What is it a paramedic does?

[Melclin]

The extended care model is a good step, and we would do well to move in that direction here.

The frustrating thing here is that we are actually allowed to do things like refer to a GP etc, its just that very few if any seem to bother doing it. Either they don't seem to have to the confidence in their own ability to decide on an appropriate course of action for the pt's treatment beyond our guidelines, or they simply don't want to have to put up with the possibility that a complaint is made and they have to justify their actions. Its simply easier to transport to the ED.

Eg, I went to a bloke about 60 who'd tripped over and skinned his knee the day before and his wife had convinced him to call an ambulance. He could drive, he had in fact driven home from where he tripped with no difficulty. He was in no particular pain except some discomfort putting weight on it. There was no reason why we simply could not have said, you don't need to go to the ED with us, how about we make an appointment with your GP. But we transported with the rationale later explained to me as being that he seemed like the type to complain to the service and he (the medic, didn't wanna get yelled at). There must be a million jobs like that, that don't need to clog up the ED.

 

[Veneficus]

The extended care model is a good step, and we would do well to move in that direction here.

The frustrating thing here is that we are actually allowed to do things like refer to a GP etc, its just that very few if any seem to bother doing it. Either they don't seem to have to the confidence in their own ability to decide on an appropriate course of action for the pt's treatment beyond our guidelines, or they simply don't want to have to put up with the possibility that a complaint is made and they have to justify their actions. Its simply easier to transport to the ED.

Eg, I went to a bloke about 60 who'd tripped over and skinned his knee the day before and his wife had convinced him to call an ambulance. He could drive, he had in fact driven home from where he tripped with no difficulty. He was in no particular pain except some discomfort putting weight on it. There was no reason why we simply could not have said, you don't need to go to the ED with us, how about we make an appointment with your GP. But we transported with the rationale later explained to me as being that he seemed like the type to complain to the service and he (the medic, didn't wanna get yelled at). There must be a million jobs like that, that don't need to clog up the ED.

Sounds like the simple solution is for the ED to yell at you more and louder. Then it isn't the path of least resistance.

I worked for a US service that could deny transport, we rarely did for the same reason you described.

 

[Melclin]

I think officially recognizing the ability of a paramedic to be able to be guided in clinical decision making about minor issues of injury, illness and social care but guidelines like those published by the Westcountry Ambulance Service trust that brown put me onto a little while back, would be a good start.

http://www.swast.nhs.uk/clinical/pdf/ECPGuidelines.pdf --I think this is it but I can't open the document on account of being capped.

What do people think about this kind of approach being extended to all paramedics? Keeping in mind the different levels of education around the place.

 

[Jeffrey_169]

I have been trying to champion that idea for years, nobody in the US wants to hear it except Skip Kirkwood. (who probably came up with the idea long before me)

I would like to discuss ideas on how to realistically make this happen.

I agree, totally. The modern EMT-P needs to diversify like the nurses did, and in reality this is will be the only way we survive as a viable and respected profession. We need to fight for more education, a higher standard of care, and and a far more diversified scope of practice. It is important for us to write our congressman and representatives and other elected and non elected officials the same way the other lobbyists do. We need to stand up and break our silence.

We are the only ones responsible for our profession, and we need to take action to improve it.

 

[MrBrown]

I have been trying to champion that idea for years, nobody in the US wants to hear it except Skip Kirkwood. (who probably came up with the idea long before me)

I would like to discuss ideas on how to realistically make this happen.

Skip is a very smart man I've talked to him a few times.

The biggest problem in the US that I can see is lack of insurance, so lack of access to healthcare services. Nations with universal healthcare do not have this problem so implementation may be much easier.

A lot of the problem could also be attritubed to inadequate education and overly laborinthien medicolegal problems as well as disparity between states in that each state will have a different standard and "nationalisiation" is a very bad word it seems in the US.

