was afraid that his dreams would be shattered. He watched a friend throw a chair at the television when his number was called.

Dr. Ungerleider operating in Panama

Ungerleider was accepted into medical school on his third attempt, landing at Rush University in Chicago. After medical school, he went into the CT surgery training program at Duke, helping start Duke’s pediatric heart program in 1986. He spent 23 years at Duke, first as a resident and later as faculty. He subsequently worked in Oregon, Ohio, North Carolina, and finally Texas. Through hard work, determination, and trial and error, he became an expert in heart defects with special expertise in aortic valve surgery.

Ungerleider believes that his parents’ divorce, followed by the loss of his stepfather and then his mother while he was still so young, gave him the resilience to withstand failure and the empathy needed to care for patients — probably two of the most important skills needed in medicine today.

As a child in Chicago, Ungerleider had been mesmerized by the soft, incessant “lub, dub,” of the model heart in the museum. And looking back now, he recognizes that the exhibit highlighted major breakthroughs in the management of congenital heart defects. Heart-lung bypass had just become a reality.

But at the time, “I only knew that, if I became one of these surgeons,” he says, “I could fix the broken hearts of other kids.”


Register Now for more NEJM Journal Watch Content

June 15th, 2017

Educating Patients About HPV Vaccination Can Feel Like Peddling Snake Oil

Elizabeth Donahue, RN, MSN, NP-C, practices adult primary care medicine in Boston, MA.

Messaging and medicine have always gone hand in hand. A Google search for wellness products of yesteryear produces a vibrant collection of ads for lotions and potions. Cod liver oil, hair tonics, and other extracts (including opium!) were promised to keep you feeling healthy and looking great. And using medical professionals to bolster product claims has long been popular in marketing. Even big tobacco companies used physicians in their print ads, citing doctors’ preference for a certain brand of cigarettes, or proclaiming one type “more filtered” or “less irritating” than the next. How effective they must have been!

Of course, these advertisements came at a time when consumers had less access to information. Now patients can see a list of ingredients, read a statistical analysis of outcomes, and rely on FDA and CDC data. Rules around advertising and claims about medicines have changed drastically. So why, in 2017, does it sometimes feel like I am peddling snake oil?

I particularly feel like this when it comes to recommending the HPV vaccine. Attending a lecture last week, I was relieved to hear that other providers feel similarly. The talk was given by an expert in STD prevention and treatment. As the conversation around HPV turned to the vaccine, and we were reminded of indications, insurance coverage, and other practical pearls, one pediatric NP asked others to share techniques they found successful in convincing parents to vaccinate their children. To be clear, low HPV vaccine uptake isn’t a case of anti-vaxxers refusing the intervention as part of an overall philosophy; rather, HPV vaccine refusal is repeatedly found in practice among a staggering number of patients and families who do opt for other vaccines. In my internal medicine setting, I see adult women, previously unvaccinated and about to age out of coverage, continuing to decline the vaccine. They do so because they recall their mothers declining it on their behalf during a shared office visit 10 years earlier.

But here’s the thing about the HPV vaccine — it really DOES do what it is supposed to. And what it is designed to do is a pretty big deal — preventing a virus that we know causes cancers. We have no other tool in our arsenal that actively prevents cancer in this way. We can reduce our risk through behavior avoidance and early screening for several of the most prevalent cancers, but this vaccine prevents the development of disease.

One commonly cited barrier to vaccine uptake is stigma about the sexual nature of HPV. HPV vaccines prevent disease transmitted through sexual contact. Anecdotally and from research findings, we often hear that parents resist because they are uncomfortable talking about the sexual health of their young children, or because they reason that it will lead to increased or earlier sexual activity (see this JAMA commentary). The data I have seen support the vaccine on those counts; in this cross-sectional study and this review, for instance, authors found no evidence of changes in sexual behaviors in vaccinated groups when compared with their non-vaccinated peers.

As for possible solutions, some experts suggest desexualizing the conversation – pointing to non-sexual routes of HPV transmission and non-genital cancers. Another possibility might be to consider nontraditional settings for vaccine education and administration. For instance, school-based anti-HPV programs in Australia include non-compulsory vaccine days that have resulted in coverage of more than 70% of the targeted adolescent female population and are already showing decreases in infections and cervical abnormalities. An extension of the program to adolescent males has also demonstrated success.

