During the course of a day, numerous people walk into a patient's room- nurses, case managers, physicians, APPs, trainees, respiratory therapists, physical therapists, just to name a few. It is easy to see how a patient can lose track of who's who. There are multiple providers on a typical inpatient service, including students, residents, APPs, and an attending physician. Although it's not impossible, it would be a rare occasion for a patient to not be seen by a physician or APP at least once a day (usually more). But multiple times, patients ask their nurse or directly ask their provider why they haven't seen a doctor yet. They may also ask why they hear different plans from different people, or why no one has told them a plan. At first glance, these comments might seem as an indicator that the team caring for the patient isn’t being attentive, isn’t knowledgeable about the patient's current condition or plan, or isn’t a united front. And it's understandable why this would be disconcerting to a patient. So why does it happen and how can you handle it?

     Some of these comments reveal a misperception (who is my doctor, why does no one come to see me, why is nothing happening), while other comments reveal true instances of confusion or breakdown in communication or that could be avoided (multiple consultants, waiting to talk to the attending, change in plan). Patients can be upset about any of a wide variety of things- untreated pain, prolonged NPO status (nil per os, meaning they can't eat), frustration about prolonged illness or another complication, or restricted activity (patients at risk for falling have to ask for assistance to get out of bed). Patients can also display anger when they are scared. For all of these issues, make sure the patient has the opportunity to verbalize their thoughts and concerns- their initial question may not actually be their real issue.

Question #1 Why haven’t I seen my doctor today? When am I going to see the person in charge?

A. Background. Patients expect their doctor to be involved in their care. They expect their doctor to examine them, ask them questions, and provide a diagnosis and a plan. They also expect to be able to ask questions and voice concerns to their doctor.

B. Why/ how does it happen? Given the wide variety of people who pass through patient rooms, it can be difficult for a patient to identify who their physician is. If the patient feels that nothing is happening or they're still in pain or they haven't had their questions answered, it's natural to ask who the boss is.

C. How to respond? Identify your role with the team- whether you're the chief resident, the attending, or even a student or young resident. If you aren't a senior team member, ensure the patient that you will bring their concerns to the attending- and make sure you follow through. If you're the attending or senior resident, your response should be tailored to the patient's demeanor. 

     - If the patient is angry, give them time to express their feelings.

     - If it's a matter of confusion, it's helpful to take a moment to explain the team structure- the other team members who they see throughout the day are direct extensions of the attending on the service.

     - If there is a real medical issue that hasn't been resolved, none of the explanations about team structure matter. If you're the attending, convey this to the patient, and make it clear that you will work with them to solve the problem.

Question #2 Why does no one know what's going on? Why are you telling me something different than what the other doctor said?

A. Background. Patients expect their doctors and nurses to take the best possible care of them, which includes having one unified plan. It would be easy to understand why a patient would be distressed or anxious when they hear conflicting plans or recommendations.

B. Why/ how does it happen? Plans are not set in stone in the dynamic field of surgery.

     - Patients with non-elective surgical issues are at risk of having changes in their plan. New fevers, changes in pain, new laboratory values, or radiographic findings can all lead to an urgent need for intervention, either surgery, a minimally invasive procedure, placing tubes, etc. This doesn't mean that the teammates who spoke to them earlier were wrong- it just means there has been a change.

     - Patients are often seen by residents, both from the primary team as well as consultant teams. Residents, especially more junior residents, don't have the same authority to tell the patient a definitive plan as the chief resident or attending. They might propose some possibilities, and then tell the patient they'll be back with their boss (common language to refer to their chief resident or attending). Sometimes patients hear one thing and don't understand that it's not the final plan.

     - In addition, when patients are first seen by the resident, there is often a time delay between the initial patient evaluation and discussion with the attending physician. It can appear that nothing is happening or that the team doesn't know what to do.

C. How to respond?

     - Explaining the team structure and reassuring the patient that they will be updated as soon as possible can alleviate some of the anxiety/ frustration. Explaining a change in plan can be tricky. It's important not to undermine other team members. It's a learning process for trainees- you don't have to make excuses. As the attending, you can reassure that patient that the team members discuss their plans with you and you have the final say in their care.

Question #3 Why was my surgery canceled?

A. Background. When a patient needs surgery, the operating team makes a plan for their operative day. The patient is made NPO, meaning they can't eat or drink before surgery. They may have their family or friend scheduled to come to be with them on that day. So it's understandable for a patient to be frustrated or angry when they are told their surgery is canceled.

B.  Why/ how does it happen? Operative cases can get rescheduled or delayed with minimal notice. Even when cases are scheduled, there is always the possibility of another patient needing a more urgent operation. This applies to cases done by the trauma team, as well as cases with subspecialists. The orthopedics team is busier when trauma volume increases, so this puts further strain on OR availability.

C.  How to respond? The frustration is understandable, so it is helpful to explain why their surgery date has been pushed back (or hasn't been set yet). It's important to NOT "throw them under the bus"- in other words, don't speak ill of other teams. You don't have to go into a big explanation, but it's helpful for the patient to understand because this can alleviate some of their displeasure with the teams, including the consultant teams. It's not a matter of the teams not thinking the patient is important- it's simply triage. Also, try to get a plan as early in the day as possible, so the patient can be allowed to eat if their surgery is postponed.

Question #4 Why is nothing happening?

A.  Background. Patients expect things to happen in a hospital to make them better.

B.  Why/ how does it happen? A lot of patient care happens away from the patient's bedside. Reviewing labs, imaging, discussing with consultants, performing procedures, phone conversations with nursing and case managers, just to name a few things that happen outside of the patient's room. However, this complaint can be a little more nuanced- sometimes the patient is trying to say they're frustrated by prolonged hospitalization, or they're scared about a complication, or they're worried they won't get back to their life as they had before their injury.

C.  How to respond? Again, if this is an issue of confusion, sometimes a brief explanation is enough. If there are specific consultant recommendations or a specific test result that is pending, attempting to contact the consultant team or expedite a radiology study in front of the patient is a small way to show the patient that things are happening behind the scenes. But if the patient is frustrated with being hospitalized or scared about surgery or a complication, those explanations won't address their concerns. Those issues require a more tailored response.

Question #5 Why can’t I eat?

A.  Background. Sometimes patients in the hospital are feeling ill enough that they have no interest in eating. But if they still have an appetite, there are sometimes when it’s not safe to eat.

B.  Why/ how does it happen? Patients can't eat before surgery- specifically, it's dangerous to have food or thick liquids in their stomach when they have sedation medication or paralytics, because there is a risk of the stomach contents coming up into the throat and then going into the airway. So while a patient is awaiting procedural intervention (surgery, minimally invasive procedure that requires sedation), they can't eat. When we are awaiting the recommendations and plan of care from a consultant, we don't allow the patient to eat until we know they don't need a procedure. Besides procedures, patients may have to abstain from eating if they have a problem with their intestines, such as an obstruction or a fistula (abnormal connection from the bowel to the skin).

C.  How to respond? Apologize, basically. There's not much else to do.