Tag: doctor/ patient relationship

Where is Relationship, Authority, and Trust in Health Care Today?


Healthcare is on a different trajectory from most other businesses today. It’s a little hard to understand why.

In business, mass market products and services have always competed on price or perceived quality. Think Walmart or Mercedes-Benz, even the Model T Ford. But the real money and the real excitement in business is moving away from price and measurable cookie cutter quality to the intangibles of authority, influence and trust. This, in a way, is a move back in time to preindustrial values.

In primary care, unbeknownst to many pundits and administrators and unthinkable for most of the health tech industry, price and quality are not really even realistic considerations. In fact, they are largely unknown and unknowable.

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Cold Hard Facts or Cold Hard Doctors?

I was first diagnosed with leukemia while travelling on a vacation in 1994. I had a persistent respiratory infection so I went to a local emergency room to get an antibiotic. I had the usual tests, including a blood test. A doctor came into the room where I was waiting and introduced himself as an oncologist. He told me that the blood test showed that I had “a terminal and incurable form of leukemia” and “less than five years to live.” Just like that. He also added that I didn’t need to rush back to New York, as there was nothing to be done.

A few months later, I sat in an office in New York of an oncologist who specialized in my form of leukemia. His manner was soft-spoken and warm. He told me that although there was no cure for my disease, there were a number of relatively mild chemotherapies that were effective in extending patients’ lives for many years, and that given developments in research, during the additional time there may well be a cure for my illness.

It turns out that the second doctor was correct. Five years after being diagnosed, bone marrow transplants became available for people my age with chronic leukemia. I had a transplant and a few years after that there was no longer any sign of the disease.

When I inquired with physician friends about my experience with the first doctor, they spoke of doctors’ fear of instilling in patients “false hope.” In my interactions with many cancer patients, I have yet to hear of any patient who felt they were given false hope. But there were many instances of patients, like myself, who were filled with “false despair.”

Now, I can’t imagine how difficult it must be to be an oncologist, to have to tell patients that they have a terminal illness, to see them go through brutal chemotherapies, to see them die. According to one estimate, during the course of their career, an oncologist will break bad news to their patients almost 20,000 times – from first diagnosis to the news that death is near. Yet, many doctors who approach this task in a cold-hearted manner seem to justify themselves with a “tell it like it is” philosophy. Easy for them, devastating for us.

Medical science readily acknowledges the placebo effect – that many patients who believe they are getting an effective medicine show improvement in their condition even when they are in fact not getting the medicine, but are instead receiving a harmless substitute. If the effect of a patient’s positive expectations can so profoundly affect his health, what then is the impact when a patient is, from the outset, given the difficult news about having cancer in a manner that so discourages his spirit?

Most lay people know the fundamental maxim of Hippocrates to physicians throughout the centuries: “First, do no harm.” This has always been understood to have to do with the medicines and treatments that physicians prescribe. In this day and age it applies equally to how doctors talk to and act toward their patients.

Andrew Robinson was a successful New York trial attorney when he was diagnosed with leukemia and told he had less than five years to live. That was more than 15 years ago. He is the founder and CEO of Patient2Patient, a company that develops disease specific guides to help patients learn how to locate and use medical information and resources on the Internet. This post first appeared at Prepared Patient Forum.

A Computer Teaches Docs the Empathy Thing

The Canadian Cancer Society says this year alone, more than 170,000 Canadians will be diagnosed with the dreaded disease. What those patients want from their doctors is a little kindness along with chemo.  That’s not something all doctors know how to provide. But a recent study has concluded doctors can learn some empathy skills.  And the teacher may surprise you.

The doctors in this study, published last week in the Annals of Internal Medicine, learned empathy – from a computer.  That’s right, a computer.

Researchers at Duke University in the US developed a computer program that teaches what cancer specialists learn when they take courses on empathy.  Researchers audiotaped between four and eight encounters between the cancer doctors and their patients – people with advanced cancer.  Those recorded sessions were submitted throughout the study period to monitor empathic responses and – in the case of the doctors who received special training in the empathic response – provide tips on how to improve.

