I’m sometimes uncomfortable about the way we doctors deal with our patients. I am a doctor, and I’m wary about apparently criticising other doctors in a way that comes across as though I regard myself as somehow virtuous and without flaw. I am human, like everyone else, and I’m clearly fallible. However, I also struggle with the idea of sitting quietly by when I see what I regard as poor medical care.
Some of my concerns relates to certain practices in medicine where I believe people are often misled about the likely risks and benefits of some form of treatment or investigation. Not so uncommonly we doctors and the system in which we work can exaggerate benefits and not properly explain the real risks of some aspect of care. I believe this to be generally true of things like statin therapy and some health screens including prostate cancer screening and mammography. Quite often I write about these issues on this site.
Sometimes, though, I take issue with poor medical care that appears to be sometimes related to, well, a lack of care. And by that I mean what appears to be a lack of genuine concern for other individuals and the absence of a deep desire to help them achieve their health goals.
About half the patients I see in practice are unhappy with their regular doctor or medical practice. I do not assume from this that half of people in the UK feel they’ve been failed by the conventional medical system. By the very nature of the work I do and the way I do it I recognise I am likely to attract a high percentage of people who are not happy with their standard medical care.
That notwithstanding, though, I am often struck by how often a patient with volunteer that they feel their doctor ‘does not care’, or ‘doesn’t even look up when he/she talks to me’, or ‘just stares at the computer screen’. Medicine is supposedly a caring profession, and people generally have an acute sense for how much their doctor actually cares. I have found that patients will forgive their doctors many things (e.g. not knowing everything, making a mistake but apologising for it), but if they sense lack of care then trust usually goes with it and then any useful and meaningful relationship is essentially over.
What made me think about this today was a short piece I found online in the Wall Street Journal from a certain Dr Harlan Krumholz. You can read the piece here but here’s an extract from it:
With the advent of digital record keeping, I worry that we are losing the ability to look our patients in the eyes, listen intently to their fears and concerns and provide the support and caring that is so necessary for a relationship that promotes healing. I have always thought that the conversations with patients have the potential to be therapeutic or harmful. We can promote the kind of communication that enables patients to be better able to make difficult choices, to be more confident in pursuing the strategies they choose and to be more likely to achieve the results that they desire. And we need to avoid the kind of communication that alienates patients from the health-care system, inhibits them from honestly disclosing how they feel and what they need, interferes with their ability to make the choices that best fit them and reduces the likelihood that they will get the outcomes they desire.
I defy any doctor or anyone else to find fault in any of what Dr Krumholz expresses here.
It is perhaps notable that Dr Krumholz is a cardiologist and also a professor of medicine at Yale University School of Medicine. Dr Krumholz has featured a couple of times before on this site as someone who has expressed doubt over the wisdom of current cholesterol management policy (see here and here). I don’t know Dr Krumholz, have never met him or corresponded with him, but just reading his views on cholesterol and the doctor-patient relationship suggest to me that he has a deep care for people. To my mind, Dr Krumholz exhibits a quality that is essential to good medical care, and I personally wish there were more doctors like him.
The human condition is one in which the psyche tends to be willing to see the value and virtue in that which it knows, and that which it thinks it knows, while also having significant difficulty in appreciating the potential importance of that which it doesn’t know. But the hardest thing of all for the human psyche is to see the potential value, merit, and would be ramifications in that which it doesn’t know it doesn’t know.
We are all human and we are all fallible, but the least fallible amongst us are those who keep a sufficiently open mind. So if keeping an open mind distinguishes you from your colleagues and permits you to see failings in group-think Dr B then I should advise that you are trading upon your strengths where others unwittingly trade upon their weaknesses.
One word of caution stems from sage advice provided by my sister-in-law, Jennifer. When the capacity to be open-minded, inclusive, and curious leads to a major transition in understanding that others cannot follow, then they (those ‘others’) will come to regard you as conceited. They won’t say as much, they may not even think so in as many words, but their intuition will lead them to treat you with suspicion, even if they don’t consciously realise they do.
