THANK YOU.......
Physicians Pet Peeves
Things that push our buttons
- Don't wait until you are on your last tablet to call the office for a refill..............plan ahead.
- Don't call at the end of the day for something that we could have more easily dealt with earlier.
- Don't wait until 4 pm on a Friday to deal with a problem that should have been dealt with earlier in the day (or week!)
- Don't expect a covering doctor to call in a narcotic or controlled substance for you.
- Remember that if you call after regular office hours and you reach a covering physician, they are not sitting in the office with your medical record in front of them.
- The best conversations under these circumstances always start with: "Hello, I am John/Jane Doe and I am a patient of Dr XXXX. I'm sorry to call after hours, but this is what I'm worried about: -------. I should mention that Dr XXXX is treating me for the following conditions: (1), (2) etc and I am being managed on the following medications: (1), (2) etc. You should also know that I have the following drug allergies: (1), (2) etc.
- If you expect or want a medication to be called in for you, please have the pharmacy telephone number readily available and be certain that the pharmacy is open.
- To gain the most out of a visit, it is best to try and focus on the problem that is bothering you most and to tell me about it first. Trying to squeeze multiple problems into a visit, often leaves both the patient and the physician feeling frustrated.
- Annual exams are encouraged, but remember they are "well patient visits". Trying to cram a year's worth of questions you have been storing up and expecting them all to be carefully covered is not the best approach.
- I appreciate that we all have busy schedules and feel very strongly about not keeping you waiting for me. Please keep your scheduled appointments, arrive on time and I will try my best to see you on time.
- Don't ask us to bend the truth or try to get you off jury duty or a paid vacation for reasons that are not medically legitimate. How can you trust a doctor in the future if you know that they are not honest?
- It is illegal to ask us to write a prescription, which is meant for you, in the name of another relative (because they have prescription drug coverage).
- It is illegal to request a handicap placard for your car unless you have a legitimate medical reason for having one.
- Coming into an examination room and finding a patient on their cell phone and then being asked by them to wait until they have ended their call. This despite the fact that there are signs clearly saying "No Cell Phone Use".
Getting along: Part 2 - Patient Rules
Posted By Rob On August 11, 2008 In Being a Doctor
I kind of figured that I would not get much disagreement with my previous post (at least from patients). It is easy for me to criticize my own profession and feel fairly safe, but turning the spotlight on patients makes is riskier.
My purpose in writing these posts is to get both sides looking at things through the other’s perspective. In this post I don’t want to get patients feeling sorry for doctors; I want them to understand how they can either help or harm that relationship.
So here are the Patient Rules:
Rule 1: Your doctor can’t do it alone
The best doctor can do very little with patients who ignore instructions. Sometimes noncompliance is partly due to physicians not explaining things well, but medical compliance is ultimately in the hands of the patient.
I am mystified as to why some patients will ignore nearly everything I say and yet continue coming in for regular appointments. It is frustrating, causing some physicians to get angry with these patients (and even discharge them). I figure it is the patient’s dollar that is being spent, not mine.
Going to the doctor has no therapeutic benefit in and of itself. If you disagree with what is recommended, don’t pretend you agree and then ignore your doctor’s advice. I would much rather have a patient tell me “I am not going to take that medication” than have them accept the prescription and not get it filled. Your doctor prescribes them for you, not for him/herself.
Rule 2: Be Honest
Nobody likes to look silly. I think the main reason most people are untruthful is that they are embarrassed about the truth. But sometimes symptoms are strange, like the man having a heart attack who described it as “a cold feeling when I take a deep breath.” Sometimes symptoms are embarrassing, like a testicular lump. Sometimes you just don’t want to feel like a wimp, so you downplay your pain.
While I can sympathize with this feeling, I don’t see any good reason to be anything but truthful with your doctor. Yes, your symptom might sound strange. Yes, you may have flubbed up and not followed instructions properly. Yes, you may be afraid of what some of your symptoms may mean. But the goal is to fix (or prevent) problems, and trying to do that with bad information is an exercise in futility.
