[Yellow Cohort] Module 7

[Leslie Kao]

Please submit your SOAPs for Module 7:

[Nabil Al-Kourainy]

Substance use disorder, in particular opioid use disorder, which is illustrated by the 42 y/o F homeless patient in the case, is a problem of epidemic proportions in the United States. As stated on CWC, substance use disorder is often accompanied by mental health disorder. Six out of ten drug overdose deaths in Michigan involved prescription opioids or heroin in 2015. In Wayne county, there were 575 drug overdose deaths in 2015. Fortunately, this problem has not gone unnoticed by the federal government or MI legislature who received ~$16 million in federal funds to help reduce opioid abuse across the state. Unfortunately, at present, despite the public outcry, there are insufficient funds directed toward drug rehabilitation and recovery efforts. The mental health component of this growing issue is often marginalized and overlooked. In October 2017, President Trump declared a 90-day public health emergency to call further attention to the problem.

As clinicians, we are on the front lines of this epidemic, it is a war of conscience and of attrition. When encountering these patients in the hospital, we are challenged to find a balance between treating withdrawal and helping to transition patients to outpatient follow-up for substance use disorder. As a clinician practicing in Michigan, I find it particularly frustrating that we are not able to discharge patients directly to treatment centers, where there are trained physicians and staff that have years of experience addressing the psychosocial components of substance use disorder. This is a glaring issue that calls for legislative action. As physicians we must lead the way in calling attention to this problem. Another area that needs to be addressed is a desperate need for increased funds for substance use disorder treatment as opposed to criminalizing this healthcare epidemic.

I recall one pt I encountered recently who had a master’s degree in political science, had recently lost his family in a car accident, and who substance of choice for use was IV heroin which was often laced with fentanyl. I counseled the pt on taking control of his life, eliminating the negative influences, and believing in himself and all the potential that he had. I was challenging to see an individual who had so much to offer, waste away. I applied motivational interviewing techniques to attempt to address the psychosocial factors that were leading to barriers to changing his behavior. I counseled and referred him to substance use disorder treatment, and I can only hope that he will follow up with it. Had I had the option to send admit him directly to a treatment facility, I think his chances of success of curbing his opioid use would be much greater.

[Nabil Al-Kourainy]

Please disregard above entry. I erroneously wrote about substance use disorder based on the case what I thought we were assigned. I have written a new entry on empathetic listening 05-02-2018.

[shanker kundumadam]

S : This week’s case was about identifying substance use disorder. The discussion mentioned about how to identify patients with substance use disorder. It also discussed about the previous classification of patients into abuse and dependence category. This was changed in the latest DSM V to substance use disorder.

O : Article in many ways throws light on to how to correctly identify patients who have substance use disorder. It also mentions that it may require extensive interviewing to get to the bottom of this issue and extract information from the patients. It may also require other measures as going through the previous EMR charts, contacting pharmacies , other physicians , running a electronic prescription monitoring system etc.

A/P : We often come across patients who have been abusing opioids and other drugs. Quite often unless in the case of alcohol we dont do a set questionnaire for evaluation of the patient, nor we periodically go through the list of DSM V criteria to diagnose substance use disorder. Bigger harm is realizing the patient having substance use disorder, but still going ahead and prescribing drugs which are potentially addictive for the patient ( something which we all have seen in inpatient services to facilitate patient discharges ). Reading this case gives us more insight into these. I would start putting in effort to identify high risk patients and identifying who among them have substance use disorder based on the criteria mentioned in the article. Will also need to be more vigilant and also need to chase every possible option to gather data.

[jie chi]

S: With increasing pressure on general physicians by managed care organizations and the public to treat and advocate for drug and alcohol addicted patients, it is more necessary than ever that physicians have the knowledge and skills to appropriately address this segment of the population. 

O : We all have a lot of patients suffering from substance abuse. It takes great effort to persuade them to have the motivation to deal with addiction and treatment is not always effective, and it is not sufficiently available to everyone who needs it. Addicted individuals are both stigmatized and marginalized, and many are too ill to advocate for themselves. This is the most common aspect of practice we have to deal with on a daily basis.

