When The Stars, The Moon, and Planet Align

Our church has a Visiting Teaching program where the women (or as we call each other "sisters") are assigned another female in our congregation to visit on a monthly basis with the purpose of watching out for them and their family, befriending them, and helping wherever needed. I recently asked our leaders if I could be assigned to visit a specific sister in our ward. She and I often sit next to each other in Sunday school and, even though there is a 10 year age difference, we have similar interests. She is a Kaiser member who also happens to be a diabetic and, like me, struggles with weight issues. In our last visit, after a discussion about how hard it is to get out and exercise after work, we made a pact to walk together instead of sitting and visiting. Using a Dr. Sallis tone, I reminded her that "Walking, even if in small increments, is the single most important thing she(we) can do to improve her(our) health."  She promised to try and walk whenever possible.

Recently, her PCP left KP and she was sent a letter saying she would have to find another. She asked me if I could recommend someone from the Pasadena clinic. I told her I wasn't sure if Dr. David Morris's panel was open or not, but that was who I would choose. Last Sunday she shared with me that she had gone on to KP.Org to use the Find a Physician feature and found that Dr. Morris' panel was indeed open. She selected him and was VERY surprised when his nurse called within 10 minutes to say "Dr. Morris would like to schedule an appointment to meet you and review your medical history." 

Just a few short days later, she went in for her appointment. "The nurse asked me if I was exercising and I was really happy to say that I was walking for a total of 30 minutes a day 5 days a week!" she said with great satisfaction. She told me that the nurse showed her on the computer screen that she needed to have a mammogram and a diabetic foot exam then she helped her book an appointment for a mammogram and asked her to take off her shoes and socks before leaving a "cute little poker thing" on the keyboard for the doctor.  When Dr. Morris came in the room he went over all of her medications with her. She is still on Actos so Dr. Morris explained that we were trying to move patients off of Actos because of the bladder cancer issues. She told him she was aware of the concerns but felt like she had really good control of her numbers and didn't want to come off yet. She commented to me that she appreciated having a conversation about her medications instead of being told what to do. They talked about how she will eventually need to start insulin and she told him she didn't think that she would EVER be able to do that so she was going to do whatever she could to avoid it. He asked her about exercising and she said "I walk because Kristen Andrews made me promise I would try." It surprised me when she said this because I didn't know I was one of the reasons she was walking which reminds me just how important it is that we speak up to our friends, neighbors, colleagues, and family about importance and simplicity of walking whenever and wherever possible. She also asked him if she should get a shingles immunization (something else I may have gently suggested because of her medical history and age). He told her she was just the right age to get the immunization and ordered it for her. She rolled up her sleeve to show me a little red mark. "See... Proof! That sucker hurt!"

After scheduling our next walking visit for the next day we opened up our hymn book to start our Sunday School session. Right before the conductor raised her right arm to lead the music, my dear friend leaned over and whispered "You didn't tell me Dr. Morris was so darn cute! That was a real plus!" What can I say... we aim to please.

Tim Ho has a phrase that he uses to describe a visit where everything goes right. He says it is like the "Stars, moon, and planets line up and the agenda of the patient, the agenda of the physician/staff, and even the agenda of the organization provide an opportunity for change." Dr. Morris and his staff created a moment like this for their patient... my friend. It's these kind of stories that make my heart beam with pride. This is how we make a difference and help improve the lives of each person that comes through our door. Saving lives... together... one person at a time.

Through the Eyes of a Patient

For years my husband and I have been Saturday morning regulars at a little restaurant nestled in the foothills of Monrovia. The term "regulars" takes on a deeper meaning here. It means you are part of a family connected by the owner who knows you by name, where you like to sit, and who you like to sit next to. One of my favorite people to sit next to is a lovely lady named "Doreen".  She is a pistol of a woman who reminds my of my late grandmother. Doreen is seventy-two years old and has wonderful stories to tell about coming from Scotland be an RN in the states, stories she will share with anyone who will listen. If Doreen comes to our table, my husband has learned to just eat his food instead of waiting for the conversation to finish because there is a chance it will be cold before she leaves. 


