Archive for the 'Doctor Communication' Category



From the desk of…. (11/2/07)

Some miscellany from the week not requiring entire blog posts on their own…fromthedeskof.gif

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Enjoyed participating in the WSYR Radiothon with Joe Galuski to raise money for the University Hospital / Children’s Hospital in Syracuse, NY. Incredible resource for families with sick children.

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Two good interviews of note on this week’s radio show: Dr. Thomas Welch, chair of pediatrics of University Hospital, and Dr. Matthew Scuderi who will talk about cartilage repair for the knee. You can download the interviews from the radio show website.

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You might be interested in some recent comments made by Marc J, an anesthesiologist, who is NOT happy with some of my posts. In fact, he would like to serve me some “salsa for the chip on my shoulder.” Hmmm…. He also suggested in one of the comments that he didn’t like attacking me on my blog where all my readers could see them — however — as you know, my email address is listed directly under my photo.

I want you, my reader, to understand all sides of the story when it comes to your care. In fact, I think it makes for smarter healthcare consumers — and shows you even better why you need to take responsibility for your own choices in your care, ranging from who your doctors will be, to how you will be diagnosed or treated, to how you will pay for your care, and everything in between.

So here are a list of Marc’s posts, although, please keep in mind that he doesn’t really intend to attack me publicly (uh-huh.)

Comment on Lemon Law for Medical Consumers by Marc J

Comment on How Apologies Lead to Fixing by Marc J

Comment on When Dirty Doctors Can’t be Identified by Marc J

In fact, Marc, you are right. There are definitely times I cop an attitude or have an “edge” to my work. I’ve been accused of that before. It started with my own misdiagnosis, and it continues because I get dozens of emails each week from people who have been wronged by the healthcare system in some way. It’s heartbreaking — and has turned me into a cynic, whereas throughout my life to this point, I’ve mostly been a pollyanna.

Guess that makes me the Ralph Nader of the healthcare system.

And yes, I have real problems sleeping at night. Because I just can’t get the word out fast enough.

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OK — out to do some gardening today! It’s a perfectly glorious autumn day here and I plan to take advantage of it. Included will be cleaning up the pieces of pumpkins left from the squirrels who have eaten right through them!

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Doctors Complain About Complaints

… and I don’t blame (some of ) them.

I’ve seen several articles in the past few days about this topic — that doctors are feeling bashed and unappreciated.

Texas physicians blast anonymous complaints

Closer look irks doctors

Some doctors have their patients complaining on their behalf.

I’m even seeing this about doctors who are overseas — yes — where universal / national healthcare works: Top doc vows to clear name after witch hunt

There is nothing new about doctors getting upset at the fact that patient consumers finally have a public voice (through the internet) that helps vent their frustrations. Nor is it news that doctors don’t like lawsuits when they’ve committed errors. In fact, there used to be a website called www.doctorsknow.us that was established specifically to help doctors blacklist patients who they thought were too difficult. The website was taken down a few years ago, and it’s very interesting to read the comments made by doctors who were supporters.

[And, in fairness, this is not true for all doctors.... nor is it true for all patients. The takeaway here should not be doctors as a whole group -- instead it should be only about those doctors who complain about their patients. ]

So we have patients complaining about doctors, and doctors complaining about patients and everyone complaining about the costs of healthcare, and the dysfunction of the “system.”

Yup – turns out this is another blamers and fixers discussion.

My observation: most complaints are rooted in mismanaged expectations that regard communications and the time/money conundrum.

Do you know of anybody who is happy with healthcare these days? Even if you have a dread disease, and get cured, you’ll complain about the cost, right?

Patients no longer “need” a medical error to get upset. The complaints I hear are that the doctor won’t spend enough time with them, or doesn’t answer all their questions, or always seems in a hurry.

Doctors are frustrated that their patients don’t understand the time constraints they are under, squeezed by health insurance reimbursements that are too low, so the doctor is forced to see more patients each day.

Doctors tell us our outcomes are less than expected because we aren’t complying with their recommended treatments — they complain that it’s often the patient’s fault when treatment doesn’t work because patients aren’t doing as they are told.

Doctors further complain that they are competing with the internet to diagnose and treat patients.

