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Becoming an
Effective Patient
Managing your doctor Patient, heal thyself There's nothing more frustrating, or more dangerous, than having to solve your own medical problems. No matter how many hours you spend searching the internet, listening to the accumulated wisdom of your Great Aunt Hilda, or engaging in games of Twenty Questions with taciturn medical personnel, you can never be sure you've got the right answer. It's not supposed to be like that. When you're sick and need help, you're supposed to be able to rely on a doctor - a doctor who is knowledgeable, who really cares what happens to you, and who will leave no stone unturned in seeing that you get exactly what you need. |
Unfortunately, having such a "model" doctor is becoming rare. Patients are on their own much more often, and to a much greater extent, than they used to be - and it's getting worse all the time.
If you've read the earlier sections of this exposition, you're acquainted with our contention that patients are feeling abandoned by the health care system because they really have been abandoned; and that (because widespread covert rationing is systematically destroying the doctor-patient relationship,) the abandonment of patients is happening by design rather than by chance. But even if you don't buy our official explanation of the problem, the problem still remains.
When you're sick and find yourself engaged in a hostile health care system, you need somebody in your corner who knows what she's doing, and who cares about you.Choosing the right doctor for yourself, and nurturing a good relationship with him, is probably the most critical step you can take in becoming an effective patient. With the right doctor at your side, the path to good health care becomes clear and wide. Without that doctor, you're lost and alone in the enchanted forest.
Qualities to seek
The following discussion pertains mainly to choosing your primary care physician (PCP). Your PCP is the one who will get to know you the best, and for the longest period of time. When you become sick she will have the best notion of your values and desires regarding your health care. Your PCP will be the gatekeeper to the wider world of medical care. She's the one with whom you'll decide on the details of your health care, and the one who will negotiate on your behalf with the broader health care system. She will recommend specialists to you when you are in need of one. Her actions (or possibly, her inactions) will do more to determine the adequacy of your health care than those of any other doctor you may see. Thus, when it comes to choosing a doctor, picking your PCP is generally the most important decision you will have to make.
Rule # 1
We ought to begin with the first rule of choosing a doctor, to wit: You hired him; you can fire him.
Choosing a doctor is different than, say, choosing a car. When you buy a new car, you can shop around to your heart's content, but once you plunk down your money and bring that baby home, you're pretty much stuck with it. If it's not everything you hoped it would be, you can't just get rid of it - why, it lost 50% of its original value the minute you drove it off the lot. Besides, it's not life and death, it's just a car. So if your new car turns out to be a disappointment, you'll usually shrug your shoulders and resolve to live with it for a few years, at least until you can justify buying another one.
It's different with doctors. For one thing, it's harder to shop around before you make your move. For another, starting with a new doctor doesn't require an up-front investment of tens of thousands of dollars. Early on, all you've invested is some time and inconvenience. And finally, choosing the right doctor potentially is a matter of life and death.
Many patients have the same attitude when they're dissatisfied with their doctors that they would have if they were dissatisfied with a car - "Oh, well, guess I'll just have to live with it." This is the wrong attitude, since, indeed, in this case you may not live with it. Doctors are serious business.
Choosing a doctor is an important decision, but it's not an irreversible one. It's not uncommon for discerning patients to run through two or three doctors before finding the right match. And there's nothing wrong with doing it that way. So if you've tried a new doctor and you're not satisfied with him, get another one. Remember: You hired him; you can fire him.
The most important factor in choosing a doctor
That would be communication.
If you can't communicate well with your doctor, you're in trouble. This is the person, after all, who will need to understand your wishes and values regarding your health care. She is the one who will need to explain to you, so that you can understand it, the nature of your medical problems - the causes, the testing that may be needed, the potential treatments, the pros and cons of the various therapeutic options, and why she's recommending one option over the others. She's also the one who has to convince your insurance carrier that the course of action you and she have decided upon is the right one, that it's medically necessary, and that they - the insurance carrier - ought to pay for it. Communication has always been important in medicine. Now it's vital.
Is your doctor really listening to what you are saying? Does he show he understands your concerns by responding meaningfully to them? When he explains medical issues to you, does he make them understandable? Does he have more than one way of explaining a difficult concept? Is he patient with you, waiting for you to grasp what he's saying, or does he try to embarrass you into saying you understand, with shakes of his head or rolling of his eyes? Do you like him, and more importantly, does he seem to like you? (This may become very important when it's time for him to go to bat for you.)
The inability to communicate effectively with your doctor is sufficient reason to move on to someone else. Without communication, you've got nothing.
The second most important factor
Does your doctor know what she's doing?
Sometimes its hard to know for sure how knowledgeable your doctor is. But at a minimum you should check to see if your doctor is board-certified in her specialty. (Note: there are board certification exams in the primary care fields of general internal medicine, family medicine, and geriatrics.) Two sources can help. The Directory of Physicians in the United States and the Official American Board of Medical Specialties Directory of Board Certified Medical Specialists list doctors who are board-certified. These books are available in most public libraries, and your doctor should appear in them. Finally, go to the Cooper Institute, which provides several extensive on-line databases on American physicians.
