Navigating the Doctor-Patient Relationship

A recent issue of Newsweek (April 23&30, 2012) had “The End of the Doctor-Patient Relationship” boldly displayed above the magazine’s logo.  Inside, the featured article was actually entitled, “The Doctor Will See You – If You’re Quick.” (p.46)

What a striking difference from the usual expression that has prevailed over the years in medical offices – “The Doctor will see you NOW.” 

It would be hard to find anyone who isn’t aware of how medicine has changed over the last 20 years, to the detriment of patient care and the decreasing personal satisfaction of both patient and physician.  The causes behind the changes, well described in the Newsweek article, are many and varied and not the focus of this column.  But changes in the power of the medical insurance industry, increasing demands on physicians and hospitals, reduced reimbursements, technological, diagnostic, and therapeutic advances resulting in better but more complex care, and limited availability of medical studies, procedures, and treatments, related to insurance guidelines, have all caused a strain in the doctor-patient relationship, which remains the bedrock of care and a potential source of great healing.  Because of the changes in medical practice and the medical climate, it becomes more important than ever that the patient be his/her own advocate and knows how to take full advantage of the time available with one’s doctor.  The image of the doctor standing in the Newsweek article with stethoscope slung over his white coat and stopwatch in hand is rather chilling, but unfortunately also increasingly relevant.

The first question is what to look for in a doctor.  My strong feeling is that you must find a doctor with whom you are totally comfortable and to whom you can relate with ease.  If you’re free to be totally yourself when you’re in your doctor’s presence, that’s half the battle, as far as I’m concerned.  The ideal scenario is one where you know you could bring up anything to discuss with no restrictions or limitations.  It’s also important that your doctor be willing to listen.  As I’ve discussed in previous columns, a feeling of being listened to is so essential – it makes you feel relevant and also engenders trust in the doctor.  The Newsweek article mentions a disturbing statistic that “the average amount of time a patient has to explain symptoms before being interrupted by a doctor is 23 seconds.” (p.50)  I would give an A+ rating to a physician who lets the patient talk without interruption for 3 to 5 minutes during the initial visit in response to the question, “What brought you here to the office?” or “What is your main complaint or concern?”  Being comfortable with your doctor and feeling that he/she is concerned about you because you are listened to and heard are extremely significant things to look for and, even more importantly, to feel.  The doctor may have less time to give you, but how that time is used is critical.

Once you’ve found the doctor who is a good fit for you, the next step is how you communicate with him/her.  Often when a patient is face to face with the physician in the examining room, anxiety about “being with the doctor” or anxiety over one’s symptoms and/or illness or what the doctor might find cloud one’s thinking.  As a result, questions that are of paramount importance to ask or that reflect one’s concerns don’t get asked or symptoms the patient might want to bring up to the doctor don’t get mentioned.  These questions, symptoms, and important information may later recur in the patient’s mind after the visit is over.  Therefore, it is crucial that you make a list of all the questions you need to ask and all the information you need to share before you go for the doctor visit.  This list can allow you to use the time you have with the doctor more constructively.  Not only is this approach more satisfying to you the patient because there is a greater possibility your needs will be met and your questions answered, but also it can give the doctor extremely helpful information that can allow him/her to understand your complaints and/or illness better and make more appropriate decisions regarding further evaluation and treatment.  Because of the trend toward more limited time with your doctor, be prepared to use every minute you have wisely.

Assertively be your own advocate, too, and insist that every question and concern be addressed, even if easy or definitive answers aren’t always forthcoming.  Finally, I think a list of questions and concerns is a good practice, because it shows the doctor you care about yourself and want to participate in your medical management.  Also, if your doctor doesn’t know about what concerns you have over your medical issues, he/she can’t help you with them.

What should you insist on knowing from your doctor?  Despite the growing sophistication of patients, there is often still a tendency to put the doctor on a pedestal and just accept what happens, or doesn’t happen, during an office visit as “the way it is.”  I’ve continued to hear some patients say something like, “If the doctor thought I should know, he/she would have told me” or “I’m doing this test (or procedure) because the doctor said I needed it, even though I’m not sure why I do” or “I’m taking this medication, but I’m not sure what it’s for.”  Every patient has the right to understand all aspects of their illness and how it is being evaluated and treated.  If you don’t understand your symptoms or why you have them as part of your disease, ask.  If you don’t understand the results of your lab tests or other investigations, ask.  If you don’t understand the rationale of your treatment or what to expect from the treatment, ask.  If you’d like to have a clearer picture of how the illness might affect you or what lifestyle changes you might need to make, ask.  Whatever information you need, ask for it.  Many doctors will give you the facts and explanations you need to know, but some might forget to give you some or all of the information you wonder about.  Living in the dark about what is happening to you creates an anxiety all its own and can block you from playing a role in your own healing.  Asking what you want to know is empowering and gives an opportunity for the doctor-patient bond to strengthen.

Learn all you can about your illness.  The more you know about the disease you’re coping with, the better prepared you are to make decisions with your doctor about your course of treatment.  I feel that understanding what is happening to you and the changes that can affect you way of life helps to alleviate a sense of being overwhelmed when faced with a new diagnosis.  That is not to say I don’t respect patients who decide that they would rather not know about their illness and instead just let the doctor take care of everything without any explanations.  This is a form of coping, too, and if this approach works and helps the patient, that is fine.  But I’ve often found that the patients who understand their disease and participate in their care and decision making frequently, but not always, have a better chance of doing well; at least they develop self-confidence and a better sense of their own innate power.  While I was practicing, I liked it when a patient questioned me about his/her disease – it made me think; it created a good connection between us; it made me have more of a sense of collaboration, a therapeutic part of the doctor-patient relationship.

