Choosing the right doctor........and when to lose a doctor
“While the treatment of a disease may be entirely impersonal; the care of a patient must be completely personal.” “The significance of the intimate personal relationship between physician and patient cannot be too strongly emphasized, for in an extraordinarily large number of cases both diagnosis and treatment are directly dependent on it.”
Francis Peabody, professor, Harvard Medical School, 1927
.....................................................and after all these years this observation has not changed!
"I go online for many things: to choose rentals when I travel, or to research consumer goods before I buy them.
When I choose a physician, though, I don’t rely on the popular consensus found online.
Satisfied patients typically don’t bother to post feedback about their doctors online; dissatisfied ones are more motivated to post complaints. But those complaints may or may not accurately reflect whether the patients actually got treatment that was right for them.
Similarly, personal anecdotes of experiences with a particular drug or other form of treatment may have little relevance to whether that treatment fits another person. I want professionals whose education, training and actual experience I can trust."
..............................................................in the age of online research this is relevant!
Francis Peabody, professor, Harvard Medical School, 1927
.....................................................and after all these years this observation has not changed!
"I go online for many things: to choose rentals when I travel, or to research consumer goods before I buy them.
When I choose a physician, though, I don’t rely on the popular consensus found online.
Satisfied patients typically don’t bother to post feedback about their doctors online; dissatisfied ones are more motivated to post complaints. But those complaints may or may not accurately reflect whether the patients actually got treatment that was right for them.
Similarly, personal anecdotes of experiences with a particular drug or other form of treatment may have little relevance to whether that treatment fits another person. I want professionals whose education, training and actual experience I can trust."
..............................................................in the age of online research this is relevant!
Crisis of Care on the Front Line of Health
By Jane E. Brody : NY Times : September 30, 2008
Does your doctor spend time talking to you? Do you see your doctor within 20 minutes of your appointment time? Are you getting the guidance you need to cope with a continuing health problem or multiple overlapping problems? Do you even have a personal physician who monitors your health and treats you promptly with skill and compassion?
A “no” answer to any of these questions — even to all of them — would not be surprising. Finding doctors who know their patients well and who deliver informed medical care with efficiency and empathy has become quite a challenge in America.
There is a crisis in medicine today, and it will not be fixed by any candidate’s proposal to provide health insurance for the 45 million Americans now without it. In fact, an increase in insured Americans could make it worse.
The crisis is a diminishing supply of primary care physicians, the doctors on the firing line — family physicians, internists, pediatricians, gerontologists and others — who practice the art and the science of medicine and who seek to put patients at least on a par with their pocketbooks.
According to a study published this month in The Journal of the American Medical Association, the number of medical students choosing to train in internal medicine is down, and young physicians are leaving the field. Other primary care specialties, including family medicine and gerontology, have also reported drops.
Primary care doctors spend far more time talking to patients and helping them avert health crises or cope with ailments that are chronic and incurable than they spend performing tests and procedures.
They are the doctors who ask pertinent questions, about health and also about life circumstances, and who listen carefully to how patients answer. They are the doctors who know their patients, and often the patients’ families, and the circumstances and beliefs that can make health problems worse or impede effective treatment.
The problem is that in this era of managed care and reimbursements dictated by Medicare and other insurers, doctors don’t get much compensation for talking to patients. They get paid primarily for procedures, from blood tests to surgery, and for the number of patients they see.
Most are burdened with paperwork and hours spent negotiating treatment options with insurers. And the payments they receive for services have not increased as the costs of running a modern medical practice have risen. To make ends meet and earn a reasonable income of, say, $150,000 a year, many primary care doctors have to squeeze more and more patients into the workday.
“If you have only six to eight minutes per patient, which is the average under managed care, you’re forced to concentrate on the acute problem and ignore all the rest,” said Dr. Byron M. Thomashow, medical director of the Center for Chest Diseases at New York-Presbyterian Columbia Medical Center.
Yet, he said in an interview, in a study of more than 3,000 patients with chronic obstructive pulmonary disease, 50 to 60 percent had one or more other illnesses, and 20 percent had more than 11 other problems that warranted medical attention.
“There just isn’t the time to address them all,” he said.
Dr. Alan J. Stein, an infectious disease specialist in private practice in Brooklyn who treats many patients with H.I.V., described his practice as “heavily cognitive.”
“I spend a lot of time talking to patients — listening to them, examining them, interpreting tests and figuring out what’s wrong,” he said in an interview. “I don’t do procedures in the office. Over the last 10 or 15 years, the income of procedure-based physicians like cardiologists has increased significantly, whereas for those in primary care it has remained the same.”
Dr. Michael Stewart, chairman of the department of otorhinolaryngology at New York-Presbyterian Weill Cornell Medical Center, said in an interview that the challenge today was that “everything is going up except reimbursement. The tendency is to see more patients in a given amount of time, and so less time is spent with each patient.”
As a result, many who became doctors because they are genuinely interested in helping people get well and stay well or live a good life despite a continuing illness are increasingly disillusioned. Like Dr. Thomashow, a growing number of independent physicians are finding that the only way they can practice effectively is to not accept insurance and to ask patients to pay out of pocket.
Dr. Allen Bowling, a neurologist affiliated with the Rocky Mountain Multiple Sclerosis Center in Englewood, Colo., decided last year to convert his “busy, high overhead, insurance-based M.S. practice to one that has lower overhead, is moderately busy, and does not accept any private or government insurance.” He did that, he wrote in Neurology Today in June, to give his patients “high-quality, personalized and moderately priced care with easy access to the neurologist.”
He is passionate about caring for multiple sclerosis patients, he said, but to continue practicing the kind of medicine they deserve, he had to change how he was reimbursed.
“Good doctors do drop out of managed care, and in the future I might have to drop out as well,” Dr. Stewart said. He acknowledged that specialists like him have an advantage.
“The amount of time I spend with patients is not such an issue,” he said. “But this is a big problem for primary care specialties where patients need a lot of time.”
Even some salaried academic physicians like Dr. Douglas A. Drossman, who runs a respected clinic where patients are treated regardless of ability to pay, often have to scramble for grants from foundations and industry to support their work with patients.
Dr. Drossman, co-director of the Center for Functional Gastrointestinal and Motility Disorders at the University of North Carolina, said the salaries he and his colleagues receive do not cover the program’s costs. The program treats patients with life-disrupting chronic conditions like irritable bowel syndrome, many of them referred by other diagnostic centers like the Mayo Clinic.
“Many patients who come to us have been to countless doctors and told that there’s nothing organically wrong with them, it’s all in their heads and they just have to live with it,” Dr. Drossman said. “These patients wonder whether something has been missed. They’ve had all the tests. There’s no need to do more. But it takes time to help patients understand theirs is a real problem and to learn how to deal with it.”
Dr. Karen E. Hauer of the University of California, San Francisco, who directed the study of medical students, said in an interview that students were “turned off by the hassles in the practice environment — the paperwork, insurance issues, pace of work and expectations to get the work done quickly without having adequate time to spend with patients.”
This is a particular problem for doctors who treat the growing older population. Trends suggest there will not be nearly enough doctors for these patients, Dr. Hauer said.
Whatever the future of health care may hold for Americans, Dr. Thomashow said, “We need to go forward with something that keeps the humanity in medicine.”
Is physician burnout really a problem?
By Dr. Suzanne Koven | GLOBE CORRESPONDENT MAY 26, 2014
The doctor will see you now — but he or she won’t be happy about it.
At least that’s what the popular news site, The Daily Beast, contends. An item published last month grimly titled “How Being a Doctor Became the Most Miserable Profession” cited high suicide rates among physicians and increasing numbers of doctors retiring early and leaving medicine for the corporate world as evidence of widespread misery among my colleagues. Loss of respect and autonomy, decreased insurance reimbursements, and larger administrative burdens — some imposed by new medical documentation requirements under the Affordable Care Act — are said to contribute to our alleged burnout.
Also last month, an editorial appeared in The Wall Street Journal titled “A Doctor’s Declaration of Independence.” An orthopedic surgeon called for physicians to say, essentially: “We’re mad as hell and we’re not going to take it anymore!” Dr. Daniel F. Craviotto Jr. claimed: “I don’t know about other physicians but I am tired — tired of the mandates, tired of outside interference, tired of anything that unnecessarily interferes with the way I practice medicine. No other profession would put up with this kind of scrutiny and coercion from outside forces.”
Craviotto recommended radical action by doctors, such as refusing to accept insurance, including Medicare, until our grievances are addressed.
I have mixed feelings about these articles, and many similar recent ones touting how awful my job has supposedly become.
On the one hand, I feel validated. There’s no question that practicing medicine isn’t as much fun as it was even five years ago. New regulations and restrictions issued by government agencies, insurance companies, and professional organizations mean I now spend time I’d rather spend with patients checking boxes, populating templates, and dialing 800 numbers.
Also, because of decreasing reimbursements, physicians are now under pressure to see patients more quickly than ever before. A primary care doctor now spends an average of 12 minutes with each patient. That’s not much time in which to see someone with a long list of complex medical problems and medications and numerous questions and complaints — not to mention a life story, tricky family dynamics, and photos of grandchildren to share.
More busywork combined with shorter visits make me feel perpetually rushed, which makes both me and my patients unhappy. Studies show that a rushed physician is more likely to make mistakes. A more pernicious effect is that when a doctor is in a hurry he or she is less likely to fully engage a patient.
For example, not long ago, I met a new patient who had a fairly simple medical history but who’d suffered much pain and loss. I found myself resisting the temptation to save time by not probing those emotions too deeply, even though I knew that doing so would forge a bond between us, a bond that would help me be a better doctor to this patient — the kind of bond that is, to me, the most satisfying part of medicine.
Still, I think that while the Daily Beast and others accurately convey, to some extent, the concerns of many physicians, they do so in an overly dramatic and misleading way.
Take the assertion that high suicide rates among doctors reflect decreasing job satisfaction. It’s true that 300 to 400 American doctors kill themselves every year. But high suicide rates among physicians have been noted for decades and have been attributed to uncontrolled depression, not job dissatisfaction. Doctors often feel embarrassed about seeking psychiatric care from their colleagues or fear that the stigma of a psychiatric diagnosis will jeopardize their livelihoods. This fear is well-founded. It’s only recently that most state medical licensing boards have stopped requiring physicians to report whether they’ve ever received mental health care — information that has been passed along to insurance companies and hospitals.
Physicians retire early, elect to work part-time, and opt out of practice for many reasons besides “misery,” including a need to care for family, a desire to explore other interests, and to seek higher salaries to pay off the six-figure debt that medical trainees, on average, incur.
The tedium associated with current medical practice is irksome, but not entirely new. My dad, who was a solo practitioner in the 1950s through 1980s, did more paperwork than I’ll ever do. He spent hours at home every night dictating notes and letters into a clunky IBM dictaphone. And I’m just old enough to remember the early days of hospital computing systems when gathering a patient’s data involved calling or even walking from lab to lab.
I’m not denying that my colleagues and I are frustrated by changes in medicine, but that frustration is more nuanced and more counterbalanced by joy than most media coverage reflects.
In a recent conversation with several colleagues about professional burnout I was struck by the fact that different people felt burned out by different things: for some it was filling out forms, for others it was being scrutinized by bureaucrats. For me, it’s being the target of anger and suspicion that seem so prevalent in society today. I appreciate patients informing and advocating for themselves. I don’t appreciate patients arguing with me about anatomy and physiology — or my motives.
Many of my colleagues said that burnout isn’t an all-or-nothing state, that they felt burned out on certain days but that often, after a vacation or even one meaningful patient encounter, they’re rejuvenated.
Interestingly, a friend of mine who’s a public school teacher told me The Daily Beast piece captured the current mood of her profession. I’ve spoken to people in many fields who feel more pressured and less appreciated in recent years.
I wonder if physicians are really no more burned out than anyone else. Maybe we get written about because people find it fascinating — or even a little gratifying? — that highly trained people who do rewarding work with good job security and relatively generous pay can be as unhappy as everyone else.
Dr. Suzanne Koven is a primary care internist at Massachusetts General Hospital.
Finding a Quality Doctor
By Danielle Ofri, MD : NY Times : August 18, 2011
“Quality.” It’s one of those words that used to mean something: actual quality you could trust. Nowadays in hospital hallways, quality is a charged word that is more corporate-speak than actual English, eliciting stomach churning and eye rolling in equal measures.
Quality. Who can argue with such a noble goal? Of course we all want quality medical care. Doctors want to provide quality care, patients want to receive quality care, and administrators want to demonstrate quality care in their institutions. All parties aligned in agreement.
The problem, of course, is that no one can agree on how to measure quality. This might be an intriguing question to untangle, if it weren’t for the fact that the quality measurement field has long since left the starting gate. Despite a lack of agreement on how best to measure quality, metrics are being applied broadly, with concrete consequences for doctors, nurses, hospitals and patients.
My own experience in being evaluated for “quality” left me with decidedly mixed feelings. Our hospital had undertaken a laudable and herculean effort to improve the care of patients with diabetes. There was no disagreement that diabetes is one of the most complicated diseases we face, and that these patients would benefit from the best medical care possible.
In that light, each doctor was given a report card citing the percentages of his or her patients whose glucose, blood pressure and cholesterol were “at goal.” These seemed like reasonable data points to evaluate how good a job we were doing.
My report card was dismal, way below the targets our institution had set. It made me feel awful, because I was already working hard. But I felt guilty about the bad numbers, so I worked harder, staying later in the office and calling patients from home. Still, my numbers didn’t seem to budge; it was downright dispiriting.
I wrote about this experience in an essay in The New England Journal of Medicine. In it, I tried to point out that these sorts of metrics don’t give a full measure of quality; they simply measure what is easy for administrators to measure. Like the blind men touching the elephant, they can describe only isolated parts of a medical encounter. Each metric might be important, but they do not add up to the totality of good medical care.
Most people, when they need a doctor, ask for personal recommendations about someone who is smart, caring, thorough, thoughtful and trustworthy. Rarely do they ask for a physician with the best stats.
The responses were swift and vehement. “Dr. Ofri, are you afraid to be measured by hard data?” was a common refrain. My suggestions that most doctors are genuinely doing their best to help their patients and that these report cards might not be accurate reflections of their care were considered evidence of arrogance.
Many of these opinions came from doctors — but mostly doctors who were not involved in direct patient care (medical administrators, pathologists, radiologists). None were in the trenches of primary care.
In contrast to these comments, I was flooded with personal letters from nurses and doctors who felt demoralized by the quality measurement system. These were clinicians who were trying their best in a dysfunctional system, but were constantly being told how they weren’t measuring up. Many said that they were ready to quit, but couldn’t countenance abandoning their patients.
I thought about these nurses and doctors when I came across a recent study that found that patient outcomes (in this case, preventing readmission to the hospital after being discharged) were correlated more strongly to the “fuzzy” measure of patient satisfaction than to the standard “objective” measures of quality.
Patient satisfaction can be an amorphous thing to quantify. But typically, when someone expresses satisfaction with a doctor’s care and would recommend him or her to someone else, it usually includes those “soft” attributes like attentiveness, curiosity, compassion, diligence, connection and communication.
There certainly are some bad doctors out there — incompetents, loafers — and they should be weeded out. But they are a minority.
This is not to say that there isn’t room for every doctor to improve. I don’t view my poor scores as a free pass to blame the system for everything. I have to take responsibility for the things that I have control over, and do my best to stay current and improve my skills.
We need to remind ourselves and the public, though, that these quality measures miss much of what makes a good doctor good. If you want every blood pressure below 130/80, hire a computer to dose the drinking water with antihypertensives. The quality measures will be perfect, and every hospital will be No. 1 in the U.S. News & World Report rankings.
But if you are facing illness — critical, chronic or terminal — you might seek other qualities.
You are sick. Now what?
Knowledge is power
By Tara Parker-Pope : NY Times Article : September 30, 2008
Are patients swimming in a sea of health information? Or are they drowning in it?
The rise of the Internet, along with thousands of health-oriented Web sites, medical blogs and even doctor-based television and radio programs, means that today’s patients have more opportunities than ever to take charge of their medical care. Technological advances have vastly increased doctors’ diagnostic tools and treatments, and have exponentially expanded the amount of information on just about every known disease.
The daily bombardment of news reports and drug advertising offers little guidance on how to make sense of self-proclaimed medical breakthroughs and claims of worrisome risks. And doctors, the people best equipped to guide us through these murky waters, are finding themselves with less time to spend with their patients.
But patients have more than ever to gain by decoding the latest health news and researching their own medical care.
“I don’t think people have a choice — it’s mandatory,” said Dr. Marisa Weiss, a breast oncologist in Pennsylvania who founded the Web site breastcancer.org. “The time you have with your doctor is getting progressively shorter, yet there’s so much more to talk about. You have to prepare for this important meeting.”
Whether you are trying to make sense of the latest health news or you have a diagnosis of a serious illness, the basic rules of health research are the same. From interviews with doctors and patients, here are the most important steps to take in a search for medical answers.
Determine your information personality.
Information gives some people a sense of control. For others, it’s overwhelming. An acquaintance of this reporter, a New York father coping with his infant son’s heart problem, knew he would be paralyzed with indecision if his research led to too many choices. So he focused on finding the area’s best pediatric cardiologist and left the decisions to the experts.
Others, like Amy Haberland, 50, a breast cancer patient in Arlington, Mass., pore through medical journals, looking not just for answers but also for better questions to ask their doctors.
“Knowledge is power,” Ms. Haberland said. “I think knowing the reality of the risks of my cancer makes me more comfortable undergoing my treatment.”
Dr. Michael Fisch, interim chairman of general oncology for the University of Texas M. D. Anderson Cancer Center, says that before patients embark on a quest for information, they need to think about their goals and how they might react to information overload.
“Just like with medicine, you have to ask yourself what dose you can take,” he said. “For some people, more information makes them wackier, while others get more relaxed and feel more empowered.”
The goal is to find an M.D., not become one.
Often patients begin a medical search hoping to discover a breakthrough medical study or a cure buried on the Internet. But even the best medical searches don’t always give you the answers. Instead, they lead you to doctors who can provide you with even more information.
“It’s probably the most important thing in your cancer care that you believe someone has your best interests at heart,” said Dr. Anna Pavlick, director of the melanoma program at the New York University Cancer Institute. “In an area where there are no right answers, you’re going to get a different opinion with every doctor you see. You’ve got to find a doctor you feel most comfortable with, the one you most trust.”
Keep statistics in perspective.
Patients researching their health often come across frightening statistics. Statistics can give you a sense of overall risk, but they shouldn’t be the deciding factor in your care.
Jolanta Stettler, 39, of Denver, was told she had less than six months to live after getting a diagnosis of ocular melanoma, a rare cancer of the eye that had spread to her liver.
“I was told there is absolutely nothing they could help me with, no treatment,” said Ms. Stettler, a mother of three. “I was left on my own.”
Ms. Stettler and her husband, a truck driver, began searching the Internet. She found Dr. Charles Nutting, an interventional radiologist at Swedish Medical Center in Englewood, Colo., who was just beginning to study a treatment that involves injecting tiny beads that emit small amounts of radiation. That appeared to help for about 18 months.
When her disease progressed again, Ms. Stettler searched for clinical trials of treatments for advanced ocular melanoma, and found a National Institutes of Health study of “isolated hepatic perfusion,” which delivers concentrated chemotherapy to patients with liver metastases. After the first treatment, Ms. Stettler’s tumors had shrunk by half.
“I don’t like statistics,” she said. “If this study stops working for me, I’ll go find another study. Each type of treatment I have is stretching out my life. It gives me more time, and it gives more time to the people who are working really hard to come up with a treatment for this cancer.”
Don’t limit yourself to the Web.
There’s more to decoding your health than the Web. Along with your doctor, your family, other patients and support groups can be resources. So can the library. When she found out she had Type 2 diabetes in 2006, Barbara Johnson, 53, of Chanhassen, Minn., spent time on the Internet, but also took nutrition classes and read books to study up on the disease.
“I was blindsided — I didn’t know anybody who had it,” said Ms. Johnson, who told her story on the American Heart Association’s Web site, IKnowDiabetes.org. “But this is a disease you have to manage yourself.”
Tell your doctor about your research.
Often patients begin a health search because their own doctors don’t seem to have the right answers. All her life, Lynne Kaiser, 44, of Plano, Tex., suffered from leg pain and poor sleep; her gynecologist told her she had “extreme PMS.” But by searching the medical literature for “adult growing pains,” she learned about restless legs syndrome and a doctor who had studied it.
“I had gone to the doctors too many times and gotten no help and no results,” said Ms. Kaiser, who is now a volunteer patient advocate for the Web site WhatIsRLS.org. The new doctor she found “really pushed me to educate myself further and pushed me to look for support.”
Although some doctors may discourage patients from doing their own research, many say they want to be included in the process.