A/P
The prevalence of alcohol and other substance use supports routine screening of this high-risk population for substance use disorders. Simple screening methods are widely available. However, physicians need training and practice in referring patients to treatment teams, monitoring patients in recovery, and providing interventions that will eliminate or reduce substance abuse before it becomes addiction. Specifically, physicians need a better understanding of the prevalence of alcohol and drug dependence in a variety of populations, along with increased awareness of the economic impact of addictive illnesses on our society. Routine screening questions should be incorporated into patient encounters, and physicians should be able to identify environments that may pose a risk for the development of addiction.

[John Dawdy]

Throughout medical school it was impressed upon us that 90% of diagnoses are made from history taking alone, which I had a hard time accepting at first. It seemed too easy and how could that possibly be given the myriad of diagnostic testing that we were learning how to use and interpret. However, the more time I’ve spent in the hospital with patients the more I understand just how true this is. The one very large caveat is that this requires us to actually listen to the patient. This is not always as simple as listening to the first sentence or knowing that open ended questions are the way to start a patient interaction before jumping into our own checklist of questions as we move through a diagnostic algorithm to get to a final destination. In an environment where we are often pressed for time and thinking a dozen steps ahead about what we need to do for not only the patient at hand but the other dozen that we are looking after it is often difficult to be in the moment, give our patient our full attention, take our vision away from a screen, and let them tell us their story. It’s been impressed on me by both mentor, experience and my patients themselves that slowing down and spending time in the moment and actively engaging with the patient will allow us to pick up on not only the stated history, but to pick up on the unwritten script that a patient is trying to tell us but is having a difficult time coming right out and saying. This highlights the importance of being a good listener within the medical field, but is a skill that extends throughout both our personal and professional lives. It allows us to make those that we are interacting with feel important, feel like what they say matter, and allows us to have better interactions with them as a whole. This sort of positive interaction goes a long way in building relationships and getting the most out of those that we have. Much like we are taught to treat others like we would like to be treated, we should listen to others as we would like to be listened to.

[Muhammad Usama]

For me empathetic listening is paying attention to another person with empathy (emotional identification, compassion, feeling, insight). One basic principle is to “seek to understand, before being understood. For me it is to connect emotionally with another person while simultaneously attempting to connect cognitively. An excellent technique that helped me connect<trong> “cogitively” is called “active listening” whereby I repeat back to the patient what I think she or he said to make certain I understand. The technique which helped me connect “emotionally” was to ask how the patient feels about the situation or perhaps to make a statement about how I believe the patient felt. Empathy is not sympathy. Whereas sympathy is “feeling for someone,” empathy is “feeling as someone.”
The specific methods which helped me become more supportive and Empathetic listener were:
1. Providing the patient with undivided attention. This is one time “multi-tasking” or “rapid refocus” will get one in trouble.
2. Be non-judgmental. Don’t minimize or trivialize the patient’s issue.
3. Read the patient. Observe the emotions behind the words. Is the patient angry, afraid, frustrated or resentful. Respond to the emotion as well as the words.
4. Be Quiet. I never try to rush to give an immediate reply. Often when I allowed for some quiet after the patient had vented, they themselves broke the silence and offered a solution.
5. Assured understanding. Ask clarifying questions and restate what I perceived the patient to be saying.

[Lea Monday]

I used the skills discussed in the listening with empathy handout today in a difficult situation. I had patient come double booked as an add on to my 1pm when I already had 3 people in the waiting room. she had already been to 3 EDs with CC of “i feel crazy” and I was already annoyed before walking in the room. However, i suppressed this and mentally prepared myself to go in there with empathy. I could tell from the ED notes that the people taking care of her were annoyed as well because she has so many serious but nonspecific complaints. She had h/o HTN but was saying she had palpitations, hot flashes, sweats, and felt like something was seriously wrong with her. This has been happening intermittently. Looking back she had been worked up for hyperaldo in past. I tried my best to listen with empathy. turns out when she said “felt crazy” she meant a sense of dread. we ended up thinking she might have anxiety of Panic D/o, but there is a change she could have hyperaldo or pheo since prior work up on that was never completed. I explained that I don’t want to blame her symptoms all on psychiatric cause when there may be something medical, and that we would get labs and support her and help her figure things out. She actually cried and said no one else took time to make her feel like her issues were important before.

