Patients now often enter a physician’s office with preconceived notions. All the parties involved are cognizant of one thing: time is limited. The patient is hoping their issue is addressed (hopefully, the provider often fears it is not more than one), the physician hoping that the right targeted information is provided. These desires are commonly not met by either side. Should there be ‘sides’ to healthcare? How did this inherently adversarial relationship develop before the parties have even met? In an earlier post I discuss the importance about navigating the healthcare system. I would like to discuss here some observations I have made both in practice and as a caregiver for my mother on the initial office visit. They address my sensitivity to issues which are viewed by others who are resigned to a new status quo and accept them as part of healthcare. Perhaps digital health technologies facilitating communication among patients and providers will help in these regards.
1. Patients see answering their questions as a value added service. I am amazed at “Is it OK if I ask a question?” To their amazement, my pat answer is “This is what I am here for.” Every encounter is concluded by asking “Do you have any (or other) questions?” The look of satisfaction after that is the only thing I need to propel me to my next patient with a sense of satisfaction and purpose.
2. Patients think they need to provide a diagnosis instead of seeking one. I have heard countless patients seeking my help (either via referral by another physician or self-referred) that they are sorry they don’t know a diagnosis for the complaints which have prompted my visit. My philosophy is that a patient is only responsible for describing symptoms. Most physicians are familiar with Sir William Osler, a great pioneer in medicine, who said “Most times it is the patient who will furnish the diagnosis.” What he meant was that the patient’s narrative, NOT a specific diagnosis would provide adequate information to make said diagnosis. While it is not as easy today, given significant therapeutic implications not present in Osler’s time, the patient’s story remains critical to focusing future investigation and questioning. I allow the patient to furnish the whole story without interruption. In the case of no specific diagnosis found for a non-serious condition, I emphasize that it is just as important in knowing what it ISN’T as what it is, and that this is not a denial of their symptoms. I encounter this often facing patients with palpitations.
3. Patients smile when I tell them that I dispense medications and suggest tests on a minimal basis. Most patients, contrary to many providers’ impression, do not seek or desire a pill, tests or procedures. Certainly they cannot be avoided in all circumstances. Initially, they want to know if the condition is (or potentially) serious, and why each therapy, test, or procedure is prescribed. Explanations go a long way. Often communication with other providers (especially regarding side effects of meds prescribed by others) is critical. I tell patients that my goal is to decrease medication use, not to increase it. I find that relatively healthy 90 year olds are on minimal medications and tell them that it is in part for this reason that they are doing relatively well. Ordering tests for defensive medicine purposes is largely unnecessary and many do not fall into accepted practice guidelines. Good patient relationships are fundamental to decreasing liability concerns. Minimizing interventions are both important in this regard and appreciated by patients as a sign of patient advocacy.
4. Patients are relieved when I acknowledge the importance and intent of caregivers. Many patients are embarrassed when significant others or other caregivers accompanying them to either ask questions, take notes or corroborate the narrative. I take time to dispel any doubt about the importance of that person. I first ask for the relationship of the person and if it is OK to share all of my thoughts with that person. The extent of caregiver support might very well affect the type of treatment plan I recommend or the need to contact that person to discuss the shared decision plan.
5. Patients are surprised when I tell them that old age is not a diagnosis. While many diseases are diseases of old age, a patient’s age itself is not a disease. Someone presenting with fatigue due to anemia should certainly not be written off as having ‘anemia of old age.’ I am not advocating exhaustive workup of elderly patients, merely stating that a discussion regarding shared treatment decisions needs to take place. Discussions surrounding advanced directives should also include how far one would like to go in testing and therapeutic procedures. This might not preclude an otherwise healthy elderly patient from undergoing a workup for a problem impairing quality of life.