Archives for posts with tag: doctors

Reposted from last year.

After a talk I gave about doctor-patient communication, a woman in her 30s raised her hand and said, “I work at a university, and whenever I see the doctor, he assumes I’m a student, and he talks down to me. This makes me very unhappy and I’m  not sure what to do about that.” I assumed from her circumstances, and from the tone of her question, that she was not free to choose another doctor. What should be done by someone who has this problem? There are various strategies, but part of the answer is to understand why the doctor might be talking down to someone.

1. The doctor’s personality is unsuited to an egalitarian interaction. If they were a chimneysweep there would be the same problem.

2. The doctor was not trained to appreciate the importance of doctor-patient communication.

3. The doctor does not know what to recommend, or recognizes, perhaps subconsciously, that there is no good evidence to prefer one route of treatment over another. This leads to a basic conflict: she wants to help the patient but also acknowledges to herself that there is no one convincing path. Since she has been conditioned to present a front of omniscience to patients, both through the system and the influence of colleagues, she is not allowed to present that ignorance, or to partner with the patient to address it. Thus, she appears abrupt or condescending.

Perhaps I am giving such a doctor too much slack? I would do the same for a patient. Systematic changes mean we should, on occasion, refrain from blaming people without considering the entire differential.

Most of the time I take care of patients in the clinic, but I regularly admit patients to the hospital as well. I try and notice what makes me uncomfortable when I see them there. (Which is probably not as completely or acutely noticed by me as by the patient – but, hey, you take what you can get on this blog. Obviously, there are no shortage of patient blogs to read as well.)

No one knows anything. The attending – me – doesn’t know discharge time because it depends on when the meds are filled and the appointments are made. The patient doesn’t know their discharge time because they are under the mistaken impression the exact time is up to me.

Decisions are made elsewhere. The patient’s wife, who is on top of things and asks impressively detailed questions which have improved care for her husband, asks what a certain specialty service is going to do about a procedure. I don’t know, and I’ll ask them. But any decisions they make are not going to be done in the room, while talking to the patient and his wife. They’ll be made in some corridor somewhere, and then transmitted to me by page or phone. Everything gets to the patient and their family third-hand.

The endpoint isn’t clear. We try to identify, at the beginning of the admission, what is the goal for discharge, but when the active issues change, as they have many times in this case, the patient can find themselves in the hospital for longer than they had expected.

Outpatient versus inpatient. The patient is understandably concerned about missing the clinic appointments he can’t keep because he’s cooped up here in the hospital. He wants to know if those services can come by. No, I start to say, by instinct, because they deal in the hospital with urgent or severe matters. But then I thought: couldn’t we do it that way after all? We do counsel smoking cessation, and do other preventive services or counseling, for patients who might not get them any other way.

An esteemed senior physician who I knew in New York says that every patient is an opportunity to do research, i.e. learn about the course of disease. Whenever I see a patient in the hospital, it feels like health services research in miniature. This is what the hospital is like: bewildering, inefficient, and at cross-purposes with itself.

No false modesty here: we have a great team, and the gentleman is getting better! Not without, though, teaching us important lessons in efficiency, patient-centeredness, and humility.

Crossposted to the blog at Talking To Your Doctor.

We come to the doctor’s or nurse’s office expecting to be told the truth about what is bothering us. Either we want to know that our symptoms are no sign of something serious; or, if it is in fact as bad as we were expecting, that there is a name to our pain and suffering. We would also like to know, obviously, if there is a way to be cured of whatever ails us.

We might not think about the obvious eventuality that the doctor doesn’t know the answer. (Perhaps you do, but I think that it’s often the case that we don’t.) Perhaps it’s because we factor that possibility into our decision about whether to seek medical attention in the first place. We don’t think that the doctor is infallible or always in possession of the right answer, but we are pretty sure that, with their professional training, they will be able to figure things out.

