1. My knee surgery: The good, the bad, and the ugly

By Marisa Deline, Practice Manager, Nursing Executive Center

What happened:

I hurt my knee playing soccer. On a Sunday morning. In a cold rain. I'd torn my ACL and meniscus in high school, so I'd been around the block before. But this time, I was in a lot of pain and my knee wouldn't bend or hold my weight. I needed care immediately—for my own peace of mind, even if not for the sake of my knee. After failing to find an open urgent care center, I hailed a Lyft and headed to the ED of a nearby hospital.

An X-ray showed no breaks and the PA in the ED couldn't detect any obvious cause of the knee issue, so he sent me home. I followed up with all of the usual steps: an appointment with an orthopedic surgeon and an MRI. Over the course of my treatment, I experienced a little bit of everything…..

The good:

The level of communication from my (eventual) surgeon. When I went in for my assessment and consult, my surgeon walked me through my MRI, answered all of my questions, didn't rush me, and ensured I understood all of my treatment options. Surgical and otherwise. He also gave me his email address and responded promptly to all of my follow-up questions. 

The skill and emotional intelligence of my pre-op nurse. It's hard to say enough positive things about this nurse. Kind, warm, and professional, she had worked for more than 20 years in the ICU before moving into this area. She explained what I could expect throughout the pre-op work-up, got the Vein Spotter when a tech was having troubling placing my IV, and explained every care step before completing it. She read my mood and chatted when I was interested, was quiet when I wasn't. She was also the one to remind the anesthesia intern to confirm my identity and drug dosage before giving me Versed for my nerve block. The intern had forgotten.

The bad:

The ED visit—from the people to the facility. On one hand, I was happy that I didn't have to wait long—I was put into the fast track and was out within two hours. But on the other hand, a few things happened that ensured I wouldn't ever return to that ED. First, the X-ray tech ran my wheelchair into the X-ray table, causing me excruciating pain. Second, I had to be my own advocate to even make it through the X-rays. My knee wouldn't bend or straighten fully, meaning I couldn't follow the tech's instructions—and he stood by wordlessly watching me struggle. I eventually asked for a towel or pillow to prop up my knee. Third, the X-ray room itself had clearly experienced significant water damage: Chunks of paint and drywall were falling off the walls, and the room smelled terribly of mold. 

The ugly:

The anesthesia team's lapses. To put it bluntly, the team made me feel like a person who happened to be attached to a very interesting knee. Not like a person. Their introductions were rushed. I didn't understand their roles. They were all in and out of my curtained area multiple times without saying hello, explaining their purpose for being there, or interacting with me at all.

Even worse: I was completely lost during the informed consent for my nerve block. I work in health care research and used to work in a clinic—but I didn't understand a word the doctor was saying, much less the benefits and risks of the procedure itself. I interrupted him and asked him to slow down. He apologized, stood closer, and then carried right on in his rushed explanation. Then he handed me the form and pointed where to sign. When I started to read the form, given that I didn't understand what it was, he interrupted to point again at the signature line and said "sign here." I felt condescended to and confused all at once.

Finally, when the team appeared at my bed to do the nerve block, I almost laughed. There were four of them. I think two of them were interns, there to do the procedure itself. One of the observers was a student, but she never introduced herself. The observer I was glad to have? The attending. He was the one that reminded the interns to do the safety check before starting the procedure. They'd forgotten.

My takeaways:

The theme behind my "bad" and "ugly" experiences was, ultimately, about caregiver empathy. I don't think that X-ray tech would have run his sister into the X-ray table. And I think he would've have been more proactive in helping me if he'd thought about how much pain I was in. I think the anesthesia team could've used a reminder that they do this every day—but it was my first time getting a nerve block before surgery. In contrast, the pre-op nurse really took the time to get to know me and was able to better support me because of it. And I appreciated it tremendously. (If you want tools to help your staff build empathy, I'd suggest looking at this toolkit).

I was also reminded of how important it is for health system leaders to prevent clinician burnout—and create time and space for clinicians to draw upon their resilience skills. (For more on how to do this, view our infographic on how to support nurse resiliency).

2. Sleep apnea testing: Why did we build it this way?

By Robert Reeve, Senior UX Designer

I'm a user experience designer at Advisory Board, so it's my job to take what we make and put myself in your shoes, dear reader. I'm infamous in these parts for always asking an honest, hard question: "Why did we build it this way?"

I wonder this about the health care industry every day. Last November I was diagnosed with sleep apnea. A year later, I still don't have a CPAP machine.

My health care has felt like a relay race where no runner knows how big the team is, how long the race is, or who they hand the baton to next.

And I feel like the baton.

I could kvetch about many aspects of this journey, like the utter lack of price transparency, or how I've been offered only high-deductible health plans. Or how even though three of my providers—my otolaryngologist, the sleep study facility, and my pulmonologist—were all within the same prominent D.C. health system I had visited before…

...I still had to fill out new patient forms at least three times.

But no, my real least favorite part of all of this is familiar to any office worker: Most of these meetings could have been an email.

Every one of these specialists had a two-month wait, every time. My pulmonologist did not provide services, or even touch me, in either visit with them.

The first visit: "So your ENT says you need a sleep study. Okay, I’ll put in the order."

The second visit: "So I have this two-page paper that shows me the results of your sleep study. Okay, I'll put in the order with a medical device provider."

