Bad Medicine: The Two Types of Doctors

1372 Relax and Succeed - Every type of doctor

Dear Doctor,

It is my hope that you will receive this with an appreciation for my intent. In no way am I interested in attacking you. To the contrary, I would like to offer my assistance. I have no doubt that you are a good person at heart. I do however feel that you (and many other doctors), would benefit by asking yourself how your patients would define a ‘good’ doctor vs ‘bad’ one.

In caring for my parents, and in tending to my own health for more years than you have been alive, I have witnessed the approaches of a very large number of doctors. In addition, people talk in labs and waiting rooms, and the general consensus about doctors is extremely clear.

Over the last several years there has been a notable shift (as one group retires and another comes on), and there is an increasing number of these weaker doctors. I suspect this is entirely innocent and unconscious, and it may in fact be that modern training leads with better science, but it may have done so at the price of developing a healers approach.

As patients in your waiting rooms and hospitals, we know your receptionists and the nurses you work with are generally the ones who are often left managing the confused, worried or angry patients you leave in your wake. I don’t not see this as an issue with you, which is why I plan to post this publicly, so that all doctors who have this common lack of awareness can also learn from our unfortunate experience.

My hope is that by offering you a compassionate explanation, maybe all of you can be better at what you do as a result. I prefer that, because it seems more likely to generate a win-win scenario for doctor and patient alike. On a broad basis, this increased awareness could have a considerable impact on the quality and cost of care in medical institutions everywhere.

I will begin by stating that I fully support the scientific method and have enjoyed studying all of science’s major disciplines. Many of the tools and methods that have doubled life spans over the last 100 years came from the evidence-based medicine for which I am grateful. It is an extremely solid basis for us to lean on both as a doctor and as a patient.

As important as that scientific knowledge is, it’s still only half the job. Because it’s not a bio-bag of chemistry sitting on the exam table, that’s a human being who is thinking about how good you are at your job the entire time you are with them, and long afterwards as well.

My general suggestion is that many of you would benefit from at least attempting to be aware that you are not singular. You are quietly being compared to every other doctor we have ever seen. In fact, if you are open to improving, the patients themselves can become fantastic resources in what is hopefully a lifelong education in what it is to be a good doctor.

Today, the weaker doctors act as though people like Dr. Patch Adams aren’t real people, and that medicine didn’t change as a result of him, and people like him, offering a bold example of what it is to be a better and more complete kind of doctor. The film, The Doctor (based on Dr. Edward Rosenbaum’s 1988 book, ‘A Taste Of My Own Medicine’) also expresses this same point, though in a much different way.

Many doctors are just people who want high grades or a good salary or status, and the world would be better off if they went into business rather than medicine. Others are equally problematic, but they are simply lacking in awareness, rather than being in the wrong profession.

Those good-doctors-in-potential are more like Patch Adam’s roommate in that film, played by Philip Seymour Hoffman. He is extremely earnest in his desire to be the best doctor he can be, but I would hope that this missive might motivate you to do as his character did, and at least experiment with being this other kind of doctor. I feel confident in saying that it’s very likely to make practicing medicine much more rewarding for you as well as us.

Our problem came from not seeing my father when we came to you. You saw a chart, an old man, a concern about breathing, and a question as to whether his troubles breathing were due to pneumonia, or something relating to his heart. At his age, these things are profoundly meaningful and quite foreboding to those who love him.

In every case, the best doctors will stay aware of that reality, and they will respond to it by offering suitable comfort. This better connects the patient to the doctor and that increases the odds of open, honest communication, which can be incredibly useful to you.

1372 Relax and Succeed - The very best kinds of doctor

In most cases you enter the exam room and often keep your hand on the door handle, as though you’re just ducking in for a second but have to go. You speak extremely quickly, which is complicated by your thick accent. Our family is well-travelled and has always been fascinated by other places and cultures, so we’re fine with a foreign doctor and an accent. But whether it’s done with a thick accent or in perfect English, slowing down to ensure you are understood would profoundly help communication. You never even seem to note whether or not your words have sunk in.

