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Showing posts with the label Doctor-Patient Relationship

Should Doctors Wear White Coats?

Many professions can be easily identified by their uniforms or state of dress. Consider how easy it is for us to identify a policeman, a judge, a baseball player, a housekeeper, a chef, or a soldier.  There must be a reason why so many professions require a uniform.  Presumably, it is to create team spirit among colleagues and to communicate a message to the clientele.  It certainly doesn’t enhance professional performance.  For instance, do we think if a judge ditches the robe and is wearing jeans and a T-shirt, that he or she cannot issue sage rulings?  If members of a baseball team showed up dressed in comfortable street clothes, would they commit more errors or achieve fewer hits?  The medical profession for most of its existence has had its own uniform.   Male doctors donned a shirt and tie and all doctors wore the iconic white coat.   The stated reason was that this created an aura of professionalism that inspired confidence in patients and their families.   Indeed, even today

Signs and Symptoms of Cancer

"Doctor, do you think I have cancer?" In a prior post, I did my best to point out that handling questions from patients and their families in a skillful manner requires a measured and cautious approach.   Paradoxically, physicians have not received much training, if any, in this aspect of doctoring, which physicians engage in dozens of times each day. In the unlikely event that you have not yet perused the prior post, here’s the link , which will serve as a brief prep course for this current posting. All of us hope and pray for a salubrious life.   Sickness scares us.   We fear any worsening of our illnesses, future mental decline, loss of physical function or any unforeseen change in our medical fortunes.   The fear of cancer hovers over all of us.    And, understandably, patients want to be reassured that their symptoms are benign and transient.   There is another genre of questions that are directed at physicians that requires a deft response.    Below, I will list s

Can I Trust my Doctor?

We all recall President Reagan’s adage, trust but verify , with regard to the then Soviet Union.  President Reagan’s choice of words indicated that trust could not be assumed.  I challenge this notion as I feel that to trust another person, an organization or even a country that trust must be assumed to exist.  That’s what trust means.  Conversely, if one has to verify its presence, then true trust is clearly not there.  If a spouse, for example, hires a private investigator to prove that his or her partner is behaving honorably, is trust present? I think that overall the public trusts their doctors, although they are wary about the medical profession writ large.   The public may view their physicians in the same way that it views politicians – they see systemic dysfunction and self-interest in both professions but folks give higher integrity marks to their personal doctor or representative.   Often, patients who I know have confidence in me voice criticisms over various frustrating

When Should I Get a Second Opinion?

 Now that I am employed by a colossal medical center whose reach extends internationally, many patients land on my schedule seeking a 2 nd , 3 rd or even a 4 th opinion on recalcitrant and unexplained digestive issues. Many of these patients travel from neighboring states coming with the hope that yet another gastroenterologist will crack the code of their illness.  Obviously, any patient who seeks another medical opinion is already dissatisfied, hence the reason for seeking additional advice..  Here is a sampling of some reasons why patients solicit or are sent for new medical opinions. Persistent symptoms Search for an explanatory diagnosis for unexplained symptoms. Quality check to verify that the original doctor’s advice is correct. Encouragement of family or close friends to seek another opinion. Dissatisfaction with the doctor’s bedside manner. Friction with the office staff or the billing personnel. Office schedule of original doctor is booked out for months. Fear that a ser

Will Artificial Intelligence Replace Doctors?

Years from now, the notion of simple telemedicine will seem quaint.  Keep in mind that as recently as a decade ago, most physicians would have denied that telemedicine could ever play a role in the medical profession. Physicians would have argued that this would dismantle the fundamental unit of medical care – the in-person office visit. Physicians would have rigidly maintained that they had to be face-to-face with their patients.   Doctors would need to observe their demeanor and body language and other non-verbal signals.   The physician would need to perform a physical examination to discover additional clues that might help to explain the patient’s symptoms.   Indeed, medical professionals and others have expressed that the act of touching itself served as a bonding experience between patients and their doctors.   The very definition of ‘bedside manners’ implies that the patient and physician are in the same location. Today, there are physicians who practice telemedicine exclus

What is Your Doctor's Medical Philosophy?

