Burnout, difficult patients, and the question that changes both [PODCAST]

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Most patients called difficult have a reason nobody has asked about. Every chart carries labels, and the labels rarely carry the person. Stella Awua-Larbi is a nephrologist who has practiced in the Chicago suburbs for more than 15 years. This episode is based on her article “The person behind the diagnosis every chart hides,” published on KevinMD. You will hear how one young patient, labeled noncompliant and difficult, changed the way she reads a chart, and why a patient days out from surgery refused to walk the hallway. You will hear why she treats social history as seriously as the history of present illness, and how asking why usually takes no extra time at all. You will also hear why she separates ordinary fatigue from disliking the work you do. Press play for the two questions she asks when a patient is labeled noncompliant, and what patients say when someone finally asks.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Stella Awua-Larbi. She’s a nephrologist, and today’s KevinMD article is “The person behind the diagnosis every chart hides.” Stella, welcome to the show.

Stella Awua-Larbi: Thank you, Kevin. Thanks for having me.

Kevin Pho: All right, let’s start by briefly sharing your story. Then we’ll jump right into your KevinMD article.

Stella Awua-Larbi: OK, so yes, I’m Stella Awua-Larbi. I’m a nephrologist. I’ve been practicing for a little bit over fifteen years in the Chicago suburbs. You know, I think the one thing I want to share about myself that I consider interesting is my journey to medicine. Just like with most of my colleagues, everyone likes science, and that’s why we ended up in medicine. But mine was, yes, I just liked science. I was doing biochemistry as an undergrad, and my goal was to go into research. Medicine was not even on the radar at all for me until, sometime in the summer between my sophomore and junior year, I just happened to volunteer at an ER.

As a matter of fact, it was a friend of mine who convinced me to come along and volunteer with her. When I got to the ER, I served as a transporter; that’s what they needed help with. So while I was transporting the patients, I started talking to them about their lives, not their illness, but where they were from, how many kids they had, just general conversation. And something really shifted in me. I was just connected to the patient in that setting, and I was like, “Oh, I want to be a doctor.” That was my journey.

And, you know, interestingly, years later, I’m realizing now that it’s really the human connection that has kept me in medicine. I didn’t really think about it that way until this past year, when I started being conscious about talking to people about going beyond a chart and learning the patient. So I think it’s a little bit interesting, how I just stumbled into medicine. That’s what I’ll call it.

Kevin Pho: So you’re a nephrologist, and I always hear that there’s a shortage of nephrologists and a shortage of people applying to nephrology. So tell us what keeps you in nephrology, and for those medical students and internal medicine residents, why they should consider nephrology as a career.

Stella Awua-Larbi: Oh, so I consider nephrology a very holistic specialty, in the sense that you cannot just learn about the kidney and forget about other things. Obviously, you have to do internal medicine before, and what really drew me to nephrology in the first place was the fact that I would still be able to keep up with the other aspects of internal medicine. I still had to know about diabetes. I still had to know about all the other aspects.

But it’s special in the sense that the patients we encounter have these really serious illnesses that are daunting for them, and you are really part of it. You might not be able to cure ESRD, but being part of that journey with a patient is really fulfilling. I know one of the reasons why maybe people are not going into medicine, or into nephrology, is that reimbursement is a big deal. It’s hard work; it’s not procedure-based. So it’s hard work, and reimbursement is less.

But there’s a certain degree of satisfaction that comes with how the patients perceive the nephrologist. Our patients really connect with us in a way that I think is quite special. So it’s a mindset of just knowing that yes, you may not be able to cure the patient, but you’re so impactful in that chronic illness that it is fulfilling for anyone who really went into medicine to help humanity.

Kevin Pho: All right. Your article is titled “The person behind the diagnosis every chart hides.” For those who didn’t get a chance to read your article, just tell us why you decided to share this one, and then talk to us about the article itself.

Stella Awua-Larbi: OK. So, you know, I decided to really write about this because, as you can attest, our conversations have really shifted in medicine. Almost 99 percent of the time that you meet another clinician, our conversation is about the insurance companies, the macros in medicine, the corporate nature of medicine, the metrics we have to meet, everything but patient care, what we really studied all these years to do. And I think that in the setting of all that, and burnout, obviously, what we do, the core of what we’ve dedicated our effort to, has been buried under it.

So I looked back and asked, “What makes me content with what I do?” Don’t get me wrong, I have my days. I get fatigued as well, and all that. But fatigue is very different from getting to the point of disliking what you do.

So what keeps me going, when I get up in the morning and I do not have the fear of going to work, is that I really connect with my patients, in the sense that I feel like I’m going to see my friends, in a way. I mean, it seems very basic, seeing them as humans, but it was my own learning. This is something that I picked up along the way.

