Babbling about The Three Sides of the Stethoscope

#191: Ever wondered why your doctor seems to rush you through your medical history? Or why getting that MRI your provider ordered takes weeks of insurance battles? The disconnect between what patients experience and how the healthcare system actually functions creates frustration on all sides.

Drawing from 15 years of healthcare experience, as both a provider and a patient, I'm pulling back the curtain on how medicine really works. When patients say "no one is doing anything for me," they're expressing a genuine frustration born from a system that often fails to communicate its processes effectively.

Medical providers use differential diagnosis, a detective-like process, to narrow down possible causes based on specific symptoms. This explains why they ask such targeted questions and sometimes seem to cut you off mid-story. It's not rudeness; it's their training to find the most critical information quickly. Meanwhile, nurses use structured communication methods like SBAR (Situation, Background, Assessment, Recommendation) to deliver life-saving information efficiently.

Behind the scenes, insurance companies create enormous barriers through prior authorization requirements that delay necessary care for 94% of physicians. Your provider may be fighting battles you never see, writing appeals and conducting peer-to-peer reviews just to get you the test they know you need. America spends more on healthcare than any other wealthy nation yet has worse outcomes because our system prioritizes "sick care" over prevention.

Whether you're a patient trying to be heard, a nurse communicating critical information, or a provider navigating systemic barriers, better communication is the key. Remember that medicine is humans helping humans, we're all learning together how to create better healthcare experiences through clearer communication.

If you've ever felt frustrated with healthcare, this episode offers practical insights from someone who's seen it from every angle. Share it with someone who might need a new perspective on navigating our complex medical system.

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• 14:36 (Cont.) Babbling about The Three Sides of the Stethoscope

Transcript

Johnna: 0:00

What is up, everyone? Welcome back to another episode of the Babbles Nonsense podcast. Today we are shifting back to some healthcare talk to kind of keep it a little bit more light and different. But I wanted to pull from both sides of my world and that being like a nurse and a provider, but also a patient at the same time and talk about how medicine truly works because believe it or not, I actually have these conversations in my day-to-day life more than I can even count. And it it begs to wonder like why nobody's talking about this. And just know that I'm also not giving medical advice. This is just my perspective after 15 years in healthcare and after lifting listening to countless patients, especially veterans during their exams. Over and over I hear the phrase, no one is doing anything for me. Um, and with my medical knowledge, it's mind-blowing sometimes to see the gap between what patients are experiencing and how the system functions. So today we're going to break down how to communicate with providers, both from the patient perspective and the nursing perspective, how medicine is actually taught and practiced, and why our system is set up for quote unquote sick care instead of true preventative care. So if this is something you're interested in, give it a listen. So thank you for staying if you stayed. Um, I want to start first from the patient perspective, like when it comes to um how frustration can build up and how we speak to providers and stuff like that, because I've been there myself. And honestly, I get where frustration builds because providers are trained in what's called a differential diagnosis. That means when you come in with a complaint, providers are building a list of possible diagnoses in their heads and working to narrow it down. So it's kind of like detective work in a way, you're kind of working backwards from like instead of so it's like if you think about detective work and how they have evidence and then they have to come to the answer, it's kind of the same thing. When you come in with symptoms, that's quote unquote evidence. And then you have to do testing to get to the true problem. But here's the key the more specific and direct you are as the patient, the easier it is for your provider to get to the right test and treatments to help you a little bit better. And I know for me, like because I do have medical knowledge, I understand this and grasp this. But when I talk to patients about it and talk about how you like patients really should advocate for themselves, like as a provider myself, I do not get upset if a patient is Googling or using Chat GPT or whatever their symptoms to kind of help explain their symptoms because maybe they're so vague they don't know how to explain them. So we can use an example like abdominal pain because it's so broad. Like if someone comes in with an abdominal pain, that could be so many different things, right? So if someone