So here is some advice for patients:

Understand that the financial pressures on doctors are beyond anything they have ever been. It used to be they would see, maybe, 20 patients in a day (21 minutes average per patient). That meant they could spend a good deal of time with you to answer your questions. Now, if they want to stay in business (and we need them to!), they must see more like 50 patients in a day (8 minutes per patient) or they won’t have enough income. If they don’t stay in business, we won’t have a doctor to see — and that is already a problem — a shortage of doctors in many areas of medicine. We patients need to adjust our expectations, respecting a doctor’s time constraints.

Knowing you have less time with your doctor, prepare well to see him. Make a concise list of symptoms to report and a concise list of questions to ask. Manage your doctor’s expectations by telling him you have those lists. When he interrupts you (within an average of 18 seconds into your meeting) — then ask him politely not to interrupt. Remember — he’s used to interrupting, so you need to let him know that’s not acceptable.

Do not allow your doctor to provide an instant diagnosis. Make him think outside the box. When he provides you with a diagnosis, ask “what else can it be?” and ask him to explain why it isn’t the alternatives.

Approach your care in a collaborative way. If you have looked up symptoms or diagnoses or treatments on the internet, then warn your doctor that you want to discuss your findings. Manage his expectations that you want to have that discussion but that you are willing to make it a short discussion.

Comply with your co-decided next steps. If you and your doctor agree on what those next steps are going to be, then you have no excuses but to comply. If you run into problems, let your doctor know immediately, otherwise he will think it’s your fault that you aren’t getting better.

Here is some advice for doctors:

Please understand — I GET that you have less time per patient. I GET that your reimbursements squeeze you. I GET that you went to med school and the internet didn’t. I GET that patients are demanding more from you when you have only less time to give. I GET that your practice approach has had to shift with these new realities. I offer this advice to make your lives easier:

You will be less inclined to find problems with your patients if you begin to respect them more. They are sick or hurt. They are scared. They are looking to you for answers and guidance. You are treating them like cattle. You are interrupting them. You aren’t thinking outside the box. And yes, I realize that in fact, if you don’t do it right the first time, you just get paid a second (or third) time for doing it again. But respecting your patients should still come first.

Respect also means it’s time to stop interrupting. I GET that you are interrupting because you know your time is so short — but don’t. If you want to speed things up, then tell your patient that’s what you are doing. “Mr. Jones, please tell me quickly what you learned because I want to spend our time finding the answers for you.”

Understand that the internet is here to stay. It’s not going away. Instead of fighting it, or getting upset with it, why don’t you guide your patients’ use of it? Manage their expectations about YOUR reactions. Provide them with a flyer about the use of the internet that asks them not to bring you stacks of printouts, and guides them to good websites for their use?

When patients don’t get better, don’t automatically assume it’s because they didn’t comply. Yes, I GET that compliance is a big issue — but assuming non-compliance is once again, a respect issue. You can get to that information by asking gentle questions mixed in with symptom or test result questions. By assuming non-compliance, you instantly put your patient on the defensive, and that throws up more roadblocks.

Advice for all:

Next time you are tempted to complain about your doctor, or your patient — ask yourself if the basis stems from communication, or if it stems from time/money constraints. In either case, the “fix” is not the opposite party, the “fix” is your approach. Take a deep breath — then see if you can fix it.

That’s what fixers do. Because complaints and blame don’t get us anywhere.

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More Evidence for the Positives of Apologies

Those of us who work in patient empowerment couldn’t help but notice the results of a Harvard Medical School study released this week about what happens to a relationship between doctor and patient when the physician makes an error. The story was reported in US News and World Report the New York Times and other outlets.

Originally published in the New England Journal of Medicine (NEJM), the commentary called Guilty, Afraid and Alone: Struggling with Medical Error basically says that when a doctor commits an error against a patient, trust is eroded and doctors feel guilty. (Did anyone question this?)

Turns out that in many cases, the patient’s family members feel guilty, too, for not protecting their loved one. Even nurses who lost family members to medical errors reported feeling isolated, and fearing their loved one was going to receive substandard care due to the guilt of those who had imposed the errors. The words “fear” and “rude” and “mistreatment” polka dot the report.

What’s the bottom line? Once again we hear the benefits of apologies by those who have violated trust. Nothing new here at all. Groups like Sorry Works have been talking about this for years. Thirty-four states have enacted legislation to grease the skids. Those doctors who understand the dynamics, even for their wallets, are beginning to get the picture.