We physicians hear it all. There are very few things a person can say to me in the exam room that will surprise me. My job is to help people, not judge them as “weird”, “crazy”, “wimpy”, or “panicky.” Don’t worry about making a good impression on your doctor. Just give the facts. That will give the best chance to get the desired outcome.
Rule 3: I don’t play favorites
I have over three thousand patients. I try to do right by all of them. I build relationships over years and even develop quasi-friendships with some patients. But I am professionally obligated to keep emotional distance. Overly liking or disliking a patient will cloud my judgment, and so I try to treat everyone the same.
It drives me (and my staff) crazy when patients come in and demand “special treatment” because “Dr. Rob knows who I am.” It is worse if people try to pretend they are my friends by using my first name. Yes, there are special circumstances where I do see a patient who walks in, but that is dictated by the medical condition, not by how well I know the person.
Doctors I take care of can be the biggest offenders. I try to make it clear from the outset that I will treat them like any other patient and not necessarily give them better access because they are doctors. If I have to give them special access, then something is wrong with the system. Besides, special access for some generally means worse access for others.
Rule 4: Don’t mess with the staff
My staff takes an incredible amount of abuse at the hands of some of my patients. It surprises me what they are willing to say to my nurses and clerical staff but not to me. In general, people see them as an obstruction to being able to see their doctor, and so have little patience for any delay.
There are certainly times that my staff is worthy of criticism, and I expect to hear some complaints. But in general, it is not the individual staff’s fault for things not running well, it is our system that causes problems. We have a system for the entire patient experience in our office, and it works most of the time. There are times, however, when circumstance makes things fall apart. There are also times when the deficiencies of the system are exposed.
My staff has a very demanding job. Remember that you are not their only responsibility - you may be the 100th job for the day. If they don’t meet your expectations, yelling at them won’t fix the problem. Talk to me or my office manager. Better yet, put it in writing so that I have ammunition to change things, because chances are really good that your frustration correlates to a frustration I have.
One of the only reasons patients are discharged from our office is when they abuse my staff. A staff member is generally more valuable to me than a single patient, and I need to show my staff that they are valued by me. It is my job to discipline (or fire) my staff, not my patients’.
Rule 5: If you don’t trust, leave
Trust is the commodity we sell. People go to the doctor because doctors have unique knowledge and experience. The stakes are as high as they can get, so why would you go to someone you don’t trust? I have seen many patients stick with doctors in whom they have lost faith “because I don’t want to hurt his feelings.” That is ridiculous.
When you go to a doctor you don’t trust, you will be suspicious about every bad outcome and won’t even trust when things go well. This is a no-win situation for the physician. It does not matter if everyone else says this is a good doctor; if you don’t trust him or her, find another doctor.
I have some specialists I trust a lot and send many patients to. Invariably, some people won’t have a good experience - perhaps the doctor had a bad day, was in a bad mood, or the two just didn’t get along. If I hear that mistrust, I always suggest either a second opinion or a change of doctors. None of my colleagues want someone sticking with them if the trust is not there; it is a very high-risk situation from a malpractice standpoint and studies have shown that negative attitudes make bad outcomes much more likely.
Find a doctor you trust.
Please note that trusting a doctor does not mean you should not ask questions. In fact, I think a physician who does not want to be questioned is one you should not trust. Questioning is often the only way to build trust. Unanswered questions tend to undermine trust.
Rule 6: No news might be bad news
“No news is good news” can be a fatal assumption. Never assume that your doctor will call you if there is a problem. I get 50-60 new documents (labs, x-rays, consults, hospital notes) every day. I order hundreds of tests every week. I just cannot keep track of them all. Some will get sent to the wrong doctor and some results never get sent at all. Despite our best efforts to develop a system that will close this loop, there are some documents I just don’t get.
