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Going For The Throat: Improving Patient Care, the Doctor’s Perspective, Part I

Post Published: 27 January 2010
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Category: Health Care Column Thyroid Diseases and Thyroid Cancers
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Written by: Robyn Davis Hahn

So, I conducted a completely informal, unscientific survey amongst my friends who are also doctors.   I asked them just a few questions about aspects of the Doctor/Patient relationship, from their perspective.   Only one of these docs was an endo, three are gynecologists (and former obstetricians), and one is an orthopedic surgeon.

Some of the answers I expected, others I did not, and all were refreshingly honest.

My first question:,  What is the most common thing(s)–mistakes, attitudes, etc. that you encounter,  patients making that could be a barrier to care or the doctor/patient relationship (either in the appointment or after)?

The answers:

1. a.   Patients need to understand that medical science is far from an exact one.   Few problems are black and white or can be fixed or diagnosed in one visit.   Many problems require out of the box thinking that may require several appointments.   The internet has been a huge help for educating patients, but can also hinder their trust in their trained physician.   Many patients arrive with preconceived notions about their illness that they have obtained from web research, not accounting for the fact that much of this information on the web is not provided by medical professionals.   This can interfere with the trust that they have in their physician.

b.   Patients need to have a better understanding of the time constraints we face as physicians.   Unfortunately the business side of medicine comes into play here.   Schedules are often too tight to accommodate those that are late for their appointments, and those that arrive with an expectation that multiple issues can be addressed in one visit.   We all wish that we could spend an hour with each patient, but the pressures of keeping the practice viable financially prohibit this.

1. It’s always a,  good idea for both doctor and patient to be open minded and to not enter the conversation with prejudice.  ,   It’s always a good idea for both to listen and talk with each other, not at each other.

1. Biggest patient mistake–for me this is often a patient not mentioning something that is bothering them for fear that it is silly, or unrelated to anything. It’s always better if a patient has some idea about their symptoms before they come. “It gets better when I….. or “It gets worse when I do…..,   Think about it before you go into the office. Another mistake is if a patient isn’t really understanding the diagnosis/treatment plan, and does not bother to ask for further explanation.

1.   Patients come in with pre-conceived notions about their problems due to either direct marketing of companies and the droves of info present on the internet.

My second question:,  What problems/mistakes do you believe most,  doctors make regarding their patient relationships?

2.   Common mistakes on the MD side of the equation:

a.   Medicine has become increasingly electronic and less personal, much to the dismay of many physicians.   Some docs,  don’t take the time necessary to foster a working relationship with patients and don’t listen well enough to appropriately address a problem.

b.   Many docs practice defensive medicine in this climate of medico-legal issues.   Many order unnecessary tests to “cover their bases”,  to avoid a lawsuit.

c.   There is little to no time to personally phone patients with results….much of this is done by nurses which tends to impede the development of a working relationship with a patient.  ,  This is an unfortunate reality for many of us.

d.   Docs sometimes enter a patient relationship with prejudice or preconceived notions about patients and their problems.   This clearly can interfere with physician-patient relationship…

2. Some doctors and patients don’t have or take time to develop relationships–they’re just checking off the boxes and medicine is increasingly transactional and not relational.

2. Biggest doctor mistake–I think the biggest mistake doctors make is not really listening to their patients, especially if in the middle of busy office hours.   Patients can often give you huge clues as to what is going on with them if you take the time to really listen. ,  This can be tough when there are time constraints.   Hence the importance of the patient really speaking out about what is bothering them.

2. I think doctors don’t listen well enough to patients complaints and therefore don’t cater therapies in an individualized manner.

My last question: What is your biggest overall obstacle to improving the lives of your patients?

