All right, so we can get started. Thank you so much for joining us today for this Member May session for the Women's Physiatry Group, Complex Cases, Crafting Careful Communication. My name is Sonia Isaac. I'm the chair for this cycle. And with me, I also have a panel I'd like to introduce. So first, myself and then Dr. Mukai, based out of Texas Orthopedic Sports and Rehab Associates. Hello. I also have Dr. Lynn Weiss, based out of NYU Langone. Hi. Happy to be here. I have Dr. Molly Andrea, based out of Moss Rehab. Hello. During the course of this session, I would love if everyone feels as comfortable to please speak up and add their comments. I want to keep this as interactive as possible, either verbally or in the chat, and we'll have someone monitoring that as well. I have a couple of cases, and at the end, there's time and space for bringing up your own cases if this discussion prompts something that you've encountered yourself. So starting off with a brief overview of the objectives, I'm hoping that we'll understand some of the unique challenges that we face as women physiatrists. I think it's a very niche area. We experience and encounter a lot of special circumstances that we may overlook in the day-to-day, but if you step back and look at the dynamics of the situation, there's better ways that we can tackle these situations that we may encounter in the future. One of the goals is maybe learning effective communication strategies for navigating sensitive conversations, and maybe learning different approaches of how we would in the future face these patient interactions. In the moment, sometimes it's hard to respond appropriately, but arming yourself with different scenarios may help us better navigate them in the future. So I'm hoping that this will lead to more discussions today as well as in the future. I'd like to learn some practical techniques from the community as well as the panel and gain some confidence and empowerment so that we can talk more about this, because like I was saying, sometimes we are embarrassed by different situations and we kind of keep it to ourselves. So today we have some public submissions as well as anonymous submissions, so I think we can learn a lot from both of them. And then lastly, learn a bit more about some interdisciplinary collaboration and how we can maybe educate different services on our roles and better identify who we are in the hospital setting. So next, some disclosures. I have nothing to disclose myself. We can go down. Dr. Mukai, anything? Nothing. Okay. Dr. Weiss? Nothing to discuss. Okay. And Dr. Andrea? No disclosures. Okay. All right. So again, today's panel. And jumping into the first case. All right. So let me just shift this over so I can read as well. So I'll read this out. I believe this was a submission, so we can discuss this afterwards. But an older woman was admitted with a left MCA syndrome and severe aphasia. Many years ago, she had undergone a type of bowel surgery that is no longer performed and was reportedly done at just one center that required a particular care procedure, capping of a colostomy, several times per day. It was not something that our staff was trained in. The hospital ostomy team was also unfamiliar with it. Prior to the admission, the family reported they would stay with the patient around the clock and perform the capping. They stayed for the first two days. They then came intermittently and yelled at the staff that she wasn't receiving the care she required while they were gone. Two of the patient's family members began splitting and triangulating the staff. Let me see if there's a second slide. No, that was the first slide. So this was anonymously submitted by the community. I can see if the number is on. No, they're not on. But in this case, we'll go through the different panel members. Is there anything that you would have done either to set the scene in the beginning or perhaps any kind of specific discussions that would have been had to make sure that we could have tried to avoid maybe some of that hostility towards the end? Let's start off with anyone. Well, I think it's important to set expectations and to be honest with the patients. So if somebody comes in with something that you're not familiar with, you know, you could say, I'm not familiar with this particular type of procedure, but I'm going to do everything I can to get the appropriate information. And then also as women, especially we tend, you really need to escalate. If you're not sure, you know, get the head of nursing involved, get somebody else involved because the patients, you know, have a right to appropriate treatment, try to find out through the medical record or calling the other physician what's going on. But I think that's a separate issue than the family itself. And, you know, as physicians, we occasionally have families that are not satisfied. So I think it's learning how to, again, set expectations, but also communicate that it is not appropriate to belittle staff. And, you know, at times we've even had contracts with families. And how would you initiate a contract with the family? Is that something that has to be instituted by the institution or how would you go about putting that in place? Well, a lot of times the case, and this is usually not the first day, it's usually in a patient who's there long-term. It's usually initiated by case management or social work. And, you know, when you're dealing with difficult families or families with unrealistic expectations to sit down and put a contract in place and say, you know, we've had some families that are overbearing that need, you know, to be at the bedside and interfere with therapy or something like that. So they, you know, we spell out, this is the reason we want this, and this is what we're going to do. And this is what the expectations are. It's not a binding legal contract, but when something does go wrong, you can go back and say, look, you know, this is what we talked about. This is why we talked about it. But it requires responsible parties on both sides. I think this is a situation that especially could benefit our institution. We typically do behavior, like rounds on a patient like this, where the whole team comes together. And that way you can kind of get everybody on the same page. You can get input from nursing, input from the therapy, and sort of take out that splitting and triangulating that's happening from the family. And typically then in that space, usually again, with the whole team, including like the neuropsychologist, case management, I think that's a really good place to come up with that behavior plan and come up with a way to figure out what's going to be the most productive, you know, behavior plan for this patient. And do you think that there would be a place to have these