It's at the Central Library in Baltimore, 400 Cathedral Street, Thursday, July 25th (tomorrow!), 7pm. See you there!
Come to discuss doctor-patient communication through the lens of doctors (me), patients (you), and the book (available for sale!).
It's at the Central Library in Baltimore, 400 Cathedral Street, Thursday, July 25th (tomorrow!), 7pm. See you there!
I dwell so often in this space on the things that doctors and patients get wrong that I feel obligated to tell a good story, about a 43-year-old lady from Panama that I saw this week. She’s a regular patient of mine [whose identifying details, obviously, are changed]. We had a long chat about her lung disease, heart failure, depression, and hip arthritis.
She got my attention right when she sat down. “I’m going to talk your ear off today,” she said, looking guilty.
“That’s the way I like it,” I responded cheerily - or, at least, I hope I was cheery.
Then she proceeded to tell me a lot about her symptoms, what she did about them, and whether she had chosen, or not, to take the medication I had prescribed. I was in patient-centered heaven. I didn’t have to prompt her at all, just sit back, type, and listen.
As she was about to leave my office, she made another remark. "I had to train myself to talk to you. I had to get used to you but now I know what to say."
Train herself: she paid attention to what she had to say, and practiced so as to get it into the form I would pay attention to.
Had to get used to me: I am not the world’s perfect listener. I have my own quirks and foibles. My patients will have to get used to those, just like I have to get used to theirs.
Knows what to say: She now has some level of confidence that she is communicating well.
Now that’s a good visit! Let’s hope she actually feels better, the next time I see her, after pursuing the treatment we agreed on.
Asking something about the other person: what doctors and patients have in common
One of the many useful pieces of advice to doctors that Atul Gawande proffers in the last chapter of his Better is that a doctor should ask every patient about something in their lives unrelated to their health complaint. Of course, this can easily give rise to unintended consequences. I asked one patient of mine, a guy in his fifties with an accent from the Maryland shore, what he liked to do with his time. "I like to race horses," he said, and when I was surprised that he didn't seem the jockey type he made it clear that he played horses. Or, rather, gambled on horses. There's nothing wrong with that, but it might not have been a personal interest he would have shared with me otherwise.
Sometimes I wonder whether patients are going to ask me about my life. They ask about my kids, which is generally a safe topic, but not much more. It's clear why: doctors and patients are careful about boundaries for good reason. We are partners in health, ideally, but not friends or relations.
In the healthcare encounter, however, we have a lot more in common than we might realize.
We both think we know more than we actually do. Doctors like to assume they act based on evidence, when mostly they (we) don't, or the evidence is incomplete. Patients think they know their bodies - and they do, they are the ones most familiar with them. But knowledge of one's own body doesn't necessarily entail a prediction of what a set of symptoms might mean. We each need the other to be informed and educated out of our complacency.
We think the other is not doing a good job. Doctors roll their eyes at patients who don't take their medications exactly as directed, even though doctors - playing the role of patients - do exactly the same thing. And the reason patients don't take medications is not just to be ornery or contrary: it's because they don't know how; are worried the medication might be making things worse; can't afford to fill the prescription; or are afraid to tell the doctor they don't agree. By the same token, doctors are put in a spot by patients assuming the absolute worse the minute they enter the exam room.
Maybe, then, doctors and patients should start asking about each other's lives more often (on suitably inoffensive topics, of course, like kids, favorite desserts, weather, and vacation plans). There is plenty of common ground. Perhaps we can expand it.
In a recent article in the New York Times, the prolific Danielle Ofri makes the point that inpatient and outpatient medicine are so different as to be on different planets. She's right, of course. In the hospital, illness is more acute and everything needs to be done faster. More resources are used. Life or death can often hang on every day's decisions. In the clinic, most things are slowly developing, many things get better on their own, and decisions are less weighty.