The following seems to be needed to make this plan work

- Disestablishment of BLS/ILS/ALS as it currently exists
- One new level with most focus on public health but with emergency care skills included
- Electronic linkage of patient records into a single system
- Total intergration into the public health system
- Independant rights to prescribe certian drugs and tests
- Registration of ambos as a health practitioner

I forsee a Bachelors Degree being the entry requirement for this sort of person who would have to operate with another practitioner while going through some sort of post-Degree internship to earn a Masters Degree which would enable independant practice.

Basically, if you put a PA in a 4WD with an ALS bag and MRx that is what I am proclaiming needs to be done.

 

[JPINFV]

The biggest problem in the US that I can see is lack of insurance, so lack of access to healthcare services. Nations with universal healthcare do not have this problem so implementation may be much easier.

That's patently false. The difference is lack of access due to monetary reasons to lack of access due to demand outstripping supply. If you're waiting years for a procedure, there's a problem with access. If some place with more universal care (e.g. Massachusetts in the US) is considering (or implemented) a law requiring physicians to see patients on a specific insurance (small business health insurance in this case) as a condition of licensure, then there's a problem with access. Access problems don't go away just because the government decides to pay for everything while setting a price that is fair to the government. Just because you give the gas station attendant a 10 dollar bill doesn't mean you get a full tank of gas.

 

[Melclin]

The following seems to be needed to make this plan work

- Disestablishment of BLS/ILS/ALS as it currently exists
- One new level with most focus on public health but with emergency care skills included
- Electronic linkage of patient records into a single system
- Total intergration into the public health system
- Independant rights to prescribe certian drugs and tests
- Registration of ambos as a health practitioner

I forsee a Bachelors Degree being the entry requirement for this sort of person who would have to operate with another practitioner while going through some sort of post-Degree internship to earn a Masters Degree which would enable independant practice.

Basically, if you put a PA in a 4WD with an ALS bag and MRx that is what I am proclaiming needs to be done.

I don't know about saying "most focus on public health with emergency care skills included". I think that's going too far. Public health is largely policy and education based and it is never going to be our primary role. I think the more appropriate term is Primary care.

I don't think is necessary of realistic to have us try to be an every-professional. This going and checking why granny smith didn't make her doctors appointment is more the domain of Royal District Nursing service or community health/social workers. I don't think we should try to become GP/District nurse/community psych workers. I think we should be streamlined EM physicians/nurses - primarily concerned with emergency medical issues but with an extensive capacity to refer to/consult with, more appropriate healthcare professionals.

Making us an every-professional is unnecessary because professionals in the various fields already exist - we just need to learn how to refer too, and work with, them better. It will also dilute the knowledge and expertise of our specific field - Imagine spending 3 years checking on grannies and counseling smokers to quit in between RSIs.

EG: Call to granny smith who can't get out of her chair. O/S She's basically fine. Now I'm not going to spend the next few weeks with her setting goals, changing the plan of her house and adjusting chair settings - its not my field and I have other things to be doing. I would however, like to be able to activate the services of an OT who could, and to consult with her GP/national electronic health records to be able to better make a decision about whether or not I should leave her at home, have a family member come and watch her for an hour, take her to her GP or rush her to a tertiary referral center.

Removing the term emergency completely from descriptions of our profession is perhaps ill-advised - we will always maintain an emergency role. However, I very much agree with you about the term pre-hospital etc. This is why the fashionable term of choice at the moment, at Monash at least, is Community Based Emergency Health. I personally like the slightly modified Community Based Acute Health, just because it feels like it takes into account things like granny smith not being able to get up - it is an acute issue, its happening now and needs to be assessed/dealt with now, but it is not an emergency in the medical sense.

Even with my extreme lack of experience I have already walked out of quite a few jobs thinking, we could do so much more for that person if we were simply taught how to use/provided with a system of inter-professional communication, consultation and activation, it wouldn't take up much more of our time, and our trip out here wouldn't have been time wasted.