More often than not, though – as we age, confront chronic diseases, take care of relatives who are ill, or run up against the wall of providers’ imperfections, ignorance, or failure to listen – we realize that our doctors don’t know things as surely as we thought. There are many questions we have, and even of the ones that doctors are prepared to answer (which themselves are a minority), they can’t give us a clear answer.

A lot in life is like this, of course: mired in uncertainty. We can have several reactions to this, in healthcare as in other areas. We can try to perfect the science, to push out the boundaries of our knowledge. Unfortunately, like a fractal landscape, the uncertainty at the border of knowledge merely shifts and curves to cover even more territory as the contacts between knowledge and ignorance lengthen.

We can declare ourselves beholden in some measure to uncertainty. If nothing is certain, empiricism is a lie, and only my truth is evident. There are some people who take that route. I think some of the anti-vaccinationists are members of this camp.

Or we can decide that certainty in knowledge is unreachable – but that uncertainty leaves space for much of what makes healthcare deliverable to people, and not to subjects of experiments or inanimate objects. It leaves room for our preferences in the face of the unknowable.

I don’t know if that is enough to cut doctors slack for what can’t be known, but maybe it can help us feel less at sea in the realm of scientific uncertainty – which is the universe, really.

Thanks to Mike Benedetti and Happiness Pony for printing this piece in their latest issue (found in your favorite Worcester, Mass., coffee shop. This is also cross-posted to the book blog.

Picking a doctor is not like choosing an ice cream flavor. But it’s not like betting on a sports game either. When we set about choosing a physician (or whoever else, nurse practitioner or physician’s assistant, who might act as our primary care provider), our personal preferences certainly come into play. We might want as our doctor a man or a woman, someone convenient by bus, someone younger or older. Some people, like it or not, prefer their doctor to be of a certain race – just like doctors treat their patients differently based on race. This is of course not my ideal but the fact of the matter. Even if we only have a limited choice of doctors covered by insurance, we might pick between the two or three available based solely on whim.

But what if we wanted to pick the best doctor available, the professional who is most likely to make us feel better? There is a plethora of information available online that purports to answer that question, from a simple Google of the doctor’s name to a search in Physician Compare (the national database of doctors that accept Medicare), to records of physicians’ prescription practices. Unfortunately, there is no foolproof way to link up this dense network of statistics to the results that actually matter to us: our health, happiness, satisfaction, and emotional needs, all of which we would like to see satisfied when we see our new doctor. There is no magic formula to predict which doctor is most likely to work well with you, the acolytes of Big Data and electronic medicine notwithstanding.

That is why choosing a doctor isn’t like placing a bet: we might not be sure if we made the right choice even when we meet them for the first time. As in other relationships, the connection with our doctor (or nurse, or whoever) might take time to develop. While available information might help us weed out the true duds, realizing that a particular doctor seems to be doing well by us might be more like finding a fine wine than picking a tasty ice cream flavor: an acquired taste.

In a recent issue of the Journal of the American Medical Association, we learn that physicians generally blame other groups for the runaway train that is American health care costs: lawyers and patients, for instance. Ezekiel Emanuel, in an accompanying editorial, bemoans this buck-passing, and identifies several domains which must be changed to remake health care, with the physician in the lead. “There is no magic solution,” he says – rather, a combined approach is needed to control health care costs.

He lists the following ways in which health care delivery must be transformed:

  • More cost consciousness in decision making
  • Increased emphasis on keeping patients healthy rather than treating exacerbations of chronic illness
  • A move toward team-based care delivery and away from individual practitioners
  • More organized and coordinated systems
  • More process standardization with customization for selected patients
  • Greater price and quality transparency (more…)

Crossposted, as you should know by now, to the blog at Talking To Your Doctor.

