Sunday, October 29, 2006

OK, this little Jeremiad (call it what you will) shows more than a bit frustration and a measure of pique that some readers will find, well, unattractive. I wrote it years ago, and it has not received favorable local reviews, but I stand by the truths therein, and the truth sometimes hurts. So now you know how I really feel.
At least, most of my medical colleagues will likely agree.

Why Your Doctor Doesn't Spend More Time With You

Since the 1970's, when the image of doctors first began to decline, polls of patients have revealed a general perception that doctors cut short their time spent with their customers, to the detriment of patient health. Patients questioned after meeting with their doctors, whether in an office, a clinic, or a hospital room, almost uniformly feel that they were short-shrifted, that the doctor came in and left in a flash. The implication is that the doctor is uncaring, is missing vital information, is greedy.

But the truth is that doctors, like any other professionals, regard patients as jobs, as work to be done, as problems to be solved. Doctors assume, after all, that that is precisely what the patients want--someone to help them in a way they cannot help themselves. So, if the doctor spends enough time with their patients to do their job correctly, isn't that good enough?

Doctors who treat patients have to be able to do three tasks correctly: they have to listen and observe, retrieve and correlate information, and think (i.e.--put it all together logically, figure out the next step). Yes, they also have to perform (procedures), and, these days, to document (a process that often takes as long as all the others combined). And, of course, they have to communicate. It's this final task that is considered lacking in the modern medical doctor.


First of all, it is not entirely clear that the actual time and effort spent communicating with patients is lacking at all. In a clever study, patients questioned as they left the doctor's office thought the amount of time spent in the encounter with the doctor was much shorter than was actually measured. Other studies have repeatedly shown that patients immediately after leaving the doctors' office recalled less than half of what the doctors actually told them specifically to remember. So, who's to blame here when a patient walks out not knowing what medicine to take when, what the test results mean, where to go next?

I have resigned myself to the fact that many patients cannot grasp as simple a concept as a prescription to take a single pill once a day until they've been told this two or three times on different occasions. In educational psychology, the term is "blocking"; people can be mentally blocked from receiving information or instruction, and no amount of time, repetition, nor visual aids is always going to break through.

The irony, however, is that doctors receive (and often accept) the blame for this phenomenon; the patient never admits that he's simply oblivious. The clinical medical profession has spent enormous effort and money trying to solve this dilemma, so far to no avail. There are courses in how to communicate, training exercises, patient-education materials galore in every media, but nothing seems to help. It is a universal, cross-cultural phenomenon, not even restricted to the prima donna American patients. It's probably unsolvable.

When a doctor perceives that the patient just doesn't get it, the doctor is best advised to make sure the patient is made no worse by whichever course is taken, schedule another visit or punt the patient along to another doc, and move on to the next patient.

Furthermore, it is only important to do all this communicating, to empower the patient with information, if it makes a difference in the patient's health, isn't it? After all, (real) doctors are a poor choice for just entertainment. There has to be a reason for doctors to spend more time talking with their patients (and families), a provable difference in health outcome.

Certainly a doctor who spends less time visiting and more time studying the medical facts may be a better choice when it comes down to critical health problems.

Why do we long for the halcyon days when a doctor stayed at the bedside for hours and held the patients' hand?

Why do we value the alternative health professionals who are pleasantly chatty while providing scientifically worthless "treatment"?

Why do we regard a doctor who analyzes and decides quickly as callous, while a deliberate, unhurried doctor must be caring and compassionate?

What's really important here--the doctor's competence or compatability?

And, no, you can't always have both. Especially when you're very sick, your doctor does not want to spend all his time around you. The truth is no one does, since sickness is unpleasant, but at least your doctor has a vision of your returning to health or greater comfort and can stick with you until you achieve it. That's all you can or should expect. That's what you, through your insurance, pay your doctor for.

Get someone else to provide the comfort, to hold your hand and give you a hug and a "There, there . . ." (If you have no one else, you're really in sorry shape; call in a social worker.) Get your five minutes with the doctor and listen carefully!

If the doctor says, "Hmm!" and walks out without a word, don't worry--you'll be fine.

