Patient and Family Centered Rounds UCSF Pediatrics Hospital - PDF document

Patient ‐ and Family ‐ Centered Rounds UCSF Pediatrics Hospital Medicine Bootcamp 2014 Introduction to Patient ‐ and Family ‐ Centered Rounds Adopting and engaging in successful patient ‐ and family ‐ centered rounds (PFCR) is no walk in the park (nor stroll through the wards). This is a complicated process, involving multiple stakeholders, sick children, and worried families and caregivers. Goals of PFCR may include the advancement of clinical care, the provision of trainee education, the inclusion of patients and families in shared decision ‐ making, and the promotion of inter ‐ professional collaboration and communication. While it would be impossible to generate an exhaustive list of the challenges providers may encounter during PFCR, there are common themes that may arise. The following offers a list of 10 of the most common challenging scenarios or barriers to PFCR, and some tips for how to optimally address them. Top 10 Challenging Bedside Scenarios (with some hopefully helpful pointers!) 1) What in the world is going on with this patient?? (clinical uncertainty)  It is OK to admit you don’t know.  Clearly and accurately identify what is known and what questions remain.  Delineate a clear plan of action. “Although we aren’t certain of the cause of your pain, we know that is not your appendix. We will obtain an ultrasound to look at your gallbladder, and will continue to treat you with pain medications and keep an eye out for new symptoms.” 2) The family has too many questions…  Establish time constraints up front – including what time the rounding encounter will end.  Encourage patients/families to write down questions to discuss later.  Set up a time that you will return to talk with the patient/family/caregiver individually. “You have many excellent questions that deserve more time than we currently have. How about I return at 1:00 pm to sit down with you, in a more personal setting, to answer all of your questions.” 3) I don’t want to undermine the residents’ relationships with patients. (autonomy vs. supervision)  Try not to interrupt the intern/student presentation. (You have the right to remain silent.)  Choose everyone’s position wisely ‐‐ The presenting trainee should be closest to the patient/family and should be sitting down. Avoid being closer to the presenter than the senior resident. If the presentation is outside of the room, stand somewhat behind the senior.  Allow the senior resident to contribute prior to speaking up. Of note, attention follows the eyes – when asked a question, look first to the senior resident. The knee jerk for most questions should be “What are you thinking about this?” or “What would you prefer to do here?” “Fantastic question. I’m interested in Dr. __________’s thoughts here.” 4) Dissension in the ranks! (attending disagrees with resident)  Ask clarifying questions about the resident’s clinical reasoning.  Acknowledge the existence of a variety of options.  In front of the patient/family, the learner is never “wrong” (see below).

Patient ‐ and Family ‐ Centered Rounds UCSF Pediatrics Hospital Medicine Bootcamp 2014 “I really like the way you are focusing on using breathing treatments to improve the clearance of mucous from his airways. However, in light of recent data showing that hypertonic saline (or concentrated salt water) may help to decrease the amount of time a patient needs to spend in the hospital for RSV bronchiolitis, what are your thoughts about trying hypertonic saline rather than albuterol?” 5) Can we really discuss THAT during family ‐ centered rounds? (sensitive subjects)  Respect patient privacy. Interview adolescent patients separately.  Call attention to social cues, and role model professionalism.  Sometimes “patient ‐ centered” discussions must initially take place away from the bedside (e.g., suspected child abuse or Munchausen by proxy, psychiatric disease, social complexities, etc.). Address how these issues will be handled prior to entering the patient’s room. “Let’s spend a few moments away from the bedside to discuss our concerns about possible Munchausen by proxy and how we should address these concerns with our patient’s mother.” 6) Is it okay to say the “C” word at the bedside? (anxiety ‐ provoking diagnoses)  Before launching into a differential, ask what the family/caregivers think might be going on. Families are often already anticipating the worst ‐ case scenario.  Use your clinical judgment regarding a family’s state of mind, and the appropriateness of addressing sensitive topics during team rounds (e.g., many people, limited time).  When there is a need to investigate for a serious, albeit unlikely diagnosis, coach your learners beforehand on how to couch the topic. “There are a lot of possibilities of what could be causing her symptoms – and we’ll have treatment options for whatever we find. While we think lymphoma, a blood cancer, is very unlikely, we want to be thorough with our work ‐ up, and so we would like to obtain some imaging of her body, in other words, an XRAY of her chest and CT scan of her belly.” 7) But they don’t speak English! (non ‐ English speaking patients/families)  Use an interpreter, preferably in ‐ person rather than phone (if available).  Negotiate interpretation method (simultaneous vs. line ‐ by ‐ line) and style with interpreter and family (e.g., you can request that an interpreter assists with ensuring family/caregiver comprehension).  Allow more time ‐‐ interpreter encounters take twice as long. To the family: “We want to ensure that you understand everything going on with your child. Please let us know at any time if you have any questions or concerns.” 8) I want to teach at the bedside, but I don’t want the patient or family to feel objectified.  Always ask permission to teach, and thank the patient/family for their participation.  Avoid or explain all medical jargon.  Incorporate the patient/family into the teaching, and invite them to ask questions.

Patient ‐ and Family ‐ Centered Rounds UCSF Pediatrics Hospital Medicine Bootcamp 2014 “Would it be okay if some of the other members of our team listen to your lungs? We know that you have an infection in your lung, which is called pneumonia, and we can hear clues that point to this infection through listening with our stethoscopes.” 9) Family ‐ centered rounds take too long!  Try creating and adhering to a schedule (e.g., 5, 10 and 15 min visits)  Prepare the patients/families/caregivers beforehand that time is limited, and establish clear goals for rounds vs. other opportunities to extensively address issues.  Keep teaching points brief, focused and relevant to the patient. “If there’s one thing I’d like for you to take away from this case, it is the fact that patients can have a serious infection despite a normal white blood cell count.” 10) Family ‐ centered rounds have deprived me of the capacity to teach!  FCR affords a rich and unique opportunity to observe learners, and to teach them about the art of doctoring, including communication and physical examination.  Take advantage of opportunities to role model (e.g., communicating a complicated diagnosis, navigating a challenging social situation, performing a physical examination).  Engaging in FCR does not forbid you from carving out time away from the bedside to flesh out differential diagnoses, discuss complex clinical decision ‐ making, or to reflect on various patient care experiences. Pay attention to their patient interactions and communication skills, including all of those intangibles that no one else is observing or critiquing (do they sit down, do they know how to calm a child or her parents, do they appreciate subtle social cues, do they appropriately utilize humor, how do they broach areas of uncertainty?). Some Final Tips for Success Hopefully, the above will offer some guidance for handling some of the common challenges of PFCR. In light of the numerous complexities involved, it is impossible to anticipate all obstacles that you may encounter. Here are 3 final recommendations requisite to achieving success. A. Be prepared. (This involves preparing ALL participants for what PFCR entails.) B. Be flexible. (Rest assured that no two days will look the same.) C. Become proficient with time management. Finally, it is important to recognize that there will be a proportion of patients/families who prefer not to engage in the rounding process, and their wishes should of course be respected. “To have a group of cloistered clinicians away completely from the broad current of professional life would be bad for teacher and worse for student. The primary work of a professor of medicine in a medical school is in the wards, teaching his pupils how to deal with patients and their diseases.” – Sir William Osler

Patient ‐ and Family ‐ Centered Rounds UCSF Pediatrics Hospital Medicine Bootcamp 2014 Two things that I will take away from this workshop: 1) 2)