I told you about how I stumbled into medicine, and this evolution in me came from a very unassuming patient, a patient who, by all accounts, fit everything that we’ve encountered in the past: noncompliant, difficult, and not really wanting to interact. You would ask her a question, and she really wasn’t interested. In her chart were all the labels that we are so accustomed to, and when I met her, she really fit that. And so, day after day, while I was taking care of her, it got taxing, as it does when you take care of a patient who would pick and choose medications and may or may not answer your questions.

So I just stopped one day and asked, “Why? Why is she in the hospital, and she doesn’t want to be heard?” And then I answered my own question and started thinking about her as a human, and it changed everything for me. What I mean by thinking about her as a human is this: I met her in her young adult life, but she had been sick since she was a toddler. She was about four when she was diagnosed with this disease, and she had spent a considerable amount of her life in the hospital.

So I was thinking, “OK, well,” and interestingly, around the time I met her, this was several years ago, one of my daughters, my youngest, was around the same age as her. So I was thinking, “OK, as a mom, if I had a child who was that sick, how would I raise her?” And I know how I’d raise her. I would go into survival mode. There’s going to be guilt. You just wake up, and you want her to get better. Your regimen would be very different from taking care of a healthy kid, where with a healthy kid, you’re looking at playdates and enrolling them in extracurricular activities, things that really shape them socially.

And so when you have a child who has spent more time in the hospital than outside the hospital, emotionally and socially, they may not be quite the same as someone who has had all these other exposures. But these individuals are really mature in the health care system. They know about their body. They know how this disease is shaping them. It shapes them mentally, and it shapes them physically. So this is the individual I’m meeting. I’m meeting an individual to whom life has been very unfair and who is being shaped in a way that I cannot even fathom.

So once I started seeing that in that patient, who’d been labeled as noncompliant and difficult, I changed. The patient didn’t change; I changed. I changed by trying to meet her where she was and not expecting her to meet me where I was. And when that shift happened, it made me feel lighter. Going into the room wasn’t daunting. It was more understanding. It was more empathy.

And I think that over time, she also realized a shift in me, because my questions changed. It wasn’t, “OK, well, your kidneys are not working. You need dialysis,” and all that. It was more recognizing what she had gone through and the fact that yes, this illness is never going to go away, “but I’m here to help you out, and this is what it looks like.” And there was a stronger relationship, a more respectful relationship, since then.

So I started paying attention to the labels of noncompliance and difficult, and I started asking why. And I really discovered a lot of truths about patients: The number of truly noncompliant patients is way less than the number labeled. That has helped me, not only in a better physician-patient relationship, but more so in my own happiness in what I do, knowing that I’m able to make a difference, not necessarily by curing everyone, but by being present. And so that is what led me to write the article.

Kevin Pho: So there’s a stereotype of patients being labeled as noncompliant, but there are so many stories behind that. Now, what are some techniques that you use to go behind the label? You mentioned earlier that doctors are so pressed for time, and there are so many nonclinical things that interfere with that doctor-patient relationship. What are some things that you do to go behind the label, to really find out why patients do what they do?

Stella Awua-Larbi: So for me, social history is as important as the history of present illness. I always ask. I still ask about social history for people who’ve retired. I ask them what they did and who they live at home with, and I try to understand the role they play in their family. It doesn’t take me extra time, honestly.

And the reason why I do that is because, you know, we all have different personalities. Our personalities show up in our job in the same way that our patients’ personalities show up in their diseases. So when you’re taking care of someone who’s maybe a corporate executive, who’s used to making big decisions and all that, and they’re in front of you and you’re telling them about their disease, if I do know what they do, I do not treat them differently, but I shift my line of questioning to involve them in the decision-making. Because once you start telling people who have a certain personality or a certain role what to do, they distance themselves. They fight you. They’ll just say, “Why do I need this? I’m not going to do it.”

So I ask about social history, what they do, what they did when they were working, and also the why. Anytime I see someone who is labeled noncompliant, I ask, “Why? Why are you not taking your medications? Is there a reason why?” And you will get an answer almost 100 percent of the time. And you have to be the judge of whether this is true noncompliance or nonadherence, nonadherence meaning it’s not because they don’t care, but because maybe they can’t afford their pills, their medications, or because they’re just really tired of taking twenty medications a day and they feel full. So there are all these scenarios. So the why is a very simple way that gives you the answer you’re looking for.

Kevin Pho: So give us an example of the type of questions that you would ask to really delve into the social history of patients. What would be some examples?

Stella Awua-Larbi: So I would use as an example a patient who is going through surgery and is refusing physical therapy or refusing to get out of bed. That’s the report you get, and I would go and ask, “Why are you not doing physical therapy?” And they would come up with an answer, and the answer might be, “Maybe I don’t feel like getting up,” or, “My pain is poorly controlled.” And I’ve stumbled on answers like, “I am too.” As a matter of fact, this is a case that happened, where a patient had refused to get out of bed three or four days after surgery.

And I talked to her. I asked her, “Why? Why are you not getting out of bed?” She said, “I’m in pain. My pain is poorly controlled.” And I said, “I will talk to the nurse about your pain control.” I went out and talked to the nurse, and I asked the nurse to get to know the patient a little bit by asking, you know, “So what are your plans for going back home? Do you want to go to a nursing home, or do you want to go home?” And this nurse was really great in working with me on that.