A doctor’s office is always on the brink of chaos - with an incredible amount of information coming in and going out, a large number of phone calls, insurance company headaches, and personnel situations that can throw the best system flat on its face. People forget that there are hundreds of other patients with thousands of test results the office is dealing with. We do what we can to tell patients test results (and with our computerized records, we do a better job than most), and I see that as our responsibility.
If you don’t get your test results, call.
One more point: we aren’t that much different from you. We have good days and bad days. My staff cry sometimes when they are mistreated by patients. I get discouraged and emotionally drained. It really helps to hear thanks. I don’t expect it all the time, but when I do get a card or a nice phone call saying I am appreciated, it can really help.
********
It can happen. Doctors and patients can get along. Like any relationship, it takes effort and give-and-take on both sides. The benefits of such a relationship are very satisfying and truly life-changing.
Getting along: Part 1 - Doctor Rules
Posted By Rob On August 6, 2008 In Being a Doctor
Why are patients mad at their doctors? In comments on my previous post, people expressed real frustration and distrust - mainly from a lack of listening and connection. Those who loved their doctors (and there were some) expressed the opposite. They had a relationship with their doctor.
Here the rules I have for getting along with my patients:
Rule 1: They don’t want to be at your office
It may seem odd to patients, but most doctors forget that going to the doctor is generally unnerving. We Work there, and being in a doctor’s office is normal to us.
Not so with most patients. The spotlight is on them and their health. They stand on the scale, undress, tell intimate things about their lives, confess errors, are poked, prodded, shot with needles, lectured at, and then billed for the whole thing. Yes, it seems that some patients are happy to be there - and I do my best to make my patients feel comfortable, but there is always an underlying fear and self-consciousness that pervades when a person is sitting on the exam table.
The best thing to do in response to that is to show compassion. If you feel awkward, scared, or self-conscious, the thing you most want is for someone else to understand how you feel. Patients are much more likely to follow a doctor’s advice when the feel that the doctor understands. Identifying the fear and relating to it are the first steps at building trust.
Rule 2: They have a reason to be at your office
People don’t like to waste time and money. They don’t come to the office to waste the doctor’s time. Yet early in my training I was incredulous at the reasons some of my patients were coming to see the doctor. Why come in for a headache? Why come in for a cold? Doesn’t the person realize that a stomach bug won’t get any better by coming to the doctor?
It took me being in my own practice (and trying to keep my business going) to realize that there is (almost) always an underlying reason for a patient to come in. Sometimes that reason is simple: they need an excuse from work, or they have terrible pain that needs to be treated. Other times, however, the reason is more subtle. When a person comes to my office with enlarged lymph nodes, for example, the real reason they are coming in is that they are afraid it is cancer. When patients have chest pain, they are afraid it is their heart.
On every visit I try to identify the real reason (or the real fear) that brings them to see me. I don’t end the visit until I have addressed that reason. If they have an enlarged lymph node, I make sure and say “I don’t think this is cancer because….” If they come in with chest pain, I say “This doesn’t sound like a heart attack because…..” If I fail to do so, then they leave the office with the fear and feel ignored.
Rule 3: They feel what they feel
Patients will often tell me their symptoms in a very apologetic tone. They seem to think that they have to come to me with the “right” set of symptoms, and not having those symptoms is their fault. Sometimes those symptoms make no sense to me at all and I am tempted to dismiss or ignore them.
But as a physician, you have to trust your patient. Only the really crazy patients make up symptoms. Yes, some may exaggerate what they feel out of anxiety or out of fear that you won’t hear them for lesser symptoms, but then your job is to uncover the anxiety, not ignore the complaint. I have heard from many patients that their doctor “did not believe” their complaints because they did not make sense. If you don’t trust them, why should they trust you?
If symptoms seem contradict what I know to be possible, I often openly tell them that this seems to contradict - but I make sure I don’t imply that they might not be being truthful. A puzzle is a puzzle. It is my job to undo a seeming contradiction. I may not ever be able to do so, but at least I don’t make them feel bad for feeling what they feel.