Dr. Fisch of M. D. Anderson recalls a patient with advanced pancreatic cancer who decided against conventional chemotherapy, opting for clinical trials and alternative treatments. But instead of sending her away, Dr. Fisch said he kept her in the “loop of care.” He even had his colleagues use a mass spectroscopy machine to evaluate a blue scorpion venom treatment the patient had stumbled on. It turned out to be just blue water.
“We monitored no therapy like we would anything else, by watching her and staying open to her choices,” Dr. Fisch said. “She lived about a year from the time of diagnosis, and she had a high quality of life.”
Dr. Shalom Kalnicki, chairman of Radiation Oncology at the Montefiore-Einstein Cancer Center, says he tries to guide his patients, explaining the importance of peer-reviewed information to help them filter out less reliable advice. He also encourages them to call or e-mail him with questions as they “study their own case.”
“We need to help them sort through it, not discourage the use of information,” he said. “We have to acknowledge that patients do this research. It’s important that instead of fighting against it, that we join them and become their coaches in the process.”
The Doctor Dilemma
By Joanne Kaufman
New York City has more MD's than anyplace else on the planet. So why is the right one harder to find than a rent-controlled six on Central Park West? It needn't be -- you just have to know WHERE to look.
When I moved to New York from Michigan after college, I was baffled to discover that finding a job (in three days) and an apartment (in four) was a lot easier than finding a doctor, perhaps because there was no medical equivalent of a real-estate broker to whom I could articulate my most basic needs: reasonable fees, in the neighborhood, warm, accessible, infallible. For a while, I even kept my suburban-Detroit medical team in place, scheduling visits home to coincide with checkups. As you can imagine, this health hajj quickly became impractical. But without a network of friends and colleagues to steer me to the right lab coat, I was reduced to finding referrals by eavesdropping on conversations in the women's locker room at the 92nd Street Y and on buses; the results were discouraging, to say the least.
After a few years of trial and error, I found my internist through my best friend's second husband's first wife. I found my dermatologist through my college roommate's brother, my radiologist through my husband's cousin, and my ob/gyn, a fertility specialist, through a former boss who provided the ultimate recommendation: She'd just gotten pregnant. Finally, I'm set. And you?
New York is a city of doctors, thousands of doctors -- nearly 60,000 at last count, the largest concentration in the country. Paradoxically, it's also a city of people searching for first-rate care that meets all their needs -- medical, emotional, geographical and, of course, financial. So what's the problem?
First, it sometimes seems easier to live with a nagging stomachache or backache than to deal with the headache of trying to pick from that big pool of docs -- particularly as medicine becomes increasingly sophisticated and presents more treatment options. You know you need a urologist. Do you go to the guy who does minimally invasive laparoscopic surgery or the one with the more conservative technique? If you're facing cancer, how do you hook up with someone with access to treatment protocols for new chemotherapy? How do you even find out that such protocols exist?
"It's much more difficult now than it once was," says Mark Reiner, a general surgeon. "In the old days, the doctor would say, 'You should see Dr. Smith. He operated on my family members.' Today, people are bombarded with ads and news reports; they're going on the Internet . . . " (This last a thorny prospect, offering reams of unfiltered information but also hospital and physicians' Websites that can arm you with plenty of useful information.) Patients whose choices are limited by their insurance plans have a whole other set of issues. Because of anorexic reimbursements from insurance companies and the government, doctors have to see seven or eight or twelve patients an hour to eke out a reasonable income these days -- which means hurried, harried care. And just when you've found a physician who's a good match, your employer switches health plans, or your doctor of choice drops out.
What complicates matters is that the doctor you just have to see is -- as often as not -- no longer taking new patients. "I think Manhattan people are obsessed with the idea of the best and whether a certain practitioner is a chic doctor," says an internist-cardiologist at New York-Presbyterian. "There's a lot of he's the only one syndrome, a desire to know the patient profile of the doctor and to know whether there are important people in a given doctor's practice. And of course, there are some doctors who cultivate that patient group."
But if your mother was right when she told you there was more than one Mr. Right (or Ms. Right), there's also more than one Dr. Right. "The question is, why do you need that one doctor?" asks Zeev Neuwirth, an internist at Lenox Hill. "Chances are, in New York City, thank God, there is someone else who can do that specialized procedure." And if the doctor you desire isn't available, someone else in his or her practice probably is. "You might be better off with that doctor's associate," says Neuwirth, "someone who isn't as senior or doesn't have the same reputation but is equally competent." Indeed, that junior doctor, intent on building a practice, may also take your insurance, while the senior guy only takes cash.
Still insist on seeing the big kahuna who steadfastly insists he's taking no new patients? "If you have another way in to that doctor aside from bullying the receptionist, use it," says Stephen G. Baum, chairman of medicine at Beth Israel. "Have your internist call on your behalf. If you know someone who's been that doctor's patient, have him intervene for you."
Most of us find our doctors through the recommendations of others, and that can be a blessing -- or a curse. One physician's type-A-personality bedside manner may be perfectly suited to your hypochondriac best friend's needs but not to your laissez-faire approach to survival.
Whether you're in an HMO or have the means to go to any doctor you desire, nothing is more important than getting comfortable with your primary-care physician, typically an internist with a specialty in some field of particular relevance to you. If you're not comfortable with the gatekeeper, you won't be comfortable with his or her referrals, which are often sought during times of crisis, and you'll end up shortchanging your health in ways you wouldn't dream of doing to, say, your appearance.
If you're fortunate enough to have a friend who's a doctor, ask for referrals, for scuttlebutt, and for guidance. But Mack Lipkin, a professor of clinical medicine and director of the primary-care division at NYU Medical Center, who frequently finds himself serving as a medical clearinghouse, says his recommendations are only as good as the information prospective patients provide at the outset. To get started, you should:
* Familiarize yourself with your HMO's Website in order to get basic information about primary-care physicians who match your requirements of location and subspecialty. Also useful: medicalconsumers.org, which offers information about the number of times a doctor has performed a particular procedure; and nydoctorprofile.com, a site run by the state Health Department that has information about whether a physician has ever been disciplined.
* Consider your comfort level with a doctor of the opposite sex (something that women grow up with but that more men are confronting -- maybe not a bad thing, since women tend to spend more time forming "partnerships" with patients). Similarly, is a doctor's age a factor in your comfort level?
* Take into account your special medical needs and likelihood of needing hospitalization. If you are at high risk for a heart attack or require ongoing treatment, you'll want a doctor who has privileges at the hospital you need to be in.
Most crucial to Lipkin is the tricky task of matching doctor-patient styles. If, for example, your mode of self-care involves vitamins, acupuncture, and the Alexander technique, you're unlikely to do well with a doctor who either doesn't know from Alexander or doesn't approve of such things. Some people prefer to try to change their unhealthy lifestyles and avoid medications -- and for them, there's no point in going to a doctor who just prescribes medication. Other things to consider along these lines:
* Do you prefer a doctor who lays out all the options and asks you to decide? Or one who says, "This is what I think would be best"? Or one who says, "This is what has to be done"?
* Do you want a doctor used to sharing a great deal of information, or one who is more low-key and reserved? "A stock analyst or lawyer or academic needs information," says Lipkin. "That's their stock-in-trade. They're not going to be happy with a doctor who boils something down to the nub. If they have congestive heart failure, they want to know exactly what it is and what it involves rather than being told the pump isn't working."
Our best advice: shop around. We are willing to interview a battalion of pediatricians before settling on the one who is right for our kids, yet too often we don't do the same for ourselves. "It's crazy to enter into a long-term relationship," says Lipkin, "where your safety and well-being and longevity are at stake, and not be in the right relationship. "If you feel not understood, not cared about," he continues, "if you feel that you can't ask for a better explanation of something, that you can't negotiate the approach to your care, you're not going to be able to tell the doctor about difficult things like that you're not taking your medicine or that you're drinking more than you feel is right. You're going to jeopardize yourself when it really counts. You're going to wake up one night, feel really sick, and not call the doctor."
So move on. If you can hire a doctor, you can fire a doctor. Here in New York, there are plenty more where that one came from
Choosing a doctor :
Tips for making the right decision
Your doctor is your family's most important health care partner, so it's important to choose this person carefully -- especially if you have a managed care health insurance plan. These plans require you to see the same primary care physician for all of your medical needs, before you get access to specialists and other medical services.
So, how do you make this important decision? First, you'll want to get some unbiased information about prospective doctors in your area -- and then meet with two or three doctors to learn more before making your final decision.
Here's how to get started:
1. Ask families, friends and co-workers about their doctors. Ask what they like and what they don't like about the care they're receiving.
2. Contact hospitals and referral services for information on doctors who are taking new patients.
3. Ask your insurance plan provider for any information they have on their member doctors.
4. Call the doctor's own medical office for information on his/her training and experience. Many offices will provide detailed brochures or biographies on request. Or look up prospective doctors in the Directory of Medical Specialists, available at your local library. This reference includes professional and biographic information on more then 400,000 doctors.
5. Visit the American Medical Association's online physician directory. Another resource for finding a doctor is DocFinder from the Association of State Medical Board Executive Directors.
6. Visit Consumers' Checkbook and BestDoctors.com for rankings of best doctors based on input from other doctors. There is a catch: both charge you for access to the search tool.
7. Call or visit the Web site of the American Board of Medical Specialties to learn if a particular doctor is board certified in a given area of medicine. Board certification ensures that the doctor has completed several years of training in the given area, and has passed a specialty-specific examination. You can confirm that a doctor has a particular specialty by calling the American Board of Medical Specialties at 866-275-2267.
8. Call your state licensing board to learn about any registered complaints or disciplinary actions taken against any of the doctors you're considering. Some state licensing boards can be found online. For a partial list, go to the American Board of Medical Specialties. For a fee, you can also get a Disciplinary History Report at DocInfo.
Once you've narrowed your search down to two or three doctors, set up a getting-acquainted meeting. A few things to ask at that meeting:
* When are the offices open? How would I get care after hours or when there aren't any available appointments?
* Are most of the visits with the doctor or with someone else, such as a nurse practitioner?
* What services does the doctor offer for health maintenance and preventive medicine?
* What approach would the doctor take for any special health needs in your family? Is he/she familiar with these conditions? How many does he/she treat per month, or per year?
When the Doctor Doesn’t Look Like You
By Pauline W. Chen, MD : NY Times Article : August 12, 2010
One night during my training, over dinner in the hospital cafeteria, a fellow resident and I had a discussion about the situation of one of our professors. Known for his blistering teaching sessions, this senior surgeon possessed the uncanny ability to sniff out lapses in memory or judgment among doctors-in-training. Early on in my internship, I showed up at one of his practice trauma resuscitations blissfully unprepared. I left an hour later with his booming and rapid-fire admonitions still ringing in my ears. “You call yourself a doctor?” he had thundered. “This patient may just be a dummy, but you are killing her!”
Nonetheless, this surgeon soon became a favorite of ours. He was brilliant in the operating room, gentle at the patients’ bedside and, as I quickly learned, highly effective in the classroom. What continued to vex me, however, was not the peculiarity of his teaching style; it was his inability to attract patients. While other, less-skilled senior doctors had waiting rooms that were overflowing, his was not.
“If I were sick,” I said to my fellow resident that night, “I know which surgeon I would ask for.”
“But you can understand why some patients and referring doctors don’t go to him,” she replied matter-of-factly. “Other guys wear Brooks Brothers, have recognizable last names and carry a degree from the ‘right’ medical school. But when a potential patient or referring doctor sees our guy, all they might notice is a foreigner with an accent and a strange name who graduated from a medical school in some developing country.”
Our professor had been born abroad and immigrated to the United States after medical school. But despite clinical accomplishments and professional accolades in this country, I knew, like my fellow resident, that there were patients and physicians whose initial impulse was to dismiss him or any other doctor with an accent or an international degree.
For more than 50 years, international medical school graduates like my former professor have filled the gaps in the physician work force in the United States. Currently, they make up fully one-quarter of all practicing physicians, and although a majority are foreign-born, approximately 20 percent are American citizens who have chosen to go abroad, most notably to the Caribbean, for medical school.
Regardless of whether they are United States citizens, all international graduates must go through an arduous regulatory process before practicing in this country, a process that includes verification of medical school diplomas and transcripts, residency training in American hospitals and the same national three-part licensing exams and specialty tests that their medical school counterparts in this country take. Many go on to choose specialties or work in the rural and disadvantaged geographic locations that their American counterparts shun. International graduates, for example, now account for nearly 30 percent of all primary care doctors, a specialty that has had increasing difficulties attracting American medical students.
Though these doctors have filled an important national health care need for over half a century, doubts regarding the quality of care they provide have continued to plague them. Health care experts interested in this issue have been stymied over the years by inadequate methodologies for evaluating the effectiveness of large groups of physicians and so have chosen instead to focus on exam scores, an admittedly crude proxy for quality of care.
But even that data has proven confusing. Studies initially revealed that international graduates tended to score lower, while more recent research shows that they routinely outperform their peers on training exams in areas like internal medicine.
Now researchers from the Foundation for Advancement of International Medical Education and Research in Philadelphia have published the first study incorporating new research methods for evaluating the performance of large groups of physicians. And it turns out that contrary to certain individuals’ worst fears, accent or nationality did not affect patient outcomes. Rather, the main factor was being board-certified: completing a full residency at an accredited training program, passing written and, depending on the specialty, oral examinations, and having proof of experience with a defined set of clinical problems and technical procedures.
The researchers examined the records of more than 240,000 patients who were hospitalized for either congestive heart failure or heart attack and examined how their outcomes correlated with their doctors’ education and background. They found no differences in mortality rates between those patients cared for by graduates of international or American medical schools. But on closer review, they found that two factors did contribute significantly to differences in patient outcomes.
Dividing the international medical graduates into those who were foreign-born and those who were American citizens who chose to study abroad, the researchers discovered that patients of foreign-born primary care physicians fared significantly better than patients of American primary care doctors who received their medical degrees either here or abroad. John J. Norcini, lead author of the study and president of the foundation, postulates that the differences may stem from the fact that as primary care has become less attractive for graduates of American medical schools, it has also become less competitive. “The foreign international medical graduates are some of the smartest kids from around the world,” he said. “When they come over, they tend to fill in where the U.S. medical school graduates don’t necessarily go.”
Dr. Norcini and his co-investigators also found that patient mortality rates were related to the doctor’s board certification and time since medical school graduation, regardless of his or her background. Those physicians in the study who were board-certified had substantially lower death rates among their patients. And the greater the number of years since medical school graduation, the more likely that doctor was to have a patient with heart attack or congestive heart failure die in the hospital.
“If you put these two pieces of data together,” Dr. Norcini said, “they make a strong argument for board certification and the maintenance of certification programs currently being put in place to improve the periodic reassessment of board-certified doctors.”
While the results of this study will help Dr. Norcini and other medical educators further refine the regulatory process for physicians from international and domestic medical schools, Dr. Norcini points out that there is a “huge heterogeneity in all these groups” and cautions doctors and patients against making broad generalizations about any physician group. Instead, when searching for the best doctors, he recommends focusing not on a doctor’s medical school or country of origin but rather on board certification.
“My hope is that we begin to rely more on objective markers like board certification as a statement of quality rather than where someone went to medical school,” Dr. Norcini said. “One can always ask a doctor if he or she is board-certified and involved in maintaining that certification. It’s a straightforward quality marker, and it’s a question that’s easy to ask.”
He added, “And as a patient, I find that reassuring.”
When it's time to find a new doctor
Dr. Jerome Groopman knew he needed to break up with his doctor.
Five years ago, when he started seeing his internist, everything was fine. But Groopman says that in time, the internist became more popular -- and hence more busy and harried -- right when Groopman needed him most.
"I have a strong family history of high cholesterol and heart disease. Every male in my family has had a [heart attack] in his 50s and 60s," he says. "I was moving into middle age, and I just didn't feel that my doctor was looking at me as an individual, and taking those factors into account."
But Groopman -- a physician and author of four books about doctors and patients -- found it difficult to leave his internist of five years. "It sounds strange, but I didn't want to insult him."
Groopman is not alone. "I really think it's a fear of the unknown," says Robin DiMatteo, a researcher at the University of California at Riverside who's studied doctor-patient communication. "But if the doctor isn't supporting your healing or health, you should go."
Here are five ways to know when it's time to think about leaving your doctor, and the best way to do it:
Groopman agrees. He says a doctor who doesn't like a patient often stereotypes him or her. "I was terribly guilty of this as a young doctor. One of my patients said she had indigestion, and I got very irritated with her, and thought she was a whiner and a complainer," he says. "It was catastrophic because she actually had a torn aorta."
The woman died. "I have never forgiven myself for failing to diagnose it," he writes in "How Doctors Think." "There was a chance she could have been saved."
So once you've decided it might be time to divorce your doctor, how do you do it? First of all, make sure whatever's bothering you isn't just a one-time thing. "Make sure it's not just a quirk of the doctor's day," Groopman says. "Maybe they're just having a bad day."
If the problems continue, Groopman, Roter, and DiMatteo agree it's best to try to express your dissatisfaction instead of just bolting. "Use the first person plural, such as 'We're not communicating well' as opposed to 'You seem distracted or irritable with me,'" suggests Groopman. "That may cause cause the physician to stop and reflect and shift gears."
When it doesn't, you can be sure it's time to get another doctor, Roter says. She described two friends who wrote letters to their doctor saying they were unhappy with some of the treatments they'd received. "The both got back letters saying, 'Good luck with your new doctor.'"
How to find the best medical treatment
Know your way around the Internet, arm yourself with statistics and don't be afraid to speak up.
By Susan Brink : Los Angeles Times Article : June 23, 2008
Even if you're not rich or well-connected, you can find leading-edge treatment when it matters. And it could well matter if your condition is rare or if few doctors have developed expertise in treating it. For starters, be Internet savvy -- and pushy. Here are some tips for getting what you need:
Be open to the hospital your insurance plan recommends.
Insurers want to keep costs down, and one way to do that is to minimize costly complications. So they try to contract with institutions that have the most experience and the best outcomes. Even HMOs contract with outside centers of excellence for some rare disorders when their own physicians lack unique expertise.
"This whole notion of centers of excellence used to be based on gestalt and individual recommendations," says Dr. William Roper, dean of the medical school and chief executive of the healthcare system at the University of North Carolina.
"It's becoming much more data-driven and evidence-based."
To determine the "best," arm yourself with numbers.
If the doctor, or hospital, you want has more experience than the one your insurer has chosen, show your insurer the numbers. A surgeon who has done a procedure a few hundred times will have better results than one who has done it two or three times. "There's a growing body of evidence that says that volume matters," Roper says.
The only way to find out is to ask, so don't be shy about asking physicians how many times they've done the procedure, or treated the condition.
And be specific. A cardiac surgeon who has done hundreds of heart bypasses is not necessarily an expert in valve replacements.
Get recommendations.
The less common the disorder, the fewer the institutions that will have deep experience with it. But it's just those institutions you want to find. Each time you talk to a provider, don't end the conversation without asking who else has experience with your condition or which institutions are known for treating the disease. Keep following the chain of recommendations to see if one or two names are consistently repeated.
Do your homework.
Track down statistics and studies as tailor-made to your condition as possible.
Search for articles at the National Institutes of Health's free archive of medical journals (pubmedcentral.nih.gov). You can often see the entire study for free, sometimes only the abstract, but poring over the list will give you an idea of which institutions are actively publishing articles. Be as specific as possible in your search. For example, don't type in "brain cancer." Use "malignant glioma," "brain tumor" and "left parietal lobe."
Find out who is doing research into your condition.
If a physician publishes a lot about your condition, there's a good chance he or she is already onto potentially better techniques, even if results haven't yet been published. "What is published is always years behind what is happening at major academic centers," says Dr. Henry Friedman, deputy director of the Preston Robert Tisch Brain Tumor Center at Duke University Medical Center in North Carolina.
Even if you don't want, or qualify for, a clinical trial, find out which institutions are researching your condition. Go to clinicaltrials.gov for a list of more than 50,000 federally and privately sponsored trials.
Make appointments.
When you find a doctor or hospital doing research into your disease, call the physician or the institution. Large academic centers all have physician referral departments set up to connect patients with the appropriate physician. Your insurance company will cover a second opinion, and going to a large center for that second opinion can be the entryway to excellence.
Whatever your disease, go online.
Look for Internet-based support and advocacy groups. For example, the National Multiple Sclerosis Society’s website has a page on recent research into the disease, who is doing it and where.
Check out the disease advocacy group's chat rooms. Patients who have gone through what you're facing have a lot of first-hand advice about what they've done, where they've gone and how it turned out. In the absence of good national quality and outcomes measures of doctors and hospitals, the personal experience of your peers is invaluable.
But beware of websites trying to sell something or promoting a treatment not available in any academic center. Leading-edge research is usually backed by the NIH and carried out by academic centers. Private organizations may be pushing their own product or technique. "Any Internet site that sounds too good to be true usually is," says Dr. Robert Adler, vice chairman of pediatric medicine at Childrens Hospital Los Angeles.
Try to change Medicare plans if necessary.