3.   Obstacles to improving patients lives

a. Many patients are not compliant with instructions/advice or do not attend follow up appointments as advised to ensure that treatment plan is optimal.

b. Many patients show resistance to comply with lifestyle,  changes as part of a treatment plan or preventive care, expecting a “quick fix” with medications or surgery instead. This is a global societal problem that many of us face as physicians.   It is often frustrating for us as physicians to see many problems that are brought on by poor lifestyle choices including smoking, poor diet, lack of exercise.   Many patients are unwilling to change these behaviors, opting for more risky treatment options with medications or surgery. If surgery is in the equation, these patients have many more complications and don’t heal as well.

c. Insurance companies dictating care.

d. Poor reimbursement from Medicare is a huge obstacle in providing care to seniors.   Many docs don’t accept Medicare for this reason, leaving this group of patients with limited access, seeking their care in emergency facilities and hospitals.   This population often requires the most care and the most time!

3.   ,  The incredible pressures and complexity of their lives–their relationships are all asymmetric.

3. There are a couple of recurring themes I see as obstacles for patients reaching optimum health. Financial constraints are the most obvious- i.e. a patient needs an expensive therapy and is unable to afford it (i.e. medications, surgeries). This is the biggest obstacle I run into more than I’d like. Number two is a the patient not taking charge of their own health by maintaining a healthy lifestyle or following the behavioral changes that have been recommended. Many medical issues I see on a daily basis are because of poor eating habits, lack of exercise and being overweight. ,  While easier said than done, losing weight and eating right can fix so many issues for patients, or prevent issues to begin with.

3. I think the major obstacle for me is that the insurance companies have put the patient and doctor at odds with each other and removed themselves from the equation.   Exorbitant co-pays and poor reimbursement have made the financial aspects of medicine part of the patient-doctor interaction.

Wow, right?,   All the doctors mentioned not listening or lack of time to develop a relationship with their patients as the biggest problem or mistake on the doctor end of things!

So here’s the funny thing–my endocrinologist friend answered me sort of free-form instead of in number form, which totally cracked me up!,   Nevertheless, I love what he has to say:

I never wanted to be a doctor; when I went with my mom/grandmother to the doctor I was always irritated by the MD’s “attitude”.   Anyway, here I am and I like to think I try to be aware of what the patient is hearing on the other side of the table.

I think one big obstacle is time, patients want to tell their story and doctors have a room full of patients to work through and many times know what they want to do before they see or talk to the patient.   Looking at diaries, counting the number of hairs in the ziplock, etc. all take time–the easy path is to just look at the numbers.   Give me time and I can connect and “fix” the patient–that’s the hard part.   Looking at labs and decision making is the easy part.

Most doctors fail to look at the “whole” patient – they look for 1 visit 1 problem.   I think it is important to understand that certain problems travel together–and look at tests in context.   For example, a TSH of 3.5 in a woman with a goiter is different from a TSH of 3.5 in a woman postpartum is different from a woman on thyroid hormone or someone with cholesterol of 200 or 300–many MDs think they are all the same.   You have to have clinical acumen.   I think you are born with this–you cannot teach it.   You can make it better in someone, but you cannot give it to them.   Throughout all this you need a provider that is not threatened by questions and not feel challenged by questions.

So the biggest mistake for doctors is not truly caring for the patient.   Patients understand and forgive many faults if at the end of the day they feel that they are your priority.   There is not a lot of work in making the difference between being a good doctor and a great doctor–it comes down to being inquisitive and caring.   Intellect helps, but is not essential.

For this week’s article, I decided to just lay out the responses I had gotten from the various doctors.   One of the things I found most impressive is that I emailed four of my doctor friends and got FIVE responses, because one of my friends forwarded the email to a colleague (whom I’ve never met) who also sent me an answer.   All of them said they would be willing to talk to me more in depth about the answers as well.   I can only interpret this as positive and more proof (to me–like I said, there’s no “science” in this survey) that the vast majority of the doctors out there at least recognize the problems we encounter in our health care and may even share our frustrations.

Next week, I will look at the answers more in depth, and offer some analysis.   Your homework is to read the answers carefully and try to imagine you and your doctor somewhere in these lines.   Does anything sound or feel familiar?

Robyn

In an ongoing effort to improve our relationships with our doctors what are your thoughts regarding this article? What points do you agree with or disagree with? Speak up and out, beautiful babies.

