What doctors wish patients knew…turnabout time!
Did you ever wonder what goes through the mind of your physician when you see him/her? I mean, they are people too! They have all the foibles and pet peeves of “regular people”, they just happen to have a very in-depth education about a very big topic! Being smart does not make them perfect. Far from it. Doctors get frustrated by patients as often as you probably get frustrated with your doctor.
The following is a list of things that doctors wish patients knew. It is not a wicked diatribe against patients. Far from it. The vast majority of patients are lovely people. I am actually blessed with a patient population that I feel must be the envy of doctors everywhere. They are bright, inquisitive and well-informed. They take part in their own healthcare, and put effort into their well-being. My “problem patients” are such a small minority that I have no reason to complain. I’m a truly blessed and lucky physician in this context.
So what do doctors wish patients knew? I’m glad I asked!!
Doctors think long-term – Patients want the quick cure!
When a primary care doctor sees you for the first time (i.e. Your Internist or Family Practitioner), they see you as someone they will be taking care of for the rest of your life, and they begin the process of identifying who you are as a patient, so they can best manage you for the years to come. They are all about “The Big Picture”. For this reason, the current over-use of Acute Care Facilities, Emergency Rooms and Minute-Clinics are a terrible and dramatic step down in care for almost all people. These places don’t know you, your health problems for the last decade or more, or all of the sundry other issues that your primary care doctor is intimate with. Patients see them as quick ways to get care, especially at odd hours when the doctors office is not open. The Quick Fix! For about 90% of medical problems, the nurse practitioner or physician assistant you are likely to see at one of these places can handle the issue without any problem. Unfortunately, you never know when your problem is going to be one of the 10%. The scary thing is, most of the time the person taking care of you doesn’t either! They just get it wrong, about 10% of the time. I know, I see the back-end of this system every day…when the patient is no better, was misdiagnosed or mistreated, and I am left to pick up the pieces a week or two later. They always tell you to follow up with your doctor. Very few ever do.
Furthermore, your doctor, in his long-term thinking, would like to offer you appropriate preventive care, but it is very hard to get some patients in for their yearly physicals and preventive maintenance care. Again, patients often want The Quick Fix and doctors want to prevent you from having medical problems in the future. Forming a long-term relationship with a primary care doctor is one of the best things you can do for your long-term health. Do not underestimate the power of having a doctor that has been with you through the years! The push towards corporate medicine is also partly to blame for the degradation of the Doctor-Patient relationship.
Day #1 Medical School: Telephone Medicine is Bad Medicine
Even my best “trained” patients often call and ask me to “call in a prescription for my cold”, or ask to to diagnose them over the phone. Some doctors will do this, and these doctors have fallen prey to the worst trap in all of medicine. They are doing the patient a giant disservice, most of the time, by trying to identify their problem over the phone and treat it sight-unseen. Any medical issue which is significant enough to require a prescription medication ought to be diagnosed properly before it is treated. Yet, many patients actually like their doctor because he will do this for them. Maybe that’s why so many doctors do it; to try to make their patients happy. Certainly, there are exceptions to this rule. If a patient of mine has had 12 ear infections in the last 24 months, and now has all of the usual symptoms of another one, it’s very unlikely that it is something else the 13th time. In these specific kinds of cases, it may be prudent to treat them over the phone. Mostly though, don’t be angry with your doctor when he demands to see you for your ailment, he is treating you properly…like he was trained. I’m quite sure that when I try to diagnose things over the phone, I get it wrong as often as I get it right. We often get the “I’m going out of town in 30 minutes” phone call, or the “I’m in Anchorage, Alaska and I have a sinus infection” phone call; leaving us either providing inadequate (and possibly dangerous) care, or being the bad guy and asking them to be seen by a doctor. The other half of this issue is that when doctors treat you over the phone, they have used their skills, spent their time, accepted liability…and do not get reimbursed. Insurance companies don’t pay doctors for a telephone consultation. Your attorney will bill you for a minimum of 15 minutes of his time for a phone call, at an hourly rate of $300 or higher…yet you expect medical care over the phone, gratis. Hmmmm!
