Last evening my short-story group got together. We’re ten guys who meet roughly once a month at each other’s homes to discuss three or four short stories we’ve assigned ourselves. We’ve been doing this for six or seven years. One of the stories we read early on was “Brokeback Mountain”, which, of course, was eventually made into the big movie.
We sometimes joke about the fact that six of the ten men are health care practitioners—four psychiatrists, a psychologist, and a family practice physician–and that the four of us non-medical types are part of the group’s “diversity.”
Usually the host assigns the stories, and last evening the host was the family practice doctor. Very occasionally, the host includes an essay among the short stories, and there was one in this batch, with the intriguing title, “Jazz and the Art of Medicine: Improvisation in the Medical Encounter”, from the Annals of Family Medicine.
It cleverly uses jazz as a metaphor to encourage physicians to view each patient as a special individual and learn to “communicate in a style that is in harmony with (the) patient’s style…” It’s an intriguing, if highly idealized, vision of the physician’s technique, in a world where many patient visits are limited to ten or twelve minutes.
Anyway, what was most intriguing about our discussion, at least to me, was to hear the physicians in our group confess to their own difficulties in communicating with their personal physicians. One of the psychiatrists described how, after consulting for two years with an internist who always appeared reticent about answering questions, the shrink finally got up the nerve to demand a frank discussion of several of his health concerns. “Then we had a wonderful conversation. I think this physician was just shy.”
Another physician member of our group wondered, “How do you react when your physician asks, ‘Do you have any more questions,’ and has one hand on the doorknob?” And a third said he often can’t remember the questions he wants to ask, when the time finally comes.
The conclusion of these experts? Patients have to put aside any sense of intimidation they might feel in visiting their doctors, and be prepared to not only ask questions, but follow up with tougher ones if they don’t feel they’re getting good answers.
While it’s reassuring in some sense to know I’m not the only one who sometimes feels flustered in the doctor’s office, I can’t help but sense that the pervasiveness of the problem of unsatisfactory doctor-patient relationships ties in to the larger issues described by Dave Milano and others—the physician as chronic-disease detector and treater, and as insurance company subcontractor. In a time-intense environment, the physician’s focus isn’t necessarily on the problems of primary concern to patients.
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Like Steve Bemis (commenting on yesterday’s post, I was intrigued by the article in today’s Wall Street Journal about the waste and fatty snack foods being fed to cattle and pigs because of rising corn prices. Many of us have bemoaned that cattle are fed too much corn and too little grass, and now we learn they’re being fed ever less corn and junk food instead. What especially struck me about the article was that there was no consideration given to the nutritional effects of the diet downgrade on the meat from the animals, except for the observation that “too much fat and salt from foods like potato chips can depress animals’ appetite and cause them to eat less. That isn’t good for producers, who want to pack as many pounds as possible on their animals.” Then again, maybe a little extra junk food mixed into the McDonald’s hamburgers shouldn’t be a huge problem.
As the major media explore the problems of contamination of our food supply, no one seems to want to address the fundamental problems of the industrial food system—even on NPR, where Tom Ashbrook’s “On Point” program today devoted time to the food contamination issue. I heard bits and pieces (unfortunately I can’t find it on the NPR site). At one point, a representative of the National Family Farm Coalition (I believe) called in to try to raise the issue, but Ashbrook could only wonder if the issue of food contamination isn’t “ideological” and “political,” and then move on to questioning a Nader-type consumer group rep who returned to the theme at hand: we need more FDA inspectors.
I think that sometimes the patient’s focus isn’t always on their problems either.
I’ll blame the system and insurance and MDs who are quick to dismiss patients especially those troublesome ones who ask a lot of questions) but patients haven’t been taught how to think about their problems and how to help themselves or how to ask for and use help.
When a system is broken, which our health care system certainly is, the effects are widespread. Patients expect quick fixes, drugs, and treatments that will make problems go away. Lifestyle changes are a fairly new concept for most, and people are mostly just really bad at adopting them.
There isn’t a lot of support (and we’re often even ridiculed) and there is confusion, and our culture is just not set up to promote healthy activities.
I know that even with my clients who are highly motivated and invited to call or e-mail me most don’t follow up. Most are just too overwhelmed to act proactively. It takes a while to incorporate health into our lives. How bizarre is that?
Once a client begins to understand that they care more about their health than any expert, and that their attention matters more than the few minutes with any specialist, good things begin to happen. But even as they feel more empowered, that sort of behavior pisses of some doctors. So they have to switch to an MD who likes clients who ask questions and need more time and are involved in their own healing.
