Some thoughts on doctoring – understanding the patient

28

Category : General, Medical Rants

Judging by the comments, many readers feel passionately about this thread on doctoring. Over the past 3 days I have thought a great deal about the essay which stimulated my thoughts, and why I thought it did not strike the right tone.

Any good commentary on patient care should start with this quote:

“The secret of the care of the patient is in caring for the patient.” — From Francis Peabody’s famed 1926 address to the Harvard Medical School

At the risk of hubris, I will add to that famous quote that in order to care for the patient we must understand the patient. Thus, this commentary will try to crystallize my thoughts on understanding our patients. I believe this is the attitude that we should stimulate in our students and residents.

Being a good physician requires knowledge. We must understand how why can treat disease. We need to know the value of testing. We must know the pharmaceutical armamentarium – both the benefits and the risks.

That is a given, a sine qua non for excellence. However, all physicians know brilliant physicians who fail at patient care.

I always ask myself (and my housestaff student team) – “Who is the patient?” and “What are their desires?”. Knowing who the patient is requires diverse knowledge. We need to try to understand their life, their cultural influences, and their financial abilities. We should understand their motivations and their cognitive abilities.

For we cannot treat patients over the long term. We can in the hospital. In the hospital we can insure that patients get their medications and the right diet. However, once the patient leaves our world, the true care reverts to the patient.

I often tell patients (with students and housestaff at the bedside) that I cannot treat their diabetes, or heart disease. What I can do is advise them on what treatments are most likely to help them – based on the evidence. What I must do is help them understand the treatment choices they are making. You can lead a horse to water, but you cannot make him drink.

In understanding the patient, and personalizing their care, I believe that patient care resembles jazz more than a symphonic rendition. I must help the patient design a treatment regimen that fights his or her moral beliefs, economic circumstance and desires. We must react and adjust to the patient’s cues – much like a soloist in a jazz trio.

Thus, if all we ask physicians to do is to learn moral values from “the great books”, we limit the range of their patient care. We should understand that patients (and physicians) differ in their moral values. As physicians, we should (I believe) allow the patient’s beliefs to trump our beliefs, as long as we explain the benefits and risk, we have discharged our responsibility.

Not every patient opts for a treatment strategy that I would personally choose. I must accept that, and do my best to help the patient achieve his/her desires.

Not all patients want to make difficult decisions. Some ask us to choose. Again, our responsibility is to use our best judgement of how we can achieve the patient’s goals. Then we do our best.

When we understand that we must treat the patient rather than the disease, then we reach a higher level of doctoring. I strive for that level. I strive to teach those concepts to my learners.

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Comments (28)

Very well said.

I agree, very well said.

“we must react and adjust to the patient’s cues-like a soloist in a jazz trio”.Yes!!Many times when I have presented the case for reducing cardio-vascular risk factors to patients and varied the presentation based on the patient’s cues, I have thought ‘this is jazz’not the recitation of the this or that guideline.Another great post.

well said indeed..a good physician neednt be a genius but someone who understands the patient.. well said..

“For we cannot treat patients over the long term. We can in the hospital. In the hospital we can insure that patients get their medications and the right diet. However, once the patient leaves our world, is not this the true failing of academic medicine ?

medical training , no matter how expertly designed by the academics, is only training.

The real world is radically different from the manicured med campus and hospital campus environs.

The real world does not care if you are moral, ( just ask your loan agent if you can get a reprieve if you offer free care, just ask you malpractice carrier if you can get a lower rate because you are concerned about the human condition, just ask the med mal lawyer if he will forgive the error as you had trying your hardest to do the right thing, etc….

In truth , when the patient leaves the controlled environs of the hospital they end up not with the doc in the community who HAS to deal with all the implications of
illness. Just ask the average doc how many hours/week are spent trying to negotiate all the myriad of barriers society has developed to prevent care of the average citizen.

” The true care reverts to the patient.”, rings hollow.

Community doc’s pick up the pieces whether or not the patient follows a prescribed medical regimen. Community doc’s face the consequences of patient’s failings. In truth true care reverts to the community doc.

You are right on the money with this one Bob and I would push it farther and say that we need to align the incentives of health care and actually reward the doctors who do give a damn about caring for their patient.