Or that's what we think. From a patient's point of view, the hospital and the clinic share many similarities:
1. The language can be bewildering.
2. No one spends enough time.
3. Decisions are made without asking you.
4. You are given medications without full information or the chance to say no.
5. People process you without introducing themselves.
6. You are made to dress and undress at the drop of a hat.
7. Everything costs too much, and it's hard to figure out why.
8. There's nowhere to put your kids.
9. If you speak another language, you have to wait for an interpreter - or sometimes you don't get one at all.
10. You are too confused, or sick, to think straight, but sometimes you are expected to share in the decision as if you are fully empowered.
11. You wait and wait for your questions to be answered.
Ofri's point is that, once upon a time, the same doctor would see patients in the hospital and in the office. Nowadays, it's most common for special doctors to see patients in the hospital, and other doctors, of the outpatient variety, to see them outside. The technical requirements of the two environments are two different for one doctor to be able to deliver good care in both.
What does it tell us, though, if the experience of the patient is similar in important ways in the two environments? Does it mean that the right kind of doctor can provide superior care to patients in the hospital and the office? Does it mean the care needs to be reshaped, in equally serious fashion, in both places? What do you think?
Like anybody, I have particular favorites among people I work with. I try to give the best care to every single person in my practice, but I can't deny there are people whose name on the schedule makes me smile. Today, I saw Ms. Mallory, not her real name. She's a dynamo - I wish I could tell you about her historical importance and her artistic talents, but then I would be identifying her and running afoul of various rules and regulations. So I'll stick to her cats. She has five of them.
Like people with five kids, she is always running from one appointment to another with one or more in tow. One of them had to go to the dermatologist the other day; the other had a general veterinarian appointment. A third needed grooming. And so it went. "I'm exhausted taking care of them!" Ms. Mallory told me, with a proud smile.
She's a little mysterious, and I find it hard to put a finger sometimes on what's bothering her. Many doctors call this "being a poor historian" but that phrase rankles me no end. Telling a good story about our symptoms is important (I discuss the reasons why at some length in my book), but often this phrase is a condescending excuse why the provider isn't listening to the patient.
Often, then, I find myself wishing I knew what was really going on with her. Ms. Mallory has her ups and downs, and her chronic medical conditions which makes it all more complicated. When she's in these peaks and valleys - some physical, some emotional - I would give anything for a deeper sense of her days and nights. To be more precise, I would love to interview her cats. Only they have a close-up view of her inner life. And, just like a wife or a husband, they know what it's like to care for and be cared for by the person they live with.
I don't do home visits. Even if I did, I wouldn't get the whole picture from a half-an-hour visit. I'd really need to be part of Ms. Mallory's inner circle to know what makes her feel better or worse. In other words, I would need to be a cat. Or speak feline. Neither of which are yet taught in veterinary schools.
A recording is now available of my interview on the Dr. Melanie Barton show on July 11th (link). Our chat starts at about the twenty-minute mark. (You can also listen to the show on iTunes.)
I also appeared on a podcast of the Radio Health Journal talking about medicine in plain language (mp3).
Let's share the glad tidings: Johns Hopkins is again ranked as the number-one hospital in all the land. I've written about this before, sharing my misgivings about ranking hospitals. What is the methodology? How sensitive is the ranking to random error, bias, and qualities of hospitals that have nothing whatsoever to do with their - quality, like reputation? What are we supposed to do with that information, who really uses it, and do they get better care as a result?
There are enough misgiving here to fill several chapters of a book, and in fact one chapter of mine is devoted to them. But the problem with measuring extends far past the ranking of hospitals. Doctors are being ranked this way, too, with the idea that public reporting of such information will help people make better choices about their health.
At the same time, many are trying to urge our health care system towards greater patient-centeredness. Various research teams are developing measures to quantify how well a given visit with a physician enables shared decision making on the part of the patient-doctor pair.
So, when presented with an array of various numbers - the rank of the hospital; the quality of the doctor; and the patient-centeredness of the practice - which one should the patient choose? Do we ask patients, as a whole, which ranking they find more important? Is each person to mix up a batch of numbers to find whatever aggregate satisfies their preference?