Test it here yourself. Another story published within days in Miami, about a 3-year old who died at the hands of medical test administrators — even though the family questioned the procedure. So very sad. And a good illustration of how we feel on the other end of the tragedy when responsibility is taken by the guilty party. Apologies are plentiful, restitution is being made. By the end of the story, you’ll feel bad for the offenders, too — although not nearly so sympathetic as you do for the family, of course.

Doctors and providers — please pay attention. Your patients truly need you to understand the guilt aspects of errors, and then step up to the plate. Your careers, and our health, depend on it.

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How to Complain to Your Doctor, Part II

We began yesterday with the story of Nancy and her husband, and the obnoxious nurse and cold and aloof doctor who performed a prostate biopsy on Nancy’s husband. Her husband was humiliated by his treatment and Nancy wanted to let the doctor know about it.

My original suggestion to Nancy was that they needed to find a new doctor. This doctor and his nurse are not going to change their stripes.

Nancy, however, decided she wanted to let the doctor know how rudely her husband had been treated by the nurse, in hopes the doctor would speak to his nurse. So she wrote the doctor a letter.

Nancy contacted me a few days ago to say her husband doesn’t want her to mail the letter. He is afraid the doctor will not treat him any longer if she mails her letter.

So, Nancy asked me, what should she do?

I actually provided a number of thoughts to her as she considers next steps. Here they are:

  • At this point, Nancy and her husband need to think more in terms of how this nurse and doctor treat them, and less about how they treat others. As noble as it would be to “fix” them for others, it seems for now that their better efforts are concentrated on improving service to themselves.
  • Prostate “challenges” are something a man must live with for the rest of his life. In some ways, his conversations and experiences with his urologist will be more intimate than his conversations and experiences with his wife. Granted, he won’t have to see the urologist very often, but — he will have to trust the doctor implicitly to make the most effective recommendations for a long, and as healthy as possible, life.
  • Her husband has two choices. He can either find a doctor he does respect and does trust. Or he can work with this one to find that level of respect and trust that is so necessary.
  • Keep in mind that the best doctors don’t have to be the nice doctors. And the more specialized a doctor, the less he really needs to be nice. That’s just a fact of life! And remember, too, that nice does not equal skilled. There are thousands of “nice” doctors who aren’t good at what they do. And vice versa, there are thousands of very skilled doctors who just aren’t very nice.
  • In order to gain respect, we have to command respect. So perhaps the best approach for Nancy’s husband is to begin thinking like a consumer and less like a patient. For example — when the nurse took him into the room to prepare for the biopsy — her husband could have asked for a sheet or something as a cover. We don’t have to act like sheep — we can ask for what we need!
  • Her husband needs to look for ways to command what he needs — because sometimes that is all that is necessary to gain someone’s respect. For example — if you have to wait in the waiting room for a long time, ASK what is taking so long and suggest that you’ll need to make another appointment if they can’t get closer to the right time. Or — if the nurse says something rude, why not ask her if she’s having a bad day? That gives her a way to reconsider how she’s treating you. (Also, maybe the reason she is so foul is because the doctor treats HER like a second class citizen? That’s very common, I am told.)
  • The real point to all of this is that (as Dr. Phil says) we treat people how to treat us. If we don’t stick up for ourselves, we get run over. Knowing Nancy’s husband will have this lifetime relationship with his doctor, it only makes sense to begin immediately to change the tenor of that relationship to one of mutual respect, and not so much like a parent and child.

So, OK, I know these aren’t ways of complaining to your doctor — some bait and switch for which I apologize. But it’s to make a point.

I used to suggest to patients that they if they have problems with their doctors or the staff in the office, they spend some time explaining it to the doctor. But first one needs to gauge whether the doctor will be receptive to those kinds of comments — and receptive here means, will the doctor actually take steps to improve the situation? In some cases, that’s still appropriate.

In this case, though, and based on a half dozen emails with Nancy and dozens of other patients, it’s clear that very often, the real problem is more about defaulting to letting the doctor and staff control them, as opposed to proactively sticking up for themselves and commanding the respect they deserve.

Sharp patients — those with patientude — know that the relationship among a doctor, staff and patient should be respectful. When patients behave as if they expect that respect, then their chances of being treated respectfully will be much improved.