 

[Shishkabob]

The biggest problem in the US that I can see is lack of insurance, so lack of access to healthcare services. Nations with universal healthcare do not have this problem so implementation may be much easier.

Fallacy, and one that I am quite tired of seeing spewed about. The vast majority of Americans have insurance, so the problem cannot be associated with that.

Now, overuse and abuse? Sure.

 

[CAOX3]

People call an ambulance for help, not necessarily an ambulance. All that is provided seems to be an ambulance.

The ambo of the future needs be a public or mental health nurse/paramedic/social worker/GP.

Words like "prehospital", "emergency" and "life support" need to stop being used.

Total intergration is required here; no more take people to the hospital but rather help people get to the right people for help and/or care. That might mean putting somebody in the car and dropping them off at a community care centre with thier broken arm or Rx'ing somebody some panadol and using thier tablet PC to make an appointment with the pts GP after entering in some notes thier doctor can see into the system.

After that thier next job might be a cardiac arrest or an anaphylaxis, then they might have lunch and go to check on somebody who thier computer tells them they went to two days and missed a doctor's appointment that was made for them at that time.

A model of care such as this has no place for traditional advanced life support and demands a radical shift in education to a ~70/30 balance between assessment and management of patients with a small emphasis on emergency care rather than the sort of 90/10 mix we have now in favour of emergency care.

We have community visiting nurses and social workers that handle what you described above and their already educated and their services actually get reimbursed. Why muddy the waters with the paramedic.

If you ask me it would be more cost effective to further educate them to handle the medical emergencies then it would be to re educate every paramedic and EMT.

 

[Melclin]

I would think the 15 or so percent of Americans who don't have insurance would be more than enough to account for a lot of those problems.

The point though is that its a lack of a single unified system and a culture of government mandated health care that make changes like universal electronic health records or shifts in standards and the roles of services such as integrating more of a primary care role into EMS, far more difficult. When you have a mess of competing services and financiers, a million ways for people to fall through the cracks, you are going to have problems keeping up with the standards of better funded, better integrated services for whom the primary goal is not profit, but better standards of care for the community.

 

[MrBrown]

Perhaps i was a bit unclear. As Melclin said, community based acute (or emergency) health is basically what we need.

We should not attempt to be every professional and do away with our specific emergency skillset however it should be more balanced in favour of having specific ability to be first point of contact out there in the community when called, sort of like a super triage system.

Let's immagine say somebody calls up at 1am coz thier nana has been sick for a week but waited until now to ring up. Rather than sending two ambo's in a flash truck with all the bells and whistles to pop her on the gurney and take her up to ED you get a solo responder in a 4WD. This ambo can tap into nana's electronic health care record on his tablet PC and see she has a history as long as my arm but nothing recent but does see her allergies and that she sometimes falls down a lot and has the falls person come over once a month to check on her. After he does an assessment he gives her some panadol and has a cup of tea, hops back on that magic tablet PC and makes an appointment with her GP for two days later and enters in some notes. I would also immagine with Bluetooth he can link up to the monitor and put in a 12 lead ECG too.

Case number two is somebody who has an infection in ther indwelling cathether. Super ambo rolls up in his beasty looking 4WD and tells the eight firefighters who are on scene doing nothing to pop back to the station and watch telly, wait, never mind they didn't show up because we have more sense here (<tongue in cheek>). He could replace the cathether, prescribe several days worth of anti-biotics and make a followup for this patient with the community health team on his tablet PC as well as enter some notes.

Case three, cardiac chest pain so super ambo is just a first responder here until the transport ambo comes along. Nothing would change.

Case four could be a kid who broke his arm falling out a tree. Super ambo rocks up and excludes any major internal injuries, gives the kid some methoxyflurane to suck on, splints the arm and can either put mum and kid in the car and take them to the urgent care (having told them he was coming on the cellphone) or get mum to take the kid herself, low clinical risk.

Case five might be somebody who this super ambo went to two days ago but missed thier GP appointment. Not sure if it'd be better to have super ambo pop in and check out why or have somebody else go and do it in some other way e.g the doctors surgery giving him a phone call.