comes in and says, My stomach hurts, we have to ask a dozen questions. Where is the pain? Is it your right upper quadrant? Um, or is it your right lower quadrant? Because depending on where your pain is, that can be make a big difference, right? So if it's your right upper quadrant, I'm over here thinking your gallbladder or your liver. If it's your right lower quadrant, I'm now thinking, is this your appendix? Is it an ovarian cyst if you're a woman? Is it testicular torsion if you're a man? Could it be possibly an inguinal hernia with referred pain? So depending on where your pain is, makes someone narrow down their differential diagnosis. I'm hoping y'all are all staying with me here. And then it determines on what kind of testing you're gonna get, right? So if you're telling me it's your right upper quadrant of your abdomen, of your stomach, your abdomen, then I may want to order an ultrasound of your gallbladder versus if it's your left lower, I may want to do, you know, do we need a testicular ultrasound? Do we need a transvaginal ultrasound to rule out ovarian cyst versus testicular torsion? Do we need a CAT scan with IV versus oral contrast depending on your body weight? Because sometimes the smaller you are, IV contrast isn't enough to see some organs. You have to do, you have to drink oral contrast. So there is a reason why providers ask certain questions. And when patients don't answer directly or when they give sometimes too much history, sometimes that can make it harder. So we have two extremes of patience. We have the patient who says almost nothing, making the provider have to drag information out of them, or you have the patient who starts with something like in 1990, and then finally 20 minutes later, they mention the real reason why they're there, and a provider may or may not have zoned out by then. And and I don't mean that disrespectfully or any kind of rude, um, but neither one of the extremes of someone having to pull information out because then now it's almost like pulling teeth to get the patient to even speak, or then you're having to like kind of hurry along the patient who's talking about he had this pain in 1990. And even though that may be important down the road with questions, that's not important. And I guess I'm maybe coming from an ER perspective, and I'm thinking like critical care, because when you're in the ER, you know, you're trained what will kill you first. That is what we are trained on, like obviously life-saving measures because you're in an emergency room. But the takeaway is for patients to be clear, to be direct, and trust that your provider is asking certain questions for a reason. The questions they're asking are not random. They're helping them narrow down that list of possibilities in their brain. And I know if you don't have any medical knowledge, you probably didn't even know that, but I thought it, you know, should obviously be shared because miscommunication is one of the top causes of medical errors. Um, the Joint Commission has cited communication failures as a leading cause in over 60% of sentinel events. And sentinel events are serious unexpected outcomes in healthcare. That shows just how much clarity matters in patient provider communications and their conversations. So, like I said, both extremes can become a problem because if you're giving too much information and it's kind of overload for a provider, think about a conversation that you have with your friend. If they're giving you so many facts and so many details that you're having to go, wait, hold on. Now I'm getting confused. You said this here, this there. It's the same with medicine and conversation. When we give too much, sometimes it becomes brain overload and you are kind of forgetting why they're there. And I don't mean that, again, I don't mean that disrespectfully, but think about there was a quote one time, and I can't remember, like people's humans' attention spans are only so long. So when we give drag out conversations, and I'm bad about it myself in my personal life, like I'll drag out conversations, long text messages, especially to men where we know like they shut down after like two or three lines. And I do the same thing. Like if I'm scrolling on social media and I come across a post that's forever long, I'm like, I'm not even reading this. And I know that's that's awful, but we have been conditioned and trained for that quick, fast-paced in our everyday life, and it kind of transcends into our jobs. And sometimes our jobs is healthcare. But again, this is just from my perspective. I'm not saying every provider is like this. Um, I have like 13 years of critical care experience, and this is just what shaped my healthcare experience because I first started in an ICU as a bedside nurse, which is critical care, and you have to learn like and discern and learn. And then I went to emergency medicine for I think 11 years, and then I did trauma for a year before I transferred and before I transferred into like clinic work where I saw that there was kind of a disconnect. But I saw it in the ER too, like like when people would come in, for example, with chest pain, and you're trying to be like, okay, does