Improvement Starts with You!
The crisis of American Medicine, and particularly primary care, leads to doctors feeling burnt out and quitting the field.
Chances are you’ve noticed this trend. Maybe you have a hard time getting an appointment with your doctor, or worse, like millions of Americans, can’t find a doctor who will accept you as a patient. If you are lucky enough to have a doctor and be able to see them, maybe you’ve perceived them to be abrupt, distracted, short on time, and not able to give you the kind of attention you feel you need.
There are many reasons for this situation, some of which I’ve covered elsewhere. But one reason is that far too many people are terrible, terrible, patients.
Oh, I’m sure you don’t mean to be awful. Chances are that you want to have a friendly, mutually-respectful relationship with a physician who can act as a trusted confidant and life guide. But because you really don’t know how the system works, can’t appreciate the pressures your doctor is under, or don’t understand how doctors think, you inadvertently waste your doctor’s time, place barriers to getting a timely and appropriate treatment for your medical concerns, and lead your doctor to pour themselves an extra strong martini each evening.
If we are to restore a sense of productivity and mutual benefit in patient-doctor interaction, patients need to step up and do their part.
When I was in medical school, we studied professionalism and bedside manner. In addition to anatomy and pathology, we had to learn how to listen better, how to ask difficult questions in sensitive ways, and how to manage our interviews with patients. I would be lying if I said this worked perfectly; a few classmates remained recalcitrantly anti-social despite four years of training and were appropriately shunted into fields like pathology, where they could practice furthering their social skills on the dead. But at least we tried.
So, dear reader, let me suggest that you do the same. After all, any relationship is a two-way street, and if we are going to restore a sense of productivity and mutual benefit to the patient-doctor interaction, we doctors really need you to step up and do your part.
Here then I present some simple rules that you can start implementing immediately to help you help your doctor and get much more out of the healthcare system in the process.
Ally With Your Doctor Against the Clock
Today’s doctors care for far more patients than they used to. Patients are, on average, older, sicker, and more medically complicated than patients of yesteryear. Caring for those patients involves navigating a complicated and bureaucratic system of phone calls, paperwork, and documentation requirements that eat up many hours of the day. In sum, doctors today are really, really pressed for time.
To get the most out of your doctor, be prepared to ask a limited number of relevant questions, communicating in the most concise manner possible. In other words, form an alliance with your doctor in the battle against the clock.
Show Up on Time, and Be Prepared to Wait
Recently, a patient called my office to say that he would be half an hour late to his appointment. My secretary replied that he would have to reschedule because I had another patient at that time. He responded by pointing out that he’s had to wait for me in the past, so I should be willing to repay the favor. When my secretary told him that wouldn’t be possible, he started yelling at her, dropped a few “F-bombs,” and hung up.
If you find my office stressful to deal with, guess how I—who must work there every single day—feel about it?
I know it’s not fair that we ask you to show up to your appointments on time and then often make you wait. But we don’t work in an environment where schedules can be tightly controlled. Sometimes patients take up a lot of time. Sometimes we must deal with a real emergency. Sometimes we have to tell people they have cancer or some other terrible diagnosis. If you are ever in this situation, you won’t want us to rush you out of the exam room just because we have another patient to see.
Please, show up on time so we don’t get further behind schedule. If we are running late, don’t take it personally.
Stop Bringing a List to Each Visit
I know you’ve read in some geriatric-oriented magazine that you should bring a list of concerns to your doctor at each visit, but please stop doing this; we detest it.
On a regular basis, patients bring a page-long list of issues. (My all-time record: a patient showed up with 33 problems for a visit that was scheduled to be 15 minutes long.)
Most visits are scheduled for 15 minutes. It takes a bare minimum of five minutes to discuss any medical problem in a competent way. You might be able to cover three problems in a typical office visit, but more likely two; if you’re really serious about the problem, just one. If you need to write a list of your concerns, you have too many problems to cover.
Instead, pick the problems you really need to cover. Use common sense. If your ankle is slightly tender a day after running for the first time in a year, you probably don’t need to consult your doctor about it. Be willing to schedule multiple visits to cover each of your problems. You can even acknowledge to your doctor that you have more issues to discuss than you know can reasonably fit into one visit, and you’d like to schedule a return to talk further.
Your doctor gets paid approximately the same for a one-issue visit or a ten-issue visit. Book one visit per issue. With one problem at a time, your doctor can give you useful advice, instead of just doing the bare minimum necessary to make sure there isn’t anything potentially life-threatening lurking in your list of concerns.
