Your voices

Compiled by Jeff Forster, Editor

On winning over the difficult patient

"A strong point of my residency program in Chicago was an outpatient continuity clinic aimed mostly at indigent patients. I was proud to be there and excited to be taking care of patients all by myself. I felt I was gradually getting to know and understand my patients–until I met Mr. B.

He was a 75-year-old black man with end-stage hypertensive cardiomyopathy, among many other complaints. In the initial interview, he was very cautious, almost paranoid, about what he said. He’d bring his own notebooks to record the details of each visit, as if he didn’t believe the doctors could keep their records complete and up to date. It was clear that he did not trust me and I did not understand him. At every follow-up appointment, he’d show up about an hour late, then demand to see the doctor right away.

In the first few months of his visits, I could clearly see that Mr. B was suffering. He was short of breath, depressed, and easily provoked, much of which I believed was attributable to his illness. I talked to his cardiologist and some of the nurses. They told me he trusted no one, was very demanding, and never smiled. I decided to do the best I could.

When he had to be admitted for minor surgery, I decided to go see him daily and spend lots of time at the bedside in an effort to understand and reassure him. I also carefully diuresed him; by the time he went home, he had shed about 20 pounds of fluid. ‘I feel like a new man,’ he said.

He had also shed much of his attitude. He started conversing with me, smiling and laughing, and said he felt better than he had in the past 15 years. He started following my medical advice, and telling me stories about his days as a used car salesman.

One day during a follow-up clinic visit, he let me in on what had been troubling him all this time. Years ago, a doctor at the clinic had told him he would die in a few months. Based on this prognosis, Mr. B had completed some business transactions and settled a court case where he could have won a lot of money.

Now that he was still living years later, he’d become very suspicious of the advice of doctors.

We developed a very healthy relationship during the three years of my residency. Eventually he stopped carrying his medical records and started trusting in mine. And he’d make it a point to ask about my entire family’s welfare at every visit. He became my favorite patient and I his favorite doctor. He’d say, ‘You’re a good doc, you’ve done more for me than anyone else.’ I knew I was just doing my job and that he was fortunate to be doing so unexpectedly well. Today he still goes to the same clinic and is a little less wary of the new doctor."

–Rahul Gupta, internist, Florala, AL

On young doctors and the AMA

"Declining membership in the AMA is particularly evident at the lowest rungs, among newly trained physicians who presumably should be the most motivated to join. The perception among many of us who have come of age in the tumultuous era of managed care is that the AMA is a nice, stodgy group in Chicago that publishes a few scientific journals, writes reports and has meetings, and offers discounts on rental cars to members. Unless a resident needs a low-cost subscription to Archives of Something, AMA membership seems of limited relevance. Special services and benefits targeted to young physicians are either insufficient or not adequately advertised.

Further, the perception of the AMA as an entrenched, self-important bureaucracy that enjoys issuing press releases on subjects that it understands only vaguely engenders a certain embarrassment among doctors. Lay people ask me with puzzlement why ‘your AMA’ has taken a certain stand at the annual meeting, and I am no less puzzled.

Nonetheless, the health of the AMA is clearly vital to the continuing health of the medical profession. No other organization has anywhere near the clout the AMA has with government and industry. So what can the AMA do to entice young physicians to become actively involved? Here are some suggestions, based on my own experiences and conversations with my contemporaries:

•Provide business advice to young physicians. Ideally, this type of knowledge would be imparted during residency, but residency directors seem reluctant or unable to offer guidance on the pragmatic aspects of running a practice. If the AMA were to develop a role as a business consultant, new graduates would likely be grateful and loyal. One option would be a mentoring program that matched physicians beginning residency with older, established physicians.

•Focus on improving working conditions for the medical profession. In a time of increasing bureaucracy and decreasing income, young physicians are concerned about the long-term economic viability of the medical profession. Older physicians may have the same concerns, but they do not face the prospect of practicing for another 40 or 50 years in a potentially deteriorating environment. The AMA should concentrate on this issue and not dissipate its political capital in other activities, such as duplicating the academic work of the specialty societies.

•Make it easier for young physicians to take part in AMA political efforts. Committee assignments that are currently awarded via competitive appointments and elections could be distributed more freely among a larger number of willing workers. The annual and mid-year meetings could be supplemented by more convenient local meetings. Not everyone who wants a voice in the AMA has the time and motivation to campaign for an election or travel to Chicago every year. Many of us are interested in offering our opinions. If the AMA were perceived as a better listener, young doctors might be more willing to make out that membership check.

