Transcripts For CSPAN2 What Patients Say What Doctors Hear 20170305

Professor talks about increases in Technology Helped policing. And we wrap up with former president george w. Bush who discusses his paintings of american veterans. That happens tonight on cspan2s booktv. Good evening and welcome to the rare become room. I direct the events here at strand. Dr. Danielle ofri it is a physician at Bellevue Hospital and a professor of medicine at nyu. She writes about medicine and the doctor relationship for the New York Times and others. She was part of the first literary journal to a rise from a medical setting. Her critically acclaimed book, what patients say, what doctors hear, has been a bestseller. Please join me in welcoming dr. Danielle ofri to the strand. Hi, thank you. It so nice to be here. The strand has been a favorite of mine. A 1 book bin and one of my major food groups forg geographc g getting through the day. I was seeing patients and i was wondering am i as good as i could be . I think we do things to make us better. Me, i go through these periodic spring cleaning. Maybe i will commit myself to learn to copy the spleen and square i will read the new england medicine journal. A couple months ago i recertified for my board and minimized 270 pages of facts that i retained for about 72 hours. I never thought about how i speak with patients. I viewed communication not much differently than breathing before writing this. I did both automatically and only paid c eshe cease. I had a couple that told the story of two events and when they told the stories they were like two different movies. I was fascinated by the gap of what patients say and what doctors hear and vice versa. When we think about what matters most in the doctorpatient interaction and we have, you know, lots of High Technology now which i love, but as i spent time reading the research and talking with doctors and patients, i ended up concluding that the doctorpatient conversation is the single more powerful tool for diagnostics and therapeutics. Given the age of genomic medicine and chemotherapy that that can hit exactly your tumor but the way we communicate is so important and gets the short stick often. When you look at what Insurance Companies pay for it is not time talk to your doctor but what procedure you got, what surgery, or the medications you get. But the idea of doctors and patients speaking is good bedside manner but i hope in writing this book i will help doctors and patients and maybe Insurance Companies and perhaps those redoing health care might come to value the time doctors and patients Work Together is worthy of counting and valuing. I wanted to start with a patient of mine who i changed their names but they simplify the challenges in communication. It was late on a thursday evening, when my office phone range. It was omar abdue. He said i am not feeling well. I need to see you. The clinic was already closing up. I had already turned off the computer. I need to see you now he said. The annoyance in his voice was apparent even with a thick west african accent. In the few months i had known him, i probably fielded 50 phone calls and he always had something wrong, something bothering him, here needed a form filled out or medication renewed. He needed it right away. He had a severe heart condition. At our first visit, he brought in papers from a cardiologist in pennsylvania that showed a m dysfunctioning heart. I took the concerns seriously despite my depleted reserve of patience for him and his voice. I suggested if he had congestion or Heart Failure things i would send him to the er. He wasnt feeling well and i wasnt going to come in on freed the clinic but because of his heart i was concerned about waiting until monday. I said you would see a colleague of mine. When i arrived on monday, he left a message i come friday and and you were not there. I need to see you. The next three days were phone calls between us. If he was feeling sick, he should come to urgent care. If he didnt feel too bad he could get a regular appointment. He left me many messages saying i need to see you. Just as i was saying goodbye on mid thursday to the last of my patients. Tall and lanky dressed in a blue track suit he signaled anxiously at me. I was unprepared at the rush of anger of thinking he could walk in and just get instant advice . Obviously whatever was bothering him couldnt have been so bad because he chose the spend the week trading messages rather than coming to the clinic. I needed to a draw a line. I said you cannot just show up without an appointment. He said i come to see you. I said i know, but i have other patients with scheduled appointments. If it is urgent, you can come to the walkin clinic. Otherwise, you need to make appointment. I only want to see you he said. I need to see you today. I knew if i gave him a medical visit now, i would reinforce the idea he could walk into my office at any time but i also understood the severity of his cardio myopathy. This wasnt the kind of patient i could take a chance on. I said just a quick visit next time an appointment. He smiled and i knew i would regret this. He figured out to be annoying consistent until i caved. The medical staff was leaving for lunch but i asked with a smile could you please do a set of vital signs. He hesitated but did so. I asked him to enter the room. He took two steps and paused almost like the muscles were debating whether to move his buddy forward or backward but he collapse to the floor with a heart stopping thud. I dropped to my knees and checked for a pulse. I said can you hear he . He was breathing rapidly slumped against the door frame and legs over the hall