Medical Guide: The Doctor/Patient Relationship

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When she attended medical school in the ’80s, it was a bit like Dragnet, says Kaiser internist Lisa Liu, M.D.: The emphasis was on “just the facts,” not patient relations.

But things, it seems, are getting better.

Today’s medical students are likely mandated to take courses in what is commonly called bedside manner—the art of the doctor/patient relationship. And doctors say that relationships with patients increasingly are less paternalistic and more egalitarian than in generations past.

It isn’t easy to cultivate such relationships in an era of curtailed office visits and crushing patient loads. But when it comes right down to it, experts say, a successful doctor/patient relationship is no different from any other relationship: It’s all about compatibility, communication, trust and respect. And both parties have to work at it.

THE TIME CRUNCH

Effective doctor/patient communication always has been the cornerstone of successful medicine, improving outcomes and leading to higher satisfaction on both sides. But just how much good communicating can go on in a 15-minute (or less) appointment?

“It’s clear patients want more time and that physicians would like to spend more time with their patients,” says Thom Atkins, M.D., a practicing physician and medical director of Sutter Express Care in Sacramento. “But the time crunch is pretty much based on the way the health system is set up, and it’s eroded the relationship, frankly.” One thing that’s helping, according to Atkins: electronic communication. (He’s Sutter Sacramento’s electronic medical physician champion.) Atkins says most surveys show that 75 percent of patients want online access to medical information such as blood tests and reports, and that the ability to e-mail a doctor confidentially also can help to bridge the communication gap. “What builds relationships is communication—how frequently it occurs, the quality of the communication—and the electronic mechanism is another way to build a relationship with a patient without building in a lot of time,” he explains. “It makes both parties feel they have access to one another, and that they are heard.”

Realistic expectations about time constraints also can go a long way, adds Kimberly Cafarella, M.D., a family practice physician for Mercy Medical Group in Folsom. “When patients come in with a laundry list of problems, they need to understand that we might not be able to get through everything in one visit,” she says. To get the most out of your visit, Cafarella suggests bringing a list with issues ranked in order of importance. “Unfortunately, we don’t have an hour to listen and chat about Aunt Mabel’s hip operation, so we have to focus on figuring out the most important things to hit today.”

Even so, a good doctor will give extra time when needed, says Liu, the Kaiser Permanente internist, who’s based in Elk Grove.
Kaiser generally allots 15 to 20 minutes for routine visits, says Liu. “But even at Kaiser, we have flexibility. If a patient needs more time, I try to give it, and I think most doctors strive to do the same. Or should.”

THE ART OF LISTENING

With time at such a premium, doctors need to learn to not only listen well but to read between the lines, says Tom Balsbaugh, M.D., of UC Davis.

“It’s being able to put into context the story patients are telling you—and maybe not telling you,” says Balsbaugh. “We need to ask ourselves, ‘What are they worried about? What are their goals?’” As residency program director and an associate professor at the UC Davis School of Medicine, Balsbaugh says effective listening is one of the things he stresses while training residents in the art of the doctor/patient relationship. “It’s not just hearing,” he says, “but listening.”

Another thing he teaches: Let the patients do more of the talking. “One of the goals should be to have the patient talking more, putting them in a more engaged and empowered position,” explains Balsbaugh. With any luck, it’s an approach an increasing number of today’s physicians are taking—though a study published just a few years ago in the Journal of General Internal Medicine showed that doctors interrupted patients’ opening statements in 37 percent of the cases.

Patients who take active roles in their health care tend to rate their relationship with their doctors as more favorable, according to Balsbaugh. Encouraging them to talk (versus telling them what to do) helps put them in this more participatory, “take charge” role.

ROUGH PATCHES

Disgruntled patients are unlikely to discuss their feelings with their doctor, say experts. But Balsbaugh says such open dialogue is a good thing, as it may actually improve the relationship. “I’ve had patients say to me, ‘It really upset me when . . . ’ or that they felt rushed at the last appointment,” he says. “Sometimes we’ve cleared up misunderstandings.”

Conversely, he lets patients know if he senses a problem. “I have said to patients before, ‘You seem a bit frustrated with this relationship—are you sure you want to keep seeing me?’”

Kaiser’s Liu uses a five-minute “time out” when there’s tension in the exam room. “Sometimes I can just feel the tension rising, and I’ll say, ‘Let’s take five minutes out, and please stay so we can talk about it.’ And they always stay.”

Unhappy patients should “absolutely” voice their concerns, adds Mercy’s Cafarella, who brings up another very good point: The way your doctor responds to a complaint can help you decide whether to continue the relationship.
“And if you’re not happy,” she says, “move on until you find a good fit.”

