Tag: doctor/ patient relationship

Politics in the Exam Room

Feb 20, 2012• 1

By David M Sack MD

An ancient maxim of dinner party etiquette, which I believe has been proffered from more than one source, is “never discuss politics, religion or sex in polite company”. In some ways, for me as a physician, entering the exam room with a patient seems to require some similar degree of discretion. But the consequences of straying outside the bounds of polite discussion in the doctor’s exam room are quite different from any awkwardness that might ensue after a social misadventure.

Dr. Henry Lee, the well-known Connecticut State forensic medicine expert likes to relate a tale of his own introduction to dinner party etiquette, which I will try to relay somewhat faithfully. His English was poor when he arrived in the U.S. and, invited to a party in which guests were seated in the traditional “boy-girl-boy-girl” arrangement, he knew he would be pressed to make conversation with the women on each side of him. A friend reassured him, “You’ll have no problem if you can just get the woman talking about herself and then all you have to do is listen politely. Simply ask ‘Are you married?’ and then ask “Do you have any children?’. This should get things going just fine.” Armed with this strategem, Dr. Lee was seated and turned to an attractive young woman on his left and asked if she was married. She replied “No”. So of course, he went on to the next question, “Do you have any children?”. He was surprised when she reacted with a look of indignation and quickly turned her attention to the guest on her other side. Puzzled at her reaction, he surmised that he must have gotten the sequence out of order. Trying out the other way around, he turned to an older woman on his right and asked confidently if she had any children. “Three!”, she replied happily. Delighted with his progress, he then inquired if she was married. Dr. Lee says he spent the dinner conversing with his soup and salad.

I have also had exam room encounters come to grief because of sex, politics and religion, but nothing has caused me more regret than politics. I will explain.

Should Your Doctor Talk with You About the Cost of Your Pills?

Feb 15, 2012• 9

By Peter Ubel, MD

I first realized something was amiss when I picked up my prescriptions and the pharmacist explained that she could not fill the anti-malarial medications as prescribed: “Your medication plan only pays for 30 days of pills, and your prescription was for five pills.” The pharmacist continued: “Your PBM [that’s an acronym for pharmacy benefits management company, the type of company that coordinates many peoples’ medication coverage] only fills this medication for 30 days at a time. And 5 pills would last 35 days.”

Expert logician that I am, I countered with some math of my own: “Well four pills, taken weekly, only lasts 28 days. If they really want to give me 30 days of coverage, they need to give me a fifth pill.” I thought it was insane to pay a whole extra co-pay to get my fifth and last pill, a co-pay I’d have to pay for my two sons too since all three of us were traveling together.

But the pharmacist was unpersuaded: “Sorry, four pills is it. You’ll need another prescription for the last pill.”

Irked, I handed over my credit card and hastily signed the bill, too bothered by the conversation to look closely at the bottom line.

When I got home and told my wife Paula about the saga of the fifth pill, she calmly looked at the bill and asked me: “If you were so concerned about a $10 co-pay, why didn’t you notice that the antibiotic you were given cost almost $200?”

Huh?

What I Learned from Listening to a Patient

Jan 26, 2012• 8

By Peter Pronovost, MD

I was reminded again recently of how important it is to sometimes just sit back and listen to what our patients have to say. Every month, as part of our hospital-wide patient safety efforts, I meet with staff and interview patients, seeking to learn how we can improve the care we provide to them.

A young patient shared two stories with me, one telling me how we get it right and one reminding me how we sometimes get it wrong, even without realizing it. She was nervously awaiting a procedure in Interventional Radiology when a nurse sensed her anxiety and called in a child life specialist. The specialists came and significantly helped relieve the patient’s suffering. She listened to the patient, offered a comforting touch, and provided her age-appropriate reading material and Sudoku puzzles, a brilliant though infrequently used intervention. If anything could take your mind off of your illness, it is Sudoku.

What was amazing was that after all the patient had been through―weeks in the hospital, countless procedures, scores of clinicians―what she remembered was the nurse’s act of kindness by caring enough to call the specialist. The patient reminded me that though we can cure disease sometimes, we can relieve suffering always, often with nothing more than a kind word, a gentle touch or a warm smile.

As I listened, the patient, along with her mother, went on to tell me more. They told me how the patient has complex allergies and that her mom knew her disease better than any clinician. They had lived with the disease for a decade. Yet at times, neither the patient’s mother nor the patient felt they were being heard by the doctors. The mom expressed frustration that clinicians often dismissed her concerns and discredited her knowledge.

Restoring Office Workflows to the EMR: Or How I Restored Patient Face Time and Got Back the Joy in Medicine

Jan 17, 2012• 28

By MARGARET POLANECZKY, MD

A report from The Blog That Ate Manhattan:

The Problem : Lost Face Time = Lost Joy

One day, about 5 years into using the electronic medical record in my practice, I came to the realization that I wasn’t having fun anymore. I was sitting throughout most of every office encounter facing a computer screen, my back to the patient on the exam table across the room. The joy of face to face interaction with people, the real reason I went into medicine in the first place, had been replaced with the more pressing urgency of data entry.