contracts on standby when you're doing the pre-admission, when you have a case that's so unique like this, or do you think that it's something that you should implement once the patients have already come to the floor? Well, I think communication is always important, you know, and I agree that the team approach is obviously the best. I don't think you need to be as confrontational with a contract unless it really comes down to that. And anything from the community? There is a question in the chat about explaining what triangulating is. That was for me. I'm Christy Clemons. I'm a rehab physician in Florida. I know about splitting, but what is triangulating exactly? So I would have to interpret the submission, but I'm wondering if it would be kind of targeting different members of the team by, or I'm assuming rather, targeting different members of the team by saying that one person said one and then the other one said another, so that multiple members of the team are facing up against each other with hearsay. I'm assuming. I don't know what the original submission wanted to say. Any other thoughts or comments about this first case? Just that this can really lead to burnout. So you have to really support your staff and let them know that they have somebody behind them who was willing to support them and, you know, not let them be the brunt of all of the, of an angry family or an upset family, you know, sometimes understand that they upset. I agree. Frequent check-ins is important because oftentimes we may not be aware of as well. Patients may present one way to the physician team and then maybe different or disrespectful to the nursing team. And I see that also as well. So checking in with our team members, making sure that everyone's being respected. All right. So let's move on to the second case. All right. So, okay. So a young woman with a history of severe TBI was seen as a new evaluation in the clinic for clearance to return to work. I was unable to safely clear her for the line of work she wanted to pursue based on published guidelines and some persistent neurobehavioral issues that were fairly readily apparent. I spent the encounter, which was fortunately witnessed by a resident, reviewing why this was a case, encouraging her that she could find meaningful work in another field and offering referrals to vocational rehab. She seemed to accept this at the end of the visit. However, within minutes of me signing the note in Epic, she began to rapid fire inbox message me to remove elements of the document, which was accurate and carefully worded. So this also was another anonymous submission. And I have had this happen to me as well, where because of access to the portal and documentation, which can be released as quickly as right after the encounter, patients are more aware of what's being documented. And we typically have this documentation in place to communicate with our colleagues. And sometimes we'll relay things in a very straightforward or direct manner, which can seem rather blunt to our patients. Other times we may capture information that they may not want to be relayed if they have documentation that needs to be released for work, for example. So any feedback regarding this case? Dr. Makai, Dr. Andrea. I mean, I think this is something that like, thankfully, I have yet to experience in sense that we have PowerChart Cerner. So our patients don't yet have full access to this Epic inbox. So I'm quite grateful at this point to not have this. But even still, I think that this is an area where it is very challenging for us as physicians to be expected to respond to the inbox needs of the patients and something like this, where it's like a rapid fire inbox messaging can be really challenging. And again, especially something like this needs to be communicated in person and having that back and forth in the Epic chat is probably not the most productive place for it to happen either. So I think that this shift in our electronic health record system is really challenging for providers. It's great for patients in the sense of giving them more access and things like that. But it leads to a lot of issues like this, I think happening. Yeah, I just want to clarify. Oh, go ahead. Oh, no, I was gonna say a lot of times I'll end up just putting what they say in quotes and putting it in the note because it's accurate. That's what the patient is saying. So, you know, sometimes I'll add an addendum saying patient contact us after the clinic visit, you know, he she states or, you know, and then put it in quotes, you know, and or, you know, if it's a misunderstanding, like they take a diagnosis that they don't really understand, and what do you mean, you know, you didn't say this, you didn't say spondylosis, you did degeneration or whatever, you know, so sometimes it's just a matter of explaining the words that you use in the note if they're confused about that. But if it's them asking us to falsify information for whatever purposes, whether it's a work related issue or insurance issue, I'll usually put it in quotes. And then, you know, if it's something subjective, then I'll just put it in quotes and put it in there, just so the patient feels that that they were heard, and I documented what they had to say. Yeah, I was gonna say that. I agree. I think that I would never change a chart to because a patient asked me to unless it was truthful. I think it's fine to say the patient disagrees with me and the patient said this, at least in I have, I use Epic. And when they message me, it's in the chart. So, you know, it's part of the record. So I don't think patients realize that. But, you know, I think saying to the patient, and, you know, I see your your thing, it's noted, I can addend my note to say that the patient said X, Y, and Z. But you have to stand firm and say that if this is my medical opinion, and you're free to get another medical opinion, but I will not change my note. I think neuropsych eval also will be good to back up the physician evaluation in this case. And if it was just discussed with the patient and the what are the problems has been found in and then it will be part of the documentation. So I believe it will just support this neurobehavioral problems has been found by a physician. So Yes, thank you, Dr. Gul, I agree. Yes. So it is slightly separate. But one of the disclaimers that I've seen from some of the consultants is just an auto text at the end of their notes saying a part of the brief nature of my of my notes, but this is for effective communication between personnel. I understand that this is now going to be related, it may not sound like what we discussed, but this is accurate to a reflection of what was discussed in the encounter, please feel free to discuss during the next follow up. So that would be a good disclaimer