Since attending that lecture, I have come to see the conundrum more clearly. I think that I had taken on my patients’ reticence to the vaccine by osmosis, which was negatively affecting my communication. I was almost apologetic when bringing up the vaccine recommendation and as a result was presenting my customers with a “soft” sales pitch. I would start off with something like, “I understand your concerns, but…” And when they would decline, I would leave the room wondering why I hadn’t closed the deal, while my rational brain was still screaming about the power of prevention, the data, the efficacy! I now realize that negative patient views of the HPV vaccine had subtly affected my approach – made me timid in my discussion and gave validation to their concerns, weakening my argument from the start. Now I am more adamant, I go in for the close right away: Here are the studies, the vaccine works, now let’s get down to business.

If you’ve found a successful approach to convincing hesitant patients or parents of the HPV vaccine’s importance, I’d love to hear about it. Please share it in the comments below.


Register Now for more NEJM Journal Watch Content

June 9th, 2017

How Giving Friends and Family Medical Advice Made Me Sick

Emily F. Moore, RN, MSN, CPNP-PC, CCRN practices pediatric cardiovascular care across the Pacific Northwest.

The other night, my sister called me asking if she should take my niece to the emergency department.  She had been complaining of abdominal pain with on-and-off vomiting and diarrhea for a couple days.  According to my sister, she had gotten to the point where the pain was unbearable. I quickly ran through my niece’s symptoms, asked a few questions, and developed a differential of what I thought it might be. I was quite certain she had an appendicitis, but thought perhaps I was overreacting given that this was my niece, not my average patient. Come to find out, she not only had an appendicitis, but her appendix had ruptured and she was quite ill.

Since I graduated from nursing school, it is not uncommon for my family or friends to call seeking medical advice. Initially, I didn’t think anything of it. I was flattered that my (large) family trusted me with their queries. However, as my practice began to focus more and more on pediatric cardiac surgery and less on pediatric primary care, I began to recognize how much I did not know regarding noncardiac body systems.

This left me not only constantly questioning the advice I had given, but also worrying about the legalities related to the situation. Granted, I was not actually prescribing for or treating my family, but they were querying me frequently over fevers, rashes, ear pain, stomachaches and the like. With each query, I would second-guess myself and perseverate over advice given. What if I had dismissed that rash as contact dermatitis and it was actually infectious, an allergic sensitivity, or something more bizarre? I couldn’t help but think that if the advice I’d given over the phone was wrong, I would land in court defending myself. This was an irrational fear, as I didn’t actually think that my family or friends would sue me. Nonetheless, it caused me a great deal of stress.

Another unpleasant side effect of trying to help was the pushback I received. The level of questioning I got in response to my advice was almost insulting at times. In my head, I told these callers, “If you trusted me enough to call me with your ailment, why aren’t you trusting my opinion?” “If Dr. Google says otherwise and you already researched this, don’t ask me.” “If you generally want my opinion, I am happy to give it, but please, I can’t stress it enough, do not rebut me with the latest entry on Wikipedia.” Of course, I never I actually said any of this.

Things came to a head when I was surrounded by a lot of severe illness in my family. Naturally one to externalize my stress, I began to notice various physical symptoms and poor sleep setting in. I knew I didn’t need to see my primary care provider, but I wanted to address my stress level. So, taking advantage of my employer benefits, I consulted with a naturopath, who recognized my infirmities as anxiety over giving my family and friends the wrong medical advice. I love my family, and I certainly love helping. However, the thought of providing misleading advice was almost crippling. I found myself thinking and rethinking the most simple of complaints.

After seeing my naturopath, I decided to cut the cord on providing medical advice to non-patients. My clinician gave me strict instructions to not respond to texts after 7 PM. As those hooked on communication devices (all of us, it seems?) can imagine, this was like having an itch I couldn’t scratch. The compulsion to check my phone haunted me. Nevertheless, I stuck to it, and I also made a plan to set firm boundaries with those calling with medical questions. I started telling people things like, “My specialty is pediatric cardiology and cardiac surgery. I am sorry your finger is swollen, but you’ll have to see your provider if it is bothering you” and “I can help change a dressing, but no, I will not buddy tape your toe and diagnose it as broken. For that, you need to see a provider.”