the chest pain, does it radiate? Does it, does it go anywhere? Does it go to your arm? Does it go to your back? Where is it? Is it on the left side? Is it on the right side? Does it hurt when you take a deep breath? Have you traveled recently? Do you have any history of coronary artery disease or heart attacks? Does your family have any history of these? These are specific questions to say, in my mind, to narrow down, could this be a heart attack? Is this musculoskeletal pain? Is this a pulmonary embolism? Those are the things I'm thinking. And I know sometimes, again, if you're not medical and you don't know this, then it does make it hard to understand why sometimes physicians or providers are being like trying to hurry you along in a story. Like again, I'm telling you, I had a lot of the elderly population would come in and go, Well, in 1999, I had chest pain that was on the right side, and I went to the doctor multiple times, went to the ER multiple times, had multiple cardiac casts, and they couldn't determine what was causing my chest pain. And even though that again could be important later, 1999 chest pain doesn't have anything to do with 2025 chest pain unless you say everything that, like if you answer everything I ask and then you say, well, you should also know in 1990 I had the same exact chest pain and I had a heart attack. That's very important, right? Like that's factual. But if you're telling me they couldn't determine what caused your chest pain in 1999 and you go through a 10 to 15 minute story, and then the outcome is they didn't know what was going on, that's not going to help something in 2025. But I don't want to deter anyone from saying what they want to say to a provider. I'm just trying to give kind of perspective from a provider standpoint. Okay. And then let's go on and move to the nursing side, like the conversations from a nursing perspective. Um, when you're speaking to a provider. So for me, you know, I've been the nurse, I've been the provider, I'm still a nurse, I'm still a provider. Um, and I worked in the ER for 11 years. One of the biggest lessons I learned from this was the shorter and more focused you report to a provider, the better, especially to specialties like surgeons. Um, providers get dozens of calls in a shift, and we have to remember that, especially if they're working 12, 13 hours, they're on call and now they're working 24 hours. So a quick, clear summary gets attention quicker than a long, drawn-out explanation, you know, will get a turned out. So, for example, let's let's think about like a patient who fell and they're on blood thinners. So, to me, a bad version of contacting a provider would be like, hi, sorry for calling, but Mr. So-and-so in room two fell in the kitchen at 2:32 p.m. Three staff witnessed this. He, we believe he hit his head. Um, I checked his MAR and he's on Eloquist, which I've known and found out is a blood thinner. I've contacted the family. They're very concerned, they're crying. Um, the patient seems to be okay. I did check them neurologically, and I don't find any neurological symptoms to be wrong at this time, but we did call EMS to send them to the ER. We just wanted to let you know that. Versus, hey, Mr. So-and-so fell, he hit his head, he's on eloquist, we send him to the ER and the family has been notified. So you like, even though the first one, yes, you're telling everything, and it's important from a nursing perspective because in nursing we see the patient and the family in the room as a whole, versus when you come to the provider side, you're seeing you're trying to make sure the patient's okay, right? And I'm not saying nursing staff is not doing that either. But then you you have way more patients. You may, like as a nurse, you may have, you know, four to five patients that you're taking care of for the day. And then as a provider, you may have 50 patients on your list to see versus call versus your calls versus everything else, right? So the quicker you can get to like, because that's just a quick, like, okay, thank you so much for notifying me. I will make sure to see this patient on my next rounds. And then, and then you could give your orders, right? Like Q2 hour neurochecks, you know, you know, if the if the ER doesn't do a CAT scan, we need to do that. And then that kind of makes it a better. So I'm sure you can see the difference in those two um communications from a nursing standpoint to a provider's. Both share the same facts. You know, one will take maybe two or three minutes where the other takes, you know, or sorry, one may take 90 seconds where the other takes 10 minutes. And as a nurse, you know, don't ever apologize for doing your job. Like I've had nurses call me before and be like, I am so sorry to contact you. Don't ever do that. You're doing your job. Like you should not have to apologize for doing your job. Um, but just rem rem remembering to give the critical details that you know they need to know is the most important part. Like, obviously, if you if you want to give more explanation, do that at the end. Like, if you need to say all that other stuff because that's just your personality, say it at the end because you've