Does your doctor seem smart to you? When you ask a question about one of you health problems, are the answers quick, logical, and cogent? Do the answers jibe with what you know to be true? Are her answers given confidently, or is she dissembling? Keep in mind that it's often fine for a doctor to answer, "I don't know," as long as she promises to find out the answer, and then follows through on that promise.
For specialists you will be seeing only once or twice, or who you are going to for some complex or esoteric medical procedure, their experience, knowledge and ability are often much more important than how well they communicate. If I'm having a heart valve surgery, I care much less about how warm and fuzzy the surgeon makes me feel during the pre-op interview, and much more about how many similar procedures she's performed, and what have been her surgical results.
The third most important factor
Is your doctor respected by his peers?
Doctors watch each other perform in the trenches, and in general, are pretty good at sizing each other up. If you can get a recommendation on a PCP from a doctor you know you can trust, that's likely to be a good starting point.
If you know some doctors, ask them what they think. Would they send their own patients to your doctor? Or, better yet, do they send their own family members to him? Do they use him as their own doctor?
If your doctor is invited to participate in the training of medical students or medical residents at the local university, that's a reasonably good sign that he's held in high regard by his peers. (A caveat from DrRich, who was a lifelong academician himself - note that academics often sing the praises of other academics not because they are especially good doctors, but because they have published a lot, or are in positions of power. Some of the most famous university doctors are not especially good clinicians. Take the advice of an academic with a grain of salt.)
Other factors to consider
Where is your prospective doctor located? Is her office convenient to you?
Which hospitals does she have admitting privileges to? Are these hospitals convenient to you, and do the specialists there (since the specialists in those hospitals are the ones she will be referring you to) have a good reputation?
What are her practice arrangements? Who covers for her when she is away?
Is her age, gender or race important to you?
What is her office staff like? Are they reasonably competent, friendly, and helpful, or is their main job to keep you out?
What are her office hours and office policies?
What insurance plans does she participate in? This may be especially important if you are likely to be changing jobs (and thus changing insurance carriers.)
Where to look
Make yourself a list of potential PCPs.
Start with your family and friends - people whose opinions you trust. Find out who their PCPs are, and whether they are happy with them. Find out why they like them. Also, talk to medical specialists, and especially to nurses and (if you know any), physicians' assistants. See which doctors they respect and admire, and why.
Another place you might consider looking is in Best Doctors in America (Woodward/White). This is a listing, updated every other year, of American physicians chosen through a survey of other American physicians. For a doctor to make the list, a large number of physicians have to assert that they would want that doctor to take care of them or their family members if they were sick. (Disclosure statement: DrRich may be partial to Best Doctors, having made the list.) Best Doctors used to be published in book form, but now is only available on the web (www.bestdoctors.com). It currently costs $25 to get a listing of "best doctors" in your area. Alternatively, you can go to your public library and get the last published edition of Best Doctors. Chances are, the doctors who appeared there a couple of years ago are still pretty good.
A problem with Best Doctors is that it is sometimes weighted toward academic physicians, and there are potential drawbacks to academics, some of which have been mentioned earlier. Also, getting "votes" for Best Doctors is to some degree a popularity contest. DrRich suspects that many of the doctors that "voted" for him, for instance, may have read his books and articles, and may have heard him lecture, but have no idea of how well he actually takes care of patients. The bottom line is that while you may find Best Doctors useful, it should by no means become your chief searching tool. Some doctors listed there really aren't that great with patients. And the large majority of excellent doctors in the U.S. are not listed there at all. If you limit your search in this way you will be cheating yourself.
Once you have made your list of doctors, check for them in the Directory of Physicians in the United States or the Official American Board of Medical Specialties Directory of Board Certified Medical Specialists in your public library. And don't forget the Cooper Institute. Make sure the doctors on your list are board certified, which is good evidence of at least a minimal level of competence.
Finally, call the office of one or two of the doctors still remaining on your list. See what you have to do to get an appointment. See whether the office personnel seem friendly and efficient, or whether they're obstreperous and obstructive. Remember that you need to deal with these people fairly often, and that before you ever get in to see the doctor, you've got to get past them. And remember that the doctor's front office is a reflection of his own personality. If his receptionists and nurses are difficult to deal with, you've got to assume that the doctor likes it that way.
The remaining step is to pick one of the "finalists" on your list, and make yourself an appointment. If after meeting with the doctor you decide this isn't going to work out, remember Rule # 1.
Why the doctor-patient relationship needs nurturing
If you've spent any time with reading the previous sections, you know that the traditional doctor-patient relationship is in deep trouble. And you know there's a good reason it's in trouble.
The traditional doctor-patient relationship requires physicians to always advocate for the best interests of their individual patients. When you are sick, the traditional doctor-patient relationship guarantees there is at least one knowledgeable professional who is looking out, above all, for your interests - not the interests of the insurance plan you're in, or of your demographic group, or even of society at large, but the interests of the individual, you. The loss of such an advocate, especially at a time when the interests of all the other parties within the health care system have never been less likely to coincide with your own, can be catastrophic.