Slowly but surely, the healthcare queries stopped. I do still get calls; the case of my niece is a perfect example. I would be upset had my sister not called in that situation. Overall though, the number of queries has lessened and, most importantly, I can sleep at night again.


Register Now for more NEJM Journal Watch Content

May 31st, 2017

Curing the Toxic Culture: First, Honor Thy Patient

Harrison Reed, PA-C, practices critical care medicine in Baltimore, MD.

In March I wrote a blog post for In Practice that detailed some of the devastating effects of a toxic workplace culture. It’s worth a read, but the main points are easily summarized: abusive environments in medicine affect nearly every aspect of professional performance and hurt both businesses and patients. They lead to lower productivity, higher absenteeism and turnover of employees, and decreased patient satisfaction. At least one large study has even linked poor workplace culture to higher patient mortality.

But I pulled a nasty trick in that last entry. I showed you a problem — and hopefully elicited some level of concern — and then dropped the mic without offering a solution. There’s a good reason for that: I don’t have one.

If there were one easy answer to fix healthcare culture, I would bottle it and travel the country selling it out of the trunk of my car. But in reality the cure for the culture is likely multi-faceted, a million small drops in an enormous bucket. Facing an insurmountable task, however, is no reason to procrastinate. There are some things we can do right now to start filling the bucket.

Step #1 starts with the most obvious but often obfuscated part of the equation: our patients. We can’t expect to treat each other better if we don’t first respect our common mission. The following ideas may prime the pump for a better patient care environment.

Photo Credit: Harrison Reed

The Right Address 

A name is often the first thing you learn about a patient when you pick up a chart or knock on an exam room door. How we address patients, to their faces or among ourselves, sets the tone for the entire relationship.

“When did our patients stop being ladies and gentlemen?” I remember one of my favorite physicians asking a room of students during my training. A respectful title might be the only way someone maintains dignity after he dons a faded hospital gown. Default to “sir” or “ma’am” or the respectful cultural analog. If patients later want you to call them by their first name or their nickname or their Twitter handle, leave that to their discretion.

Even with the best of intentions, few things are as condescending as calling an adult stranger “Honey,” “Sweetie,” or “Dear.” Early in my career I made this mistake, thinking it would comfort my patient as her blood pressure plummeted and she neared cardiac arrest. With her last few seconds of consciousness she turned to me and said, “That’s ‘ma’am’ to you.”

She was right.

They’re Listening

Regardless of their clinical condition, assume your patients are listening to you. They probably are. Exam room curtains aren’t soundproof and endotracheal tubes don’t block tympanic membranes. Even sedated patients are often aware of their surroundings. And families walking through the halls definitely are.

Speak to — and about — patients as if they can hear you at all times. Sure, it might look silly when you update an unresponsive person on his care plan or talk a sedated patient through a procedure. But some of you have probably discussed your dating woes with your pet cat, so you can certainly manage this.

Talk Nerdy

Conversations with patients and families represent a minefield rife with opportunities for miscommunication. Clinicians who spit out too much medical jargon can leave laypeople dazed and confused. Conversely, dumbing down a subject below your patient’s understanding can add insult to injury.

While we are often taught to limit medical terminology in discussions with patients, I like to use it and then quickly define or explain it. This covers both of the above scenarios, and the quick education can inoculate your patient against the next clinician who comes in flinging technical terms.

Incremental changes can, over time, increase the sense of professional pride in your workplace. The kindness you show your patients is much more likely to translate to respect among your colleagues. It’s a small but important step toward curing the toxic culture.


Register Now for more NEJM Journal Watch Content

May 18th, 2017

Changing Health Care — Reflections from Across the Pond

Megan Tetlow, PA-C

Megan Tetlow, PA-C, is from Fort Myers, Florida, now working in Sheffield, England, as part of the National Physician Associate Expansion Program. She practices in gynecologic oncology and is a guest blogger for In Practice.

I’m an American physician assistant living and working for the government-funded National Health Service (NHS) in the U.K. I also write for this blog about the differences between the U.S. and U.K. health systems. I have thus far been moderately successful at avoiding political discussions in the public sphere. But the recent passage of the American Health Care Act by the U.S. House of Representatives has me changing my tune. Let me explain why.