One of the many useful pieces of advice to doctors that Atul Gawande proffers in the last chapter of his Better is that a doctor should ask every patient about something in their lives unrelated to their health complaint. Of course, this can easily give rise to unintended consequences. I asked one patient of mine, a guy in his fifties with an accent from the Maryland shore, what he liked to do with his time. “I like to race horses,” he said, and when I was surprised that he didn’t seem the jockey type he made it clear that he played horses. Or, rather, gambled on horses. There’s nothing wrong with that, but it might not have been a personal interest he would have shared with me otherwise.

Sometimes I wonder whether patients are going to ask me about my life. They ask about my kids, which is generally a safe topic, but not much more. It’s clear why: doctors and patients are careful about boundaries for good reason. We are partners in health, ideally, but not friends or relations.

In the healthcare encounter, however, we have a lot more in common than we might realize.

We both think we know more than we actually do. Doctors like to assume they act based on evidence, when mostly they (we) don’t, or the evidence is incomplete. Patients think they know their bodies – and they do, they are the ones most familiar with them. But knowledge of one’s own body doesn’t necessarily entail a prediction of what a set of symptoms might mean. We each need the other to be informed and educated out of our complacency.

We think the other is not doing a good job. Doctors roll their eyes at patients who don’t take their medications exactly as directed, even though doctors – playing the role of patients – do exactly the same thing. And the reason patients don’t take medications is not just to be ornery or contrary: it’s because they don’t know how; are worried the medication might be making things worse; can’t afford to fill the prescription; or are afraid to tell the doctor they don’t agree. By the same token, doctors are put in a spot by patients assuming the absolute worse the minute they enter the exam room.

Maybe, then, doctors and patients should start asking about each other’s lives more often (on suitably inoffensive topics, of course, like kids, favorite desserts, weather, and vacation plans). There is plenty of common ground. Perhaps we can expand it.

Cross-posted to the blog at Talking To Your Doctor.

Let’s share the glad tidings: Johns Hopkins is again ranked as the number-one hospital in all the land. I’ve written about this before, sharing my misgivings about ranking hospitals. What is the methodology? How sensitive is the ranking to random error, bias, and qualities of hospitals that have nothing whatsoever to do with their – quality, like reputation? What are we supposed to do with that information, who really uses it, and do they get better care as a result?

There are enough misgiving here to fill several chapters of a book, and in fact one chapter of mine is devoted to them. But the problem with measuring extends far past the ranking of hospitals. Doctors are being ranked this way, too, with the idea that public reporting of such information will help people make better choices about their health.

At the same time, many are trying to urge our health care system towards greater patient-centeredness. Various research teams are developing measures to quantify how well a given visit with a physician enables shared decision making on the part of the patient-doctor pair.

So, when presented with an array of various numbers – the rank of the hospital; the quality of the doctor; and the patient-centeredness of the practice – which one should the patient choose? Do we ask patients, as a whole, which ranking they find more important? Is each person to mix up a batch of numbers to find whatever aggregate satisfies their preference?

These are big questions. As I outline in my book, there is evidence that precious few patients or doctors actually use these rankings. Perhaps if we include patient-centeredness in the mix, and automatically generate a weighted average (or some other statistical combination of measures) that corresponds to patients’ preferences, people will feel like they are getting the best doctor they can find. That would be something to truly celebrate.

Cross-posted at the blog at Talking To Your Doctor.

Thanks to Matthew Wynia at the American Medical Association who distributed to a group I’m involved with the following quote from the Dialogues of Plato about doctor-patient communication. I believe the translation is from Jowett, 1937, but I’m not sure. 

In the LAWS, Book 4 [says Wynia in a summary], we have the following discussion between the Athenian and Cleinias regarding patients lacking autonomy (because they are ruled by others) and autonomous (self-ruling) patients.

The Athenian asks: “You are aware that there are these two classes of doctors?”

Cle. To be sure.