way. He placed his right hand over his chest and said my heart and i was swamped for guilt. I called for oxygen and a stretcher. His pulse was 130. His fingers were so cold that the oxygen saturation monitor couldn couldnt pick up a reading. I held his hand as we pressed down the hall striding to keep my remorse at bay prying he was going to be okay. He opened his eyes to my words. He nodded slightly and i tried to figure out the mistake. He had been demanding and i put my foot down maybe a bit too decisively but maybe the problem was more than that. Maybe we were not hearing from each other. George bernard once said the single biggest problem is the illusion it is taking place. I was intrigued how we actually study communication. The field of communication resource comes from english teachers who are interested in public speaking. They came up with the idea that the way you convey information is a speaker stands up and says what they have to say loud and clear and unpack it and get the information. There is fascinating studies done by a researcher named janet vels in canada. She is curious how the listener affects the speaker. She took pairs of students and one student was told to tell a very dramatic story that happened and the other person had to listen. They told one grup of listeners while the speaker was speaking they had to thing about the day holidays coming up for the rest of the year. So the person is trying to figure out the holidays and not surprisingly they were lousy listeners. They didnt do much in the way of generic nodding to let you know they are listening and gave almost no specific responses like responding to key parts of the story. For the second set of listeners they had those listeners press a button each time the speaker used a letter t. These speakers did well with the nonspecific responses like uhhuh and yeah but were equally as bad at giving a response. Just let them go and i called my colleagues, five minutes, ten minutes 20 minutes, forever. I would never do with my patients. Found a study that did that. A swiss study. They the doctor said, what can i help you with . The patient spoke ask the doctor just nodded. The average monologue for the patient, 92 seconds. Right . The tsunami we fear. Thought, okay, ill try this in my clinic. The next i dade. I asked my patient what that wandded and i just nodded and put. The first patient was 30 seconds. The next patient had back pain, minute minute, minute and a half. Then the kicker, josephine na teacher, she was a saddled with a vast awry of insoluble pain, compounded by option anxiousity, december, and Irritable Bowel Syndrome and a demanding mother to care for. If i let her talk uninterrupted this visit would unfurl like a labyrinth. A hear a dizzying lift of systems, rundown of of mothers medical ills and critique of operas. I wouldnt be able to provide any easy solutions for her systems. But id be forced to explain the decisions of her mothers doctors and the artistic director of the met, who desindicates desindicates the opera and we would be sour and the whole thing would a mess. But i promised myself id let every single patient talk today. If eliminated the socalled difficult patient mist dad to would be flawed. I girded myself for battle and asked, how ick help you today . And put her on the stop watch. Every single thing certain she said, from my toes to my head. There are shooting pains in gums. Scam was painfully sensitive. Neck pain down her spine. Mother had insomnia and up at all hours of the night paining. Each time she paused said, game hi, anything else . And there always was. Im only 45, she said, but i feel like im 85. Every step hurts. My head feels swollen. I scribbled a few notes and maintained eye contact. I said let get everything on the table and then well figure out where to go from there. I let her keep talking until she fully, truly, absolutely come to the end of all she had to say. In the silence i reached over to click off the stop watch. I estimated, eight hunts, ten minutes, but in fact it was four minutes and seven seconds and the next had come occupy unscathed. I suppressed the urge to say, wow. Instead i turned back and said, it that everything . She nodded. I looked the list. When viewed on the page it actually didnt seem to overwhelm me. It was long. But it was final. She had already had the Million Dollar workup which is all negative. Explained to her she had something going on. Medicine is very poor at explaining pain syndrome. Doesnt mean we cant start treating the systems. We went down the list together, trying to identify which pains might be helped with ice packs, treat with local heat and massage, treated with physical therapy, might respond to pain medications weapon talked about our antidepressant could be help and seeing a therapist decrease her stress. We stalked about at any rating pain. The end of the visit she said something i read about but never actually heard a patient say. Just talking about all this has made my feel better. I wanted to sing an aria, which i refrained. But i was impressed at real estatizing something else. Realize something else, talking it out made me feel better i. I think most doctors would say, we hate patients like miss garza. Those patients who come in with a million complaints, list of a mile long, 50 questions, 20 medications, 16 things found on the internet. We dread this patients we say we want informed patients and take control of things but its hard. You have to 15 minutes and a lot to good through. Especially if we feel like we cant do much because their issues are related toy life, soyoure economic issues, lousy job bad shoes. Something we dont have control in