KEEPING THE DOCTOR HAPPY

There are a lot of books and articles on practice management for doctors, teaching them how to keep their patients happy. This is obviously important because if the patients are happy, the doctor’s practice is likely to do well. However, a doctor has lots of patients and an occasional unhappy patient is not likely to affect him too much. However, most patients have just one doctor and therefore learning how to keep the doctor happy should be far more important for patients.

A doctor’s time is precious and he only has a few minutes to spend with each patient. The patient needs to make sure that he can make the most of these few minutes. It helps if the patient is considerate and learns to look at life through the doctor’s viewpoint.

Doctors are busy people and appreciate thoughtful patients who have prepared for their visit. The more the time and energy a patient is willing to put into preparing for his visit, the more the doctor appreciates these efforts and reciprocates.

A person should do his homework so that he is well prepared for the consultation. This can be hard to do when one is ill. So it is a good idea to do this on a proactive basis. The medical records should be updated and arranged in order with a one-page summary, so the doctor can quickly review the salient features.

A list of questions to be asked should be made. However, the list should not be very long, expecting the doctor to answer all the questions. Ideally, one should do his own research, answering the easy ones himself. It is always helpful to show the doctor that one has done his homework, and is well prepared. Not only will this would create a respect in the doctor’s mind, also the level of conversation can be taken one grade higher.

Doctors understand that medicine is not a perfect science, that outcomes are always uncertain and that the more the patient is engaged in his care, the better the outcome is going to be, both for the patient and the doctor.

Doctors like being productive. Efficient and effective, as well as well informed patients can help them to achieve these goals. Doctors will naturally have a soft corner for these patients, who then get treated like VIPs. Doctors are much more likely to respect patients who know what's happening to them, rather than someone who's completely clueless.

Some people expect doctors to do all the work for them. While doctors are hard-working, they appreciate patients who are willing to put in some effort on their own. Patients need to know that they need to contribute as partners, rather than be passive recipients and expect the doctor to put in all the effort.

It's actually not very difficult to keep the doctor happy because most doctors are fairly simple creatures who take pleasure and pride in their professional work and making sure that their patients get well. Most patients have got so used to complaining when they go to their doctor that they often forget to say simple things like a simple appreciation for helping them to get better. The patient who does remember to be complimentary to the doctor is actually likely to have a much happier doctor, making a world of difference in the quality of care which one gets from the doctor.

It’s equally important be courteous to the doctor’s staff as well. After all, they are the ones who are responsible for controlling access to the doctor. If the doctor’s staff remembers a particular patient as a person who smiles and is thoughtful about their needs and requirements, he is likely to have a much happier and kinder doctor. Patients who are smart & learn to keep their doctors and the staff happy are much likelier to be happy patients.

There is a lot of talk on how doctors need to be empathetic, and the need to spend time and energy in understanding the patient's expectations. It is equally important that the patient is equally empathetic, so that he can see things from the doctor’s perspective. Doctors are humans too, and patients who care about fulfilling their doctors’ needs (respect and gratitude) find that the doctors would tend to care much more about them as well. After all, a person wants a doctor to treat him as a person, and not just as another number.

As with any other relationship, this involves a bit of give-and-take, and the more one invests in it, the more one receives. And the rewards of these efforts can be huge.

Both the patients as well as the doctor have different concerns and priorities, and the trick is to get the doctor on one’s side, making him see things from one’s point of view. In order to do this, one needs to understand what makes the doctor tick.

When a person is sick, he wants the doctor to drop everything else and focus all his time and energy on him. This is a tall order. A doctor is a busy professional, with lots of other patients to see. However, if the doctor comes across a pleasant person in the patient, who is reasonable and understanding and can see things from the doctor’s perspective, he is much more likely to go out of his way to meet the patient’s needs. After all, it’s not just about understanding the disease, but also about understanding the doctor.

HOW GOOD IS YOUR DOCTOR??

Time has been ever-changing. And it’s time it changes again. In the past, medical care was more sporadic than it is now, diabetes affected mostly older patients, who didn’t live long enough with the disease to develop complications, there were no blockbuster drugs for many diseases, and doctors did not manage nearly as many patients on multiple medications as they do now.

In those times, there wasn’t much doctor-patient interaction between visits. Today, doctors manage more chronic conditions; use more medications and laboratory monitoring, more patient education, and more administrative work for the patients than before.