to include. However, I think in this case, it was rather different because she wanted items removed from the note that were discussed. So this is great. Thanks. Anything else about this case? I would love to hear from some of the other people not on the panel just what their experience has been because I need to learn from this too. I need to learn from other people. I never changed my note, just like you said. So and that's what you told me. That's what I found. That's what I wrote. This is your report. And so if you don't agree with you, as you said, and you can have another opinion. And so, I mean, I don't know what the rationale of her, I guess she wants to go back to work. She didn't want to lose her job and she doesn't want the people know she has problems. And I mean, they could be financial restraints. I mean, it could be a lot of things. It's just kind of, you know, she agreed when you saw her and now she went back home and everything has changed. Oh, my gosh, I don't want this to be written on my record. And but just like a lot more from that, you know, her irrational decision or coming back to physician. So just change your note. So that's not possible. It's written, it's written, and so we're liable of that. And just writing the, you know, truth and what experience and personal knowledge and diagnose and give recommendations. So that's the way I would respond to patient back, just saying. And that's what our visit was. That's what we agreed on it. And if you have any other meaningful information to me, I will be happy to see and any further evaluations we could do. But, you know, that's what the visit was. That's what my note is. Yes. Anything else from the community as well? I have a spin-off question regarding this that Dr. Gould just reminded me of. So I had a discussion with another physiatrist in which they had to draft a letter for a medical professional that had to return to work describing a little bit about the nature of their brain injury as well as the effect that it would have on the work. So requiring some oversight in the beginning. This person had progressed quite well and had some decreased insight still. So they weren't clear to fully return without limitations. So when this letter was provided, it was a similar case where they requested that things be redacted from the letter. And so less detail be provided, less restrictions be placed. So how would you have navigated that situation? You mean this is a physician returning to work? I'm going to say it was a higher level medical professional. I don't think it matters. Depends on the job description. How would you have navigated providing that clearance to the level that you felt comfortable with? And I'll provide more detail with what this person ended up doing. I think it will take a team of work and depending on the patient's problems and it has been is there is a TBI and is any cognitive neurobehavioral problems obviously and the psych and neuropsych and if there is any physical disability, we're just going to have to get the backup reports and then just like from the physical therapist and occupational therapist. So I think that will be just kind of our job and it's putting all this information we receive from the team. I mean rehab is a teamwork, right? From the team and then to give the best advice to the patient and depending on the job description. I mean it depends on just like the job description depends on a psychiatrist versus a neurosurgeon and a thoracic surgeon or plastic surgeon. I mean the skill sets are just different even that patient is a physician and what is the specialty, what is the specialty requires, what is the you know the practice focus and skill set is required for that. Yeah, it looks like in the chat we have Sherry, Ludwig and Lauren both agreeing that the neuropsych testing is an excellent subjective evaluation. Right and I think that was pursued as this patient had been following with neuropsych but in order to provide safe clearance and worded correctly, the physician had reached out to the supervising member of this person's team to find out what policies were in place regarding their internal clearance so that there was a discussion had that it was that they would have their own internal review prior to clearing. Dr. Andrea, you have another guest. Yeah, she's my dog. Whenever I'm doing anything she decides it's about now is the time to insert herself. That's Bailey just making her appearance. All right, so well let's move on to the next case. Let's see, it's gonna, there we go, case three. Okay, this, let me see, this was submitted by one of the members of the community. I'm not sure if they're on. I can read for them if they're not. I don't think they are. Okay, so I'll read it for them. If you are here, please feel free to chime in. So case three, I'm a woman and tend to appear younger. At that pre-COVID time, I was often wearing professional attire to the hospital, not scrubs. In the first case, the patient's husband gave me an impromptu bear hug and a huge kiss on the cheek after sharing good news. In the second case, the patient's daughter grabbed my shoulders and shook me in a gesture of despair and frustration after it became clear that spine surgery would not be clearing her father from her cervical collar, from his cervical collar. Both of these episodes happened while I was rounding and another, other clinical team members were present. In the second case, a senior Paymenter resident was rounding with me on the consult service. So how would you set your physical boundaries in this case? I know that we share in our patients highs and lows, and it's hard to distance ourselves, but you know, boundaries, our boundaries are very important. So how do you go about setting those? I think it's important to say I do not feel comfortable with physical, either hugs or touching or whatever. And it's also important, you know, this happened during rounds for others in the team to call it out as well. You know, our, in our hospital, you know, we respect each other's boundaries. And so hugging is not out because if the person doesn't have, doesn't feel comfortable saying anything it's very important. And this goes for women in general, when you see something that goes on and you perceive that the person is uncomfortable, support the person and tell them, you know, I've got your back. So I think it's perfectly reasonable. Men say this all the time, you know, I don't like that. So we can say it too. We can say, you know, thank you. I understand you're happy, but I would prefer not to be touched. Has anyone else been in this situation? I mean, I have been in situations, but I guess I didn't have any concern about it. And I didn't mind to be, you know, my patients, I mean, a lot of my patients hugged me and because of the