I also feel that if you are a patient, it is important to have a clear sense of what responsibilities you have in your own care.  Part of the doctor’s job is to give you instructions about your diagnostic workup and your treatment.  Your job as a patient is to follow these instructions and do them correctly.  It’s a good idea to repeat the instructions back to the physician to make sure you understand the directions and have interpreted them correctly.  Next, you have to do what was suggested, even if at times it might be difficult and/or requires your full attention.  It is not your job to change the dosage of a medication or a dosage schedule or to avoid the medication altogether without consulting the physician first.  Get the lab tests or X-rays or other diagnostic tests done before your return visit.  Remember, the doctor can advise and guide you, but he/she needs you to participate in the evaluation and treatment of your medical problem.  Not holding up your end of the deal and following through with your responsibilities is non-productive, potentially dangerous, and may even reflect your unwillingness to help yourself.

Another part of navigating and effectively utilizing the doctor-patient relationship is to discuss with your physician the emotional issues that may arise from the physical problems you’re experiencing.  Being ill may make previous emotional problems or difficulties re-emerge more prominently.  New emotional issues or factors may occur because of the difficulty of the symptoms and the associated life situation changes that result.  The emotional aspects of an illness can be and often are as significant as the physical symptoms.  If not addressed, they can have a significant effect on the course of and recovery from the illness.  Your physician’s office is the place to bring up emotional difficulties, even if your visit time is limited.  Again, the doctor can’t help you unless he/she knows about what you are experiencing.

Sometimes just talking about anxiety or depression can help relieve the stress of these symptoms.  If the emotional problems or reactions that have been reactivated or kindled by the disease are more complex or require more intensive therapy, the physician can refer you to an appropriate mental health therapist for evaluation and treatment.  Whatever course is decided, it is important to recognize the feelings and emotional reactions an illness generates and discuss them with your doctor.  As Shannon Brownlee states in her Newsweek article mentioned above, “When patients reported that their doctors focused on their feelings and worries and listened to them carefully, they not only felt better, but objective measures showed they had fewer symptoms of disease.” (Newsweek, April 23&30, 2012, p.49)

I also think it’s important to convey to your physician your understanding of your own illness.  In the article “Healing Skills for Medical Practice” (Ann. Int. Med., 2008; Vol 149:720-24) physicians who were regarded by their colleagues as “especially good at establishing and sustaining excellent patient relationships” talked about how patients themselves can provide so much helpful information on their own medical condition, and how important it was to let patients convey their understanding of their own illness.  Just taking the opportunity to be heard and acknowledged, by a physician who would welcome this type of sharing, is healing in itself, but it also gives the physician insight into what you are experiencing related to the illness.  Speaking about your perception of your illness also can help the physician communicate more effectively with you using language and terms that you could understand and find meaningful.  Finally, communicating ideas on how you might be able to help yourself can give the physician insight into possible therapeutic plans that may work for you and be within your capabilities.  This is another aspect of advocating for yourself and participating in your care.

Another issue to discuss with your doctor is the support system you have in place for yourself.  Many physicians will bring this up themselves, but if not, express a need to discuss it.  You may not need any particular help or support, but if your illness is more involved and life-altering, you might.  A support system could consist of family, friends, a religious community, or a group that shares common interests with you.  Also, another type of support system can be present through your living arrangement or a long term care insurance program.  A support system of caring family and friends can be a great source of strength during a time of illness by providing help with practical tasks and personal needs and/or emotional and spiritual support when it is needed.  Sharing information with the doctor about your support network gives him/her helpful information that may be of great value in determining your care plan and strategy.  If you have no support framework in place, you should discuss that with your physician also; he/she may have ideas to suggest to you that could help you build a secure support system around you.

The final suggestion I have is get to know your doctor’s office staff.  Not only can they help you navigate the office, answer questions, and solve problems, especially in the area of medical insurance, but also they are your main connection to your physician in time of need.  The office manager is usually in charge of the daily functioning of the office, but certain office staff may be able to help you with specific problems or questions (billing, lab test orders or results, prescription refills, emergency appointments, questions you have for the doctor).  Get to know who among the staff handles what and ask for them when you call.  In many offices, any of the staff can handle most problems and that won’t be necessary, or the phone answering system of the office will have choices to direct your call.  But it still doesn’t hurt to get to know the staff that supports your doctor.  They are the people that can help you reach your doctor if an emergency is occurring.  This is another part of advocating for yourself with expediency and having a sense of what direction to go when you have medical needs.

In closing, I would like to mention that I have started a medical coaching practice where I will act as a Practical Health Care Advisor.   Through 45 minute phone conversations, my aim is to help clients interact with their doctors more effectively, be prepared for doctor office visits, comprehend what their doctors have told them, understand their illness and its ramifications better, and recognize and cope with the emotional and spiritual aspects of being ill.  The phone sessions would be on a one-on-one basis and tailored to the individual client’s needs.  Please refer to my website www.DrDonFriedman.com for more details and an explanation of the services I am offering or email me at DrDonF@gmail.com