[shanker kundumadam]

Listening with empathy not only helps you get deeper into the history and get valuable pieces of information , but also help create a great rapport. This is important both in inpatient and outpatient settings. Even though we all went into medical schools with a strong urge to serve humanity, be compassionate and kind , over the course in time we could become mechanical and start seeing patients as mere numbers and lab values, interesting or just a bread and butter case. We often forget there is a lot more behind those superficial aspects. When we give out a bad news to a patient say for example a diagnosis of cancer, for us its just another 15 mins in our busy day, but for them those 15 minutes is life changing , and those 15 minutes gonna change not just their lives but also 100s of people that are connected to them. This is not the kind of doctors that we thought we will end up being when we got out of medical school, but somewhere through out our training we have become a mechanical machine who just hears facts and analyze, plan and treat and not bother about the emotional and deeper aspects. For some physician it may be just the way they are but for most of us its the lack of time we get to spend with a patient that has made us so mechanical. When you have a clinic day with 20 minutes per patients and because of infrastructure and late shows this time further cut shorts to maybe 10 minute per patient, its hard to switch to an empathetic mode. We really have to try much harder around this challenge and learn how to be still a empathetic listener despite having a very short time frame.

[Leslie Kao]

Being a supportive and empathetic listener not only encompasses the words we say but also the body language that we portray. Sometimes a patient will come in and say one thing, but being empathetic and supportive requires reading in between the lines for what they are really concerned about. I had one patient in clinic on Tuesday, who is a regular patient of mine and generally upbeat and happy. However, she came into clinic in a sour mood, complaining of medication changes that had been made by a previous physician and how she was now confused and unhappy with her regimen. Having seen this patient every other month for almost a year, I knew that this was not her normal mood or demeanor. After some more questioning, the patient was actually having personal issues with her granddaughter who was taking advantage of my patient. While she did not feel like she was in any danger, all the patient needed was to vent about her current situation. She didn’t require solutions only someone to listen to her complaints.

[Nabil Al-Kourainy]

The doctor-patient relationship is built on a foundation of mutual respect and trust. Both of these qualities require a certain degree of rapport. When a patient encounters a physician he or she goes into that interaction with an expectation of empathy. To empathize or to be sensitive to feelings thoughts or experiences that the physician him/herself has not personally experienced presents an emotional challenge. While the physician may be able to intellectually understand what the patient is saying, the symptoms and emotions that come with diagnoses, it is an impossibility to fully appreciate the patient’s experience. Nevertheless, in an effort to gain the patient’s trust, to determine how to best help him/her through their presenting symptoms, as physicians we must maintain our best efforts to empathically listen to our patients. In order to accomplish this goal during the doctor-patient encounter, the clinician must maintain discipline and allow the patient to tell their story. This can often prove difficult in the inpatient setting as the physician is caring for multiple patients simultaneously and has to mentally triage those who are the most sick or distressed. It is important to have an appropriate balance between the open-ended and straight forward yes or no questions when conducating the patient interview. Often times though, while we think it might be faster to be more direct in our questioning, the patient can invariably reveal the diagnosis, if one possesses a caring ear.

In efforts to improve my own listening ability and in doing so become a more empathetic and supportive physician, I can make sure that I give my patients the opportunity to air out their feelings, often the cathartic expression with a willing listener will lend itself to the creation of rapport. In the outpatient setting, when time is often of the essence, I can give my patients a few minutes to direct the conversation and then ask them what seems to be troubling them most and unless clinically contraindicated, focus my attentions on addressing their primary concerns. If the patient has multiple complaints, which is often the case, I can schedule follow-up visits to address the chronic issues, focusing on the most acute symptoms.

As I practice empathetic listening, I will be able to pick up on subtle clues in body language and tone that I might be missing when asking directed questions. This will allow me to better capture the emotional acuity that the patient is presenting with. I can also validate their concerns so that they understand that my goal is to help get them through whatever ails them. In the event their symptoms are not reversible, then it is also important to communicate that I wish to help them achieve comfort and dignity and that their concerns and feelings maintain top priority. Ultimately, I can do a better job treating each patient as an individual rather than a cluster of symptoms. Through active efforts to maintain empathy and humility, trying to place myself in the mindset that the patient is projecting, recognizing the fears or worries that the patient has and not only acknowledging those concerns, but validating them, I can improve my overall bedside approach.

[ShivaniA]

A supportive/empathic listener does a good job of being an active listener with the participant. He/she pays attention to not just the words, but the tone and body language as well. Being a better listener helps the patient feel that he/she‘s thoughts are valuable. It helps me be a better physician by integrating the “science” part with the art of healing. Often the patient is giving us the diagnosis in his/her words. Patients may feel better simply after being allowed to share their thoughts. We may also pick up something else that may be going on that the patient may not tell us outright such as a home situation. Active listening is a valuable skill to have.