I have been a conservative medical practitioner since my training days decades ago.  As readers of this blog have read (?endured) repeatedly, I am very hostile to over-diagnosis and overtreatment.  While I don’t have data, my strong sense is that I order fewer scans, offer fewer prescriptions and order fewer lab studies than my peers.  I am not suggesting that my approach is the optimal pathway to medical quality, only that it has always defined my medical comfort zone.  My philosophy can be summarized as less is more . Patients have their own medical philosophies and over time tend to link up with medical professionals who share their approach.  Some patients laud physicians who test them liberally regarding these doctors to be very thorough and conscientious.  “My doctor is so thorough, on my first visit he ordered blood work, a CAT scan and is sending me to 2 specialists!”  Patients who prefer a more measured and conservative approach seek likeminded doctors.  When the patient an

How to Choose a Doctor

For most of my career, I was in a small private practice.  Our staff were like family.  We prided ourselves on providing highly personalized attention to our patients which started at the moment that the patient was greeted by our receptionist.  For a patient to enjoy an optimal medical experience, every member of the team needs to perform at a high level.  The doctor is but one member of a larger team.  Indeed, I have heard personally of patients who have left medical practices who liked the doctors but not the staffs.  Everyone counts. We saw patients who were self-referred or sent to us by referring doctors or by family members.  I have always asked every new patient how they came to see me personally, and I still do.  It is always gratifying when a patient is recommended to us by a medical professional or a family member.   You took care of my grandmother and she raves about you!   This not only feels good to the doctor, but the patient arrives already having confidence about the

Should Doctors Charge Patients to use the Patient Portal?

My employer,  a rather large and well known medical behemoth based in Cleveland, recently announced that patients may be charged for medical advice solicited on the patient electronic portal.  This has generated an array of opinions ranging from accusations of corporate greed to defending physicians’ right to be compensated for practicing medicine. Implementing this new program violates the following reality of human nature. Folks will not support losing an established benefit.   Consider how organized labor reacts when management aims to reduce worker benefits.   How would any of us feel if our employer cut back our vacation allowance?     How might homeowners feel if their mortgage interest is no longer tax deductible?   You get my point.   Over the past few decades, I have provided thousands of hours of free medical care on the phone and electronically.   I never felt that I was being ripped off since this was the only system I knew and I accepted it.   Similarly, patients n

Colonoscopy in the Elderly. How Old is too Old?

I am frequently asked what is the upper age limit for offering screening colonoscopy.   Patients today are often more informed on certain medical issues than their doctors are.   I support their empowerment.   Of course, we physicians, as actual medical professionals, presumably have more credibility in opining on the practice of medicine.   In my own life, I always give great weight to the folks I hire, whether they are tradesmen or professionals.   Why would I not give consideration and deference to one who has years of training and experience?   If I needed an attorney to litigate an issue, would I presume to advise on the optimal trial strategy?   ‘ He who represents himself has a fool for a client.’ Patients can acquire a great deal of medical knowledge, but they are not as easily able to exercise sound medical judgment.   This takes us professionals years to develop.   Consider this weighty maxim:   It takes 10 years to acquire 10 years of experience.     Indeed, I am still t

Telemedicine is Here to Stay! The Demise of the Doctor Visit?

In a  prior post as a teaser, I promised to prove that the medical profession agreed with me that the physical examination is not a critical component of patient care.  In my medical training days, such a remark would have been considered heresy and the sinner would have found himself in a stockade in the public square.   Proof that the physical examination in many cases is superfluous is the explosion of telemedicine.  The volume of these virtual office visits is rising by the month.   If the physical examination was so critical and indispensable, then telemedicine could not operate successfully.  But it is and it threatens to make traditional doctors' offices like mine quaint, if not obsolete.   I anticipate that in the next 10 to 15 years that most patients will be seeing physicians or other medical professionals in digital arenas, not face to face in traditional offices.    By then, I may have gracefully exited the profession, but I will be an avid spectator.    The ce

Do I Need a New Doctor?