Pretty harsh there, familydoc. People need time to absorb things about which they know nothing (their health or their medications, for example) and might need to hear things more than once. The DOC knows what he is talking about, but the patient may be hearing all this for the first time. Written instructions are helpful sometimes, as are repeat visits. Patients are scared of docs, scared of what they may hear and scared to be sick.
Hire a nurse with empathy or a social worker for your office to repeat, re-teach and answer the inevitable phone calls if you have no patience for such things. It's good for the patients and good for business, too.
Mimi is correct, but the solution to utilize ancillary health providers does not solve the mis-perception that the doctors themselves do not spend enough time with patients. Indeed, having the doctor shuffle in and out quickly and leaving the communication to the nurse or whoever only aggravates the problem.

I'm suggesting that patients simply take their precious encounter time with the doctors more seriously.
You know, I completely understand where you, and probably other docs are coming from. I do think that the lack of attention and respect paid to those 5 minutes with the professional stems partly from a diminishing lack of long-term patient-doctor relationships in general, and a corresponding decrease in the amount of trust patients have in their doctors today.

It's become so easy and common to seek out a "second opinion" that if patients don't find the answers they were looking for the first time around, they often don't even pay attention at all. A big problem.

That said, the smallest efforts - like a genuine, warm smile or pat on the shoulder make ALL the difference in terms of how we regard our doctors, and really, they needn't eat up an extra second. Warmth can be communicated - even if it's not all that end-game necessary - via nonverbal cues, and I think we are all far more forgiving of curtness when we still feel liked.

Rational or not.
She's so right. So is Mimi. You're ALL right.

I think we're addressing the psychological need for care-taking by medical providers. Why else do people run to the E.R. for so many non-emergencies.

It's emotional. That's why they block, too.

It's really why some of us are blogging. We're sick of whatever it is we say flying off into space, not connecting in our patients' synapses.

Maybe the answer is to always treat people as if they're needy emotionally, even address it that way, then write the prescriptions.
Ok. Therapy doc's point is a little obscure. I think I know what she's trying to say: it's a two-way street on communication.

That being said, I still long for patients for whom the message outweighs the medium.
Hmmm... You out and out wrote this to goad people -- or else you would have chosen different language. So I'm guessing you're not surprised at this piece's response.

And I'm guessing you've been at this a long time and that it's getting to you -- the whole patient/dr dance? I'm guessing you've also never been seriously sick...

The tip off? Phrases like, "I'm suggesting that patients simply take their precious encounter time with the doctors more seriously" and "schedule another visit or punt the patient along to another doc" and "not even restricted to the prima donna American patients" and my favorite, "doctors, like any other professionals, regard patients as jobs, as work to be done, as problems to be solved."

I'm a professional who works with people. Have for the last 25 years. And I don't look at them as a commodity or merely a problem to be solved like the NY Times crossword puzzle. They've always remained human beings to me. Some I like better, some I like less. But, nevertheless, I've never felt the need to dehumanize them into "here comes the next paycheck or punt."

Here's the bottom line for me. I'm an intelligent, capable person -- sick or well. I treat other people with respect, and I expect to be treated with that same respect.

It's not a matter of how much you know -- there are lots of docs who'll know as much as you know. It's a question of whether you actually remember that you're treating a live human being, and not something to be shuffled off to someone else because they're requiring you to make the effort to remember that they are human.

PS. I have a family doc I love. Because he's good, and because he does treat us as humans.

PPS. I doubt you're as much a hard ass as you write yourself to be here. More likely just frustrated by what people want from you that you don't have the energy to offer.

And if you are such a hard ass, maybe you should consider switching careers and go work and problem solve on something that can't talk back, or that doesn't require any compassion which seems to annoy you. Like cars.
I guess I again failed to communicate the point. Or were you really listening?

Of course, your doctor, every doctor, even I realize that the patient is a human being. We're in the business of bettering and saving human lives.

I love to talk to patients, to learn as much as possible about their lives, particularly their social histories, family structures, and occupations. I like to share bits and pieces of my personal life so that they will understand where I'm coming from. But there are realistic constraints to the process. It's really not about being friends.

I have to do a lot of interpersonal interaction in order to practice my specialty. A surgical specialist may not need to in order to provide the highest order of humane care.
And even I have to do or order some unpleasant procedures for my patients, and I don't do so without feeling for them.

Fundamentally the process is one of creating a therapeutic alliance, which is not the same as becoming good friends. It's a contract for care built on mutual respect and trust, not on superficial mannerisms.
Then there's the other side: "Physicians often lost focus and wasted patients' time when they talked about themselves, a study concluded."
Unfortunately, I couldn't open the link, but I'll keep digging for the article. It may support the concept that there is often too much emphasis these days on the "bedside manner" and not enough on the job of complex decision-making.
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