Antibiotics do not cure the Common Cold
I wrote a blog about Antibiotics (https://seussmd.wordpress.com/2010/03/22/antibiotics-in-the-garden-of-good-and-evil/), and you can read the whole kit-and-kaboodle there, but the take home message is that most upper respiratory infections are caused by viruses. Viruses do not respond to antibiotics, which can only kill bacteria. Prescribing antibiotics for a simple cold does you much more harm than good, as we incur antibiotic resistance and expose you to the possible side effects or allergic reactions that all antibiotics can cause. Patients feel “cheated” when they don’t leave their doctor with a prescription, and only receive advice on how to feel better. Frustrating, I’m certain, but we still do not have a cure for the common cold! Doctors who prescribe antibiotics for every sniffle are just too lazy to discuss the downside of prescribing them, and would prefer to make their patients happy and get them out the door. It takes much more “effort” and time for us to explain why an antibiotic is not appropriate than to just write out a prescription. If you doctor ever tells you an antibiotic is not appropriate for your infection, be happy that you have one that still practices medicine properly! Good doctor! Nice Doctor!
Most supplements are a waste of money, or possibly even dangerous
I wrote a very exhaustive blog about herbal remedies (https://seussmd.wordpress.com/2010/07/18/the-herbal-minefield/). Most are merely a waste of money, and will neither help you or harm you. Some offer some minimal benefit. Some are very beneficial. Many are outright harmful. Many have a multitude of interactions with each other or with prescription medications (this is the danger when a supplement contains dozens or possibly hundreds of chemicals, since it is not purified in any way). All are harmful if they are used instead of seeing a doctor. Do not self treat yourself with herbal products. You are probably neither qualified to diagnose the problem, nor qualified to use the proper herbal remedy. Honestly, most of the “doctor replacements” out there who prescribe with herbal remedies are not qualified to diagnose you either, though they may have an extensive knowledge of the herbal products they use. There is no problem seeing them as a supplement to normal medical care from a licensed Medical Doctor or Osteopathic Physician, but do not use them as replacements! I have had 2 patients in the last several months who caused themselves liver damage with herbal supplements (Valerian and Kava Kava); thankfully they recovered after stopping the supplements. I had one patient who fell prey to a “Holistic Health Center” who sold her $1200 worth of supplements, based on suspect blood tests that no doctor would condone. As PT Barnum once said, “There is a sucker born every minute”.
Please take your medicine
Medical non-compliance is one of the toughest things doctors deal with in practice. It is especially frustrating when the patient expects to be cured, but does not follow directions. This happens more often than I care to admit.
“Mr. Smith, I see you are back today with diarrhea and abdominal pain. I saw you in December and again in March for this same problem. It’s now May and you have it again? Did you see the gastroenterologist like I asked you to?”
“No Doc, I just haven’t had time.”
“Are you taking the medication I prescribed back in December?”
“Well I took a few doses and it seemed to help, but once it ran out, I didn’t fill it again.”
Unfortunately, sometimes the repercussions of non-compliance are much more serious than some diarrhea. A very dear person, very close to me, recently had a stroke because they did not take their medication for very high blood pressure. Their doctor did not make it clear to them what the repercussions of non-treatment might be, but the doctor did prescribe the medication and it is the responsibility of the patient to follow the directions of their physician or be prepared to deal with the consequences, and be responsible for them. In her case, she had side effects from the medications which she didn’t care for, and stopped the medication. She ought to have returned to her doctor to discuss other options, but this is a common tale! If you cannot comply with the directions of your doctor, do not just stop treatment! Please make an appointment with your doctor to find another treatment option.
We cannot cure all things
It is the 21st century, and many patients believe that we can cure nearly all that ails them with a simple pill, and diagnosis is as easy as passing a magic wand (or Tri-Corder) over their body. Unfortunately, medical science is not perfect. We cannot diagnose or treat everything. Of the things we can treat, we may not be able to completely cure every problem. Realistic expectations are something that were lost sometime in the last century. If someone has used and abused their back for the last 50 years, and they come into my office with back pain and degenerative arthritis, they may have to accept that a certain amount of pain and disability will be present for the rest of their lives due to this wear-and-tear on their body. We cannot turn the hands of time backwards! Most patients come to realize this, but often not before much frustration and ire is directed towards his physician(s), either to their face or behind their back. Trust me, we’re not holding back on you! If there was a magic pill to fix what ails you, we would use it!
