No, don’t panic, I’m not leaving State Road Family Practice 🙂
I’ve had some interactions with patients and their families this week that prompted me to write about what constitutes a good doctor-patient relationship. Sometimes (actually I’m blessed to say it’s much more often than not) the relationship is like a great friendship, with lots of mutual respect and a sense of working together for the good of the patient. However, sometimes the relationship is rocky from the start or things happen to break the trust between the doctor and patient.
Usually building a good relationship in medicine is like building a good relationship anywhere else, you have to earn the trust and keep earning it by being honest, reliable and respectful of each other. In medicine however it is critically important that each half of the relationship is confident that the other half is being honest and can be counted on to do their best.
Most people have had the experience of being let down or disappointed by someone. When it’s your doctor that lets you down it’s really troubling because sometimes the doctor’s decisions are life-or-death. Some folks make the decision to vote with their feet and change doctors without ever telling the doctor what prompted that decision. Some brave folks decide to leave but make a call or write a letter explaining their decision in order that the doctor can learn from the experience. Others (usually after a lot of hard thinking) decide to stay and give the doctor another chance.
When it’s the patient that lets me down it’s really hard for me to continue taking care of that patient. In order to make good therapeutic decisions I have to be able to trust that the patient will do what they’ve agreed to do and that they’re answering my questions truthfully. You’d be surprised how regularly I find out that patients have lied to me. Whether they’re trying to get something they don’t think I’ll give them (like an inappropriate narcotic prescription for instance) or they simply don’t want to disappoint me, I’ve learned to “trust but verify” important information.
There are some patients that simply won’t take my advice. Whether it’s the diabetic who won’t work with me to get her diabetes under control, the fifty-three-year-old executive who’s too busy to go for the colonoscopy, or the parents who won’t allow their children to be vaccinated, these people make me crazy. I’ve looked one in the eye and asked her “Why do you come to see me when you don’t believe I know what I’m doing and won’t do what I ask you to do?!” Another patient has had just about every possible bad consequence of uncontrolled diabetes and refuses to come in regularly for visits or get bloodwork done. When I can’t take it anymore I usually will apologize to them for not being able to motivate them to take better care of themselves and ask them to find another doctor.
If it shocks you that a doctor would dismiss a patient for refusing to follow his/her advice, you should be aware that while I do it very rarely it’s going to get more common. The government and many health insurance providers are instituting a “pay-for-performance” program that is supposed to pay doctors more for providing better care. They will be defining “better” care as care that produces better outcomes. For instance, a better diabetes doctor has patients that have better-controlled blood sugars and better cholesterol numbers and see the podiatrist and the eye doctor regularly. When these measures are implemented what do you think will happen to a doctor who takes care of a lot of noncompliant patients? His numbers will look bad and he won’t be paid as well. We’re human too and while doctors are in medicine because we love doctoring, we find noncompliant patients tough to deal with. When you add the financial incentive, doctors will be more likely to send noncompliant patients away and tell them to find another doctor. Before long noncompliant patients won’t be able to find a doctor willing to take care of them (especially as medical records are centralized and a doctor will be able to quickly and easily access records from multiple previous doctors).
The next time you’re tempted to disregard your doctor’s advice, please keep this discussion in mind. Please make sure you understand why your doctor wants you to do a certain thing or get a certain test or see a certain specialist. Make sure your doctor is aware of and fully understands the reasons you might not want to or be able to do what he or she recommends. Maybe a compromise or less invasive/expensive/involved option is available. Remember that good relationships are based on mutual respect, trust and good communication.
If you’ve done all you can to communicate well with your doctor and you’re not getting better or you don’t feel your care is all it should be, then it’s probably time to move on and find another doctor. On the other hand, if your doctor has made recommendations and ordered tests and referred you to specialists and you can’t find the time to follow through, you just might find that YOU’RE the one getting the pink slip.
PS – if you don’t believe me about Pay For Performance, check this site: http://www.ahrq.gov/qual/pay4per.htm