Such a system like this demands very high levels of knowledge and skill, far in advance of what I believe most ALS providers have. That is why I said it would be inappropriate to try and build this sort of knowledge into a traditional Paramedic education as most of the focus there is on simple assessment and treatment for urgent, life threatning jobs.

I envisage something like an RN/PA/ALS hybrid would be needed and would be at least at a Bachelors level, probably a Masters degree qualification.

Something like what I immagine is being piloted by the ASNSW http://www.changechampions.com.au/resource/Katie-ODonnell.pdf

 

[Melclin]

I believe Queensland has had an extended care program for a while too. Victoria have trialed the idea, but I don't know where its going from there.

The CARE program and ideas like it, separate to the idea of a fully fledged Extended Care Provider, is a good idea because it gives legitimacy to what we are already told we are ALL supposed to do at uni but never seem to once we graduate.

Having a masters level program for paramedics allowing them to get all the "s**t jobs and none of the good ones" is going to present problems.
The CARE program is a great idea because it can be rolled out to just about everyone, and its only needs to involve minimal training because it deals with clinical scenarios that we already have the education (in theory) to deal with, but for whatever reason (some mentioned in my earlier post), we are still referring to ED. The CARE training package should probably just be integrated with the degree (maybe as a compulsory follow up to the internship). Its not exactly overwhelmingly complex as it stands, and as I say you wouldn't really be adding anything, just putting a greater emphasis on certain 'minor' issues.

 

[MrBrown]

I agree however I think we need to go beyond the education which is presently offered to much more focus on assessment and clinical decision making.

Are you taught to differentiate between the zillion possible types of abdo pain, probably not, am I, not really.

Whatever training is included in the Extended Care scope around assessment, clinical decision making and referral options should really be part of the core ambo degree.

 

[Jeffrey_169]

Originally Posted by claytondirk View Post
I understand what you’re saying but most people are not going to go above and beyond to be a great pt advocate and I highly doubt it will ever be that stressed in the school part of the paramedic programs because there is a lot to learn already and I guarantee the schools don't care because the more people they can run thru their program at a faster rate the more money they are going to make and that's the bottom line.

First off I would like to state if the paramedic is not willing to go the extra mile for pt advocacy, then perhaps another occupational selection should be considered.

Paramedics and EMT's do far more then "scope of practice" entails, at least in my experience. I cannot speak for paid services, as I have never been paid (this is NOT an argument of paid vs. volunteer, I just don't want to speak out of turn), but as a volunteer I have responded to everything from a pt. assist from falling, to the older and/ or disabled who are simply lonely and need someone to talk to. Patient advocacy is not always as cut and dry as some might like to think, but it is important and pivotal to what we do. I have never refused to be a counselor, a friend, an ear, or a rescuer to anyone who calls, and I have never had the displeasure of knowing someone who has. As medics we are often second only to the dispatcher who sends us of who the public relates and judges the entire system by. I agree, we do need more medics and EMT's who are willing to do what is best for the patient, even if it is only for the lonely person who has no family, and is lonely. Loneliness is a killer of our old, and when we lose them we lose our history and our experience.

I would like to say also pt. advocacy, common sense, and compassion are not something which can be taught in a simple 2 year degree program. You either care about people or you don't. I have been told emotional reactions are not conducive to the professional, and to this I strongly disagree. Caring and compassion are direct results of emotional responses, and we as medics need to understand this. There are far too many of us who feel emotions have no place in what we do and anyone who thinks a patient can't sense our biases need to strongly reconsider their position.

When I went to my first EMT class several years ago I was taught if you have biases and you are not willing to stand up and do what is best for your patient, ALL of them, then you are in the wrong class. I have ben to several classes and seminars sense, and there too this is/ was strongly emphasized.