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Is Your Doctor Lying To You?

The doctor-patient relationship, like any good relationship, is built on trust. After all, the patient is naturally at the mercy of their physician in most cases, because the physician is the expert. Sure, the patient should have the ultimate say in their care, but the information they are basing their decisions on typically comes from the physician, and they must trust that what they are being told is the truth. Unfortunately, a recent study by Lisa Iezzoni and colleagues finds that doctors aren’t always so honest with their patients.

In a survey of a representative sample of physicians, more than a third of doctors fail to completely agree with the statement “Physicians should disclose all significant medical errors to affected patients.” Nearly one-in-five fail to completely agree with the statement “Physicians should never tell a patient something that is not true.” That’s right, more than 17% of doctors felt that there were times when it was okay to lie to patients.

As for their actual behavior, 11% of physicians reported rarely, sometimes, or often (in contrast to never) telling a patient something that was not true, and 55% reported rarely, sometimes, or often describing a patient’s prognosis in a more positive manner than warranted. Admittedly, the latter case could be perceived as compassionate rather than dishonest depending on the circumstances.

What are we, as patients, to make of these findings? Well, on the one hand, the truth could be even worse than the results suggest because of “social acceptability bias.” In other words, doctors know that admitting to being dishonest isn’t the “right” answer to give, so they may ironically be dishonest about reporting their dishonesty. At the same time, the framing of the results may actually be misleading. By taking four responses (never, rarely, sometimes, and often) and grouping them into two categories (never vs. not never), important information is obscured. If most of the doctors who admit to lying are in the “rarely” category, perhaps that’s not so bad. If, on the other hand, most of them reported lying “often” that’s a little scary. Unfortunately, the way the data are presented, it isn’t clear which is the case. I think it would have been better to put two responses in each category so that “never” and “rarely” were combined and compared to “sometimes” and “often.”

My sense is that doctors, like all people, sometimes lie–perhaps more often by omission rather than commission–but that we should not be too worried about the results of this survey. Don’t assume your doctor is lying to you or that they are always being honest. That’s what second opinions are for.

D. Brad Wright is postdoctoral fellow at Brown University and  holds a PhD in health policy and management from the University of North Carolina.  He has worked as the Assistant Director of Health Policy for the Association of Clinicians for the Underserved. You can follow him at his blog Wright on Health where this post first appeared.

A Cowardly New World

Last month, the National Post’s Tom Blackwell reported that a growing number of hospitals say patients and their families are secretly recording doctors and nurses. Some say it’s a symptom of the breakdown of trust being patients and their physicians.  Welcome to a Cowardly New World.

The biggest examples that reported in the National Post included a video camera installed in a clock radio to secretly record doctors and nurses as they treated a patient.  The footage was used as evidence regarding substandard care at Sunnybrook Health Sciences Centre in Toronto.  At Toronto’s University Health Network, a video camera was reportedly concealed inside a teddy bear.  A camera concealed in a wrist watch was used to record evidence against a Calgary psychiatrist.  Smart phones are also being used overtly and also surreptitiously.

I have experienced this first hand in the ER.  On one occasion during a night shift, as I was about to stitch up a patient’s cut, his buddies asked if they could record me doing it.  I thought it was kind of cute and innocent.  The recording took place in a closed room away from other patients so there was no risk anyone else could be filmed surreptitiously.

To be clear, that example was overt.  I had another patient encounter that was quite different.  I remember seeing an elderly patient who came to the ER with a medical problem.  Both the patient and a relative were present in the room the first time I saw him.  I came into the room a second time to give the patient and the relative some test results.  As I walked into the room, I noticed that a cell phone was on a chair in the room; it was seated in the middle of the seat cushion, sort of like an invited guest.  I paid no further attention to it.