already got the provider's attention. I guess what I'm saying is get the provider's attention and then say whatever you need to say. So if you need to say Mr. So-and-so fell, hit his head. He's on Eloquist, we sent him to the ER, family was notified. I just wanted you to know that this was witnessed by three people. We did, you know, see it. We did check his mar. He's on Eloquist, which is a blood thinner. Like you can say all that at the end because you've already got the provider's attention. Just say what you need to say to get the provider's attention. Um, and that goes into the S-bar method, which is situation, background assessment, and recommendation is actually the gold standard for structured nurse-to-provider communication. Hospitals nationwide train on this because it improves outcomes and it reduces errors. Because again, think of I need to look, I'm gonna look it up really quick so I can just have the facts about how long does it take for people to lose interest in a conversation from non-biased sources, because I think it's seconds, um, which is crazy. I I remember reading it and then I can't remember what it said. So let's see. So it says from a 2023 study found that young adults could maintain optimal attention during a continuous task for an average of 76 seconds before losing focus. And that's can't become more recent because attention spans um are influenced by digital technology. So that's why we live in this digital world. And if you're someone's attention span is gone in 76 seconds, you know, again, we yes, we do our best to stay focused, especially in the careers that we choose, but that does not take away from statistics or, you know, kind of human evolution and whatnot. But, anyways, I want to also address why the system fails and why it's broken, so that just from the provider, if you're listening, I mean, y'all know this, and then the patient, you may not know this. Um, so here's where we're gonna zoom out for a little bit. The reason patients often, in my opinion, feel unheard is because our system is not preventative, it's reactive, it's quote unquote sick care. Um, insurance companies usually are in control most of the time, and I don't know if patients know that. Like your provider may want to order an MRI, like let for um for your back pain or something. But insurance requires like what's called step therapy, and their step may be first you have to order an x-ray. If there's nothing on the x-ray, second, they have to go to six weeks of physical therapy. Um, and then third, you know, if they go to physical therapy and they're still having pain, then you can order the MRI um before it gets approved. But and I'll give you an example of this. I worked in a clinic, you know, where we did spine pain management and we had a patient that fell, it was acute injury, even on top of their chronic pain, but they fell at work and they came in, you know, not able to really lift or move their one of their lower legs. I can't remember if it was right or left, but I wanted to order an MRI of the back because we did an x-ray in office and it didn't show anything. And an x-ray is going to show you certain things like a vertebral fracture, like a bone fracture. Sometimes it can show you if the discs are, you know, narrowing, which is degenerate to disc disease. Um, it can't always show things like a herniated disc, spinal stenosis, um spinal canal compression, um, nerve root ending compression. It can't show you those things. MRI is gold standard for that. So if an x-ray doesn't look like if you're looking at the x-ray and you're looking at the patient and their symptoms and they're not matching, the next step would be to do an MRI. I'm not going to send someone to six weeks of physical therapy, not knowing what's going on in their back with an acute injury, because we can worsen it with manipulation and movements and stuff like that in physical therapy. So for this particular patient, I had to appeal because their insurance denied their MRI, I think two or three times. And appeals take a while, guys, and that's why it becomes cumbersome. Um, but it's, you know, obviously doing what's right for the patient. And it takes time because you're still in clinic, you're still seeing patients, you're then having to write this long appeal with medical literature to back up why you want to do this. Meanwhile, the insurance company is just doing their job. They're following this step-by-step algorithm, and it's usually someone with no medical knowledge until you appeal it. Some insurance is two, some is three. And then you can do what's called a peer-to-peer evaluation where you actually get to speak to a provider, tell them what you've done, give the give the symptoms, tell them the x-ray was unremarkable, and this is why you don't want them to go to physical therapy prior to MRI, and then it gets approved, but that's weeks later the patient's been sitting in pain and they're mad at the provider because they feel like the provider's quote unquote not doing anything. Meanwhile, behind the scenes, they're actually doing as much as they possibly can for this patient. And this isn't rare. Um, according to the AMA, prior authorization