RESPECTED PROFESSIONALS

"Not too long ago, physicians were far and away the most respected professionals. In a Gallup Poll taken in December, 2008, physicians ranked fourth, behind nurses, pharmacists and high school teachers. Why the drop in respect and admiration? There are many reasons, many of which we are powerless to alter.
With the emergence of HMOs and other managed care organizations, patients have less choice as to who their doctor might be. These choices may change each time an employer renegotiates the contract. When physicians are employed by these organizations, there is tremendous pressure to see as many patients as quickly as possible.

"In addition, the public has unreasonable expectations from the medical community. Several times each week excited announcements of the impending cure for some horrible malady or eradication of a dreaded pestilence blare from our TVs and newspapers. I find it interesting to count how many times the qualifiers may, could, might and possibly are used in these breathless reports. They then disappear into some black hole seldom to be heard of again and are replaced in a day or two by the next miracle cure or silver bullet.
Patients now have almost unlimited access to medical information—some accurate, some misleading, and some patently false—via the internet, television, and countless magazines. They can arrive in our offices as well-informed participants in their health care. They can also arrive as simply confused by, or frustratingly unaware of, the limitations of their newly found knowledge.

"We can do little to change these things. But we are not without fault. In large measure we have ourselves to blame for our slipping regard and prestige. In many cases we have drifted away from being personable, caring physicians who are our patients’ advocates in order to run more efficient practices and to be technically more proficient practitioners. Somewhere along the way we seem to have lost sight of the idea that the patient comes first. We have forgotten that the disease doesn’t have the patient— the patient has the disease."

 

CHECKPOINT

"1. PATIENTS DESERVE RESPECT

"Patients are the sole reason for our existence. They are the ones for whom we spend years learning to care.

"Society recognizes their importance as citizens when it establishes standards of training before we can be licensed to treat them. Our government recognizes their importance through Medicare, Medicaid, and the myriad government-sponsored health programs.

"Patients should be important to us as individuals. They are not interesting diagnostic puzzles to be solved. Neither are they merely broken nor flawed mechanisms to be mended or fixed. True, they do need to be diagnosed and treated. But they are living breathing people who deserve to be understood and respected."

"2. WITHOUT PATIENTS WE ARE OUT OF WORK

"Patients are the ultimate source of our livelihood. This was much more apparent in the days before insurance, HMOs, and prepaid medical care. This is likely to re-emerge in the near future as more and more patients become in essence self-insured and begin to shop and compare fees—and attitudes— among doctors. We expect to receive good quality service at restaurants, in our schools, from entertainers, mechanics, builders and anyone else who charges us for their services. We cease to patronize those who demonstrate their lack of appreciation by indifferent or surly service. Patients feel the same about us. We are being paid well for our services. It is incumbent upon us to be sure that patients, at the very minimum, get their money’s worth for the care we render."

"3. TREATING PATIENTS IS A PRIVILEGE, NOT A RIGHT

"A third thing that escapes many physicians is, that no matter how highly skilled we may be, patients are doing us a great favor by allowing us to treat them, not vice versa.

"It is of paramount importance to remember this during our training. Medical students and residents are extremely bright and intelligent. However, in all honesty, if you, your wife or your child becomes seriously ill, are you going to have the top student in your class, or even the chief resident, care for them? I think not. In our training, many of the patients we treat have no choice who their physician will be. We are their doctors because they are on the teaching service and have nowhere else to go. They are allowing us to learn medicine on them. In a sense, they are our guinea pigs. We owe them big time.
When we are asked to see patients in consultation, they have little choice. They see whom their doctors tell them to see.

"Similarly, with the rapid proliferation of hospitalist programs, many of our patients don’t choose us. They are either referred to us by their private physicians who do not admit to the hospital, or they are simply assigned to us from the emergency room. It is easy to forget that here, also, the patients are doing us a favor by allowing us to treat them. We are beholden primarily to them, the patients, not to the referring physician, the hospital or whatever group might employ us. "

 

BAD PATIENTS ARE  PEOPLE TOO

"We all tend to do well with 'good' patients, but what are good patients? They are usually those who are near our own age, education, and social status, who possess a pleasant demeanor, and who pay promptly for our services. Unfortunately, there are not enough of these to go around. So how do we approach all patients as good patients?