What makes a good doctor, and how to measure it? Should doctors be judged on the basis of the outcome of treatment? Real outcomes of treatment are not values of blood pressure or blood sugar; they are the number of deaths due to negligence, strokes, heart attacks, hospital-acquired infections and the like.

In today’s scenario, such events are seen as preventable and punishable. Ironically, even the insurance industry has no trouble recognizing “Acts of God” as events beyond human control in all spheres other than healthcare.

There is too little discussion about responsibility of the patient. Both in medical malpractice cases and in the healthcare debate, it appears that it is the doctor’s fault if the patient doesn’t get well. If a diabetic patient doesn’t follow his doctor’s advice, then the concerned doctor must not have tried hard enough. And as the logic goes, the doctor should be penalized with a smaller paycheck or huge penalties.

A few comparisons illustrate the dilemma of judging the outcomes. Are firefighters ever penalized if the house they’re dousing to the best of their ability still burns down? Do the police investigating a murder case not get a paycheck if the crime remains unsolved? Is the military shamed in full public view if it loses a war? Even if we were to accept and embrace outcomes-based judgments in health care, the main question remains how to and who would we measure outcomes? We already know that an episode of hospitalization for a given life threatening disease can seem successful, but any readmission due to the same disease can cast doubt on that. First, of course, not all of that “outcome” is dependent on a single provider or even a group of providers, but involves ancillary staff, hospital resources and much more.

There can be a mediocre doctor, but with a good team and excellent support staff, he might be able to work wonders. On the other hand, even the smartest doctor who knows the science perfectly might not be able to deliver consistently reliable care if there a lack of proper system built around him to do so.

In measuring doctor quality, skills like empathy towards patients should be also taken into account, which can be measured through patient experience surveys. Likewise, focus must also be on intellectual skills, such as ability to make difficult diagnoses and emotional intelligence, ability to collaborate and effectively lead teams. People don’t really bring these things into consideration, erroneously assuming that all doctors have them.  For measuring good systems, the current metrics are prevalent such as whether the doctor is able to achieve good blood pressure and diabetes control.

In addition to the qualities of humility and empathy, a doctor also needs to be technically proficient. For example, a surgeon’s empathy and kindness matter, but it may not be as critical to his being an effective surgeon as his technical and team management skills. For physicians, their effectiveness is much more dependent on their ability to listen, be empathic, and take the patient’s values into consideration.

Also, much of what happens in sickness and in health is not dependent at all on the doctor. For example, a miserable weather pattern can make the rate of relapse of common cold and flu higher for one month than the next. What kind of bureaucracy would it take to create a judgmental scale that factored in such things?

Other than short term outcomes for specific diseases like some surgery, hospitalizations and such discrete episodes of care, how can the outcome be measured in primary care and disease prevention? When patients switch doctors, who gets the credit or blame for future outcomes?

Defining outcomes is fraught with scientific and ethical problems, since quality targets really aren’t, or shouldn’t be, the same for all the patients. For example, the elderly diabetics with “ideal” blood sugars are more likely to suffer harm or die than those with sugars that are a little higher (due to a higher incidence of attacks of low blood sugar).

In almost every area of medicine, every case is a different one, and that must be considered if doctors are to best serve each of their patients. It is ironic and very sad that those who used to consider the doctors next to God are the ones who look for crude, universally applicable target outcomes. Up until now, the gold standard of scientific research has been to prove which standardized interventions work best for large groups of patients, even if there are subgroups that aren’t helped at all by them.

The central question for who should judge the outcome of the treatment hinges on the priorities of whoever holds the purse strings. Health insurance companies, if the profit motives are overlooked, prioritize population management. They pay for what works for most people, knowing full well that some patients will not get the best care for their individual situations, for example when certain medications or procedures are not covered. Politicians also favor the population view of health care. If a patient is paying the doctor directly, he expects the doctor to deliver the care that works for them. If the government or an insurance company is paying, they expect doctors to deliver care that meets their standards, because they don’t trust the patients to know what is best for them, with their main focus being to have the doctor do what helps most of the patients, even if some are not helped or are not happy with what they are getting.

With all the political talk about “Patient Centeredness” during the current scenario, patients and the relatives need to be given every option about the ways how their health can be taken care of. With limited choice and no responsibility, patients tend to feel entitled and deprived at the same time. This creates a toxic environment for delivering health care.