long relationship. So, and well, if you feel comfortable being hugged, then that's not an issue. And if you hug back, but obviously whoever wrote this did feel uncomfortable. So I think it's okay to say, you know, absolutely, absolutely. I mean, you know, that's the position's preference, you know, we all have a different types of best side manners and then different types of the patient relationships. Both parties have to be comfortable with that. So any uncomfortable situations have to be communicated. And it's interesting that, you know, I wonder if this person were a six foot five male, if they would have gotten a hug or, you know, yeah. So I think it's very important to say, I'm a female, I'm professional. These are my boundaries. Yeah. She may have kind of caught on guard. She didn't, she probably didn't expect that or didn't really have any time to respond. It just happened, you know? Yeah. I had a situation as a resident where there were, there's an attending physician who's a female and a PA who was with us as well. So we're all young females and there was a patient in the ICU, maybe it was, no, I think it was, I don't know, it wasn't that ICU, but they were making inappropriate comments. They were cognitively intact. They're making inappropriate comments. And my attending at the time was doing a physical exam and he made some inappropriate comment to the extent of, and then drew her in towards him, like pulled him when she was trying to do a strength exam, like drew him in towards or drew her in towards him and made some, and just, you could tell she was very uncomfortable and caught off guard, very caught off guard. And I have a pretty expressive face. And so the patient at that point made eyes with me and I made a very disapproving facial expression. And at the time, I think my attending was so caught off guard that she didn't really have the wherewithal to make any comments about the situation. So I did. And he said, Oh, you didn't like that. And I was like, no, I didn't appreciate that. And I don't think she did either. So please don't do that. And, you know, it was one of those situations where we all like ended up leaving and had like a debrief about what happened. And that's when, to your point, I really think it is like, I wonder what that like senior resident or whoever was with this attending physician, what their perspective on it was, because I knew, I think it's important. Sometimes we're not able to say it, but for those that are witnessing it to kind of speak up and say, Hey, that's not okay. So the second case is sort of assaulting, you know, because that is a physical contact. It is not a physical contact. It is not a pleasant way and grab her shoulder and trick her in. And so, and I think this is serious. And so it's, it should be, I mean, in my opinion, that should be reported. Yeah. You can always stop, just stop at that point, stop the visit, stop the, you know, I mean, I had a patient grab my butt when I was doing a hip injection and I turned around and, you know, it was going to clean the area and, you know, he, he grabbed my butt. I turned around and he grabbed my butt and I turned around and he said, I'm so sorry. I'm really nervous. I just, I need to, I just needed to squeeze something. So I said, stop. I left the room. I opened the door. I left the room. I got a staff member and I came back in and I said, sir, if you want me to still do this procedure, which I'm willing to do right now, I'm going to have, you know, this, you know, nurse or MA here, you know, he can hold your hand if that's what you need, or you can hold onto the table and I will, I'll finish the procedure. But if you do that again, I'm not going to complete this procedure. We will, we will, we'll just cancel the visit. And he apologized. He was actually crying by the time he left because I think he was embarrassed or something. But, and then I told the referring doctor what happened so that they were aware that he was doing this in case they decided to, you know, cause this, this guy needed a hip injection for a diagnostic purpose to decide if he needed a hip replacement. So I wanted the surgeon to be aware, you know, he probably be around female nurses and other staff members. So I just wanted to let him know. And I think he had a big, you know, talking to, with the patient and he wrote me a letter of apology, that kind of stuff. I had another patient that I started doing an EMG. I gave the first shock and he jumped up and he kicked the trashcan into the wall and said, there's gotta be a better way, you know, and I left the room. I mean, so sometimes you just have to leave the room. If you're in by yourself, there's nobody else around you, or if no one else is helping you, you may have to just X, you know, just leave extricate yourself from that, you know, from that situation, both to allow them to take a pause, you know, with whatever emotion that they're feeling, but also you, so that you can kind of collect yourself and then decide how you want to proceed. You could potentially just cancel or discharge the patient or transfer the care to somebody else, or, you know, you could turn around and, you know, and, and that's where the, the body language comes in. So, you know, if you're feeling uncomfortable because they're being really touchy-feely or that's what they're known for, maybe you stand a few feet back so they can't just kind of, you know, they would have to lunge at you and take a couple of steps to get to you. So you can kind of, you can, you can create those boundaries both physically, but also, and verbally too. So, and, you know, making eye contact and looking at them. So they know that, you know, you are aware and you know, and you're not going to be intimidated and, you know, that's, that's just not acceptable. I agree. Yeah. And good for you for, for speaking up two things. First of all, in Epic, we can have a behavioral red flag that comes up on the chart that, you know, because other staff members may experience similar things. So if you see a behavioral red flag, you can look and see what the ideology is. But also it always shocks me when you read about, you know, patients who are not patients, women who are sexually assaulted and men too, they almost invariably their initial reaction is not, Hey, stop that. You're, you're, you're in such a position of vulnerability and shock that you don't see anything for the most part. And then people think you're making it up or something like that where you never said anything. So I think it is very important to, to speak up and say, this is not appropriate. And again, very, very important because so many people freeze and don't say anything are just so shocked that the people around them say, no, this is not okay. Yeah. And I think another situation which I've come