A pediatrician writes about a remarkable resident and family-centered care

The KCRC prides itself on providing family-centered care from the housekeepers to the pediatric attendings. Families participate in all the interdisciplinary team meetings and share in making clinical decisions. Families serve on the KCRC Advisory Board and search committees. And the KCRC values each patient and his or her ability to make functional and developmental progress at their own rate. Insurance payment for inpatient head injury rehabilitation is based completely on the established metrics of cognitive and physical recovery from trauma or disease. The KCRC staff champion all the children, infant to adolescent, especially the most disabled. Well, usually, that is….

This six-month old baby, a former 28-week premie, was making no progress and had made no changes since she had been transferred from the NICU three months earlier. Not even a reflexive suck or doll’s eye opening. No change in her vital signs. Not even diurnal variation in her body temperature which remained rock solid at 94 degrees even with swaddling. No response to cuddling in the rocking chair or lullabies from the nurses. One of the parents called the nurses’ station regularly every afternoon to inquire about her progress, but they had long stopped visiting. There were no wrist rattles or pretty pink onesies hanging on her crib.

The family wasn’t ready to take her home with their other three healthy children and they weren’t agreeable to her transfer to a nursing home. The doctors, the nurses, the social workers, the finance officers, the Clinical Ethics Team, their family doc and the local public health nurse had all tried unsuccessfully to reason with the family. The lullabies gradually stopped, the pediatric team skipped that crib on morning rounds and the chart notes became more about the responsibilities of the institution than the rights of the patient. A Medicaid nursing home bed was identified in Richmond and transportation for a safe transfer was arranged with one of the KCRC nurses in company. A final summit with the family was planned on a Saturday morning……who on the team had the best rapport or the most power? Who would sit in the family lounge over coffee and deliver the absolutely final eviction notice? There were no volunteers.

I was the inpatient attending outlining the tasks for the weekend, including the parent conference scheduled on Saturday morning. I had assumed that I would end up doing the dreaded duty. But no, my intern, Dr. H., suggested that she thought she would like to try…she had answered the phone yesterday at the nurses’ station when the mother called in and she had given the 24-hour update to the mother. It felt like a connection to Dr. H. I acquiesced but felt a little guilty in doing so, And so it was that I dawdled in the house staff office, waiting to be called for the inevitable rescue of my first-year resident. And here she was at my elbow…

“We need a priest….right now,” she said to me.

“What for….? I can probably get the hospital chaplain on call to come in,” I replied, more than a little nonplused by the urgency of the conversation and the unexpected call for clergy on a Saturday morning.

“No, no!” she insisted. “We need an honest-to-God Catholic priest…right now, before they change their minds.”

“Okay, okay, but what’s happening about the transfer? Shall I call the ambulance service?” I pressed. “What’s going on in there? Shall I come in with you?”

She shook her head and rushed to say: “No, no.” Her words erupted: “I introduced myself and sat down. And right away …when I asked about the baby’s first name… you know how you’re always supposed to call the baby by her name when you deliver bad news? I think you taught me that even… the mother started sobbing and I got her a Kleenex, you know, I had the box right next to me just like I was supposed to….well, I put my arm around the mother’s shoulders and patted away and she just kept sobbing…then the father explained that their baby didn’t have a name, probably not even a soul …because she had been too sick in the NICU to be baptized, and then the chaplain was a Unitarian and now she would end up in limbo if she went out in the winter air to get to the ambulance… and then out on the highway to Richmond there might be an accident ….she’s so little and the traffic is so fast on route 64.” She took a quick breath and kept going. ” SO, I need a Catholic priest right now… and the baby’s name will be Mary Beth, and then the baptized baby Mary Beth can go live at the nursing home in Richmond… then, if anything happens to her, she will go straight, absolutely straight without questions asked, to heaven… and then, the parents can go back to church again, to Saturday night confession again and take communion at Sunday mass with all their neighbors…. It’s okay, honest, we just need a Catholic priest right now.”