These are big questions. As I outline in my book, there is evidence that precious few patients or doctors actually use these rankings. Perhaps if we include patient-centeredness in the mix, and automatically generate a weighted average (or some other statistical combination of measures) that corresponds to patients' preferences, people will feel like they are getting the best doctor they can find. That would be something to truly celebrate.
Slave doctors and slave patients: Plato on autonomy and what we can learn from it today
Thanks to Matthew Wynia at the American Medical Association who distributed to a group I'm involved with the following quote from the Dialogues of Plato about doctor-patient communication. I believe the translation is from Jowett, 1937, but I'm not sure.
In the LAWS, Book 4 [says Wynia in a summary], we have the following discussion between the Athenian and Cleinias regarding patients lacking autonomy (because they are ruled by others) and autonomous (self-ruling) patients.
The Athenian asks: “You are aware that there are these two classes of doctors?"
Cle. To be sure.
Ath. And did you ever observe that there are two classes of patients in states, slaves and freemen; and the slave doctors run about and cure the slaves, or wait for them in the clinic. They never talk to their patients individually, nor do they allow them to talk about their own individual complaints. The slave doctor diagnoses and prescribes a remedy on an empirical basis, [but does so] as if he had exact knowledge; He gives his orders [to the patient], like a tyrant, and then rushes off, to see some other slave who is ill, all the while projecting an air of confidence and assurance;…
But the other doctor attends and practises upon freemen; and he carries his enquiries [with his patient] far back, and goes into the nature of the disorder in a scientific way; he enters into discourse with the patient and with his family, and is at once getting useful information from the sick person, and also instructing him as far as he is able. [The physician] will not prescribe for the patient until he has first convinced him; at last, when he has brought the patient more and more under his persuasive influences and set him on the road to health, he attempts to effect a cure.
Now which is the better way of proceeding in a physician and in a trainer? Is he the better who accomplishes his ends in a double way, or he who works in one way, and that the ruder and inferior?
Cle. I should say, Stranger, that the double way is far better.
There is much to note here. First is the distinction between slaves and freemen, not just among patients but among physicians. And the two are paired: a slave doctor deserves, so to speak, a slave patient - or perhaps the two are yoked together, each deserving no better than the other. For Plato, as we know from the Republic, is wedded to the hierarchy.
We can take away at least two lessons to our own day. First is that our care, in our enlightened republican democracy of the U.S. as much as in Greece, is inseparable from the economic stratum of its provision. It is a universally known but much hidden and ignored truth that the poorest and disadvantaged get the least care, a problem I discuss at length in my book. Further, though, we can read the terms "slaves" and "free [people]" more broadly. When a patient and provider can look beyond what others have called the "tyranny of the acute" and focus on the deeper issues that affect health, both become free to find the cure at the end of healing.
That, in closing, is the idea that fascinates me the most here. While, in my practice today, I think about treatment as inseparable from a cure (thinking about a correct treatment entails considering a cure), the account in the Laws seems to suppose something else. Only once a patient is on the "road to health" can the physician "effect a cure." I am not sure how to take this, but I find attractive the notion of cure as a process brought about by a long-term relationship between doctor and patient.
There are plenty of books out there to teach us how to boldly and proudly advocate for ourselves in the doctor’s office. Doctors have held the reins too long, goes the story, and ignored what patients want and need. So it’s time for patients to step up and ask for what we deserve. If there are medications prescribed, we should know how, when, and why. If there are tests to be ordered, we should have the results in hand. We should even have unfettered access to our medical records—this last expectation has a slogan attached, too: “Give me my damn data!”
But is open data the key to improved health? Check out the excerpt from Talking To Your Doctor at KevinMD.com.
The author of Talking To Your Doctor and Making Sense of Medicine blogs about the books, shared decision making, doctor-patient communication, and the redeemable imperfections of healthcare.