affecting. And these are the patients who get shunted from doctor to doctor, think we doctor tries to turn off the spigot and get them to stop talking. So i learned from miss garza that letting it all come out in fact made a visit more efficient. It phil it felt like a lot but on the page it wasnt so bad. We couldnt handle all today. Said lets do the top three. Save the next four for the next visit. I think she felt less anxious, that she wasnt going to have to get it all out and he was able to calm down. I its interesting we do at lot of research in medicine, about the drugs, and always interested in the outcomes we want everything to be evidencebased, but there is any evidence for how we speak . How we as doctors talk to patients, change the medical outcome . There was landmark study in 1964, patients were going from abdominal surgery, and if any of your ever halved objectal surgery you know that post on pain is terrible and we treat with narcotics but they cause vomiting, nash nausea, respiratory distress. And with this very simple study was they took 100 patients going surgery the next morning and the night before surgery, the sunniesallist the sunnies anesthesiologist talk to patient and then they gave 20 minute discussion about the postop pain, how its caused lee clenching muscles, where and when the pain might oowe cure, how to relax your muscles to ease the pain, and if that didnt work, how to call the nurse. That was it 20 patients. The surgeon inside idea what was in which group. You can guess the patients had better pain relief but they needed half the amount of narcotics than the other patients. Thats an enormous increase, anything that dedecreeses the amount of constipation but the patients were discharged three days early easterly than the other group. Thats almost 15,000 costs plus the days in the hospital when you could be at home. So a simple intervention of speaking to patients and explaining what is going to happen no rocket science, changed outcomes in a meaningful way. Theres a more recent study involving physical therapists and back pain, and one of my favorite studies. Back pain is the number one thing i sunny clinics. Everyones back hurts, and its part of life but the third leading cause of doctor visits. So time, money, medications, physical therapy, and when i send my patients for physical therapy, my preferred mode of treatment, think in terms of, he exercises the physical therapist will do, the massage, the ways of lifting they instruct the paint, sometimes they use electrical stimulation. Dont think how does the physical therapist communicate with the parent. A study took patients going for back therapy. Half goss the treatment, the electrical stimulation and half got sham. You hook the thing up but dont turn it on and tell them the new machine is really quiet. The people who got the stimulation did better than the placebo group. And the people who got the sham stimulation had 25 reduction in pain, so just having the wholeup relieve but those with the actual pain had the 45 . So the simulation actually works and then half the physical therapy wiz were engaged, how the pain limits their activity, they expressed a lot of empathy. They really actually tried to make a good doctorpatient connection. They expressed optimism the pain would get better, and those maintainers who not stimulation at all. The machine was off but a engaged therapist had a 55 reduction in pain. More than the machine by itself. What we say was more powerful than the machine. The patients who had both the machine and engaged physical therapist had a 75 reduction in pain. And again, it didnt take very much, just took a little bit more attention to speaking the visit wasnt any longer but the act of the physical therapist connecting, communicating, empathizing, made a difference in the patients pain. You can say this is a placebo and might be but if you have back pain and you get 75 in pain 45 , that is meaningful. A patient said i dont care if its a dill pickle but if i reduces the pain,ll take it. And the idea of placebo, comes up is that something that is unethical to give a patient a placebo that doesnt help . Ill share with you one last story. And this patient this story takes place when i was a resident, and so i trained at bellevue during the height of the aids epidemic. It was well past midnight on the aids ward. Patients were streaming in. But even the aids ward eventually quieted down at night except, that its, for the howler. The howler was a patient in his 30 asks who earned his nickname for this nightly bouts of wailing. He kept scream took the nurses about pain. This went on night after night, despite extensive medical evaluations to see if there are any missed explain firings his pain. Nothing seemed to help and the nightly youing was agitating other patients, not to mention driving the nursing staff to distraction, the head nurse paged me. 3 00 in the morning. You have to do something, she said, before somebody strangled him. Triaged back into the patients room. I had been on my feet for more hours than i could counted. My fourth visit to the howler that night. By the point we are were exas operated with each other. He was sullen cranky and i was at my wits end. I felt bad for the patient but his moans burrowed into my brain. I rummaged around in my pockets to city what i could come up with and pulled out a vial of say leap. On a whim i saline, on a women i found a syringe and peeled back the wrapper and i drew up one cc of plain saline. You know about tylenol, right . I said to the patient, who was continuing to twist in his bed sheets and you heard of tylenol number 3, the kind ive codeine. I held up the