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Wednesday, September 21st 2011

Establishing Immediate Trust

I’ve written before about a sense of urgency sometimes lacking amongst patients and family and friends when asking permission for surgery. The majority of the time that appears to come from being overwhelmed, rarely it comes from a lack of trust.

I was thinking about situations in which physicians need to establish trust in very short order. I suppose that’s always the case in the patient-physician relationship. But there’s something to be said for the acuity of a hospital visit and what things like resident work hours, increased physician hand offs, co-management of patients between different physicians have done for the inpatient-physician relationship and what it means for establishing trust during a scary period for most people – when they’re in the hospital.

Last night, for example, I was cross covering at the county hospital. Basically I’m on rotation at another hospital, but because the county hospital, with its high level of neurotrauma, is the only participating facility in my residency that we take in house call at they need residents at the other facilities to come take call there some nights.

Not quite inevitably but often there are inpatients at the county hospital who are going to the operating room the next day and who have not been consented for surgery. And so that responsibility falls to me overnight.

This is a situation where I’ve never met this patient before, haven’t participated to this point in his care and in our first encounter I’m going to go over, amongst other things, what potentially horrific sounding things could happen to him during brain surgery.

It’s not easy presenting it with some confidence, humility, frankness to someone you’ve just met and leaving the situation with them feeling confident in the major step they’re taking tomorrow. I’ve certainly bungled it, and seen many another physician bungle it, even when they have a good pre-existing relationship with the patient.

I think the key is being confident, friendly but professional and dedicating some time to explaining the situation.

That may seem obvious, but sometimes the response on a busy cross cover night is to rush the situation. The patient usually knows they’re going to surgery tomorrow and has a general idea why and what for. Sometimes amidst the ICU and the consults the idea is to do the consent as quickly as possible and move on.

Being frank about who you are, your role in the introduction, describing the surgery and then being frank and honest but apologetic and realistic in the risks are good strategies for making patients as comfortable as possible as they contemplate surgery the next day. Doing it earlier, rather than later in the evening is also a good move.

And then poof, after such an important life discussion you’re gone. As for that patient I consented last night there is a good chance I may never see him again. That probably says something about physician coverage, work hours and the like but I’m not sure what in full.