Ath. And did you ever observe that there are two classes of patients in states, slaves and freemen; and the slave doctors run about and cure the slaves, or wait for them in the clinic. They never talk to their patients individually, nor do they allow them to talk about their own individual complaints. The slave doctor diagnoses and prescribes a remedy on an empirical basis, [but does so] as if he had exact knowledge; He gives his orders [to the patient], like a tyrant, and then rushes off, to see some other slave who is ill, all the while projecting an air of confidence and assurance;…

But the other doctor attends and practises upon freemen; and he carries his enquiries [with his patient] far back, and goes into the nature of the disorder in a scientific way; he enters into discourse with the patient and with his family, and is at once getting useful information from the sick person, and also instructing him as far as he is able. [The physician] will not prescribe for the patient until he has first convinced him; at last, when he has brought the patient more and more under his persuasive influences and set him on the road to health, he attempts to effect a cure.

Now which is the better way of proceeding in a physician and in a trainer? Is he the better who accomplishes his ends in a double way, or he who works in one way, and that the ruder and inferior?

Cle. I should say, Stranger, that the double way is far better.

There is much to note here. First is the distinction between slaves and freemen, not just among patients but among physicians. And the two are paired: a slave doctor deserves, so to speak, a slave patient – or perhaps the two are yoked together, each deserving no better than the other. For Plato, as we know from the Republic, is wedded to the hierarchy.

We can take away at least two lessons to our own day. First is that our care, in our enlightened republican democracy of the U.S. as much as in Greece, is inseparable from the economic stratum of its provision. It is a universally known but much hidden and ignored truth that the poorest and disadvantaged get the least care, a problem I discuss at length in my book. Further, though, we can read the terms “slaves” and “free [people]” more broadly. When a patient and provider can look beyond what others have called the “tyranny of the acute” and focus on the deeper issues that affect health, both become free to find the cure at the end of healing.

That, in closing, is the idea that fascinates me the most here. While, in my practice today, I think about treatment as inseparable from a cure (thinking about a correct treatment entails considering a cure), the account in the Laws seems to suppose something else. Only once a patient is on the “road to health” can the physician “effect a cure.” I am not sure how to take this, but I find attractive the notion of cure as a process brought about by a long-term relationship between doctor and patient.

Cross-posted to the blog at Talking To Your Doctor. Hey, did you know you can preorder the book there too?

At Johns Hopkins, we now have a brand new electronic medical record (from the EPIC quasi-monopoly). I am liking it more than I thought I would. But one of the downsides of computer record-keeping is that free form narrative is trapped in forms and checkboxes – which come to think of it is no innovation of the computer age, merely something facilitated by it. Thus the patient’s story about why they came to the doctor is shaved down to one phrase or sentence which fits into the “Chief Complaint” box in EPIC. Of course, even that sort of limited reason can be of interest. For example, a recent study from the Mayo Clinic, too recent to include in my book, counted up the non-acute (i.e., chronic, or long-standing) reasons behind the visits of about 150,000 thousand patients. The most common problems were joint issues, skin complaints, “disorders of lipid metabolism,” and upper respiratory infections. Fascinating: how many of the patients with “lipid disorders” came with numbers out of the so-called “range of normal” which they thought needed treatment only because a drug exists to do so? How many complaints could be dealt with over the phone, or by email? How many lipid panels are done unnecessarily?

On the other hand, often the reason-for-visit expressed in a phrase or two often doesn’t get down to the nub of what brings one of us in to see our doctor. Often we are sidewinded by pain, knocked out of breath by a death in the family, beset by fatigue and futility, or with too many problems to count. Sometimes I can’t limit someone’s complaints to just two or three because they have a dozen or more.

This is just to say that counting the reason for a visit is important, and useful. But sometimes we can also refrain to count and just let the story be told without any interference. That could be a visit more narrative than EPIC.

Five things I wished I said more often:

1. Look, it’s near the end of the day and I’m stressed. Can you remind me to slow down and listen?
2. Just because I am a radical skeptic when it comes to the utility of many tests doesn’t mean I don’t care about your symptoms.
3. Put your cell phone away, please.

4. Tell me something about yourself that doesn’t have anything to do with your illness.
5. What sort of person are you really, deep down?