“To be human means to fell inferior” (Alfred Alder). To be human is to be acutely sensitive to the prospects of being aware of how inferior we are. In the face of familiar explanations, ones that seem plausible, yet are not so objective under the duress of harsh analysis, this inferiority complex forces the mind to recoil from anything that is more objective, a bit more involved to explain, not so simple as the lie, and/or less familiar than the lie.
The willingness of the least conscious aspects of our minds to take short-cuts greatly eases the passing and propagation of a lie compared to the prospects for the truth. If we point this out and they perceive us to be conceited then that is their loss. The average human is possessed of intelligence in broadly the same measure. The difference between distinguished and average lies mostly in the extent of the ability to make optimal use of the intelligence we are born with.
For the most part, and excepting present company, doctors general qualify via distinguished use of applied memory, so if their intelligence doesn’t always shine through it is because it hasn’t especially been encouraged.
Dr Briffa:
I’m a 63 yr old woman who visit many doctors and am researching how to keep myself healthy. The only doctor I do see (every 5 years or so) is my pulminary specialist to get drugs from him. To give you an example of how uncaring he is, I told him (after much research on my part) that I had installed a chlorine shower filter to prevent the near death experiences I had in the shower, he didn’t even look at me when he said, “well if you think it helps.” He should have said, “wow, I’ll suggest that to other patients to see if it helps them.” The fact that he doesn’t even recommend this option to his patients disgusts me. We just need to be pro-active with our health and not trust it to strangers. That’s why so many of my friends are drug-dependent addicts. Take these statins and take pain killers to deal with the muscle pain. A friend of mine was hospitalized when she tried to stop the pain killers. She hadn’t realized they were addicting. So much grief out there and so little concern.
Thanks for the post. Lately, I’ve been wondering if I should continue seeing my primary care doctor. The ‘relationship’ has been bumpy. She has been very curt when asking questions or giving advice. Then, she is friendly and agreeble to concerns and wishes – even to the point of prescribing lab work to find out the particle size of my high LDL, which turned out to be the large fluffy kind.
She works for the Legacy health group here in Portland, Oregon. The group includes many clinics, labs and hospital. In other words, the people at the top of this beast get huge salaries, which should not be confused with profits.
Well, twice my office visits with her have been ended with a nurse coming in and saying the Emergency Room has called for her. Once she apologized for the call, then she said that emergency room work was more interesting! The funny thing is that other Legacy doctors I’ve seen also get calls from the ER or are late to my appointment because they are stuck in the ER. Do you see a pattern? BTW, the ER calls come about 20 minutes into my visit.
I could describe the story of how the Legacy group got me to see her for constipation and how she prescribed a medicine that came with the warning to give it to diabetics with caution. Well, she gave no hint that it could raise my blood sugars!! Instead, she had to go to some place called ER, where she can make more Legacy profits.
Thanks for the post and the opportunity to respond. I’m surprised at how down I’m about Legacy. It was helpful to write and think about it. I’m definitely going to get a new doctor not connected to Legacy.
I had suffered from so many medical conditions over the last few years. I’m 25. Doctors advised me this was growing up… I had heartburn, fatigue, piles, mental foggyness, depression, stress and my ADHD was quite bad.
They’d tried everything the guidelines say, telling me to not eat fat to stop these conditions.
I eventually got fed up and done my own research, I decided to go low carb and have not looked back. I very rarely have any flare ups of heartburn since going low carb, and all my other conditions have disappeared or diminished greatly.
When I told my doctor this, or any doctor for that matter – that I was not eating many carbs anymore and instead eating natural animal fats and coconut fat, etc, they were shocked and advised against it… They quoted cholesterol and artery clogging saturated fats. But I shrugged them off, saying what I’ve read makes far more sense than the current guidelines.
I hardly ever go the doctors anymore, not because I have anything against them… But I tend to sort a large majority of my health out on my own now, and I don’t have anywhere as near as much health problems as I used to have!
And now my mum and dad are also on low carb. They’ve lost loads of weight they have struggled with, and their health problems are vanishing!
Thank you doctor, its wonderful to know there are doctors like you who really cares. I am blessed to have a doctor like that Dr Gail Aahford, she is caring and understanding.
I don’t think it’s always a lack of care – rather the need to be typing the notes as the consultation goes on to save time. It’s easier to concentrate on the keyboard when you are not a great typist!