The relative said the patient’s daughter (a physician) and was en route the hospital to speak with me.  I started to tell the patient and the relative my working diagnosis and my management plan.  Suddenly, the cell phone talked!  A voice emanated from the smart phone’s speaker disagreeing with me!  The daughter had been surreptitiously listening in all along.

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Solving the Primary Care Shortage

GundermanOne of the top students at one of the nation’s largest medical schools, Ishan Gohil has made an unusual – and to many of his colleagues – inexplicable decision.  Instead of seeking to train in one of medicine’s most highly specialized and competitive fields, he says, “I elected to pursue a career in family medicine.”  Many view his choice of primary care as ill-advised, largely because family medicine is one of the least competitive fields and ranks at the bottom for income of all medical specialties.

Until his third year, Gohil had planned to pursue orthopedic surgery, which is considerably more difficult to get into than family medicine.  In 2014, the average score on Step 1 of the US Medical Licensing Exam for students entering family medicine was 218, while for orthopedic surgery it was 245 (the overall average is 230).  Average annual salary levels diverge even more widely, at $122,000 for family physicians and $488,000 for orthopedic surgeons.Continue reading…

An Open Note to Open Notes Objectors

Screen Shot 2014-07-20 at 5.59.22 PMThere is a growing group of articulate and engaged patients committed to getting access to all their medical information in order to be better positioned to work collaboratively with their clinical teams. Published studies like the OpenNotes project have consistently shown significant benefits and a lack of serious problems. Health care systems are slow to change and just beginning to understand both the need and value to this more transparent and collaborative approach.

My institution, for example, is not ready (or even interested) in anything approaching opening chart notes to patients. In fact, although our secure portal will be launched in the near future, there was some resistance to making even problem lists, medication lists, lab and x-rays available through the portal.

That need not prevent individuals from contributing to change. A few years ago I began providing every patient with a copy of their office visit note as they left the office after their visit. The intent was for us to do the assessment and plan collaboratively and make sure they have a copy of our (collaborative) plan.  Patients have been very appreciative, and use it to share the assessment and plan with family and consultants, and as a reference. A few bring it back at the next visit with notes on it about what they did and what happened.

To the objectors who say that one cannot be honest in a note if the patient is going to see it, I say: balderdash. (Actually, what I say is much stronger…)  For one thing (the smaller point) the patient is already allowed to see it if they but ask.  More importantly, this argument depends entirely on the principle that the clinician knows best and needs to keep secrets in the interest of the patient. What I have experienced is a variation on the advice I got many years ago regarding relationships: if it’s important, then it’s important enough to be open about and deal with. If you aren’t willing to deal with it openly, you are not allowed to save it up and spring it on your partner (patient) later.

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The Angry Patient: A Primer For Physicians.

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Hospitals are environments where emotions can run high. These emotions cross all boundaries and can affect physicians, hospital staff, patients and their families. Dealing with an “angry” patient is a common challenge that physicians face.

The first step for a physician encountering an angry patient is to remain calm and allow the patient to express his or her concerns. In my experience, “angry” patients can be viewed as falling into several different categories. By understanding and thinking about these categories, physicians can begin to identify the root of the anger and take measures to address it. This exercise might seem simplistic at first. However, you’ll be amazed by how powerful the results can be.

Why do patients become angry? What are the common “root” causes?

1. Pain

Medical illness is often accompanied by pain, so much so that pain is often considered the fifth vital sign. Assessment and treatment of pain is an important factor for all medically ill patients. Anger is a common emotion in patients with pain, especially chronic pain. It is thought that the presence of significant anger may in fact further aggravate the feeling of pain. Physicians must not only be able to assess pain, but also to weigh the benefits and the risks in prescribing analgesics. When any patient appears to be “angry,” the presence of pain, especially untreated/undertreated pain, must be considered and rectified as a matter of urgency.

