Performing under pressure

Tuesday, December 30, 2008

Performance, expectation and patience may be the three guidelines that mark the career stability of coaches as the dust settles after the end of the NFL regular season. While some teams enter the year with championship aspirations, others just look for improvement. Performance failure may be acceptable if there is little expectation for success. But regardless of how a team performs from one year to the next, even the most patient owner may lose that virtue.

Medicine is no different. Patient and family expectations may not be matched by the care provider’s assessment of the situation and without communication that mismatch leads to loss of patience and frustration. Each half of the partnership needs to be on the same page of the playbook and that is sometimes very difficult.

Expectations may actually be unrealistic, colored by the age of information and entertainment in which we live. While House and ER show patients routinely recovering after CPR is performed, the medical world knows that it is the rare patient that walks out of the hospital intact physically and mentally if their heart has stopped. The art of medicine requires skill to balance hope and reality when visiting with family at the bedside. It’s news when somebody wakes from a coma after years and that is what sticks in people’s minds, not the hundreds of people who never waken.

Sometimes it’s the numbers that make it hard for the patient and family to understand what the consequences of decisions that need to be made urgently. The media has touted the wonders of TPA, a clot busting drug that can be used to reverse the symptoms of a stroke. In reality, in a certain segment of carefully chosen patients, 33% or one third of stroke patients who receive the drug will get better. But there is a down side; one in sixteen, or 6%, will have bleeding in their brain and a potential catastrophe. Explaining why a patient may or may not be a candidate for the drug is hard enough for families to deal with, but then, if the drug can be used, another major decision needs to be made. The expectation of a magic bullet has been lost and if a bad outcome occurs, it is difficult to remember that 6% risk conversation.

Frustration can also occur when medicine is perceived to move too slowly. Within an hour, less 20 minutes for commercials, a wealth of tests can be done to evaluate every nook and cranny of the body, but reality is much slower. A patient who presents to an ER with abdominal pain may need a CT scan of the belly to look for the cause. This one test may take 2-3 hours or more because logistically, it can’t happen any quicker. It takes an hour to drink the contrast dye and allow it to filter throughout the bowel to help identify the anatomy, an IV needs to be started and blood tests to be drawn to check kidney function because of a separate intravenous dye that is injected to show some of the blood vessels. The scan itself takes 10-15 minutes and then the computer has to reconstruct all the images, perhaps 300 or more. Finally add more time as the radiologist interprets the study and makes sense of all the data.

The key is communication. For the doc, it’s explaining what might be reasonable, tempering expectations and then working hard to meet those goals. For the patient and family, it’s listening and asking questions to understand the direction and strategies for care. If two sides are on the same page, then the patient wins. Nobody is happy if a tug of war exists. For a football coach, the principles are the same. The only difference is that there is a city full of fans cheering or booing in the background.

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