In order to maintain what partnership is left today between doctors and patients, there needs to be a sense of trust, shared by patients and providers. And there must be, after all, some ways to achieve this.

CONFESSIONS OF A DOCTOR

I always wanted to be a doctor for as long as I can remember.  As a teen, the choice seemed to perfectly meld my affinity for science, academics, and helping others. For ten long years, I lived, breathed, and worked towards my goal to become not just another one, but one fine doctor.

In school, I studied the foundational cornerstones of science and humanities and focused on how health impacts the rest of our lives. In college, I learned about different aspects of each organ system and marvelled at the miracles of the human body.  During post graduation, I strode in the wards during the wee hours of the morning, rubbing the sleep out of my eyes as I provided care to patients. When I finally achieved my goal to call myself a certified maxillofacial surgeon, I beamed as I walked into my new workplace that had my name posted on the wall outside the department.

Despite my lofty dreams and expectations, practising maxillofacial surgery was nothing like I hoped it would be.  My days were filled with opportunities to meet and grow with patients and families, but my tit-bits of time were sliced into 10-15 minute increments.  As my practice size increased, I was persistently pressured to add extra patients over my lunch hours, before the day started, and into time slots already booked with other patients. The need to move increasingly efficiently sparked anxiety within me. I was halfway through greeting one patient before I was also surreptitiously listening for the opening and closing of the room door to signal that another patient was waiting.

The physical and emotional work of completing a visit every 10-15 minutes, repeatedly refreshing my smile before I burst into the next room began to make me feel like a machine.  As a robot in the factory of medicine, the demands of my job pulled at my greatest skills of empathy and compassion, two of the character traits that made me most suited for primary care.  However hard I tried, it was hard to feel compassionate for a patient when I was already ignoring my raging headache, need to urinate, and fatigue.  Despite my gut instinct to address the “one last thing” that patients often bring up at the end of a visit, the pressure of metrics that detailed my length of visit and wait time for patients pressurized me to ignore their concerns, even if my actions translated into another visit, another day.

When I did have time to sit down, I was crowded into the corner of a small room shared by two other doctors, trying to make phone calls, complete patient records, and converse with staff.  My brain and my inner self were desperate for peace, though I knew it would be only moments before the next patient was ready in the next room to begin again.

By the time I got home each evening, I was a deflated emotional balloon, sucked of energy and ambition and left with little to share. When my own wife rushed to greet me, I offered her a quick hug and then silently wished she would quiet down.  After dinner, I rested with her until it was time to open my laptop again and work through additional papers, e-mails, and other tasks.  My wife personified my laptop as a bed-fellow in our marriage.  I struggled for the emotional energy to make my steadfast lifetime partner feel loved.

I attended various meetings where doctors were referred to as “lazy, whiny, irresponsible, and unmotivated”.  I gazed through the picturesque windows of the large halls as I listened to the mantra that we need to see more patients, more efficiently, and work longer hours as if I were listening to the drumbeat at a funeral march.

Doctors are tasked to learn and practice mindfulness, meditation, and regular exercise. While I try to make exercise a priority, I simply can’t find the time to learn the other soul-saving techniques in my current work environment.  I think it is not only a doctor’s responsibility to take care of ourselves, but the scaffolding of the health care system needs allow for practices that will sustain those of us at its very core.

I sometimes feel worn out by the push to provide efficient and effective care for others while ignoring my own personal needs.  I am saddened by the palpable wounds that I have left in my personal life through lack of energy, lack of engagement, and inability to be there when people need me.  I am discouraged that despite so many years of focus and sacrifice, Google has become a smarter and more esteemed doctor than I.  I am worried that the advent and elevation of pseudo-science has led to opinions of thousand doctors being outweighed by the thoughts of a handful of rebels.

As I am thinking to re-cultivate the human that has been suppressed by the robot that provided medical care, I look forward to regaining the health and happiness that we seek for all.

DECISION MAKING: SHOULD PATIENTS HAVE A SAY??

When there is a talk about a doctor-patient consultation, it usually means that when someone falls ill, he goes to a doctor, who then tells him what to do. This is usually perceived as a one-way road, where the doctor is the one in-charge. He takes the history, examines the patient, orders laboratory tests, makes a diagnosis and provides treatment. Whenever there is an unforeseen error in the process, the focus usually is on mistakes made by doctors or the medical staff. However, the truth remains that often, mistakes are made by patients as well.