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How to Complain to Your Doctor – Part I

Several months ago, I heard from Nancy about a terribly embarrassing experience her husband had suffered during a prostate biopsy. From the beginning of the procedure through the end, he had been treated inconsiderately and rudely by the nurse. The urologist was condescending and short. And ultimately, once the biopsy was over, and wearing no clothing and with no covering, her husband was told by the nurse to get up and get dressed…. whereupon he got off the table and fainted. When he came to, he was crumpled on the floor, covered in blood, surrounded by a half dozen people, naked, and horribly, horribly embarrassed.

Nancy was appalled at the behavior of the nurse who she felt treated her husband like a second-class citizen. She also felt as if the urologist had no interest in hearing about the event. Her husband was afraid to say anything because he didn’t want lesser treatment from the urologist, whom he will have to see from now on, on a regular basis. But Nancy was afraid her husband would decide not to keep his appointments at all, based on the excessive rudeness of the nurse. He had already postponed his next appointment a few times.

Nancy’s question to me: she wanted to complain, but how could she do it so the doctor would talk to the nurse, and how could she make sure the nurse and doctor wouldn’t take it out on her husband at later visits?

There are actually several aspects to this question. Like healthcare itself, there is prevention, treatment of symptoms, and finding a cure.

Prevention would have had to have taken place long before Nancy’s husband was biopsied. Prior to ever seeing that urologist, he should have asked among his friends, others who have suffered through prostate cancer or had previously been biopsied, to find a urologist they respected and spoke highly of. That very likely would have found him a much better doctor than this one is turning out to be.

Treatment of symptoms is addressing the event itself.

Finding a cure is the walking — the taking his business elsewhere — leaving that doctor in the dust and finding one her husband can talk to.

Setting prevention aside in Nancy and her husband’s case (too late!) my choice would have been the cure. If this doctor had been their auto mechanic, or any other service provider, then they never ever would have put up with the behavior of either the doctor OR the nurse, correct? Nor should they in this case. Especially in the case of a specialty like urology…. while you won’t find them on every street corner, there are enough good urologists out there — so why not find one you can communicate with?

But Nancy wants to treat the situation. She wants to write a letter to the doctor, and she has questions about how she should approach that, what she can say that would most effectively explain her and her husband’s dissatisfaction with their experience with that doctor and his staff.

So here’s your cliffhanger…. tune in tomorrow! I’ll tell you what I’ve suggested and what’s going to happen from here.

(Link here for part II)

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How Doctors DON’T Think: Groopman on the Today Show

My physician-guru, Dr. Jerome Groopman, was on the Today Show this morning to highlight some of the excellent points he made in his book, How Doctors Think. (My editorial opinion — it’s a must-read for anyone who is having trouble getting diagnosed correctly.)

But I’m beginning to swerve from my usual train of thought surrounding how most doctors think. Whereas I’ve always taken it to a next step to help patients help themselves — I’m taking a bit of a detour today.

Groopman’s background information about the way doctors arrive at diagnoses must be understood by patients:

  1. Doctors make snap judgments about their patients. For example, a doctor will ascribe any symptom a woman over age 50 has to menopause. Or if a patient is diabetic, the doctor will assume any subsequent health problems are related to diabetes.
  2. Doctors always go with their first impressions — and they form them within the first 18 seconds of seeing the patient — which also means they not only don’t listen to anything the patient says after those first 18 seconds, but also means that they try to fit any additional symptoms the patient might recognized into their first impression.
  3. Doctors are not taught to think in med school. They are taught to answer quickly — which means — they don’t think outside the box, because that takes too long.

So the bottom line is that smart patients will bring doctors up short on all this by asking “what else can it be?” or questioning their doctors about symptoms that don’t seem to fit into a profile for their diagnoses.

And I absolutely agree with that bottom line — I’ve agreed with it many times before.

However — I’m also beginning to think a bit differently about this conundrum, too. Whereas I am all about the patient taking responsibility, and I think all patients should be actively participating in their diagnosing and treatment decisions — at what point do we just say, “Whoa!! Hold on!! That may be how doctors think — but they are thinking wrong!”

Groopman stated that 15 to 20% of all diagnoses are incorrect, and that half those patients are then harmed by that misdiagnosis.

Think about it this way: that means that, on average, if you have been to the doctor 10 times, then YOU WERE MISDIAGNOSED TWICE!

