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10 Rules for Good Medicine

The recent discussion of the appropriateness of bringing patients back to the office has really gotten me thinking about my overall philosophy of practice.  What are the rules that govern my time in the office with patients?  What determines when I see people, what I order, and what I prescribe?  What constitutes “good care” in my practice?

So I decided to make some rules that guide what I think a doctor should be doing in the exam room with the patient.  They are as much for my patients as they are for me, but I think thinking this out will give clarity in the process.

Rule 1:  It’s the Patient’s Visit

The visit is for the patient’s health, not the doctor’s income or ego.  This means three things:

  1. All medical decisions should be made for what is in their interest, including: when they should come in, what medications they are given, what tests are ordered, and what consults are made.
  2. Patients who request things that are harmful to themselves should be denied.  People who ask for addictive drugs or unnecessary tests should not get them.  Patients who are doing harmful things to themselves should be warned, but only in a way that is helpful, not judgmental.
  3. All tests done on the patient should be reported to them in a way that they can understand.

Rule 2:  Minimize

Many doctors and patients have a “more is better” mentality.  This not only costs more money to the system, but it can cause harm to the patient.  Here’s what I think should be done:

  1. Patients should only be seen when a visit is appropriate. Use as few medications as possible, and when necessary, use the
  2. cheapest one that will do the job.
  3. Order as few tests as possible.  No test should be ordered for informational purposes only; the question, “What will I do with these results?” should always be answerable.  If it is not, the test should not be done.
  4. When changes are made, make only a few at a time.  Many simultaneous changes make it hard to tell what helps and what hurts.

Rule 3: Relationship = Better Care

Relationship is one of the best tools for achieving optimal care. This means that the patient knows the doctor and trusts them, and the doctor knows the patient.  This does not happen with sporadic care, but instead with consistent, long-term care by one provider.  The result of this includes:

  1. Patients with long-term significant medical problems should come in on a routine basis.
  2. The best-case scenario for regular visits is that there are no medical problems, in which case the visit will be mainly social.
  3. There is a medical benefit to the social visit, with the doctor understanding the patient better and the patient trusting the doctor more.
  4. There are frequent cases where the patient doesn’t think there is something wrong, but a regular visit reveals either serious problems, or allows intervention to prevent a serious problem.

Rule 4: Keep Priorities Straight

When a patient comes in with a problem, there are three goals:

  1. Rule out bad things
  2. Make the problem better
  3. Make a diagnosis

#’s 1 and 2 are of equal importance, with #3 a distant third.  This means that you always should address the fear that caused them to come to be seen (e.g. patients with chest pain should be reassured it is not the heart, if possible).  But stopping with #1 is unacceptable; #2 must be done as well.  Sick people want to feel better, and it is the doctor’s job to try to accomplish this.

Rule 5: There is ALWAYS a Reason

It’s very easy to actually believe that people’s actions revolve around you when you are a doctor.  It’s not only human nature to take this view, it’s a natural response to the stress and pressure of the job.  But there are bad consequences to this state of mind:

  • If you can’t figure out why people come in, then they are just wasting your time
  • If you can’t make sense of symptoms, then they are not telling the truth
  • If a person is acting in a way that is irritating and annoying, they are doing so by choice to bother you
  • A person who seems emotionally weak is that way by choice

Avoiding these assumptions will make care better, both in the ability to see things objectively and to offer care and compassion.

Rule 6: If the House is Burning Down, Don’t Cut the Lawn

Focus is one of the most important things in an office visit.  Both doctors and patients can lose sight of the purpose of the visit. I use this line whenever someone asks me about minor issues in the face of bigger things.  Weight loss may be important in the long run, but it is not pertinent when a person is in the office with a heart attack.

There are no quick fixes or magic wands.

Rule 7: Compliance follows Communication

I have a hard time remembering things, so I am not surprised when my patients aren’t compliant.  In my experience, it is far easier to remember things I think will benefit me.  My job is to help my patients with this, not seeing perfect compliance as the norm. The best way to do this is to communicate.  I need to communicate in a way that doesn’t just convince them of my opinion, but gives them reason to change theirs.  This means that I need to know what they think is important (by listening) and then find a way to turn that into motivation.