I am a parsimonious practitioner.  While I can’t cite statistics, I strongly suspect that I order fewer laboratory studies, prescribe fewer drugs and order fewer diagnostic tests than do my peers.  Medical minimalism has always been my medical world view.  This can feel a bit lonely at times in a profession that is rife with over-diagnosis and over-treatment.  I am not suggesting that my approach is the only reasonable medical approach, only that it’s the style that I’m most comfortable with.  All of us should consider the philosophy of the professionals we engage.   And the professionals need to gauge the goals and risk tolerance of those they serve.   These relationships may need to enter into negotiations from time to time in order to agree on which pathway to pursue. Physicians, judges, law enforcement professionals, teachers and others are not homogenous philosophically.   While folks may (hopefully) agree on the facts, the interpretations may differ. Consider two different

Should I Fire My Doctor?

A day prior to this writing, a man well into his eighth decade came to see me for the first time.   He wanted advice from a gastroenterologist.   So far, this quotidian event is hardly newsworthy.    I asked him, as I ask every patient, if he had ever consulted with a gastroenterologist (GI) previously.   For me, this is a critical inquiry as it often opens a pathway to a reservoir of information.   For instance, if the patient responds that he saw a GI specialist 3 months ago for the same symptoms, but no cause was determined even after extensive testing, then I know that obtaining these records will be critical. Or, if a patient tells me that he loved his prior GI specialist, but he has to see me because his insurance has changed, then I know that I have be particularly mindful to establish good rapport. Sometimes, patients change physicians or specialists because they are dissatisfied.   Patients uncommonly volunteer the reason, but I ask them directly why they have sought to m

Doctors Performing Unnecessary Medical Procedures

If a patient wants a colonoscopy done, and it’s not medically indicated, should the doctor still do it? If the physician complies with this request, has he or she committed an ethical breach?   Should the medical board or some other disciplinary agency be notified to investigate? Of course, in a perfect world every medical procedure or prescription would be advised only if it is medically indicated.   But the world is not perfect and there are instances when good physicians may deviate from established medical dogma. We Inhabit an Imperfect World Consider these examples and whether you think that a disciplinary response is appropriate. A patient is due for his next screening colonoscopy in 2 years, which would be 10 years since his last exam.   He approaches his doctor with anxiety because his coworker was just diagnosed with colon cancer.   He asks that a colonoscopy be scheduled now.   The doctor agrees. A patient wants his colonoscopy performed in December, after his deducti

Why Won't My Doctor Refill My Prescription?

Medical care has various tiers of service with differential quality levels.    Each level is designed to meet a specific level of need.  Physicians and patients do not always agree on what level of service is appropriate.  Sometimes a patient feels that a higher level of service is necessary and other times the physician has a similar view.  Consider the listing below of potential medical encounters.  Physician and patient dialogue through the Electronic Medical Record (EMR) portal Physician and patient phone call to discuss a medical issue. Telemedicine visit with audiovisual capability. Traditional office visit with a physician or medical professional. Emergency Room (ER) Visit. Each one of the above encounters has value, but clearly they are not equal experiences.   The objective is to match the level of the encounter with the medical need.   For example, if you are uncertain if your recently prescribed erythromycin should be taken with food, then an ER visit would seem a step or

The Right to Refuse Medical Care - Saying 'No' to a Colonoscopy

An 85-year-old woman was referred to me because she was anemic.  She was accompanied by her son.  Anemia, meaning a decreased blood count, is a common reason that patients are sent to gastroenterologists.  The reason for this is that internal bleeding in the gastrointestinal tract – even silent bleeding – can cause anemia.  Gastroenterologists are always locked and loaded with our arsenal of scopes ready to probe into your digestive system in search of a bleeding lesion that would explain anemia.  While we are always hopeful that any discovery will be benign, at times the news is more serious.  Just after I entered the exam room, the patient offered this declaration. “I am not having a colonoscopy!” I had not yet even introduced myself to her and her son, but she was determined to set the ground rules.  Of course, it should be the patient who determines her own future, but generally this occurs after some dialogue with a medical professional.  After all, this is why patients come