Rule 4: They don’t want to look stupid
I remember when I broke my shoulder - a compression fracture of the neck of the humerus bone - and went to the orthopedist office. I always felt self-conscious about how much pain I was reporting. A colleague had fractured his humerus the year before and had reported he was back to doing surgery within a few weeks. Here I was, a few months out and couldn’t even lay down in bed. I felt like a wimp. Was this other guy just tougher than me? My orthopedist made me feel much better when he explained that my colleague had a mid-shaft fracture, while mine was right in the shoulder joint - a much slower place to heal.
This event made me realize how many patients felt when they came into my office. People are often worried that they are over-reacting. They wonder what I must think for a person to come to the office with that symptom. This is especially true of parents bringing their children in. Nobody wants to be “that mother that over-reacts to everything.” In response to this, I try to specifically say, “I am glad you came to the office for this because…” or “Yeah, I can see how that worried you because it could be….”
Rule 5: They pay for a plan
What do people pay for when they come to the medical office? They pay for opinion, yes. They pay for knowledge as well. But what they really pay for is a plan of action based on their circumstance. If they have an ear infection the plan is to use antibiotic (maybe) and treat the pain. If they have abdominal pain, the plan may be much more complex. They want to know what is going to be done and want what is done to help.
I try and give a plan, either verbal or written, to each patient that walks out of the exam room. What medications are given and why? What medications are to be stopped? What tests are ordered and what will the results mean? When is the next appointment? What should they call for if they have problems? The better I can answer these questions, the more confidently the patient will walk out of the exam room. The days of paternalistic medicine are over - no handing a prescription and just saying “take it.” Patients should know why they are putting things in their body.
Rule 6: The visit is about them
With all of the stresses in a doctor’s office, I get tempted to complain about things. Who better to complain to than someone who feels much the same way? But patients are paying for you to take care of their problems, not the reverse. I keep my personal gripes or frustrations to myself as much as possible.
‘The Hateful Patient’ revisited
By Dr. Suzanne Koven : Boston Globe : February 27, 2012
For many years I was this woman’s doctor and she was my patient. The relationship had not been easy. Her list of complaints about me was long and she recited it often: I prescribed too many drugs, but not the ones she needed. My office was inconveniently located, but the doctors nearer to her home were even more incompetent than I was. I didn’t spend enough time with her (even though our visits routinely lasted three times longer than scheduled), but it didn’t matter, because I couldn’t help her anyway.
Every time we met, an old joke came to mind - the one about the man who whines, “The food in this restaurant is terrible, and the portions are so small!’’
One day, something - I don’t know what - made me interrupt my patient’s accusatory litany to ask: “Is there anything I can do to make you happy?’’
Maybe it was because she had mellowed a little over time. Now that she was old and very sick, her negativity had lost some of its nasty edge. Maybe it was because we both knew she wouldn’t live much longer. Maybe it was because my mother, who was about this woman’s age, who colored her hair nearly the same auburn shade, whose suffering I felt as powerless to relieve, was also dying then.
Had I, too, mellowed? Had my stiff, professional forbearance of this woman softened into empathy or, a word we don’t use as much anymore, sympathy? Or, could it be that what I felt for the old woman, widowed, in a wheelchair, tethered to an oxygen tank, was - now here’s a word you never hear anymore - pity?
Or, perhaps, I was merely exasperated.
Whatever it was that prompted my question, her surprising answer popped out as if it had been on the tip of my patient’s sharp tongue all the years I had known her. She said: “Just tell me that you love me.’’
I didn’t know how to respond. I didn’t love her. I didn’t even like her.