[…] Here’s a must-read post from Medrants about how doctors can care for patients, in a truer sense of the word: I always ask myself (and my housestaff student team) – “Who is the patient?” and “What are their desires?”. Knowing who the patient is requires diverse knowledge. We need to try to understand their life, their cultural influences, and their financial abilities. We should understand their motivations and their cognitive abilities. For we cannot treat patients over the long term. We can in the hospital. In the hospital we can insure that patients get their medications and the right diet. However, once the patient leaves our world, the true care reverts to the patient. I often tell patients (with students and housestaff at the bedside) that I cannot treat their diabetes, or heart disease. What I can do is advise them on what treatments are most likely to help them – based on the evidence. What I must do is help them understand the treatment choices they are making. You can lead a horse to water, but you cannot make him drink. So many doctors get in their own way by failing to consider the patient as an autonomous entity. I’ve met that type repeatedly; they lay down a set of orders, and if you haven’t managed to follow them perfectly and are so brave as to admit such, you are dismissed as an idiot. Or even worse, when you do follow their recommendations and it doesn’t get the results they expect, they assume that you are non-compliant and treat you like an idiot. I’ve encountered this again and again and again. I’ve never had a doctor assume that it’s his job to educate me and my job to decide which tradeoffs make sense. I know I could stand to lose weight, but I have other factors in my life right now making an hour a day at the gym pretty much an impossibility. Should I be derided for that? Should it be up to my doctor to decide that the time and money that would go into that gym membership must be spent there, that I can’t prioritize my own life? Why can I not make this decision for myself? And why does making a choice different than the one that the doctor assumes he would make in my place make me an idiot? I’m sure it’s frustrating to make recommendations all day and have people refuse to follow them. But it is also frustrating to get a diagnosis and be told that as a result you must give up all control over your own life. I suspect that the approach Dr. Centor is advocating here actually results in people taking his recommendations more often than they would if he simply told them what to do and walked out. I have yet to find a doctor who shows me that level of respect. (And lest you wonder, I don’t think I’m a difficult patient. I take my meds and I don’t give attitude. At least, I don’t think I do. But I have found some of my doc’s recommendations impossible to follow. Does that make me difficult?) [0] Comments (0 views) |  [0] Trackbacks  | Permalink […]

“I know I could stand to lose weight, but I have other factors in my life right now making an hour a day at the gym pretty much an impossibility. Should I be derided for that? ”

“Should it be up to my doctor to decide that the time and money that would go into that gym membership must be spent there, that I can’t prioritize my own life?”

“But it is also frustrating to get a diagnosis and be told that as a result you must give up all control over your own life”

it is instructive to note that many patients who go to a gym 30 min- 1 hour 4 days/ week report that they feel they have MORE control in their lives as well as benefit in numerous other ways.

Many insurance companies
will pay for gym memberships (or at least offer 50% discounts).
why ? because people who spend about 3 hours/week exercising have less doctor visits, less medications, and less illness. if it is “impossible” to exercise 3 hours/week (gyms are not necessary) then
you should re-arrange your priorities.

“But I have found some of my doc’s recommendations impossible to follow. Does that make me difficult?”

if this refers to exercise a few hours/ week ,
the answer is yes

nd, you completely miss the point. When DB tells a patient that he cannot cure their diabetes what he is trying to change is the long and commonly held paradigm that says that a patient’s health is entirely in the hands of their physician. The reality of chronic diseases is that patient complience with medications and attempts to improve their overall health (excerise, healthy diet, stop smoking, etc.) are much more iportant than any single medication that their doctor orders.

I have an amazing number of patients who appear to completely forget about the fact that they have serious chronic medical problems until they show up back in the office for a follow up visit. Then it’s like, are you checking your blood sugars? “No”. Are you cutting down on carbohydrates or are you following any weight loss diet? “No”. Were you able to make it to a diabetic teaching class? “No”. Are you getting any kind of exertion at least 3 x week? “No”. Did you stop smoking? “No but I cut back to only 10 cigs a day!”. Are you taking your medications every day as instructed? “Not unless I feel bad”. Then why did you come back today if you are not doing anything to help yourself and your medical conditions? “Because you told me to come back in a month and I need refils on my insomnia medication.”

For chronic conditions, how well a patient does is mostly up to them. A physician’s job in these cases is to make recomendations on treatments. They cannot force a patient to be complient nor is it appropriate to do so. I will not vilify a patient for not following my recomendations as long as they completely understand the consquences of their INactions.

Chris Rangel

Have you ever had a loved one with a chronic condition? So far I Know 2 people with spina bifida, one with fibromyalgia, one with migraine, one with chronic sciatic pain, three with diabetes, one with lupus and one with MS. Oh, and I forgot the primary sclerosing cholangitis and another who has macular degeneration.