requirements delay necessary care for 94%, 94% guys, of physicians. And more than a third of physicians report that these delays have led to serious adverse events for patient care. So that's why like it's so frustrating as a provider, like when you you are medically trained and and I get it, there's there's always got to be checks and balances. Like I truly understand that, and I appreciate that in any healthcare where like someone's like, Well, I don't really feel this is necessary. But when you see that it's, you know, literally, I'm not kidding. Someone who graduated high school, got a job at insurance company, has no medical training, and they they are doing what they are trained to do, and that's to follow an algorithm. If they don't meet these requirements, we don't approve it. And there is a huge gap there because we're not preventing anything. Let's say this particular patient, I did not do the appeals, I did not do the peer-to-peer because it just took too much time. Let's say that. And let's say I was like, okay, fine, let's just send her to physical therapy and she had a herniated disc, and then I made it worse by sending her to physical therapy. I just as a provider could not live with myself doing that. So of course I fought for this patient. And of course, we got the MRI ordered. But at the end of the day, it's not always like that. It's not always that easy or simple because it's frustrating. And so your provider may be frustrated at situations like that and then have to come in the room and try to put on this, you know, smile to see the next patient when they're super frustrated at a situation that has nothing to do with the new patient in the room. And again, I get it. People, I when I have these conversations with friends and family members, they're like, Yeah, but you chose that career. Yes, I did. But at the end of the day, we are all humans, and that's what I'm trying. We're not robots. We can't just turn off certain feelings and we do the, and I trust me, guys, we do the best we can, but even your provider is gonna have a bad day and be frustrated about patient care, or maybe they were just cussed out in the room before you, or maybe they, if you're working in an ER or ICU, maybe they just lost a patient that they coded for two or three hours and they're sad and they don't have time to decompress that. So I guess maybe the perspective I'm coming from is maybe show a little grace. Like obviously, if they're not doing what's right for you in front of you, then obviously point that out. But if they are doing what's right in front of you and they're not doing what you expect of them, maybe you are expecting a little more hand holding or expecting a little bit more, you know, I don't know if compassion is the right word here, because I feel like even when I've been in those head spaces, I still have compassion and I'm still doing what's right for my patient. I'm still listening. I'm still, I may just not be as talkative or, you know, as smiley. And I don't know the right word for that, but I hope that makes sense and I'm hoping I'm making it um make sense. But um there's also, I want to move on to the next thing, there's also what's called the preventative care gap. And when the Affordable Care Act was passed during Obama's administration, preventative services like pap smears and mammograms were supposed to be covered at 100%. And while the test itself might be free, facilities still bill you for using the machine or for coming into the facility itself, which leaves the patient frustrated and distrustful of insurance because it's like, no, preventative health care is supposed to be there to not deter someone from getting screenings. Because let's be honest, it's a lot cheaper to pay for a mammogram screening versus chemotherapy for never getting checked out. And that's where the irony is. Preventative care saves the money. And I'll give you an example. The CDC estimates that every $1 spent on childhood vaccines saves $13 in healthcare cost. Yet our system still prioritizes reacting to illnesses instead of inventing investing in preventative care. We wait until you're sick, which that's a whole nother like theory, right? What's what's that called? Um, conspiracy theory, where you know, Big Pharma owns a lot of things, they push out drugs, like politicians are pushing out drugs. Let's say, and you almost want to think like, why are politicians backing this? You have no medical training. Um, you're saying all this this stuff with no no years in research, no years in medicine, and yet we listen because you know we're taught to trust these people, and then it's like a cycle, like nobody's getting healthier. Actually, America, I'm pretty sure, and I'll look up that statistic. Let me actually look up that. I think America is probably one of the sickest countries, maybe. Um where let me look that up. Where does America lie when it comes to I'm gonna put in quotes sickness compared to other countries? Because other countries do it a lot differently. Um a lot of people are like most countries do allow people to have health care. And so it says that um in many respects the US has worse outcomes than other high-income countries