The original Medicare plan has more geographic flexibility than the private plan alternatives. (First of all, consider carefully when choosing a plan.) If you need help changing plans after a diagnosis, try calling the Medicare Rights Center (medicarerights.org or [800] 333-4114), a national consumer organization that provides counseling about Medicare. "Sometimes our advocates have been able to help people get off the private plan and back on original Medicare," says Paul Precht, director for policy and communications at the center. "But it's getting harder."
Be realistic.
Don't think you can find a cutting-edge technique developed by one surgeon, then ask your own doctor to do it. "That's like going to a restaurant with a recipe from another restaurant and asking the kitchen to make it," Adler says. You could ask the doctor who developed the procedure if he or she has trained any others. If so, find out where they are practicing, and how experienced they have become. That process of training others, and having them fan out, is how once-unique techniques spread across the country, but it takes a lot of time.
Be prepared to fight.
Use the ammunition you've accumulated through research. Fights with insurance companies can be frustrating and drawn out, so if you're also fighting disease, you might need to enlist a spouse or friends to make phone calls and write letters, to the insurer, to legal aid societies or to a private lawyer.
If you're wrangling with Medicare, the Medicare Rights Center might be able to help fight a denial.
Get your doctor's support.
Whether you're facing Medicare or an insurance company, your chosen doctor is your best ally. He or she is the one best armed with numbers to make your case to the insurer.
For example, surgeons at Johns Hopkins Medical Center published a study in 1995 of a surgical technique, called a Whipple procedure, that can help some pancreatic cancer patients. The study examined all 501 cases of pancreatic cancer in which the procedure was used between 1988 to 1993 throughout Maryland.
It found that 54% of Whipple procedures were performed at Johns Hopkins Medical Center. The remainder were performed at 38 other hospitals throughout the state. The in-hospital death rate at Hopkins was 2.2%, compared with an average of 13.5% at the other hospitals. But what probably got the attention of insurance companies was that the cost at Johns Hopkins was $26,204, compared with an average of $31,659 at other hospitals.
Even if there isn't such incontrovertible, published proof supporting your decision, your chosen physician will likely have other numbers.
If you lose the fight and continue to be convinced that where you go matters to you, be prepared to shell out.
Whether it's a higher co-payment for going out of network, or taking on the entire cost yourself if you can afford it, your preference may be important enough to you to pull out your checkbook or credit card.
Make a choice.
Finally, try not to second-guess your own decision. "No one really knows what the outcome will be," Adler says. "Make the best decision you can in the time you've got, and then don't look back."
The Doctor Will See You ... Eventually
By Lesley Alderman : NY Times : August 1, 2011
"How much of human life is lost in waiting!” Ralph Waldo Emerson lamented in his 1841 essay “Prudence.”
Lately that observation has begun to seem particularly keen. I just did a quick tally: Over the past month, I have spent a total of six hours in three different medical offices, and nearly half of that time was spent just waiting to be seen. In one month alone, I lost three hours of this “human life” dawdling in waiting rooms.
No one likes to be kept waiting. But it’s particularly annoying to spend an hour or more in a waiting room when you’re self-employed, like me; when you bill by the hour, as many lawyers, architects and designers do; or when you’re just plain busy.
Lisa Qiu, 23, an inventor in Manhattan, recently waited for 50 minutes to see her gastroenterologist. During the wait, the receptionist quizzed Ms. Qiu about her bills and asked her to fork over that day’s co-payment.
When the doctor finally called her in, “she didn’t bother to apologize,” said Ms. Qiu.
Some consumers are clearly getting fed up. When MedPageToday.com, a medical information Web site, recently asked readers if they thought patients who were kept waiting for a scheduled appointment should get a discount on their bills, nearly half of the 3,200 respondents said yes. And 16 percent said that a discount wasn’t necessary but that waiting patients should get a small token, like a gift card, that compensated them for being inconvenienced. Thirty-eight percent said no acknowledgment was necessary.
Nationwide, the average wait time to see a doctor last year was 23 minutes, according to the health care consultants Press Ganey. Neurosurgeons have the longest wait times (30 minutes) and optometrists the shortest (17 minutes), according to the report.
In urban areas and among certain specialties, however, the waits can be much longer. Doctors work very hard, of course, and they are treating humans, not car parts. Emergencies can throw a well-planned day into chaos, and doctors who accept insurance may feel forced to overbook their schedules to assure they can bill for every minute of the day.
But still: Patients are paying customers who have financial and time pressures of their own.
“You should be seen within a few minutes of a scheduled appointment,” said Dr. Mark Gray, medical director of West Care Medical Associates, a primary care group in Manhattan with six offices. “But it goes both ways. We expect our patients to be respectful of our time, too.”
Rather than girding for combat, asking for discounts or storming out in a huff, consider a few ways to minimize (or at least cope with) protracted waits.
FIND A NEW DOCTOR
“I will not see a doctor who keeps me waiting for hours without a very good excuse and a very big apology,” said Rachel Schwartz, 47, a lawyer who lives in Brooklyn. “I have begun to surround myself with great doctors who don’t make me wait and who are as respectful of my time as I am of theirs.”
If you set out to find a new doctor, be aware that an ultraefficient practice may not be quite what you need, either. Many doctors schedule 10- to 15-minute appointments and speed through the day with robotic precision. A doctor who does not keep you waiting also may not spend much time with you. So be sure to ask about the length of appointments, too.
A CONCIERGE PRACTICE
If you can afford it, you may have better luck with a doctor who does not take insurance. Dr. Catherine Hart, an internist in Manhattan, allows 60 minutes when seeing a new patient and 30 minutes for an annual checkup. She does not accept insurance, but she rarely keeps patients waiting and is available 24/7 by phone or e-mail.
By comparison, the average doctor’s visit today is around 19 minutes, according to the National Center for Health Statistics.
“Everyone’s time is valuable,” Dr. Hart said. “We’re living in a medical mecca. Why put up with long waits?”
SPEAK UP
Julia Lloyd, 48, has a rare heart condition that few doctors in the country are qualified to treat. When she was repeatedly kept waiting by her specialist, she spoke to him directly.
“By talking it over, I realized he wasn’t out playing golf or something. He was dealing with emergency situations and doing his best,” said Ms. Lloyd, who lives in the San Francisco Bay Area. After their conversation her doctor agreed to start informing the front desk when he was running late, so patients could know what to expect.
“As patients, we need to learn how to speak up,” Ms. Lloyd said. “At the same time, doctors need to learn to listen.”
BE ON TIME
If you’re late, not only do you throw off the schedule for others, but you may also be put at the end of a very long queue.
Ask whether you have a firm appointment. Some offices with long waits book patients in groups — say, at 9 a.m., noon, and 4 p.m., Dr. Gray said. Patients are seen in the order in which they arrive. If that’s how your doctor’s office operates, ask if you can have a scheduled appointment instead; if not, show up 15 minutes before the specified hour.
Book the first appointment of the day. You’ve probably heard this advice countless times. That’s because it works. Unless your doctor books blocks of patients at once or an emergency crops up, you’re likely to be seen pronto.
CHECK IN
Before you leave for an appointment, call to find out if the doctor is running late, or ask the minute you walk in the door. Ms. Lloyd now goes out to a nearby cafe if her doctor is delayed.
NECESSARY APPOINTMENTS ONLY
Sometimes small issues can be resolved without setting foot in the doctor’s office. If you’ve had a sinus headache for three days, for instance, you may not need an appointment. Your doctor’s office should be able to tell you over the phone that the best treatment is an over-the-counter antihistamine and an anti-inflammatory medication.
Still, it’s impossible to completely avoid time in the waiting room. Heidi Boghosian, executive director of the National Lawyers Guild, has resigned herself to the fact that “some New York doctors double-book or schedule appointments so closely that they need to juggle two or more patients in different examining rooms.”
“When I’m left in the exam room, instead of sitting and worrying about when the doctor will show up, I now lie down on the examining table and focus on deep breathing,” said Ms. Boghosian, who lives in Lower Manhattan.
Prudent. Emerson would approve.
Unhappy endings
When proactive patients and harried physicians clash, breaking up is hard to do
By Liz Kowalczyk : Boston Globe : October 8, 2007
Pearl Lischinsky had been Dr. David Steinberg's patient for 16 years when she developed an aggressive blood cancer in May 2005. Their appointments grew more frequent, and she always brought her youngest daughter to help sift through treatment options.
It wasn't long before the visits grew tense.
Karen Lischinsky was devoted to her mother and arrived at appointments prepared with Internet research and questions about chemotherapy. But she felt Steinberg acted insensitively and rushed, bolting out the door before addressing her concerns and failing to make time to discuss important end-of-life issues.
Steinberg, a hematologist, felt he patiently tried to answer her questions, but that they were endless and hostile. Even when he said he had another patient waiting, 15-minute appointments would stretch 30 minutes beyond their scheduled time, his attorney said.
The smoldering conflict erupted during one appointment, with Karen saying she was firing Steinberg. Steinberg argued that she couldn't fire him because he was her mother's doctor, not hers.
Several weeks later, Pearl Lischinsky got a letter from Steinberg saying that he was "very fond" of her but that "The behavior exhibited towards me by your children is so negative and hostile that it affects my ability to continue providing effective care for you." Steinberg gave her 30 days to find another doctor.
Open conflict in the doctor-patient relationship can be painful and time-consuming for both sides. There is little guidance available for patients, families, and doctors about how to manage these difficult situations.
Some doctors and communication specialists say disputes are occurring more often as patients and families - encouraged to be critical consumers who take control of their medical care - research treatment options and become more opinionated about care, an approach that can cause old-school physicians to bristle. Sometimes, patients and families go too far, making excessive demands, or crossing boundaries.
At the same time, doctors are more pressed for time, making lengthy conversations inherently difficult for both sides.
"This relationship is changing right before our eyes," said Dr. Gordon Harper, a child psychiatrist who for many years taught a class on communication skills at Harvard Medical School. "There's much more opportunity for conflict."
While little data exist about how often conflicts occur or relationships are ended, neither is rare.
"Most of the time, [patients] just walk with their feet," said Dr. Leonor Fernandez, an internist at Beth Israel Deaconess Medical Center. "They don't have to explain why." Even if they need their medical records, someone else in the office other than the doctor handles getting them, she said.
Communication an issue
Studies by Dana Gelb Safran, a researcher at Tufts-New England Medical Center and vice president of Blue Cross and Blue Shield of Massachusetts, have shown that about 8 percent of Massachusetts adults change primary care doctors each year because of relationship issues, including poor communication.The relationship between doctors and patients has eroded since the late 1990s, Safran said, as doctors became more harried at the same time as patients became more engaged in their medical care.
But, Safran said, relationships now appear to be stabilizing as more physicians focus on increasing patient satisfaction.
Ending a relationship is tricky for doctors, who must guard against ethical lapses and claims of illegal abandonment. ProMutual Group, the largest medical malpractice insurer in Massachusetts, said the most common reason physicians call the company's telephone consultation service is for advice on when and how to call it quits.
Patients who won't follow medical advice, don't pay bills, verbally abuse or physically threaten staff, stalk a doctor, repeatedly miss appointments, or engage in criminal behavior, such as stealing prescription pads, are fair game for termination, ProMutual advises. But the company recommends against firing patients who are in medical crisis, need treatment for an acute problem, or who are more than 20 weeks pregnant - all of which could be considered abandonment.
The Board of Registration in Medicine, which licenses doctors in Massachusetts, has received 85 complaints of abandonment since 2004; so far the board has disciplined doctors in 11 of those cases.
Most doctors say they have at least one stressful relationship with a patient or family.
Seven years ago, Dr. Thomas Lee, an internist at Brigham and Women's Hospital, prescribed a generic diabetes medication to an elderly woman who is a longtime patient. She developed a rash and concluded she was allergic to all generics.
Lee explained that this was impossible, and refused to prescribe brand name drugs when a low-cost generic alternative was available, which her health insurer also required. They argued about it constantly. Still, she wouldn't back down, even risking her life by refusing to take a generic heart medication.
When her heart rate soared and she still wouldn't take the drug, Lee's nurse suggested she find another doctor, but the woman refused. "I want him to write the prescription," the patient said, according to an article Lee wrote in the Annals of Internal Medicine in July 2004. "If he won't and I die, it will be on his head. I've known him for so many years and he knows me really well. I don't want to start over with someone new."
To save the relationship, Lee compromised. He prescribed brand-name drugs for serious problems, and generics for the ones she could live without.
The woman is still his patient and gives him small gifts at Christmas. "We are still fighting, and she is still winning. But I am not giving up," he wrote in a recent e-mail.
Ways to work it out
When patients or family have many questions, Dr. Beth Lown, an internist at Mt. Auburn Hospital and a specialist on communication, said she tries to determine whether anxiety or fear is motivating them, and will sometimes enlist help from a social worker. Often, she suggests a contract both sides can live with to talk at a specific time each day or week.
Karen Lischinsky said she was definitely anxious about her mother's condition. She was driving back and forth between her jobs teaching sociology at several local colleges and her parents' home in Swampscott to cook meals, wash laundry, and bring her mother to the beauty salon. Her father, who has Alzheimer's, also needed special attention.
"We were a frightened family about to go down the road of watching our mother die," she said. But "we had a reasonable number of questions. We as family had a right to know some of the consequences of chemotherapy."
David Gould, Steinberg's attorney, said the physician did not call in an outside mediator because he believed he could handle the family's questions on his own. As head of the hospital's ethics committee, Steinberg knew how to manage difficult situations, he said. "He didn't feel until the very end that he wasn't able to deal with the situation." During that final appointment, the family threatened to sue, Gould said, although Karen Lischinsky said this is untrue. (Steinberg declined to be interviewed for this story.)
Another Lahey hematologist, Dr. Neil Weiner, eventually took over Lischinsky's care. The retired secretary died in December at age 77.
Her three children still hurt from Steinberg's actions, Karen Lischinsky said, and the family has filed a complaint with the Board of Registration and met with the hospital's ethics committee.
He has not attended the meetings to avoid conflict of interest, his attorney said. But the family is trying to get Steinberg, who denies he abandoned his patient, to meet with them.
"I want to ask why he sent that letter saying the children were disruptive," Karen Lischinsky said. "I want to ask why there wasn't a process (before he sent it.) We're the ones who have to live with it."
Learning to Ask Tough Questions Of Your Surgeon
By Laura Landro : WSJ Article : January 9, 2008
While many Web savvy patients today can ask a doctor about minute details of their circulatory system or cancer treatment, when it comes to asking the really tough, personal questions, they often clam up. Even when going under the knife, patients are often too intimidated to ask how qualified a surgeon is, or what safety procedures are in place.
But as complications and errors dog some surgical procedures, experts say it is increasingly crucial for patients to vet their surgeons and take an active role in preventing mistakes.
To help patients be more pro-active, health-care groups, hospitals and medical specialty societies are offering new resources, including Web sites, books and checklists of questions to ask. The aim is to help patients select qualified surgeons, prepare for operations, and overcome the fear that often inhibits them from asking tough questions.
These new efforts are spurred in part by the sharp rise in surgeries performed in outpatient facilities; including doctor's offices and surgical centers, where patients aren't guaranteed the same access to care as in a hospital should something go wrong. A rash of recent news has highlighted the risks, such as the death of rap mogul Kanye West's mother after an office cosmetic procedure by a surgeon who was facing disciplinary action at the state medical board and two malpractice suits that ended in significant payouts.
Since patients can't prevent mishaps once they are under anesthesia, it is all the more important to question surgeons beforehand. "Patients should feel free to ask their surgeon anything they want answered about the operation or the surgeon's competency to perform it," says Thomas Russell, a surgeon and executive director of the American College of Surgeons. "There are no questions that should be off the table."
In a new book to be published this month, "I Need an Operation...Now What? A Patient's Guide to a Safe and Successful Outcome," Dr. Russell provides patients with lists of questions for surgeons, including their success rates, how many operations they perform in a year, and whether they have any health issues of their own that would interfere with their ability to do the procedure. While he suggests using a respectful and nonconfrontational tone, he also urges patients to "size up" the surgeon's communication skills -- and avoid those who are unresponsive, distracted or rushed.
Ronda Collier, a 43-year-old Ann Arbor, Mich., marketing professional, consulted several surgeons prior to having brain surgery a few years ago, but she recalls being too worried about seeming offensive to ask whether a doctor had a good safety record or used recreational drugs or alcohol. With a checklist such as that devised by Dr. Russell, "You can simply say I have this list of questions recommended to me and I'm just going down the list," she says. "It's not a personal attack."
Consumer Guides
Most major hospitals around the country have added to their Web sites checklists such as a 2005 brochure prepared by the federal Agency for Healthcare Research and Quality, "Having Surgery? What You Need to Know." And state medical boards have added consumer guides, such as the Massachusetts Medical Board's guide to asking questions during office-based procedures.
But by far the most useful information comes from medical specialty groups and nonprofit disease advocacy organizations that offer tips for specific surgeries. SpineUniverse.com1, which is affiliated with spine-related medical societies, offers a list of questions specific to back surgery, while breastcancer.org provides a list of questions to ask the doctor before making decisions about mastectomies and lumpectomies.
The American Society for Dermatologic Surgery recently launched a patient-safety campaign urging consumers to check a practitioner's qualifications and credentials before undergoing any cosmetic surgery procedure, offering up some gruesome pictures on its Web site (asds.net2) of complications that resulted from botched lasers, high-tech light devices and chemical peels.
And the American Board of Medical Specialties, whose 24 member boards certify about 85% of U.S. physicians, recently began airing a televised public-service announcement about the importance of board certification, a process that requires doctors to take continuing medical-education courses and periodic exams to demonstrate competency. Its abms.org Web site allows patients to search by name and specialty to verify a physician's certification. Consumers can also use state medical boards' Web sites to see whether a surgeon's license is current and whether there are any disciplinary actions pending; for a $9 fee, the Federation of State Medical Boards (www.fsmb.org3) will also run a search.
To be sure, most of the estimated 40 million surgical procedures that Americans undergo every year are safe, and quality groups such as the Joint Commission, which accredits hospitals and other health-care providers, have in recent years pushed the adoption of new safety measures, such as the use of pre-surgery antibiotics to prevent infections, and post-surgical monitoring to prevent strokes or blood clots.
Resisting Change
Yet many of those safety measures aren't being universally followed, in part because of the frenetic pace of many hospitals but also because hospitals haven't done enough to improve the processes of care. Moreover, surgeons are often resistant to changes in the way they do things -- such as stopping a surgical procedure to do a safety check, says Peter Angood, a surgeon who is vice president and chief patient safety officer of the Joint Commission.
Though still infrequent, wrong-site surgeries -- a term that includes the wrong procedure, wrong site or wrong person -- continue to bedevil safety experts. The Joint Commission in 2004 issued a protocol for all hospitals that includes a final safety check and requires the marking of the procedure site with an indelible marker. But the number of reported cases of wrong-site surgery have actually increased, at a rate of about five to eight new cases per month -- for a total of nearly 550 since 1996.
Preventing Mistakes
A study of near-misses and wrong-site surgeries in Pennsylvania showed that correct information from patients or families was often key to preventing a mistake; Dr. Angood urges patients to participate in marking the site and ask whether surgeons are following the wrong-site prevention steps. The Joint Commission Web site (jointcommission.org4) has more information on the wrong-site protocol; consumers can download a brochure, "Help Avoid Mistakes in Your Surgery" and check the safety record of the facility at qualitycheck.org.
Aside from complications and errors during surgery, patients should ask about issues that may affect recovery after an operation, and what types of post-operative complications may occur. Dr. Russell of the American College of Surgeons advises patients to speak up about any concerns such as a wound that doesn't heal or pain that isn't controlled, and includes a list of post-operative complications to watch out for such as swelling in the legs that could signal a blood clot. In addition to his $19.95 book -- proceeds will be used for safety and education research -- the college offers free consumer information about what to expect from a number of different surgeries on its www.facs.org Web site.
Uncertainty Is My Co-Pilot
Benjamin Brewer, MD : WSJ Article : March 12, 2008
Uncertainty is a constant companion for family doctors.
Anyone with anything can walk through the door at any time. We have to figure out what to do in just a few minutes, often with scant resources.
The uncertainty that hangs over many cases seems strange to patients who expect doctors to come up with the one true answer and cure on the spot. Patients crave reassurance, but it's often tough for us to say anything definitive.
Patients present their doctors with undifferentiated problems, such as fever or trouble sleeping. Sometimes a common disease like a sore throat will present in a striking way. Or worse, a serious problem like lung cancer will present with a common symptom like a stubborn cough.
There's a steep penalty for being mistaken, however. An uncertain diagnosis often leads to expensive defensive medicine in the form of extra X-rays and lab tests. Tests like those can be a crutch. In my experience, they don't always help with diagnosis as much as a thorough medical history or physical exam.
Recently, a 20-year-old patient came in with a sore throat. Her tonsils were big and swollen with a shaggy white coating on them. She had no fever but did have some impressively swollen glands in her neck. Her liver, spleen and other lymph glands seemed OK. I thought she probably had a viral illness, maybe mononucleosis. A rapid strep test was negative and so was her influenza test. I did a throat culture and drew blood to send to the lab.