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14 Responses to “Going For The Throat: Improving Patient Care, the Doctor’s Perspective, Part I

  1. YatPundit says:

    Patients need to have a better understanding of the time constraints we face as physicians.

    here’s a great example of the lack of communication and understanding of business at work on the part of physicians. They want patients to check in an hour early, just like the airlines. If the patients are all there and lined up, just like Southwest Airlines, they can flow through the system evenly. What this does not address is when the physician forces the patient who was on time for an appointment to wait 1+ hours. When that happens, the office worker who thought she could get away with a long lunch is taking a half-day of sick leave. The self-employed guy (and in a recession, that’s a LOT of people) is flat out losing money. Not only does the medical practice do this to its patience, but they usually don’t even have the courtesy to check in with the patient and apologize for the delay.

  2. Robyn says:

    YP, I HEAR you loud and clear. In my checklist article last week, I listed several causes for doctors running late. By far the most common is patients ARRIVING late, or exactly at their appointment time. Multiply that by even 4 patients and you are an hour behind. Another patient cause is wanting the doc to address more than one issue at the appointment, causing it to run over the “allotted” time, or bona fide emergencies. Docs can be inefficient themselves and run over, too. Or, the office staff can be inefficient/inept and put things behind.

    Here’s a common scenario I get (I’m a veterinarian). My 6:00 and 6:20 appointments both show up at 6:10. If we check in and start the first one, who was late, we will be delayed with the second one even though they were “on time”. If we start with the second one and make the first one wait they get irate because technically they were “first”. It’s a lose:lose scenario.

    I ran over 1 hour late for appointments on Sunday because people walked in with a dog hit by car and an obviously displaced radial/ulnar fracture (he had surgery yesterday–a group discounted effort by myself, an orthopedic surgeon, and my clinic–he did great, and is an awesome dog, and will have a new home!). Last week I had a cat that came in for “routine physical” (for which we book 20 min) that actually hadn’t eaten in 3 days and was dehydrated. Sigh, here we go again!

    For me, it’s the nature of the business. We plan our asses off, and still leave the clinic late every night 😉 I get some very upset people, and I get some very understanding people–they know I will drop everything if their dog comes in with the broken leg.

    Now–where we excel–and where human doctor’s OFFICES could learn a thing or two, is how our receptionists deal with this. They check in with the waiting patients every 5-10 minutes, update the time, get them a coffee or water, etc. If people can’t wait, we reschedule rather than leave them in limbo wondering where the staff went. And if I think someone was really dis-served (ie, we drop the ball), I try to send the person/pet home with *something*–a discount coupon, a dog toy, catnip, etc. in apology. How far would a free coffee coupon from Starbucks go for me every time my doc is 30 minutes behind? Hmmm…FAR!!!!

  3. kaytee says:

    Per #1 b: of course patients are going to want “multiple issues” addressed at their appointment. It can take up to 6 weeks to GET that appointment. And, in my experience, a minimum of two weeks for any non-urgent appointment, if you want your “assigned care provider”. There even have been times when “no appointments are available with that provider until the next schedule comes out– call back next week”.

  4. Robyn says:

    kaytee–
    That comment was made by a Gyn. Obviously with endocrine issues, we have a whole ‘nother ball of wax. I think, in essence, it’s important to let the receptionists know in advance if you are basically a recheck of your “normal” problems, or if there are NEW problems. I think even if you call well after the appointment was made, but before the visit, if something new crops up, the advance notice is welcome. Personally, what I have found effective is to explain AT my appointment to my doc that I have new/more/different, and is there a way to either a) get additional time immediately, b) schedule additional time for the near future (within a week), or c) have additional time with a PA, FNP, etc. under their supervision? So far, I’ve had docs do all 3 of these depending on the circumstance, and I’ve been happy with the results. I’ve also had docs give me their emails for me to send additional questions so that we could stay “on point” during the actual appointment time.

    I do realize that some doctors are just pricks, though. Thanks for your comment–you FOR SURE are not the only one with that frustration. Basically, if the practices could allow docs more time with each patient to begin with, we wouldn’t even need to have this conversation!

