Healthcare 2 - The Patient-Doctor Relationship
If experience qualifies as expertise, then, on the subject of the physician-patient relationship, I am an expert. During my career as an emergency physician, I saw well over 100,000 new patients. As a patient I survived two cancers, multiple blood clots in my lungs, and a bunch of other non-lethal problems. In addition, I have read a number of books about the physician patient relationship. So, now that you know my credentials, here is what I have learned...
All patients want to be treated with respect. They want the doctor to listen carefully, ask questions and respond in a non-demeaning manner. This needs to be done in person, with eye to eye contact. The information acquired needs to be in the doctor's head and not just in his computer. Information in the computer is for billing, to refer back to, or to send to another physician. A good doctor builds a model of the patient in his head consisting of age, sex, prior medical history, family history, psychosocial status, current symptoms and current emotional and functional state. The physician needs to know if this patient is capable or interested in participating in creating a treatment plan and evaluating how much risk he is willing to take? Does the patient have an educational background to understand the diagnostic approach as well as the treatment plan?
Getting to this place is not easy and requires conversation, real conversation, the give and take of talk back and forth between two people. Even if you don't like your physician or the doctor doesn't like you, for the relationship to work, the conversation must happen. My first lymphoma was treated by a very smart, well educated physician who I didn't like. We had conflicts over the telephone about patient's of his I had seen in the ER. I actually hung up on him once. He was such an aggressive advocate for his patients that he could be overbearing. But he knew what he was doing and I knew that, so when I needed someone with expertise, I went to him, and under his care I was cured. We forged a relationship in the best sense of the word and it wasn't based on liking it was based on the exchange of information.
Medical science works. I can testify to both from the giving and receiving ends. World-wide healthcare statistics such as life expectancy, infant mortality, etc. clearly demonstrate the effectiveness of western medicine in contrast to traditional Chinese medicine, homeopathy, chiropractic, and aruvedic medicine. And it works even though most non-medically educated people don't really understand how it works. When I retired I left several copies of the book The Spirit Catches You and You Fall Down by Anne Fadiman for my ER partners. No book explains the gaping chasm between world views more clearly than Fadiman's account of the western, allopathic physicians trying to explain and treat a Hmong child with Lennox-Gastaut Syndrome. The Hmong view of the inner workings of humans have no area of overlap with the scientific view. In order to explain to the Hmong parents of the ill child what was needed required a complete reeducation of the physician about how the Hmong see the world. Even if one is born in America, unless you studied human biology, most people have only a rudimentary understanding of the scientific explanation of the pathophysiology of disease. We are all Hmong to some extent and our personal physicians need to know how much.
It is the responsibility of the physician to communicate to the patient in a way commensurate with the patient's world view. This is why the doctor needs to understand who the patient is. Once the doctor knows that, in all honesty, sometimes silently writing a prescription, handing it to the patient and simply saying "Take this," is adequate. Other times an hour discussion of treatment options, side effects, home health needs, emotional support and psychiatric care may be needed. Sometimes through a translator. This is another reason the business model of health care is so inadequate. It treats all patients as identical and all doctors as identical. We are not 'units' we are people and we are all different.
Almost every physician-patient interaction teaches an observant doctor something new. Every patient's story has unique aspects that flesh out the natural history of whatever disease process is making the patient ill. Doctors who listen carefully are rewarded with new knowledge. I was pleased to read about a present day, brilliant diagnostician who spent half his time practicing internal medicine and half time in the emergency room. One of the things I loved the most about working in the ER was that most patients gave me the first opportunity to make a diagnosis, to solve the problem that was bothering them. To meet them, have a conversation, get to know a little about who they are, gather information, and put together a reasonable hypothesis about what is bothering them. And be the first one to do this.
Business has poisoned the patient-physician relationship by treating, as I said above, both doctors and patients as 'units', replaceable parts in a mass produced machine. When the doctor and patient are sitting face-to-face it is like a sporting event. Each player brings their own skills and foibles that when combined make the contest unpredictable. Standardization of care. Best practices. Evidence based medicine. Guidelines. Algorithms. None of these concepts are bad and some may actually improve care, but when they are applied as laws, they do harm. Atul Gawande has written about improving medicine and suggested doctors use check lists to be sure we don't miss something important and mentors to observe how we deliver care and make suggestions. All these ideas have benefits unless they are applied like laws rather than information.
Just one example of the difficulty of businessfying medicine - abdominal pain. Over the course of my career I saw thousands of patients with abdominal pain. The book The Early Diagnosis of the Acute Abdomen by Cope along with hundreds of journal articles and years of experience, gave me a pretty good idea of how to figure out why someone was having abdominal pain. I took a history, did a physical exam, sometimes ordered lab and radiology studies. All this took time, conversation, and judgement. At the end, it could be as easy as slipping in a suppository for constipation and other times it could be telling the 45 year old father of two that he had advanced colon cancer. How does one organizes these two situations into a structure with replaceable parts?
I should have left off the above paragraph because it is more about the nefarious influence of business on medicine than the physician-patient relationship. But cramming people into 15 minute slots harms the relationship so I left it in. I always look for a doctor for whom I seem more important than his business. Any doctor who looks at a patient as a source of income rather than a human being in need, has been spoiled by the new industrial-medical complex.
