The Healthcare Dance

The relationship between healthcare professionals and their patients (patients including both the actual patient and their healthcare proxies) resembles a dance.  And I have begun to realize that neither party always knows whether to follow or lead.  Recently, a woman receiving short-term rehab at a SNF experienced an acute onset of aphasia; she had no prior history of cognitive impairment .  She was alert and oriented but had nonsensical responses to questions and displayed retarded motor movements. This was a new development that came on suddenly.  The nursing home staff examined the resident and called the doctor; the doctor asked the nurses to keep monitoring the resident and call him back with any changes.  The family said, "Well, this should clear up shortly. The doctor has said to just keep watching her."  After 24 hours and no improvement, I pressed the nurses to take a harder look, emphasizing that this is a big change in this resident.  The nurse said, "Well, if the family insists we can encourage the doctor to send her to the hospital for further evaluations."  Did the doctor and SNF staff not realize how big of a change this was for this resident? Did they project cognitive impairment on her that was so common for other SNF residents? Were they waiting for the family to push for more care?  And was the family waiting for the medical staff to push the alarm that something was wrong?  They appeared to be in a dance and not sure who was leading.  My conversation with the nurse led to a longer assessment of the resident and conversation with the family.  The nurse called the doctor and requested that the resident be sent to the hospital. This woman with the acute onset of aphasia had a a cerebrovascular accident, or a stroke.  She spent five days in the hospital and then returned to the SNF with a new rehab plan for speech therapy and a new blood-thinner.  Maybe diagnosing the stroke will make no difference in this woman's outcome, but it made me realize how ambiguous this dance between healthcare professionals and patients can be.  The patient may be assuming and wanting the professionals to be the lead, but the professionals may be waiting for the patient to be in charge, especially in this age of patient-centered care.  Healthcare, and more so in geriatric medicine, is a give and take from both sides.  Good clinicians realize that they are only seeing a snapshot of the patient and that this patient has about seven decades of complicated social and medical history that cannot be captured in the snapshot.  Thus, patients must fill in those gaps, and healthcare professionals must be willing to take the time to ask good questions and complete full assessments.  Patients and healthcare proxies often must advocate for this level of attention and not sit idly by as healthcare professionals do their jobs.