[Kalyna Jakibchuk]

“What does it mean to me to be a “supportive and empathetic listener”? In what specific ways can I be a more supportive and empathetic listener to my patients, colleagues, friends, and family? How does being a better listener benefit others? How does it benefit me?”

Being a supportive and empathetic listener means to make an effort to listen uninterrupted and show understanding. Consciously thinking about being empathetic prior to certain conversations would be helpful to remember. I thought the point in the Listening with Empathy module that focused on different ways that people express the same needs was interesting. It can be frustrating as a health care worker when patients are unkind. In reality they may sometimes have different learned ways of expressing their needs. Sometimes when we have a better understanding of the reasoning we realize that if we were in the same situation we might act the same way, as frustrating as it may be. Listening with empathy helps the other person feel better about themselves and possibly motivated to help/listen to others. If someone feels listened to/supported they are more likely to do the same for you in the future or to work towards a positive relationship. Sometimes people ‘keep score’ and if they have lost trust or reflect on a record of behavior that showed so and so was not supportive they may think ‘why should I be helpful or cooperative?’ In patient care, an uncooperative or unwilling patient is difficult to treat.

[Syed Umer Mohsin]

For being a good physician, one not only needs a sound knowledge of medicine and ability to diagnose diseases and treat them but also to connect with patients. A physician’s job does not end with prescribing the right medication. A good physician will make sure his patient complies and adheres to the treatment plan may it be medications or lifestyle modifications. You can achieve this by strong patient-physician rapport. I believe having an empathic communication establishes strong relationships. Patients are more likely to work with physicians when they feel their concerns have been heard and understood.

[Sahrish Ilyas]

What does it mean to me to be a “supportive and empathetic listener”?
**Being an empathetic and supportive listener means many things including offering one’s undivided attention while listening, refraining from being judgmental, and acknowledging the other persons viewpoint and emotions.

In what specific ways can I be a more supportive and empathetic listener to my patients, colleagues, friends, and family?
**By minimizing distractions (eg not using cellphones), meeting in person (particularly important for family and friends), replying promptly. Additionally it’s important to follow up and check with the person to see how they are doing/progressing.

How does being a better listener benefit others?
**It benefits others because their problems are being listened to intently and likewise addressed in a more appropriate manner.

How does it benefit me?”
**It benefits me because it enhances the trust and confidence others put in me and strengthens my relationships, most importantly the patient-physician relationship. One of my patients today had a breakdown today after telling me about a difficult situation she had been having at home. She kept repeating that I had to come in and tell you. And she instantly cried upon sitting down and opened up and I sat quietly and listened and held her hand and when she was done she was like thank you so much for listening I was going crazy and I feel better now that I have that off my chest.

This is a good example of how being an empathetic and supportive listener strengthens your relationship with your patients – they trust you and have more faith in you as their physician.

[Deya Obaidat]

In every day encounters, the most challenging step for any physician is to diagnose and treat the patient and achieve the best health care possible for the patient, and that all starts from taking a really good history where the patient will guide you in the direction of the diagnosis, listening is the greatest part when it comes to achieve the goals, from my own experience I found out that patients will tell you what’s going on without even asking too many questions if you are welling to listen and pay attention to what they have to say.

Being a supportive and empathetic listener means to put yourself in the other person’s shoes and understand their point of view and their emotions so you can address them in a way that will be suitable for the patient so she/he will be comfortable with dealing with the physician.

Anyone can be a supportive and empathetic listener if they have the welling to do it, and you can be more effective if you are welling to give the patient your time and not rushing the interview, also you can prevent interruptions (like putting your phone on silent before the interview), active listening rather than passive listening is also important where you have to be engaged with the conversation in a way to keep the patient feeling that you care about what is going on with him/her.

Effective listening will help others by helping the physician to reach to the right diagnosis and select the appropriate treatment in a fashion that will make the patent satisfied and happy with the results, also sometimes (in a lot of cases) some patient would want someone to listen to what they have to say.

Effective listening benefits me as it will build up a strong relationship between me and the other parties, as we can form an agreement and understanding of our challenges and situations, and by the end of the day to solve those problems and obstacles.