to expect inappropriate comments or forward comments would be in the brain injury population. So having that expectation going into the room or having someone being present with you or family members is also something a little bit protective in that case. So this was a great discussion. Anything else about these two cases? There was a third one from this member as well, before I move on. Has anyone in the community experienced something like this? And did they have a way to react that was helpful? And I guess another add on to that is like, did anybody in the community have, how are they, how are you feeling supported by the institution and the hospital? Because that's something that I feel like we've come so far to shifting to patient centered care patient, you know, that like, I don't know, I guess I'm just not familiar with like what policies are in place at hospitals to protect us and make sure that patients are, I don't know, respecting our boundaries. A great question. I think coming back to the contract also would be an option in that case. Anyone else from the community? Okay. So I'm going to jump on to the next case. All right. So a third case involved a younger male SCI patient without co-occurring TBI or other neurocognitive issues who was verbally abusing the staff, including myself with discriminatory epithets, but was not medically ready for discharge when I was a covering weekend attending with a junior female resident. And again, she gave more feedback as to how she navigated these cases. So in all these cases, it was important to establish a few boundaries while preserving professional rapport, balancing patient's needs and clinician safety, well-being, modeling best practices for the trainees and staff, and taking time to debrief with team members, residents, and leadership afterwards to check in and assess team members' understanding of the situation, reactions, and any next steps at the level of the immediate team involved and or by higher level supervisors or hospital leadership. So the great summary point, and I'm grateful that she mentioned this, is also checking in with our junior members to see how they responded and to see if there's anything that they can take away or navigate the situation differently in the future. This is great. Anything from the panel or the community about this third case and the summary? Okay, so let's move on to the fourth case. Okay. Okay, so this was also, this is an anonymous submission. I had an interaction with a surgeon that really shook me. This male surgeon and I disagreed on pain management for a patient. I reached out to him because I wanted to explain my rationale. I felt that he was trying to put me down and even said I should be more like one of my male colleagues who was a junior to me. This surgeon was mid-career and I was early career at that time. He and I don't typically work together because he does non-cancer surgeries and I do cancer rehab. There was much discussion and arguing against my proposed pain management plan, often using belittling statements. After extensive conversation, he was finally amenable when I thoroughly explained my cancer rehab specialty, my role and my connections to other cancer specialists. So a little bit of background because I've reviewed the case with this, the member that submitted this. She mentioned that this was the first time that she had this kind of interaction with this individual. And it was almost as if it was a one-way conversation for the first 30 minutes and he would not hear her out. And it took multiple attempts to really enforce her expertise in the cancer rehab area, as well as name-dropping multiple members of his colleagues that she had worked with in the past and to establish her reputation for him to finally hear her and then agree with the plan that he had refuted. So any feedback about this? Good for her for sticking to her guns and being tenacious and not backing down. It can be very, very intimidating. I know when I was a medical student and the chief of surgery, I was rounding with him and he said, you know what's wrong with you? You need to think more like a male. I, of course, didn't say anything. I was so intimidated. He was this big guy and I was a medical student, but really good for her for standing her ground and knowing that she was right and doing the right thing by the patient. I think there's a number of different issues here. She knew what was right. And so she not only stood her ground for herself, but also for her patients. Has anyone else had a similar issue or scenario? Mine wasn't, you know, I've, we've all had interactions with surgeons and I mean, mine, I've had a few. They weren't as bad or egregious, you know, as this one, but I try not to, I don't take it personally, even if there is misogyny involved, which it seems like there probably is in this case, but, you know, you can't take that. I can't take that on board. So I don't know if I, I don't know if she needed the surgeon's permission or buy-in for this treatment plan. You know, I probably wouldn't have kept arguing with him. I would have just said, okay, thanks, bye. And then, you know, done what I wanted to do. But, you know, again, if she needed his buy-in, then yeah, she had to keep talking. But I think for me, what I had to learn, and it took me a long time is, and it's easier said than done, but don't take it personally. I mean, this guy's an ass, you know, that's all there is to it, I think. I hear you, I agree. So one thing that may have kind of complicated the situation is, you know, we want to maintain a referral base, make sure that we continue to get these patients. So even though it's not a surgeon that she may have interacted with regularly, the conversation will spread, right? So you want to continue to advocate for your patients, but also make sure that the teams that are referring your patients to you feel comfortable with your management and agree with letting you take over. Because ultimately, having these patients come over is for their benefit. So I think that was, that may have been one reason why she was trying so hard to have this surgeon see her point of view and agree. That's a good point. I don't often see the big picture, so that makes sense. And I will mute myself now, thank you. No, no, no, no, no, please, I want your comments. Anyone else? I'm just kind of reading this and his comment that just telling you need to be just like one of the male colleague. And so that is just kind of discrimination and male or female, we are physicians. So in our role, it's not different, it's the same as your opinion versus one of his male colleague opinions. So I don't know how he needs to be told that. And so, I mean, this is kind of a little difficult situation because depending on his referrals, you don't wanna