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Better Utilization of a Doctor Visit


All too few people make the most of their physician encounter even though it's true that the average patient is doing a better job than they used to.

I gave a talk to a group at Google the other week and made the point that, in spite of Silicon Valley being a well-educated area, with most people active on the internet, all too few people make the most of their physician encounter. And my unscientific survey of some other area doctors reinforces that observation.

It's also true that the average patient is doing a better job than they used to. They are better informed, probably in no small part due to the internet. And they tend to speak up a bit more than the previous generation. Some might chalk up that change in behavior to a rise in consumer awareness.

That is a factor, but we should look more to the blunt wedge that the rising cost of health care and the managed care movement has driven between doctors and patients. High costs and the ability to pay have become the tail that is wagging the dog. Patient loyalty used to be more widespread than it is now with both doctors and patients historically valuing its comfort and utility. While still extant in the land as a prized quality, it has clearly taken a back seat to economic pressures. People move on when their insurance company says to.

With loyalty, and its precursor familiarity, becoming less common, it is even more important for accuracy of diagnosis, control of runaway costs and effective results from compliance for there to be a better job done of managing less familiar encounters. And patients have to do their part in learning to feel more comfortable in getting "quality," however that is perceived, and value, which people do have a firmer sense of. So far, I have seen too little mention of patient responsibility in the health care debate.

We can agree that medical encounters would benefit all involved to a greater degree if patients came to them better prepared. It would help to understand how to improve if we review what some of the roadblocks are. The first is that people are anxious. If they don't feel well, they fear the worst, especially if they have discussed their symptoms with a "friend," have just heard some scare story on the media or made only a cursory glance at the ’net.

Which leads to the second pertinent aspect of human nature: When we are anxious, sometimes we clam up. Or we babble, wandering off-point all over the place. Or we bring up everything possible to avoid confronting the symptom that has induced our fear. And we don't retain information when we are anxious, which makes the visit even less effective.

One manifestation of patient anxiety, the "good" reason for the visit versus the "real" reason is a perennial. Some of you might recognize this as the patient with a minor chief complaint turning back on the way out of the door as the "oh, by the way…" moment. I remember one 5 p.m. Friday patient turning back to mumble about "crushing chest pain…" (He had his by-pass on Monday).

Related to the anxiety factor is the historical Intimidation and Authority factor, which, happily in my own experience, is fading. Some doctors are still the Delphic Oracle dictating from the dais; but the culture inside and outside of medicine is changing. It used to take some measure of fortitude to stand up to Old Doc Jones to question him eye-to-eye, but now, not so much. Which means that people are more engaged and therefore in a better position to be helped, satisfied and compliant.

If we are being honest, then one of the reasons for the cultural shift both inside and outside of medicine diminishing the Old Doc Jones effect is the 50% ratio of women now emplaced. Yes, some of the female medical pioneers were pretty crusty themselves, they had to be. But now encounters are easier, especially for women and children. It’s long overdue, but here we are.

And don't neglect the mind-numbing effect of technology proliferation and the still-too-rampant use of jargon by doctors. All are very off-putting. As a primary care physician I have spent a surprising percentage of my time with patients translating what specialists have told them to understandable English.

You see where I am going with the second half of this interaction. There are a number of reasons why patients may be anxious, intimidated and unprepared. On our side of the interaction, happily there is a new movement in medicine to reemphasize doctors doing a better job of interviewing and explaining, and communicating to patients. If asked, most doctors will tell you that they do a "great" job of it, but how many times have you overheard other doctors doing a "great" job? Even allowing for differences in style and personality, most of us could do better — a lot better. Me, too.

To help our patients, try putting a few suggestions on making the most of your encounter in your patient brochure, if you haven't already instituted this, and then reinforce its usage by encouraging your patient to use them. If you want better compliance, reinforced loyalty and reduced costs and miscommunication, give it a try. There is no downside!

A few suggestions for patients might be to: 1) write all questions down ahead of the visit and leave space to write the answers (every study I've seen shows much of what we say is going by the time the patient hits the parking lot and gone by the time they run their errands and get home); 2) please, put your questions in order of their importance to you as we may not have time at this visit to get to them all; 3) do not leave until you are comfortable with a) what's wrong, b) what are we doing to investigate, c) what are we doing to treat and d) what is the timeline (recovery, next visit, etc.); and 4) bring any new records or prescriptions with you.

I'm sure that you can add more and if you have any additional ideas that you would like to pass along to our colleagues, please let me know. Patients too often avoid taking any responsibility for their visit to the doctor, but if we all — doctors and patients alike — stop and take stock, everyone stands to gain.

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Victor J. Dzau, MD, gives expert advice
Victor J. Dzau, MD, gives expert advice