I took time off work, rode my bike across D.C., and sat in the waiting room for two 15-minute appointments across four months. I asked about telemedicine. It seemed like a no-brainer solution to all these problems. I was shocked to learn this specialist didn't offer it.

Now obviously, this health system can't control the entire health care industry, but they can control making this process more seamless, right? The information-sharing, the wait times, the convenience of video chat?

So why are they built this way?

3. A tale of two surgeons

By Allison Cuff Shimooka, VP of Marketing and Operations

When I was 20 weeks pregnant with my first child, she was diagnosed in utero with a cleft lip and palate. With several months until my due date, I had a lot of time to pick a care team—and it was during this process that I had both my worst and best experience with physicians.

The worst was my first post-diagnosis visit. Despite having spent the entire day at their organization, having diagnostic tests and speaking to members of the care team about our situation, the lead surgeon of the cleft team had no clue who we were when he finally sat down with us. Importantly, he didn't see anything wrong with that.

When I asked him questions about his surgical volumes, he was offended that I would even ask, responding with a very curt, "More than enough." When we asked if we could see some photos of children with clefts whom he treated, in order to better understand what to expect, he took out his laptop and proceeded to page through a random assortment of photos, many of children with incredibly severe conditions completely unrelated to our situation. I left the visit in tears. I knew that technically he was a skilled surgeon, but he was not someone I wanted to partner with for the next 15+ years of my daughter's care journey.

Fortunately, we had a completely different experience with another pediatric plastic surgeon a week later. His response to our questions was detailed and prompt, and he congratulated us on doing our homework. When we asked to see photos, he had a ready-made photo book and selected which pictures to share with us based on the severity of our daughter's cleft. Put simply, he and his care team treated us with respect and compassion. I left the visit feeling hopeful and empowered, like we had found a partner in caring for our child.

4. The abnormal heartbeat—and what it taught me about empathy

By Rachel Schulze, Editor, Daily Briefing

About a year and a half ago, I had a nerve-wracking 20-hour medical ordeal that started in my primary care provider's (PCP's) office, took me to the ED for an overnight stay, and ended at a cardiologist's office. It was an experience that taught me that—while everyone in medicine is often obviously working very hard to solve problems— they can sometimes forget just how anxiety-provoking those problems can be. 

The event began on Thursday afternoon when I went to see my PCP for shortness of breath. I wondered to myself if I'd developed asthma.

My PCP had another theory: Since I was taking a medication that can increase the risk of a blood clot, she immediately sent me to the ED for a CT scan and other monitoring. The word "blood clot" made my heart sink.

Cue a trip to the hospital where, while waiting, I was provided some sort of flu-related nasal injection (why this was suddenly essential wasn't clear). Fortunately, once I got the CT scan, it showed no blood clot. But I wasn't in the clear: I was shocked to learn that my EKG showed an abnormal heart rhythm. That led to an overnight stay at the hospital and directions to see a cardiologist.

After six or so hours of hospital "sleep"—with an IV in me and a 4 a.m. wake up for testing—the next morning, a stranger appeared at the foot of my bed and told me I was to come to his cardiology practice that day. A cardiologist? I was 25—and scared. I was also too tired to understand what he saw saying and accidentally made an appointment with another cardiologist.

The cardiologist I saw determined there were no immediate concerns and directed me to see him again in a month. When I asked if he had any idea what was the cause of my symptoms, nonplussed, he guessed it could be acid reflux.

I still didn't have a diagnosis, but since the immediate concerns were addressed, the process ground to a halt while papers were faxed between offices. I didn't hear from anyone for a week, so I called my PCP to follow up, and she diagnosed me with asthma.

I applaud the providers for acting fast on a scary symptom, and I was relieved that the problem was not more serious. Looking back, however, I'm struck by just how overwhelming the whole ordeal was, and wish each provider could have shown more empathy for how quickly these situations can accelerate. For months afterward, I would worry something had been overlooked in the haste to rule out an immediate issue. Each provider acted appropriately for his or her step along the way, but without seeing the greater picture, each one failed to provide the empathy that a 25-year-old concerned about why she was having trouble breathing.

5. Judging cost of care: My experience at a freestanding ED

By Megan Clark, Managing Director

A trip to a freestanding ED gave me new insight into the challenge of in-the-moment education about cost of care.

After breaking out in hives on a Saturday night, I started by going to my local urgent care. Unfortunately, it was closed. As I approached the front desk of the freestanding ED, the man who greeted me explained that because this was a freestanding ED, the cost of care could be more expensive than in other settings. As I was handed a clipboard with forms to fill out, I was also handed a waiver to sign attesting that I had been informed upfront that I was in a freestanding ED and told the potential impact on cost of care.

While I strongly believe that we should be transparent with patients about the cost of care, I'll tell you it was totally disorienting to stand there in the middle of an allergic reaction and try to reasonably process this cost information. I sat for a few minutes in the waiting room and debated: Did I want to leave? Try to find another option at this late hour?

At this point, my symptoms were getting worse and getting back in the car was not the right answer for me. I was lucky because I had a moment to stop and think—but in the middle of so many emergencies there isn't the luxury of time. Therefore, looking back, I don't critique the site of care (I am grateful the freestanding ED was there, and I would go again if I needed it) or the communication (since the information was clearly presented). But the piece of the experience that sticks with me is how hard it is to process decisions about the cost of your care once you already need it.