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I was recently inspired by another article in Medical Economics, and curiously, have a solution for each legitimate gripe, based on decades of sorting through the combatants in this health-care disaster we’re engaged in on a daily basis.
Let’s face it, we’re all experiencing the mixed blessings of longevity-not only are patients living longer, but physicians are also practicing medicine longer, postponing their retirement until the kids (or grandkids) are out of school and on their feet. This means for primary care doctors, including family practice physicians like me, and internists, the added blessing (or sometimes curse) of having long-term relationships with patients. Some of my practice includes extended families where I care for the parents, kids, and grandparents-what a challenge! Of course, there are wrinkles in these long-term relationships, but generally, they can be ironed out if addressed.
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I was recently inspired by another article in Medical Economics (by author Rose Krivich, “Top 11 gripes physicians have with patients"), and curiously, have a solution for each legitimate gripe, based on decades of sorting through the combatants in this health-care disaster we’re engaged in on a daily basis.
In no particular order, here we go:
Yes, people do miss appointments, and it is both annoying and financially a disaster for the doctor if this happens often. But, there are extenuating circumstances, and a good office manager can sort through the “Dog ate my homework” stories we all hear (the funniest being “I’m too sick to get out of bed”), and with some kindness and intelligence, help resolve issues of absence. Car accident? That’s a given. We routinely let the patient have the benefit of the doubt. “Stuff happens,” to approximately quote Forrest Gump, and kindness and common sense dictate some laxity is reasonable. But we do have to stay in business, so having a 24-hour cancellation policy in effect and reinforcing this at every point in the appointment process not only generates necessary income but minimizes holes in the schedule.
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Always an issue, but look on it as more of a challenge. Is the patient secretly uncomfortable with the treatment approach? Often use of a long-term drug such as a statin for hyperlipidemia is prescribed routinely, but the patient may manifest his resistance by simply losing or ignoring the prescription. It may be frustrating for the physician, but this is a fixable problem-maybe the drug is too expensive? Look for alternatives. Have lifestyle changes, diet and exercise been explored? We can be creative, especially if these are big issues, like heart disease, that need a concrete, durable solution.
Yes, everyone wants a bargain, and especially these days, when it seems like an adversarial relationship between the doctor and the insurance company has blossomed, there are many mixed messages. Does the patient get a once-a-year free (no copay) healthcare exam? Is lab work included? And if so, (drum roll) which lab tests are really covered? This is not a time when we can legitimately take out our collective frustration on the patient. They are generally not equipped to decipher the fine print gobbledygook that governs culpability when it comes to testing. A simple explanation that the office will attempt to bill for the visit and testing as preventative care, but there may be some patient responsibility is both honest and accurate. In the long run, aren’t we partners in our patients’ health, not opponents?
Next: 'Last time I looked, we were all human'
Rudeness should not be tolerated, on the part of our own staff, or patients. That having been said, being in a doctor’s waiting room may be the most stressful situation some of these people have ever faced-a swirling, hideous maelstrom of all their fears, financial woes, and we expect them to be…nice? Some kindness and guideline-setting by our own staff may help minimize friction and promote the concept that we, as health care givers, really do care about our patients’ health, and want to help them. For the incorrigibles, who may feel it’s acceptable to repeatedly take out their woes on our staff or us…the door is right over there. Use it. Protecting our staff and our own safety is a huge part of a successful practice.
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There, I’ve said it-families can be wonderful, but noisy ones in our waiting rooms may be out of control. Establishing guidelines (both written, posted, and verbal) may help to eliminate noise, cellphones and food, but if people can’t, or simply won’t comply, then there’s always the hallway or the street. We considered using a Faraday Cage to eliminate all signals in our office, but couldn’t implement it without losing our own cell phones.
A virtue, to be sure, but not always possible. Having a firm policy in place may help, and letting patients know in advance that they need to be prompt or may lose their appointment seems to do the trick. Be firm, but be kind. Remember, when raising our kids, they always needed limits.
Last time I looked, we were all human, and then there are the additional limits of space and time-meaning, I simply cannot address thirty major problems that include and sometimes transcend 14 systems, in a 30-minute visit. Warn the patient, in advance, that their problems may need to be prioritized, and that you can and will address the direst of them during the visit, but they may need to follow up for future appointments in order to be comprehensive and not miss anything. This isn’t a disaster, it’s an opportunity to be thorough and really help the patient. If, on the other hand, the patient is simply wordy, or his fear has manifested as approach-avoidance, the physician may have to be confrontational and address how important the communication process is. But, above all, let the patient have a voice, and be heard, even if only for 30 minutes.
Possibly my favorite of all these bugaboos. As doctors, we are reputed to be the worst patients in the world. There’s a modicum of knowledge at our disposal, nevertheless, when you or I get sick and actually need to consult with a physician, even if the problem isn’t one we’re handy with (for example, my PSA recently went from a delightful .5 to an unpleasant 5.5. Boy, did I learn a lot in a hurry!), we cope, and listen.
Next: 'Why not assume some of the weight when a difficulty erupts?'
Sadly, our patients rarely have that ability to soak up information and process it. And of course, fear kicks in and paralyzes the rational brain, quickly. So, some of the things we never studied in medical school, but hopefully have picked up in the real world, come to the fore. Such as, speaking simply (not in Medicalese), looking the patient in the eye (not at our computer screen) and making sure there is real comprehension, and most of all…patience.
Put things in writing, to be taken away for later reference, because nine-tenths of what we say will disappear like farts in a windstorm when the patient walks out our office door. Schedule follow-up visits, and allow them to ask any questions they may come up with before they leave the office. My one clinical pearl, passed on to me by my dear departed dad, is that the last thing the patient says, however hesitant, may be the most important element of the entire conversation. Howard Patt’s shining example: “By the way Doc…is it normal for me pee carbonated?” (This was back in World War II, and the patient had developed a post-operative fistula between the bowel and bladder. Whoops!)
Well, it isn’t acting, folks. We do this all day long, and barely comprehend how insurance works. Why should the patient? The explanations given out by the insurance companies are deliberately dense and incomprehensible, and like it or not, our job as caregivers is to help. My office managers are much better than I am at explaining the ins and outs of private insurance, but I do truly feel sorry for the patient who has been misled into thinking that their new flimsy insurance card is akin to a Gold MasterCard. It isn’t, trust me.
If a complex problem erupts unexpectedly most of the insurance companies, however understaffed, are mandated to provide nurse case managers who can help a patient with a new issue, like adult-onset diabetes or cancer. We do, like the Buddha says, need to practice patience.
I’ve stopped at nine issues, rather arbitrarily, but could go on and on-experience dictates that half of the perceived “problem” we may have with a patient is due to our own stance, and can be worked on. As doctors, if our efforts to heal and help are met sometimes with success, we are willing to take the credit. Why not assume some of the weight when a difficulty erupts? Maybe an addendum to the Hippocratic Oath is past due.
Stephen Patt, MD is a semi-retired family medicine physician who lives with his beloved wife Lisa and wonder dog Sally Salt in the wilds of Topanga Canyon. He may be reached at Doctorpatt@yahoo.com.