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February 9, 2004

Your Doctor Is A Person Too

Authority figures are always hard for us to just talk to. Talking to a person is very different than requesting an audience, demanding someone listen to your opinion, or accusing them of never really listening to you. I, as a physician, have been approached by nervous and anxious patients in all of those ways. The most aggressive patient to practitioner approach is to overtly or covertly threaten legal action if you don't get exactly what you think you need.

What in the world could bring a patient to practitioner relationship to an open or hidden adversarial status?

The hoary old statement, It takes two to tango, is a revealing comment in person to person relationships. In retrospect poor patient to practitioner communication is the result of actions by both parties.

It is certainly true that as the professional in any such relationship the practitioner bears the major responsibility for a smooth relationship. The old retail statement, The customer is always right, applies to all customer/provider relationships. That principle certainly was operational in the patient/practitioner relationship many years ago. However if one examines that historic relationship one soon sees that the society environment behind it was much different than today. First, the authority figure (the healthcare practitioner) was generally agreed to have the correct answer to any problem. Second, the business relationship between the patient and practitioner was direct without third party payers between them. Third, society in general was educated in and understood the concept of personal responsibility for actions and that if one engaged in destructive behavior there would be consequences.

We will examine those factors.
The load of responsibility born by a healthcare practitioner is immense. This load is increased by a legal system that is quick to attack if there is an adverse event. Just ask yourself how you would change your behavior if you thought any adverse outcome of any action on your part must be defensible in a court of law. When your dinner guest gets nauseated from your Béarnaise sauce you immediately look to see if your documentation of how you made it, what the ingredients were, and how you served it is defensible and meets the standard of preparation found in a standard cookbook. This defensive posture might lead you to give a defensive answer to the person who inquired as to how you made this since it tastes different than they expect.

The professional bearing the responsibility of caring for you needs to feel secure in themselves of their ability to have the knowledge and judgment to make correct decisions. However, speaking from personal experience, there are times where part of the professional knowledge one brings to any solution is that the current solution has a degree of uncertainty. The professional, to appear professional, must maintain a demeanor that implies the situation is well controlled and the solution will work. The need to maintain a reassuring manner in the face of adversity requires a good deal of ego energy. This can lead to a defensive posture and an apparent irritation when a judgment is questioned. When the added burden of having to explain why managed care will or will not allow something is added to all of this the practitioner irritation level can get to the boiling point.

The professional is supposed to take into account that the patient may be confused, scared, angry, and etc in the face of a major medical problem and always maintain an accepting, supportive, caring manner. I think if you will reflect on these factors you will realize that at times this is an almost impossible task. I have had times when I responded directly to an attack. My most memorable is the mother who announced, "I don't like you and I don't want you to take care of my daughter". I replied, "I don't like you either but both of us need to take care of and support your daughter." The two of us did that and at the end a good outcome to a very difficult clinical problem occurred and we became friends.

The lesson here is that in this arena of communication one must, at times, get beyond individual ego-centric actions, and come to a mutual respect and understanding. At times it is important that this problem just be recognized and managed directly. I have, at times, told a patient that it seemed that we could not maintain a comfortable professional relationship such that I could help them and that I thought it best if I arranged other care. There have also been times when a patient confronted me and told me of the discomfort felt when dealing with me. In most of those instances we discussed the dynamics of the problem and then went on to a lasting professional relationship.

"By gentleness the hardest heart may be softened. But try to cut and polish it, and it will glow like fire or freeze like ice."

If one can establish a mutually respectful dialogue then they can proceed to examine all the factors involved in any clinical decision and arrive at a mutually comfortable result. This mutual respect will allow the patient to bring all the information they can find on the internet or from other sources and freely discuss it with the practitioner.

The change in the business relationships of healthcare has been one of the most destructive events in its long history.

The healthcare practitioner and the patient used to directly discuss the costs of any test or treatment. Both understood the cost-benefit ratio since they dealt with it directly. Then came the third party payer concept and the practitioner and patient were removed from the financial aspects of any clinical decision. This allowed the concept of spending any amount to try and achieve even a one good percent outcome. This led to the expectation that this one percent outcome would be the result.

The cost of this free-wheeling relationship became more than society was willing to pay just at the time that the politicians convinced the populace that it was their right to have any and all types of healthcare no matter how costly or unlikely to give a good result.

This conflict of financial reality and outcome expectations led to anguish and angst on the part of both patient and clinician. This friction and irritation as a background level of noise in the healthcare system can impede the communication between them in any situation. The patient can appear angry and accusatory and the practitioner can appear defensive. Comfortable, comprehensive communication cannot occur in that environment. The practitioner quickly and efficiently and perhaps irritably delivers the care allowed by managed care. The patient accepts the care in a state of irritation with the system. Both parties have barriers to real communication in such a situation. The patient's irritation may have been further compounded by an irritable attitude on the part of some of the supportive personnel in the system. The practitioner's irritation may have been further compounded by just having finished a telephone conversation with some clerk reviewer who was telling them why some procedure was not allowed because the reasons given by the practitioner did not fulfill all the necessary criteria in a checklist the clerk had.

The concepts of personal responsibility cannot be taught in the relationship between a clinical practitioner and a patient.

However this is an area where it is easy to raise the irritation level of the practitioner. I can remember well the tension it created in me when a patient did not follow a prescribed course of care and then was upset the expected result did not occur. It is not reasonable to expect a great clinical outcome in a pregnancy when the patient's breakfast is a pastry and a soft drink, the lunch is a taco and a diet soft drink, and supper is pizza and beer. I have taken care of patients who managed their pregnancy in that fashion and then were dismayed when complications occurred and their laissez faire lifestyle had to be curtailed.

If the practitioner and the patient have a good level of communication the necessary concepts of the personal responsibilities of the patient can be discussed in a supportive and friendly manner. I remember instances where such open discussions led to a somewhat different course of treatment which had a good outcome.

Remember the concept of Learning Theory, "If you cannot tell me what I told you in such a fashion that I recognize it as what I thought I told you then we have not communicated."

Such a level of communication only occurs if patient and practitioner realize that both are people with the foibles of any person and then talk to each other to resolve differences in a non-judgmental fashion.

We can talk to each other if we talk to each other and not at each other.

Neither the patient nor the practitioner can solve the problems coming from this new third party payer system. If they mutually discuss their irritations with the system they then become partners once again in the solution of the patient's problems. Real communication can then occur.
November 4, 2002

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