have him just kind of get upset about it. And so cut his referrals also, but I mean, it's just, it's not appropriate comment. It's, I mean, it's very discriminative, so. Yeah, sometimes it helps to reflect back to the person, like, wow, you seem to be really upset about this or about my plan, what about my plan? Which part of it is upsetting you so much? Or which, why do you feel that way? Or why can't you be more like this guy? Or what do you mean by that? And kind of repeating it back to them. But forcing them to say something that's ugly can sometimes make them kind of stop and realize, why are you saying that? What do you mean? You seem to be very upset by this. What is making you so upset? Yes, good way, good way to open the communication further. I love that technique. Repeating back what they've just told you, it can be quite powerful. I work with 35 orthopedic surgeons, all male. Well, you know, in my early days, I was a very, very male-dominated field. So that's a challenge to be able to, you know, stand on your feet. And I'm one of you, I'm not different, so. Exactly. All right, so let's shift on. If no other comments regarding this case. All right, case five. Okay, so this is by a member in the community that I believe is on today. So I can read the case out and then she can provide more details. So my male resident and I received a consult to evaluate a post-kidney transplant patient for acute level rehabilitation candidacy. During this bedside encounter with my resident at my side, I was explaining to the patient the role of rehab in post-transplant recovery when a male attending surgeon entered the room. The attending physically took over the space where I was standing and started talking with the patient in Spanish. He then turned to my resident who was now standing behind me and reiterated the conversation to him in Spanish. I politely told the surgeon I was the attending physician and asked that he please discuss the Dyspo plan with me included and specifically in English. I'm proficient, but not fluent in Spanish. The surgeon scoffed in my face and continued to speak directly to my resident and patients. Yeah, thanks, Dr. Isaac. Yeah, I submitted that. It happens all the time. I'm a consultant. I round with these, you know, they're wonderful residents and probably some of them are on here. So you all are wonderful, but it does happen, I think, oh my gosh, like 85%, probably like 95%. Okay, 90, let's say 90% of the time. And they're wonderful, but it's when it's a male resident and again, they're wonderful, they're competent, but you know, they haven't finished residency yet and they're not like board certified fellowship trained in like spinal cord injury or whatever. So it's a little bit difficult and I really don't know how to, I didn't know what to do in that situation. So I just kind of like let it roll because also Dr. Andre, to your point, do we really feel that supported? If I may speak freely, no, I do not feel really that supported. So I don't really wanna make a big deal out of it, whether it's interaction with a patient or interaction with another colleague. So it was really a difficult situation. So Dr. Isaac, I know you're asking for solutions and different strategies, but I'm sort of at a loss here. I'm not sure how, you know, what other people, let's see, Lauren says something. Oh my gosh, I like that, Dr. Shapiro, thank you. So the comment section says, I say soy gringa and English, por favor, very slowly and then they laugh and change what they're doing. So I using humor as a wonderful method. Oops, sorry, I keep doing that. But, you know, this is a perfect place, Dr. Cochran, for getting techniques on how to navigate this situation. So anyone with any input. Well, I think this is a good place that Dr. Mackay said, you know, it seems to me that you have a problem with female attendings, why is that? I don't know if we'll ever get an answer for that. Probably the other thing is it depends on how comfortable your resident feels because as a male resident, he probably should be, you know, not groomed is a wrong word, but, you know, he should be counseled and taught to be an advocate for his female colleagues. So if he's feeling like his female attending position is not the best, he should be counseled and taught to be an advocate for his female colleagues. But if his female attending position is being disrespected, then if that male surgeon is talking to the male resident, he can turn around and say, I don't know, Dr. So-and-so, let me ask my attending, Dr. Cochran, you know, what do you think about blah, blah, blah, you know? And you can do that kind of in a soft, but not really passive aggressive, but you're kind of making a point like, hey, you're being an asshole, you know, and you're doing it in front of the patient too, you know, and who knows what the gender of the patient is too, but. No, I think that's wonderful. And I, you know, maybe that should be part of, you know, the consult rotation. You know, I'm not sure, you know, I would hope that, you know, any resident would sort of, you know, would sort of default to that. But, you know, this just wasn't the case. So, but I really do like that. But I think that's a conversation you could have had afterwards too, to debrief, you know, because maybe he was shocked or he didn't know how to handle it. So giving him, empowering him to say, you know what? I'm your attending, I'm the one that's gonna be evaluating you at the end of the rotation. Really, you're in my specialty, you're a PM&R resident. And I want you to learn from this experience that we're gonna have, you know, I mean, it's not just this surgeon, but there may be other consultants or even non-physicians that are, you know, not showing the respect and we have to have a united front as a team. And we're gonna have different roles. And, you know, right now I'm the one that's gonna be making the ultimate decision. And, you know, we need to define those roles, whether it's in front of the patient or, you know, with consultants. I've had some- I guarantee you. Sorry, go ahead. I've had some great male residents that I've worked with that do a pretty good job of when we're first meeting a patient, they'll establish who they are. And then, you know, I feel like a lot of patients don't know what attending, residents, you know, they don't know what that means, but they'll instead say, she's my boss. She's the one who makes all the decisions. And like, you know, I'm just learning, which I always really appreciate. I've never counseled, you know, but I feel like that's a great way to phrase it to patients. And, you know, she's my boss and, you know, she's the one who makes all decisions. So, and that patient encounter goes so much better. And I'm not sitting there having, you know, them stare at