What do You Expect From a Doctor?
Six Habits for Healthier
Patient Encounters
David Loxterkamp, MD
Abstract
Expectations lie at the
heart of America's health care crisis. Although doctors cannot control for the
unrealistic demands of a consumer-centric society, we might ask what we would
want in a physician. Someone who listens longer and lets us express ourselves
in our own words? Someone who cares about the outcome—our personal outcome—and
not just the "clinical course"? Most patients do not demand
perfection. Not cure. Not even relief, no matter what the TV commercials
promise or how badly they wish them to be true. What we all desire is a plan
that connects us to another human being—our doctor—which is a kind of relief
all its own. The author identifies 6 simple habits that will lead to healthier,
happier encounters with patients and their illness.
Introduction
Expectations lie at the
heart of the American health care crisis. That's because we Americans expect a
lot. As patients, we expect to live long, productive lives with replaceable
joints, clear lenses, and revitalized hearts. We expect to receive a diagnosis
and treatment for every complaint. We expect high-tech solutions for
commonsense problems. We expect our doctors to be flawless and self-confident,
and doctors, in turn, expect to be compensated for the stress of their
relentless demands. Americans—or at least those with means—are said to enjoy
the best health care system in the world, but even the most fortunate soon
discover that health is a gift, as much dependent on genetics and good luck as
it is on lifestyle choices and access to care.
When patients demand
specific drugs, tests, or diagnoses, they prevent us from being a doctor—a
professional whose training, skill, and dedication are put in the service of
their recovery. Likewise, when we take a chief complaint at face value, our
patients are short-changed. Neither patient nor doctor should expect the doctor
to be a booking agent, approving parent, or frat brother. Yet bedside manner,
face-to-face time, and a sense of connection—what we once unabashedly called
the doctor-patient relationship—matter as much as the services that are
delivered.
The son of my neighbor was
brought to me with a high fever. The child was healthy in every other respect,
so I advised a wait-and-see approach: clear liquids, ibuprofen, call if the
condition worsens. I saw the boy each day thereafter and over the busy on-call
weekend—his most worrisome findings morphing from uncontrolled fever to a loss of
appetite, stiff neck, and enlarged lymph nodes. On Monday, I consulted the
closest infectious disease specialist by telephone, but her tests proved
inconclusive. The next night the boy developed pain with swallowing, and
another on-call physician suggested a CT scan that revealed an abscess behind
the boy's throat. He was hospitalized at the referral center and quickly
recovered on intravenous antibiotics.
Without a solid diagnosis
or signs of improvement, the boy's parents and I were emotionally adrift, each
of us swamped by our respective responsibilities and worries. I later admitted
to the mother that her son's retro-pharyngeal abscess was the first I had seen
in a child. I consoled myself in the belief that the delay in diagnosis caused
no harm, but ruminated anyway on the boy's prolonged suffering, the mother's
loss of trust in me, and the damage to my own self-confidence.
The 2 things that patients
should expect from their doctor are competency, which diplomas and board
certification attest to, and a moral compass that puts others' needs above the
physician's. Beyond that, a few simple habits might assure that mutual
satisfaction flows from the patient's encounter:
Identify
Patients need know to whom
they are speaking—specifically, the health professional's level of training and
responsibility. When continuity of care is challenged by after-hours coverage,
urgent care visits, and the increasing presence of nurse practitioners,
physician assistants, medical students, and residents-in-training, the patient
may no longer recognize the "doctor" by sight or voice, and feel
fortunate to see anyone at all.[1]
Listen
Patients want their doctors
to listen and instinctively know that talk alone is therapeutic.[2]
Instead, doctors interrupt them within the first 12 seconds.[3] It
saves so little time. Most patients will tell their story in 2 minutes or less.[4]
Moreover, listening demonstrates the doctor's respect and concern. It involves
more than the auditory nerve; intentional listening requires eye contact, the
interpretation of body language, and positioning oneself so that both pairs of
eyes are level.
Touch
A careful physical
examination often provides invaluable clues to the correct diagnosis. Even when
an examination is unnecessary, its performance conveys a commitment to
thoroughness. Touching establishes a physical connection and sense of intimacy
between the doctor and patient that invites communication and reassures the
patient that there is no need to conceal or loathe their wounded part.
Look
Much of the patient's time
at the doctor's office is consumed by waiting and then is delegated to
others—secretaries, medical assistants, mid-level practitioners, scribes.
Though this delegation allows physicians to practice "at the top of their
license," it subtracts from the time it takes to get to know their
patients and earn their trust. With whatever time remains, it is imperative
that the doctor look at the patient and not at the computer, smart phone, or
clock.