One Saturday morning Doreen's story was about her new primary care doctor who was younger and didn't seem to like being personal with her patients. She told me how much she missed her old doctor who took an administrative position. Curiosity got the best of me and I asked Doreen where she went for her health care. When she replied, "Kaiser Permanente" my husband and I both smiled. Twenty years ago I would have kept my employers identity a secret because our reputation wasn't that great, but now, I said with pride in my heart "I work for Kaiser." "Really?"... Doreen perked up with excitement. "Oh dear..." she said with her Scottish accent, "I wish I had my old doctor back. I understand she has a wonderful new role now, but I miss her dearly. She took the time to listen to me. My new doctor is very good, but she likes to look at the computer and type, which, I must say... she is very good at typing." Hearing Doreen find the good in every situation garnered another chuckle from me. I asked which one of our facilities she went to and who her doctor was then and is now.  When I told her that her last doctor is a good friend of mine, she bubbled with joy and said, "Isn't she lovely dear! I used to be able to call her with a question and she or someone from her team would call me back.  Will you please tell her I said Hello? I'd love to talk to her sometime. My new doctor said she prefers to communicate through email so I had to have my son show me how to use the computer so I can talk to her. " As she spoke, I couldn't help but make a mental note "what happened to the patients preferred communication?" I listened to my friend describe a couple things she would change if "she was running things." At one point she said, "Oh dear, I'm talking too much. Tell me what you do for Kaiser?" I said, "I run a proactive care program that is meant to improve your care experience." Doreen's eyes got big and she laughed "Now I've gone and got myself in trouble. Don't get me wrong, my doctor is good, she just is too young to want to listen to an old bird like me." I assured her that no one was going to be in trouble and that her insight was valuable to me. From that day on, Doreen has been my secret shopper. Each Saturday amidst the tables of other regulars, we sit for at least 10-20 minutes as she gives me the scoop. "Employees parking in the Emergency parking lot causing patients who need easy access to park in a remote lot. Why did Kaiser move that department to a different location without telling the patients? Do you know that area has just been empty for months? Isn't that a waste of money?" I don't try and provide excuses, I just listen. On Monday's, when I'm back at the office, I go over all of my mental notes and reach out to the administrators who need to know what their patients see, hear, and say. Sometimes I am able to come back to Doreen with answers to her questions and other times I have resolutions to share.


In the spring of 2011, after taking a few weeks off from our regular Saturday routine, my husband and I walked in to the Peach to find Doreen on her way out. Was it just me or were there tears in her eyes? I stopped to hug her and she broke down in my arms. We stayed in that embrace until we could both gather our composure. I didn't know why she was crying, but I cried with her. Then she whispered, "I have breast cancer." My heart sunk. I am estranged from my mother and my grandmother passed away two years ago so Doreen is like my mother and grandmother rolled up in one beautiful being. She told me she had gone to Rhuematology and they reminded her to get her mammogram done. (Thank goodness for Proactive Care) When she did, they found the tumor and biopsies confirmed it had spread to 5 of her lymph nodes. My mind raced with questions about stages, but I knew I needed to let her guide the conversation. She would tell me what she was strong enough to tell. Doreen seemed disheartened as she explained to me that she wasn't sure if she would be able to go through with the treatment because she didn't drive and she wouldn't be able to get to her appointments because the location was too far away. "There must be options. Our social workers should know about resources available" I said. She told me she checked with the Social Worker and her Oncologist and both had no solutions to offer. I asked her if she would mind if I helped her handle this one and she gave me permission to ask around. We spoke for a few more minutes before she left to get some rest, still recovering from her biopsies.


A phone call to one of my doctor friends, who also happens to be the Assistant Medical Director for Quality and Clinical Guidelines for KP SCAL and, more importantly, an Oncologist, and I learned that our Los Angeles Medical Center had apartments nearby where patient's could stay while they were undergoing treatment. Why our Social Worker didn't know about this vital program was something I would fix later, my first priority was helping Doreen. She would spend the week at the apartments and the weekends at home. Her dispair turned to hope. She started her own walking club with other patient's who, as she put it, "Seemed so sad - I knew walking would make them feel better." Even on bad days, she carried her sense of humor with her, teasing the nursing staff and other patient's. On Saturday's, she would confide in me about how she was really feeling and in true Doreen fashion, share with me her ideas for improving the care experience. "Everyone is very good on an individual basis, but it doesn't seem like they talk to each other. It would be nice if there was a case manager who could help guide you through the process. The social worker is good, but this doesn't seem to be her expertise", she would say. "I found out they had support groups offered by Kaiser from another patient." 