This isn’t an issue with an accent; even if you were speaking English clearly, you go so fast, and seem so generally in a rush, that we honestly almost feel bad interrupting you for clarity about our concern. It does not help you as a doctor when we have a concern, but feel your scheduling needs are taking precedence over our health concerns.

In the case of my father, your response was to let go of the door handle, grab your stethoscope, and listen quickly to his lungs. The entire exam took under a three minutes and you didn’t ask a single question about changes in his diet, behaviour, or about any other useful information. And I wish that was more uncommon but in fact you are in a unfortunate majority today.

If a doctor’s going to use the Socratic Method to come to some sort of well-founded diagnosis, you need data. The better the data the better the analysis. Even from a science perspective bad communication is a loss of valuable data.

As an illustration of how it can be, and of who you’re being compared to and why patients universally prefer the other approach, I will use an example from my own life and my now-retired, but excellent and very popular doctor. I had been seeing him since I was 20.

Every visit started in his office, in comfortable chairs, in a non-medical environment. This helped patients relax. He would review my file carefully, and then he would always begin by asking about my life. How was I eating? How was work? Was I stressed about money or living in excess or using any substances? Data, data, data.

After that 5-10 minute conversation –wherein he relaxed patients so they would talk about scary or potentially embarrassing things– we would shift to the exam room where he would do his examination, ask more questions, and then tell you to come to his office once you were dressed. Once back in there, he was often in a book or on his computer, reading up on the latest relevant studies, or even boning up on some basic science.

The humility of slowing down and checking himself was worth a lot. He accepted that all humans are fallible, and that scientific knowledge doubles every seven months, and his humility bred a strong confidence in us as patients. Also, that kind of constant double checking was why he was concerned about, for instance, opioids, a decade before others even started talking about them. That is being an excellent doctor.

You may be wondering how all of this materially helps medicine, so allow me to provide an example.

I once went in with a very painful, bloated stomach that had become chronic over time. He greeted me warmly, then lead me into his office. He listened carefully, then took me into the exam room to check me over.

When I joined him he was reading, then he turned to me and sat quietly in his chair and stared at me, thoughtfully, with his fingers templed in front of his mouth and his brow furrowed in thought. He searched through mind’s data-banks of the previous conversations we had on previous visits, and here is what he said:

“You’re still dating the Italian girl?”

“Yup. She’s awesome.”

“Wasn’t her mother moving to Canada this summer?”

“Yeah, she got here a few months ago. She’s settling in pretty good.”

“Is she planning on working?”

“Yes, but she’s waiting for paperwork.”

“So, she’s home all day?”

“Pretty much, yeah.”

“So, is she doing any of the cooking?”

“Yeah it’s been great. She’s really good and she does almost every meal.”

“Your last name is Scottish. And your Mom is from Saskatchewan, isn’t she?”

“Yes and yes.”

“Grew up eating a lot of potatoes did you?”

“Tons. Love them.”

“Me too,” (involving himself helps maintain the connection between us). ”But now it’s mostly pasta?”

“Almost exclusively.”

“Since your symptoms line up with the diet change that’s our most likely candidate. Otherwise you’re extremely healthy. For a few people the issue can be gluten, so we can check for Celiac disease but, it runs in families, so if no one else has it that’s much lower odds.

“But when I just checked while you were getting dressed, a lot of gluten misdiagnoses are turning out to be allergies to other things in some kinds of wheat, like fructan. And I just checked, and they often use durum wheat for pasta. So let’s (note, he describes it as something ‘we’ are doing), try cutting out the pasta for two weeks. If nothing happens, we can do more testing, but if the stomach goes back to normal, then we’re probably dealing with an allergy. You can try introducing the pasta one meal a week until your body tells you to stop. The angry mother-in-law I can’t help you with.”

“You want me to go home and tell an Italian woman her cooking makes me sick?”