If you would like to explore this further, I suggest Dr. Lown's book, The Lost Art of Healing. In it he explains how the physician-patient relationship comes from the physician taking a careful history of the patient's problem and incidentally of the patient themselves. Knowing the patient leads to better understanding of their problems.
All patients want to be treated with respect. They want the doctor to listen carefully, ask questions and respond in a non-demeaning manner. This needs to be done in person, with eye to eye contact. The information acquired needs to be in the doctor's head and not just in his computer. Information in the computer is for billing, to refer back to, or to send to another physician. A good doctor builds a model of the patient in his head consisting of age, sex, prior medical history, family history, psychosocial status, current symptoms and current emotional and functional state. The physician needs to know if this patient is capable or interested in participating in creating a treatment plan and evaluating how much risk he is willing to take? Does the patient have an educational background to understand the diagnostic approach as well as the treatment plan?
Getting to this place is not easy and requires conversation, real conversation, the give and take of talk back and forth between two people. Even if you don't like your physician or the doctor doesn't like you, for the relationship to work, the conversation must happen. My first lymphoma was treated by a very smart, well educated physician who I didn't like. We had conflicts over the telephone about patient's of his I had seen in the ER. I actually hung up on him once. He was such an aggressive advocate for his patients that he could be overbearing. But he knew what he was doing and I knew that, so when I needed someone with expertise, I went to him, and under his care I was cured. We forged a relationship in the best sense of the word and it wasn't based on liking it was based on the exchange of information.
Medical science works. I can testify to both from the giving and receiving ends. World-wide healthcare statistics such as life expectancy, infant mortality, etc. clearly demonstrate the effectiveness of western medicine in contrast to traditional Chinese medicine, homeopathy, chiropractic, and aruvedic medicine. And it works even though most non-medically educated people don't really understand how it works. When I retired I left several copies of the book The Spirit Catches You and You Fall Down by Anne Fadiman for my ER partners. No book explains the gaping chasm between world views more clearly than Fadiman's account of the western, allopathic physicians trying to explain and treat a Hmong child with Lennox-Gastaut Syndrome. The Hmong view of the inner workings of humans have no area of overlap with the scientific view. In order to explain to the Hmong parents of the ill child what was needed required a complete reeducation of the physician about how the Hmong see the world. Even if one is born in America, unless you studied human biology, most people have only a rudimentary understanding of the scientific explanation of the pathophysiology of disease. We are all Hmong to some extent and our personal physicians need to know how much.
It is the responsibility of the physician to communicate to the patient in a way commensurate with the patient's world view. This is why the doctor needs to understand who the patient is. Once the doctor knows that, in all honesty, sometimes silently writing a prescription, handing it to the patient and simply saying "Take this," is adequate. Other times an hour discussion of treatment options, side effects, home health needs, emotional support and psychiatric care may be needed. Sometimes through a translator. This is another reason the business model of health care is so inadequate. It treats all patients as identical and all doctors as identical. We are not 'units' we are people and we are all different.
Almost every physician-patient interaction teaches an observant doctor something new. Every patient's story has unique aspects that flesh out the natural history of whatever disease process is making the patient ill. Doctors who listen carefully are rewarded with new knowledge. I was pleased to read about a present day, brilliant diagnostician who spent half his time practicing internal medicine and half time in the emergency room. One of the things I loved the most about working in the ER was that most patients gave me the first opportunity to make a diagnosis, to solve the problem that was bothering them. To meet them, have a conversation, get to know a little about who they are, gather information, and put together a reasonable hypothesis about what is bothering them. And be the first one to do this.
Business has poisoned the patient-physician relationship by treating, as I said above, both doctors and patients as 'units', replaceable parts in a mass produced machine. When the doctor and patient are sitting face-to-face it is like a sporting event. Each player brings their own skills and foibles that when combined make the contest unpredictable. Standardization of care. Best practices. Evidence based medicine. Guidelines. Algorithms. None of these concepts are bad and some may actually improve care, but when they are applied as laws, they do harm. Atul Gawande has written about improving medicine and suggested doctors use check lists to be sure we don't miss something important and mentors to observe how we deliver care and make suggestions. All these ideas have benefits unless they are applied like laws rather than information.
Just one example of the difficulty of businessfying medicine - abdominal pain. Over the course of my career I saw thousands of patients with abdominal pain. The book The Early Diagnosis of the Acute Abdomen by Cope along with hundreds of journal articles and years of experience, gave me a pretty good idea of how to figure out why someone was having abdominal pain. I took a history, did a physical exam, sometimes ordered lab and radiology studies. All this took time, conversation, and judgement. At the end, it could be as easy as slipping in a suppository for constipation and other times it could be telling the 45 year old father of two that he had advanced colon cancer. How does one organizes these two situations into a structure with replaceable parts?
I should have left off the above paragraph because it is more about the nefarious influence of business on medicine than the physician-patient relationship. But cramming people into 15 minute slots harms the relationship so I left it in. I always look for a doctor for whom I seem more important than his business. Any doctor who looks at a patient as a source of income rather than a human being in need, has been spoiled by the new industrial-medical complex.
If you would like to explore this further, I suggest Dr. Lown's book, The Lost Art of Healing. In it he explains how the physician-patient relationship comes from the physician taking a careful history of the patient's problem and incidentally of the patient themselves. Knowing the patient leads to better understanding of their problems.
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