[Marvin Kajy]

What does it mean to me to be a “supportive and empathetic listener”?

To me, emphatic listening is a way of listening and responding to another person that improves each other’s understanding and trust. It enables the physician to receive and accurately interpret the patient’s message, and then provide an appropriate response. The response is an integral part of the listening process and can be critical to the success of the treatment plan.
There are obviously several benefits to empathetic listening. For example, it builds trust and respect, it allows the patient to release their thoughts and emotions and it creates a safe environment that is collaborative between the patient and the physician.

This is very important in medicine because everything that we do is based on the history and physical exam. A patient is not going to divulge certain pieces of information if s/he suspects that the physician is not trustworthy. In certain cases, the patient may even refuse the physical exam. Patients will naturally respond better to doctors who they think are actively listening to their needs.

In what specific ways can I be a more supportive and empathetic listener to my patients, colleagues, friends, and family?

There are multiple ways one can be more supportive of the people around them. For example, greeting someone with a warm smile. The best thing a person can do is to listen with intensity to what someone else is saying without interrupting. This means clearly paying attention to what they are saying and provide support/comfort when appropriate.

How does being a better listener benefit others?

Medicine is a team sport and the internal medicine doctor is often times labeled “the quarterback”. Being able to effectively communicate minimizes errors. It also builds mutual trust and increases productivity between teams. To illustrate, emphatic listening leads to respect and trust between two individuals. Problems are solved faster if people are encouraged to explain problems and be given the freedom to work though solutions out loud before being told what to do.

How does it benefit me?

I believe that emphatic listening will allow me to be more impactful when communicating with others. Being an empathetic listener requires a willingness to put yourself in the shoes of the other person so they feel heard in a non-judgmental way. This will give me insight in what the patient is going through on a day to day basis and it will allow me to establish long term relationships with my patients

[shahram]

“What does it mean to me to be a “supportive and empathetic listener”? In what specific ways can I be a more supportive and empathetic listener to my patients, colleagues, friends, and family? How does being a better listener benefit others? How does it benefit me?”

Being a supportive and emphatic listener is one of the must-have qualities for a good physician. I agree with what everyone has stated regarding the benefits of being empathetic. In my opinion, most of the physicians are empathetic towards their patients and that is one of the reasons they chose to be physicians in the first place. But the question is are they always able to show empathy or not?
Not only you are supposed to empathetic, but you should be able to demonstrate empathy in each and every encounter. Everyone is different and we should practice how to demonstrate empathy in our own way. Patients are definitely more likely to work with physicians in adhering to management plans when they feel their concerns have been heard and understood. Being empathetic brings greater joy in our pt encounters and also helps you grow as a human being.

[Shivani]

A supportive/empathic listener does a good job of being an active listener with the participant. He/she pays attention to not just the words, but the tone and body language as well. Being a better listener helps the patient feel that he/she‘s thoughts are valuable. It helps me be a better physician by integrating the “science” part with the art of healing. Often the patient is giving us the diagnosis in his/her words. Patients may feel better simply after being allowed to share their thoughts. We may also pick up something else that may be going on that the patient may not tell us outright such as a home situation. Active listening is a valuable skill to have.

[Marc Vander Vliet]

Being a supportive and empathetic listener is an important skill in medicine and in life. We are more likely to affect change in our patient’s when we are able to see their problems to the perspective of their own eyes. Even if we are masters of the latest guidelines and medical therapies, if we are unable to motivate our patients because we are unable to understand them we are less likely to be successful physicians. Having a natural curiosity in other people makes being empathetic easier. Practicing empathy is an important medicine it is also important in our personal relationships. All relationships are healthier if we attempt to see life through the eyes of the people we interact with and understand their joys and struggles from that perspective.

[Brandon Twardy]

There is a fine line between empathy and sympathy which I think is sometimes blurred. Empathy is defined by an understanding and sharing of our patients feelings. Whereas sympathy is having that understanding without taking on the feelings as our own. It is important as physicians to have an understanding of what our patients are going through in-order to advocate for them and their decisions as well as to provide appropriate care. However, this doesn’t mean we have to take on their emotions as our own to understand them. We have to be careful how much of each patients particular situation and emotion we are taking on as our own rather than sympathizing with, as it can ultimately negatively effect our own practice and well being.

[wsumed]

The Will to Believe : William James : 9781438520810

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