"Most patients are neither saints nor villains—they are just people. While most are nice, or willing to be so, some have sour, negative dispositions. If we are honest, we must admit that some physicians have this same tendency. We need to take patients as they are, and we need to take them one at a time. Start viewing patients as a group and they become depersonalized and stereotyped, often characterized by the most bothersome one we have seen recently. In fact, each is an individual with a distinct set of beliefs, fears, anxieties, and prejudices.

"As we see our patients, it is extremely important for us to know our own weaknesses and prejudices, and as best we can, keep them under control. I have great difficulty tolerating whiners. Give me a crotchety, plain-spoken stoic any day. A whining patient to me is like fingernails scraped across a chalkboard. Others relate poorly to old people, children, drug abusers, chronic pain patients, uneducated patients, patients on disability, uninsured patients, dirty patients, and hypochondriacs. We all have our hang-ups, but when one of these people shows up, hold your tongue, remain amiable and make an extra effort to understand or, at the very least, to tolerate them nicely.

"It’s almost always counterproductive to become short, angry, confrontational or smart-alecky with a patient. When I have done so, almost without fail, it has come back to bite me. Tell them that they are not sick or it is all in their head, and they will become critically ill that night just to prove you wrong.
Even worse, they may unknowingly make you confront yourself as I found out.

"Mr. R. and his wife were immigrant Russian Jews who had been adopted by our local synagogue while they awaited permission to emigrate to Israel. Mrs. R. spoke little English. She was severely depressed and was brought to me by her sponsor, a patient of mine. Every week for three months, I saw Mrs. R. and, with the aid of her husband as an interpreter, I struggled to help her. These visits were always long, tedious and energy draining. If that were not enough, each time, after checking out, Mr. R. would ask to see me again for “just one more question.” I hid my irritation as best I could and answered his questions. One day I had finally had enough. I was two patients behind and had been up most of the night in the emergency room. I was in no mood for the one more question that followed another trying visit with his wife.

“ 'This time, he’s just going to have to wait,' I snapped at my nurse. “Let him cool his heels in the allergy room.”

"I left him sitting there for 45 minutes.

"Mr. R. jumped to his feet as I entered the allergy room.

“'What’s the problem?' I asked, too sharply.

"Seeming not to notice my attitude or his long wait, he grasped my hand in both of his and began speaking with his heavy Russian accent. “Dr. Dew, we will be leaving for Israel in three days. I want to thank you for being so kind and helpful to Nadia.” He turned and retrieved a large coffee table volume of Rembrandt from the chair. It was obviously expensive, and he was obviously poor. 'Please accept this as token of my appreciation.'

"I thanked him profusely, all the while searching for a convenient rock to crawl under.
Put your best foot forward—even when it’s hard. Otherwise, it might end up in your mouth."

 

SIT DOWN AND STAY A WHILE

"Once you have introduced yourself, sit down. During discharge interviews with patient advocates at our hospital, patients almost always commented favorably if their physicians had done this. Most practice management consultants say it’s inefficient and you should never sit when seeing a patient in the office. They are wrong! Even if it is just a sore throat, sit down. In the hospital it is even more important. If there is no chair in the room, go to the nurses station and bring one back. This says to the patient, “You are important, and right now you are the sole focus of my attention.” You can sit on the edge of the bed, but this is awkward and, in my case, I invariably disturbed the leg with the broken hip.

"Studies have shown that you spend no more time when you sit while talking to the patient than when you remain standing, looming over them. These same studies have shown that the patient perceives that you have stayed much longer than you actually have.

"When you are running behind, try to avoid fidgeting, looking at your watch or giving other nonverbal signals that you are in a rush.

"I have had patients tell me that certain physicians who saw them seemed so eager to get out of the room that a family member would stand in the door to prevent them from bolting until they had answered all of their questions. The memory of a hurried doctor will linger and will most likely be passed on to others, regardless of the outcome of the illness."