And so I called St. Thomas right around the corner from the KCRC. We had a priest in no time. No one seemed too concerned that his Saturday morning attire featured sandals, jeans and a clerical collar under a sweat shirt. Dr. H. and the nurse stood in as godmothers. The baby was duly baptized “Mary Beth in the name of the Father and the Son and the Holy Ghost. ”

The Pediatric faculty and residents at Monday’s morning report were stunned when Dr. H. reported the successful transfer of Mary Beth, the hugs from these most difficult parents and the general disbelief of the KCRC staff. Dr. H. was recognized at the formal Rotunda dinner the following June as the most family-centered resident in Pediatrics. And the staff and faculty at the KCRC reflected once again that family-centered care is redefined by each family and not by the staff.. Isn’t it grand to have all those idealistic students and residents around to teach when we wise ones lose our way?

A nursing school faculty member talks about a graduate seminar

One experience that stands out is when I co-taught a graduate psych seminar with a psychologist. We started teaching this small group in 1996, neither one of us really knew each other, so we had to have a lot of trust in order to figure out how to co-teach as well as how to work well together for the students. It just became a real positive time in my week, and I think she has said the same thing, that we both really looked forward to Thursdays because it was a day when we were not only teaching the students but we were also trying to model to the students what it was like to be in a collaborative relationship.

We would start each class with a co-round. It was a 3-hour class with about six or seven students, and we would spend the first hour going around the room and doing a check-in period. She and I both participated, but we were able to model how much to disclose, boundary issues, a relevant thing to bring to the group in terms of peer supervision.

I come at this from a nursing perspective with a psych/mental health specialty. What was also neat about the experience is that although we came from different disciplines, we really showed a lot of respect for each other’s discipline so that when a student would bring up something that had more to do with nursing care, she would answer. But then she would say, “Well, Sarah has an idea about that.” And if it had something to do with brain anatomy or physiology, I would say what I thought, and then I would say, “But I know that she has a different take on that, and she might be able to talk a little more about the limbic system and how it affects behavior.”

We didn’t think about this, it just naturally occurred that we were modeling collaborative teamwork in this group. And we got to know the students really well because of the processes that we used, and we also got to know each other really well.

The other part about this that was special was the environment. Because I had just been selected to live in one of the Pavilions up on the lawn, and we said, “Hey, we have enough chairs, we have sofas…” So we met there, and we’d have my golden retriever on the floor wagging his tail, wanting to be loved. And we had really ratty old sofas – they were like something you would find at the Salvation Army – and people would come in and you had to be comfortable because there were these thick sofas with pillows and blankets.

It was in a beautiful setting, and people looked forward to coming just because they got to walk through the garden to get to class. Sometimes at the health system I’m a little isolated from the academical village and once a week, it brought me to thinking, “This is really the ideal, to be teaching a seminar in a room that’s like a coffee shop.” And I think that changed the whole dynamic because we could have had the same people sitting in this sterile, bright room, and I don’t think we would have gotten the same outcome. People felt comfortable talking about difficult psychiatric cases. We needed a private environment; we didn’t necessarily need all this academic stuff. We needed more something that would simulate a psychotherapist’s office.

When I had to start teaching this seminar by myself, I grieved for that a little bit, and I thought, “Oh, I’m missing something.” And I also wasn’t teaching in the Pavilion anymore. Well, what I did was, the next semester I had seven students, and I taught it in a small room, and I brought in lighting that was low lighting; we were able to turn off the fluorescent lights and have low lighting.

I did some other creative things, like we’d start out each session with either a guided imagery, or some kind of relaxation or deep breathing for the entire class. It sounds a little touchy-feely, I know. But at the same time, when we looked at the Standards of Care for the psych mental practice, relaxation was in there 27 times in a 14-page document. And so I thought, “What better way to teach that than to say,

A firm director writes about the growth of a resident

One of my greatest graduate medical education pleasures is watching new M.D.s evolve into physicians. Few faculty members enjoy the same broad vantage point that firm directors hold. The 3 year window during which we supervise, precept, and mentor residents with their continuity patients allows us to see them uniquely. We see them as they tentatively struggle to find the correct forms on the first day in ambulatory clinic, and later as they gain a confidence among their colleagues marking a successful transition to second year. We see them as they sort themselves into generalists and all variety of sub-specialists. We see them finally as they complete their residencies and commence the job of directing their own education. When I first set out to write about a success in graduate medical education, I was thinking of something I witnessed in a specific resident….. Retrospectively, witnessing her transition may be much more generalizable.

