By ROB LAMBERTS, MD
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:
- 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.
- 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.
- 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:
- Patients should only be seen when a visit is appropriate. Use as few medications as possible, and when necessary, use the
- cheapest one that will do the job.
- 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.
- 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:
- Patients with long-term significant medical problems should come in on a routine basis.
- The best-case scenario for regular visits is that there are no medical problems, in which case the visit will be mainly social.
- There is a medical benefit to the social visit, with the doctor understanding the patient better and the patient trusting the doctor more.
- 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:
- Rule out bad things
- Make the problem better
- 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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Thanks for sharing. I can identify.
[…]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.[…]
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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.
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”
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? A doctor who has given long-term care to a patient–does that doctor have the right to try to assume an authoritative position over the patient? Isn’t that a wee bit much? We’re not talking about some wise-guy patient here, but a patient who is a decent person sometimes overcome by all manner of problems, some not medical, but problems nonetheless! Isn’t the doctor overstepping the line when he or she withholds the needed prescription-medications as a method of forcing the patient to come to the office? We’re talking about a patient whose concern for his own healthcare is logical and deliberate; who is not avoiding going to the doctor’s office by choice but is only delaying it slightly so that he can manage it.
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.
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 just principles. Until then their will be a continuing escalation of failure in the health care industry.
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.
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 love to hear feedback.
http://www.surveymonkey.com/s/globalaccesshealthcaresurvey
Vik: here are my rules for doctors along this line: http://distractible.org/doctor-rules/
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.
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.
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.
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
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 to debate and harangue the doctors, but I am not willing to abdicate my responsibility towards my well being either.
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 I call the office, ask to speak to him, and explain the problem. He is SHOCKED, just SHOCKED, at the price difference and says yes of course she can take 50 mg in the am and 100 mg in the pm for the same total daily dose.
This was totally avoidable if he had educated himself on what must be a very frequent prescription for him. Most patients, also, would just fill it since they are not paying.
I’m sure it is easy to find other examples. I believe docs should educate themselves on the costs of their frequently prescribed drugs in this manner and avoid a lot of waste.
Vikram: My advice is quite biased, of course, but I honestly think that an educated patient along with a TRUSTED PCP is the most cost-effective approach. There is no way a non-medical person will be able to know if the decisions they make are the best, having not had the cross-section of experience. That does NOT mean that the patient should be passive; the patient’s job is to take the advice of the PCP along with what they can read from trusted Websites (I like UpToDate and the Mayo Clinic sites). It’s not bad to read several sources, then go to the doc with your questions. In the end, the decision belongs to the patient and the job of the PCP is to give the best information they can give. A trustworthy PCP will understand and encourage the patient’s final say in the process.
Why a PCP? Seeing patients every day gives a wealth of experience that goes beyond the formal education/training. Plus, PCP’s are not financially rewarded for sending you for more tests and spending more money (as opposed to many specialists). You pay your doctor for something you can’t get anywhere else: experience and training, but the decision in the end is yours.
Thanks Doc. Just curious, if you would be able to advise your HSA/HD patients on where to get good and affordable treatments from?
This apart, I would really love to see a patient’s dossier. One understated aspect of a patient’s lives is that they make decision regarding doctors and treatments to choose. Now doctors are very well trained in their profession so they can make sound decisions, most of the time. We the patients have zilch education but have ultimate authority to take our decisions on our behalf. It’s a tough job, if someone is trying to do it responsibly.
Any suggestions, from anyone if any book to educate patients exists?
These are good rules guidelines. There is one section where I may differ; the section on using the least expensive medication.
My guideline is:
I will prescribe what I consider the best medication for a particular scenario without regard to cost. I will become completely knowledgeable about a medication including benefits and side effects but not formulary. I will allow a generic substitution, but I will rarely write specifically for a generic unless it makes Wal-Mart’s printed list. Costs are beyond the control of the prescribing doctor that it does not make sense for a physician to make decisions based on it. A general ball park figure for a medication might be helpful, but I have had patient’s bring the same medication from two different pharmacies and the final price could vary by more than 150%. Medications are cheaper at a pharmacy when there is a competitor on the same corner. A pharmacist might change a medication because it costs less (and he receives a higher dispensing fee) and tell the patient that a particular medication is cheaper. Though this may be true, the reality for the patient is that both medications have the same copayment. Sometimes the difference in price might be miniscule. This is just the tip of the iceberg. In a similar fashion, I may recommend a consulting physician, but I don’t base it on cost. I may recommend a particular facility, but unless it is a cash paying patient where I can negotiate a lower cost for the patient, I don’t recommend a facility based on cost.
There is no possible rule on cost.
He he. Grandstanding? I didn’t realize I was doing that! Our practice has been on EMR for 12 years and it is used well by more than just me. None of our staff or docs would ever practice without it. I’ll post on this, but I refer back to the PICNIC acronym and Dr. Coffee’s reference. Computers certainly CAN be in the way, but it’s more a case of dumb docs than it is misplaced tech. The tech needs improvement, but it is an improvement over paper charts.
In concert with Propensity. Rob is grandstanding on the virtues of his typing skills. The patient has a chief complaint. The computer has a lack of usability disease. The patient gets shortchanged. The computer gets the attnetion. Sad.
Rob’s list is too long for me to remember. Put it on the computer as an app to enable me to go through the list.
“The person is the patient. In contrast, the patient, according to Blumenthal and Halamka, is the computer.”
“that is, the doctor with his/her nose in the computer would’ve had their nose in the paper chart as well.”
The problem isn’t the computer in the exam room: it’s the overwhelming bureaucratic and administrative load of Meaningful Use and the PCMH that will inevitably require that doctors, nurses, and staff spend more time in front of the computer and less time in direct patient care.