Prescribing Antibiotics Over the Phone

Recently, a gastroenterologist in our group left our practice.  Of course, the remaining physicians must do our best to provide ongoing care as best we can for her patients.  Ongoing care does not mean seamless care even though some patients expect that a new covering physician will simply assume the reins without so much as a hiccough or a speed bump.  More realistically, there will be a transition period and some inconvenience to the patients and to the covering gastroenterologists.  I was assigned to cover her patients immediately after her departure when the volume of incoming laboratory and procedure results would be heaviest.  Even normal laboratory and radiology results require more work than usual for a covering medical professional.  We can’t simply shoot off a message ‘your biopsy result was benign’ and consider the case to be closed.  There may be many other lingering active medical issues to address.  A modest laboratory abnormality, which would be expeditiously handled in

Were You Discharged from the Hospital Too Early?

You sent my father home from the hospital too soon.   Three days later, he was worse than ever and needed surgery! I’ve heard similar lamentations from patients and their families over decades.   Every doctor and hospital nurse has also.   And I acknowledge that sometimes families are correct; folks were sent home too soon.   However, in my long experience, most patients are not sent to the street too soon despite some folks feeling otherwise, usually after the fact.    First, let’s all agree that the medical profession – like your own occupation – is a human endeavor which means that perfection is aspirational.   An imperfect outcome or a catastrophic development does not mean that medical carelessness or negligence has occurred.   Medical malpractice is a real issue, but that is distinct from adverse medical outcomes, which is what I am focusing on in this post Medicine is not mathematics.   There is no formula or set of proofs that will reliably bring us the desired result

Why This Doctor Gave Up Telemedicine

During the pandemic, I engaged in telemedicine with my patients out of necessity.  This platform was already destined to become part of the medical landscape even prior to the pandemic.  COVID-19 accelerated the process.  The appeal is obvious.  Patients can have medical visits from their own homes without driving to the office, parking, checking in, finding their way to the office, biding time in the waiting room and then driving out afterwards.  And patients could consult physicians from far distances, even across state lines.  Most of the time invested in traditional office visits occurs before and after the actual visits.  So much time wasted! Indeed, telemedicine has answered the prayers of time management enthusiasts. At first, I was also intoxicated treating patients via cyberspace, or telemedically, if I may invent a term.   I could comfortably sink into my own couch in sweatpants as I guided patients through the heartbreak of hemorrhoids and the distress of diarrhea.   Clear

Treating the Medically Uninsured

Imagine that you are a physician and the patient sitting before you has no medical insurance. This means, of course, that this individual will have to pay personally for the costs of blood tests, radiology studies, consults with medical specialists, prescriptions, diagnostic tests and even surgeries.   What do you think it might cost your patient if he is suffering from issues such as chest pain, weight loss, abdominal pain or dizziness?   Standard evaluations for these medical symptoms can cost many thousands of dollars.   Medical Care Ain't Cheap So, assuming you are the doctor, how would you modify your advice to be sensitive to your patient’s sober financial realities?   Which of the following modifications would you support for a patient who has no insurance? Instead of ordering a stress test for chest pain, prescribe heart medicine to see if this resolves the issue. Instead of sending the patient to the Emergency Room for a question of appendicitis, presc

Practicing Medicine in the Gray Zone

Many issues have clear and obvious solutions.  Consider some illustrative examples.  If a light bulb has burned out, then most of us would agree that popping in a new bulb should be the enlightened response.  If a flower bed is dry, then we reach for a hose.  If our car’s fuel gauge is nearing empty…   I think you get the point here. Here's a slightly more complex scenario.    Let’s say that your car has a rattle.   The mechanic may not know the cause or the solution, at least initially, but we can all agree that there is a specific malfunction that can be remediated with a targeted intervention.   As with the dead light bulb example above, there is a specific, reparable defect present.  Unlike in the automotive world, other disciplines operate with a loose, flexible and proprietary framework.   Consider the financial industry.   One need only read a newspaper’s business section for a week to appreciate the divergence of opinions on financial and investment matters.   Experts c