These are all members of my immediate family, or long time friends(2). Each of them has adapted to their own chronic condition over the time they have had it, but I have a big issue with your comment that “how well a patient does is mostly up to them.” Nuh-uh.

These people depend on experts to manage their care- everything from specialists appointments to what kind of treatment they will receive. If their symptoms are dismissed as being “female problems” or lifestyle problems, they are often treated with disdain, like they are the cause of their disease. I don’t know how for three years when my brother’s liver was going, every single doctor accused him of having a drinking problem at ages 18-21. He didn’t drink as a rule, and when he had the occasional beer, it caused problems. They flat out told him he was lying.

Migraine and MS were treated as female exaggeration. Now that Botox is available, my best friend no longer goes to Emergency once a month to “tell the doctors what to do”. Because she requested a narcotic at a specific dose IM she was deeemed to be a drug seeker for over twenty years. My girlfriend with MS was told her MS symptoms were just a repercussion of her having been given anasthesia for labour. For 4 years she struggled to understand what the hell was going on with her body, and she was devastated and empowered by her diagnosis. At least she wasn’t a drama queen.

Another family member has been deemed fit to work by WCB even though crippling pain travels down the sciatic nerve whenever he is up for a short period of time. Excercise, Tens, acupuncture, psychology—-none of these have managed the pain to any great deal, and he has a young family to support on 350 dollars a month, because there is nothing else to be done.

Diabetes can be held at bay with diet and excercise. True. What if you do those things and things still go aout of whack.

I may continue this, but I guess I have a different view of things. Sometimes the management happens when someone who CAN help finally validates your diagnosis, and then helps find appropriate treatment. That is a good first start.

hey rangel, I get Db’s point. I totally agree with you
and totally agree with gmm……(which stands for gmm)

there all types of people. all types of maladies and everyone needs a different approach.

but if someone is going to find excuses not to to even the minimum to help their diabetes I am going to use first encouragement and then finally lecture them sternly.
I try not to villify them, (unless its monday.)

anyway I just look at the problem from a personal ,holistic view and a molecular level as well.

You and I know that the cellular mechanisms of insulin resistance are going to harm or kill millions of americans and that good diet and exercise can stop these atherogenic metabolic changes that lead to illness and hospitalizations. (Osama Bin Laden should invest in Kentucky fried chicken franchises and he will be victorious eventually )

these frenetic postings lack discipline, so i am going log off to eat another donut and tommorrow i will villify my first patient that has donut breath.

hey aren’t you a hospitalist ? it kind of makes sense that you won’t berate patients for misbehaving, as your bound to admit those nuckleheads whose bellies hang over there belts.

Gmm stands for Michelle and then a middle name and a last name backwards-lol! I am not a medical anything, I am just a person with a ton of questions and opinions about medicine, how it is practiced and how it affects people. I have seen so much that is truly bad about medicine, both personally, and as a bystander that I just cannot stand it. Not one more minute. I read everything I can find on all the conditions in my previous post (and more) because knowledge is soothing. It also occasionally points people to things that they never would have considered as treatment options. I will be a patient myself soon, for what is turning out to be a chronic condition (that will remain nameless because it is the most absurd and embarassing condition for a chick to have—my friends are still laughing about it!!!!) As a patient it is interesting to see how patients are perceived by doctors and I hope you get a sense of how doctors can be perceived by patients.

The word non compliant drives me nuts by the way. It infantalizes, puts a psychological spin on, and makes a person feel like they are an in jail all in one. Is there not another way to phrase that? I am not a child, a psychiatric client, or prison inmate. The word compliance sends a message of top down management. If people are to be equal partners in their care, maybe the language doctors use should reflect that. There certainly is a place for a doctor to be the expert regarding treatment options and availability, but the importance of establishing at least a modicum of a relationship ought to be important as well if doctors are going to work in a model that holds the patient as a shareholder in their own health.

Thank you for your agreement, nd that stands for nd, and enjoy your doctoring.

Does having an anonymous place to vent/learn/ agree help you to be a better doctor by the way? I am curious and you can reply at missyalots@hotmail.com if anyone ever wants to.

Does having an anonymous place to vent/learn/ agree help you to be a better doctor by the way?