Research online, but do so carefully and only at respected web sites
Someone’s medical blog (including mine!) is not a “reputable” source of medical information! I wrote a blog on critical thinking (https://seussmd.wordpress.com/2011/02/15/critical-thinking-a-lost-art-form/) as a lost art form, and it applies here. Just because you read something on the internet, does not make it true. Do not blindly Google the term “cancer cure” or “hypertension” and expect to get useful/reputable/reviewed information. There are good web sites for medical information (which I will list in a moment). If you do find something online which you think is applicable to you, print it out and bring it to your doctor! If I had a dime for every time someone came in with internet-born medical misinformation….well….I’d have a lot of dimes!
http://www.cdc.gov (information on travel health, infectious diseases and preventive care)
http://www.fda.gov (for drug information)
http://www.medlineplus.gov (Diseases and conditions)
http://www.webmd.com (Diseases and conditions and medications)
http://www.cancer.gov (National Cancer Institute information about cancer)
Generic Medications almost always work as well as the higher priced brand name medications
There are rare exceptions to this rule, but almost all generic medications (made in the United States and filled through licensed pharmacies) have a very high quality control, and work identically to the much higher priced, brand-name medications. Medications made overseas are beginning to become problematic, although ones which are proven to come from Canada are probably still ok. There are counterfeit medications flooding the market, usually through internet drug providers, and these medications may contain little or none of the active ingredients. The TV program 60 Minutes did an program on this very recently. There are also a few drugs, which are prescribed in tiny little doses (micrograms instead of milligrams, or very few milligrams) where even a small difference in the dose can lead to dramatic overdose or underdose! It hardly matters if your allergy pill contains 180mg of Allegra or 184mg, but it can be very bad if your blood thinner contains 2mg of warfarin or 2.5mg! So, for drugs where accuracy is important, or the doses are very small, your doctor may elect to only allow the brand name medication to be used.
Fevers are not ordinarily harmful
This is a common problem, especially in pediatrics. Mothers see that their child has a fever and rush for the bottle of Children’s Tylenol or Motrin. I don’t blame them! We love our kids and we are very protective of them, especially when they are sick. The fact is, that fevers are part of the natural immune response against infection. Unless the fever is very high (i.e. 104+) there is little harm being done, and possibly the fever is helping to kill the infection! Certainly, fever can make people feel pretty crappy, especially kids. It is not harmful in these cases, to treat the fever to make them feel better. However, if the person feels ok with the fever, it is probably ok to just let it be! The exception to this rule is a fever in a child less than 3 months of age or anyone who is taking medications which suppress the immune system. For these two sets of people, fever can be a sign of very serious disease and that patient should see a doctor quickly. Fevers that do not go away within a few days should also probably be evaluated by your physician.
Our work does not end when we walk out of the exam room, nor did it begin when we walked in
Most good doctors will review the chart for a few minutes before they come into the room to see you, to re-familiarize themselves with your case. If consults were obtained with sub-specialists, we read those carefully, which can often take 5-10 minutes. Once we leave the room, we must carefully document the entire encounter. For me, it usually takes between 3 and 10 minutes to complete the chart after we see you. If tests were ordered, we have to evaluate them when they come back. If they are normal, this may only take 3-4 minutes. If they are abnormal, it can take 5-15 minutes, especially if we have to look something up to properly evaluate the results. If we must communicate the results to you, we either write a note on the results and mail them off to you (all patients in my office get a hard copy of every test we order sent to them in the mail with my comments on each test) or if the results are complicated we call you. This runs between 3 minutes (easy notes) to 15+ minutes for a complex phone call. If you see another doctor and they call to discuss your case, this can take another 5-20 minutes of our time. Now add up all that time for every patient we see every day. Your 15 minute time slot seems a lot bigger now, doesn’t it? Much like an iceberg, most of our time on your case can’t be seen!