Don’t Use Your Physical as a Catch-all Visit
Many patients show up for an annual physical with a list of all the concerns they have accumulated over the course of the year. An annual physical typically gets thirty minutes in the schedule, so we have more time to talk. Right?
Sorry, but no. In a typical thirty-minute physical, my assistant first has to check you in and go over a bunch of “measures” that insurance companies require (screening questionnaires for depression and alcohol use; documentation that you have received some type of literature encouraging you to quit smoking if you use tobacco; documentation that you have received some type of weight loss counseling if you are overweight, and so forth). Then I have about ten minutes to review your EKG and labs; make sure your cholesterol, blood sugar and blood pressure are okay; make sure you are up to date with all of your cancer screening (mammograms, colonoscopy, etc), and finally do your exam. I have a few minutes to document all of this in the chart. If I miss anything, I won’t get paid and will leave myself open to massive litigation should anything bad ever happen to you. That leaves little time to discuss anything that might be on your mind.
Sorry, reader, but your physical is really the visit for your doctor and for your insurance company, not for you. By all means, feel free to ask a few quick questions or discuss a minor issue, but this is not the visit to tell me that for the past six months you’ve been experiencing chest pain or passing blood in your stool.
“I’m just here for my annual and I feel fine,” are the most beautiful words in the English language to a primary care doctor.
We Really Don’t Need to Know Everything About You
Did you have a bout of bronchitis that lasted a week and then resolved six months ago? Do you feel fully well now? Good; don’t bring it up then.
Too many patients feel the need to tell me everything involving their health since I last saw them. There is zero chance that you are going to get through a period of several months without a common cold, a minor traumatic injury, or an ache somewhere. If it is gone and no longer an issue, don’t bring it up. It’s not relevant; you are wasting precious time that could be better spent on other issues.
Lead with the Punchline
“About twenty years ago, Dr. Smith told me I might have Thoracic Outlet Syndrome…,” began a middle-aged woman on a recent visit. Thereon followed a very long story. I heard about the specialist she saw in Boston at the time. I heard about her grandmother’s sudden collapse and death of unknown causes fifty years ago. It was more than ten minutes before we got to her actual concern: she’s been having headaches. Headaches, for the uninitiated, have nothing to do with Thoracic Outlet Syndrome.
Back when I was a resident, an older doctor gave me helpful advice on how I should talk to other doctors: always lead with the punchline. Start by telling the cardiologist: “I’m worried my patient might be having a heart attack,” before filling them in on relevant background details like the fact that the patient has diabetes and smokes.
This is also great advice for patients. Had the above patient just started by telling me she was concerned about headaches, we would have avoided the verbal equivalent of a car chase, and not wasted ten minutes discussing something of no relevance to her concern.
Tell Us Your Symptom, Not Your Diagnosis
Once upon a time, a man was stung by a bee. Nothing bad happened to him, but when he developed some pain in his foot a few weeks later, he went to an emergency room, where he reported he was having an allergy to a bee sting. He was treated with a course of steroids.
That’s the part of the story where I came in. I saw him for a complication of the steroids he was treated with. Oh, and while at it, I diagnosed him as having tendonitis in his foot; no relation to bee stings.
Patients do this all the time. Rather than reporting their symptoms to their doctor and then letting their doctor ask questions to help figure out the nature of the problem, they lead the witness by directing the conversation to their own diagnosis.
Patients can be comically or catastrophically wrong in their diagnoses.
I’ve treated patients who opened by telling me they had Lyme disease (turned out to be leukemia) and a bad reaction to a chili pepper (esophageal cancer), among dozens of others. Patients can be comically or catastrophically wrong in their diagnoses.
There’s nothing wrong with telling your doctor you are concerned about a possible illness, but “I’ve been very tired lately, and I’m having rashes and fevers. Could this be Lyme disease?” is a very different start to the conversation than “Ever since I came down with Lyme disease, I’ve felt awful.” The former is an opening to a broader conversation that lets your doctor consider all of the possibilities. The latter is at best a distraction that wastes time, and at worse, can lead to getting the wrong diagnosis.
Don’t Try to Order Your Own Tests
Patients call my office all the time requesting specific tests to be ordered. This is the flip side of the self-diagnosis problem.
A common scenario involves the caller requesting to have their thyroid checked because they are tired. Sure, thyroid problems can cause fatigue. So can dozens of other illnesses. If we don’t discuss your symptoms first and just willy-nilly order a test you’ve thought up on your own, there’s a good chance we’ll miss something important.