Was her illness just a bad viral sore throat or something worse? We wouldn't know the final answer for several days.
Pain relief, fluids and reassurance were the treatment I offered until the results came back. I fended off her mother's request for an antibiotic when she didn't improve immediately.
The initial mono test came back negative. It's frustrating when the tests you order don't confirm your suspicions. Further work I ordered at a specialized lab showed she had mononucleosis, as I had originally suspected. I'd taken the extra step because I figured that she and her parents would think the worst if I didn't prove it was mono from the beginning.
It's not always easy for patients or their doctors to wait for an answer. In medical school, our professors frighten all the reassurance out of us by talking up all the bad diseases that start out looking like something minor. I'll never forget my patient with a stuffy nose that developed into a life threatening disease called Wegener's Granulomatosis and the small bump on a child's leg that turned out to be cancer.
It takes three years or longer after med school before the ability to confidently heal comes back. Some doctors never quite get it back.
One reason is a problem my teachers pointed out 15 years ago: Diagnostic skills are in decline. A reliance on lab tests and X-rays has stunted doctors' willingness and ability to perform top-notch medical histories and physical exams.
Medical students' interest in general internal medicine and family medicine has dropped for more than a decade and hasn't yet stabilized. Nurse practitioners and physician assistants with less clinical diagnostic training than doctors are filling the primary care workforce void. It's been my observation that they order more tests to evaluate the same problem than doctors do because of the experience factor. Like a teenager behind the wheel, adding speed and power without careful judgment can compound problems.
With CT scans and MRI's of ever increasing sensitivity, radiologists are peering into the body and finding all sorts of little blood vessel abnormalities, calcium deposits and nodules of uncertain significance. Radiologists often put disclaimers on borderline reports such as "Clinical Correlation Required." When I see that I have about the same gut reaction as when I see "Some Assembly Required" on toys my kids got for Christmas.
Results like those leave referring physicians like me to wonder if we should biopsy these suspicious areas, follow them with more scans or ignore them at our peril. It seems to me that if these scans hadn't been ordered so freely in the first place, we wouldn't end up chasing so many incidental findings later on.
Illnesses don't always follow textbook descriptions. There will always be tough diagnoses, the occasional missed diagnosis, and sometimes puzzling patients with no identifiable diagnosis. However, there are fewer doctors today who can be considered master diagnosticians. The old experts are retiring and they're not being replaced. The rest of us all think we're above average. That's one diagnosis we're pretty certain about.
Finding a way to ask doctors tough questions
By Laura Landro : WSJ Article : March 4, 2009
Waiting to see his dermatologist about a skin rash, John Barnett heard the doctor sneeze loudly before he came into the exam room. The Seattle-area retiree says it took all his courage to ask, "Are you going to wash your hands before you examine me?"
Despite efforts by advocacy groups and others to empower patients, challenging a doctor or nurse on whether they are correctly doing their jobs remains downright intimidating. Signs and posters in hospitals urge us to "Speak Up" if we see a potential medical error. More nurses wear buttons these days that say "Ask Me If I've Washed My Hands." But even the most outspoken and assertive among us may suddenly turn meek when we are sick or vulnerable in a hospital, fearing that our treatment will suffer if we antagonize caregivers.
"It's all too common for patients and family members to remain silent when they suspect something is wrong or improper in their care," says David Shulkin, chief executive of Beth Israel Medical Center in New York City. "Patients and families must be willing to leave their comfort zone and speak up, and every institution has to think about how they can get patients more engaged in their own care," he says.
More and more institutions are making the effort to help patients take an active role in caring for their own health.
Kathy Todd was hospitalized in 2007 with complications before and after the premature birth of her daughter at a Seattle-area hospital. She found herself reluctant to ask nurses for anything she needed. She endured hours of pain one day when a nurse didn't administer pain medication because she didn't ask for it.
"I was sick and dragging myself down to the [neonatal ICU] to see my baby, and in that crisis situation I became very meek and took whatever they said and questioned nothing," says Ms. Todd, who is 31 years old. But after getting to know nurses, she says she realized she was being too reticent. She later agreed to go on a patient advisory board at the hospital and help new mothers through the experience. "You can't expect every patient who comes through to have the presence of mind in a crisis to ask for what they need or raise questions," she says. "It's up to the doctors and the hospital to set the tone and the culture to give people the bravery they need."
A growing number of institutions are taking steps to help. At Beth Israel, 53 physicians contributed chapters to "Questions Patients Need to Ask," a new book edited by Dr. Shulkin on issues ranging from how to ask about infection-prevention measures to what to do if a technician drawing blood misses a vein too many times -- after the second try, the book suggests, ask for someone else. The book is available online for $19.99.
The Robert Wood Johnson Foundation's new Aligning Forces for Quality program is providing $300 million in grants for community programs designed to get consumers to take an active role in their own care, especially those from certain racial and ethnic backgrounds. The Puget Sound Health Alliance, a coalition of employers in Washington state that received a grant, has set up a public Web site with a list of questions patients should ask surgeons, including whether they are following a state-endorsed checklist that includes checking patients' medication allergies and determining the risk of blood loss.
There is some evidence suggesting that greater patient involvement can improve medical outcomes. For example, the Robert Wood Johnson Foundation surveyed 600 patients with chronic illnesses in the Seattle area last year and found a link between how patients feel about their encounters with doctors and how well they adhere to their regimens. One finding: Among patients in treatment for depression who felt their medical providers treated them fairly, 90% took their medications regularly. But adherence to a regimen was just 60% among patients who said they feel they haven't been communicated with or were treated poorly.
"The culture around medicine is changing very quickly as patients begin to understand the full impact of medical errors and see that quality health care is not a given," says Bruce Siegel, a professor in the department of health policy at George Washington University who runs the Aligning Forces for Quality program. Many physicians are trained "to think of ourselves as little gods" and resist patients who question their authority, Dr. Siegel says. But "the more enlightened physicians are beginning to realize this could be a positive thing for health care."
The Pennsylvania Patient Safety Authority, which tracks medical errors and recommends preventive measures, says research conducted in the state shows patients are increasingly willing to ask certain questions of their doctor. It says patients will seek a better explanation of something they don't understand or question the reason for a procedure or unfamiliar drug.
But patients are most reluctant to ask anything that might be viewed as confrontational, such as requesting that health-care providers confirm a patient's identity before a procedure or asking practitioners to wash their hands, the group says. Hand washing is considered the most important preventive measure against the spread of potentially deadly infections.
I had that in mind on a recent visit to a Florida emergency room after my husband cut his forearm to the bone in a fall. As the doctor approached him, I said: "I have to ask you to wash your hands, according to that sign right there." The doctor took umbrage, gave me a speech about washing her hands 15 times a day, then gave them a cursory rinse under the faucet. "You don't use the hand sanitizer gel in that dispenser?" I ventured. "I don't like that stuff," was her response. After that, the doctor donned gloves and sewed him up nicely.
For Mr. Barnett, the Seattle-area retiree, the request that the dermatologist wash his hands had a better outcome. He says the doctor responded, "Oh yes, I should," and went and did so. Mr. Barnett, 78, says he believes passivity with doctors is more common in his generation. He says the experience taught him the importance of speaking up when he feels uncomfortable about his health care. Mr. Barnett now volunteers as an advocate for people in nursing homes, and serves on a state advisory committee about preventing hospital infections.
Delia Chiaramonte, a Baltimore physician who works as a consultant helping patients with serious medical conditions navigate the health-care system, says patients can be assertive in asking questions and challenging medical staffers without being offensive or confrontational. "Sometimes acknowledging the doctor's hard work can make them more interested in giving you what you want," Dr. Chiaramonte says. One approach she recommends is to say: "Wow, you really seem to be working hard today. Thanks so much for giving me a few extra minutes to talk about my concerns."
John Clarke, clinical director of the Pennsylvania Patient Safety Authority, suggests that someone too intimidated to ask if a doctor or nurse has washed his or her hands can say, "I'm concerned about getting germs from another patient." But Dr. Clarke says patients have to be prepared to escalate their expression of concerns. "If you think something is truly dangerous, you just have to say 'Stop, I'm not supposed to get this procedure,' " he says.
Many hospitals make use of the "Speak Up" campaign launched in 2002 by the Joint Commission, the nonprofit group that accredits hospitals. The program provides free brochures and posters to hospitals urging patients to take a role in preventing medication errors, infections and wrong-patient procedures. The brochures, available at www.jointcommission.org, provide lists of questions to ask medical practitioners, urging patients, for instance, to make sure doctors and nurses check their wristband and ask their name before administering medicine.
Mark Chassin, president of the Joint Commission, says hospitals also have to educate staffers about the importance of being receptive to patients who may fear speaking up. "Patients and families are usually sick, scared and anxious when seeking care, so [challenging a doctor] is not the same as beefing up your assertive self to negotiate on price when you are buying a car," he says.
At bedside, stay stoic or display emotions
By Barron H. Lerner, MD : NY Times Article : April 22, 2008
A young doctor sat down with a terminal lung cancer patient and her husband to discuss the woman’s gloomy prognosis. The patient began to cry. Then the doctor did, too.
The scene was undoubtedly moving. But should physicians display this much emotion at the bedside?
For years, medical schools and residency training programs studiously avoided the topic of emotions. Doctors learned the nuts and bolts of cancer and other serious diseases. Yet when it came time to reveal grim diagnoses, they were largely on their own.
These days, all medical schools have some type of education in topics like the physician-patient relationship and breaking bad news. But knowing how to respond to a personal wave of stress or sadness remains a major challenge. Is crying O.K.? How about hugging a patient who starts to cry?
One physician who cautions against excess emotions is Dr. Hiram S. Cody III, acting chief of the breast cancer service at Memorial Sloan-Kettering Cancer Center. Although Dr. Cody emphasizes the need for doctors “to understand, to sympathize, to empathize and to reassure,” he says his job “is not to be emotional and/or cry with my patients.”
There are two reasons for this stance, Dr. Cody tells young physicians on rounds: It is not therapeutic for the patient, and it will cause “emotional burnout” in the doctor.
These beliefs are shared by many other physicians, but some new data suggest that crying in a medical setting is common among young doctors. At a recent meeting of the Society of General Internal Medicine, Dr. Anthony D. Sung of Harvard Medical School and colleagues reported that 69 percent of medical students and 74 percent of interns said they had cried at least once. As might be expected, more than twice as many women cried as men.
In some instances on the wards, the emotions just flow. For example, in the 1988 PBS documentary “Can We Make a Better Doctor?” a Harvard medical student, Jane Liebschutz, sees her patient unexpectedly die during a cardiac bypass operation. She suddenly bursts into tears and wanders away from her colleagues until the chief surgeon, who has witnessed what happened, assures her that her response was natural.
Other physicians may choose to place themselves in emotional situations. Dr. May Hua, an anesthesiology resident at Columbia University Medical Center, recently told me that during her internship, her supervising resident, Dr. Benita Burke, skipped lunch to spend extra time with her cancer patients. They dubbed this time “mental health rounds,” during which they could address issues that were not strictly medical. Many times, Dr. Burke would wind up in tears or giving an embrace.
“I think patients adored Benita,” Dr. Hua said, “both as their doctor and as their friend.”
But even as she admired her colleague, Dr. Hua realized that such public emotion was not for her. “I knew this was something I couldn’t do, because I needed to have a level of detachment to these people.”
I understood exactly what Dr. Hua meant. Whether because of my personality or my being a man, I, too, have never cried in front of a patient.
Dr. Burke says she believes that her crying stems from being “very involved” in her cases, which leads her to “take everything to heart.” In the case of the lung cancer patient, Dr. Burke had been the first physician to inform her that further aggressive treatment was unlikely to help. In other words, the patient was dying.
Dr. Burke said she realized that this level of involvement was uncommon but believed that she could not be any other kind of doctor. “I’ve always been a very emotional person at baseline,” she said.
Dr. Sung’s study concludes with a call for senior doctors to acknowledge and discuss openly the apparent high rates of crying among medical trainees.
Yet while health professionals — not only physicians but also nurses and social workers — may debate among themselves the propriety of emotional displays, what probably matters most is what patients think. Just as different doctors respond differently to sad situations, so do patients and their families. While some might appreciate physical contact or tears, others find such displays to be too “touchy-feely.”
Cancer patients may encounter such situations more than most. One breast cancer survivor, Sharon Rapoport, of Roanoke, Va., said she greatly admired physicians like Dr. Cody, who may appear reserved but communicate their concern through their actions.
But Ms. Rapoport also said she had an extra appreciation for doctors who felt comfortable with outward displays of emotion. “If that means tears,” she said, “bring them on.”
Dr. Barron H. Lerner teaches medicine and public health at Columbia University Medical Center.
By Jane E. Brody : NY Times : September 30, 2008
Does your doctor spend time talking to you? Do you see your doctor within 20 minutes of your appointment time? Are you getting the guidance you need to cope with a continuing health problem or multiple overlapping problems? Do you even have a personal physician who monitors your health and treats you promptly with skill and compassion?
A “no” answer to any of these questions — even to all of them — would not be surprising. Finding doctors who know their patients well and who deliver informed medical care with efficiency and empathy has become quite a challenge in America.
There is a crisis in medicine today, and it will not be fixed by any candidate’s proposal to provide health insurance for the 45 million Americans now without it. In fact, an increase in insured Americans could make it worse.
The crisis is a diminishing supply of primary care physicians, the doctors on the firing line — family physicians, internists, pediatricians, gerontologists and others — who practice the art and the science of medicine and who seek to put patients at least on a par with their pocketbooks.
According to a study published this month in The Journal of the American Medical Association, the number of medical students choosing to train in internal medicine is down, and young physicians are leaving the field. Other primary care specialties, including family medicine and gerontology, have also reported drops.
Primary care doctors spend far more time talking to patients and helping them avert health crises or cope with ailments that are chronic and incurable than they spend performing tests and procedures.
They are the doctors who ask pertinent questions, about health and also about life circumstances, and who listen carefully to how patients answer. They are the doctors who know their patients, and often the patients’ families, and the circumstances and beliefs that can make health problems worse or impede effective treatment.
The problem is that in this era of managed care and reimbursements dictated by Medicare and other insurers, doctors don’t get much compensation for talking to patients. They get paid primarily for procedures, from blood tests to surgery, and for the number of patients they see.
Most are burdened with paperwork and hours spent negotiating treatment options with insurers. And the payments they receive for services have not increased as the costs of running a modern medical practice have risen. To make ends meet and earn a reasonable income of, say, $150,000 a year, many primary care doctors have to squeeze more and more patients into the workday.
“If you have only six to eight minutes per patient, which is the average under managed care, you’re forced to concentrate on the acute problem and ignore all the rest,” said Dr. Byron M. Thomashow, medical director of the Center for Chest Diseases at New York-Presbyterian Columbia Medical Center.
Yet, he said in an interview, in a study of more than 3,000 patients with chronic obstructive pulmonary disease, 50 to 60 percent had one or more other illnesses, and 20 percent had more than 11 other problems that warranted medical attention.
“There just isn’t the time to address them all,” he said.
Dr. Alan J. Stein, an infectious disease specialist in private practice in Brooklyn who treats many patients with H.I.V., described his practice as “heavily cognitive.”
“I spend a lot of time talking to patients — listening to them, examining them, interpreting tests and figuring out what’s wrong,” he said in an interview. “I don’t do procedures in the office. Over the last 10 or 15 years, the income of procedure-based physicians like cardiologists has increased significantly, whereas for those in primary care it has remained the same.”
Dr. Michael Stewart, chairman of the department of otorhinolaryngology at New York-Presbyterian Weill Cornell Medical Center, said in an interview that the challenge today was that “everything is going up except reimbursement. The tendency is to see more patients in a given amount of time, and so less time is spent with each patient.”
As a result, many who became doctors because they are genuinely interested in helping people get well and stay well or live a good life despite a continuing illness are increasingly disillusioned. Like Dr. Thomashow, a growing number of independent physicians are finding that the only way they can practice effectively is to not accept insurance and to ask patients to pay out of pocket.
Dr. Allen Bowling, a neurologist affiliated with the Rocky Mountain Multiple Sclerosis Center in Englewood, Colo., decided last year to convert his “busy, high overhead, insurance-based M.S. practice to one that has lower overhead, is moderately busy, and does not accept any private or government insurance.” He did that, he wrote in Neurology Today in June, to give his patients “high-quality, personalized and moderately priced care with easy access to the neurologist.”
He is passionate about caring for multiple sclerosis patients, he said, but to continue practicing the kind of medicine they deserve, he had to change how he was reimbursed.
“Good doctors do drop out of managed care, and in the future I might have to drop out as well,” Dr. Stewart said. He acknowledged that specialists like him have an advantage.
“The amount of time I spend with patients is not such an issue,” he said. “But this is a big problem for primary care specialties where patients need a lot of time.”
Even some salaried academic physicians like Dr. Douglas A. Drossman, who runs a respected clinic where patients are treated regardless of ability to pay, often have to scramble for grants from foundations and industry to support their work with patients.
Dr. Drossman, co-director of the Center for Functional Gastrointestinal and Motility Disorders at the University of North Carolina, said the salaries he and his colleagues receive do not cover the program’s costs. The program treats patients with life-disrupting chronic conditions like irritable bowel syndrome, many of them referred by other diagnostic centers like the Mayo Clinic.
“Many patients who come to us have been to countless doctors and told that there’s nothing organically wrong with them, it’s all in their heads and they just have to live with it,” Dr. Drossman said. “These patients wonder whether something has been missed. They’ve had all the tests. There’s no need to do more. But it takes time to help patients understand theirs is a real problem and to learn how to deal with it.”
Dr. Karen E. Hauer of the University of California, San Francisco, who directed the study of medical students, said in an interview that students were “turned off by the hassles in the practice environment — the paperwork, insurance issues, pace of work and expectations to get the work done quickly without having adequate time to spend with patients.”
This is a particular problem for doctors who treat the growing older population. Trends suggest there will not be nearly enough doctors for these patients, Dr. Hauer said.
Whatever the future of health care may hold for Americans, Dr. Thomashow said, “We need to go forward with something that keeps the humanity in medicine.”
Is physician burnout really a problem?
By Dr. Suzanne Koven | GLOBE CORRESPONDENT MAY 26, 2014
The doctor will see you now — but he or she won’t be happy about it.
At least that’s what the popular news site, The Daily Beast, contends. An item published last month grimly titled “How Being a Doctor Became the Most Miserable Profession” cited high suicide rates among physicians and increasing numbers of doctors retiring early and leaving medicine for the corporate world as evidence of widespread misery among my colleagues. Loss of respect and autonomy, decreased insurance reimbursements, and larger administrative burdens — some imposed by new medical documentation requirements under the Affordable Care Act — are said to contribute to our alleged burnout.
Also last month, an editorial appeared in The Wall Street Journal titled “A Doctor’s Declaration of Independence.” An orthopedic surgeon called for physicians to say, essentially: “We’re mad as hell and we’re not going to take it anymore!” Dr. Daniel F. Craviotto Jr. claimed: “I don’t know about other physicians but I am tired — tired of the mandates, tired of outside interference, tired of anything that unnecessarily interferes with the way I practice medicine. No other profession would put up with this kind of scrutiny and coercion from outside forces.”
Craviotto recommended radical action by doctors, such as refusing to accept insurance, including Medicare, until our grievances are addressed.
I have mixed feelings about these articles, and many similar recent ones touting how awful my job has supposedly become.
On the one hand, I feel validated. There’s no question that practicing medicine isn’t as much fun as it was even five years ago. New regulations and restrictions issued by government agencies, insurance companies, and professional organizations mean I now spend time I’d rather spend with patients checking boxes, populating templates, and dialing 800 numbers.
Also, because of decreasing reimbursements, physicians are now under pressure to see patients more quickly than ever before. A primary care doctor now spends an average of 12 minutes with each patient. That’s not much time in which to see someone with a long list of complex medical problems and medications and numerous questions and complaints — not to mention a life story, tricky family dynamics, and photos of grandchildren to share.
More busywork combined with shorter visits make me feel perpetually rushed, which makes both me and my patients unhappy. Studies show that a rushed physician is more likely to make mistakes. A more pernicious effect is that when a doctor is in a hurry he or she is less likely to fully engage a patient.
For example, not long ago, I met a new patient who had a fairly simple medical history but who’d suffered much pain and loss. I found myself resisting the temptation to save time by not probing those emotions too deeply, even though I knew that doing so would forge a bond between us, a bond that would help me be a better doctor to this patient — the kind of bond that is, to me, the most satisfying part of medicine.
Still, I think that while the Daily Beast and others accurately convey, to some extent, the concerns of many physicians, they do so in an overly dramatic and misleading way.