My resident arrived from a prestigious medical school full of optimism that science and study and diligence were master for any problem that an ambulatory clinic patient could present her. She dressed sharply, had a shiny stethoscope, and quick answers in her assessment and plan….. but was surprised by the subtleties as they unfolded in the first patient we shared. She clung to a naive optimism. A little more study and diligence would prevail. When a non-English speaking patient had difficulty in registration, she took him there herself and translated. When he had trouble getting a prescription, she picked it up at the pharmacy and shipped it to him.

Several months into internship she received a page from one of her newly assigned clinic patients. The woman was in pain. The pain was unbearable. She had no medication. No clinic appointments were available during the harried resident’s ICU rotation. Other doctors were not helping. The husband was outraged. The young resident prescribed medication over the phone in escalating doses while scrambling to find a way for the patient to be seen by anyone to initiate a comprehensive pain management strategy. With the patient’s calls spinning out of control, and frustrated by a system that seemed to make it impossible for her to meet the desperate patient’s needs, the resident paged me for help. I suggested that she gather a little background and, indeed, the patient was using multiple physicians and pharmacies. The betrayed resident lashed back at her manipulator. This was a bad patient. All symptoms were contrived. All problems were obstructionist. Any maneuvering by the patient was threatening. She lapsed into a self righteous and na

A pathology professor talks about the art of self evaluation

The story that I am recounting is actually when I was a medical student. I was in my surgery rotation and loving it, and I was paired up with a general surgeon who was notorious for being pretty rigorous and pretty crass. But for some reason the two of us got along extremely well, and so even on his private clinic days he allowed me to rotate with him.

It came to the end of the rotation, and I was pretty sure I was going to get a good evaluation from him. I went into his office, and he handed me a blank evaluation. He said, “You fill it out.” He said, “You have 15 minutes. Go into the other room while I am seeing this patient and fill out the evaluation.”

Of course, it was so hard for me. For somebody who tried to be humble, trying to rank yourself on a 5-point scale! I was looking at all the items on the form, and I thought, “You know, I really did do pretty well in this, but do I give myself a 5 for that?” So I tended to downgrade myself on some things. I turned it back to him after 15 minutes, and he looked at it, and he shook his head at me and handed me another blank one. He said, “Now fill it out honestly.” So I went back and again just couldn’t get myself to put 5’s down for anything. Again I turned it back to him, and he shook his head again, and he said, “I’m giving you one more chance.” He handed me another blank evaluation, and so I went back out – it was taking me much less time at this point – and I finally gave myself 5’s for a couple of things.

I went back into his office, and he took it from me and said, “Well, we’re getting there.” Then he pulled out an evaluation that he had already filled out, and he had pretty much given me outstanding evals all the way down the list.

It wasn’t the evaluation that sticks in my mind but our discussion afterwards. He said what he wanted to teach me more than anything else was to self-evaluate. He said that after medical school these evaluations would be far and few between, and it would be up to me to decide whether I was doing well or not, and I had to cultivate being honest with myself. He said that you can shape a dynamic career that way because if you are honest and know what you are good at, then you can capitalize on that. And if you know what you are not so good at, then you can either choose to avoid that or you can try to improve yourself so you are better in those particular areas.

I think the reason it stands out in my mind is that he was right on the money. Sometimes when I’m working with a resident or student, I can tell they just haven’t tapped into looking at themselves. They’re too worried about what everybody else thinks, and they’re not focusing on the joy of learning or the joy of capitalizing on the skills they do have. So I try to do that same thing – not assigning them a blank evaluation – but asking them to evaluate themselves and tell me what their strengths are. It’s hard for people to do that, and I think maybe that’s because we are so used to being graded and so used to always having something that needs improvement. Taking it from the other perspective is just as important, asking yourself, “What am I really good at?”

It’s very hard for them to do, and often I have to jumpstart the process by saying, “Okay, I am going to tell you something that you are really good at doing.” Then I ask, “Do you think that is a true evaluation?” They hear that it is okay to just put things out there on how they perceive themselves. What saddens me is that sometimes people really can’t see it. They don’t see that they are a good teacher or that they really do have a good eye or a sense of pathology or that they are efficient, or that they work well with the support staff. They haven’t realized that everybody is not that way.

I think we are all very good about saying what our shortcomings are. But being honest with what our strengths are can improve our whole lives – our work lives, even our personal lives – in knowing that we are smart, we are capable. We need to self reflect and realize our worth and that we are in this for a reason, and we are bringing things to the table that are unique.