Plan
After taking a history,
performing a physical examination, and making an assessment, the doctor then
outlines the specific steps that will lead to the patient's recovery. Though we
recognize that the plan is a tentative and educated guess, patients cling to it
like a life preserver, relieved that a doctor is holding the rope that will
pull them from their pain, uncertainty, and fear. A plan is never more
necessary than when patients lack a definitive diagnosis or clear prospects for
recovery. And although patients want to be involved in creating the plan, most
are happy to leave the final decisions to their doctor.[5]
My neighbors needed to know
why their son was sick, when his symptoms would abate, and what signs might
signal a setback in his recovery. Plans should also identify the costs, risks,
markers, and likelihood of success. The most important plan is often the one we
keep in the back of our minds.
Follow-up
Even when doctors arrive at
a brilliant diagnosis or offer cutting-edge cures, the job isn't done. We must
also prepare patients with a prognosis, provide test results, and guide them
through the travails of their illness. Much goes on after an office visit to
assure that this happens. On a typical day, primary care doctors will see 18
patients whom they can bill. But they will also initiate, return, or review
more than 90 telephone calls, e-mail messages, prescription refills, laboratory
results, imaging reports, and outside consultations.[6]
Medicine is a performing
art, and so it is that on some days our actions disappoint. What recourse do
disgruntled patients have? Some will leave their doctor, though departures are
rarely noticed and relocation offers no guarantees. Some will file a complaint
or initiate a lawsuit, but their cases are almost always settled out of court,
dismissed, or decided in favor of the defendant.[7] Patients have
come to expect professional interactions that are scrubbed of warmth, personal
attention, and effective communication, and that is sad. Reform, when it comes,
often hinges on patients' initiative—a letter of complaint or an arranged
meeting with the doctor or office manager, but they should know that their
doctor wants to be understood and respected as badly as they do.
The parents of the boy did
not expect me to diagnose his problem right away (though they assuredly wished
I had). But they had reason enough to thank me for their son's recovery, as
their card of thanks conveyed:
We are writing to express our gratitude for making yourself so available
when [our son] was sick. It was a trying time, but it would have been far worse
had we no one to turn to. We consider ourselves especially fortunate to live in
a community where our family doctor cares so much about the health and
well-being of our children….
Many physicians receive
such notes, but not for their medical prowess (which, again, is expected, and
not easily judged) but for their compassion—for actions that arise out of love
and kindness, not duty and fear. Patients want their doctor to listen longer
and allow them to express themselves in their own words. They want doctors who
care about the outcome—the patient's personal outcome, not just the clinical
course —even if, in bearing witness to it, doctors will absorb their distress
(what Anatole Broyard once described as "brooding").[8]
Patients want to know that there is way out of their loneliness, confusion,
panic, and pain. Most are not demanding perfection. Not cure. Not even relief,
no matter what the TV commercials promise or how badly they wish them to be
true. What we all desire is a plan that connects us to another human being—our
doctor—which is a kind of relief all its own. Patients come to us for
conversation, friendship, and hope, trusting in this well-worn path to
recovery.
* David Loxterkamp is the
author of a new book, What Matters in
Medicine: Lessons from a Life in Primary Care.
References
- Harris G. Who gets to be called a doctor? NY Times Well Blog. Oct 1, 2011. http://well.blogs.nytimes.com/2011/10/01/who-gets-tobe-called-a-doctor/.
- Tannen D. Why sisterly chats make people happier. NY Times. Oct 25, 2011. http://www.nytimes.com/2010/10/26/health/26essay.html.
- Rhoades DR, McFarland KF, Finch W, Johnson AO. Speaking and interruptions during primary care office visits. Fam Med. 2001;33(7):528–532. http://www.interruptions.net/literature/Rhoades-FM01.pdf.
- Langewitz W, Denz M, Keller A, Kiss A, Ruttimann S, Wössmer B. Spontaneous talking time at start of consultation in outpatient clinic: cohort study. BMJ. 2002;325:682–683. http://www.bmj.com/content/325/7366/682.full.
- Chung GS, Lawrence RE, Curlin FA, Arora V, Meltzer D. Predictors of hospitalised patients' preferences for physician-directed medical decision-making. J Med Ethics. http://jme.bmj.com/content/38/2/77.short.
- Baron RJ. What's keeping us so busy in primary care? A snapshot from one practice. N Engl J Med. 2010;362:1632–1636. http://www.nejm.org/doi/full/10.1056/NEJMon0910793
- Kane C. Medical liability claim frequency: a 2007–2008 snapshot of physicians. AMA Economic and Health Policy Research. August 2010.
- Broyard A. Doctor talk to me. NY Times Book Rev. Aug 26, 1990. http://www.nytimes.com/1990/08/26/magazine/doctor-talk-to-me.html?pagewanted=all&src=pm.
Ann Fam
Med. 2013;11(6):574-576. © 2013 Annals of Family Medicine,
Inc.
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