Take the assertion that high suicide rates among doctors reflect decreasing job satisfaction. It’s true that 300 to 400 American doctors kill themselves every year. But high suicide rates among physicians have been noted for decades and have been attributed to uncontrolled depression, not job dissatisfaction. Doctors often feel embarrassed about seeking psychiatric care from their colleagues or fear that the stigma of a psychiatric diagnosis will jeopardize their livelihoods. This fear is well-founded. It’s only recently that most state medical licensing boards have stopped requiring physicians to report whether they’ve ever received mental health care — information that has been passed along to insurance companies and hospitals.
Physicians retire early, elect to work part-time, and opt out of practice for many reasons besides “misery,” including a need to care for family, a desire to explore other interests, and to seek higher salaries to pay off the six-figure debt that medical trainees, on average, incur.
The tedium associated with current medical practice is irksome, but not entirely new. My dad, who was a solo practitioner in the 1950s through 1980s, did more paperwork than I’ll ever do. He spent hours at home every night dictating notes and letters into a clunky IBM dictaphone. And I’m just old enough to remember the early days of hospital computing systems when gathering a patient’s data involved calling or even walking from lab to lab.
I’m not denying that my colleagues and I are frustrated by changes in medicine, but that frustration is more nuanced and more counterbalanced by joy than most media coverage reflects.
In a recent conversation with several colleagues about professional burnout I was struck by the fact that different people felt burned out by different things: for some it was filling out forms, for others it was being scrutinized by bureaucrats. For me, it’s being the target of anger and suspicion that seem so prevalent in society today. I appreciate patients informing and advocating for themselves. I don’t appreciate patients arguing with me about anatomy and physiology — or my motives.
Many of my colleagues said that burnout isn’t an all-or-nothing state, that they felt burned out on certain days but that often, after a vacation or even one meaningful patient encounter, they’re rejuvenated.
Interestingly, a friend of mine who’s a public school teacher told me The Daily Beast piece captured the current mood of her profession. I’ve spoken to people in many fields who feel more pressured and less appreciated in recent years.
I wonder if physicians are really no more burned out than anyone else. Maybe we get written about because people find it fascinating — or even a little gratifying? — that highly trained people who do rewarding work with good job security and relatively generous pay can be as unhappy as everyone else.
Dr. Suzanne Koven is a primary care internist at Massachusetts General Hospital.
Finding a Quality Doctor
By Danielle Ofri, MD : NY Times : August 18, 2011
“Quality.” It’s one of those words that used to mean something: actual quality you could trust. Nowadays in hospital hallways, quality is a charged word that is more corporate-speak than actual English, eliciting stomach churning and eye rolling in equal measures.
Quality. Who can argue with such a noble goal? Of course we all want quality medical care. Doctors want to provide quality care, patients want to receive quality care, and administrators want to demonstrate quality care in their institutions. All parties aligned in agreement.
The problem, of course, is that no one can agree on how to measure quality. This might be an intriguing question to untangle, if it weren’t for the fact that the quality measurement field has long since left the starting gate. Despite a lack of agreement on how best to measure quality, metrics are being applied broadly, with concrete consequences for doctors, nurses, hospitals and patients.
My own experience in being evaluated for “quality” left me with decidedly mixed feelings. Our hospital had undertaken a laudable and herculean effort to improve the care of patients with diabetes. There was no disagreement that diabetes is one of the most complicated diseases we face, and that these patients would benefit from the best medical care possible.
In that light, each doctor was given a report card citing the percentages of his or her patients whose glucose, blood pressure and cholesterol were “at goal.” These seemed like reasonable data points to evaluate how good a job we were doing.
My report card was dismal, way below the targets our institution had set. It made me feel awful, because I was already working hard. But I felt guilty about the bad numbers, so I worked harder, staying later in the office and calling patients from home. Still, my numbers didn’t seem to budge; it was downright dispiriting.
I wrote about this experience in an essay in The New England Journal of Medicine. In it, I tried to point out that these sorts of metrics don’t give a full measure of quality; they simply measure what is easy for administrators to measure. Like the blind men touching the elephant, they can describe only isolated parts of a medical encounter. Each metric might be important, but they do not add up to the totality of good medical care.
Most people, when they need a doctor, ask for personal recommendations about someone who is smart, caring, thorough, thoughtful and trustworthy. Rarely do they ask for a physician with the best stats.
The responses were swift and vehement. “Dr. Ofri, are you afraid to be measured by hard data?” was a common refrain. My suggestions that most doctors are genuinely doing their best to help their patients and that these report cards might not be accurate reflections of their care were considered evidence of arrogance.
Many of these opinions came from doctors — but mostly doctors who were not involved in direct patient care (medical administrators, pathologists, radiologists). None were in the trenches of primary care.
In contrast to these comments, I was flooded with personal letters from nurses and doctors who felt demoralized by the quality measurement system. These were clinicians who were trying their best in a dysfunctional system, but were constantly being told how they weren’t measuring up. Many said that they were ready to quit, but couldn’t countenance abandoning their patients.
I thought about these nurses and doctors when I came across a recent study that found that patient outcomes (in this case, preventing readmission to the hospital after being discharged) were correlated more strongly to the “fuzzy” measure of patient satisfaction than to the standard “objective” measures of quality.
Patient satisfaction can be an amorphous thing to quantify. But typically, when someone expresses satisfaction with a doctor’s care and would recommend him or her to someone else, it usually includes those “soft” attributes like attentiveness, curiosity, compassion, diligence, connection and communication.
There certainly are some bad doctors out there — incompetents, loafers — and they should be weeded out. But they are a minority.
This is not to say that there isn’t room for every doctor to improve. I don’t view my poor scores as a free pass to blame the system for everything. I have to take responsibility for the things that I have control over, and do my best to stay current and improve my skills.
We need to remind ourselves and the public, though, that these quality measures miss much of what makes a good doctor good. If you want every blood pressure below 130/80, hire a computer to dose the drinking water with antihypertensives. The quality measures will be perfect, and every hospital will be No. 1 in the U.S. News & World Report rankings.
But if you are facing illness — critical, chronic or terminal — you might seek other qualities.
You are sick. Now what?
Knowledge is power
By Tara Parker-Pope : NY Times Article : September 30, 2008
Are patients swimming in a sea of health information? Or are they drowning in it?
The rise of the Internet, along with thousands of health-oriented Web sites, medical blogs and even doctor-based television and radio programs, means that today’s patients have more opportunities than ever to take charge of their medical care. Technological advances have vastly increased doctors’ diagnostic tools and treatments, and have exponentially expanded the amount of information on just about every known disease.
The daily bombardment of news reports and drug advertising offers little guidance on how to make sense of self-proclaimed medical breakthroughs and claims of worrisome risks. And doctors, the people best equipped to guide us through these murky waters, are finding themselves with less time to spend with their patients.
But patients have more than ever to gain by decoding the latest health news and researching their own medical care.
“I don’t think people have a choice — it’s mandatory,” said Dr. Marisa Weiss, a breast oncologist in Pennsylvania who founded the Web site breastcancer.org. “The time you have with your doctor is getting progressively shorter, yet there’s so much more to talk about. You have to prepare for this important meeting.”
Whether you are trying to make sense of the latest health news or you have a diagnosis of a serious illness, the basic rules of health research are the same. From interviews with doctors and patients, here are the most important steps to take in a search for medical answers.
Determine your information personality.
Information gives some people a sense of control. For others, it’s overwhelming. An acquaintance of this reporter, a New York father coping with his infant son’s heart problem, knew he would be paralyzed with indecision if his research led to too many choices. So he focused on finding the area’s best pediatric cardiologist and left the decisions to the experts.
Others, like Amy Haberland, 50, a breast cancer patient in Arlington, Mass., pore through medical journals, looking not just for answers but also for better questions to ask their doctors.
“Knowledge is power,” Ms. Haberland said. “I think knowing the reality of the risks of my cancer makes me more comfortable undergoing my treatment.”
Dr. Michael Fisch, interim chairman of general oncology for the University of Texas M. D. Anderson Cancer Center, says that before patients embark on a quest for information, they need to think about their goals and how they might react to information overload.
“Just like with medicine, you have to ask yourself what dose you can take,” he said. “For some people, more information makes them wackier, while others get more relaxed and feel more empowered.”
The goal is to find an M.D., not become one.
Often patients begin a medical search hoping to discover a breakthrough medical study or a cure buried on the Internet. But even the best medical searches don’t always give you the answers. Instead, they lead you to doctors who can provide you with even more information.
“It’s probably the most important thing in your cancer care that you believe someone has your best interests at heart,” said Dr. Anna Pavlick, director of the melanoma program at the New York University Cancer Institute. “In an area where there are no right answers, you’re going to get a different opinion with every doctor you see. You’ve got to find a doctor you feel most comfortable with, the one you most trust.”
Keep statistics in perspective.
Patients researching their health often come across frightening statistics. Statistics can give you a sense of overall risk, but they shouldn’t be the deciding factor in your care.
Jolanta Stettler, 39, of Denver, was told she had less than six months to live after getting a diagnosis of ocular melanoma, a rare cancer of the eye that had spread to her liver.
“I was told there is absolutely nothing they could help me with, no treatment,” said Ms. Stettler, a mother of three. “I was left on my own.”
Ms. Stettler and her husband, a truck driver, began searching the Internet. She found Dr. Charles Nutting, an interventional radiologist at Swedish Medical Center in Englewood, Colo., who was just beginning to study a treatment that involves injecting tiny beads that emit small amounts of radiation. That appeared to help for about 18 months.
When her disease progressed again, Ms. Stettler searched for clinical trials of treatments for advanced ocular melanoma, and found a National Institutes of Health study of “isolated hepatic perfusion,” which delivers concentrated chemotherapy to patients with liver metastases. After the first treatment, Ms. Stettler’s tumors had shrunk by half.
“I don’t like statistics,” she said. “If this study stops working for me, I’ll go find another study. Each type of treatment I have is stretching out my life. It gives me more time, and it gives more time to the people who are working really hard to come up with a treatment for this cancer.”
Don’t limit yourself to the Web.
There’s more to decoding your health than the Web. Along with your doctor, your family, other patients and support groups can be resources. So can the library. When she found out she had Type 2 diabetes in 2006, Barbara Johnson, 53, of Chanhassen, Minn., spent time on the Internet, but also took nutrition classes and read books to study up on the disease.
“I was blindsided — I didn’t know anybody who had it,” said Ms. Johnson, who told her story on the American Heart Association’s Web site, IKnowDiabetes.org. “But this is a disease you have to manage yourself.”
Tell your doctor about your research.
Often patients begin a health search because their own doctors don’t seem to have the right answers. All her life, Lynne Kaiser, 44, of Plano, Tex., suffered from leg pain and poor sleep; her gynecologist told her she had “extreme PMS.” But by searching the medical literature for “adult growing pains,” she learned about restless legs syndrome and a doctor who had studied it.
“I had gone to the doctors too many times and gotten no help and no results,” said Ms. Kaiser, who is now a volunteer patient advocate for the Web site WhatIsRLS.org. The new doctor she found “really pushed me to educate myself further and pushed me to look for support.”
Although some doctors may discourage patients from doing their own research, many say they want to be included in the process.
Dr. Fisch of M. D. Anderson recalls a patient with advanced pancreatic cancer who decided against conventional chemotherapy, opting for clinical trials and alternative treatments. But instead of sending her away, Dr. Fisch said he kept her in the “loop of care.” He even had his colleagues use a mass spectroscopy machine to evaluate a blue scorpion venom treatment the patient had stumbled on. It turned out to be just blue water.
“We monitored no therapy like we would anything else, by watching her and staying open to her choices,” Dr. Fisch said. “She lived about a year from the time of diagnosis, and she had a high quality of life.”
Dr. Shalom Kalnicki, chairman of Radiation Oncology at the Montefiore-Einstein Cancer Center, says he tries to guide his patients, explaining the importance of peer-reviewed information to help them filter out less reliable advice. He also encourages them to call or e-mail him with questions as they “study their own case.”
“We need to help them sort through it, not discourage the use of information,” he said. “We have to acknowledge that patients do this research. It’s important that instead of fighting against it, that we join them and become their coaches in the process.”
The Doctor Dilemma
By Joanne Kaufman
New York City has more MD's than anyplace else on the planet. So why is the right one harder to find than a rent-controlled six on Central Park West? It needn't be -- you just have to know WHERE to look.
When I moved to New York from Michigan after college, I was baffled to discover that finding a job (in three days) and an apartment (in four) was a lot easier than finding a doctor, perhaps because there was no medical equivalent of a real-estate broker to whom I could articulate my most basic needs: reasonable fees, in the neighborhood, warm, accessible, infallible. For a while, I even kept my suburban-Detroit medical team in place, scheduling visits home to coincide with checkups. As you can imagine, this health hajj quickly became impractical. But without a network of friends and colleagues to steer me to the right lab coat, I was reduced to finding referrals by eavesdropping on conversations in the women's locker room at the 92nd Street Y and on buses; the results were discouraging, to say the least.
After a few years of trial and error, I found my internist through my best friend's second husband's first wife. I found my dermatologist through my college roommate's brother, my radiologist through my husband's cousin, and my ob/gyn, a fertility specialist, through a former boss who provided the ultimate recommendation: She'd just gotten pregnant. Finally, I'm set. And you?
New York is a city of doctors, thousands of doctors -- nearly 60,000 at last count, the largest concentration in the country. Paradoxically, it's also a city of people searching for first-rate care that meets all their needs -- medical, emotional, geographical and, of course, financial. So what's the problem?
First, it sometimes seems easier to live with a nagging stomachache or backache than to deal with the headache of trying to pick from that big pool of docs -- particularly as medicine becomes increasingly sophisticated and presents more treatment options. You know you need a urologist. Do you go to the guy who does minimally invasive laparoscopic surgery or the one with the more conservative technique? If you're facing cancer, how do you hook up with someone with access to treatment protocols for new chemotherapy? How do you even find out that such protocols exist?
"It's much more difficult now than it once was," says Mark Reiner, a general surgeon. "In the old days, the doctor would say, 'You should see Dr. Smith. He operated on my family members.' Today, people are bombarded with ads and news reports; they're going on the Internet . . . " (This last a thorny prospect, offering reams of unfiltered information but also hospital and physicians' Websites that can arm you with plenty of useful information.) Patients whose choices are limited by their insurance plans have a whole other set of issues. Because of anorexic reimbursements from insurance companies and the government, doctors have to see seven or eight or twelve patients an hour to eke out a reasonable income these days -- which means hurried, harried care. And just when you've found a physician who's a good match, your employer switches health plans, or your doctor of choice drops out.
What complicates matters is that the doctor you just have to see is -- as often as not -- no longer taking new patients. "I think Manhattan people are obsessed with the idea of the best and whether a certain practitioner is a chic doctor," says an internist-cardiologist at New York-Presbyterian. "There's a lot of he's the only one syndrome, a desire to know the patient profile of the doctor and to know whether there are important people in a given doctor's practice. And of course, there are some doctors who cultivate that patient group."
But if your mother was right when she told you there was more than one Mr. Right (or Ms. Right), there's also more than one Dr. Right. "The question is, why do you need that one doctor?" asks Zeev Neuwirth, an internist at Lenox Hill. "Chances are, in New York City, thank God, there is someone else who can do that specialized procedure." And if the doctor you desire isn't available, someone else in his or her practice probably is. "You might be better off with that doctor's associate," says Neuwirth, "someone who isn't as senior or doesn't have the same reputation but is equally competent." Indeed, that junior doctor, intent on building a practice, may also take your insurance, while the senior guy only takes cash.
Still insist on seeing the big kahuna who steadfastly insists he's taking no new patients? "If you have another way in to that doctor aside from bullying the receptionist, use it," says Stephen G. Baum, chairman of medicine at Beth Israel. "Have your internist call on your behalf. If you know someone who's been that doctor's patient, have him intervene for you."
Most of us find our doctors through the recommendations of others, and that can be a blessing -- or a curse. One physician's type-A-personality bedside manner may be perfectly suited to your hypochondriac best friend's needs but not to your laissez-faire approach to survival.
Whether you're in an HMO or have the means to go to any doctor you desire, nothing is more important than getting comfortable with your primary-care physician, typically an internist with a specialty in some field of particular relevance to you. If you're not comfortable with the gatekeeper, you won't be comfortable with his or her referrals, which are often sought during times of crisis, and you'll end up shortchanging your health in ways you wouldn't dream of doing to, say, your appearance.
If you're fortunate enough to have a friend who's a doctor, ask for referrals, for scuttlebutt, and for guidance. But Mack Lipkin, a professor of clinical medicine and director of the primary-care division at NYU Medical Center, who frequently finds himself serving as a medical clearinghouse, says his recommendations are only as good as the information prospective patients provide at the outset. To get started, you should:
* Familiarize yourself with your HMO's Website in order to get basic information about primary-care physicians who match your requirements of location and subspecialty. Also useful: medicalconsumers.org, which offers information about the number of times a doctor has performed a particular procedure; and nydoctorprofile.com, a site run by the state Health Department that has information about whether a physician has ever been disciplined.
* Consider your comfort level with a doctor of the opposite sex (something that women grow up with but that more men are confronting -- maybe not a bad thing, since women tend to spend more time forming "partnerships" with patients). Similarly, is a doctor's age a factor in your comfort level?
* Take into account your special medical needs and likelihood of needing hospitalization. If you are at high risk for a heart attack or require ongoing treatment, you'll want a doctor who has privileges at the hospital you need to be in.
Most crucial to Lipkin is the tricky task of matching doctor-patient styles. If, for example, your mode of self-care involves vitamins, acupuncture, and the Alexander technique, you're unlikely to do well with a doctor who either doesn't know from Alexander or doesn't approve of such things. Some people prefer to try to change their unhealthy lifestyles and avoid medications -- and for them, there's no point in going to a doctor who just prescribes medication. Other things to consider along these lines:
* Do you prefer a doctor who lays out all the options and asks you to decide? Or one who says, "This is what I think would be best"? Or one who says, "This is what has to be done"?
* Do you want a doctor used to sharing a great deal of information, or one who is more low-key and reserved? "A stock analyst or lawyer or academic needs information," says Lipkin. "That's their stock-in-trade. They're not going to be happy with a doctor who boils something down to the nub. If they have congestive heart failure, they want to know exactly what it is and what it involves rather than being told the pump isn't working."
Our best advice: shop around. We are willing to interview a battalion of pediatricians before settling on the one who is right for our kids, yet too often we don't do the same for ourselves. "It's crazy to enter into a long-term relationship," says Lipkin, "where your safety and well-being and longevity are at stake, and not be in the right relationship. "If you feel not understood, not cared about," he continues, "if you feel that you can't ask for a better explanation of something, that you can't negotiate the approach to your care, you're not going to be able to tell the doctor about difficult things like that you're not taking your medicine or that you're drinking more than you feel is right. You're going to jeopardize yourself when it really counts. You're going to wake up one night, feel really sick, and not call the doctor."
So move on. If you can hire a doctor, you can fire a doctor. Here in New York, there are plenty more where that one came from
Choosing a doctor :
Tips for making the right decision
Your doctor is your family's most important health care partner, so it's important to choose this person carefully -- especially if you have a managed care health insurance plan. These plans require you to see the same primary care physician for all of your medical needs, before you get access to specialists and other medical services.
So, how do you make this important decision? First, you'll want to get some unbiased information about prospective doctors in your area -- and then meet with two or three doctors to learn more before making your final decision.
Here's how to get started:
1. Ask families, friends and co-workers about their doctors. Ask what they like and what they don't like about the care they're receiving.
2. Contact hospitals and referral services for information on doctors who are taking new patients.
3. Ask your insurance plan provider for any information they have on their member doctors.
4. Call the doctor's own medical office for information on his/her training and experience. Many offices will provide detailed brochures or biographies on request. Or look up prospective doctors in the Directory of Medical Specialists, available at your local library. This reference includes professional and biographic information on more then 400,000 doctors.
5. Visit the American Medical Association's online physician directory. Another resource for finding a doctor is DocFinder from the Association of State Medical Board Executive Directors.
6. Visit Consumers' Checkbook and BestDoctors.com for rankings of best doctors based on input from other doctors. There is a catch: both charge you for access to the search tool.
7. Call or visit the Web site of the American Board of Medical Specialties to learn if a particular doctor is board certified in a given area of medicine. Board certification ensures that the doctor has completed several years of training in the given area, and has passed a specialty-specific examination. You can confirm that a doctor has a particular specialty by calling the American Board of Medical Specialties at 866-275-2267.
8. Call your state licensing board to learn about any registered complaints or disciplinary actions taken against any of the doctors you're considering. Some state licensing boards can be found online. For a partial list, go to the American Board of Medical Specialties. For a fee, you can also get a Disciplinary History Report at DocInfo.
Once you've narrowed your search down to two or three doctors, set up a getting-acquainted meeting. A few things to ask at that meeting:
* When are the offices open? How would I get care after hours or when there aren't any available appointments?
* Are most of the visits with the doctor or with someone else, such as a nurse practitioner?
* What services does the doctor offer for health maintenance and preventive medicine?