COMPATIBILITY COUNTS

Like Cinderella’s glass slipper, patients often have to shop around for the perfect fit. But some just get lucky. When Sacramentan Wayne Strumpfer confronted cancer of the chest cavity at age 29, he instantly sensed he was in the right hands with his oncologist, David Harrison, M.D., who’s with Sutter.

“When we first met, I just liked him,” remembers Strumpfer, who 16 years later remains cancer-free. “I remember someone saying he was very straightforward but not a real big hand-holder, and that some people like that and some people don’t,” he says. “But for me, it was a good fit.” A major factor in their compatibility was a shared view that treatment should be as aggressive as possible—and it was, with four grueling rounds of chemotherapy.

While that kind of natural compatibility makes it easy for doctors and patients to get along, Balsbaugh suggests that doctors also can learn to read their patients’ personalities and bend accordingly. “Some patients like things to go at a superfast pace, and others are slow and deliberate,” he says. “Some patients who need to quit smoking want to go at their own pace and don’t want to be lectured, while others won’t do anything unless I urge them on.”
Sometimes, Balsbaugh adds, compromise is needed. And, like marriage, you have to work at keeping the relationship strong. “Sometimes it’s gonna be easy, sometimes hard, but you need to be willing to try.”

Still, there are times when irreconcilable differences make divorce the best option. If you’re in that boat, all experts offer the same advice: Ask around. Word-of-mouth recommendations are always better than plucking a name off the Internet.

A WISH LIST FROM DOCTORS—Ever wonder what doctors want from patients? Kimberly Cafarella, M.D., sat down with her colleagues at Mercy Folsom to compile this list of things they wish patients would do (or not do) to make for a better working relationship.

* Don’t self-diagnose. Telling your doctor “I went on the Internet and I think I have cancer” frustrates doctors and makes the diagnostic process more difficult, says Cafarella. “What I need is for you to give me the story, and the symptoms and the history,” she says. And be as specific as possible.

* Listen, even when it’s hard. When the news is bad, patients sometimes don’t want to listen, says Cafarella. “Sometimes what we say may not be what you want to hear, especially if it has to do with weight loss or smoking or other lifestyle issues,” she says. “But we’re not trying to make people feel bad—we’re trying to help you.” At the same time, she says, if your doctor isn’t a good listener, find one who is. “It’s our job to listen, too.”

* Be a patient patient. Just as it didn’t take 15 minutes for your health problems to develop, it’s not going to take 15 minutes to resolve them.

* Discuss your expectations. Both doctors and patients come to the table with expectations, but they’re often unspoken. To avoid that trap and to make sure you’re on the same page, Cafarella suggests you have conversations about your expectations from the very first visit.

OUR MINI-SURVEY SAYS . . .

OK, so it’s hardly substantive data. But we were encouraged by the results of our mini-survey on doctor satisfaction. Of 11 local patients:
 9 say they’re happy with their doctors
 11 say their doctors listen to them
 10 say their doctors encourage questions
 7 say they are confident in their doctor’s ability    to properly diagnose and treat them

Still, nothing’s perfect. Respondents reported these as their greatest frustrations:
 Doctor running late for appointments (long waits)
 High medical costs
 Failure of doctor to offer new solutions    to long-term problems
 Language barrier
 Extraordinarily busy office

Other comments
Positive:
“The doctor I have now is the best I have ever seen. She seems to be on top of her demanding schedule, takes time with her patients and sets high expectations for health maintenance. I feel lucky.”

“I was impressed with my doctor from the first visit, when he took the time to ask questions about my life—not just my medical history.”

“My doctor not only listens but also remembers me each time she sees me, which isn’t often. I’m impressed by that.”

“My doctor makes me feel like the research I’ve done and the questions I ask are valid.”

“I feel like I hit the gold mine with my doctor: She blends Eastern and Western practices, which I intuitively feel is right.”

“The office is very good at referrals when they can’t figure something out.”

Negative:
“I was chagrined when my doctor prescribed pills for high blood pressure but never took the time to talk to me about more natural approaches—even basic things, like reducing my sodium intake.”

“I have been happiest with a primary care doctor when I haven’t had any long-term health challenges. Now that I’ve experienced those challenges, I see how little mainstream medicine knows about how to help people with chronic, low-level problems. The doctors themselves must be frustrated that they can’t offer any real help. That’s why they come off as passing judgment on their patients’ lifestyles—they have to blame the patient because they can’t face the fact that their own thinking is so limited.”

“I don’t like it when my doctor bugs me about why I’m not having babies.”