No, this is not a place of deep learning. its a place to waste about 10 minutes of time.. This is a place to have some fun.

there are quite a few medical sites that are password protected where the discourse is divided
into medical information gathering (usually subdivided into organ systems) and categories that are lumped in the
business of medicine. usually these password sites do not allow stupid comments (which is why I am here… now, this moment in time)

one thing you might gather on this site is that medical care is influenced by many outside forces. The physician’s approach to work is very much changed (for the negative) in our current climate.

The insurance industry drives everything. Both the patient and doctor lose.

as for bettering our skills, that is a continous challenge that occurs in other venues. ( not as fun as this)

nd

Insurance companies run the world!! They tell teachers how to teach, social workers how to do their jobs, and doctors how to do theirs. Risk assessment and management are terrible words, and I could not agree more. And it upsets me, because it does have the effect of distancing everyone from each other.

I KNOW there are locked sites that allow for real discussion of medical issues. Those help you do your jobs better and I know of people who have been helped by them- my daughter was one of them. For those I am truly grateful. And maybe this is JUST fun, but I think that even having an outlet for “stupid comments” is better than a kick in the butt with a wet cement boot.

This is fun for me too, in a completely opposite way. I find that by being just “someone out there” I can be more coherent, and not feel judged like I do when I am standing in front of a doctor that tells me something CAN’T be true– and half an hour later a test result comes in that completely validates what I have said, and I STILL have to “Be Compliant” because I need a referal or treatment or whatever else. At that point I really want to have a melt down and tantrum, but I know I have to hold it together til I get home and can call my mom or friends.

I am sure that is what doctors feel when they deal with the personalities and bureaucracies that they do each day, not to mention the actual diagnoses.

Keep having fun, thanks for the comments, and have a good weekend.

hmmm… I do not like to hear that you experiences with
doc’s have been poor.

I would suggest that if you do not yet have a doc you like try speaking to patients as they leave a doctors office. You will quickly get a sense of the satisfaction they have.

less practical info is to consider the following:

doc’s work in a variety of settings
some are self employed but have huge office expenses that force them to be quick with patients,
some self employed doc’s have small unassuming offices in drabby neighborhoods but their costs are low so they can spend more time with patients.

some doc’s are employed and some employers have strict
time requirements that a doc must meet to stay employed.

others are employed by benevolent entities like
” the sisters of mercy health care system” and give doc’s more leeway in number of patients that must be seen/day.

and for pete’s sake do not tell a doc you are not compliant.

just lie and tell the doc ” I am compliant”

You do not have to like the word, but you must say it like you like it.

in fact state the phrase “I am compliant” 3 or 4 times in the first few minutes of your meeting and that doctor will jump through hoops to help you, especially if it is male aged 35 and over.

how do I know this?

I work with male middle age doctors,
I know middle age male doctors,
middle age male doctors are my friends.

The best doctors I have met, barring one feminist gynecologist who advocated me ditching a kid because she thought I was pregnant at 16-(I was in my twenties, read the chart and don’t make assumptions), have been women. The next group is male doctors under 40. The worst can be older gentleman doctors. I NEVER tell doctors I am not compliant- but I do want to yell and scream when they FINALLY find out that my 14 year old child really is allergic to the Tetanus vaccine and is having a reaction in their office to the 3rd test they administered that day, and say ——yes this IS a 1 in 400,000 person reaction, but I did not make it up. I did not tell a lie—————-The most satisfaction I get that day is when I whip the same study/medical article out of my bag with pertinent points highlighted in pink , as the doc does making one last attempt to be the boss– and see him take his article back and put it on his desk. Then we go over my article- remember I have highlighted the PROPER information.

I realize that I have no medical training. But my curiosity and willingness to educate myself should not be held against me. That day I felt like a Munchausen’s mother for a full hour as this doctor told me that my 14 year old child could not have actually had a hive reaction to the tetanus shot, and because it had happened nine hours after their shot that proved it. I must be exaggerating he intimated, because he knew if he said it that would not have been professional.

I had looked up brachial neuropathy. I looked up reactions to tetanus toxoid. I looked up Guilliane Barre Syndrome……. By the time I got the specialist appointment it was 4 months after the shot so I had looked up the fact that very little is done to track adverse reactions to vaccines. The neurologist appointment was 10 months after the vaccine. I live in Canada. Unless I had gone to emergency the night it happened,( I didn’t because it went away with Benadryl- the problem happened when it kept coming back) this is how specialist services work. We have no choice- but in theory an illness won’t bankrupt you either. I am not liking an American system because a catastrophic illness can be a problem, but I also wish that Canada would find a way to deal with waiting times, and bureaucracy and lack of political will.