Scrolling through social media, I saw a GoFundMe page from a family struggling to cope financially in light of an unexpected diagnosis — a heart-wrenching story of a young mom diagnosed with cancer while pregnant. Now she (and her spouse) face the financial and emotional complications of undergoing primary chemotherapy and radiation while caring for a newborn and two other young children. Any parent can tell you how difficult it is to care for a newborn, much less doing so while undergoing cancer treatments … and taking care of other children … and not taking too much time off work lest you lose your job and, with it, your employer-sponsored health insurance and main source of paying medical bills. The most disturbing part of this story is how shockingly prevalent it appeared to be. I realized we live in a world where a working American family must rely on the charitable donations of strangers to have a chance of survival.

When British health care providers talk to me about health care in the U.S., their great fear is of patients needing care that they won’t receive because they can’t afford it. I explain private insurance and Medicaid and how many practices treat patients regardless of their ability to pay. But the truth is, there are millions of families who make too much to qualify for Medicaid but not enough to afford top-tier private insurance. And even if you have good insurance, you’ll likely have to pay a large amount out of pocket in addition to your sizable monthly premiums, should you ever actually need to use it. For instance, my mother broke her shoulder last year, and despite good employer-sponsored private insurance, she paid $8,000 out of pocket for the required surgery.

Unfortunately, these problems will only increase if the American Health Care Act is passed by the Senate. For example, the home state of the patient described above could choose to make cancer a pre-existing condition. If that happened, she could expect her insurance premiums to skyrocket. Even more troubling, under this new act, the patient’s pregnancy itself could potentially be classified as a pre-existing condition.

It has always bothered me that in the U.S. health system, one diagnosis or hospitalization can equate to economic ruin for a patient. However, it was not until I became a health care provider and resident in another country and in another health culture that I acquired a different perspective. I no longer believe that these situations are unfortunate—rather, they are inevitable. But they should be avoidable, and and I find them no longer tolerable.

I also find it intolerable that a health care bill opposed by the American Medical Association, American Academy of Family Physicians, American Nursing Association, and other professional medical organizations could be presented to Congress as a serious plan, let alone passed by the House.

I had always thought that as a health care provider, it was my duty to do the best I could for my patients, within the restraints of the system. I worked hard to help patients who couldn’t afford treatment to get linked up with charity groups or patient assistance. I filled out Medicaid applications and sent appeal letters to insurance companies. But I didn’t fight to change the system. Now, I believe that as health care providers, we must go a step further and become patient advocates, fighting bad health care policies as vigilantly as we fight disease. Our patients deserve it.


Register Now for more NEJM Journal Watch Content

May 11th, 2017

Leaving Against Medical Advice (AMA): A Clinician’s Dilemma

Alexandra Godfrey, BSc PT, MS PA-C

Alexandra Godfrey, PA-C, practices emergency medicine in North Carolina.

“You’ll have to sign out against medical advice (AMA) . Your blood pressure is high.” The ER physician stood in the doorway of my room.

“What difference would it make now?” I asked.

The doctor fiddled with the cuffs of his white coat, then glanced at his cell phone.

I picked up my car keys.

“High blood pressure is dangerous,” he added.

I looked down at the floor, watching puddles form around my feet as the snow melted on my UGGs. A cold wind blew snow against the window, causing the blinds to rattle.

“I don’t know the cause of death,” I said.

The doctor tapped his foot on the floor; “You could have a stroke. And your insurance might not cover this visit, if you leave AMA.”

I leaned forward in my chair, holding my head in my hands. It was then that I saw the photograph tucked in the top of my purse. Perhaps this would help?

I reached into my purse and offered the picture to the doc – that grainy ultrasound image of my son.

“Do you want to see his picture?” The doctor shook his head. I crumpled in my seat. Tears gathered.

“High blood pressure might damage your kidneys or your heart,” he said, crossing his arms over his chest.

Damage my heart?

I bit down on my bottom lip, then formed my hands into a temple. My obstetrician had insisted I come to the ER.  I hadn’t wanted to come. The experience had been awful from the beginning.

I looked at the doctor through the arches of my fingers.