Propensity: I will
Eric: Yes, these are simplistic. They are rules, not laws. There will always be exceptions, but in the context of a post they need to be kept general.
Michael: Thanks for your comments. I wrote the compliance bit because docs tend to blame-shift things on patients. They don’t see that they have a role in the issue. We can achieve better compliance if we take the time and explain (and listen, of course).
As a like-minded family doctor, I really enjoyed this post, and I do wish that more doctors shared this same view. Some specific comments on your Top 10:
Rule 1 – It’s the Patient’s Visit. Totally agree. Patients shouldn’t be made to come in to the office if they don’t really need it. But our current system really pays for visits. So guess what the system gets? Visits! This is one reason I am so excited about the PCMH concept.
Rule 2 – Minimize. I have been burned again and again when ordering a test to “reassure” myself or the patient. PS – this is why I hate the full body CT. What do you do with all those incidentalomas.
Rule 3 – Relationships. One of my core beliefs is that life is all about relationships. I agree that better relationships lead to better care. This is my biggest worry about PCMH, will the team-based model dilute the doctor-patient relationship? I think it will to some degree, but the benefits will outweigh the negatives, particularly if we are mindful of the issue.
Rule 5 – ALWAYS a Reason. I think this can be one of the most fun parts of our job. Why did you come in TODAY? What is really going on? And I have found that when someone says, “I don’t know”, they usually know, but may not be aware that they know.
Rule 7 – Compliance follows communication. I am not a huge fan of “compliance”, feels too laden with negative judgment. I like to tell my students to think that rather than the patient has a compliance problem, think that you and the patient have an alliance problem. And then work on the only thing you have any control over, your actions, explanations, etc.
Rule 10 – Enjoy. Absolutely! We have the best job in the world, and it seems that the more I focus on the good stuff, the more good stuff that comes. That seems to be true for my patients as well.
And I love your PICNIC acronym in the comments. You are right on about docs who bury their noses in computers are the ones who buried them in paper charts. This was shown in a nice study (Frankel R, et al. Effects of exam-room computing on clinician–patient communication: a longitudinal qualitative study. J Gen Intern Med. 2005;20:677–82.) Computers can really be used to improve care, but, like with most things, the devil is in the details.
What’s wrong with social visits is that for people who work, we have to take a half day off, spend a load of money (and we pay, if it’s through insurance or directly, we pay). I don’t want to pay to socialize. And I don’t want to use sick leave, which I need in case I get sick. So that’s a half day of my meager vacation time. (I may get to choose if I’m lucky.) To pay to socialize? no thanks.
Great rules. I would have to question rule 1.2 though as a little to simplistic. Patients request things that are harmful all the time, and as doctors we prescribe them. It can be as simple as a statin or more complex, like coumadin for a patient who has had GI bleeds. All interventions, no matter how insignificant we perceive them to be, will have some risk of harm associated with it. The question is will it provide the patient with a greater amount of benefit. Take “addictive drugs” as an example. I would agree that use of these drugs should not be prescribed for patients without pain. However, for patients living with advanced illnesses, use of opioids may be able to give them the ability to regain function.
If you do say so yourself.
Propensity: My opinion (as someone who has been on EMR for 12 years) is that it is a case of PICNIC (Problem In Chair Not In Computer) – that is, the doctor with his/her nose in the computer would’ve had their nose in the paper chart as well. We have computers in every exam room, but it is a tool and is used in a way that I can face the patient during the encounter. Since I type while not looking at my hands, I can take very good notes and keep eye contact. Doctors can hide behind computers if they are intent on hiding, but in my view a computer is a great tool to engage the patient IF USED PROPERLY.
Hey Rob,
Good rules, in general, but a little weak on the psychological issues of patients.
Most importantly, abiding by the rules is incompatible with face buried in computer terminal with hand on the clicker. The person is the patient. In contrast, the patient, according to Blumenthal and Halamka, is the computer.
What’s wrong with “social visits”? I’ve seen older folks on Medicare come in with some vague complaint just so they can talk to somebody. Kids are far away, friends are dead and folks are lonely. Is having someone to talk to, someone who cares, less therapeutic than a bunch of colorful pills for depression? I’ll gladly pay a little more taxes for this simple comfort for the elderly.
Yes! People with chronic problems often ask me “do I have to wait that long to see you?” It is something you have to read from the patients – I don’t want to make even a perception that I am doing this for “just social reasons,” but the longer a person is a patient, the less they resist this. It does take sensitivity.
I think pcb has a good question about people wanting to pay for social visits.
Does a physician really build a meaningful relationship seeing someone for 15 minutes once a year to renew a bcp prescription?
great post.
on point #3. I agree that social visits are important to develop trust and are important for the doctor/patient relationship. But…does anyone want to pay for them? The reason we’ve been able to get away with those sort of visits is the 3rd payor system we have. Insurance companies don’t get to decide how often the patient comes in, but they still have to pay for the visit. The patient often has no cost, or a small copay.
How many people with high deductibles or out of pocket expenses want to pay to socially interact with you if there isn’t any pressing medical need? And how many payors want to keep paying for it?
Great comments!I believe in primary care as well. The patient is still the most important person in this industry!
I loved this post – it’s what is good in health care today. I hope other physicians and providers strive to live by these guidelines too.
Wow! Great post! Clearly you have done a lot of introspection here, which is, in my opinion, the best part about interactive blog-type communication. Group learning. Collective wisdom. Whatever.
I think patients should print this and bring it to their docs!
Good stuff. I would want you to be my doctor.
Thanks for the guidelines, they are helpful in maintaining my power as a patient.