Fragile, special, confidential, explosive, based entirely on trust and often fraught with misunderstandings.. Over 8000 articles and chapters have been written on the subject..
I believe every patient and every doctor wishes to build a long and healthy association based on mutual respect and trust. Yet, people generally do not like most of the doctors they meet. And doctors complain about being verbally, emotionally and sometimes physically abused by their patients on a regular basis.
Being happy with their doctor is essential to keeping patients motivated about their treatment ,and successful long-term disease management. Because let’s face it – Most illnesses do not have a cure. They can only be managed, with the intention of keeping the patient most comfortable on the smallest effective dose of medication. Doctors face the unenviable task of letting the patient know that ‘I can help you though I can’t fix you’. Just as you cannot learn from a teacher you do not like; you cannot heal under the care of a doctor you do not trust. Even if the ‘person in control’ of the relationship is doing everything right.
Where are we all going wrong?
When does a doctor fail?
– Most patients are dissatisfied by the attitude of their doctors rather than their personal competence. Lack of time, lack of support staff, lack of empathy, lack of equipment, language barriers, fear of being verbally abused and fear of litigation makes doctors spend less time counselling their patients while focusing all their energies on treating symptoms. The mental, physical and psychological strain of rigorous medical training often numbs the doctor’s sensitivity and ability to empathize.
– A patient’s illness affects their loved ones as well. It is important to counsel the patient as well as their parents/spouse, in order to preserve quality of life while working on the science of disease management. This can be achieved by creating patient education literature, having support staff (a nurse or junior doctor) who can counsel the patient after the preliminary consultation, or by organizing camps and workshops where patients and their families can be educated on a holistic approach towards managing their ailment. After all, it is not just about the medicine. The right diet, good attitude, avoiding disease triggers, lifestyle modifications and/or exercise and physiotherapy are just as important as the drugs.
– The system often keeps doctors starving in order to increase “productivity”. Managed Health Care and corporatization of Medicine has created a vicious cycle of ‘rewarding’ doctors, not on the basis of the quality of care provided, but on the basis of turnover; with incentives for performing more tests and procedures. This could inherently create a conflict against patient interest.
– The competition to enrol patients forces doctors and health care providers to over-promise while they under-deliver. This is a recipe for disaster.
– Good doctors understand responsibility better than privilege and practice accountability better than business.
Where does a patient go wrong?
– An over-anxious patient is often unable to comprehend the doctor’s advice. They are easily confused and agitated. They hear with the intention of arguing and refuting rather than really “listening”. They tend to repeatedly interrupt the doctor, seek third or fourth opinion and lash out against doctors or bad-mouth them over minor or imaginary slights. This could be the result of a personality disorder, lack of inner strength or emotional immaturity.
– In most Asian countries, a vast majority of patients do not enjoy medical insurance and pay for treatment through their teeth. This fosters bad patient behaviour like self-medication, relying on pharmacists and nurses to administer treatment, or searching the internet for a diagnosis. Patients also end up seeking quacks, refusing essential medication and investigations, harassing doctors for unpaid consultations via phone or email, and refusing payment for repeat visits.
– A lot of patients are not good at record keeping and tend to change doctors frequently at whim. For instance, if a skin disease has been evolving for the last few years, your fourth dermatologist will struggle to replicate your entire case history and past treatment, if you do not have a record of your old prescriptions and reports. In such a case, certain tests may have to be repeated. This is likely to aggravate a patient who is already frustrated with the repeated rounds of treatment.
– Lying and concealing pertinent facts is detrimental to successful medical management.
– Lastly, patients often lament against the commercialization of medical practice. However, most patients are often responsible for it themselves. They forget that hospitals are not hotels and the doctor is not a valet. Some disregard hospital rules, some let their children run amok, and many violate the visitation rules.
Doctors are only human beings. They’re neither saints nor smooth-talking politicians with thick skin. Medical treatment and surgeries require focus and concentration. Threatening, harassing or yelling at your doctor ruins their will and motivation to give their best to their jobs.
