Great job as always Eric. Thank you for thinking about "soft skills" that so many trainees (and practicing doctors) are suboptimally proficient in. Please keep the Intern Series going as long as possible. It was a great idea, and I've already recommended it to every UAMS intern and AI for this year.
Nick, thanks for the kind words and support! Soft skills in clinical medicine are always more challenging to teach because they are more dependent on real world practice. It's more challenging to provide feedback too since there is more subjectivity involved (compared to something like reading an ECG). As the academic year starts up, I'll need to slow down the intern series a little bit (I've got one more to be released tomorrow). I'll be mixing in some topics that are more intended for preclerkship students, but will definitely revisit the intern videos from time to time. My goal is to have a set of about 30 by next summer.
Thank you for the video and the series overall. I start my first night in the surgical ICU tomorrow, my intern handbook tells me they conduct family meetings frequently and at any hour here. This was just in time
Great points . Thank you . There is a set of skills for someone to run these meetings which are equally useful for patient , families and medical team .
Dr. Strong, you mention multiple times that the intern from the primary team can be the representative of the primary team and perhaps even lead the family discussion. In my training, I've seen that it is very institution-dependent and I'd like to share my experience. I am a third year internal medicine resident who rotates at a large safety net hospital and a private academic hospital. At the safety net hospital, the house staff has a lot of autonomy and independence, so I was leading family meetings as an intern. However, when I tried to do this at the private academic hospital, I was steamrolled by the palliative care attending and this attending only wanted attendings and fellows to contribute to family meetings. As the resident, I pretty much stood quietly in the corner, despite the patient and the whole family acknowledging I was the physician who spent the most time with the patient every day.
Thanks for your comment. That experience is really unfortunate. Where I was a resident, we trained at 3 different hospitals: large public hospital, a VA hospital, and a private university hospital. Interns were given total autonomy to organize and run family meetings at the public hospital and the VA. At the university hospital, there was more attending involvement, but interns (or residents) were still generally allowed to run the meeting if they chose. The two exceptions at the uni hospital were the heme/onc services and the ICU, where fellows or the relevant subspecialty attendings generally led the meetings - so I can easily imagine interns at a private hospital being told they *couldn't* lead a meeting. But I think that's a terrible arrangement. As an intern or resident that's not something one could push back on without getting labelled a troublemaker. Maybe it's something that a group of senior residents could discuss with the PD? What I am surprised about is that it was a palliative care attending steamrolling the housestaff. The pal care attgs I know are always eager to observe intern-run meetings, and give feedback afterwards. They want interns to learn these skills. This is touching on the broader issue of how housestaff are often given different levels of autonomy at different types of hospitals. For example, a chief surgery resident functioning like an attending surgeon when in a VA hospital's OR, but functioning like a senior resident when in a university hospital's OR - a difference which I feel is wholly inappropriate.
@@StrongMed Thank you for sharing your experience. Unfortunately, resident autonomy at our private hospital can be lacking across the three services we rotate through. It's a very attending driven hospital. I understand the point of having residents rotate through a service is for their education and attendings' interests should not significantly interfere with that unless it is for the best interests of the patients. I may bring it up at our next house staff meeting. Yeah, I was surprised by the aggressiveness of that palliative care attending too. Our other palliative care attendings at that private hospital and at our safety net hospital are all amazingly patient and supportive of the learning process. On the subject of house staff autonomy and supervision, our surgery residents are woefully undersupervised at our safety net hospital because the attendings don't get reimbursed as much as they would at the private hospital. Unfortunately, many surgical attendings, especially those of subspecialty services, cover both hospitals and the institution-at-large between the two hospitals is trying to segregate the faculty so that they only stay at one hospital and conflicts of interest like that don't arise. In any case, as a medicine resident that both places and receives consults from surgical residents, I have discovered that some surgical services are so undersupervised that junior and senior residents will sometimes only staff with their chief residents (residents in their last year, not board-eligible) and the attending may not have been consulted on every case! We can usually sense this is happening when we get recommendations from the surgical services that don't really make sense, evidence-based medicine or otherwise.
If the patient wanted clergy to be present during a family meeting, I would support it 100%. However, while I've certainly help facilitate bedside visitation by clergy countless times, I've literally never had a patient request clergy be present for a family meeting, even when they were prompted to let us know who they wanted to attend. The only time I've heard of a colleague specifically suggest clergy be present was for an end-of-life discussion in which the patient felt their religion did not allow them to be DNR/DNI. After confirming with the patient that this was ok to discuss with their pastor, the physician asked the pastor if this was an accurate interpretation of their doctrine, and apparently the pastor felt it was not - which was the focus of the meeting. But that was an exceptionally rare occurrence. One very specific situation that I've heard of clergy in family meetings is with individuals of the Jehovah's Witness faith (who don't accept blood transfusions). I've had representatives of the patient's church come to the hospital to speak directly with me about the relevant restrictions and their "suggestions" for alternatives to transfusions. I always insist these conversations occur at the bedside with the patient's consent, which functions sort of like an unusually awkward family meeting involving the medical team, patient, and church. And then once the church reps have left, I circle back to the patient to make sure they have nothing else to add (which sometimes they do: "Doc, please give me blood if I'm literally going to die without it, but just don't tell anyone from the church.") With all the above being said, I suspect the experience of clergy in family meetings may be different in other parts of the country and world. Northern California is not a particularly religious region of the US.