Patients themselves can’t make up for that deficit. In addition to patients taking responsibility for participation, I think we need to throw some of the onus back on doctors, too. We can’t simply accept that they don’t do their jobs correctly, we must begin making them responsible for getting it right.

So whereas I usually provide a bottom line to patients, today I’m going to do that for doctors:

  • Doctors, stop interrupting us.
  • Doctors, begin thinking outside stereotypes and profiles.
  • Doctors, stop trying to fit our symptoms into your own little boxes and start building the right boxes to fit them into.

(OK — I can’t help myself here…..)

And patients — start making doctors do all of the above!

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How Apologies Lead to Fixing

I’ve talked before about blamers and fixers. Here’s a way of looking at that concept that may make you a wiser patient.

One of the big questions about medical mistakes is whether practitioners should own up to them. Until recently, doctors were highly discouraged from admitting any kinds of problems had taken place, whether it was prescribing the wrong medications or amputating the wrong limb. The thought was that by admitting guilt, they would be setting themselves up for losing lawsuits.

Once again — the concept of blame creates problems. The fix is what might seem surprising.

Studies have shown that in fact, when doctors are willing to accept responsibility enough to apologize, and review and learn from their mistakes, malpractice lawsuits are far less likely to be filed. In fact, a study undertaken at the University of Michigan Hospital where they have a policy of disclosure for both errors and near-misses, reflected a two-thirds reduction in medical malpractice claims, according to All Things Considered on NPR.

Clearly — taking responsibility can even save money!

What no one I know about has yet examined is this: why does that happen? Why can something as simple as a doctor’s apology keep a patient from filing a lawsuit?

Here’s my guess at the reason:

When young children misbehave, they are blamed for the problem they caused, then taught by their parents to apologize. The apologizing itself is deemed a way to begin the “getting beyond” whatever their indiscretion was, both for the misbehaver and for whomever the victim was. Also, as children, when someone hurts us or does something we know was wrong against us, we are taught to learn to accept an apology as the first step toward forgiveness. That’s how we learn the beginnings of closure, and we learn to depend on closure as the way to get over whatever happened.

Later, when something bad happens to us that we have no control over, we human beings want to blame. It gives us something to focus on. We blame the terrorists for 9/11. We blame the government for Katrina problems. We blame faulty design for the Challenger blowing up. Sometimes we even blame God, or whomever we revere, when something horrible happens that we can’t point any other finger at.

Often, that finger-pointing blame is appropriate. Who or whatever we blame deserves it, and what we want is for the object of our blame to then feel appropriately guilty — and therefore to apologize. The acceptance of that guilt is what lets us begin the closure process. Any healing that may take place will be based on that closure.

The Institute of Medicine tells us up to 98,000 Americans are killed by medical errors or misdiagnosis each year — which means 98,000 doctors deserve the blame. When those 98,000 doctors were told they were not allowed to apologize, then families of the victims had no way to begin their closure process by accepting an apology and starting to forgive. They needed to find closure in some other way. So they filed lawsuits.

That the number of malpractice lawsuits were reduced to one-third of previous levels because doctors are allowed to apologize, should therefore come as no surprise. In fact, in the NPR story used to illustrate the point, not only did the victim of the medical error feel relieved that she had been apologized to, but she further stated that she felt as if they had listened to her, and had learned from the mistake made on her, so that another woman wouldn’t suffer later from the same mistake.  She no longer felt like a victim.  In fact she felt like she had inspired something very positive.

The NPR story said that up to 70 percent of hospitals are now leaning in the direction of disclosure and apologies. That’s excellent. I hope to hear soon that 100% of hospitals are buying in.

And what can patients do in the meantime?

In my opinion, we can measure how patient-centered a hospital is by examining its policy about error disclosure. If they support disclosure, and allow their doctors to apologize and learn from errors, then they are far more likely to be interested in outcomes for patients than those hospitals that don’t support this sort of transparency.

So, taking this idea another step: as patients, if we think we may need to be hospitalized in the near future, we can actually use this information to our advantage. Call the hospital and ask what their policy is. Ask a doctor who has an affiliation at that hospital what their policy is.

Are they forthcoming and pro-learning? Or are they offended that you asked the question so they dance around the answer?

See what they respond, and how they respond. Tune in to their attitude. It can tell you a lot. And that might make a huge difference in your hospital experience.

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Learn more about doctor’s apologies here.

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