the male resident, looking at them as though they're the, attending physician. So I think that's something that like, I guess, I feel like in the future, having that kind of incorporated into my teaching for a start of rotation with the resident is also sort of helpful. I think on the flip side, what I've seen the female residents do is sometimes, you know, they, I noticed that the female residents use their first names a lot. They'll go in and say, hi, I'm, I'm Molly, you know? And it's like, no, you're a resident. You're, you have an MD. You graduated from medical school. You call yourself doctor because they're not gonna know. You, you, you know, call yourself that. And that's what I do. I walk into a room. some of my male colleagues feel comfortable saying, hi, I'm Greg, so-and-so. I always walk in and say, I'm Dr. McKay. I don't even say my first name to give them the opportunity to do so. I've had some tricky people, they'll say, well, what's your first name? And I'll say, so before I would say my first name and they would start calling me by my first name. So now when they ask me my first name, I'll say, hi, but I prefer to be called Dr. McKay. And I just roll it off my tongue. It felt really uncomfortable at the beginning, but I just say it every time. And along those same lines, I think that patients always need to be referred to by their first name. Yes, I say, Mr., yes. Right, you don't refer to them as Gary or- No, I walk in and I'll say, hi, Mrs. Smith. Good morning, how are you doing today? I'm Dr. McKay. I'll be the one, blah, blah, blah, all that kind of stuff. I shake their hand if in a pre-COVID, whatever you feel comfortable with, but setting those, defining your role, their role, and making sure that, because I think sometimes, and this is what I've seen with the more, like the older male patients, I think they feel out of control. And their defense is to try to put themselves at your level and they'll try to call you by your first name. And the other piece of it is being in the South, I know the difference between someone who calls me sweetie or honey from a nice perspective, like they really like you and they don't mean anything bad by it. And then those who are trying to bring you down to their level by calling you honey or sweetheart. And I do, I noticed that distinction and I will acknowledge that. And the ones that are doing it to make me come down to their level, I'll redefine the boundaries if I need to. Yeah, there's a huge difference. I'm from Boston, I trained in Boston and New York and now I'm in Miami. And what is the term like mommy or something? I don't know. I'm still getting used to it. Mommy? Yeah, I don't know. I clearly don't speak Spanish. So, but Dr. Mukai, that's a really, really great, really great couple of points you made. It happens the majority of times I'll go into a room and say, hi, I'm Dr. Cochran and blah, blah, blah. But then, oh, like their family member calls and they're like, oh, I'm sorry, I'm talking with one of the nurses or I'm talking with one of the therapists, the physical therapist or something. So then, you're like, you just want to kind of, you want the encounter to have a certain flow and be positive. But what would you say? Like, actually, pump the brakes, I'm actually a doctor or how would you- Yeah, I would say, actually, I'm the doctor. Okay. Actually, I'm the doctor. Yeah, yeah, just confront them. Just confront them as soon as you can. And you are not a nurse, you are talking to doctors, not the nurse. So, because the other piece of it is you're going to get a complaint later from the patient saying, I never saw the doctor the entire time I was at that hospital. It happens a lot, yeah. So I say, you know, there are cameras everywhere, you're welcome to look at the footage. And it doesn't help that I found that some institutions will put your first name in bold and big font and then your little last name in a little, sometimes it says MD, sometimes it doesn't, sometimes it's physician, you know, and it just really, I think it's different in the business world where they call each other by their first name versus, you know, in healthcare settings, there really does have to be, and it's not a bad hierarchy, but there is a hierarchy in terms of your knowledge-based training and responsibility. Correct. Thank you. That was all very helpful. Thank you so much. I feel armored, you know, for to feel empowered to rock these consults tomorrow. Thank you all very much. Well, go watch Harrison Bucker's graduation speech on YouTube and that'll help fire you up a little bit too. Awesome, awesome. Before every single encounter, I'm probably going to do that then. Thanks, Dr. Mukai. It'll actually make you more angry, but you'll see what I mean. It's so bad. Have you guys watched it? This was what case? The homemaker, right? The vocation? The one you're talking about? Yeah. I don't know what that is. I'm going to look it up. Oh, you need to watch it. It's a Kansas City kicker. Yeah. So cringy. Yes. Okay. Ready to be triggered. So now I'm going to open it up. I'm done with our submitted cases. Now is a perfect and wonderful opportunity for anyone else to chime in with any scenarios that they've encountered or if you wanted to expand on any other cases that we had prior in this session. Well, if you guys don't mind, if I double or triple dip, I actually had a case today that I think is fairly common, but we had a patient who had a stroke and the poor thing just isn't progressing at all. She may have improved one fem level and sit to stand, but with her ADLs, she's max assist or dependent. And she really has not progressed in the last two and a half weeks that she's been here and the family's upset. And, oh, well, we see her, she got on the exercise bike today and that's great. That is some progress, but I had to try to explain that we go by the fem levels and we have to see a certain amount of progress in a certain time. I've had this conversation many times over the years and I'm still not any better at it than I was 20 years ago. It's just hard to explain our definition of progress versus their definition and why can't the patient stay for two months and blah, blah, blah. So if anyone has found a good way to handle that, I would love to hear it. I usually let the insurance company be the bad guy. So I'll usually say, yes, like, you know, first I will say, I understand what you're saying and I get it and I'll restate what they just said. Like I did, I saw him on that bicycle. He looks great. I can see that that's so much better than a week ago, but the insurance company is looking for this measure that we can't control. It's like, it could be for me on the outpatient side, why I can't get an MRI because they want an MRI, because the insurance is requiring certain things