And the following day, the nurse flagged me down while I was doing my rounds and said, “Dr. Awua-Larbi, I’m so glad you took the time to tell me to get to know the patient, because the reason why the patient refused to get out of bed was that the hospital gowns don’t fit her.” She was too embarrassed, because of her body habitus, to walk in the hallway, maybe half naked, in that hospital gown. But no one had ever really asked why. From report to report to report, it was, “The patient doesn’t want to do physical therapy.”

So the answer, the question, is very simple: Why? And, “How do you think we can help you achieve your goals?” So those two things, why, and how do you think we can help you achieve your goals? It’s not really a big line of questions. It’s really just those two things that would open a doorway to why the patient is not adhering to the medical plan.

Kevin Pho: So tell us what happened next in the story, once you, quote unquote, opened a doorway for that patient, really connected with that patient, and found out why she was doing what she was doing. Tell us how that connection with the patient and that relationship with the patient really helped her clinically and helped you better treat that patient.

Stella Awua-Larbi: Clinically, the patient feels that they’re being listened to. One of the biggest things that patients complain about is that no one is listening. So this patient might have thought, in her head, that she had told people that her pain was poorly controlled. But when someone feels listened to, even if they’re still dealing with an active illness, they are content. They know that someone is in their corner. Someone is being an advocate.

And for me, it really lessens my burden, in the sense that I just really feel less tired. I feel that I made a difference, that I did hear out the patient, because you’d have patients saying, “Maybe you’re the first person who actually asked me why,” or, “You’re the first person who did something.” And I’m not trying to say this to put myself on a pedestal, but more so, what it does for me is I walk out of the room knowing that I was a difference maker without curing anyone. So that in itself makes me feel lighter, and it really lessens the burden that we feel, or I feel, as a physician in a busy practice.

Kevin Pho: We’re talking with Dr. Stella Awua-Larbi. She’s a nephrologist. Today’s KevinMD article is “The person behind the diagnosis every chart hides.” Stella, do you have any advice for physicians, again, pressed for time? What are some techniques that you can share with other physicians in terms of better connecting with patients?

Stella Awua-Larbi: So just asking a patient, “How are you? How are you doing?” There’s no mystery to it, just simple conversations: “How are you doing?” In the outpatient setting, what I have done is ask patients about what vacations they went on, or what their grandkids or their kids are doing, and I’ll document it somewhere in my chart if I’m not going to remember. And then I pick it up again the next time I see them, six months later: “So how was your vacation? Did your granddaughter graduate?” and stuff like that. So when patients realize that you’re asking about something that, to them, is important, but to me might be minuscule, they feel like, “Oh, my goodness, my doctor remembered. My doctor cares.” So those are simple ways.

In the acute setting, it’s walking into the room and asking the patient, “How are you doing?” And when you’re delivering whatever news you’re going to give them, it’s spending a little bit of time, one extra minute, explaining what the test results mean. Because how we practice in the outpatient setting is very different from inpatient. In outpatient, because you’re sitting facing the patient, it’s very easy to explain to them what their lab value means, versus in the hospital, you’re standing, you have your patient list. You tell them, “Well, you know, your creatinine number is four today, and we’re just going to monitor it,” and then you walk away.

What I do is I pause and just say, “Well, your kidney number, this is what it means, and this is what it takes for you to go home,” or, “If it doesn’t get better, maybe, you know, this is what is going to happen.” But I explain it to them in a way that they have understanding. I think that when someone has an understanding of what is going on in their body, they are less afraid. So it’s really not just informing, but explaining a little bit what the lab results mean, or the imaging means.

And when you do that with the patient and the family and whatnot, they’re looking to see you come in and explain to them what is going on in their body, without just telling them what their lab results are. So it’s just being cognizant of that. Yes, that would take an extra thirty seconds or a minute, but it would also lessen the dissatisfaction that comes with patients feeling like they’re not being listened to.

Kevin Pho: And my final question: Just please share your take-home messages that you want to leave with the KevinMD audience.

Stella Awua-Larbi: OK, my take-home is that our profession is noble. No matter how much we’re buried in the macros of medicine, we are in a very noble profession. And the reason why I say that is I think that health is everything. A lot of issues, the financial issues and social issues, we can get out of; we find ways. When you’re hit with a certain illness, it’s really out of your hands. This is where we meet our patients: the crossroads, their before and after. So being aware of that makes us relevant. Our stage is very important.

So I want my colleagues to embrace that and understand that we are in a very special profession, and we cannot allow the corporate nature of it to take that away from us, and to understand that we meet patients at their crossroads and are part of their decision-making.

Kevin Pho: Stella, thank you so much for sharing your story, time, and insight. Thanks again for coming on the show.

Stella Awua-Larbi: Thanks for having me, Kevin.

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