People come into this profession with a Hollywood mentality, and this is another cause of our issues. As someone else already stated, we are the liaison between the care the patient and definitive care, whether it be social, psychiatric/ psychological, medical, or surgical; if we are to provide the proper and necessary interventions we need to be more educated in multiple disciplines. It has been proven in several studies all around the world the psychology plays a major role in the health of a people; sunlight exposure, diet, exercise, etc. also play a major role in both treatment and preventive care. Most medics, and therefore EMTs do not get a proper education on the ENTIRE person, and so there treatments and referrals are limited to the ER protocols.
As the ones on the front lines of EMS we are the ones who need to press for more education, higher scope of practice, and more jurisdictions to make better decisions for our patients. No one is going to just give it to us unless we fight for it. There need to be more involvement in our own occupation from within if we are to improve our public image and our ever increasing educational demands. We need to do more, we need to be better educated, and we needs vast improvements in our scope of practice, but it will not come unless we fight for it and receive the proper education.

 

[Veneficus]

“You either care about people or you don't. I have been told emotional reactions are not conducive to the professional, and to this I strongly disagree.”

Emotional attachment or reactions can lead to poor judgments, missed findings and overlooked considerations. It is why Doctors do not treat family members. The emotional and sometimes physical distance helps maintain objectivity. It can also make a patient feel more comfortable at times by removing a perception of expectation, disappointment or judgment.

“Caring and compassion are direct results of emotional responses,”
I don’t agree. I care about my patients, I want do my very best to take care of them. Not because I have an emotional connection, because it is my personal value set.

“and we as medics need to understand this. There are far too many of us who feel emotions have no place in what we do and anyone who thinks a patient can't sense our biases need to strongly reconsider their position.”

By training yourself to remain objective and distanced, you can put aside your biases.

I always like my patients to feel they will get the very best I can provide, no matter what circumstances brought them. That they can be honest and forthcoming without my disapproval. That all are treated equally.

 

[reaper]

Bravo my man, Bravo!

 

[Jeffrey_169]

“You either care about people or you don't. I have been told emotional reactions are not conducive to the professional, and to this I strongly disagree.”

Emotional attachment or reactions can lead to poor judgments, missed findings and overlooked considerations. It is why Doctors do not treat family members. The emotional and sometimes physical distance helps maintain objectivity. It can also make a patient feel more comfortable at times by removing a perception of expectation, disappointment or judgment.

“Caring and compassion are direct results of emotional responses,”
I don’t agree. I care about my patients, I want do my very best to take care of them. Not because I have an emotional connection, because it is my personal value set.

“and we as medics need to understand this. There are far too many of us who feel emotions have no place in what we do and anyone who thinks a patient can't sense our biases need to strongly reconsider their position.”

By training yourself to remain objective and distanced, you can put aside your biases.

I always like my patients to feel they will get the very best I can provide, no matter what circumstances brought them. That they can be honest and forthcoming without my disapproval. That all are treated equally.

Bravo my man, Bravo!

Veneficus, you are someone I highly respect and admire. I have learned greatly from you in my time here on this site, and although we do not always agree, we can disagree in a respectful and professional manner.

This is one of those times I simply cannot agree with you, but why remains a mystery. Allow me to elaborate; how can someone risk their life to save someone they have never met? How can someone take such a low paying job, in some cases no pay at all, risk their health in a variety of ways, and not care about and have some degree of concern for their patients? I understand objectivity is essential to what we do, and I understand we need to have a certain degree of distance from the ones we encounter; however, there has to be some compassion and concern for our patients if we are to perform adequately and remain in this line of work for any length of time.

Compassion for someone is not unprofessional, nor is completely avoidable as we as a race are by nature social creatures. We are more complicated in our social stratification, but we are not unlike most other creatures in how we deal with the loss of another person. We are, as a matter of survival, social and endearing creatures. Any anthropologists will agree to this (as I am an anthropology and psychology student, as well as a biology major).