to be checked off the list before I'm allowed to do that. So then it makes it like you and I are on the same team, but it's them. But, you know, I'm acknowledging what you're saying and what you're, you know, I'm not denying what you're seeing and what you're saying. So you're kind of acknowledging that and they're feeling heard. But, you know, being able to say that, I don't know, it's hard because I think a lot of times as women, the other part of what's ingrained in us is the people-pleasing part, where we don't want to be disliked. We want to be liked. We want to be the good person and it's easier to, you know, it's hard to be the messenger of something negative. I'm trying to read the comments as you, as it pops up, but it's hard. Yes, there's a couple of comments and, oh, thank you about the, oh, is that the commencement you're talking about? This week? Oh, I saw that. I appreciate it. Okay. There's a couple of comments I just wanted to read out and then I had some feedback also to Dr. McKay. So, I don't think it's anything you are doing. The families feel like you are taking something away. That feeling is very strong and so they can't comprehend anything you say after that. That's true. The next comment, it's easier to describe progress in terms of how much physical assist is required. One versus two people, max versus min assist. Yes, so that is something that I've used in the past to take a step back and look at it big picture to explain to the patient's families that the scores that are sent to the insurance company or the level of assistance is how objectively they look at the progress week to week. And although there are changes being made day to day and week to week, and that those progresses will continue, gross picture, the insurance company may not see a change because from last week to this week, it's remained a max effect. And at some point, if you don't show progress, we may get hit with denial. So I like to be proactive prior to that point, trying to get to the next DISPO plan that will work for the patient and family, whether that may be slowing it down so that we can get more rehab time, switching to outpatient, whatever that may be. The other thing I frequently utilize is family meetings. I think they're difficult, but wonderful, where we have the PT's, OT's, speech therapists, the case manager, the nursing team, the physician, the resident, the patient, any member of the family that would like to be there to get a breakdown from every discipline that's involved with where the patient started as to where they are now, as well as what our projected hopes and timeline is. These conversations are very difficult, but oftentimes that is a moment where I can finally get a breakthrough as to establishing a realistic plan. Anyone else with any other feedback or experiences? I think the family meeting's super helpful. I think that paired sometimes with the family training we'll do, so we'll do a family training to start and then finish with a family meeting. And that way, they've just seen how much assistance, because I think it's sometimes hard for them to contextualize what that even looks like. But once they actually see, wow, how much help there's, their family member needs to go up the stairs, and then we have that meeting and the therapist is able to say, hey, this is what we mean by this. And if you remember how it took two people to really help get up the stairs, I think that's when it really sinks in. And I think another way that I've been able to get through to patients is also saying like, this isn't the end of your rehab journey. Like, it may feel that way, but we're still gonna continue to work together and outpatient therapy is definitely an option and it's something you can do multiple times a week. And so I think a lot of times, I'm always surprised at how surprised the patients are when I say, hey, I'm gonna see you after you discharge from here. They're like, oh, really? Like, this isn't it? So I think establishing that, that this isn't the acute inpatient rehab isn't the end of it. It's just the beginning and that there's lots of areas for us to continue that journey. I think it's very difficult to deal with the unrealistic patient and their family. And so, I mean, my challenge was that some families, they think the patient needs to have a therapy rest of their life and as long as they need it. And so it's coming to the point that, you need to realize and when you plateau and we can justify the therapy, you're just gonna have to take over and the family, caregiver or institution, whatever is in the plan. And so, and I mean, I like the idea that, of course we have to follow all patients after the discharge. So this is some inpatient rehab facilities and at least I can say that in my hometown and they don't have a follow-up by physiatrist. And the practice setting, they don't have any, they are inpatient rehab facility. They don't have any outpatient follow-up opportunities for these patients. And my question was, the inpatient physiatrist, who sees those patients? And we just send them to primary doctor. That is a very, very wrong decision. So primary care doctors, they are not gonna appreciate the patients and the rehab needs and they are not gonna really follow them just like we do. And they're all concerned about the patient's hearts and lungs, right? And the patient is in a wheelchair and I'm sorry you had a stroke, you're in a wheelchair. So I think I advocate and all our learners and to make sure those patients and after inpatient rehab, they have a follow-up opportunity because that's not, as you said, that's not end of the progress. And that's those patients that just a year or two, maybe more to continue to make a progress. Any other feedback from the community? If not, thank you so much. I think this was a wonderful session. I'm so excited with the participation, the cases that were submitted, the panelists for your wonderful expertise and everyone's opinion. And thank you for sharing. I hope that this conversation continues beyond today. I hope this becomes a series, but I'm reachable on the FIS forum. My email is there as well. If there's anything that you wanna discuss further, if you wanted clarification regarding anything that was discussed, any other comments from the panelists or members of the community before we close out for the evening? I just wanna thank you, Dr. Isaac, for organizing this and for leading us. So thank you very much. Of course, thank you. Thank you very much. Great discussion. You all have a good evening. Great job. Thank you so much. Thank you.

Women's Physiatry Group

communication challenges

gender dynamics

difficult patient interactions

professional boundaries

assertiveness

family meetings

outpatient therapy

patient expectations

comprehensive care