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Great job as always Eric. Thank you for thinking about "soft skills" that so many trainees (and practicing doctors) are suboptimally proficient in. Please keep the Intern Series going as long as possible. It was a great idea, and I've already recommended it to every UAMS intern and AI for this year.
Nick, thanks for the kind words and support! Soft skills in clinical medicine are always more challenging to teach because they are more dependent on real world practice. It's more challenging to provide feedback too since there is more subjectivity involved (compared to something like reading an ECG).
As the academic year starts up, I'll need to slow down the intern series a little bit (I've got one more to be released tomorrow). I'll be mixing in some topics that are more intended for preclerkship students, but will definitely revisit the intern videos from time to time. My goal is to have a set of about 30 by next summer.
Thank you so much for these pearls of knowledge!!!
Thank you for the video and the series overall. I start my first night in the surgical ICU tomorrow, my intern handbook tells me they conduct family meetings frequently and at any hour here. This was just in time
Great points . Thank you . There is a set of skills for someone to run these meetings which are equally useful for patient , families and medical team .
These videos are amazing.
This is gold! thank you
Fantastic, thank you!
Dr. Strong, you mention multiple times that the intern from the primary team can be the representative of the primary team and perhaps even lead the family discussion. In my training, I've seen that it is very institution-dependent and I'd like to share my experience. I am a third year internal medicine resident who rotates at a large safety net hospital and a private academic hospital. At the safety net hospital, the house staff has a lot of autonomy and independence, so I was leading family meetings as an intern. However, when I tried to do this at the private academic hospital, I was steamrolled by the palliative care attending and this attending only wanted attendings and fellows to contribute to family meetings. As the resident, I pretty much stood quietly in the corner, despite the patient and the whole family acknowledging I was the physician who spent the most time with the patient every day.
Thanks for your comment. That experience is really unfortunate. Where I was a resident, we trained at 3 different hospitals: large public hospital, a VA hospital, and a private university hospital. Interns were given total autonomy to organize and run family meetings at the public hospital and the VA. At the university hospital, there was more attending involvement, but interns (or residents) were still generally allowed to run the meeting if they chose. The two exceptions at the uni hospital were the heme/onc services and the ICU, where fellows or the relevant subspecialty attendings generally led the meetings - so I can easily imagine interns at a private hospital being told they *couldn't* lead a meeting. But I think that's a terrible arrangement. As an intern or resident that's not something one could push back on without getting labelled a troublemaker. Maybe it's something that a group of senior residents could discuss with the PD?
What I am surprised about is that it was a palliative care attending steamrolling the housestaff. The pal care attgs I know are always eager to observe intern-run meetings, and give feedback afterwards. They want interns to learn these skills.
This is touching on the broader issue of how housestaff are often given different levels of autonomy at different types of hospitals. For example, a chief surgery resident functioning like an attending surgeon when in a VA hospital's OR, but functioning like a senior resident when in a university hospital's OR - a difference which I feel is wholly inappropriate.
@@StrongMed Thank you for sharing your experience. Unfortunately, resident autonomy at our private hospital can be lacking across the three services we rotate through. It's a very attending driven hospital. I understand the point of having residents rotate through a service is for their education and attendings' interests should not significantly interfere with that unless it is for the best interests of the patients. I may bring it up at our next house staff meeting.
Yeah, I was surprised by the aggressiveness of that palliative care attending too. Our other palliative care attendings at that private hospital and at our safety net hospital are all amazingly patient and supportive of the learning process.
On the subject of house staff autonomy and supervision, our surgery residents are woefully undersupervised at our safety net hospital because the attendings don't get reimbursed as much as they would at the private hospital. Unfortunately, many surgical attendings, especially those of subspecialty services, cover both hospitals and the institution-at-large between the two hospitals is trying to segregate the faculty so that they only stay at one hospital and conflicts of interest like that don't arise. In any case, as a medicine resident that both places and receives consults from surgical residents, I have discovered that some surgical services are so undersupervised that junior and senior residents will sometimes only staff with their chief residents (residents in their last year, not board-eligible) and the attending may not have been consulted on every case! We can usually sense this is happening when we get recommendations from the surgical services that don't really make sense, evidence-based medicine or otherwise.
If loved one is in icu are they are supplied have a family meeting
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What about Clergy? Priests or Rabbi
If the patient wanted clergy to be present during a family meeting, I would support it 100%.
However, while I've certainly help facilitate bedside visitation by clergy countless times, I've literally never had a patient request clergy be present for a family meeting, even when they were prompted to let us know who they wanted to attend.
The only time I've heard of a colleague specifically suggest clergy be present was for an end-of-life discussion in which the patient felt their religion did not allow them to be DNR/DNI. After confirming with the patient that this was ok to discuss with their pastor, the physician asked the pastor if this was an accurate interpretation of their doctrine, and apparently the pastor felt it was not - which was the focus of the meeting. But that was an exceptionally rare occurrence.
One very specific situation that I've heard of clergy in family meetings is with individuals of the Jehovah's Witness faith (who don't accept blood transfusions). I've had representatives of the patient's church come to the hospital to speak directly with me about the relevant restrictions and their "suggestions" for alternatives to transfusions. I always insist these conversations occur at the bedside with the patient's consent, which functions sort of like an unusually awkward family meeting involving the medical team, patient, and church. And then once the church reps have left, I circle back to the patient to make sure they have nothing else to add (which sometimes they do: "Doc, please give me blood if I'm literally going to die without it, but just don't tell anyone from the church.")
With all the above being said, I suspect the experience of clergy in family meetings may be different in other parts of the country and world. Northern California is not a particularly religious region of the US.