I have had wonderful experiences online with doctors. I have received study information regarding new treatments with chronic pain. I have received well wishes from those unable to provide help. I have been treated as a person. In person, with most specialists I have met, I have been treated like a moron, or a young child— at around 40, I am extremely young looking, but that is no excuse. My DOB should be on your chart.

I have had some awful experiences with doctors. I have yet to forget or forgive. Now, please know that I visit the doctor ONLY when I am sick–pneumonia, emergency operations, unexplained hives, possible broken body parts. I am not a hypochondriac, and I try not to mess around with medication. I am very afraid of all parts of the hospital except maternity. I just do want you to know that I try to use health care responsibly….

I am sure you have your own horror stories. I know that people are people. And I really should stop it with this thread because I am a chatterbox who is far to opinionated, I think.

Thanks nd

I do not like seeing doctors either. (I hate dentists)
But as I am a physician, I do feel bad that the medical system failed you. I am very sorry and apologize.

I think I can explain why your online experiences with
doctors is wonderful and in the office it is terrible.

Online care is paid for by credit card, fast and simple.
The doctor is unencumbered by the interupptions from
calls from nursing homes, emergency room, Intensive care unit, hospital floor, insurance company. There is no fighting with the insurance company. the online doc has only the expenses of the online connection and computer.

it is a pure service.
You speak online, ask your questions. the doc has to do one thing and one thing only at that moment. it is to speak to you.

as I am speaking to you.

If you were to ask me a difficult qustion. I would simply open up my window to my online medical text book and do a search on your symptoms and questions and email you the info. I might fax in a script. But sadly if you developed in illness that required urgent attention I could not help you. the physician that can help you is summoned or called by the ER.

now that physician who is called on, must work super fast with the patient who is sitting in front of him. In fact, most calls take 5-10 minutes to discuss a sick patient. Many doc’s receive several calls daily for sick patients. so the patient in the office feels slighted and they are.

And that is the North American doctor in 2005.
so what are young Canadian and American doctors in
training planning to do to deal with this uncomfortable
and stressful situation ? Dermatology.

I know it is upsetting, it is upsetting to physicians as well.

thank you gmm

Grand Rounds

Welcome to the latest iteration of Grand Rounds. On behalf of the greedy rapacious pharmaceutical industry, I’m glad to be hosting this week. Unfortunately for everyone, the research end of the G.R.P.I. is not immersed in the ceaseless flow of…

That was quite post! I agree with the entire thing, and I’m amazed at some of the comments I’m seeing …

As a person with a chronic illness which is hard to manage (not diabetes) … I have to say that I’m completely aware that my care rests almost totally in my hands. If I skip meds, eat something I shouldn’t, don’t report a new infection … no one is there to slap my hands … but I can certainly tell that I’m making myself worse. All my physician can do is treat what I present with, and hope that I’ll behave …

That said, I don’t think I personally *know* any physicians who would (could) have written that blog post. For that reason, (and a few other reasons,) I’ve stopped seeing all but one of my physicians, and the only reason I still see him is because I know that I wouldn’t live long without the delicate balance of meds he’s prescribing.

I think there is some serious frustration on both sides of people equation in medicine. You physicians are expected to be perfect, to never make a mistake, to never have a headache, to never have a bad day … personal problems … and to be on tap 24/7. And if you do make a mistake – God help you and your insurance company! You have pressures on you to keep patients from costing the system too much – and pressures on you to cover all of your bases … tough job. I don’t know why anyone would want it …

From the patient’s perspective, medicine is becoming so impersonal that it’s frightening. A chronically ill person can see so many different specialists, that no one has a clue what anyone else is doing. If the generalist is not on top of the situation, organizing the data that he receives from all of the different specialists, then the patient can be in serious trouble. Too many cooks, and all of that … and to mix a couple of metaphors, none of them are connecting the dots.

Furthermore, there’s a trend toward dumping patients on hospital based physicians when they’re admitted … which leaves a patient without the generalist they’ve carefully chosen for themselves and learned to trust, and who knows their particular problems best … and all at a time when they’re at their most vulnerable and frightened, and need that familiarity every bit as much as they need whatever treatment they’re about to receive. I can’t tell you how threatening is.

It leaves me feeling that I shouldn’t bother to see anyone – because when I’m most in need, I’m going to be stuck with some stranger anyway – one who may not even speak my language!

