Preconference Tidbit #11 – Lasting Connections…How they are built

by Paul Uhlig

Consider a story of two medical teams seeing patients in adjacent rooms. Both teams arrive on the floor at the same time, and leave at the same time. How they do their work is very different. Let’s watch.

Team A

Team A stands in the hallway while the intern presents the patient to the attending. In their pre-rounds meeting, the team decided to see this patient first, because the intern will be attending a conference in a half hour. The presentation is very thorough and there is a lot of interaction between the attending and the team. “So, what do you think is going on with the patient?”, the attending asks. “What are we going to do?” The intern presents a differential diagnosis and recommendations for a plan of care. The resident asks several clarifying questions. The attending turns to the medical student, asking, “So, why are we considering a paracentesis when we didn’t do that in the patient last week? “What will we need to watch for afterward?” The attending listens carefully, teaches a little about liver disease, and then she asks another question of the intern, “What aspects of this patient’s presentation don’t quite fit together?”


After several minutes of additional discussion the team enters the patient’s room. The patient is alone. No nurse is present. No family is present. The attending and the intern stand by the patient. They are polite and respectful. The patient answers their questions. The intern tells the patient the care plan: “I have ordered a CT scan for later today. We are also going to draw off some fluid from your abdomen for tests.” The patient looks worried and is quiet. The attending asks permission to examine the patient and demonstrates a fluid wave on the abdominal exam. She asks the patient if he has any questions. He says, “No, but my wife was wondering when I will be coming home.” “We don’t know yet,” the intern says.  “We’ll have to see what the tests show. We should be able to tell you more tomorrow.” “I will call you when everything is set for the paracentesis,” the intern says to the attending. The team says goodbye and leaves the room. 

Team B

During exactly the same time, Team B is seeing a different patient with almost exactly the same medical problems. The patient’s wife and daughter are present. The patient’s nurse is present. The wife, daughter, and nurse are greeted by the rest of the team as they enter the room. Several people sit down close to the patient. The wife and daughter join the circle and to sit close to the patient. Someone takes a minute and brings an extra chair into the room. The medical student notices a picture of a young boy on the wall, and a crayon drawing that says, “Get well really fast, Grandpa!” The student smiles and says, “So you DID bring in Chase’s picture!” “Yes, he’s quite the guy,” says the patient. “My daughter and her family got in from El Paso yesterday. This is our daughter, Jeanne,” he says, smiling at her. “She is Chase’s mom.”

For the next fifteen minutes, a conversation takes place between everyone present, in ordinary language. Each person in turn around the circle adds thoughts and suggestions. Liver disease is discussed, a CT scan is decided on, a paracentesis is discussed and plans are made to do that later this afternoon. Several things are mentioned by the nurse that result in changes in the sequence of several tests. A medicine is changed because the patient’s wife remembered how weak it made him feel several months ago at another hospital. A safety checklist is reviewed and blood clot prevention medicines are added that had been overlooked. One of the medical students says, “Do you know that Chase can come up here if you want? I think he will feel better seeing you. I remember when I visited my grandpa in the hospital. I was only nine then, and people were worried whether it would be hard on me, but it made me feel so much better when I saw him. If you would like Chase to visit, I can be here if he has any questions.” The plan is written on a white board as it evolves. Everyone is clear about what is going to happen, and why. It turns out that Chase has his first baseball tournament next week. “We’ll do our very best to get you there,” the attending says. “You better! ‘Cause otherwise I’m signing out of here,” the patient says with both a smile and clear eyed look that brings a smile to the attending’s eyes. “Got it!”, she says. “We WILL get you there,” she says. “Together we will find a way.”

These two patients may have essentially the same medical plan, but they have very different care plans. And they, their families, and the health professionals caring from them are having notably different care experiences. One group of people is working together, co-assessing events and co-developing a plan of care in a way that involves all professions, invites the patient and family to participate, and illuminates nuances of care that would have been missed without the conversations around the circle. The other is doing a really good medical job, but, hundreds of things are missing that they aren't even recognizing aren't there. 

More importantly, one group is forming connections that are likely to last far beyond this hospital stay. Six months from now, if you ask Team A’s patient about the rounds this morning, it is likely that little will be remembered.  "Well, I guess they came in each day, but I don't really remember much about it." If you ask the patient and family cared for by Team B about the rounds this morning, names are likely to be remembered, the invitation to have Chase visit will probably be remembered with gratitude, and someone will probably say, “You know, his team won that tournament!” The entire experience will have a different kind of meaning, closely connected to the human spirit.

Do these differences matter? In terms of hard, measurable clinical outcomes, yes, evidence shows that they definitely do. But what may matter even more is that these differences produce a different kind of care. Does this matter? Yes it does. Very much.

The nice thing is, it’s not “either/or.” With collaborative care you get both. You get better clinical outcomes, and you get a fascinatingly different human experience. Most of us who have tried it don’t ever want to go back. We are somehow changed for having done it, definitely for the better.

For practitioners, joy is back, hope for the future is back, and why we went into healthcare in the first place is remembered again. For patients and families, fear and worry are smaller, awareness and knowledge are greater, and there is a validating sense of participation and control. They ARE listening! We CAN do this! We will do this together.