My revisit routine went something like this – I’d enter the room, briefly greet the patient (undressed and sitting on the exam table) and then, apologetically saying “Let me just open your chart”, I’d log on and begin interacting with the more immediately demanding presence in the room – the EMR. I’d turn around as often as I could to look at my patient, but mostly I listened but kept my back to her and I typed. After which I’d rush over to her side, do the exam, then head back over to the computer to make sure I got all her orders, refills and charges in as required. A brief goodbye, and I was on to my next patient.

As more and more mandatory clicks were demanded from the EMR to prove I was a good doctor – smoking history reviewed (click), medication reconciliation (click, click, click,click), problem list review (erase duplicates from ENT , remove resolved problems, add today’s, then click that I had reviewed what I just did) – the actual moments of face time with my patients had became smaller and smaller, till they were almost an annoying distraction from the real task at hand – finishing my charts.

Should Your Doctor Be Thinking About Society’s Healthcare Costs?

Jan 17, 2012• 5

By David Shaywitz

You probably want your doctor to care about people, but how much do you want her to care about all of them? That’s the question I ask when I read articles – generally by bioethicists, often respectable ones – asserting that one of the moral responsibilities of physicians is to be responsible stewards of the healthcare dollar.

This rhetoric concerns me, because I worry it may ultimately degrade the already-challenged physician-patient relationship.

The cornerstone of medicine, the most fundamental principle, in my mind, is the absolute, rock-solid belief that your doctor is your unqualified advocate and will work as hard as possible to provide you with the best medical treatment possible, as if you were a member of her own family (Dr. Marty Samuels and I originally described this as “The Uncle Marvin Test”).

To be clear: this doesn’t mean the most expensive pills – by all means prescribe or substitute an equivalent generic, when available. This doesn’t mean the most expensive diagnostic studies – it’s generally in the patient’s medical interest to avoid unnecessary procedures that usually carry some intrinsic risk and also can lead to false positive results that can in turn lead to needless anxiety — and on occasion, permanent harm. This doesn’t mean extra days in the hospital – a hospital is one of the world’s most dangerous places, and it’s often in a patient’s best interest to be discharged as soon as possible (see here if you need more convincing).

Mind the Gap

Dec 23, 2011• 22

By Stephen J. Downs

It’s a simple idea – show patients the notes that doctors write about them– but it’s also a dangerous idea … in the best sense of the word. It’s dangerous because the very idea forces a conversation and in the course of that conversation, some uncomfortable tensions surface. Jan Walker and Tom Delbanco, co-directors of OpenNotes, a project supported by the Robert Wood Johnson Foundation’s Pioneer Portfolio that enables patients to see their doctors’ notes via secure e-mail after a visit, published a preliminary set of results from their first study. Actually, it’s just a pre-study: they surveyed doctors and patients about their expectations of how the OpenNotes idea would play out. And what they found is fascinating – and uncomfortable.

Doctors and patients are clearly divided about the expected benefits and consequences of the OpenNotes intervention. On a wide range of possible benefits, ranging from a greater sense of control to increased medication adherence, doctors are more skeptical than patients. But what really jumps out are the responses to questions of whether patients would find the notes more confusing than useful, and whether the notes would make them worry more. The gap is dramatic. In each case, most doctors said “yes” while less than one in six patients agreed. Ouch. That’s a big gap and my sense is that we should be talking about what it means. From my perspective, it appears that many doctors are underestimating their patients and that this underestimation could lead to less patient engagement and ultimately poorer care. Call it a hunch.

Are Doctors Becoming Obsolete?

Nov 26, 2011• 9

By David Shaywitz, MD, PhD

The idea that physicians are going to be far less important in the medicine of the future seems to be a central assumption of many next-generation health companies, an assertion that, like undergraduate Shakespeare productions set in the present day, may once have felt daring and original, but now seems merely tedious.

The logic goes something like is: Patients are accustomed to seeking insight from their doctors but doctors are far less good at providing this advice than most patients realize. As more consumer-based tools for managing health become available, patients will recognize that they now have the means and the motivation to take care of their health better than their physicians, and medical care will move directly into their hands.

Arguably, a form of this already happens today, as patients make extensive use of non-prescription products (e.g. the Vitamin Shoppe reported net sales of $750 million in fiscal year 2010), non-traditional practitioners (e.g. total revenue received by chiropractors is estimated by Hoovers to be about $10 billion), and seek medical advice from friends on Facebook (which may have directly saved at least one life).

What these data don’t convey, however, is something I’ve had the privilege to experience first-hand: Doctors enjoy an exceptionally durable bond with patients — especially those patients with chronic illnesses. The level of trust reported by patients for their physicians is remarkable, and the role of physician as trusted adviser is difficult to overstate. It’s a huge burden to manage disease on one’s own, and it’s generally reassuring to know your physician is with you at every step — something I believe still happens, by the way, although obviously not in every case.