Lessons on Patient Care Learned at Home

I am a second-year pediatric oncology fellow at St. Jude Children’s Research Hospital in Memphis, Tennessee. So, I am far from an experienced care provider. I have been married to my wife, Rachel, a pediatric oncology nurse, for about 3 years. So I am also far from an experienced husband. But in this time, I have gained a new perspective from what she has taught me involving patient care and doctors’ interactions with nurses. This has also made me aware of the ways I can enhance the care I give pediatric oncology patients, as a fellow and in the future as an oncologist. I think some of these insights may help other fellows as well.

I met my wife when I was a pediatric intern and it was far from a scene in a medical television series. Rather, I was post call in mid-December trying to finish my progress notes, leave the hospital, and complete my Christmas shopping. Due to the high number of respiratory infections on our service, I was short on rest and would likely have been a hazard to others and myself on icy Minnesota roads if I had driven to the mall. She offered to give me a ride that evening and while driving and shopping, we soon realized we had much more in common than caring for children. We held similar interests in music, sports, and shared a love for running. One of our earliest dates (her idea) was a nationally televised college basketball game and takeout Chinese food; and it could not have been better!

A first-year oncology fellow is a newly minted, board-certified pediatric physician, capable of starting or joining a practice. For many, only days before beginning a fellowship, they might have been overseeing a complex pediatric inpatient service. Then the gears suddenly change and they are submerged again, in new patients, new diseases, new faculty, mid-level providers, nurses, and cafeteria food. As a fellow, the expectation is to know the most about every patient and then some. At times, the process of gaining this information takes place outside of the patient room, leaving less time for the interactions that we who care for children crave. Deeper relationships with patients and their families can get lost in learning how to correctly enter and then retrieve information from the computer medical record.

Rachel has pointed out to me many times that doctors are not always the best communicators. Shocking, I know. Thankfully, with computer order entry in most hospitals, far less time is spent interpreting handwriting now. Prior to meeting Rachel, I didn’t understand the difference between TID and Q8H and I don’t think I am alone when I admit I have no idea what volume of heparin is used to lock a central line. However, I also discovered that many nurses are unaware of the level of activity a resident or fellow is responsible for while they are on call, or with the current

duty hour system. In a profession in which 2 individuals work so critically together to ensure the health and safety of a shared patient, much of each other’s job is surprisingly poorly understood. Learning more about the other’s job not only improves the workplace, but also elevates the care we can all provide to our patients.

I had never heard of, or even thought of, “flushing” prior to meeting Rachel, but it is especially prevalent among teenage patients. I had assumed that what was recorded in the patient chart was the absolute truth. “Flushing” is when a patient forgets to tell their nurse when they void and the event is not recorded, which gives the appearance that the patient is fluid positive. For a resident or fellow, this can lead to unnecessary diuretic use and fluid mismanagement, especially when cross covering numerous patients overnight. To the patient, this might seem like a trivial thing that nurses ask them; however, it leads to improved decision making of the primary team when the correct information is understood.

I used to think doctors were the only ones with stressful jobs (trust me, that thought lasted only a few days). I never fully understood how busy a single patient could keep a nurse until I learned the steps that occur after a medication order has been entered. For the medication to have its proper effect, it might need a premed, a fluid bolus, specific urinalysis parameters prior to and during administration, and/or specific monitoring at 15-minute intervals. These steps have one thing in common: they all require a nurse to be present in the patient’s room.

Despite what I used to think, patients tell doctors and nurses different things. I believe that patients trust all of their caregivers and I am not trying to imply that patients make up stories, but certain levels of trust develop differently over time. With the current state of fellow education being spent less at the bedside and more at the computer desk, how our limited time in the presence of our patients is used is critical in building patient trust and habits for future practice as an attending. A patient, for instance, might disclose a personal matter or report vague symptoms not yet reported, just as the nurse is getting ready to start an IV medication. To a patient, doctors can sometimes appear to be on a tight time schedule popping in for a quick check-in, while a nurse can seem more devoted with their time just by being present in the room so much more often. Many times, when a busy fellow is in a patient room, it is all business with concrete discussions about pain, rashes, and stool consistency. With young children, comfort level is often correlated to the time spent with that provider. My 6-year-old patient hasn’t read my CV and her trust in me is based on the foundation that I know who Elmo is, not because of any medical journal publications I may have submitted. This realization has made me focus more on being fully engaged with my patients and their families when I am with them. This means that I try to limit outside distractions, do my best to be on time, and, when I am late, explain why I am running behind. Over time, I believe this builds trust and lets my patients and their families know that I am dedicated to them as a provider.

Many times as trainees, especially newer fellows, it is easy to feel threatened when an experienced nurse raises a question, or worse yet, corrects an error. Questions can seem like another opportunity to highlight a fellow’s gap in knowledge rather than become opportunities to learn more. For me, I used to think that a nurse would look down on me when I said, “I don’t know.” I have learned that this is not true. Nurses don’t equate an “I don’t know” answer with ability, but rather honesty, especially when the fellow later returns with the answer.

My personal perspective of patient care has changed since I met Rachel and other great nurses like her. Many of these things I’ve learned from being married to a nurse are similar to any lasting relationship: strong communication, understanding of the other’s situation, and honesty. The learning continues, beyond patient care. One of the more recent lessons Rachel taught me is that regular laundry detergent should never be used in a high-efficiency washing machine, unless you plan to mop your floors later that night.

Ross Perko, MD is a second-year pediatric oncology fellow at St. Jude Children’s Research Hospital in Memphis, TN.