“Do you own a dictionary.” I asked.

“Yes – why?”

“You should look up the word empathy,” I replied in a quiet voice.

I got up then and walked out. I did not look back. Not once.

I had never left a hospital AMA before. And I have not left AMA since. Even now, years on, I know I made the right choice. It changed everything.

The AMA Dilemma

Certainly, patients discharged against medical advice are both a concern and a challenge for healthcare providers due to the increased risk of both litigation and adverse medical events. Furthermore, these patients are  more likely to be readmitted for the same or a related condition. Additionally, they frequently suffer from serious underlying pathology.

What does leaving against medical advice (AMA) mean?

When a patient leaves AMA, the patient is leaving before their treating physician recommends discharge or despite medical advice to the contrary.

This definition implies the patient received and understood the medical advice given. In practice, the term AMA is often used regardless of whether medical advice was given or not. Additionally, patients are frequently required to sign an AMA form. Unfortunately, these attestation forms are often confusing, coercive, and written in language beyond the reading level of the patient.

This creates two important questions:

  • If a patient does not have sufficient information or understanding to make informed decisions, are they in fact leaving against medical advice?
  • Shouldn’t health literacy be a consideration in AMA discharges?

Who leaves AMA?

Identifying those patients most at risk for leaving AMA is important if we are to design interventions to prevent it. Variables include:

  • Alcohol or substance abuse
  • Male sex
  • Low socioeconomic status
  • History of leaving AMA
  • Black race
  • Psychiatric disorders
  • Absence of health insurance
  • Homeless

AMA Healthcare Disparities

Certainly, the choice to leave a medical facility lies with the competent patient, but the choice to designate the discharge as AMA lies with the medical provider. Despite this, there is a lack of data about providers who discharge patients AMA. To fully understand AMA predictors, we need to know more about clinicians.

It is well known that clinician attitudes vary based on patient characteristics. Such variability may shape the quality of care given. Stigma may result in lower quality care resulting in poorer outcomes. Furthermore, if you consider the groups most at risk for AMA discharge, there’s clear intersectionality between them. For instance, a black sexual minority male is more likely to be homeless, less likely to have insurance, and at higher risk of depression or other mental illness. Consequently, a disproportionate number of patients leaving AMA come from stigmatized or marginalized minority groups.

Why do patients leave AMA?

Recognition of the reasons patients leave can help us negotiate these encounters. They may include:

  • Personal and financial obligations
  • Breakdown of communication between the patient and medical staff
  • Dissatisfaction with care
  • Lack of trust in the healthcare provider
  • Not understanding the need for further testing or treatment

Medico-legal Considerations

Above all, providers need to be aware that the simple signing of an AMA form does not confer absolute medico-legal protection. Furthermore, not giving discharge instructions, follow-up or medications could be construed as coercion, negligence or unwillingness to consider alternative options for the patient. Moreover, advising a patient that their insurance will not cover their visit if they leave AMA is not only incorrect but could also be considered coercion.

This article provides an excellent review of medico-legal standards.

In Conclusion

For me, leaving the ER AMA gave me precious time alone with my son. Moreover, it removed me from a hostile and unpleasant situation. I returned to the hospital the next day to deliver my son. He had died suddenly in the second trimester. No amount of ER medicine would have changed that outcome. My experience that night precipitated my return to education and pursuit of a career as an emergency medicine PA.

Certainly, the onus is on all providers to carefully examine the role that their bias, language, and behavior might play in triggering an AMA discharge. Furthermore, patients must understand the medical advice given and the potential sequelae of their decisions if we are to document AMA. Providers should take time to explore their patient’s thinking and engage them in shared decision making. Repairing the patient-clinician alliance may help facilitate communication and rebuild trust. And of course, you don’t get told to read the dictionary…

Register Now for more NEJM Journal Watch Content

NP/PA Bloggers

NP/PA Bloggers

Elizabeth Donahue, RN, MSN, NP‑C
Alexandra Godfrey, BSc PT, MS PA‑C
Emily F. Moore, RN, MSN, CPNP‑PC, CCRN
Harrison Reed, PA‑C

Advanced practice clinicians treating patients in a variety of settings and specialties

Learn more about In Practice: Reflections from NPs and PAs.