liquid fill syringe, even a tylenol number 4, i said. Slowly removed the cover off the needle, but this do i paused for dramatic effect this is tylenol number 5. The patient stopped howling and gave me an interested look. Without a word, he lower his pajamas and allowed me to inject the saline in his gluteus maximus. The patient and i waited together, allowing the minutes to tick by. After what seemed like a mutually agreeable time i stood up and bid him good night. The patient put his head on the pillow and promptly fell aslope. The ward was silent. Did feel guilty that it committed an outright deception with the patient. Something i knew was a true nono. On the other hand, it was the first time he got a full night of sleep, say nothing about the patient ooh patients and the nurse. The nurse brought me a cup of coffee the next morning. This is a fascinating thing. We think of a ma seen bow as the sugar pill we use in a Clinical Trial but a placebo always have an effect and before we haddabilities of mr i or lung transplants, placebos is what doctors did, witch doctors, all medical profession if we had nothing else and many people get better with placebo, and placebos can be a number of things and we know it probably active visits the endorphin system. We have studies on the techniques of placebo and took normal volunteers and gave them a hot pad on the calf and then dripped an i. Of pain medication to relieve the pain. And they had their heads in a functional mri. So first they gave the painful stimulus and let the fentanyl flip and patients pain got better. The fentanyl worked. Then they said, now well start the pain medication and theyre pain got even better just by making the little announcement. And then they said, the painful stimulus again. Well now stop the fentanyl because were worried theres an increase in opinion pain but the still gave and it there was in benefit. The entire effect of fentanyl was wiped out by saying its not going to help you. When they did the fmri they could see that the pain reaches of the brain light up whether you give the pane medication or just say youre going to give it. So it seems to have a neurological effect and if it works, why not . As long as were not skipping out on another necessary medication. Kind of look at placebo differently now. Used to think its unethical but now its unethical not to give its try when somebody is not goaling help with traditional mean sod now my favorite placebo is a multivitamin itch had a patient say issue need a multivitamin or give me more energy if i take a vitamin, and the answer is no; thats no study to support that and i would normally say, take it if you want, just going to be wasting your money. If you have a vitamin deficiency its useless. Now i say, you know, many of our patients say that taking a multivitamin gives them a lot of energy. Its not other lie because patient does say that. And i let think take it. If it helps, great. Its not skipping out on the Blood Pressure medication dont see any harm a in that and you can let them know that it may work as a placebo and in fact surprisingly openly placebos can help. Theres tied of patients with Irritable Bowel Syndrome which hey were given a placebo and said theres nothing in here, but theres a lot of research to show that placebos decrease pain. A third of patients got better and there are no side effects and wont cost anything. So also we look for ways to increase eefficiency and we need to look our he speak and improve the patient outcomes. I want to end with the followup of the man and then take questions. When i think back to my communication mishand withomar amadou i can see more clearly how and white whereas so exas sir operating if the geometry of our conversation went awry with divergent dialogues. Appreciated the severity of this yard keeves i bass irritate by the muss clarity of miss ininsistence and labeled him as a, quote, difficult patient. I discern entitlement, i became resentful. Hate stopped argue being appointments and phone calls might havent been able to intuit the animating impulse of his desperation. Those who dont face down death cant accomplish the serious vulnerability that serious disease engenders. Raw fear is a motivating force like in other. When i tried to imagine being mr. Am adieu, never gaiting a an unforgiving medical still, in a foreign language, i can begin to understand his approach. Why wouldnt he persy on what he perceives as necessary and refuse to take no it but i wasnt able to come blend that until his body crumb el in my office and i feet the life moving away. After his faulty pace maker was replaced and the lick wade remove from the lung dime a post operative appointment. I was a life to see him filling my doorway. When i shook his hand, the hand that had been frigid the last time i helped it, basque backed in the warmth basked in the warmth. The recent tuneup did not give cardiac reserve. He would not be doing the 200 meet are dash anytime soon, but we dodged the bullet this time, at least, and both exhaled cautious sighs of relief. Mr. Amadous first question is when our information appointment would be. Normally this irritate me but now his voice unforward. Couldnt promise we would never have Miss Communications in the future or that i or he 0 wouldnt getting a aggravate when things didnt work out but i could promise i would pay more attention how i listened and spoke. My favorite poet, john stone, who passed away, he wrote in his poem, to graduating medical class some years ago, and amongst the many sage lines he told them, you will learn to see most acutely out of the corner of your eye, hear best if youunder inner ear, a more astute lesson