Patients waiting at the out-patient centre forget that this is just one part of the Department. Doctors need to attend to in-patients and emergencies as well, and sometimes despite best effort and intention, delays and chaos are inevitable. When patients regard themselves as “customers” and the doctor as merely a “service provider”, it damages the sanctity of this special relationship.
Legitimate Patient Concerns
– In the Managed Health Care scenario, patients are legitimately concerned if the doctor is working in their best interest or if they care more for the organization, their own jobs or the financial turnover of their Departments. This ambiguity erodes trust and promotes suspicion and resistance to the doctor’s advice.
– Standardization of practice – In other words, relying on “evidence-based medicine” could be misconstrued as a cover to run an entire battery of tests for routine complaints. The subjective history of the patient and the physician’s instinct and assessment is given lower credence over lab reports.
– Corruption in medical practice cannot be denied. While the Consumer Protection Act can protect patients against negligence, it cannot account for corrupt practices.
– Loss of patient confidentiality in Managed Health Care where non-medical personnel have access to patient information.
Legitimate Doctor Grouses
– Lack of training – In patient counselling, simplifying medical terminology for better patient comprehension, and managing difficult or emotionally labile patients. Yet the onus of building the rapport lies on the doctor.
– Doctors rightfully turn away patients who are badly behaved, refuse to pay, misbehave with staff or disrupt the functioning of their office. Sexual harassment of female doctors and nursing staff is known to occur, though it is under-reported. ‘Firing’ such patients does not amount to negligence or patient abandonment.
– Patients walking in without a prior appointment, patients turning up late for their appointments, and no-show by patients who block the doctor’s time – these are common occurrences worldwide. They lead to loss of revenue, delays and chaos at the doctor’s office.
– Unrealistic expectations of the patient, despite counselling and education. Doctors are not Gods and they can only treat as far as the science has evolved. In Cosmetic Dermatology & Plastic Surgery, patients with unrealistic expectations are often refused treatment. Doctors and caregivers become the victims of the patient’s misplaced anger and poor self-esteem.
– Not every patient can be saved. Patients die or suffer complications despite the best possible care. And doctors have the unenviable task of breaking the news while handing over the bill for treatment! In some cases, a patient may develop an allergic reaction to a prescribed medicine. These are unpredictable reactions, which can be treated. However, patients tend to blame doctor over nature, and expect doctors to treat the complications without further charge.
As a patient, what can I do to build a better relationship with my health care providers?
This article is not about the cases of clear medical negligence, corruption and/or cases where patients felt robbed of their dignity. This article focuses on why good doctors are often misunderstood and maligned. The focus is on how patients can also contribute towards building this relationship, and what turns good patients into difficult ones.
– Respect is a two-way street. When patients attack their doctors either verbally or physically, doctors begin to practice “defensive medicine” which does not benefit anyone.
– Respect the doctor’s time. Empathize with the other ill patients who also demand the doctor’s time and attention.
– Do not consult a doctor over phone or email outside of office hours, unless it is an emergency.
– Be truthful. Carry the records of your previous treatments and investigations. Be prepared to narrate the history of your illness in chronological order – with timelines, disease evolution, response to previous treatments, triggers, and specific concerns you may have regarding your treatment.
– Doctors are justified in charging their consultation fee even if you refuse treatment or plan to seek second opinion.
– Do not interrupt a doctor when they are attending to another patient. Wait your turn.
– Bring along one significant other for your consultation. Do not come in large numbers. This is disruptive.
– Do not quit drugs against medical advice. And do not self-medicate. These are bad patient habits that annoy doctors no end. Abrupt withdrawal of certain medications like oral steroids and benzodiazepines could in fact, be dangerous.
– Do not use the internet to diagnose yourself. Seek a doctor for diagnosis. If you are unconvinced, then seek a second opinion from the concerned specialist. Once you have your diagnosis in hand, you can ask your doctor to refer you to the right website, literature or patient support group. Always check the source of your information.
