Sunday, February 10, 2013

Helping Your Doctor Stop and Think


"Men more frequently require to be reminded than informed."
Samuel Johnson: Rambler #2 (March 24, 1750)

It is always a good rule of thumb to stop and think.  In medicine for physicians who are treating patients, it is a necessity of good care.    For good medical care to occur, the ability of a physician to stop and think is dependent on their ability to truly listen carefully to each and every patient in a way that recognizes their unique problems and circumstances.  Physicians are taught that way but in today’s world in which time is limited, they sometimes need to be reminded. The prepared, informed, confident patient is in the best position to remind the doctor of the need to slow down, listen and think.
 
In a recent article in a local newspaper, Dr. Murray Feingold, who is physician in chief of the Feingold Center for Children, makes that point.  (For full disclosure purposes, The Feingold Center was previously known as the National Birth Defects Center and my wife, Dr. Rhonda Spiro, was associate physician in chief working closely with Dr. Feingold.)  In his article, Dr. Feingold laments the fact that less time is being taken to listen to patients.  He also notes that computers may compound the problem as the physician may be more focused on data entry and the computer, than on the patient.  Dr. Feingold even talks about one hospital that prohibited the use of a computer in the exam room as they found it took away from the personal connection with the patient.  It is sometimes hard to stop and think when you are just looking to the next field that you have to fill in an automated record. 

Like any rule, the “stop and think” rule has certain exceptions.  The reason that the training of health professions includes drilling on certain emergencies is to ensure that the treatment of a life threatening situation that is time sensitive is performed automatically.    There is an old joke that makes this point.  An ER doctor, an Internist, and a Surgeon go duck hunting.  The Surgeon looks up and says, “Look, a duck!” and he shoots.  The Internist looks up and says, “Look a duck...or maybe it is a mallard or a goose!”  And then he finally shoots.  The ER doctor looks up and shoots and then says, “What the hell was that?!”  The ER doctor is trained in certain situations to act reflexively, such as acting to save someone who is bleeding profusely after a bad accident and whose life depends on very swift action.  In those types of cases you want a physician who acts even before taking the time to think too deeply. 
    
But most of the time, the ability of a doctor to stop and think is important and may be critical to getting the best care.  For many people we help, our ability to coach them on how best to encourage their doctor to stop and think, is paramount to their having a productive trip to see the doctor.  

You may believe that doctors will always stop and think however, when a physician is seeing many patients a day and most of them are “routine” and time is limited, it is hard to really think about each and every patient in a unique way.  This past week I saw my cardiologist for a routine, yearly appointment which actually occurs about every year and a half as I keep putting it off because I have no present cardiac problems.  I have a history of coronary artery disease and had a coronary stent placed in 2001.  My cardiologist is a caring, smart professional who I have, in the past trusted with my life.  My goals for this appointment were to discuss with him my medications to see if we should change or perhaps eliminate some of those medications.  In his busy day, however, I was healthy, doing well, and he just wanted to get to the next patient who probably had more immediate needs than I did.  I did not get the thoughtful doctor that this cardiologist has been in the past.  His attitude was you are doing fine so just keep doing what you are doing and I will see you next year or so.  I do not know if he had an emergency waiting for him at the hospital or if he was just harried from a busy day and from personal life matters.  I only know that no matter how hard I tried, I could not engage him in the discussion I needed.  I could not get him to stop and think and really listen to my concerns about being on medications, all of which have potential side effects, and my potential ability to do without some of them. 

So I now consider my next move which will probably be to call him and talk to him about it and ultimately to switch cardiologists if I am not comfortable with his listening to me and really thinking about me.  When you are a patient, it should all be about you (or me if I am the patient).  Don’t be embarrassed by that.  Don’t be self-conscious about it.  It really is all about you when you are the patient.  You go to a physician in order to get the benefit of their knowledge, their experience, their skills, and their active evaluation of you, however healthy or sick you are at that moment in time. 

So a real trick for people, who you help, is to give them ways to encourage their doctors to stop and think.  There are a number of techniques for accomplishing that:

  1. Help them develop questions that they bring with them to an appointment.  They should have them written down and they should make it clear with body language and bearing that they do not plan to leave until the list of questions is answered in a way that is understood. If the doctor leaves the room before they are done, they should politely ask his staff, who will probably come in to usher them to a different room or to see them out, that they need to continue talking with the doctor to get questions answered. 
  2. Coach them to be honest.  If they have to say, “Doctor, I feel like you are not listening to me and you are rushing out of the room instead of helping me understand what I need to understand in order to follow your advice”, encourage them to just say it.  They should not feel embarrassed or feel ignorant. 
  3. Help them be confident.  It can still be a bit intimidating to go to the doctor.  When your clients are confident and less likely to be intimidated, they are likely to be better at encouraging their doctor to stop and think. 
  4. Tell them to be pleasant but direct.  Getting very excited and angry will only get someone labeled as irrational and that is harmful to getting the best care. 
  5. Ultimately, if your client is unsuccessful, they should think about switching to another doctor.  A doctor patient relationship is personal and sometimes two people are just not a good fit.  While technical knowledge is important in a doctor, the ability to communicate with a specific individual is just as important.

Good, thoughtful physicians know the importance of listening, and thinking as critical parts of diagnosis and treatment.  As Dr. Feingold put it in his article, “I could not practice medicine without a computer because so much information is now available it is impossible to remember, or even be aware of all of it.  However it is still the findings culled from the history and physical examination that remain the mainstay of leading the patient’s physician to the correct diagnosis.  That means going back to the basics, taking the time to listen to the patient and doing a thorough history and physical examination.  After gathering all of this essential information, then new high tech studies can be used more effectively and efficiently.”

So help your clients help their doctors to be better doctors.  Help them remind their doctors to stop, listen and think.