For example, a patient supposed to take 0.5 mg of a medicine ended up taking 5 ml by mistake. Mistakes like this are upsetting and irritating for both patient and doctor. The patient is scared that by taking too much medicine, she may end up causing harm to himself. The doctor is irritated, because he feels that he did an excellent job explaining to the patient exactly what to do, and that if he did not understand, why did he not just ask him for clarification and cross check with him, rather than pretending to understand. Doctors sometimes forget that patients can be quite intimidated by them.

There can be many reasons for these mistakes. Sometimes, patients are confused, because the doctor has not explained things properly. Patients do not understand the doctor’s medical jargon, and are scared to cross question the doctor or are reluctant to display their ignorance. They therefore continue to dumbly nod their head, and the doctor is misled into thinking that the patient has understood.

A key component of the consultation needs to be the fact that the doctor needs to consult with the patient as well. Unfortunately, this is something that is quite often forgotten. A doctor needs to understand that everybody makes mistakes, and it is best to be understanding. After all, no one goofs up deliberately.  Rather than start assuming that all patients are idiots, these mistakes can actually be great learning opportunities.

Sometimes these are minor issues, which can be safely ignored. However, sometimes these mistakes can create major problems, but these can be tackled only if there is a healthy communication between the patient and the doctor.

Thanks to the advances in medicine, patients today have a lot of choices. Each patient is different, and depending upon their personality, world-view, religion and culture, every patient would tend to select a different option. There is no single right answer, and doctors, like any other normal human being, are not mind readers. They need to take into consideration the patient’s personal preferences, which can only be found out by talking to the patient.

Doctors cannot afford to guess. And they should also not try to impose their choices on the patient. They need to be non-directive and non-judgmental, and allow the patient to decide. They need to ask the patient which line of treatment they would prefer, explaining the pros and cons of each option. This is not a sign of weakness on the part of the doctor. It is actually a sign of strength.

Sometimes patients get confused when the doctor asks them for their opinion. They believe that the doctor is confused and does not know what to do, which is why he needs their advice. In reality, this means that the doctor is a good professional, who is being respectful of his patient’s belief. He understands that it takes two to tango, and that patients need to provide inputs so that doctor can help them to make a decision which is right for them.

In making any decision regarding the treatment, both the doctor as well as the patient should be involved, with both the parties sharing information, taking steps to build a consensus about the preferred treatment so that an agreement is reached on the treatment to be implemented.

In decision-sharing, the doctor does not actually ask the patient to make the final decision on his own. He just describes different treatment options, tell the patient how effective each of the option is, and lay out the potentially negative side effects and their chances of happening. But a doctor can’t know what the patient wants out of treatment, or what he fears about it. Those ideas and feelings play important roles in the decision-making process.

The only way to have a healthy doctor-patient relationship is when both contribute. This will help the patient gets the best possible medical care. All this seems quite obvious, but is rarely followed in real life.

The problem is that most of the doctors have big egos, especially the big specialists in the big towns, who are brand names in themselves. They think they have all the answers with them, and are happy to dish them out to everyone who comes to them. After all, when one has a hammer in his hand, all he sees are nails. As long as everything goes on fine, patients go on to meekly agree with whatever the doctor has to say. They are passively compliant. When things go wrong, as they are bound to do in any complex biological system, patients become angry and vengeful.

On the patient’s part, he should also share all information with the doctor, like if he is also taking any alternative medicines. Patients often hide this information from their doctor, because they are scared he may get upset with them for doing a non-standard treatment.  However, if they get better and share this information, the doctor can learn from their experience, if he is willing to keep an open mind. Maybe he can even start advising other patients to try out alternative medicines.

A medical consultation needs to be a two-way process, where both doctor and patient provide their inputs, and take responsibility for the outcomes. Sadly, many doctors still believe that shared decision making means sharing the decision the doctor made with the patient. Doctors need to respect their patients and their choices.

A doctor-patient interaction can play a very important role in reducing the errors which patients make inadvertently, and it's important that doctors and hospitals invest in tools and techniques which help patients to become better informed, encouraging them to have a say in the treatment process.