  5. Social comments and analytics for this post…

    This post was mentioned on Twitter by katieschwartz: Going for the Throat: Improving Patient/Doctor Relations from Dr’s Perspective, disease or not, MUST READ/Comment #HCR http://bit.ly/a15PiK

  6. YatPundit says:

    Patients being on time for appointments and docs smoothing over ruffled feathers when patients kept waiting really boils down to one thing-communication. A good receptionist is the key there. That’s why a good receptionist is hard to find, and most physicians are the last people you want to be training someone in the social graces. 🙂

    They check in with the waiting patients every 5-10 minutes, update the time, get them a coffee or water, etc.

    You could easily start a side business teaching docs how to increase their profitability by simply being courteous to their patients. My guess is nobody really considers that a serious business opportunity because it’s too obvious. Customer service and customer retention is outside the mental process of a guy or gal who has spent their career learning the their trade.

  7. Martin says:

    The key thing I see here is time, or the lack of it. Because insurance companies’ reimbursement schedules are so screwy, doctors (particularly primary care physicians) have to see many, many patients in a day just to make money at the job, which results in lack of decent treatment for the patient.

    Patients, on the other hand, are constrained by the demands of jobs that don’t offer paid sick leave (or any sick leave at all), employers who think 60-hour work weeks are the standard all should meet, families that need taking care of, and a million other things that can sap the time needed to be properly diagnosed, treated, and get well.

    I’m going through this with my own HMO, Kaiser, which is one of the better ones. My PCP is great, but she can only see me for 20 minutes at a time–hardly enough to get any kind of serious, clinical diagnosis.

    The kind of societal reform we’d need to fix all of this will take a generation, but one thing that can and should be fixed in the health care reform process is reimbursement for PCPs, or moving them to a different payment structure that allows them more time for patients. This will also encourage more PCPs to get into the practice–as it is, we’re losing them in droves to more specialized (and higher-paying) areas, especially in California.

  8. Robyn says:

    YP-
    You are right. But as a veterinarian, we don’t get paid by insurance–it’s a more direct consumer service industry. Basically, we have to try harder to keep business. If doctor offices had to do the same, I can guarantee the same “courteousness” would appear.

  9. Robyn says:

    Martin,
    This is true, too. One of my friends said she gets paid $28 for a Medicaid patient, and that by and large, these (older) patients need more care. That’s not a lot of money to promote really caring, and it means you have to see more people (and therefore less time/patient) to pay your malpractice, your equipment, your lease, your staff, etc.
    The HC industry does need GLOBAL reform, and you are right it took forever to get this broke and will take forever to fix.
    But, every trip, no matter how long, begins with one step. If we can get HC reform to begin, we can hopefully keep it going.

  10. Robyn says:

    Oh, and YP, we just had our quarterly business meeting. In 2009, we cut back on total labor expenses for nursing staff AND doctors, but INCREASED receptionist expenses. Because they are the image of your practice, for good or bad, and they can make or break your business.

  11. lori says:

    I have always felt and still do feel that it would be very helpful if physicians offices made their patients aware of how they run their office and what the patient can do to make the most of their visit. I have seen this only twice in all the docs I have seen over the years. We complain about them and they complain about us.

    They are providing a service (a very important one) and I think a lot of the things that frustrate the physician about the “patient” could be lessened greatly if they communicated by putting a couple of notices on the reception window/area or bulletin board, or even get a pamphlet printed up. They post reminders about bringing in our list of medications and put up notices about flu shot availability, etc.

    I am sure patient’s would respond quite favorably to this and it would even lessen their never ending phone calls of “routine” questions.

  12. Robyn says:

    Lori,
    I think this is a great idea. Even a handout given when you fill out all your new patient forms would be a start!

  13. finnsters says:

    Doctor / patient relationship can absolutely forgive the wait times, etc… Even though an unexpected topic arose at my annual today, my provider made me “feel” like she had all the time in the world. It makes a world of difference.

  14. You’ve displayed a beneficial control over both language and the topic. I infrequently happen to observe it.

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