One more point I would like to make. To say one can hide their personal biases, especially when dealing with those who already have complex issues and to those who are naturally intuitive, it can be seen. Children are especially insightful. To separate ourselves in the manner which you stated would result in us being robots, and no one wants to deal with a concrete slab as a clinician. Bed side manner is an important factor, especially when dealing with those who are lonely and disconnected.

In my studies and experiences I have learned a great deal of the human condition. We are all people if we try to train ourselves to be robots acting upon pure academics we will not only see a lack in bed side manner, but also a much higher burn out rate as we will be expected to bottle up the grief we feel and dismiss it as simply unprofessional. It is not possible, in my opinion, to be as objective without desensitization. A certain degree of separation and objectivity is paramount, but where does one draw the line in the sand?

I am only disagreeing because it makes no sense to me, but as I have learned about you already you have a way of explaining things that normally do. I am simply asking for more definition.

 

[sdadam]

There are many things that we as paramedics would need to do in order to bring about change in Paramedicine as a whole. The way I see it it would take education, paramedic leadership, individual identity, public awareness, and higher pay.

Education, a BS program in Paramedicine is the only way that we have a future as anything but gurney transport technicians. Once established, state and city governments must legislate that the bachelors program is the minimum education required to work as a paramedic. Similar to the increase in scope from EMT-B to EMT-P. As long as the basic education beyond a paramedic license is a high-school diploma, or a GED no one is going to consider allowing paramedics to give medical advice, make decisions about definitive care, and act independently of medical direction. And I don't blame them.

Paramedic Leadership, this is something we do very poorly in my opinion. In most systems I encounter nurses run Paramedicine. From base hospital radios, to paramedic school director positions, to "nurse educator" positions at EMS and fire services. I understand how this happened, when EMS started there was no one to supervise it, the only logical choice was the nurses. For the past 30 years they have done a great job, but now it's time that paramedics started leading Paramedicine, there should be base hospital paramedics on the radio (after all who is in a better position to give you advice in the field, someone who has been there, or not?), paramedic directors of paramedic school, and so forth. However this will never happen unless paramedics match the educational level of nurses, the choice between a licensed paramedic with a bachelors in Paramedicine, and an RN with a two year RN program is much easier to make in favor of the paramedic.

Individual identity, If you were on duty and asked 100 people what they though you did just looking at you in uniform, what responses would you get? Here are the most common I get; Firefighter, EMT, Security Guard, Ambulance Driver, Medic or Paramedic. Do the same for a police officer, or firefighter and you don't get the same range of responses. EMS needs to cut it's ties to the fire service. I know that this is a highly debated topic, but if we want our profession to reflect the statements in this thread, it is mandatory. The fire service is incredible at what they do, and I am thankful for them, but they will never accept fire service personell spending a half an hour on scene talking to an elderly woman about the trouble she has refilling her prescription medications then another half hour making calls and finding a solution (having the freedom to help people in this way is, after all what we are talking about right? Not just the emergencies, but responding to the need of the patient whatever that may be). Paramedics must stand alone in order to grow as a profession, Paramedicine can't be the job that firefighters do when they aren't fighting fires.

Tying in to the above point the public must be educated, they must be aware of the services that paramedics provide. Educated when it is appropriate to call 911 for a paramedic and when not to. They must be presented the idea that a paramedic is a pinacle of medical knowledge and care, that whatever their problem is, a paramedic will be able to help them either directly or by setting up a plan of action which will change their circumstance. This is not the image the "Ambulance Driver" brings to mind. Though we can only tell them this if we give paramedics the education to make it true.

The last issue, and always one of the central ones is pay. Paramedics must be paid well. Paramedicine must be a profession that one can work in for a lifetime, making a good and honest living, and raising a family if they chose, not needoing to be a firefighter in order to pay their bills. However I firmly believe that like nurses, paramedic pay will not increase until two things happen. The first I have talked about at length, education. The second ties into paramedic leadership, we must unite as paramedics on a national scale, as much as I have mixed feelings about unions, a National Union of Paramedics just might do the trick.

