I once took care of a man who had injured his ankle badly (trimalleolar fracture) while trying to enjoy a football game on a Saturday night. He had been seen at another hospital emergency department and was now crutching his way into my exam room with his leg in a bulky splint less than 12 hours later.
I listened intently, waiting to better understand why he was now here in my ED on a Sunday morning. He relayed his story, clearly frustrated, and finished up by saying, “and they didn’t even do anything for me!”
I paused, flabbergasted, then said: “So aside from taking x-rays, setting and splinting your ankle, providing you with pain medications, crutches and a referral to an orthopedist, what is it that you feel they didn’t do for you?”
We hear this comment come from patients a lot in medicine. And I continue to be baffled by it. What, exactly, does the patient expect when they come to see us?
Recently I had a chat with a new acquaintance. A man who is, by all measures, quite healthy, intelligent, level-headed, and who avoids doctors at all costs. He told me a story of his nephew who was recently hospitalized with a febrile illness. He had a high fever, myalgias, malaise, and was admitted to the hospital over concerns of bacteremia or sepsis. Dozens of lab tests, x-rays, liters of intravenous fluids and 3 days later, his nephew got better. No specific cause was found and he was discharged home.
Their story closed with “and they didn’t even do anything for him.”
This time around, I couldn’t resist and asked, “Why do you say they didn’t do anything for him?”
He replied, “Well, they didn’t do any procedures or do surgery or anything to treat him. He just got better by himself.”
I think that sometimes doctors are not great at setting expectations for themselves. When we use our brains to think, it’s often overlooked as the most critical part of our medical evaluation. People want to see us DO something. When no visible action occurs on our part, it seems like we didn’t do anything. Or, if we don’t offer what the patient expects, we didn’t DO anything.
My new friend explained further: “I went to see my doctor about this shoulder pain I had. He did x-rays and sent me to a specialist. They told me there was nothing wrong, so I started to think about why my shoulder hurt. I realized that I always carried my bag on my right shoulder, so I figured maybe I should start alternating shoulders and the pain went away!”
I commented, “So, it seems like you don’t go to the doctor because we don’t offer you solutions.”
This got me thinking about goals. My ED goals are to make sure that my patient isn’t going to get sicker because of an intervention I need to initiate now. I want to make sure I’m not sending a patient home from the ED with the wrong diagnosis or on the wrong treatment. This isn’t enough for the patient. The patient wants to know “what is wrong with me?” and “what should I do to make myself better?” It’s not enough to tell them: “You don’t have a problem causing your shoulder pain that would benefit from hospital admission, surgery or a specific medication,” even if this is absolutely true.
We need to think beyond the goals of making sure our patients have received their routine screening, or that we asked all of the check-box questions regarding safety in the home, or that our patients have reached their target A1C. While these are important markers, in all honesty this is not what patients are looking for when they come to see us. They want their concerns addressed and to know that we care.
Another friend of mine told me that he purposely did not make his recommended appointment for routine colonoscopy screening because he was performing an “experiment” to see if his doctor would notice and reach out. They didn’t reach out. He was disappointed.
As a physician, my initial thought was, “Really?! Who has time to not only make medical recommendations but then hand-hold an able-bodied adult through the process of following through?” But, at the root of my friend’s “experiment” was the deep-seated feeling that his doctor didn’t actually care about him.
I’ve been told by another friend that they didn’t feel like his doctor really cared to hear from him in between annual visits. Another friend says that she feels like her doctor sees her as a “cash cow” because she is on Medicare and she is told that they cannot advise her over the phone or provide medication refills unless she goes into the office.
“I know why they want me to come in. It’s because they won’t be able to bill me otherwise.”
There is a real disconnect. How do we repair the broken patient-doctor relationship? I think we underestimate the effects of changes that we can make individually to improve relationships with the patients that we see.
Take time to really give your patient your time. Even if it’s for 10 minutes. A doctor’s day is hectic and crazy, but investing 10 minutes to talk to the patient while sitting down and looking them in the eye and not the computer screen can go a long way to developing a sense of rapport, trust, and real communication.
Try to express what you can do for the patient and set a realistic expectation as to what you cannot do. Although you may not be able to take the problem to complete solution in one day, discuss what you think the next steps are to try to solve the problem. It wasn’t until I told the father of my 12 year-old patient that my job in the ED was to make sure his daughter didn’t have a life-threatening problem or an issue that needed hospital admission or a procedure to fix that he actually understood my role in his daughter’s medical care.
Explain your thought process. Give your patients a window into what you are thinking. This helps them to understand that a lot of work is actually occurring in your brain—that just because you didn’t do a procedure, it doesn’t mean you aren’t working for them. I take patients and their families through my differential diagnosis and thought process as to why I recommend we proceed with the plan I have outlined. This helps them to understand I’m not just running tests to cover my liability (which I’m sure we’ve all been accused of at some point in our careers), but to help get to an answer that would benefit the patient.
Try to keep your patient’s perspective in mind. Even though we are being worked to the bone these days, we are actually there for the patients. Not the other way around. If my patient has a long wait, I start my interaction by introducing myself to the them and their family/friends and thank them for their patience. It stinks to wait. I hate making people wait. But, it’s the reality of what we do. Acknowledge that the system is difficult for your patient as much as it is for you.
Don’t brush off your patient’s concerns, even if they seem ridiculous to you. Take a moment to understand what they’re worried about and explain why you don’t share the concern from a medical perspective.
We’re not super-human. We’re not perfect. The health care system is making it harder and harder to do our jobs. Take back your practice patient-by-patient by putting the energy you do have into things that can improve your patient-doctor relationship. This can only pay off for both of you in the end.
Dr. Irene Tien is a board-certified emergency medicine and pediatric emergency medicine physician who still loves to help patients in the emergency department. She creating a space to connect with patients via her telemedicine service and blog My Doctor Friend.
Dr. Tien is a 2018–2019 Doximity Author.