I think the system is broken, in more ways than I’ve touched on here … and that it’s going to get worse before it gets better (IF it gets better.) While medical advances continue at a breathtaking pace, the medical system crumbles under its own ungainly weight. None of the advances are going to do the physicians or patients any good if the “delivery system” fails.

I agree with you. the “system” is broken.

the system is the massive insurance and regulatory beuracracy that forces the physician to make actions that do not lead to improved patient care but rather fullfill the mandates of the beuracracy.

This ” system” is not apparent to the patient, so the patient concludes that it is the physicians shortcoming that fails them.

From a generalist physician’s viewpoint, the “system” causes such enourmous frustration and time demands that the patient is given less time than they deserve.

Today for example I had to answer about 7 faxes.

Several were warnings that a formerly preferred drug for my patients is now requiring pre-authorization. (Pre authorization is generally another separate one page document that demands very detailed information as to why the patient must be on the old medicine, and a detailed explanation by me as to why the new prefferred drug is not suitable for the patient.)

while I spend about 10 minutes on these stupid forms, I cannot simultaneously attend to the patient in the room.

another form was a revised form , demanding proof that a 89 year old paient of mine needed oxygen. She has been on oxygen for 2 years and every 6 months I must re-certify that she needs it. again, every minute I spend on forms. I must spend corresponding less time for patients.

all of these faxes were for patients who have not been in the office for at least one month. some days I receive 5 faxes others over 10.

these examples are a small fraction of the mandates imposed by insurance and government agencies that I MUST
do, otherwise patient services are denied.

so, to cope with these paperwork and beuracratic issues I must higher more staff. So I must see more patients in a day to pay for this staff.

which leads to your observation

“Furthermore, there’s a trend toward dumping patients on hospital based physicians when they’re admitted … which leaves a patient without the generalist they’ve carefully chosen for themselves”

The generalist simply ,out of exhaustion, is unable to do hospital work as the office work is relentless.

hence there are 10,000 hospitalists now in the U.S. but the demand is for 25,000. Hence record low number of students are choosing primary care.

http://www.graham-center.org/x468.xml

A very sad commentary is that about 75 % or more of these hospital based physicians were once primary care physicians who decided that the beuracracy of primary care was not worth fighting. Hospital care remains much less hassle free for the physician. It is intense ,as every patient is very ill, but their are far fewer paper work hassles.

the medical system, as long as controlled by comanies that make billions of dollars of profit, will ot change.

why would any industry give up such a profitable enterprise ?

Just a quick note- I did not and never have paid for information from doctors on the web. I read what they have published, google their addresses and ask for any information that they could share. They all, without fail, have responded. And if they have had nothing to offer, they have at least offered their good wishes. Just a clarification, because I think that it needs to be said that there are people who are generous with their time, ideas and hope.

Thank you nd for the wonderful and thought provoking discussion. I had a much better reply made up last weekend, but then was blocked on the site as a spammer, and it must be lost in cyberspace.

nd: That is not only a sad commentary, it’s also a truly terrifying one from the perspective of a patient …

… do you see a solution from your own perspective?

Is there a way that we – all of us, physicians and patients – could begin to affect some sort of change? What sort of “medical revolution” would restore sanity and balance in what is becoming as large a problem as our massively out-of-control government?

Moof you ask, what can be done ?

I have random thoughts, probably laughable but you asked for it.

On national level:
As long as patients and physicians
are managed by the insurance beuracracy I think only organized political pressure will work. Industry groups, including health insurance companies spend countless millions per year to influence legislation. Lobbyists should be banned. Support all attempts to restrict access of lobbyists to your legislators.

There is little the patient or primary
care doc can do unless patients and docs band together.

Health care ,when such a huge source of profit by insurers, likely will linger in its current state.

On a state/county or community level:
There may be practical steps that might reduce the barriers to personalized health care. But without
clear understanding of the specific barriers nothing
will be effective. to gain understanding

1.Form discussion groups (kind of like here)

patients and docs discuss and work together to understand the “system imposed” barriers to providing personalized care.