“This way I get paid for an extra visit after she tries to do you in with a poison meatball.”

Bingo. That worked. I was fine and could eat pasta once or twice a week and I survived the ‘mother-in-law,’ (although that was a close one). Even if it turned out I had Celiac Disease, or any other permanent root cause, he had explained how to avoid it as an issue because there is no effective cure for either Celiac disease or a fructan allergy.

He essentially told me to listen carefully to what my body told me. That’s brilliant advice that I have used since that day. It amazes me how much people will eat things that hurt them and then blame the food rather than change their habit, as he prompted me to do by helping me to appreciate my own role in the maintenance of my own health.

Note, in that example, our trip to the exam room was just to check to see if I had any symptoms I couldn’t sense, but other than that there were no tests required, no expense to the system, none of the common suggestions about drugs or antacids. Just wisdom gleaned from data and a request to follow-up if the food experiment didn’t work.

It saved me time, the system money, and it made me recommend him to all of my closest friends, who were all excellent patients who managed their health responsibly. Plus the doctor and I got to like each other –I considered him a valued friend within a few years. It’s fantastically better than the drive-thru effect that currently exists in yours –and it seems now most– doctor’s offices. You lose as much through that as we do.

1372 Relax and Succeed - There is a reason it is called health care

Doctor, I can appreciate that everything in life is now very expensive and that running an office, and having such an excellent receptionist and all of your other administrative responsibilities, all add up to a lot of responsibility. I do respect that. Just as I want you to see my dad not as symptoms and a question, but as a human with needs, I have done the same in thinking about you.

Please know I am not questioning either your good heart, your education, or the challenges of practicing medicine today. Most patients will come in prepared to respect you, but we will lose that respect if we feel it is not being genuinely reciprocated.

Fortunately, despite the challenges that all doctors face, the fact remains that many doctors do find a way to be this other kind of doctor, so clearly that is possible while maintaining some level of financial viability. I doubt any patient, nurse or medical receptionist has found that the difference between these doctors is about money.

Good medicine is about attention. It’s about, are we distracted or focused? It’s about actual compassion brought on by real consideration of the complete human before us. You’re the leader in the exam room. The patient is often scared, confused, embarrassed or in pain. They’re often in their worst state of mind, so it’s a lot easier for the patient to open up and be honest with you if you’re the one that initiates the building of that rapport, through your demeanor.

To be honest with you doctor, I’m not sure I’ve made anything clear with this. I can see kindness in your eyes despite the rush, so I do hope this slows you down. In my experience, we all get better at any job through realizations of deeper layers of the job we hadn’t previously considered.

I know I have been made better by wise criticism in my own work, so I do hope this has that effect for you as well. The criticisms can sting at the time, but I’ve always liked those moments in the end because they always leave me feeling bigger and more capable, and my aim in taking the time to write this is entirely to be beneficial to you.

My father has always been like a wise Buddha, teaching smart lessons about a good life. And even with dementia, he often has a notably positive impact on all of us around him. He brings out the best in us, and when we lose patience it’s like he’s the monk putting us through our spiritual training.

It’s through his innocence that he does this. Because he is guileless he assumes all others are too. He takes people as they are. That’s why, despite your harried care, he thinks you’re fine the way you are. But it is my hope that with the guidance of your experiences with him, that you too might consider him a temporary guide. Because in the best of worlds, I’d like to think this unfortunate experience will lead you to more fully appreciate your patients as people, not as only the issues they present.

If you’ve managed to keep reading until here, thank you. I do appreciate your consideration and wish you the very best in both your personal and professional life. I do hope hope this communication can help you gain more joy from your work days, because I can only assume it would be a much nicer day spending time with human beings than with just their diseases, injuries and illnesses.

Finally, please don’t forget to thank and value your nurses and receptionists. There are many times when it is they who protect you from angry or painful reactions I’m sure you would rather not experience. I am confident they are often keenly aware of many ways that the doctors they work with could be better.

Thank you.

peace. s

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