“My doctor never calls me back”
A busy doctor may easily receive 20 or 30 phone calls each day, sometimes more, especially if they have a busy practice in nursing homes or if they have several patients in the hospital at the time. If your doctor spent even 5 minutes returning each phone call, he would have to add 100-150 minutes to his day. And, truthfully, we all know that not even one of those phone calls is actually likely to take him less than 5 minutes from beginning to end (including documenting the phone call in the chart afterwards). Doctors must come up with ways to ensure that your issues are dealt with, without spending 3+ hours on the phone every day. Allowing the front office and nurses to deal with some of the issues is one answer. Having them ask the doctor about the phone call between patients, then calling the patient back with an answer is another. If the problem is too complex, they will either ask you to make an appointment if that is appropriate, or the doctor will call you back himself. Now, if you are calling your doctor’s office and no one is calling you back at all….then you have a good reason to complain! Don’t put up with that!
Respect is a Two-Way Street
It is assumed that your doctor will be professional and courteous with you. If he/she isn’t, find a new one. But that street goes both ways. The following is a short list of things that happen every day, but ought not, if patients were likewise courteous:
- If you have an appointment, please show up. “No Shows” are not only discourteous, they are financially ruinous. The empty time in our schedule cannot be replaced, ever, when you just don’t show up. Many offices, mine included, will charge you a fee if you do not show up. Our office gives you “Three Strikes”, then you are charged for every No-Show without 24 hours notice.
- Please show up to your appointment on time. The #1 reason (by far) that doctors run behind on their schedules is because patients show up late and expect to be seen. If someone shows up 10 minutes late, and the doctor sees them anyway and spends the usual and customary time with them, he is now 10 minutes behind for the rest of the day. Every single patient behind them will be seen 10 minutes late. If two people show up 10 minutes late, the doctor is now 20 minutes behind for everyone else…including the ones that were kind enough to show up on time! If a patient is given the 2:00 – 2:15 appointment slot, and they show up at 2:15, ought the person scheduled at 2:15 have to wait for them, and every patient after that? At my office, we don’t think it is appropriate for a single patient to decimate the schedule for everyone who was courteous enough to show up on time. If you show up more than 15 minutes late to your appointment, we will not see you. You are welcome to wait until I might have an opening in my schedule, or you are free to reschedule (later in the same day if available), but we do not allow the tardy patient to delay the on-time ones! Funny, once this happens to a patient once or twice, they show up on-time after that!
- Do not call after hours for anything other than emergencies. Doctors have lives as well. Doctors like to eat dinner with their families, go to movies or plays, go golfing, and all the other things “normal people” do. If they are being paged in the middle of the movie, it pretty much ruins the movie while they get up, leave, answer the page and come back. So, if it can wait until the next business day…then it ought to. Actually, almost all of my patients are very good about this, but there are always a few that will call you at 10pm to refill their prescriptions over the phone.
- Pay your physician promptly. We are amongst the few professions that bills for our services after the fact. Your plumber would demand payment immediately and you wouldn’t think twice about paying him, yet my office always has folks who take months to pay their bills. Doctors are not in the business of offering lines of credit, and if you don’t pay promptly, they are essentially giving you a 0% interest loan. This backlog of collections can actually make it impossible for a small office to function.
The “Oh, by the way…” or The Long List
When patients make an appointment, they are always asked what the appointment is about. This is done for a couple reasons. The first reason is so that the doctor can prepare for your visit by reading your chart with an eye for things that might be causing the problem. The other is so that the receptionist can estimate how much time will be required to take care of your problems. If you state that you want to talk about your allergies, and nothing else, they will probably put you into the schedule for a standard 15 minute appointment (even shorter in some offices! I have seen appointment slots as short as 5 minutes in some offices). Many patients then think, “As long as I’m here, I might as well ask him about these other things”. Doh! You have been given a 15 minute appointment slot, which is not enough time to take care of more than 1 or 2 issues. Some patients actually walk into the office with a list of 10 or 12 things, even though they only mentioned one when they made the appointment. Be prepared for the doctor to only be able to handle 2 or 3, then ask you to make a follow-up appointment to deal with the other issues in a longer time frame. Remember that problem with doctors running late? Late patients were the #1 cause? This is the 2nd most common cause of doctors running late.