Once these systemic barriers are articulated, then
create a grass route local organization in your
to problem solve each of these barriers and find
ways to overcome them. If these issues are fixed
both patient and doctor win.

see tedious example #1 on next post for a tedious
example of how insurance companies force doc’s to
deal with issues (which save their plans money) but diminish time with patients

also, see tedious but sad example #2

2. attend as many pertinent local health seminars
or self help groups as you reasonably can. Often
times you can gather and share lots of information
that will help you improve your care. Network
with healtcare providers (Nurses, doc’s, therapists,
etc…)

On a personal level

1. Find a doctor who practices in a unique way.

see not so tedius example #3 on the next post

2. If you like your doctor and don’t want to lose her/him,
support the relationship. do not assume the doc feels appreciated, a simple card will do. If you wan’t to play the guilt angle, send a religious card. (works for me)

you then ask if a medical revolution will occur.

I think an economic revolution (crisis) will occur first.

The annual U.S trade defecit and budget is now almost one TRILLION dollars/year. We cannot pay these debts off, so we are headed for an economic meltdown. Already we see huge layoffs by our major manufacturers and high paying jobs ( GM, Ford, Compaq ) . High paying jobs have decent health insurance. low paying jobs have lousy health care insurance. As our bills pile up, we need to down size our financial and medical expectations. ( The number of uninsured is increasing by 1 million/year.)

As the uninsured go up, more patients will pay cash for their office visits and then the doc will revert to a simpler kind of care. Fees are posted on the wall. Patient pays , doctor unbothered by insurance hassles will pull up a chair, listen to you carefully, examine you carefully, order less tests and think more carefully to help you. and then poof, medical revolution.

ignore below if you are tired of reading.

There is a movie called Brother Sun Sister Moon, where Saint Francis sings a slow hymm while attending to the wounds of lepers ( Mycobacterium skin disease)

if you want your dream to be…
build it slow and surely

small beginnings greater ends
heartfelt work grows purely

if you want to live life free
take your time
go slowly
do few things but do them well
simple joys are holy

day by day
stone by stone
build your secret slowly
day by day you’ll grow too
you’ll know heavens glory

now that is medicine.

tedious example # 1

(For example, I just recieved notice that one of the
nations large pharmacy benefits plan as of
Jan 1 will no longer have lipitor on prefferred
status, but they will place crestor on preferred
status. If Patients are kept on lipitor they will be forced to pay an extra 25 dollars/month. So our staff
will be receiving about 100 phone calls by patients
who have been thus far doing great on lipitor but
must be changed to crestor. As the monitoring of crestor
( a new drug) is more intense we will also have to
order new sets of labs on these patients at more frequent
intervals for the first year. thus we will have 100 phone
calls from patients each which will take @ 5 minutes,
we will have to mail out lab slips to 100 people, review
additional 100 lab results, call back or write
to the 100 patients to inform them of the results.

so I guess about 600 minutes ( 10 hours) will go to
just this one single drug changed

Another formulary plan TODAY plan announced that they are dropping pravachol
as preffered but will now have lipitor preffered. so there goes another
10 hours.

I anticipate probably another 10 drugs to switch which could take about total 75 hours of time from me and my nurse this year. None of this work on our part is reimbursed, not one medicsl benefit is provided to the patient. The following year many of the new preferred drugs will be replaced by other drugs.

which means patients suffer due to to profit motive
of the pharmaceutical benefit plan, who is hired
by the health insurance company.

this is just but one SMALL example of the things
that must be done by a primary care office that
interfere with personalized care.

why does one plan favor lipitor, another favor pravachol, another favor crestor? why do they change from year to year. ?

Pharm benefit companies make profits.

tedious and sad example #2

We have a national crisis in Doc’s training in Obstetrics , the liability is too great. 10 years ago , almost 1000 med students chose OB/GYN /year , now for the past several year the numbers are far far less only 770 students chose OB/GYN

not so tedious example#3
I have been reading about a new breed of practices
that radically departs for the 3.5 employees/doc office
where multiple insurance companies are accepted.
Some doc’s are running solo offices ( no fulltime employees), these docs see only about
12 people/day, typically only deal with hassle
free insurance plans and self pay patients.
from my reading office visits are Much longer
and more perosnalized then the traditional office
setting. These offices are not in large buildings
and office just rent out unused space from other
businesses or health care providers. They do
not advertise ( they don’t need to as word of mouth
is all they need)

http://www.aafp.org/fpm/20020200/29goin.html

I’m going to cut and paste this conversation into to a “page” on my blog. I’d like to be able to refer to it in the future without having to “hunt it down.”

nd: Do you have your own blog?