in communication i could hardly imagine. Thank you. [applause] happy to take any questions. Im a student of Public Health and also a patient. Has anyone ever done a study why Insurance Companies ignore all of the research that says that paying doctors to spend more time talking to patients reduces the need for all of these vary, very expensive tests . Seriously. Thats a great question. Insurance companies dont read Much Research but it really reflects back on how the insurance system came to be. This was put together when in the easterly days of Health Insurance and created by me ama, in consultation with Insurance Company officials, but in the setup there the doctors who were specialists were way overrepresented compared to primary care doctors and naturally things they did, procedures, surgeries, got more money and also those are things you can count and for an Insurance Company you can count how many hours in the or, human units of blood hospital. Do you count a conversation and measure an effective conversation . So we tend towards paying for things we can count and we have a fee for Service Model so services, things you did, things you cut, put in holes, got money and things you talked about, well, anyone can do that so that is not considered service. Youre right, one could only home when we retoo our medical system we think about that. Cautiously optimistic, but im not holding my breath. Thank you. So, thank you for sharing some of your book with us today. Im a pharmacist, and i definitely see the issue of communicating with patients in everyday life. There has been some kind of push towards better care, medicare star ratings. The thing is, just graduated. They dont teach news school necessarily teach us in school necessarily how to effectively communicate with patiented. Even our Communications Class had very specific benchmarks and questions to ask without necessarily being able to ask a question based on the answer. So, how do you think the education model should be tweaked for Healthcare Professionals to, a. , be able to teach a class and have students retain it. Thank you for the question. How do we teach communication skills which is critical. In medicine, just like Insurance Companies, we tend to marking thises we can measure so we make core except sis and a one to four scale, did you achieve this competent. Its hard to measure our they communicate. The real way to do itness a small setting with a role mod whole shows houston i happens. My parallel is multicultural sensitive. A big push about healthcare provedors being aware of the patients varied culture backgrounds and we have power point presentations, and most of my attendings were old are white men and starch white coat who never went to peace corps or traveled in guatemala and the bring them to the bed side of the guatemalans or the alcoholic, but these oldschool doctors were very interested in the patients and asked questions and did a thorough example and thorough exam and give the patients their full attention, and this made the connection, and so being told, oh, hispanics like this and asians like that, doesnt really give a competency but listening carefully and paying attention makes the connection despite the cultural gulf. I think watching these doctors from very different stations in life, and rotations, negotiate a connection with how i learned it, and so its in a Small Group Setting and also making choices who we have as our teacher. We may tend to want to get the specialists wonderful the Great Research in an area but a they have a lot of knowledge, which is wonderful for one part of medicine, but we often forget about bringing in those who can model how to communicate. Maybe the nurse practitioner, the pharmacist, nutritionist, the general practitioner doctor who expensed more time talking with patients. So its an issue of doing it in realtime rather than having a slide show ask and you cant do multiple choice tests but you can watch how our students communicate. One thing we sometimes do is videotape them. Wont video taped myself talking to a patient and watched it. I was amazed all these thing its did. For example, when i think hard i close my eyes. I had no decide i close mid eyes. They might think im asleep. Realize i talk to much with my hands, but also watch yourself as you talk with a patient is a great way so see if you connected, making eye contact . And in the book i go through the rotor to system of communication, which divides all the statements you make, the statements that the questions of information, question of explanation, statements of empathy, questions of understanding, then you can actually tally up how much someone spoke and what they said, what the patient said and you can see, boy, the repeated the same thing ten times but never once reassured the patient. And these are ways to actually get better. Boy, im missing the boat on this. Another example is helping patients take their medication. Medication adherence. Less than half the prescriptions we write get filled and taken as the prescription says and many of these are important, patients missing out on the full benefit. So we harang a patient. You have to take the medication, youll be blind in a wheelchair, stroke, heart attack. That opportunity work very well. That doesnt work very well but dent know any other way. A wonderful study, video tape editors and patients speaking and then interviewed them belt afterwards and it was fascinating that the the information on what the patients couldnt take the medication were there but only in the post visit interview and the patient spoke about the cost of medication, caused sexual dysfunction or made them feel sick