* What approach would the doctor take for any special health needs in your family? Is he/she familiar with these conditions? How many does he/she treat per month, or per year?
When the Doctor Doesn’t Look Like You
By Pauline W. Chen, MD : NY Times Article : August 12, 2010
One night during my training, over dinner in the hospital cafeteria, a fellow resident and I had a discussion about the situation of one of our professors. Known for his blistering teaching sessions, this senior surgeon possessed the uncanny ability to sniff out lapses in memory or judgment among doctors-in-training. Early on in my internship, I showed up at one of his practice trauma resuscitations blissfully unprepared. I left an hour later with his booming and rapid-fire admonitions still ringing in my ears. “You call yourself a doctor?” he had thundered. “This patient may just be a dummy, but you are killing her!”
Nonetheless, this surgeon soon became a favorite of ours. He was brilliant in the operating room, gentle at the patients’ bedside and, as I quickly learned, highly effective in the classroom. What continued to vex me, however, was not the peculiarity of his teaching style; it was his inability to attract patients. While other, less-skilled senior doctors had waiting rooms that were overflowing, his was not.
“If I were sick,” I said to my fellow resident that night, “I know which surgeon I would ask for.”
“But you can understand why some patients and referring doctors don’t go to him,” she replied matter-of-factly. “Other guys wear Brooks Brothers, have recognizable last names and carry a degree from the ‘right’ medical school. But when a potential patient or referring doctor sees our guy, all they might notice is a foreigner with an accent and a strange name who graduated from a medical school in some developing country.”
Our professor had been born abroad and immigrated to the United States after medical school. But despite clinical accomplishments and professional accolades in this country, I knew, like my fellow resident, that there were patients and physicians whose initial impulse was to dismiss him or any other doctor with an accent or an international degree.
For more than 50 years, international medical school graduates like my former professor have filled the gaps in the physician work force in the United States. Currently, they make up fully one-quarter of all practicing physicians, and although a majority are foreign-born, approximately 20 percent are American citizens who have chosen to go abroad, most notably to the Caribbean, for medical school.
Regardless of whether they are United States citizens, all international graduates must go through an arduous regulatory process before practicing in this country, a process that includes verification of medical school diplomas and transcripts, residency training in American hospitals and the same national three-part licensing exams and specialty tests that their medical school counterparts in this country take. Many go on to choose specialties or work in the rural and disadvantaged geographic locations that their American counterparts shun. International graduates, for example, now account for nearly 30 percent of all primary care doctors, a specialty that has had increasing difficulties attracting American medical students.
Though these doctors have filled an important national health care need for over half a century, doubts regarding the quality of care they provide have continued to plague them. Health care experts interested in this issue have been stymied over the years by inadequate methodologies for evaluating the effectiveness of large groups of physicians and so have chosen instead to focus on exam scores, an admittedly crude proxy for quality of care.
But even that data has proven confusing. Studies initially revealed that international graduates tended to score lower, while more recent research shows that they routinely outperform their peers on training exams in areas like internal medicine.
Now researchers from the Foundation for Advancement of International Medical Education and Research in Philadelphia have published the first study incorporating new research methods for evaluating the performance of large groups of physicians. And it turns out that contrary to certain individuals’ worst fears, accent or nationality did not affect patient outcomes. Rather, the main factor was being board-certified: completing a full residency at an accredited training program, passing written and, depending on the specialty, oral examinations, and having proof of experience with a defined set of clinical problems and technical procedures.
The researchers examined the records of more than 240,000 patients who were hospitalized for either congestive heart failure or heart attack and examined how their outcomes correlated with their doctors’ education and background. They found no differences in mortality rates between those patients cared for by graduates of international or American medical schools. But on closer review, they found that two factors did contribute significantly to differences in patient outcomes.
Dividing the international medical graduates into those who were foreign-born and those who were American citizens who chose to study abroad, the researchers discovered that patients of foreign-born primary care physicians fared significantly better than patients of American primary care doctors who received their medical degrees either here or abroad. John J. Norcini, lead author of the study and president of the foundation, postulates that the differences may stem from the fact that as primary care has become less attractive for graduates of American medical schools, it has also become less competitive. “The foreign international medical graduates are some of the smartest kids from around the world,” he said. “When they come over, they tend to fill in where the U.S. medical school graduates don’t necessarily go.”
Dr. Norcini and his co-investigators also found that patient mortality rates were related to the doctor’s board certification and time since medical school graduation, regardless of his or her background. Those physicians in the study who were board-certified had substantially lower death rates among their patients. And the greater the number of years since medical school graduation, the more likely that doctor was to have a patient with heart attack or congestive heart failure die in the hospital.
“If you put these two pieces of data together,” Dr. Norcini said, “they make a strong argument for board certification and the maintenance of certification programs currently being put in place to improve the periodic reassessment of board-certified doctors.”
While the results of this study will help Dr. Norcini and other medical educators further refine the regulatory process for physicians from international and domestic medical schools, Dr. Norcini points out that there is a “huge heterogeneity in all these groups” and cautions doctors and patients against making broad generalizations about any physician group. Instead, when searching for the best doctors, he recommends focusing not on a doctor’s medical school or country of origin but rather on board certification.
“My hope is that we begin to rely more on objective markers like board certification as a statement of quality rather than where someone went to medical school,” Dr. Norcini said. “One can always ask a doctor if he or she is board-certified and involved in maintaining that certification. It’s a straightforward quality marker, and it’s a question that’s easy to ask.”
He added, “And as a patient, I find that reassuring.”
When it's time to find a new doctor
Dr. Jerome Groopman knew he needed to break up with his doctor.
Five years ago, when he started seeing his internist, everything was fine. But Groopman says that in time, the internist became more popular -- and hence more busy and harried -- right when Groopman needed him most.
"I have a strong family history of high cholesterol and heart disease. Every male in my family has had a [heart attack] in his 50s and 60s," he says. "I was moving into middle age, and I just didn't feel that my doctor was looking at me as an individual, and taking those factors into account."
But Groopman -- a physician and author of four books about doctors and patients -- found it difficult to leave his internist of five years. "It sounds strange, but I didn't want to insult him."
Groopman is not alone. "I really think it's a fear of the unknown," says Robin DiMatteo, a researcher at the University of California at Riverside who's studied doctor-patient communication. "But if the doctor isn't supporting your healing or health, you should go."
Here are five ways to know when it's time to think about leaving your doctor, and the best way to do it:
- 1. When your doctor doesn't like it when you ask questions
- 2. When your doctor doesn't listen to you
- 3. If your doctor can't explain your illness to you in terms you understand
- 4. If you feel bad when you leave your doctor's office
- 5. If you feel your doctor just doesn't like you -- or if you don't like him or her
Groopman agrees. He says a doctor who doesn't like a patient often stereotypes him or her. "I was terribly guilty of this as a young doctor. One of my patients said she had indigestion, and I got very irritated with her, and thought she was a whiner and a complainer," he says. "It was catastrophic because she actually had a torn aorta."
The woman died. "I have never forgiven myself for failing to diagnose it," he writes in "How Doctors Think." "There was a chance she could have been saved."
So once you've decided it might be time to divorce your doctor, how do you do it? First of all, make sure whatever's bothering you isn't just a one-time thing. "Make sure it's not just a quirk of the doctor's day," Groopman says. "Maybe they're just having a bad day."
If the problems continue, Groopman, Roter, and DiMatteo agree it's best to try to express your dissatisfaction instead of just bolting. "Use the first person plural, such as 'We're not communicating well' as opposed to 'You seem distracted or irritable with me,'" suggests Groopman. "That may cause cause the physician to stop and reflect and shift gears."
When it doesn't, you can be sure it's time to get another doctor, Roter says. She described two friends who wrote letters to their doctor saying they were unhappy with some of the treatments they'd received. "The both got back letters saying, 'Good luck with your new doctor.'"
How to find the best medical treatment
Know your way around the Internet, arm yourself with statistics and don't be afraid to speak up.
By Susan Brink : Los Angeles Times Article : June 23, 2008
Even if you're not rich or well-connected, you can find leading-edge treatment when it matters. And it could well matter if your condition is rare or if few doctors have developed expertise in treating it. For starters, be Internet savvy -- and pushy. Here are some tips for getting what you need:
Be open to the hospital your insurance plan recommends.
Insurers want to keep costs down, and one way to do that is to minimize costly complications. So they try to contract with institutions that have the most experience and the best outcomes. Even HMOs contract with outside centers of excellence for some rare disorders when their own physicians lack unique expertise.
"This whole notion of centers of excellence used to be based on gestalt and individual recommendations," says Dr. William Roper, dean of the medical school and chief executive of the healthcare system at the University of North Carolina.
"It's becoming much more data-driven and evidence-based."
To determine the "best," arm yourself with numbers.
If the doctor, or hospital, you want has more experience than the one your insurer has chosen, show your insurer the numbers. A surgeon who has done a procedure a few hundred times will have better results than one who has done it two or three times. "There's a growing body of evidence that says that volume matters," Roper says.
The only way to find out is to ask, so don't be shy about asking physicians how many times they've done the procedure, or treated the condition.
And be specific. A cardiac surgeon who has done hundreds of heart bypasses is not necessarily an expert in valve replacements.
Get recommendations.
The less common the disorder, the fewer the institutions that will have deep experience with it. But it's just those institutions you want to find. Each time you talk to a provider, don't end the conversation without asking who else has experience with your condition or which institutions are known for treating the disease. Keep following the chain of recommendations to see if one or two names are consistently repeated.
Do your homework.
Track down statistics and studies as tailor-made to your condition as possible.
Search for articles at the National Institutes of Health's free archive of medical journals (pubmedcentral.nih.gov). You can often see the entire study for free, sometimes only the abstract, but poring over the list will give you an idea of which institutions are actively publishing articles. Be as specific as possible in your search. For example, don't type in "brain cancer." Use "malignant glioma," "brain tumor" and "left parietal lobe."
Find out who is doing research into your condition.
If a physician publishes a lot about your condition, there's a good chance he or she is already onto potentially better techniques, even if results haven't yet been published. "What is published is always years behind what is happening at major academic centers," says Dr. Henry Friedman, deputy director of the Preston Robert Tisch Brain Tumor Center at Duke University Medical Center in North Carolina.
Even if you don't want, or qualify for, a clinical trial, find out which institutions are researching your condition. Go to clinicaltrials.gov for a list of more than 50,000 federally and privately sponsored trials.
Make appointments.
When you find a doctor or hospital doing research into your disease, call the physician or the institution. Large academic centers all have physician referral departments set up to connect patients with the appropriate physician. Your insurance company will cover a second opinion, and going to a large center for that second opinion can be the entryway to excellence.
Whatever your disease, go online.
Look for Internet-based support and advocacy groups. For example, the National Multiple Sclerosis Society’s website has a page on recent research into the disease, who is doing it and where.
Check out the disease advocacy group's chat rooms. Patients who have gone through what you're facing have a lot of first-hand advice about what they've done, where they've gone and how it turned out. In the absence of good national quality and outcomes measures of doctors and hospitals, the personal experience of your peers is invaluable.
But beware of websites trying to sell something or promoting a treatment not available in any academic center. Leading-edge research is usually backed by the NIH and carried out by academic centers. Private organizations may be pushing their own product or technique. "Any Internet site that sounds too good to be true usually is," says Dr. Robert Adler, vice chairman of pediatric medicine at Childrens Hospital Los Angeles.
Try to change Medicare plans if necessary.
The original Medicare plan has more geographic flexibility than the private plan alternatives. (First of all, consider carefully when choosing a plan.) If you need help changing plans after a diagnosis, try calling the Medicare Rights Center (medicarerights.org or [800] 333-4114), a national consumer organization that provides counseling about Medicare. "Sometimes our advocates have been able to help people get off the private plan and back on original Medicare," says Paul Precht, director for policy and communications at the center. "But it's getting harder."
Be realistic.
Don't think you can find a cutting-edge technique developed by one surgeon, then ask your own doctor to do it. "That's like going to a restaurant with a recipe from another restaurant and asking the kitchen to make it," Adler says. You could ask the doctor who developed the procedure if he or she has trained any others. If so, find out where they are practicing, and how experienced they have become. That process of training others, and having them fan out, is how once-unique techniques spread across the country, but it takes a lot of time.
Be prepared to fight.
Use the ammunition you've accumulated through research. Fights with insurance companies can be frustrating and drawn out, so if you're also fighting disease, you might need to enlist a spouse or friends to make phone calls and write letters, to the insurer, to legal aid societies or to a private lawyer.
If you're wrangling with Medicare, the Medicare Rights Center might be able to help fight a denial.
Get your doctor's support.
Whether you're facing Medicare or an insurance company, your chosen doctor is your best ally. He or she is the one best armed with numbers to make your case to the insurer.
For example, surgeons at Johns Hopkins Medical Center published a study in 1995 of a surgical technique, called a Whipple procedure, that can help some pancreatic cancer patients. The study examined all 501 cases of pancreatic cancer in which the procedure was used between 1988 to 1993 throughout Maryland.
It found that 54% of Whipple procedures were performed at Johns Hopkins Medical Center. The remainder were performed at 38 other hospitals throughout the state. The in-hospital death rate at Hopkins was 2.2%, compared with an average of 13.5% at the other hospitals. But what probably got the attention of insurance companies was that the cost at Johns Hopkins was $26,204, compared with an average of $31,659 at other hospitals.
Even if there isn't such incontrovertible, published proof supporting your decision, your chosen physician will likely have other numbers.
If you lose the fight and continue to be convinced that where you go matters to you, be prepared to shell out.
Whether it's a higher co-payment for going out of network, or taking on the entire cost yourself if you can afford it, your preference may be important enough to you to pull out your checkbook or credit card.
Make a choice.
Finally, try not to second-guess your own decision. "No one really knows what the outcome will be," Adler says. "Make the best decision you can in the time you've got, and then don't look back."
The Doctor Will See You ... Eventually
By Lesley Alderman : NY Times : August 1, 2011
"How much of human life is lost in waiting!” Ralph Waldo Emerson lamented in his 1841 essay “Prudence.”
Lately that observation has begun to seem particularly keen. I just did a quick tally: Over the past month, I have spent a total of six hours in three different medical offices, and nearly half of that time was spent just waiting to be seen. In one month alone, I lost three hours of this “human life” dawdling in waiting rooms.
No one likes to be kept waiting. But it’s particularly annoying to spend an hour or more in a waiting room when you’re self-employed, like me; when you bill by the hour, as many lawyers, architects and designers do; or when you’re just plain busy.
Lisa Qiu, 23, an inventor in Manhattan, recently waited for 50 minutes to see her gastroenterologist. During the wait, the receptionist quizzed Ms. Qiu about her bills and asked her to fork over that day’s co-payment.
When the doctor finally called her in, “she didn’t bother to apologize,” said Ms. Qiu.
Some consumers are clearly getting fed up. When MedPageToday.com, a medical information Web site, recently asked readers if they thought patients who were kept waiting for a scheduled appointment should get a discount on their bills, nearly half of the 3,200 respondents said yes. And 16 percent said that a discount wasn’t necessary but that waiting patients should get a small token, like a gift card, that compensated them for being inconvenienced. Thirty-eight percent said no acknowledgment was necessary.
Nationwide, the average wait time to see a doctor last year was 23 minutes, according to the health care consultants Press Ganey. Neurosurgeons have the longest wait times (30 minutes) and optometrists the shortest (17 minutes), according to the report.
In urban areas and among certain specialties, however, the waits can be much longer. Doctors work very hard, of course, and they are treating humans, not car parts. Emergencies can throw a well-planned day into chaos, and doctors who accept insurance may feel forced to overbook their schedules to assure they can bill for every minute of the day.
But still: Patients are paying customers who have financial and time pressures of their own.
“You should be seen within a few minutes of a scheduled appointment,” said Dr. Mark Gray, medical director of West Care Medical Associates, a primary care group in Manhattan with six offices. “But it goes both ways. We expect our patients to be respectful of our time, too.”
Rather than girding for combat, asking for discounts or storming out in a huff, consider a few ways to minimize (or at least cope with) protracted waits.
FIND A NEW DOCTOR
“I will not see a doctor who keeps me waiting for hours without a very good excuse and a very big apology,” said Rachel Schwartz, 47, a lawyer who lives in Brooklyn. “I have begun to surround myself with great doctors who don’t make me wait and who are as respectful of my time as I am of theirs.”
If you set out to find a new doctor, be aware that an ultraefficient practice may not be quite what you need, either. Many doctors schedule 10- to 15-minute appointments and speed through the day with robotic precision. A doctor who does not keep you waiting also may not spend much time with you. So be sure to ask about the length of appointments, too.
A CONCIERGE PRACTICE
If you can afford it, you may have better luck with a doctor who does not take insurance. Dr. Catherine Hart, an internist in Manhattan, allows 60 minutes when seeing a new patient and 30 minutes for an annual checkup. She does not accept insurance, but she rarely keeps patients waiting and is available 24/7 by phone or e-mail.
By comparison, the average doctor’s visit today is around 19 minutes, according to the National Center for Health Statistics.
“Everyone’s time is valuable,” Dr. Hart said. “We’re living in a medical mecca. Why put up with long waits?”
SPEAK UP
Julia Lloyd, 48, has a rare heart condition that few doctors in the country are qualified to treat. When she was repeatedly kept waiting by her specialist, she spoke to him directly.
“By talking it over, I realized he wasn’t out playing golf or something. He was dealing with emergency situations and doing his best,” said Ms. Lloyd, who lives in the San Francisco Bay Area. After their conversation her doctor agreed to start informing the front desk when he was running late, so patients could know what to expect.
“As patients, we need to learn how to speak up,” Ms. Lloyd said. “At the same time, doctors need to learn to listen.”
BE ON TIME
If you’re late, not only do you throw off the schedule for others, but you may also be put at the end of a very long queue.
Ask whether you have a firm appointment. Some offices with long waits book patients in groups — say, at 9 a.m., noon, and 4 p.m., Dr. Gray said. Patients are seen in the order in which they arrive. If that’s how your doctor’s office operates, ask if you can have a scheduled appointment instead; if not, show up 15 minutes before the specified hour.
Book the first appointment of the day. You’ve probably heard this advice countless times. That’s because it works. Unless your doctor books blocks of patients at once or an emergency crops up, you’re likely to be seen pronto.
CHECK IN
Before you leave for an appointment, call to find out if the doctor is running late, or ask the minute you walk in the door. Ms. Lloyd now goes out to a nearby cafe if her doctor is delayed.
NECESSARY APPOINTMENTS ONLY
Sometimes small issues can be resolved without setting foot in the doctor’s office. If you’ve had a sinus headache for three days, for instance, you may not need an appointment. Your doctor’s office should be able to tell you over the phone that the best treatment is an over-the-counter antihistamine and an anti-inflammatory medication.
Still, it’s impossible to completely avoid time in the waiting room. Heidi Boghosian, executive director of the National Lawyers Guild, has resigned herself to the fact that “some New York doctors double-book or schedule appointments so closely that they need to juggle two or more patients in different examining rooms.”
“When I’m left in the exam room, instead of sitting and worrying about when the doctor will show up, I now lie down on the examining table and focus on deep breathing,” said Ms. Boghosian, who lives in Lower Manhattan.
Prudent. Emerson would approve.
Unhappy endings
When proactive patients and harried physicians clash, breaking up is hard to do
By Liz Kowalczyk : Boston Globe : October 8, 2007
Pearl Lischinsky had been Dr. David Steinberg's patient for 16 years when she developed an aggressive blood cancer in May 2005. Their appointments grew more frequent, and she always brought her youngest daughter to help sift through treatment options.
It wasn't long before the visits grew tense.
Karen Lischinsky was devoted to her mother and arrived at appointments prepared with Internet research and questions about chemotherapy. But she felt Steinberg acted insensitively and rushed, bolting out the door before addressing her concerns and failing to make time to discuss important end-of-life issues.
Steinberg, a hematologist, felt he patiently tried to answer her questions, but that they were endless and hostile. Even when he said he had another patient waiting, 15-minute appointments would stretch 30 minutes beyond their scheduled time, his attorney said.
The smoldering conflict erupted during one appointment, with Karen saying she was firing Steinberg. Steinberg argued that she couldn't fire him because he was her mother's doctor, not hers.
Several weeks later, Pearl Lischinsky got a letter from Steinberg saying that he was "very fond" of her but that "The behavior exhibited towards me by your children is so negative and hostile that it affects my ability to continue providing effective care for you." Steinberg gave her 30 days to find another doctor.
Open conflict in the doctor-patient relationship can be painful and time-consuming for both sides. There is little guidance available for patients, families, and doctors about how to manage these difficult situations.
Some doctors and communication specialists say disputes are occurring more often as patients and families - encouraged to be critical consumers who take control of their medical care - research treatment options and become more opinionated about care, an approach that can cause old-school physicians to bristle. Sometimes, patients and families go too far, making excessive demands, or crossing boundaries.