If the AMA can address these concerns and make a sincere effort to listen and adapt to the needs of young physicians, the organization should have no difficulty expanding its membership base."

–Murad Alam, dermatology fellow, Brookline, MA

On building a successful medical practice

"There are no failures in medicine. Anyone who would fail at medicine would probably fail at anything. As members of a four-generation medical family, we offer some tips for building and maintaining a successful medical practice:

•What’s the worst thing you can say about another doctor? That he’s incompetent, lazy, dishonest? No–the worst thing you can say is, ‘I never heard of him.’ Building your own practice means developing effective relationships with your medical colleagues in the community.

•Good doctors are colleagues, not competitors. When your colleagues give you advice, it is usually sincere and should be considered. Remember: When three people say you’re drunk, lie down.

•In designing office plans, add one foot to every room and you’ll have it right. Especially in the hallways. Architects like four-foot hallways, but you should insist on five feet so that two people and a wheelchair can pass easily. Also, just as no diamond can be too big, the nurses’ reception area cannot be too large.

•When you enter a patient’s room, sit down. I guarantee you will be out in one third the time. When you stand, the patient senses you are anxious to leave and will try to keep you in the room. But if you sit immediately, the patient will conclude that you are there to listen and will then proudly tell others, ‘My doctor would have stayed all day if I’d wanted him to.’ If the doctor will just shut up long enough, the patient will share what’s wrong.

•Never tell a patient that his complaints are due to ‘old age.’ Rather: ‘It’s because you are older.’ That’s kinder and more effective.

•The more you write on the chart, the better. About 30 percent of complaints to medical boards are based on inadequate records.

•If you’re awakened by a phone call from a patient around 1 am, you may or may not have to leave your house. But if the call comes in at 4 am or after, start putting on your shoes. Any call at 4 or 5 in the morning signifies a true emergency. Otherwise the patient would wait until the office opens.

•After you have finished your examination, made your diagnosis and, if appropriate, given the patient a prescription, watch intently as the patient reaches for the doorknob. He will often turn to you and say, ‘By the way,’ and out will come the real reason for the visit."

–Martin H. Zwerling, otolaryngologist/allergist, Aiken, SC, and his granddaughter, Jennifer Almy, internist, Aiken SC

On why doctors are bad businessmen

"As a physician with an MBA from Harvard, I’ve not only treated 150,000 patients, I’ve also had the privilege of working with fantastic doctor-entrepreneurs in developing centers for cancer care, ambulatory care, and occupational medicine. In each case, these entrepreneurs showed that physician-managed, high-quality care can generate huge profits.

In many respects, what I learned in my medical training was perfect for entrepreneurship–the ability to make quick and independent decisions, the capacity to work long hours at a high-energy pace, the aptitude to interact with a wide variety of people. More recently, however, in raising money for two health-related Web sites, my interactions with venture capitalists and others have shown me why many doctors are considered bad businessmen:

1. Socialism vs. capitalism. Physicians operate in a fairly socialistic environment. Prices are controlled, and even customers who can’t pay have a ‘right’ to treatment. Can you imagine that it’s 3 am, and the only surgeon in the hospital starts badgering the patient for more money before he performs that life-saving appendectomy? Doesn’t happen; the price is set. For this reason, doctors are not accustomed to negotiations and are out of their element in a capitalist business where everything is negotiable.

2. The ‘I am the greatest’ syndrome. Business success requires a great deal of self-promotion. In the medical community, this is frowned upon, and the skill is not cultivated. Hard work and good medical skills build a practice; doctors get judged on results, and, since business results are sometimes nebulous, style is a very important part of deal making. Most doctors are not used to playing that game.

The medical profession is a straight-shooting one. The doctor-doctor and doctor-patient relationships are built on total trust. Business people, on the other hand, often consider straight shooters to be naïve suckers, and they consider shading the truth to be part of the art of the deal.

3. Wildebeests vs. lions. Doctors (the wildebeests) are on their feet treating patients all day while the business guys who’ll be across the table in the evening (lions in the grass) are sitting in meetings all day developing strategies to eat the doctors alive in negotiations.

Doctors certainly have the smarts to be great businessmen, but they can no longer depend on a large cash flow from their practices to bail them out of business mistakes. My advice to doctors is to study up on the particular business they are interested in–read, ask questions, talk with experienced people in the field. Expect people to shade the truth; recognize that style does matter. Start with something small, then work your way up. And always take a CPA or other experienced business person with you to important business meetings."

–Alfred M. Martin, family practitioner, Atlanta

Jeff Forster. Your Voices.

Medical Economics

2001;1.