100% compliance is not expected, but it is nice to see motivated patients; it’s my job to encourage, not judge.

Rule 8: People Come to the Doctor’s Office

When people come to see me, they interact with more than just me; they interact with my staff.  They deal with our system that we have set-up, good or bad.  A bad experience in the office usually has nothing to do with the quality of medical care, it usually is because of a poorly run office encounter.

A big part of taking care of patients is running the office efficiently (which was one of my biggest frustrations in a practice run by the hospital – they didn’t care about the patient encounter, they cared about the referrals).  This takes a lot of work that doesn’t seem to be reimbursed and doesn’t seem pertinent to medical care, but patients who are frustrated and upset don’t listen as well, and frustrated healthcare workers don’t give as good of care.

Rule 9: The Buck Stops Here

I believe in primary care.  I believe it is I am the one who my patients call “my doctor,” and I see this as a big responsibility. I need to know as much about them as possible, getting information from anywhere else they get medical care.  My problem and medication lists need to be as accurate as possible.

I am advocate, doing what is in the best interest of the patient, not the drug companies, hospitals, or specialists.  I am confidante, listening to anything the person has to bring to me and knowing as much about them as anyone on the planet.  I am advisor, collecting medical information and giving them an opinion as a trusted person with their best interest in mind.  I am comforter, shutting up and listening when that’s appropriate to do.

Rule 10: Enjoy the Good Stuff

There’s a lot to complain about in our system.  There are a ton of stressful things and a lot of bad stuff we see.  The simple fact that so many of us keep going back to work is witness to a lot of benefits. Remembering what’s good about being a doctor is key to maintaining the energy to face the rest.  Here are some of my favorite things:

  • I have a lot of patients who I really like, enjoying my interaction with them.
  • I see a lot of inspiring people, getting up when they are knocked down time after time.
  • I get to play with babies and tickle kids (and get paid for it!).
  • I save people’s lives and make them feel better.
  • I get to say the right thing at the right time, really making a difference when it counts.
  • People openly tell me how much they appreciate what I do.
  • I work with a bunch of folks who are good to be with and like-minded in their desire to help our patients.

These things are what get me up in the morning.  They are what make dealing with insurance companies, stupid government policies, and rude doctors and patients possible.  They are the balance to the suffering and pain I see.  No, they greatly outweigh all of that stuff.  Really. I wouldn’t do the job if that weren’t the case.

ROB LAMBERTS is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at Musings of a Distractible Mind, where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player. He is a primary care physician.

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Ihsan Shantidavevedoctor sabelotodoChristos K. ZirosInternet T1 Recent comment authors
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Ihsan Shanti
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[…]The recent discussion of the appropriateness of bringing patients back to the office has really gotten me thinking about my overall philosophy of practice. What are the rules that govern my time in the office with patients? What determines when I see people, what I order, and what I prescribe? What constitutes “good care” in my practice? So I decided to make some rules that guide what I think a doctor should be doing in the exam room with the patient. They are as much for my patients as they are for me, but I think thinking this out will… Read more »

daveve
Guest
daveve

Do away with the feudalistic medicocentrism in medicine and give the people a much greater voice in their care-failing that let the feudal mischief of modern medicine be spent-the sooner the better.

doctor sabelotodo
Guest

thanx bob..especially #9..i am very passionate and determined that “the buck stops here”..if i am not my patient’s advocate then who will be…i have always said “don’t hurt my daughter, my dog or my patients”

Christos K. Ziros
Guest
Christos K. Ziros

What about the doctor who tries to force a patient to come in for an office visit by withholding necessary prescriptions for, well, diabetes and cardiac care, for example? Is a doctor allowed to use such threats or behavior against a patient when the doctor well knows that the patient has financial problems and no healthcare coverage and in some cases has valid reasons that interrupt the patient’s own plans to come to the office? Is it proper for a doctor to act as if he or she is an authority over the patient? Is the doctor the patient’s boss?… Read more »