despite spending far more. And it says, um, that's too many charts. Let's see. Break it down short paragraph. Sorry, guys, I should have actually looked this up prior to doing this podcast, but I was like, let me just look it up while we're here. All right, so compared to other wealthy nations, America is one of the quote unquote sickest despite spending the most on health care. Chronic conditions like obesity, diabetes, and heart disease are far more common in America, and in America, our life expectancy is lower. The U.S. also has higher infant and maternal mortality and more deaths from conditions that could have been prevented with earlier health care. A big reason is that our system is built around quote unquote sick care, treating illnesses once they appear, rather than preventing them from the beginning. Things like insurance barriers, high cost, and fragmented access make it harder to get earlier screenings or timely treatment, while social factors like income inequality and lifestyle risk add to the burden. In short, Americans pay more but get worse outcomes, making the U.S. stand out as an outlier in global health. So that is wild. That is wild. Um, but I we can't I kind of knew that. I just didn't know statistically where it stood. Um, but anyways, I just want to kind of break it down like this. If you're a patient, just remember, be clear, direct, and specific with your symptoms. And again, guys, just know that this is my perspective. This does not mean it's the end all be all or how all providers think or feel. Um, and I trust that the providers are asking questions for a reason. And if you don't feel like they are, get another provider. Advocate for yourself. You know, do it respectfully. And if your provider isn't a good fit for you and you need someone who does a little bit more hand holding versus being a little bit more direct, do that. Choose what's right for you. Don't forget as a patient, you have a choice in your healthcare as well. The way I practice as a provider is that this is a collaborative agreement. Like, I want you to talk to me. I want my patients to say, hey, are you listening to me when I said this? I still don't feel good with this. I know we've tried this. Can we try this? Like, I don't mind that. I know some providers do. And if you need someone who collaborates with you and your current provider's not, then change providers. If you don't want the collaboration and you just want to trust your provider and you're like, you know, I don't care if someone's direct with me. I know, you know, they come highly recommended. I don't need the hand holding, then choose that provider. Just remember, as the patient, you also have a choice in healthcare. Don't forget that. And I I educate my patients this all the time. Don't forget that you also have a choice. Yes, us as providers, we are supposed to advocate for our patients, but don't forget that you can also advocate for yourself or your family members. If you're a nurse, remember you don't need to apologize for doing your job, deliver short, focused reports, and then you can add whatever you need to add once you get the provider's attention. Don't forget frameworks like SBAR to keep communication clean. And for all of us, we need to push for a healthcare system that prioritizes prevention, not just reacting once we're really once we're already sick. And that does come down to unfortunately politics, and I'm not going to get political on this podcast, maybe one day, but this year I've actually paid more attention to politics than any years previous because I didn't realize how important it was. Maybe it's just because I'm getting older. And things like healthcare really matter to me, obviously because I work in it, obviously because I talk to patients on a daily basis about it. And I am very passionate about what I do and how I can help my patients. Um, so just remember that sometimes that does come down to looking at policies in healthcare. I think they sometimes overpromise and underdeliver, but that's another topic for another day. Um, we just have to remember at the end of the day, medicine is about humans helping humans. And the clearer we can communicate, the better chance we all have at real healing. And just remember, this is not to give any medical advice or what to say or what to do, because I want you to obviously communicate with your provider how you want to communicate. I'm just trying to give a little bit of a tips and you know tricks to maybe catch that attention and then say other things. I know we all have to learn this in our everyday life, but just remember at the end of the day, everyone's humans and you know, we're not we're not chat GPT, believe it or not. Um, we don't know everything and we're all learning together. But thank you for tuning in to this week's episode. I hope it gave you a new perspective. If it did, obviously share it with someone who might need to hear it. And as always, this again is not medical advice, just one nurse practitioner's perspective from years on both sides of the stethoscope. Actually, three sides of the stethoscope being the patient, being the provider, and being the nurse. But until next time, guys, bye.