When I was a mystery shopper one thing that always scored high marks was eye contact and acknowledgement. If medical staff could be reminded to look up and smile when they encounter any patient that would go a long way to make us feel valued.
In the hospital department where I work, we have all had to go on Customer Care training courses….I wonder if doctors are required to do the same? If not, they should be!!
That is really wierd! I saw this blog on your tweet list and I thought ‘heart and looking in the eyes’. I had literally 4 hours ago been reading about an eye Dr who can see how furred your blood vessels are from looking in your eyes, and improve sight and, correct heart disease through vitamin therapy. He is of course getting all the harassment one would expect from the mainstream. One has to ask why they don’t leave him alone if it doesn’t threaten them in any way?
http://www.betterhearts.org/
Dr Sidney Bush of Hull, Yorkshire has excellent credentials too.
I say let him alone, people are grown up, let them see evidence and choose for themselves.
Apparently he is nice to be around too, attentive as recommended by the cardiologist 🙂
Hi John,
Worth mentioning Dr. Jerome Groopman’s Book “How Doctors Think”.
It’s a brilliant analysis of real-life case studies where doctors, with a mix of intellectual arrogance, lack of listening skills and ‘pre-made’ categorizations interrupt their patients describing symptoms (on average within 18 seconds!), and decide on likely diagnoses and treatment, often with disastrous consequences.
Groopman is a brilliant Boston oncologist with a big heart and much compassion who speaks from experience and offers direct, intelligent questions patients can ask their doctors to help them get the care they need.
We found a new doctor recently and I’m so picky about them. This is one of my criteria; if they don’t treat me like a person, I won’t come back. I’m also pretty self-educated and hate to be dismissed. This doctor spent over an hour with our 1st meeting and laughed with me and showed compassion at the struggles I have. He supports a low-carb lifestyle. I think I’ve struck gold!
I am a Stop Smoking Advisor running one to one clinics and found out very early on that Patients respond much better to advice if a rapport is quickly established. On meeting a new Patient my first question is “What would you like me to call you?”. Nearly always their preferred name is a shortened version or different to the one on the medical record. Using that name frequently then helps to build a relationship. I wonder how many GP’s do that?
I always remember a Vet telling me that he studied for his qualification for seven hard years but the one thing he really needed to know was never covered at all: How to deal with the animal and pet owners! I bet the same is true for Doctors.
As for looking at a person – surely that is a fundamental body language technique for any communication, or at least you would think so; I’m always amazed how many people do not do it.
A couple more tips I would pass on to you Dr John or any other healthcare professional who is interested: questioning is the key, then actually listening to the answers; sadly this does not always happen. Lastly, looking Patients in the eyes is great but if you really want to ram an important bit of information home then focus on their right eye; for some reason it works.
In my experience this has got steadily worse over the years, not better-despite innumerable changes in (supposed) ‘patient centredness’ in medical training which should have resulted in things getting better. When I was young-back in the 1950’s and early 60’s our family GP in Birmingham was someone who knew every member of the family , instantly, by name, knew a fair bit of their medical history, without recourse to (of course non existent )computers and was, in every way a wise counsellor. My guess would be that he would have been born in the late 1890’s(he retired in the eartly 1960’s) and so would have trained-at the latest – in the early 1920’s. I remember my dad saying he had told him that he could tell a fair amount of why a person had come by how they entered the room, sat, and began talking-and a fair bit more by looking in their eyes. To some doctors today this would sound horribly ‘alternative’, and, yet, this man was in most repects a very conventional and traditional doctor of the ‘old school’-he had even been a navy doctor in WW2. As Jhn Briifa suggests, the point was he paid attention, he looked , he listened, and he made you feel attended to, cared about and listened to. Its very rare to find that theses days, as some many doctors sit fixed to their computers, and give off a disturbing whiff of instant diagnosis and ‘pill pushing’. Not only is this discouraging for their patients on a human level, but it means that the doctors are much less likely to find out whats really the patients concern or what their symptoms really are perceived to be.
Wonderful Post! I am a Cardiology EP Doc. I find it very important that with eye contact should become the metaphysical contract between two humans of trust and doctor patient confidentiality. It comes to show that their honesty and useful (For the doc) insight would surely come to follow.