In 1978, MGH psychiatrist James E. Groves published a now-classic article in the New England Journal of Medicine titled “Taking Care of the Hateful Patient.’’ “Hateful patients,’’ Groves noted, “are not those with whom the physician has an occasional personality clash.’’ Rather, they’re the patients whose names evoke cold dread every time they appear on a doctor’s schedule or in his or her phone messages. That would certainly describe this patient, whose calls and visits never failed to induce in me a long silent groan. Groves argued that if a physician owns up to his or her negative feelings about a patient, and specifically characterizes those feelings, treatment becomes more effective.
For example, Groves wrote, if a patient repeatedly makes a doctor angry, the patient is likely a “demander’’ whose unreasonable expectations simply need to be redirected into a desire for good medical care. A patient whom a doctor finds depressing may be a chronic “help rejecter’’ who needs reassurance that the doctor won’t abandon him or her once a symptom abates. Two other categories of hateful patients Groves identified are “clingers’’ and “self-destructive deniers.’’
I didn’t read Groves’s article until just recently, but if I’d read it earlier I doubt it would have helped me much with my patient. For one thing, she wasn’t really hateful - I didn’t hate her any more than I loved her. Also, she didn’t fit neatly into any of Groves’s categories. She could be clinging, demanding, help-rejecting, and in denial, sometimes all at once.
And she could also be, I had to admit, inspiring. As with most people, my patient’s flaws were the flip side of her virtues; the same orneriness that made her so unpleasant to me had seen her through several life-threatening illnesses. I sometimes wondered if she’d survived the odds against her out of sheer spite.
In fact, for all her overt hostility toward me, this woman was a remarkably good patient. She kept appointments, took her medications faithfully, and, even when ill, tried her best to maintain a consistent exercise routine and healthy diet.
Did it really matter, then, what I felt about her? Groves concluded that ultimately a doctor’s feelings toward a patient are only important insofar as they affect his or her behavior. I always believed that, though I had negative feelings toward this patient, my behavior toward her was helpful and appropriate - that I had played the good doctor to her good patient - despite the tension that clouded our every exchange.
Still, that day when I found myself unable to tell the woman that I loved her, I began wondering what I did feel for her. There was no simple answer. She evoked in me feelings of guilt, protectiveness, admiration, annoyance, helplessness, responsibility, inadequacy, defensiveness, frustration, and even affection.
Once, when another doctor saw her in my absence and commented on what a pain she was, I flinched as you might when someone criticizes a close relative you’ve criticized liberally yourself. She was a pain, yes. But she was my pain.
The woman lived only a few months after that day. At the end of her life, our relationship seemed to soften. She became less prickly with me and I stopped dreading her calls and visits.
I can’t say that I came to love the woman, but her bold question did force me to acknowledge my complicated feelings toward her, to let my guard down with her, to stop resisting her presence in my life.
That day she asked me to tell her that I loved her, I couldn’t think of anything to say. Lacking words, I leaned in to hug the woman, first moving aside the metal part of the stethoscope slung around my neck so it wouldn’t get trapped between us and press painfully into her bony chest.
It was an awkward hug, not entirely sincere on my part - probably not entirely satisfactory to her, either. But the distance between us had been partially bridged, and we both knew it.
By Dr. Suzanne Koven : Boston Globe : February 27, 2012
For many years I was this woman’s doctor and she was my patient. The relationship had not been easy. Her list of complaints about me was long and she recited it often: I prescribed too many drugs, but not the ones she needed. My office was inconveniently located, but the doctors nearer to her home were even more incompetent than I was. I didn’t spend enough time with her (even though our visits routinely lasted three times longer than scheduled), but it didn’t matter, because I couldn’t help her anyway.
Every time we met, an old joke came to mind - the one about the man who whines, “The food in this restaurant is terrible, and the portions are so small!’’
One day, something - I don’t know what - made me interrupt my patient’s accusatory litany to ask: “Is there anything I can do to make you happy?’’
Maybe it was because she had mellowed a little over time. Now that she was old and very sick, her negativity had lost some of its nasty edge. Maybe it was because we both knew she wouldn’t live much longer. Maybe it was because my mother, who was about this woman’s age, who colored her hair nearly the same auburn shade, whose suffering I felt as powerless to relieve, was also dying then.