Would dearly love to find a physician like you describe in “not so tedious example #3” … unfortunately, all of our local docs either run offices which are “A Department of [Yadda Yadda] Hospital” or in specialty care. There are 4 hospitals locally … 6 in a 25 mile radius … and I’m not near a large city. This is a highly medical area.

There are only two physician names which come up repeatedly as being “well loved” by an eclectic group of patients, but they’re so busy that they’re impossible to see unless you’ve already got a foot in the door.

… For the nonce, I’ll just “make do” with my nephrologist, and hope that nothing else comes up. 0.o

Thank you for the time you’ve taken in answering the comments I’ve left.

[…] 1. Some thoughts on doctoring – understanding the patient 2. On great cases and interesting cases 3. A serious conversation 4. The white coat ceremony 5. On being a general internist – time is of the essence 6. How do we avoid arrogance? 7. Is the Oregon assisted suicide law legal? 8. The danger of public report cards 9. The future of general internal medicine 10. Supply and demand […]

The worst thing I’ve seen doctors do is talk outside their area of expertise, and then talk down to the patient who is seeing a specialist and has educated himself/herself on his/her condition. Pediatricians, for instance, have no business diagnosing developemental disorders — they can suspect them, but send the kid I-beg-of-you to a specialist. Do no treat, diagnose or do anything involved with managing them. This would be like a divorce lawyer handling a complex business tax issue. But they will assert their superior knowledge. They will assume that a mother is being hysterical or overprotective. You know, perhaps if the mother seems “hysterical” it’s because when she takes him to the playground, her toddler leaps the fence and disappears in the amount of time it takes her to put something back in a diaper bag, and because when she puts him in time-out he covers his room, walls, floors, self, clothes with feces.

I have two young kids with PDD-NOS and ADHD. Can I tell you how many pediatricians missed the diagnoses? Because they’re bright and highly verbal and not retarded, and because they make great eye contact? I had a consultation with one pediatrician about my youngest when he was about 20 months old and was told to spank him and that he was having problems due to my failure to discipline him properly. I went to another pediatrician, and begged her for some help, because my then 3 year old child was behaving in ways that were life-threatening. “I don’t believe in medicating children that young,” she simpered. Hmm. Well. On the way back from the major teaching hospital three months later, where my kid was handily diagnosed, he wriggled out of his properly-fastened five-point safety restraint (an engineer watched in awe as he did this once, to see how he did it), disabled the child safety lock, and opened the door to the minivan while it was in motion on a four-lane divided highway at 55-miles per hour. He’s the kid you read about who wanders out of the house and turns up on the bottom of a pond, or jumps off the roof. Our house was locked down like Ft. Knox. All I got from pediatricians were stares (gosh why doesn’t she discipline those children!) and shrugs (I’m sorry, I don’t know what the problem is). Except for the pediatrician who saw my oldest when he’d just turned two and informed me that his verbal skills were “quite poor for a four-year-old.” Yeah, lady, look at his chart. He’s two. “Yeah, and you should see how poor his driving abilities are for a twenty-year-old, especially getting that five-speed out of that uphill parking space on really steep grades. What’s your point?”

Thank heaven I found a pediatric psychiatrist who isn’t afraid to medicate three-year-olds. My littlest is on three drugs (Adderall XR, clonidine and 0.25 mg of Risperdal). At the age of 20 months, he had the speech of a 13-month-old. But the medication changed his life. Because the kid can pay attention, he can learn. Because he can learn, he can develop. Because he can develop, he’s learned new strategies. Overnight he became a different kid. He immediately began seeking out interactions with peers. He became connected. He started using pronouns and prepositions. He stopped running away. He could go to petting zoos, swimming pools, parks, restaurants. His whole life improved. He’s bright, and now he has a chance to actually have relationships and to learn.

My older one was fortuitously diagnosed because the staff at the hospital that diagnosed my youngest one suggested I get my older one evaluated for the same thing. And all this time the spank-him pediatrician was telling me, “No, he can’t know his letters, shapes and colors at 27 months…not the way he’s behaving.”

He’s on medication, too, and is Gifted and LD, which makes it really fun.

But the point is, my experience of pediatricians is that when it comes to developmental issues in children, even though they are out of their depth, they refuse to listen to parents or to refer the parents to the right folks. Look, guys, I promise to vaccinate my autism-spectrum kids (and I do, right down to the flu shots) if you promise not to try to diagnose developmental disorders.

[…] Some thoughts on doctoring – understanding the patient Filed under: General, Medical Rants — rcentor @ 6:58 am […]

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