2. Fear and worry

Being medically ill, especially if one is hospitalized, can be an intensely destabilizing experience for both the patient and his or her caregivers. In some cases, an unknown prognosis, the occurrence of complications or the impact of the illness on their independence, can make patients fearful about the future. This worry can manifest as anger, and since patients cannot direct their worry or anger toward their illness, this anger may be displaced onto people around them, including hospital workers. Attempting to recognize, and where possible alleviate, their worries is often very helpful.

3. Feeling unheard or uninvolved 

Any patient who displays anger in a hospital setting is guaranteed to attract attention. For some patients the expression of anger may actually suggest that they feel “unheard” in the medical setting. They may feel that they do not have enough information about their condition or their concerns have not been addressed. The question then arises, how do we make them feel heard? Do they understand why they are in the hospital? Do they understand what their treatment options are? Do they feel they have been part of the decision-making process? Ensuring that patients feel they are involved in their care can reduce the anger that can arise out of being “unheard” in a hospital.

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Optimal Positioning Strategy and the “Quantified Relationship” in Baseball and Health Care

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Strategy in baseball used to be a fairly straightforward matter. A few strategy rules – a right handed pitcher was more successful against a right handed batter, lefty against lefty, no left handers at infield positions except for first base, don’t hold the runner at first with two outs and a left handed batter, and sacrifice bunt to move a runner at first with less than two outs- were taken as gospel and practiced by the community.

It was baseball’s version of the 10 commandments, written in stone and for the first century of baseball, unchangeable.

The world changed, though few knew it, in 1946 when Cleveland manager Lou Boudreau moved his shortstop to the right of second base against the legendary dead pull hitter Ted Williams of the Boston Red Sox.

However, like many innovations, it is only with the advent of large data sets that the revolution that started that July day in Cleveland impacted day to day strategy.

A players position on the field is no longer the result of the manager’s intuitive hunch, or even the result of consulting a written document of the past several encounters between a particular pitcher and a particular batter- a scatter gram of where this batter is likely to hit the ball. Instead, major league teams are increasingly relying on sophisticated, large data sets that are housed on remote servers.

These data sets run complex algorithms predicting the best solution for a particular ecosystem- elements of which include – batter, pitcher and all the defensive players and their particular gifts, skills and tendencies- and even the weather and time of day.

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How Much Will It Cost to Let Me Die?

flying cadeuciiIt was probably the most awkward question I had been asked before, and I did not have an answer…

He was a middle-aged gentleman, neatly dressed—very simple and unassuming. He blended like a lifeless statue in the waiting area. What sparked my notice of him was his accompanying robust file, crammed with familiar pink discharge slips from the ED.

He was clearly what we call a “frequent flyer”, but this would be his first visit in our surgical clinic.

I escorted him into the assessment room, exchanging the usual salutations as he edged unto the exam table, wincing with discomfort. His chief complaint read, “acute abdominal pain and constipation x 1 week.”

Vying to understand more about his issue, I asked, “Sir, how long have you had this problem?” Embarrassed, he lowered his head.


I retreated and instead remarked, “Ok. Let’s start from today. Where do you have the most pain?”

Tenderly, his frail digits unbuttoned his shirt, exposing a wasted torso, which hoisted an extraordinarily distended abdomen. It appeared rigid and tense. I reached out to gently palpate it to confirm the realism of my observations. He flinched.  His stoic affect instantly collapsed into an aching frown.

Tears welled in his eyes. Something terrible was going on inside. Cancer.

He needed to be admitted and surgery would be very likely, if not too late. I was aplomb in my explanation of his condition, feeling proud of my thoroughness and precision. Yet, seemingly unengaged, he politely interrupted and asked, “How much will it cost to let me die?”

I paused.  It was probably the most awkward question I had been asked before, and I did not have an answer. During my training, I was taught to order tests wisely, to avoid superfluous exams and to minimize inefficiency of resources; in spite of this, I had not ever stopped to think about cost in this context.

In my mind, it was my duty to provide the best, quality care to extend life, foremost. Yet, his concern was different. How much would it cost to die?


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