Members of the American public are frequently surveyed about their trust in various professionals. Doctors and nurses usually wind up near the top of the list, especially when compared to lawyers, hairdressers and politicians. Trust in professionals is important to us: they possess expertise we lack but need, to solve problems ranging from the serious (illness) to the relatively trivial (appearance).
How much professionals trust us seems irrelevant: our reciprocity is expressed in the form of payment for services rendered or promised, our recommendations to friends and families and repeat appearances.
So I was surprised to read an article in the Annals of Family Medicine describing a new scale to measure doctors’ trust in their patients. This scale, based on input from focus groups and validation surveys of physicians, was developed for research purposes on the grounds that trust is a “feature of the clinician-patient relationship that resonates with both patients and clinicians.”
Hmmm. I hadn’t really thought about trust being a two-way street in my relationship with the doctors and nurses who take care of me. But given the push for us patients to become actively engaged in our health care, it’s not surprising that questions would arise about how dependable we are as partners. And it is a sign of the times that as clinicians increasingly face incentives to deliver evidence-based medicine and are held accountable for our health outcomes, our trustworthiness as partners has become professionally, if not economically, important to them.
While this new scale is only a research tool, its creation nevertheless raises interesting questions about how traditional notions of trust in medicine are changing in the new clinician-patient relationships that the media urges us to forge. So let’s examine it as a reflection of the idea of physicians’ trust in their patients.
Here are nine of the 18 items of the trust scale. Clinicians are asked:Continue reading…
He came in for his regular blood pressure and cholesterol check. On the review of systems sheet he circled “depression.”
“I see you circled depression,” I said after dealing with his routine problems. ”What’s up?”
“I don’t think I am actually clinically depressed, but I’ve just been finding it harder to get going recently,” he responded. ”I can force myself to do things, but I’ve never have had to force myself.”
“I noticed that you retired recently. Do you think that has something to do with your depression?” I asked.
“I’m not really sure. I don’t feel like it makes me depressed. I was definitely happy to stop going to work.”
I have taken care of him for many years, and know him to be a solid guy. “I have seen this a lot in men who retire. They think it’s going to be good to rest, and it is for the first few months. But after a while, the novelty wears off and they feel directionless. They don’t want to spend the rest of their lives entertaining themselves or completing the ‘honey do’ list, but they don’t want to go back to work either.”
He looked up and me, “Yeah, I guess that sounds like me.”
“What I have seen work in people, especially men, in your situation is to get involved in something that is focused on other people. Volunteer work at the food pantry, work for Habitat for Humanity, or anything else that lets you help other people. I think the reason people get depressed is that they turn their focus completely on themselves, which is not what they are used to when they are working.” (I knew that this man had a job that helped disadvantaged people).
“That’s great advice, doc.” he said, with a brighter expression on his face.
“It’s from experience,” I responded. ”I’ve seen a lot of retirees start to feel like they are on a hamster wheel, just entertaining themselves until they die. I know I wouldn’t want to retire that way. Knowing you, I wouldn’t imagine you would either.”
We talked for about 15 minutes about the various groups around town that would need someone of his skills. I told him about how my parents went to Africa for a year after Dad retired. He actually taught physics over there, but that is what they needed. Of all the time I spent with him, over half of it was regarding his post-retirement “blues.” He wasn’t clinically depressed, so I couldn’t charge for depression as a diagnosis. The code I used? 99214 for Hypertension and Hyperlipidemia.
Summary:Most hospital patients have no idea that the resident treating them could be coming to the end of a 30-hour shift. If he is exhausted, the resident’s judgment may be impaired. Yesterday, the union that represents some 13,000 residents and interns nationwide (CIRSEIU), the American Medical Student Association (AMSA) Public Citizen, the consumer advocacy organization based in Washington DC, as well as sleep scientists at the Harvard Medical School’s Division of Sleep, announced the results of survey published in BMC Medicine, revealing how little the public knows about residents’ hours.
Sleep deprivation is likely to lead to errors; residents themselves acknowledge that lack of sleep has caused them to make mistakes that harm, and sometimes even kill patients. Exhaustion also affects how they feel about their patients. In 2008, the Institute of Medicine (IOM) recommended capping shifts at 16 hours, saying that longer shifts are unsafe for patients and residents themselves. The Accreditation Council on Graduate Medical Education (ACGME), the group that oversees the training of physicians in the U.S currently allows resident physicians to work for 30 consecutive hours up to twice per week. The ACGME has been reviewing the IOM recommendations and is expected to announce its decision later this month.
The problem: residents represent cheap labor. Some say that the ACGME faces an inherent conflict of interest because its board is dominated by the trade associations for hospitals, doctors and medical schools that benefit from the residents’ long hours. Is this true?