Had I, too, mellowed? Had my stiff, professional forbearance of this woman softened into empathy or, a word we don’t use as much anymore, sympathy? Or, could it be that what I felt for the old woman, widowed, in a wheelchair, tethered to an oxygen tank, was - now here’s a word you never hear anymore - pity?
Or, perhaps, I was merely exasperated.
Whatever it was that prompted my question, her surprising answer popped out as if it had been on the tip of my patient’s sharp tongue all the years I had known her. She said: “Just tell me that you love me.’’
I didn’t know how to respond. I didn’t love her. I didn’t even like her.
In 1978, MGH psychiatrist James E. Groves published a now-classic article in the New England Journal of Medicine titled “Taking Care of the Hateful Patient.’’ “Hateful patients,’’ Groves noted, “are not those with whom the physician has an occasional personality clash.’’ Rather, they’re the patients whose names evoke cold dread every time they appear on a doctor’s schedule or in his or her phone messages. That would certainly describe this patient, whose calls and visits never failed to induce in me a long silent groan. Groves argued that if a physician owns up to his or her negative feelings about a patient, and specifically characterizes those feelings, treatment becomes more effective.
For example, Groves wrote, if a patient repeatedly makes a doctor angry, the patient is likely a “demander’’ whose unreasonable expectations simply need to be redirected into a desire for good medical care. A patient whom a doctor finds depressing may be a chronic “help rejecter’’ who needs reassurance that the doctor won’t abandon him or her once a symptom abates. Two other categories of hateful patients Groves identified are “clingers’’ and “self-destructive deniers.’’
I didn’t read Groves’s article until just recently, but if I’d read it earlier I doubt it would have helped me much with my patient. For one thing, she wasn’t really hateful - I didn’t hate her any more than I loved her. Also, she didn’t fit neatly into any of Groves’s categories. She could be clinging, demanding, help-rejecting, and in denial, sometimes all at once.
And she could also be, I had to admit, inspiring. As with most people, my patient’s flaws were the flip side of her virtues; the same orneriness that made her so unpleasant to me had seen her through several life-threatening illnesses. I sometimes wondered if she’d survived the odds against her out of sheer spite.
In fact, for all her overt hostility toward me, this woman was a remarkably good patient. She kept appointments, took her medications faithfully, and, even when ill, tried her best to maintain a consistent exercise routine and healthy diet.
Did it really matter, then, what I felt about her? Groves concluded that ultimately a doctor’s feelings toward a patient are only important insofar as they affect his or her behavior. I always believed that, though I had negative feelings toward this patient, my behavior toward her was helpful and appropriate - that I had played the good doctor to her good patient - despite the tension that clouded our every exchange.
Still, that day when I found myself unable to tell the woman that I loved her, I began wondering what I did feel for her. There was no simple answer. She evoked in me feelings of guilt, protectiveness, admiration, annoyance, helplessness, responsibility, inadequacy, defensiveness, frustration, and even affection.
Once, when another doctor saw her in my absence and commented on what a pain she was, I flinched as you might when someone criticizes a close relative you’ve criticized liberally yourself. She was a pain, yes. But she was my pain.
The woman lived only a few months after that day. At the end of her life, our relationship seemed to soften. She became less prickly with me and I stopped dreading her calls and visits.
I can’t say that I came to love the woman, but her bold question did force me to acknowledge my complicated feelings toward her, to let my guard down with her, to stop resisting her presence in my life.
That day she asked me to tell her that I loved her, I couldn’t think of anything to say. Lacking words, I leaned in to hug the woman, first moving aside the metal part of the stethoscope slung around my neck so it wouldn’t get trapped between us and press painfully into her bony chest.
It was an awkward hug, not entirely sincere on my part - probably not entirely satisfactory to her, either. But the distance between us had been partially bridged, and we both knew it.