On another Saturday morning, Doreen was quiet and not as talkative as normal. I asked her what was wrong and she told me her Oncologist had retired and she had a new young doctor. The medication was really making her feel horrible and she just wasn't sure she wanted to continue with the treatment at age 72. She tried to talk to her new doctor about it, but she just seemed to be in "I can save you from this disease" mode. Doreen wanted to have a real conversation with someone that would help her explore ALL options, including doing nothing. In her sweet Doreen way, she said "I'm sure she is a wonderful doctor, but I wish I had someone who could understand that I am old and tired. I've done some research of my own and there are some studies that say treatment at 72 isn't always the best choice." Once again, I asked for her permission to consult my Oncologist friend, Dr. Schottinger, who also happens to be in her late 50's and perhaps more relatable.  I arranged for the two of them to talk.  Dr. S reviewed her chart and assured Doreen she was in very good hands and agreed with the treatment recommendations, but suggested she talk to her doctor about the extreme fatigue she was experiencing and ask to switch to a different medication. She spent 45 minutes on the phone with Doreen... consulting, reassuring, and listening. Doreen called me afterwards and said she felt like a weight had been lifted and that Dr. S allieviated so many of her concerns. Doreen spoke to her doctor at her next visit and together they made changes to her medications which she didn't cause the fatigue she felt before.


Doreen continues to go through treatment and has good and bad days. She is still walking every day and living life full of hope, but ready to stop the treatment if she feels the quality of her life is diminished in any way. She speaks up. Sometimes to her doctor directly and sometimes through me, but she has a voice nonetheless. Doreen continues to be my secret shopper and I know she loves it as much as I love her for doing it. In fact, she is the perfect kind of secret shopper because she knows how to highlight the good while looking for opportunities for improvement. She always apologizes for "carrying on", but I cherish every moment with her. She has taught me so much about improving care just by reminding me to see things through the eyes of a patient. We all have something we can learn from the Doreen's of the world and it's time for the world to listen.


I am grateful to Doreen for allowing me to share her story so others can learn from her too.

The Push-Away Moment

"The importance of the "push away moment" cannot be overemphasized.  It is when the agenda of the patient, the agenda of the physician/staff and even the agenda of the organization aligns and provides an opportunity for change.  It's when the the stars, moon and planets line up.  When it comes down to it, it is a tragedy when the opportunity passes because the physician/staff keeps pecking away at the keyboard." Timothy Ho M.D. 

Electronic Health Records are an amazing innovation. They allow physician's to record and view pertinent information to guide their patients along the right care path. They allow electronic decision support to provide recommendations based on the patients medical history. An EHR gives us the ability to send orders to our labs and pharmacy electronically and appropriately bill for the services provided while allowing us to capture vital data for reporting agencies. The downside, and biggest provider/patient complaint, is it steals away eye contact time with the patient and, if not balanced with a personal touch, may make the encounter feel very impersonal.  The challenge for physician's is finding that right balance and knowing when to push away the computer and just listen to the person sitting in front of them. 

Last year I wrote a blog about overcoming chronic insomnia in which I described a moment  where the Sleep Neurologist was taking a detailed medical history to uncover what brought me to him. For most of the intake, he would look at me quickly to ask a question then turn to the computer to type my answers. Eye to eye contact was minimal. I explained how my health had deteriorated to where I was having migraines 3-4 days out of the week because I wasn't sleeping and the Ambien I had become dependent upon was causing me to sleepwalk and do crazy things I couldn't remember. He asked me to describe a couple of sleepwalking episodes and as I did, he typed. He typed and typed and typed... until I, choking back some tears, started describing the latest episode where I had taken a pair of scissors and cut my hair - in my sleep. It was at that moment that he experienced what my doctor friend Timothy Ho once referred to as a "Push-Away" moment. That, as he described it, is a moment where you realize that the most important thing you can do for your patient is to stop typing, look the patient in the eyes, and just listen. 

When I finished spilling out what was a very embarrassing and scary episode for me, my doctor looked me directly in the eyes and with great assurance said "I can help you, if you are willing to make a lot of changes, starting with stopping the Ambien." That was the moment for ME, the patient, when this visit changed. I went from feeling alone and desperate to feeling heard. It was the concern in his eyes and voice that reinforced the fact that my situation was as serious as I believed it to be. It was the confidence in his words that made me feel like he really could help me. If we didn't have the push-away moment connection, I probably wouldn't have taken his strategies for overcoming my insomnia to heart. 

If providers practice listening for clues and learn to take advantage of push-away moments, patients may feel more committed to complying to medical advice and recommendations. Push-away moments may even lead to better medication adherence, people exercising more, giving up tobacco, and completing important screening tests. Why not push away your computer and give it some thought?