or embarrassed to use it in public or cut them in half to make them last. All these things were the real reason they cooperate take medication but never came up in doctorpatient visit but a the doctors never asked. So, lesson from. That. In the middle of of in hang rang of harang, i might ask, what this hardest thing about having diabetes and the most important things come out. Could be the special pressures of family, walking down the street and the good food is expensive. Thing is didnt know about. So lots of communication that can improve health. Good evening, doctor. The risk of being into booed i look for Health Health insurers y, we need you, too. You henningsed this. I used to work for Affinity Health in the broncs which is a medicate pair. And during orientation they showed a video and a lot of what you just it interests interviews of patients and one thing they talked about in terms of noncompliance in medication and where they were embarrassed to admit they didnt understand what the doctor had told them. The course of treatment and they were ashame to say to the doctor, i dont understand or ask a followup question and they felt either they were burdening the doctor or felt foolish or that the doctor would look down on them. If is that something that came up in your book or study theyve been able to county. S up a lot. I have a patient who has very difficult to control diabetes and miss medication adherence was table. So every sift i would make this great medication list and write it clearly and underline some colors and we were getting nowhere and each visit i tried harder to make a better medication list for him. Took me a year before he confessed to me he couldnt read. And im making all these lists and couldnt read and he was too embarrassed to admit that. Never asked so for years this man has been going through life with a bagful of medications. Now one thing i do is ask my patients, do you smoke, do you drink, how far in school, where are you from and ill find patients who attended third agreed or first agreed and at least i know i no need be to careful with health literacy. Things like that. So, asking instead of saying are you taking your meds . Which they say, yeah. Said many people have trouble take all their medicationedful ever had any difficulty taking medications and if i word it that way, theyre more likely to say they dont take it. My grandmother, may she rest in peace, she believed firmly in cutting every pill in half. Whatever the doctor gave, half. Cholesterol, identify erode, whatever it was in half, and no matter what said to her, she always cut it in half. And im sure doctors had no idea. She wasnt doing it abuse of cost just firmly believed what after that theyve gave was too much. The ended up dying of a sudden event in her home, cardiac event or stroke, and her biggest fear was ending up in a nursing home, debilitated, and maybe by cutting her staten in half, she didnt lower the cholesterol so much she got the heart attack, rather than endling up with dementia. And im very much more humbled noun we i ask parented about patiented about medication, made indication interact and we dont know if he dont ask the patient has the information but we need ask in a way that is not so threatening. If you feel that suggest they bring somebody with them, parents, someone cant hear or i dont bringing someone with you can be helpful. One caveat if the adult child or the patient comes, they doctors talk to the child. Its very tempting because that person speaks more quickly and more fluent in ponding. We have be to careful to address the patient to whatever ability they have. Sometimes dementia or earth hearing issues and bring someone who can be helpful and the timeworn advise of making a list before you come in and if you have 40 things on the list and if you can only get to three or four at most in any depth, and so prioritize and recognize you can hit a couple but not all. And you can get to some at another time. I also suggest that patients at least recognize that their doctors are stuck in untenable situations. Theres way more that must be done than can be done that time. So you have no choice but to multitask, which is terrible thing to do. Dilutes your attention or youll never finish and get dinged for being inefficient because your running over. I try to do i try to let the patient talk for the first minute without writing anything down and then say, i dont want to miss what youre saying do you mind if i use the computer to write while youre speak so i can write it down. We acknowledge the necessary iness of the computer and then tend of thrift to say, anything else . Even though we hate to say this as doctors because you open the pandoras box but by asking that, it lets parent patients know that patients know that youll have a chance to get it there and wont be anxious to get everything last thing in. So i encourage doctors to, and did i get this right . Let me repeat back what you said. Is this everything you told me . One thing that could help improve communication is for the patient to bring a tape recorder or some kind of recording device. Ive never done it because im i not sure i dont know how the doctor would react to that question and i wonder what your opinion and is maybe the doctor should also record for his or her own benefit. Maybe it should be an investigation of the doctor and then give a copy to the patient. Something like that. Some doctors dictate in front of the patient and then print out a coup of the dictation. Some ideally if there is enough to record or review ever visit but cosmism lessons. I take the cello and we tape the lesson and i try to record if theres a key