Internet T1
Guest

In life its not always the medicine that can heal but the lifestyle of a person. The post is really unique. It enlightens us even me personally that we have to change the way we live. If we are sick we will not only depend on the medicines the doctors give. We will be healed with the way we live and act everyday. Hope to see this kind of post in the Internet once again.

david
Guest
david

What nonsense is this. If we want better health care we need to depose the fat cats that maintain the status quo of expensive and poor quality health care. The so called experts in health care are wanting for expertise as they are wanting from caring directly about what matters most to people they serve. Healthg care is about laissez faire capitalists who wish to impose their will on the public and make as much money as possible. Let the feudal mischief of the health care industry be spent and the public restored to right reason and the government to… Read more »

health rules
Guest

Ask a lot of questions and be inquisitive. Doctors use a lot of technical jargon. Ask them kindly to explain what they mean and to give examples. Ask them for additional literature if necessary. They usually have many brochures in their office that will help explain more about the condition discussed.

Julia DeWahl
Guest
Julia DeWahl

Great post – reminds me also of how important ethics needs to be to doctors. I am working on researching telehealth and virtual doctor visits that provide medical advice. I wonder how ethical these are, since the visit is not in person, is done without a relationship with the patient, and often lacks a medical history. In case anyone’s interested, here’s a survey we are using to gather data on using top Indian doctors to provide medical advice to Americans when they can’t get to their regular doctor. I do worry about the ethics of it all, though, and would… Read more »

Rob
Guest

Vik: here are my rules for doctors along this line: http://distractible.org/doctor-rules/

Nate
Guest
Nate

most PBMs allow members to look up cost onlines in a matter of a minute or two. How about making a PC available in the office for patients to look up cost then discuss?
I’m thinking this might actually save money. You can buy a decent web pc for under $200. I’m sure most already have an internet connection so that would be no additional cost. It would only take a couple Bev MDs calling back to change to offset the total cost then actually start saving you money. Personal responsibility and engaging the patient could have other positive results.

Contrarian
Guest
Contrarian

bev M.D., I think we agree on the education aspect of the cost of medicine. That’s why I stated that I use Wal-Mart’s printed list of the cost of generic medications. It is the only fixed price list for medication that I am aware. Eventually they will have an app for cost comparison of medications for the consumer, but it is not here now.

pcp
Guest
pcp

Bev:
Don’t blame the doc. The costs were probably the reverse at the pharmacy down the street. The pricing of drugs is so opaque, so changable, and so dependent on so many unknowns that it is impossible (even using electronic resources) for the doc to know what something is going to cost.

Vikram C
Guest
Vikram C

I earlier alluded to patient decision making. Here are some of patient decision areas that I could think of.
1. Branded vs generic
2. Choosing Doctor & Hospital , first time
3. Changing doctor
4. When treatment is not working
5. Supplementary and alternatives therapy alongside prescribed medicine.
6. When to visit and not to visit doctor.
7. Handling second and possibly conflicting opinion.
8. Side effects and limitations of medicine.
9. Overmedication, concern or actual experience.
10. When you think you know more than doctor about your condition

Vikram C
Guest
Vikram C

Rob, Thanks for your reply. I am generally in agreement with what you say. Probably the stakes aren’t too high when visiting a PCP. But let’s say it’s one of those case, say, as happened in St John’s Hospital, MD. Hundreds of patients got letter from hospital that they were possibly unnecessarily stented. One doctor in question has been stripped of his position. Now if I were to be the unfortunate one to get such advice and based on my extensive research I find that it’s not necessary, what should I do- trust doctor or myself? I am not looking… Read more »

bev M.D.
Guest
bev M.D.

Contrarian; I agree with what you say up to a point. Example: I once took my daughter to a dermatologist for acne. He prescribed, among other things, 75 mg tetracycline (or it could have been doxy, that’s not the point) bid. So when I go to fill the prescription, 75 mg is, like $80, but 50 mg or 100 mg is an order of magnitude lower – like $8. (I am inventing the exact $’s b/c I don’t remember, but it’s the huge difference that matters.) Since I have an HSA and no drug benefit, this matters to me. So… Read more »