I once saw a patient with florid Lyme disease. He first experienced a rash a month earlier, and called his doctor to request a test for Lyme. It came back negative, and he was reassured—not understanding that the blood test for Lyme does not typically turn positive until weeks or months into the infection. A quick physical exam by a doctor is the more accurate way to make the diagnosis early in the course. His doctor was at fault for not inquiring further and for enabling the behavior, but the patient also made the mistake of trying to be his own doctor.
You will always be a terrible doctor. Focus instead on being a good patient.
After years of training and a decade in practice, I still sometimes make mistakes. What hope do you, who have no such training or experience, have of knowing how to practice medicine? Don’t try it. You will always be a terrible doctor. Focus instead on being a good patient.
Answer the Question You’ve Been Asked
Doctors may seem curt and abrupt at times, but there is a method to our madness. The precise answer to a few quick questions often goes a very long way toward making a diagnosis.
Have you had chest pain constantly, every single minute of the day, for several months? You are not having a heart problem. Have you had chest pain, off and on, for two days, that reliably gets worse every time you go up a flight of stairs? You are leaving my office in an ambulance.
And yet I constantly have conversations like this with patients:
Doctor: “When did the chest pain begin?”
Patient: “Oh, a while ago.”
Doctor: “What’s a while? An hour? A day? A month?”
Patient: “Oh, you know. A while now.”
Doctor: “Is it a dull ache, or a sharp pain?”
Patient: “Well, you know. It hurts.”
Be Honest
As an attorney once quipped to me, “You can lie to your spouse. You can lie to your priest. But if you lie to your lawyer or your doctor, you’re just hurting yourself.”
We know that patients lie to us all the time. They tell us they are taking their medication, while their pharmacy informs us they haven’t picked the script up in months. They tell us they are faithful to their spouse, even as they come to be treated for their third sexually transmitted disease in a year.
It would be disingenuous to state that doctors never pass judgement on a patient, but in the exam room, we’re pretty good about trying to remain an objective sounding-board for whatever is going on in your life. I’ve had patients disclose drug problems, drinking problems, extramarital affairs, and even sexual experiences with the family pet. Whatever embarrasses you is not going to shock me. The more honest you can be with us, the more we can help you.
Save the Customer Service Complaints
Did you have a shitty experience calling my office, checking in to your appointment, or with some other aspect of how my practice runs? Feel free to mention it to me briefly. I appreciate feedback and will pass it along to my office manager. But then let’s move on. I’ve had so many patients over the years spend valuable time chewing my ear off about a customer service complaint over which I have no control. Trust me, if you find my office stressful to deal with, guess how I—who must work there every single day—feel about it?
Don’t Call My Office If You Can Avoid It
Recently a patient called asking for their lab results. When I looked them up, I noted that the patient was scheduled to see me just two days later, in part to review their lab results. I get it; patients get anxious and seek reassurance that their labs are okay. But every time you call my office, a secretary has to take the call, create a message in our computer system, and then pass the message to me. I have to open the chart and spend a minute or two reviewing it; I have to type up a response message; I have to send that message back to the secretary, who has to return the call to the patient. All of this ties up the telephone for patients who really do need to talk to us, and gives me less time to spend with the patient in front of me.
It’s not uncommon for me to get more than fifty phone messages in a single day; they eat up hours of my time and my staff’s time. Many of them are for trivial matters that can wait. Keep in mind that the quick question you have is not a tiny snowflake, but rather a small part of a massive avalanche.
Remember that We’re Human Too
Everybody has bad days; doctors are no exception. I’ve seen patients after having a terrible night of sleep, after having a big fight with my kid at breakfast, after being in a car accident on the way to work, after learning of the terminal diagnosis of a close friend, and while my wife was undergoing cancer treatment.
If you were experiencing any of the above, you might feel free to let your co-workers or clients know, and they’d cut you some slack if you weren’t your warmest and sunniest self that day. But due to ethics of the medical profession, we’re expected to not tell patients about our own personal struggles; the focus of the visit is about the patient. The next time you see a doctor who is behaving like an uninterested or arrogant jerk, remember that they might be an arrogant jerk, or they might just be having a really bad day.
Final Thoughts
Patients are not the only reason that doctors are stressed and burnt out, and it will require a lot of systemic change to fix what ails American medicine. But arguably nobody has a higher stake in the well-being of the medical profession than patients themselves. After all, when doctors are suffering, their patients won’t be far behind. So work to be the best patient you can be, and resolve to be part of the solution. It’s something that you can do, right now, without waiting for an act of congress, a technological innovation, or a reform from the insurance industry. Your doctor will thank you for it, and have the space to provide you with better care in the process.
This is one of an ongoing series from Dr. Bittermilk, offering solutions to a variety of issues surrounding the U.S. medical system.
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Dr Reginald Bittermilk