The systemic change we’re talking about involves the clients as much as the practitioners. We’re starting to demand a whole other sort of care, and that will begin to change the system eventually – but tehre will be a lot of dissonance before that really takes hold.
In the last year, I have have become more organized and do a few things to maximize the brief doctor appts. First, when I schedule the appt, I try to remember to ask the scheduler how long of an appt is he/she scheduling for me. Usually 15 minutes. That helps me be realistic with what can be discussed and what can’t. I have been successful in getting a longer scheduled appt by asking and explaining that I have some things to discuss that might take more time.
I try to compose a list of questions or discussion points so that *neither* of us goes off on unnecessary tangents too much (with an extra copy for the doc). I put the most important items on my list of concerns at the top and the least important concerns at the bottom, because that’s when time is often running out and those can wait or do with less time perhaps. I put any current medications & doses, vitamins, supplements, medical issues and/or history somewhere on the page, too, in abbreviated form as a reminder, too, even though the nurse has noted that already. The short appts also mean that much of the discussion often takes place on the exam table in the horrible gown (rather than clothed and in the doc’s office), so I start the appt waiting with a pen and my list in hand, as well as a sturdy writing surface, so that I am not unequipped to make notes during the appt. It is near impossible to gracefully retrieve that stuff with dignity in the presence of a doc in those gowns, even for an immodest person. Better to keep them in hand the entire time if possible.
I also try to prepare whatever info I think might be pertinant to the discussion, whether it is from the old labs (my patient file is chronological, so I highly doubt my new doc has gone through it and certainly has no time to look up my hazy recollections during my 15 minutes). I have even sometimes found it useful to make a chart from a database of my old lab reports that charted levels over time. I don’t think any of my docs had a good way of seeing change over time without a lot of shuffling back and forth from one paper or computer screen to another.
I request (either from the doc, the nurse, or with a medical release form) a copy of all lab reports for myself if tehya re not offered, and sometimes the consultation notes, too. I can’t believe it took me so long to do that! I started doing this when a new doc came into the exam room and mistook me for another patient. Then when I got a copy of my 10 years of records, I found the "other" patient’s consult notes from that day ended up in my patient file, as well as three other patients’ records. Who knows if any of my info ended up in another person’s file? The medical records person I spoke to was very concerned and highly recommended keeping a complete file of my own. It’s our right to have those records and well-worth doing for a lot of reasons. I’m not especially suspicious, just that goof-ups happen and this is a good way to keep it to a minimum. Also, I found it useful to understand my own health by looking back over time.
If anyone else has some useful suggestions, I’d love to know them. Dave, glad to hear that medical professionals make goofy patients, too.
Amen!
The health effects of junk foods when eaten by human are pretty well documented – from Pima Indian studies to "Supersize Me". It’s somewhat distressing, therefore, that so many of us continue to consume food like this – or worse – allow our children to consume it. In my opinion, dietary habits are where the greatest change in improving public health could be made.
He has me e-mail him my ideas and opinions about his health and issues and then just forwards that to his MD or Nurse Practitioner. So far they have appreciated the input – I know because he gets test results and their comments back also by e-mail and sends it on to me to look at.
So one suggestion is to ask your MD if you can e-mail him or her any questions you didn’t get to, or for answers you didn’t understand. Some insurance companies are reimbursing MDs for e-mail to patients. Some MDs won’t do it because it is a paper trail, some love it because they can respond when they have the time – not have to find a patient on the phone.
I’ve also found that Nurse Practitioners generally spend more time and also are more willing to use e-mail and talk on the phone, so that is also an option. Use a Physician’s Assistant or Nurse Practitioner for regular stuff and MDs for more complex issues.Because NPs and PAs are used to doing the "screening" sorts of cases, they are often better than an MD at listening and putting together pieces of the puzzle. Their training is more inherently holistic and also preventative.
I would love to use email for healthcare communication. So far none of my providers use it. I’ll keep asking, though. Perhaps I’ll ask my insurance about their email policy, too.
I also agree about the NPs and PAs. Years ago I had a NP at Duke University for my primary care. She was fantastic. I recently found a NP in Gynocology in my local network who is fantastic, has longer appts, and definitely has better "puzzle-building skills". She has made a huge difference in "quality of life" for me this year compared to the previous several years and that has helped me put off an elective surgery for pelvic prolapse repair, perhaps indefinitely. I wish I had found her years earlier. But she is so popular it is hard to get an appt without a lengthy wait. That’s the price for quality, I guess.
For the "On Point" program regarding food safety and the FDA, check out WBUR’s website:
www . wbur . org
On Point has its own site also (part of wbur’s site):
www . onpointradio . org
You have a great blog!