At the same time, doctors are more pressed for time, making lengthy conversations inherently difficult for both sides.
"This relationship is changing right before our eyes," said Dr. Gordon Harper, a child psychiatrist who for many years taught a class on communication skills at Harvard Medical School. "There's much more opportunity for conflict."
While little data exist about how often conflicts occur or relationships are ended, neither is rare.
"Most of the time, [patients] just walk with their feet," said Dr. Leonor Fernandez, an internist at Beth Israel Deaconess Medical Center. "They don't have to explain why." Even if they need their medical records, someone else in the office other than the doctor handles getting them, she said.
Communication an issue
Studies by Dana Gelb Safran, a researcher at Tufts-New England Medical Center and vice president of Blue Cross and Blue Shield of Massachusetts, have shown that about 8 percent of Massachusetts adults change primary care doctors each year because of relationship issues, including poor communication.The relationship between doctors and patients has eroded since the late 1990s, Safran said, as doctors became more harried at the same time as patients became more engaged in their medical care.
But, Safran said, relationships now appear to be stabilizing as more physicians focus on increasing patient satisfaction.
Ending a relationship is tricky for doctors, who must guard against ethical lapses and claims of illegal abandonment. ProMutual Group, the largest medical malpractice insurer in Massachusetts, said the most common reason physicians call the company's telephone consultation service is for advice on when and how to call it quits.
Patients who won't follow medical advice, don't pay bills, verbally abuse or physically threaten staff, stalk a doctor, repeatedly miss appointments, or engage in criminal behavior, such as stealing prescription pads, are fair game for termination, ProMutual advises. But the company recommends against firing patients who are in medical crisis, need treatment for an acute problem, or who are more than 20 weeks pregnant - all of which could be considered abandonment.
The Board of Registration in Medicine, which licenses doctors in Massachusetts, has received 85 complaints of abandonment since 2004; so far the board has disciplined doctors in 11 of those cases.
Most doctors say they have at least one stressful relationship with a patient or family.
Seven years ago, Dr. Thomas Lee, an internist at Brigham and Women's Hospital, prescribed a generic diabetes medication to an elderly woman who is a longtime patient. She developed a rash and concluded she was allergic to all generics.
Lee explained that this was impossible, and refused to prescribe brand name drugs when a low-cost generic alternative was available, which her health insurer also required. They argued about it constantly. Still, she wouldn't back down, even risking her life by refusing to take a generic heart medication.
When her heart rate soared and she still wouldn't take the drug, Lee's nurse suggested she find another doctor, but the woman refused. "I want him to write the prescription," the patient said, according to an article Lee wrote in the Annals of Internal Medicine in July 2004. "If he won't and I die, it will be on his head. I've known him for so many years and he knows me really well. I don't want to start over with someone new."
To save the relationship, Lee compromised. He prescribed brand-name drugs for serious problems, and generics for the ones she could live without.
The woman is still his patient and gives him small gifts at Christmas. "We are still fighting, and she is still winning. But I am not giving up," he wrote in a recent e-mail.
Ways to work it out
When patients or family have many questions, Dr. Beth Lown, an internist at Mt. Auburn Hospital and a specialist on communication, said she tries to determine whether anxiety or fear is motivating them, and will sometimes enlist help from a social worker. Often, she suggests a contract both sides can live with to talk at a specific time each day or week.
Karen Lischinsky said she was definitely anxious about her mother's condition. She was driving back and forth between her jobs teaching sociology at several local colleges and her parents' home in Swampscott to cook meals, wash laundry, and bring her mother to the beauty salon. Her father, who has Alzheimer's, also needed special attention.
"We were a frightened family about to go down the road of watching our mother die," she said. But "we had a reasonable number of questions. We as family had a right to know some of the consequences of chemotherapy."
David Gould, Steinberg's attorney, said the physician did not call in an outside mediator because he believed he could handle the family's questions on his own. As head of the hospital's ethics committee, Steinberg knew how to manage difficult situations, he said. "He didn't feel until the very end that he wasn't able to deal with the situation." During that final appointment, the family threatened to sue, Gould said, although Karen Lischinsky said this is untrue. (Steinberg declined to be interviewed for this story.)
Another Lahey hematologist, Dr. Neil Weiner, eventually took over Lischinsky's care. The retired secretary died in December at age 77.
Her three children still hurt from Steinberg's actions, Karen Lischinsky said, and the family has filed a complaint with the Board of Registration and met with the hospital's ethics committee.
He has not attended the meetings to avoid conflict of interest, his attorney said. But the family is trying to get Steinberg, who denies he abandoned his patient, to meet with them.
"I want to ask why he sent that letter saying the children were disruptive," Karen Lischinsky said. "I want to ask why there wasn't a process (before he sent it.) We're the ones who have to live with it."
Learning to Ask Tough Questions Of Your Surgeon
By Laura Landro : WSJ Article : January 9, 2008
While many Web savvy patients today can ask a doctor about minute details of their circulatory system or cancer treatment, when it comes to asking the really tough, personal questions, they often clam up. Even when going under the knife, patients are often too intimidated to ask how qualified a surgeon is, or what safety procedures are in place.
But as complications and errors dog some surgical procedures, experts say it is increasingly crucial for patients to vet their surgeons and take an active role in preventing mistakes.
To help patients be more pro-active, health-care groups, hospitals and medical specialty societies are offering new resources, including Web sites, books and checklists of questions to ask. The aim is to help patients select qualified surgeons, prepare for operations, and overcome the fear that often inhibits them from asking tough questions.
These new efforts are spurred in part by the sharp rise in surgeries performed in outpatient facilities; including doctor's offices and surgical centers, where patients aren't guaranteed the same access to care as in a hospital should something go wrong. A rash of recent news has highlighted the risks, such as the death of rap mogul Kanye West's mother after an office cosmetic procedure by a surgeon who was facing disciplinary action at the state medical board and two malpractice suits that ended in significant payouts.
Since patients can't prevent mishaps once they are under anesthesia, it is all the more important to question surgeons beforehand. "Patients should feel free to ask their surgeon anything they want answered about the operation or the surgeon's competency to perform it," says Thomas Russell, a surgeon and executive director of the American College of Surgeons. "There are no questions that should be off the table."
In a new book to be published this month, "I Need an Operation...Now What? A Patient's Guide to a Safe and Successful Outcome," Dr. Russell provides patients with lists of questions for surgeons, including their success rates, how many operations they perform in a year, and whether they have any health issues of their own that would interfere with their ability to do the procedure. While he suggests using a respectful and nonconfrontational tone, he also urges patients to "size up" the surgeon's communication skills -- and avoid those who are unresponsive, distracted or rushed.
Ronda Collier, a 43-year-old Ann Arbor, Mich., marketing professional, consulted several surgeons prior to having brain surgery a few years ago, but she recalls being too worried about seeming offensive to ask whether a doctor had a good safety record or used recreational drugs or alcohol. With a checklist such as that devised by Dr. Russell, "You can simply say I have this list of questions recommended to me and I'm just going down the list," she says. "It's not a personal attack."
Consumer Guides
Most major hospitals around the country have added to their Web sites checklists such as a 2005 brochure prepared by the federal Agency for Healthcare Research and Quality, "Having Surgery? What You Need to Know." And state medical boards have added consumer guides, such as the Massachusetts Medical Board's guide to asking questions during office-based procedures.
But by far the most useful information comes from medical specialty groups and nonprofit disease advocacy organizations that offer tips for specific surgeries. SpineUniverse.com1, which is affiliated with spine-related medical societies, offers a list of questions specific to back surgery, while breastcancer.org provides a list of questions to ask the doctor before making decisions about mastectomies and lumpectomies.
The American Society for Dermatologic Surgery recently launched a patient-safety campaign urging consumers to check a practitioner's qualifications and credentials before undergoing any cosmetic surgery procedure, offering up some gruesome pictures on its Web site (asds.net2) of complications that resulted from botched lasers, high-tech light devices and chemical peels.
And the American Board of Medical Specialties, whose 24 member boards certify about 85% of U.S. physicians, recently began airing a televised public-service announcement about the importance of board certification, a process that requires doctors to take continuing medical-education courses and periodic exams to demonstrate competency. Its abms.org Web site allows patients to search by name and specialty to verify a physician's certification. Consumers can also use state medical boards' Web sites to see whether a surgeon's license is current and whether there are any disciplinary actions pending; for a $9 fee, the Federation of State Medical Boards (www.fsmb.org3) will also run a search.
To be sure, most of the estimated 40 million surgical procedures that Americans undergo every year are safe, and quality groups such as the Joint Commission, which accredits hospitals and other health-care providers, have in recent years pushed the adoption of new safety measures, such as the use of pre-surgery antibiotics to prevent infections, and post-surgical monitoring to prevent strokes or blood clots.
Resisting Change
Yet many of those safety measures aren't being universally followed, in part because of the frenetic pace of many hospitals but also because hospitals haven't done enough to improve the processes of care. Moreover, surgeons are often resistant to changes in the way they do things -- such as stopping a surgical procedure to do a safety check, says Peter Angood, a surgeon who is vice president and chief patient safety officer of the Joint Commission.
Though still infrequent, wrong-site surgeries -- a term that includes the wrong procedure, wrong site or wrong person -- continue to bedevil safety experts. The Joint Commission in 2004 issued a protocol for all hospitals that includes a final safety check and requires the marking of the procedure site with an indelible marker. But the number of reported cases of wrong-site surgery have actually increased, at a rate of about five to eight new cases per month -- for a total of nearly 550 since 1996.
Preventing Mistakes
A study of near-misses and wrong-site surgeries in Pennsylvania showed that correct information from patients or families was often key to preventing a mistake; Dr. Angood urges patients to participate in marking the site and ask whether surgeons are following the wrong-site prevention steps. The Joint Commission Web site (jointcommission.org4) has more information on the wrong-site protocol; consumers can download a brochure, "Help Avoid Mistakes in Your Surgery" and check the safety record of the facility at qualitycheck.org.
Aside from complications and errors during surgery, patients should ask about issues that may affect recovery after an operation, and what types of post-operative complications may occur. Dr. Russell of the American College of Surgeons advises patients to speak up about any concerns such as a wound that doesn't heal or pain that isn't controlled, and includes a list of post-operative complications to watch out for such as swelling in the legs that could signal a blood clot. In addition to his $19.95 book -- proceeds will be used for safety and education research -- the college offers free consumer information about what to expect from a number of different surgeries on its www.facs.org Web site.
Uncertainty Is My Co-Pilot
Benjamin Brewer, MD : WSJ Article : March 12, 2008
Uncertainty is a constant companion for family doctors.
Anyone with anything can walk through the door at any time. We have to figure out what to do in just a few minutes, often with scant resources.
The uncertainty that hangs over many cases seems strange to patients who expect doctors to come up with the one true answer and cure on the spot. Patients crave reassurance, but it's often tough for us to say anything definitive.
Patients present their doctors with undifferentiated problems, such as fever or trouble sleeping. Sometimes a common disease like a sore throat will present in a striking way. Or worse, a serious problem like lung cancer will present with a common symptom like a stubborn cough.
There's a steep penalty for being mistaken, however. An uncertain diagnosis often leads to expensive defensive medicine in the form of extra X-rays and lab tests. Tests like those can be a crutch. In my experience, they don't always help with diagnosis as much as a thorough medical history or physical exam.
Recently, a 20-year-old patient came in with a sore throat. Her tonsils were big and swollen with a shaggy white coating on them. She had no fever but did have some impressively swollen glands in her neck. Her liver, spleen and other lymph glands seemed OK. I thought she probably had a viral illness, maybe mononucleosis. A rapid strep test was negative and so was her influenza test. I did a throat culture and drew blood to send to the lab.
Was her illness just a bad viral sore throat or something worse? We wouldn't know the final answer for several days.
Pain relief, fluids and reassurance were the treatment I offered until the results came back. I fended off her mother's request for an antibiotic when she didn't improve immediately.
The initial mono test came back negative. It's frustrating when the tests you order don't confirm your suspicions. Further work I ordered at a specialized lab showed she had mononucleosis, as I had originally suspected. I'd taken the extra step because I figured that she and her parents would think the worst if I didn't prove it was mono from the beginning.
It's not always easy for patients or their doctors to wait for an answer. In medical school, our professors frighten all the reassurance out of us by talking up all the bad diseases that start out looking like something minor. I'll never forget my patient with a stuffy nose that developed into a life threatening disease called Wegener's Granulomatosis and the small bump on a child's leg that turned out to be cancer.
It takes three years or longer after med school before the ability to confidently heal comes back. Some doctors never quite get it back.
One reason is a problem my teachers pointed out 15 years ago: Diagnostic skills are in decline. A reliance on lab tests and X-rays has stunted doctors' willingness and ability to perform top-notch medical histories and physical exams.
Medical students' interest in general internal medicine and family medicine has dropped for more than a decade and hasn't yet stabilized. Nurse practitioners and physician assistants with less clinical diagnostic training than doctors are filling the primary care workforce void. It's been my observation that they order more tests to evaluate the same problem than doctors do because of the experience factor. Like a teenager behind the wheel, adding speed and power without careful judgment can compound problems.
With CT scans and MRI's of ever increasing sensitivity, radiologists are peering into the body and finding all sorts of little blood vessel abnormalities, calcium deposits and nodules of uncertain significance. Radiologists often put disclaimers on borderline reports such as "Clinical Correlation Required." When I see that I have about the same gut reaction as when I see "Some Assembly Required" on toys my kids got for Christmas.
Results like those leave referring physicians like me to wonder if we should biopsy these suspicious areas, follow them with more scans or ignore them at our peril. It seems to me that if these scans hadn't been ordered so freely in the first place, we wouldn't end up chasing so many incidental findings later on.
Illnesses don't always follow textbook descriptions. There will always be tough diagnoses, the occasional missed diagnosis, and sometimes puzzling patients with no identifiable diagnosis. However, there are fewer doctors today who can be considered master diagnosticians. The old experts are retiring and they're not being replaced. The rest of us all think we're above average. That's one diagnosis we're pretty certain about.
Finding a way to ask doctors tough questions
By Laura Landro : WSJ Article : March 4, 2009
Waiting to see his dermatologist about a skin rash, John Barnett heard the doctor sneeze loudly before he came into the exam room. The Seattle-area retiree says it took all his courage to ask, "Are you going to wash your hands before you examine me?"
Despite efforts by advocacy groups and others to empower patients, challenging a doctor or nurse on whether they are correctly doing their jobs remains downright intimidating. Signs and posters in hospitals urge us to "Speak Up" if we see a potential medical error. More nurses wear buttons these days that say "Ask Me If I've Washed My Hands." But even the most outspoken and assertive among us may suddenly turn meek when we are sick or vulnerable in a hospital, fearing that our treatment will suffer if we antagonize caregivers.
"It's all too common for patients and family members to remain silent when they suspect something is wrong or improper in their care," says David Shulkin, chief executive of Beth Israel Medical Center in New York City. "Patients and families must be willing to leave their comfort zone and speak up, and every institution has to think about how they can get patients more engaged in their own care," he says.
More and more institutions are making the effort to help patients take an active role in caring for their own health.
Kathy Todd was hospitalized in 2007 with complications before and after the premature birth of her daughter at a Seattle-area hospital. She found herself reluctant to ask nurses for anything she needed. She endured hours of pain one day when a nurse didn't administer pain medication because she didn't ask for it.
"I was sick and dragging myself down to the [neonatal ICU] to see my baby, and in that crisis situation I became very meek and took whatever they said and questioned nothing," says Ms. Todd, who is 31 years old. But after getting to know nurses, she says she realized she was being too reticent. She later agreed to go on a patient advisory board at the hospital and help new mothers through the experience. "You can't expect every patient who comes through to have the presence of mind in a crisis to ask for what they need or raise questions," she says. "It's up to the doctors and the hospital to set the tone and the culture to give people the bravery they need."
A growing number of institutions are taking steps to help. At Beth Israel, 53 physicians contributed chapters to "Questions Patients Need to Ask," a new book edited by Dr. Shulkin on issues ranging from how to ask about infection-prevention measures to what to do if a technician drawing blood misses a vein too many times -- after the second try, the book suggests, ask for someone else. The book is available online for $19.99.
The Robert Wood Johnson Foundation's new Aligning Forces for Quality program is providing $300 million in grants for community programs designed to get consumers to take an active role in their own care, especially those from certain racial and ethnic backgrounds. The Puget Sound Health Alliance, a coalition of employers in Washington state that received a grant, has set up a public Web site with a list of questions patients should ask surgeons, including whether they are following a state-endorsed checklist that includes checking patients' medication allergies and determining the risk of blood loss.
There is some evidence suggesting that greater patient involvement can improve medical outcomes. For example, the Robert Wood Johnson Foundation surveyed 600 patients with chronic illnesses in the Seattle area last year and found a link between how patients feel about their encounters with doctors and how well they adhere to their regimens. One finding: Among patients in treatment for depression who felt their medical providers treated them fairly, 90% took their medications regularly. But adherence to a regimen was just 60% among patients who said they feel they haven't been communicated with or were treated poorly.
"The culture around medicine is changing very quickly as patients begin to understand the full impact of medical errors and see that quality health care is not a given," says Bruce Siegel, a professor in the department of health policy at George Washington University who runs the Aligning Forces for Quality program. Many physicians are trained "to think of ourselves as little gods" and resist patients who question their authority, Dr. Siegel says. But "the more enlightened physicians are beginning to realize this could be a positive thing for health care."
The Pennsylvania Patient Safety Authority, which tracks medical errors and recommends preventive measures, says research conducted in the state shows patients are increasingly willing to ask certain questions of their doctor. It says patients will seek a better explanation of something they don't understand or question the reason for a procedure or unfamiliar drug.
But patients are most reluctant to ask anything that might be viewed as confrontational, such as requesting that health-care providers confirm a patient's identity before a procedure or asking practitioners to wash their hands, the group says. Hand washing is considered the most important preventive measure against the spread of potentially deadly infections.
I had that in mind on a recent visit to a Florida emergency room after my husband cut his forearm to the bone in a fall. As the doctor approached him, I said: "I have to ask you to wash your hands, according to that sign right there." The doctor took umbrage, gave me a speech about washing her hands 15 times a day, then gave them a cursory rinse under the faucet. "You don't use the hand sanitizer gel in that dispenser?" I ventured. "I don't like that stuff," was her response. After that, the doctor donned gloves and sewed him up nicely.
For Mr. Barnett, the Seattle-area retiree, the request that the dermatologist wash his hands had a better outcome. He says the doctor responded, "Oh yes, I should," and went and did so. Mr. Barnett, 78, says he believes passivity with doctors is more common in his generation. He says the experience taught him the importance of speaking up when he feels uncomfortable about his health care. Mr. Barnett now volunteers as an advocate for people in nursing homes, and serves on a state advisory committee about preventing hospital infections.
Delia Chiaramonte, a Baltimore physician who works as a consultant helping patients with serious medical conditions navigate the health-care system, says patients can be assertive in asking questions and challenging medical staffers without being offensive or confrontational. "Sometimes acknowledging the doctor's hard work can make them more interested in giving you what you want," Dr. Chiaramonte says. One approach she recommends is to say: "Wow, you really seem to be working hard today. Thanks so much for giving me a few extra minutes to talk about my concerns."
John Clarke, clinical director of the Pennsylvania Patient Safety Authority, suggests that someone too intimidated to ask if a doctor or nurse has washed his or her hands can say, "I'm concerned about getting germs from another patient." But Dr. Clarke says patients have to be prepared to escalate their expression of concerns. "If you think something is truly dangerous, you just have to say 'Stop, I'm not supposed to get this procedure,' " he says.
Many hospitals make use of the "Speak Up" campaign launched in 2002 by the Joint Commission, the nonprofit group that accredits hospitals. The program provides free brochures and posters to hospitals urging patients to take a role in preventing medication errors, infections and wrong-patient procedures. The brochures, available at www.jointcommission.org, provide lists of questions to ask medical practitioners, urging patients, for instance, to make sure doctors and nurses check their wristband and ask their name before administering medicine.
Mark Chassin, president of the Joint Commission, says hospitals also have to educate staffers about the importance of being receptive to patients who may fear speaking up. "Patients and families are usually sick, scared and anxious when seeking care, so [challenging a doctor] is not the same as beefing up your assertive self to negotiate on price when you are buying a car," he says.
At bedside, stay stoic or display emotions
By Barron H. Lerner, MD : NY Times Article : April 22, 2008
A young doctor sat down with a terminal lung cancer patient and her husband to discuss the woman’s gloomy prognosis. The patient began to cry. Then the doctor did, too.
The scene was undoubtedly moving. But should physicians display this much emotion at the bedside?
For years, medical schools and residency training programs studiously avoided the topic of emotions. Doctors learned the nuts and bolts of cancer and other serious diseases. Yet when it came time to reveal grim diagnoses, they were largely on their own.
These days, all medical schools have some type of education in topics like the physician-patient relationship and breaking bad news. But knowing how to respond to a personal wave of stress or sadness remains a major challenge. Is crying O.K.? How about hugging a patient who starts to cry?
