Crashing the Clinic

By Michael Pottash MD MPH

A few years ago, I began loitering around our pulmonary medicine teaching clinic hoping that my presence would prompt the pulmonary fellows to ask their sicker patients what they understood about advanced lung disease. I even hoped that I might be invited into the patient’s room so that the fellow and I could assess their disease state awareness and provide education if the patient so desired.

We know these conversations are important but we worry about not having the time, of depriving a sick person of hope, of not having the skill to navigate a difficult conversation, and we often assume that patients know how sick they are. And yet, patients desire the opportunity to hear this information and want their clinicians to initiate the conversation. My plan was to show the fellows that patients welcome these conversations, and they can be incorporated into a busy clinical practice.

In working with the fellows, I deemphasized clinical outcomes: We rarely discussed advance directives, code status, or hospice (not to say that we didn’t make a hospice referral or two). We focused on the process of the conversation: asking permission, questioning more than telling, listening more than speaking.

I always recorded the time when I entered and exited the patient’s room. On average, these conversations took thirteen minutes and never more than thirty (for some of the more acute cases). In debriefing, I would always ask the fellow how much time they felt had passed. Inevitably they would overestimate and be surprised by how little time it took to cover so much technical and emotional information with their patient.

Besides seeing how grateful patients were to have had this opportunity, the most rewarding part of the educational experience was when fellows admitted their surprise, despite their assumptions, that patients did not know the stage of their illness, nor what to expect. They couldn’t understand how a patient tethered to an oxygen tank or having been admitted to the hospital several times last month did not know how sick they were. These fellows spend the other half of their training running a busy intensive care unit, and I know their dismay in admitting a critically ill person for the final days of life. I know their frustration when the patient or their family don’t seem to know the extent of the illness. And I watched them realize that the problem was here in their clinic.

I remember one such patient. She was thin, frail, and short of breath at rest, even with the assist of her oxygen tank. She must know what comes next, the fellow told me. I suggested we find out. She had a sense of how sick she was, but no one had ever asked if she knew nor gave her the opportunity to ask questions about the future. The fellow admitted that he wouldn’t have asked, assuming she must have known, feeling pressured to move to the next patient, scared to make her depressed. To his surprise, the patient expressed her gratitude. The fellow admitted that in less than ten minutes we provided her with the most important doctor’s appointment of her life.

I got busy and I don’t hang out in the fellow’s pulmonary clinic anymore. Though I still think about that time and wonder what I learned. I didn’t keep track of how many advance directives we completed. I don’t remember how many DNR orders we entered. But I remember how we felt in those moments when the patient expressed their gratitude for the difficult information. I remember when the fellow realized that they could make a difference for the patient with a few minutes and some open-ended questions. And I remember that our learners need the opportunity to practice these conversations with their patients so that, like any other clinical skill, they will improve.

These conversations are the first thing to be jettisoned when we feel uncomfortable, or clinic gets busy. Educators should prioritize these conversations so that their learners have practice opportunities in training.

Michael Pottash MD MPH is a palliative medicine physician at MedStar Washington Hospital Center and associate professor of medicine at Georgetown University School of Medicine.