My recent post on the patient who thought I wasn’t worth paying caused a lot of discussion. Most of it focused on the financial stresses of a patient in our system – something I am all too well aware of. But some commenters (one in particular) felt that I was being excessive in my requirements for the patient.
While I think the person was way off-base in their comments, it did get me thinking about a difficult topic: how much is too much? How often does a person need to come back, and when does bringing people back for frequent follow-up become excessive? Some psychiatrists bring patients back every month for prescription refills, even patients who are stable. I’ve had patients complain about physical therapists and even chiropractors who bring them back for multiple visits, incurring multiple charges to the patient. These may all have merit (I certainly understand the psychiatrist’s perspective), but in each case I have had patients suggest that the clinicians were bringing them back to make more money.
The more I thought about this, the more I realized that there is definitely cause for concern that docs may bring people back to ensure a full schedule. Since my schedule is full and my income is adequate, I have no need or desire to generate more business than I already have. I have practiced for fifteen years, so I seldom have a slow day. This makes the temptation to bring people in these grey areas much lower. But there certainly are times when people complain about us “forcing” them to come in to be seen. These areas include:
Our policy is that we are unwilling to call in antibiotics unless there is a sore throat and fever associated with exposure to a documented case of strep in the house (seen in our office). That is our policy, but reality says that the policy gets bent on a regular basis. If I know a woman has frequent UTI’s, I sometimes will call in a prescription. Overall, however, we stick by these rules because we are taking the risk of prescribing a medication, and have often found unexpected findings (such as high blood pressure or wheezing) in cases that sound straightforward.
But how often should a diabetic get seen? I go a maximum of 6 months for the stable type-2 diabetic, although I usually do every 3 or 4 months. What about the person with hypertension? I like to see them every 6 months, but I do sometimes flex to 12 months for the particularly stable patient. Do I fault people who are more rigid with their guidelines? Not at all. Even other physicians within my own practice are more rigid than I am on seeing patients. I have the biggest practice, though, and so am trying to get everyone seen.
When copays were only $10 or $20, people didn’t argue much with being brought in more frequently. Now that deductibles and copays are high, the frequency of complaints is much greater. Ideally, the decision would have nothing to do with the charge, but would be based on what was medically right. But medical rightness is a very subjective thing, and many doctors will have different standards. When I get patients from other practices, they often have to adjust to our more rigid rules. Sometimes they complain, and occasionally they leave to find a doctor who doesn’t force them to come in.
I have enough patients now that I don’t worry about such things. I practice in a way that I think is best for my patients and have enough business that I don’t have to generate my own business.
Still, would it be better if primary care was cheaper? I am not sure. A bad consequence of the $10 copay days is that patients began to think we were worth only $10. The disconnect of people from the true cost of care made them much more likely to be high-utilizers. In an ideal world, I would only be driven to see patients based on their medical needs, and patients would trust that this was the case. But we don’t live in an ideal world.
We don’t even live in a mediocre world. That means that the argument and misunderstanding will rage on until…well…until the politicians can fix healthcare.
Rob Lamberts, MD, 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.
If there is a central theme to my work, it is this: medicine is a human thing.
On the Facebook page of my podcast, I recently asked for readers to tell me some of the “war stories” they have from the doctor’s office. What are some of the bad things doctors do wrong? I quickly followed this with the flip-side, asking readers to comment on the best interactions that they’ve had with their doctors.
The response was overwhelming, and equally quick to both rant and rave. They told stories about doctors who didn’t listen, explain, or even talk with them. They told about arrogance and disconnectedness from the people from whom they were seeking help. They also told about doctors who took extra effort to listen and to reach out in communication. They talked about doctors who genuinely seemed to value them as humans.Continue reading…
In the Oscar-nominated movie “Up in the Air,” Ryan Bingham (aka George Clooney), travels around the country firing employees for company bosses who don’t have the stomach to do it themselves -– the ones who prefer to “outsource the downsizing function.”
He finds his own job threatened by a hotshot business school graduate who convinces the president of their company that it would be more efficient to do the long-distance layoffs via the Internet.
Sitting in a hotel bar, our hero makes a passionate speech to his young colleague about how important it is to fire people face-to-face: that a look in the eye, a few words that personalize the institutional rejection and a handshake allow them to maintain some small shred of dignity at the very moment they lose their identity as a valued employee.
This speech resonates with me as I contemplate the waves of e-mail notices in my inbox announcing new electronic tools and personalized Web-based services and sites that can help me take care of myself. I can take a picture of my rash with my iPhone and send it to my dermatologist. I can check online to see when I had my last tetanus shot or schedule my next mammogram. I like interacting with my doctors by e-mail about minor matters. And if I lived in the empty plains of Eastern Montana, I would probably often prefer a telemedicine visit with a doctor or nurse over a 10-hour round-trip drive for a 20-minute in-person appointment.Continue reading…