One physician who cautions against excess emotions is Dr. Hiram S. Cody III, acting chief of the breast cancer service at Memorial Sloan-Kettering Cancer Center. Although Dr. Cody emphasizes the need for doctors “to understand, to sympathize, to empathize and to reassure,” he says his job “is not to be emotional and/or cry with my patients.”
There are two reasons for this stance, Dr. Cody tells young physicians on rounds: It is not therapeutic for the patient, and it will cause “emotional burnout” in the doctor.
These beliefs are shared by many other physicians, but some new data suggest that crying in a medical setting is common among young doctors. At a recent meeting of the Society of General Internal Medicine, Dr. Anthony D. Sung of Harvard Medical School and colleagues reported that 69 percent of medical students and 74 percent of interns said they had cried at least once. As might be expected, more than twice as many women cried as men.
In some instances on the wards, the emotions just flow. For example, in the 1988 PBS documentary “Can We Make a Better Doctor?” a Harvard medical student, Jane Liebschutz, sees her patient unexpectedly die during a cardiac bypass operation. She suddenly bursts into tears and wanders away from her colleagues until the chief surgeon, who has witnessed what happened, assures her that her response was natural.
Other physicians may choose to place themselves in emotional situations. Dr. May Hua, an anesthesiology resident at Columbia University Medical Center, recently told me that during her internship, her supervising resident, Dr. Benita Burke, skipped lunch to spend extra time with her cancer patients. They dubbed this time “mental health rounds,” during which they could address issues that were not strictly medical. Many times, Dr. Burke would wind up in tears or giving an embrace.
“I think patients adored Benita,” Dr. Hua said, “both as their doctor and as their friend.”
But even as she admired her colleague, Dr. Hua realized that such public emotion was not for her. “I knew this was something I couldn’t do, because I needed to have a level of detachment to these people.”
I understood exactly what Dr. Hua meant. Whether because of my personality or my being a man, I, too, have never cried in front of a patient.
Dr. Burke says she believes that her crying stems from being “very involved” in her cases, which leads her to “take everything to heart.” In the case of the lung cancer patient, Dr. Burke had been the first physician to inform her that further aggressive treatment was unlikely to help. In other words, the patient was dying.
Dr. Burke said she realized that this level of involvement was uncommon but believed that she could not be any other kind of doctor. “I’ve always been a very emotional person at baseline,” she said.
Dr. Sung’s study concludes with a call for senior doctors to acknowledge and discuss openly the apparent high rates of crying among medical trainees.
Yet while health professionals — not only physicians but also nurses and social workers — may debate among themselves the propriety of emotional displays, what probably matters most is what patients think. Just as different doctors respond differently to sad situations, so do patients and their families. While some might appreciate physical contact or tears, others find such displays to be too “touchy-feely.”
Cancer patients may encounter such situations more than most. One breast cancer survivor, Sharon Rapoport, of Roanoke, Va., said she greatly admired physicians like Dr. Cody, who may appear reserved but communicate their concern through their actions.
But Ms. Rapoport also said she had an extra appreciation for doctors who felt comfortable with outward displays of emotion. “If that means tears,” she said, “bring them on.”
Dr. Barron H. Lerner teaches medicine and public health at Columbia University Medical Center.
The Doctor Will Never See You Again
Physicians Can Boot Patients for Unruly Behavior, Drug Abuse and Other Reasons, but Must Follow Rules
WSJ Article : Melinda Beck : February 9, 2010
When is it appropriate for doctors to "fire" patients?
Patients can and often do leave doctors they don't see eye to eye with, find inconvenient or can't afford. But doctors must follow strict ethical rules when they want to dismiss a patient.
The list of reasons is relatively short, according to medical associations: Patients who are chronically abusive, disruptive or drug-seeking may be asked to leave a practice. So might those who habitually miss appointments or refuse to pay reasonable bills. Failing to heed medical advice isn't necessarily grounds for a split, but some doctors suggest that patients who won't quit smoking, use illicit drugs or have potentially harmful habits (daily enemas, say) might be more comfortable in another practice.
"Physicians talk about this all the time—the 'difficult patient,' " says Lori J. Heim, president of the American Academy of Family Physicians who practices at Scotland Memorial Hospital in Laurinburg, N.C. "A lot of problems arise because the physician and the patient just don't click."
One increasing point of contention: vaccinations. These days, some pediatricians refuse to care for children whose parents won't let them be vaccinated out of fear that vaccines cause autism, despite considerable evidence to the contrary.
"When we do the prenatal visits, we let families know up front that this is how we run things," says Marcy S. Baker, a Tampa, Fla., pediatrician. Vaccination "is the most important thing you can do to protect your child. If you don't trust us on this, will you trust us on other things?"
A 2006 survey by the American Academy of Pediatrics found that 74% of members who participated had one or more parents refuse at least one vaccination in the past year; 32% of those parents changed their minds after education efforts from the doctor. Only about 16% of pediatricians said they sometimes discharge families if the parents won't relent.
"The vast majority of physicians just agree to disagree," says Seattle pediatrician Douglas Diekema, former chairman of the AAP's bio-ethics committee. The group recommends that approach over severing relationships, he says, "because it gives you the opportunity to continue the discussion. Two years later, if the child gets whooping cough, the parents may well change their mind."
Doctors have plenty of professional leeway about which patients they choose to treat in the first place (as long as they don't discriminate on the basis of race, gender, age or religion). They can close their practices to new patients, refuse to accept some insurance plans or limit the number of Medicare or Medicaid patients they treat for financial reasons. But when they do start seeing a patient then walking away is considered unprofessional—and often in violation of state-licensing rules.
"You cannot abandon!" Raymond Scalettar, former chairman of the American Medical Association, explains in an email. AMA guidelines state that a doctor may withdraw from a case only after giving the patient enough notice to find another physician. State rules vary, but doctors generally must document the behavior, inform the patient what the problem is, give him or her a chance to change, then send a certified letter stating the relationship is over, while still agreeing to provide treatment as needed for another 30 days.
Sometimes difficult patients just want attention. Early in her career, Dr. Heim says, she developed a technique for dealing with those who were disruptive or rude. "I'd tell them, 'I want to touch base with you on the phone every other week or see you once a month until you are stable.' Then they knew they didn't have to throw a fit to have somebody pay attention to them," she says. "After a few months, I'd say, 'Do we need to do this so often?' They'd usually say, 'No, I'm good.' "
Dr. Heim did part ways with a patient after the state warned her that he was getting multiple prescriptions for pain medications from other doctors. She tried to get him into rehab but to no avail.
Some states, including North Carolina, now have password-protected Web sites that let doctors see whether a patient has gotten prescriptions for controlled-substances from another doctor. Some practices also require patients who need long-term pain medication to sign a contract promising not to lose, sell or abuse such drugs and not to seek them from other doctors simultaneously.
The contract approach also comes in handy with other kinds of problematic patients. Michael Bannon, a general surgeon and chairman of the ethics subcommittee at the Mayo Clinic in Rochester, Minn., recalls a patient who was treated for a year with a hole in her intestine that wouldn't heal. She refused to let nurses care for the wound, and she would lock herself in the bathroom for long periods. Dr. Bannon eventually realized the patient was reopening the wound herself with a pencil, and when confronted, she admitted it. After consulting with lawyers, the hospital drew up a contract with rules she had to obey.
"We said, 'We're not going to allow you to come back here with self-induced, recurring problems,' " says Dr. Bannon. The contract, he says, "creates a kind of time-out and a reality check for the patient." In this case, the patient didn't return.
The right of doctors to refuse to treat some patients was upheld by the Fifth Circuit Court of Appeals in the 1987 case, Brown vs. Bower.
John D. Bower, director of a kidney-dialysis program in Jackson, Miss., ran out of patience with a teenage patient who would frequently miss his dialysis appointments, then go on beer-drinking binges and require emergency treatment. "I liked Mike a lot," says Dr. Bower. "But he was an incorrigible person. He would pinch the nurses on the butt. He would knock over trays of sterile equipment and he'd show up in the middle of the night needing dialysis."
When Dr. Bower told the patient he would no longer treat him, a local advocacy group sued. Dr. Bower argued that forcing a physician to treat a patient would violate the 13th amendment of the Constitution, which outlawed slavery, and the appeals court agreed.
In the end, Dr. Bower had to treat the patient anyway, because the hospital had funding under a law that required it to treat anyone in need of care. Four years later, the patient died in a car accident.
"There will always be patients like old Mike," says Dr. Bower. "I thought the world of him, but ...I couldn't get him to see that it was his life we were talking about."
Physicians Can Boot Patients for Unruly Behavior, Drug Abuse and Other Reasons, but Must Follow Rules
WSJ Article : Melinda Beck : February 9, 2010
When is it appropriate for doctors to "fire" patients?
Patients can and often do leave doctors they don't see eye to eye with, find inconvenient or can't afford. But doctors must follow strict ethical rules when they want to dismiss a patient.
The list of reasons is relatively short, according to medical associations: Patients who are chronically abusive, disruptive or drug-seeking may be asked to leave a practice. So might those who habitually miss appointments or refuse to pay reasonable bills. Failing to heed medical advice isn't necessarily grounds for a split, but some doctors suggest that patients who won't quit smoking, use illicit drugs or have potentially harmful habits (daily enemas, say) might be more comfortable in another practice.
"Physicians talk about this all the time—the 'difficult patient,' " says Lori J. Heim, president of the American Academy of Family Physicians who practices at Scotland Memorial Hospital in Laurinburg, N.C. "A lot of problems arise because the physician and the patient just don't click."
One increasing point of contention: vaccinations. These days, some pediatricians refuse to care for children whose parents won't let them be vaccinated out of fear that vaccines cause autism, despite considerable evidence to the contrary.
"When we do the prenatal visits, we let families know up front that this is how we run things," says Marcy S. Baker, a Tampa, Fla., pediatrician. Vaccination "is the most important thing you can do to protect your child. If you don't trust us on this, will you trust us on other things?"
A 2006 survey by the American Academy of Pediatrics found that 74% of members who participated had one or more parents refuse at least one vaccination in the past year; 32% of those parents changed their minds after education efforts from the doctor. Only about 16% of pediatricians said they sometimes discharge families if the parents won't relent.
"The vast majority of physicians just agree to disagree," says Seattle pediatrician Douglas Diekema, former chairman of the AAP's bio-ethics committee. The group recommends that approach over severing relationships, he says, "because it gives you the opportunity to continue the discussion. Two years later, if the child gets whooping cough, the parents may well change their mind."
Doctors have plenty of professional leeway about which patients they choose to treat in the first place (as long as they don't discriminate on the basis of race, gender, age or religion). They can close their practices to new patients, refuse to accept some insurance plans or limit the number of Medicare or Medicaid patients they treat for financial reasons. But when they do start seeing a patient then walking away is considered unprofessional—and often in violation of state-licensing rules.
"You cannot abandon!" Raymond Scalettar, former chairman of the American Medical Association, explains in an email. AMA guidelines state that a doctor may withdraw from a case only after giving the patient enough notice to find another physician. State rules vary, but doctors generally must document the behavior, inform the patient what the problem is, give him or her a chance to change, then send a certified letter stating the relationship is over, while still agreeing to provide treatment as needed for another 30 days.
Sometimes difficult patients just want attention. Early in her career, Dr. Heim says, she developed a technique for dealing with those who were disruptive or rude. "I'd tell them, 'I want to touch base with you on the phone every other week or see you once a month until you are stable.' Then they knew they didn't have to throw a fit to have somebody pay attention to them," she says. "After a few months, I'd say, 'Do we need to do this so often?' They'd usually say, 'No, I'm good.' "
Dr. Heim did part ways with a patient after the state warned her that he was getting multiple prescriptions for pain medications from other doctors. She tried to get him into rehab but to no avail.
Some states, including North Carolina, now have password-protected Web sites that let doctors see whether a patient has gotten prescriptions for controlled-substances from another doctor. Some practices also require patients who need long-term pain medication to sign a contract promising not to lose, sell or abuse such drugs and not to seek them from other doctors simultaneously.
The contract approach also comes in handy with other kinds of problematic patients. Michael Bannon, a general surgeon and chairman of the ethics subcommittee at the Mayo Clinic in Rochester, Minn., recalls a patient who was treated for a year with a hole in her intestine that wouldn't heal. She refused to let nurses care for the wound, and she would lock herself in the bathroom for long periods. Dr. Bannon eventually realized the patient was reopening the wound herself with a pencil, and when confronted, she admitted it. After consulting with lawyers, the hospital drew up a contract with rules she had to obey.
"We said, 'We're not going to allow you to come back here with self-induced, recurring problems,' " says Dr. Bannon. The contract, he says, "creates a kind of time-out and a reality check for the patient." In this case, the patient didn't return.
The right of doctors to refuse to treat some patients was upheld by the Fifth Circuit Court of Appeals in the 1987 case, Brown vs. Bower.
John D. Bower, director of a kidney-dialysis program in Jackson, Miss., ran out of patience with a teenage patient who would frequently miss his dialysis appointments, then go on beer-drinking binges and require emergency treatment. "I liked Mike a lot," says Dr. Bower. "But he was an incorrigible person. He would pinch the nurses on the butt. He would knock over trays of sterile equipment and he'd show up in the middle of the night needing dialysis."
When Dr. Bower told the patient he would no longer treat him, a local advocacy group sued. Dr. Bower argued that forcing a physician to treat a patient would violate the 13th amendment of the Constitution, which outlawed slavery, and the appeals court agreed.
In the end, Dr. Bower had to treat the patient anyway, because the hospital had funding under a law that required it to treat anyone in need of care. Four years later, the patient died in a car accident.
"There will always be patients like old Mike," says Dr. Bower. "I thought the world of him, but ...I couldn't get him to see that it was his life we were talking about."
When Should You Fire Your Doctor?
Communication problems, a disorganized staff and misdiagnoses signal it's time for a change.
By Kristen Gerencher : WSJ : June 29, 2013
Feel worse when you leave your doctor's office than when you went in? It may be time to find a new physician.
No one relishes the hassle of switching health-care providers. But if you're frustrated with communication problems, a disorganized staff or a doctor's poor bedside manner, a change may keep your health—and health costs—from suffering.
Among patients' biggest medical gripes are unclear explanations, delays in communicating test results, hard-to-resolve billing disputes and rushed office visits, according to a recent Consumer Reports survey of 1,000 Americans. Difficulty getting a timely appointment also ranked high.
If the doctor-patient partnership isn't working, it's important to try to fix it or find a better fit, says Orly Avitzur, medical adviser at Consumer Reports and a neurologist in Tarrytown, N.Y. "Like in any relationship, sometimes the chemistry just isn't right."
If you're thinking of leaving your doctor, weigh your options. Your doctor may be more receptive to your concerns than you think. If you don't want to confront him or her, or if your chief complaints are with administrative issues, tell an office manager or ask for a patient satisfaction survey, Dr. Avitzur says. Some doctors' offices use such surveys, which can be filled out anonymously, to improve their practices.
Another solution if your doctor is in a group practice and you have a problem with his or her style is to switch to another physician in the same office.
Of course, not all problems are repairable. Should you decide to cut ties, remember that you're entitled to receive a copy of your medical information, except psychotherapy notes, under the federal Health Insurance Portability and Accountability Act.
Doctors' offices typically charge an administrative fee per page copied, and each state has different laws as to how much that can be, according to the U.S. Department of Health and Human Services. Starting in late September, patients will be able to get a copy of their electronic medical records as well.
Here are five reasons why you may want to fire your current doctor:
1 You leave with more questions than answers.
Communication is a shared responsibility, but physicians have a duty to explain things in clear language. If that's not happening, don't be intimidated to say so. "It's important that you speak up and say 'I'm still not clear what's wrong with me' or 'I'm still not clear what is the next step,' " Dr. Avitzur says.
After a hospital stay, effective communication with your doctor can help keep you from having to be readmitted, which can be costly.
2 Your doctor dismisses your input and questions.
Your doctor should encourage your questions and consider any Internet research you've done, says Alanna Levine, a spokeswoman for the American Academy of Pediatrics and a pediatrician in Tappan, N.Y. At the same time, patients should be open to guidance on which online information sources are reliable, she says.
3 Your doctor has misdiagnosed you.
Firing the doctor makes sense if a missed diagnosis turned into a life-threatening or catastrophic event. But not every missed diagnosis is a sign of negligence, Dr. Avitzur says, and sometimes patients are wise to first see whether the doctor apologizes or offers a credible explanation of what went wrong.
Sometimes, what seems like a missed diagnosis is actually the natural course of an illness, Dr. Levine says. For example, a child may have a miserable cold that a pediatrician calls a viral infection and treats with comfort care. But an ear infection could develop hours later, requiring a second office visit and antibiotics, she says.
4 Your doctor balks at a second opinion.
Your doctor shouldn't be offended if you want a second opinion, Dr. Avitzur says. Most physicians are used to the request and are happy to supply names of other doctors, she says. "If the reaction you get makes you feel badly, that's definitely a reason to fire your doctor."
Health insurers typically cover second opinions.
5 Your doctor isn't board-certified.
Being board-certified, or board-eligible if it's a doctor right out of medical school, means the physician has ongoing assessments and extra continuing-education requirements in his or her specialty beyond those required for a license to practice medicine in your state. You can check board certification free at certificationmatters.org or call 866-275-2267.
Communication problems, a disorganized staff and misdiagnoses signal it's time for a change.
By Kristen Gerencher : WSJ : June 29, 2013
Feel worse when you leave your doctor's office than when you went in? It may be time to find a new physician.
No one relishes the hassle of switching health-care providers. But if you're frustrated with communication problems, a disorganized staff or a doctor's poor bedside manner, a change may keep your health—and health costs—from suffering.
Among patients' biggest medical gripes are unclear explanations, delays in communicating test results, hard-to-resolve billing disputes and rushed office visits, according to a recent Consumer Reports survey of 1,000 Americans. Difficulty getting a timely appointment also ranked high.
If the doctor-patient partnership isn't working, it's important to try to fix it or find a better fit, says Orly Avitzur, medical adviser at Consumer Reports and a neurologist in Tarrytown, N.Y. "Like in any relationship, sometimes the chemistry just isn't right."
If you're thinking of leaving your doctor, weigh your options. Your doctor may be more receptive to your concerns than you think. If you don't want to confront him or her, or if your chief complaints are with administrative issues, tell an office manager or ask for a patient satisfaction survey, Dr. Avitzur says. Some doctors' offices use such surveys, which can be filled out anonymously, to improve their practices.
Another solution if your doctor is in a group practice and you have a problem with his or her style is to switch to another physician in the same office.
Of course, not all problems are repairable. Should you decide to cut ties, remember that you're entitled to receive a copy of your medical information, except psychotherapy notes, under the federal Health Insurance Portability and Accountability Act.
Doctors' offices typically charge an administrative fee per page copied, and each state has different laws as to how much that can be, according to the U.S. Department of Health and Human Services. Starting in late September, patients will be able to get a copy of their electronic medical records as well.
Here are five reasons why you may want to fire your current doctor:
1 You leave with more questions than answers.
Communication is a shared responsibility, but physicians have a duty to explain things in clear language. If that's not happening, don't be intimidated to say so. "It's important that you speak up and say 'I'm still not clear what's wrong with me' or 'I'm still not clear what is the next step,' " Dr. Avitzur says.
After a hospital stay, effective communication with your doctor can help keep you from having to be readmitted, which can be costly.
2 Your doctor dismisses your input and questions.
Your doctor should encourage your questions and consider any Internet research you've done, says Alanna Levine, a spokeswoman for the American Academy of Pediatrics and a pediatrician in Tappan, N.Y. At the same time, patients should be open to guidance on which online information sources are reliable, she says.
3 Your doctor has misdiagnosed you.
Firing the doctor makes sense if a missed diagnosis turned into a life-threatening or catastrophic event. But not every missed diagnosis is a sign of negligence, Dr. Avitzur says, and sometimes patients are wise to first see whether the doctor apologizes or offers a credible explanation of what went wrong.
Sometimes, what seems like a missed diagnosis is actually the natural course of an illness, Dr. Levine says. For example, a child may have a miserable cold that a pediatrician calls a viral infection and treats with comfort care. But an ear infection could develop hours later, requiring a second office visit and antibiotics, she says.
4 Your doctor balks at a second opinion.
Your doctor shouldn't be offended if you want a second opinion, Dr. Avitzur says. Most physicians are used to the request and are happy to supply names of other doctors, she says. "If the reaction you get makes you feel badly, that's definitely a reason to fire your doctor."
Health insurers typically cover second opinions.
5 Your doctor isn't board-certified.
Being board-certified, or board-eligible if it's a doctor right out of medical school, means the physician has ongoing assessments and extra continuing-education requirements in his or her specialty beyond those required for a license to practice medicine in your state. You can check board certification free at certificationmatters.org or call 866-275-2267.
Breaking up is hard to do.....