The problem, of course, is that the health care system simply can't afford the traditional doctor-patient relationship anymore. There's no way that HMOs, hospitals, insurance carriers, or federal regulators can allow doctors to continue directing the spending of health care dollars as if the only important consideration is the welfare their patients. In thousands of ways (detailed in previous sections) doctors are being coerced into giving the needs of each of these other parties a higher priority than the needs of their patients. The methods being used to apply this coercion are extremely heavy-handed, and are proving to be utterly overwhelming. No matter how deep their professional integrity, doctors simply cannot continue advocating for their patients' best interests as vigorously as they want to, or as their professional mandate requires them to. For many doctors, this circumstance causes far more than merely frustration - it causes a sense of utter defeat. The medical profession, many feel, is being totally destroyed. Thus, the systematic destruction of the doctor-patient relationship is bad for everybody. It gravely threatens the professional survival of doctors, and the physical survival of their patients.The effective patient's strategy
In becoming an effective patient, you've got to take the weakened state of the doctor-patient relationship into account. Simply assuming that your doctor is always going to be acting in your best interests - no matter how good a doctor he is, or how ethical - is a big mistake.
The effective patient understands this, but she understands something else, too. She understands that her doctor (if she's chosen her doctor wisely) deeply wants to honor the traditional doctor-patient relationship, since honoring that relationship is his first duty as a professional. She understands that, despite all the coercive pressure to the contrary, her doctor will occasionally go up against an HMO for the benefit of a patient. He needs to do this as a matter of professional pride - just to be able to live with himself. (The HMOs understand this, too. Letting the doctors win one now and then - only, of course, after putting up a stiff resistance - costs them some money, but in the long run keeps the doctors mollified. It keeps the doctors working, and it keeps them quiet. It's just one of the costs of doing business.) The effective patient also understands that, as much as he may want to, her doctor cannot go to the wall for every patient, or for every issue that comes up for a given patient. The process would be too grindingly difficult, and fatal to his career. She knows that her doctor must choose his battles carefully.
The effective patient understands all this, and nurtures her relationship with her doctor accordingly. She tailors the relationship in such a way that, when the chips are down, she is likely to be one of those her doctor will go to the wall for.
To be such an effective patient, consider following these three general strategies:
Strategy 1 - Be empathetic. Show that you understand the constraints under which your doctor is laboring, and adjust your expectations accordingly. Don't be too demanding, especially regarding the small stuff. Show that you respect your doctor's skills, and that having her skills working for you is worth a few minor inconveniences. After all, you make clear, you know how hard it is to be a good doctor these days, and you're thankful she's there for you despite everything.
Strategy 2 - Align your interests with those of your doctor. Remember: you and your doctor are in this together. He feels your pain, and you feel his. You both want the same things. You both want the patient (you) to get good health care; and you both want the doctor's practice - and professional integrity - to thrive. So while you fully expect to get the care you need from your doctor, you will help him to deliver that care as efficiently and as cheaply as possible.
You will not bother him needlessly, or thoughtlessly. You will make the most efficient use of your time with him. (See Managing your own health.) You will learn how his office operates, and cooperate with his office staff in minimizing interruptions and special requests. (For instance, inquire as to the best time to call the office with questions, or to speak with the doctor.) The main idea is: you are interested in making the doctor's job as easy for him as possible, while still having your own vital needs served.
Strategy 3 - Become engaged in your own good health. Nothing makes doctors crazier than patients who completely neglect their own health, then expect their doctors to pull out all the stops for them when they get into medical difficulties. The fact is, your doctor simply cannot afford to vigorously advocate for every problem for every patient. This being the case, which patient is your doctor more likely to fight for when they get sick - the obese smoker who has made no visible effort to take care of himself, or the diabetic who has carefully tried to follow her difficult diet and drug regimens?
Maybe it isn't fair, but it's nonetheless true. If a doctor is considering stepping out of line and jeopardizing his own security to fight for his patient's best outcome, you can be sure he's more likely to reserve that action for a patient who's fighting right at his side for the very same thing.
You greatly increase the likelihood that your doctor will go to the wall for you if you are fully engaged in maintaining your own good health. You need to stop smoking, lose weight, exercise, take an interest in disease prevention, and during your visits to your doctor, demonstrate how involved you are with your own health care. Make yourself into the kind of patient that doctors find it a pleasure to see. (See Managing your own health.)
Summary
By understanding how and why the doctor-patient relationship is under fierce attack, you can "manage" your own doctor-patient relationship to make yourself a more effective patient.
Any doctor worth her salt will respond favorably to patients who seem to understand the duress she faces each day in the practice of medicine, who try to help her keep her head above water while she provides health care, and who take an active role in maintaining their own health. Patients like that are worth their weight in gold, and doctors try hard to provide them with the best health care they can possibly manage.
Next - Managing your health plan
Surviving the Health Care System is adapted with permission from YourDoctorintheFamily.com
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