moment, we just ill turn on my tape recorder for the two minutes so can i collect the key thing its its helpful to go back. Might not be a bad idea as long as both parties are okay with it. Give it a try. Talking about going over things with the patients, one thing that always strikes me and a lot of doctors do this, is where theyll good over stuff with you hat happened during the appointment but wont go over the discharge instructions, so i went with a friend of mine to urgent care the other day and the doctor did a very good job of asking if she had any questions but then the discharge wasnt until you exited the office and it was picked up at reception. So we get home, and she looks at and it says, the doctor said to me that if i wasnt feeling better in a few day is should take this antibiotic because it had been she had been prescribed medication for an upper respiratory infection and then a wait and see antibiotic. But on the discharge instructions it says delayed or wait and see but doesnt say how much time. And i looked at and it she was absolutely right. And so she had to, while feeling ill, go, find the number for urgent care, call them back, have the doctors name and so forth. And this seems to be a problem where discharge instructions tend to be given to you outside of the doctors office, by a reception, so if theres anything on it that confuses you the doctor is already off seeing another patient and you have to wait an now half the point of leaving or parting ways, whether its from a visit or hospital, is a very fraught moment and in fact when they interview patients leaving the hospital, most of them dont even know theyre on diagnosis or their doctors name, which is strikingly but they do know the nurses name. Probably because nurses spend more time in the room and are touching more. So every time we part ways is a good time to remind ourselves to stop and here are the top three things to remember and heres my name. I do that again because patients forth give. Forget their names attempt. So to remind them, heirs my card and heres how to reach me if you forget something. We forget how much happens in a visit and how hard tomorrow special if youre in pain or sick or frightened april. Hard to retain information. So thank you for the question. I believe we have time for one more question. My question is really dish a specific population that may have issues with memory or whether its something with alzheimers or tbi or all different ages. What this doctors responsibility in ensuring theres compliance with treatment. If the patient themselves is not reliable, then who is it that steps in to be able to do it if the patient is not necessarily capable of doing that on their own. Thats a tough ethical quandary, the patient isnt able to do all the things needs to be done, who steps in. Depends on the level. If the patient doesnt have decisional capacity to make a decision, thats Legal Definition and someone has to be appointle legally of guardian and then can make the decisions short of that, if we if a patient has capacity and has a basic understanding but isnt quite taking the medications well, you can only try to help that patient who is getting a visiting nurse or home attendant and encourage the family but you cant really enforce anything and cant be responsible for the patient taking that. But its trying to help the patient get the services they want if theyre amember amenable. People dont want anyone in their home or coming near me. Had a patient, an elderly woman who has a family but she is really getting frail and i suggested home hospice and they were howeverred bat horrified but that meant death. But then i urged them to give it a try. They were so thrilled with the hospice care. Its been more than a year in hospice. I spoke to the family this morning. And they said shes doing faxly. The additional d faction fantastically. The help improves the patient. Sometimes getting over the stereotype of what home care or hospice means, helping patients take the step and seeing it usually makes things about better but not always so easy. Thank you. So, thank you very much. Happy to answer any more questions when i sign your books. Thank you very much and have a wonderful evening. [applause] book tv tapes authors events all over the country. Here are the event wedll be covering this week this is who was looking at well get to this magnificent images who was looking at images taken from south america, because the whole sky had to be covered. There was a second observatory built in peru to photograph the stars of the Southern Hemisphere and she was looking at images of the clouds and she discovered a couple thousand variable stars and made a fundamental clover about the pattern of variation that the stars that took the longest time to go through their cycles tended to be the brightest stars, and she figure all of the stars she was looking at were roughly the same distance away song the ones that looked brighter really were brighter and that observation led to the first usable yardstick for measuring what we would call now galactic distances in space. And her work enabled the size of the milky way to be determined, and maybe getting ahead of thy the slides here. Thats okay. Figure out that the milky way was not the only galaxy in the universe. The universe consisted consistef multiple galaxies. Host it be fair to say that time they werent sure if the universe was maybe just a few hundred thousand light years across, and maybe that was it . That was it, or even the shape of the universe. This led to us looking at what geometry of globar and place ourself its one the gee onlity. You can watch this and other programs online