However all of these things are closely tied together, for instance, as long as becoming a paramedic is seen as a stepping stone into the fire service, no one is going to dedicate the time to get a bachelors degree in it, so the education issue is difficult to accomplish without the individual identity, leadership is tied to education as well as stated earlier. It is a very complicated issue.

These are just my thoughts on the whole thing.

 

[MrBrown]

Education, a BS program in Paramedicine is the only way that we have a future as anything but gurney transport technicians.

Agreed ...... but, you're preaching to the converted here mate.

From 2012 the Bachelors Degree will be required here to be a Paramedic (super ILS ambo) and a Post Graduate Diploma will be required for Intensive Care Paramedic (ALS)

Paramedic Leadership, this is something we do very poorly in my opinion.

I agree but in some ways we need to get away form it; eg Paramedics teaching Paramedics. While our faculty here are Paramedics they are all at Masters or PhD level.

Individual identity ... Paramedics must stand alone in order to grow as a profession, Paramedicine can't be the job that firefighters do when they aren't fighting fires.

Agreed, but again, you are preaching to the converted lol

 

[Veneficus]

how can someone risk their life to save someone they have never met? How can someone take such a low paying job, in some cases no pay at all, risk their health in a variety of ways, and not care about and have some degree of concern for their patients?

I nurse I know likes to say "I have empathy, not sympathy."
I think it is possible to care about people, even individuals without emotional attachment or reacting emotionally.

I understand objectivity is essential to what we do, and I understand we need to have a certain degree of distance from the ones we encounter; however, there has to be some compassion and concern for our patients if we are to perform adequately and remain in this line of work for any length of time.

I agree but compassion is not emotional attachment. Careers are often shortened by emotional distress. Especially carrying others emotions as your own.

One more point I would like to make. To say one can hide their personal biases, especially when dealing with those who already have complex issues and to those who are naturally intuitive, it can be seen. Children are especially insightful. To separate ourselves in the manner which you stated would result in us being robots, and no one wants to deal with a concrete slab as a clinician. Bed side manner is an important factor, especially when dealing with those who are lonely and disconnected.

It is an acquired skill. The ability to smile, address them by name, a pat on the shoulder, the touch of a hand, making the person comfortable. addressing about non medical concerns like "how much does this cost?" "what will life be like?" "what is happening to me?"

In my studies and experiences I have learned a great deal of the human condition. We are all people if we try to train ourselves to be robots acting upon pure academics we will not only see a lack in bed side manner, but also a much higher burn out rate as we will be expected to bottle up the grief we feel and dismiss it as simply unprofessional. It is not possible, in my opinion, to be as objective without desensitization. A certain degree of separation and objectivity is paramount, but where does one draw the line in the sand?

A robot is not a skilled clinician. Nor is a skilled clinician a robot. However when you are called to help, whether a patient shows up to you or you go to them, as I stated before it is possible to have compassion and even empathy without personal attachment.

The line is different with each patient. But I find starting with absolute objectivity and working towards the line to be more beneficial to both the patient and the provider than starting with connection and trying to move towards objectivity.

It is the art of being a clinician. Bedside manner, with compassion but not emotional connection, objectivity without being cold, professional without being condescending.

Sometimes people say "treat every patient like it was your mother." Would you ask your mother her sexual history? How many partners? Vaginal sex? Anal sex? Oral sex? Protection? What kind? Ever treated for a STD? A partner treated for an STD? Sex work? In the past? Currently? Pregnacy and deliveries may be easy. How about miscarriages and abortions?

Would you feel comfortable discussing this with your children? How about your grandmother? Would they be comfortable discussing it with you? Would they answer you honestly?

I use this example because it unnerves the most people. Some will be ok with it, most are not. But all your patients must be able to discuss these things with you. A clinician should have genuine concern for their patients, but once you get too close you lose the professional relationship.

I guess it could be said "you can be friendly, but you cannot be friends."