I wrote a blog on Critical Thinking (https://seussmd.wordpress.com/2011/02/15/critical-thinking-a-lost-art-form/) which explains this more completely. Doctors make decisions based on large amounts of data from well constructed studies that are designed to provide overwhelming evidence that the treatment provides benefit which outweighs the risks. This is called Evidence Based Medicine. Often, patients will not follow the advice of their doctor based on a single circumstance they happened to witness; an exception to the rule. My adage is “There are exceptions to all rules, but do not make your rules by the exceptions”. Perhaps your doctor has prescribed a medication for you to lower your cholesterol, which is very high. This medication has been shown, in very large and well-designed trials, to lower your risk of heart attack or stroke by 50%. When you get home, you call your best friend and tell her about your new medicine. She tells you that she took the same medication but it inflamed her liver and she had to stop it. This frightens you, even though your doctor warned you that it was a rare side effect of the medicine. You decide not to take it. Does this thinking process sound familiar? This kind of thinking process is the bane of physicians everywhere. It is sometimes very hard to convince patients that the experience of thousands of patients is more important than the experience of one patient that they happen to know.
Doctors are not insurance experts
There are thousands of insurance plans in the state of Illinois alone. Thousands. There is no way we can know what plan covers what. It would take 1 or 2 full time employees to keep abreast of every plan, especially when they will often change without much warning. It is the responsibility of the patient to know (or find out) what is covered by their plan. If your doctor orders a test, medication or therapy and you are not certain if it is covered, then find out before you undergo the test, take the medication or get the therapy! All insurance plans have toll-free numbers you can call and ask if the proposed service will be a covered benefit. Piece of cake, really, but patients still become angry when they find out that their insurance plan didn’t cover the therapy which they undertook and they end up with a bill! A little bit of due diligence, before or after the visit, can go a long way!
Primary Care doctors are working on very tight margins
It used to be that being a doctor meant you would work very hard in medical school, give up a decade or more of your life in hospitals for training, but at the end you would make a good living. This is still true for sub-specialists. Primary Care doctors are now so poorly reimbursed by insurance companies that our hourly wage is decidedly lower than most plumbers and many other skilled laborers. How can this be? The reimbursement for office visits is very low; the non-physicians who made up the reimbursement scales felt that procedures required more skill than brain-work. Thus, I can spend an hour with a patient, sorting through dozens of medical problems, complex medical histories and a long list of medications; to finally come up with a complex treatment plan for 6 or more complicated medical issues. The reimbursement for this work is less than the money a dermatologist receives for removing a two moles off your back; a 10 minute procedure requiring very little thought. That is half the problem. The other half is that the reimbursement rates are based on the Medicare Guidelines for reimbursement (which are very low). Usually, private insurance will pay us 10-20% more than these very low rates and adjust whenever the Medicare rates adjust. Since 1995, the reimbursement rates for primary care have remained flat and unchanged while inflation (at 3% yearly) has raised the cost of overhead and cost of living by 48%. This represents, essentially, a 48% pay cut since 1995 for all specialties. While sub-specialists operate at a profit far above their overhead, primary care doctors now have such narrow margins that their take-home pay has dropped to the point that trying to convince new doctors to choose primary care as a specialty is nearly impossible apart from doctors from foreign medical schools that may not have any other option. When you toss in the gargantuan costs of medical school….well…you see the picture! I still drive my 11 year old Toyota Camry.
By Apollo the Physician…
I have the privilege of being a doctor. It is an occupation which represents a time-honored trust between physician and patient. In no other occupation does someone tell a stranger their innermost secrets and trust them with their very lives, on a daily basis. It is a responsibility that doctors take very seriously. The reputation of physicians has been tarnished somewhat in this age of the corporate takeover of medical care. The almighty dollar has taken precedence over the doctor-patient relationship. For this, I am sorry beyond my ability to express. This is not the medical system I entered into when I started medical school in 1988, and I hope it is not the one I am practicing in when 2018 rolls around. I am honored to practice medicine. I am honored to work amongst some of the brightest and most caring people I will ever meet, anywhere. While the medical establishment may have critical flaws in it, the doctors who participate in the care of patients are largely a group of caring and skilled human beings. Please remember…they are human beings. Just like you.