Another Sweet Spot

12 Comments / Being a Doctor / By

What is my job?  I am a doctor.
What is the goal of my job?  To heal and prevent disease.

Really?  Do I actually heal people?  No, I give them information and tools with which to be healed of specific illnesses.  Not all people get healed, either.  Some people need their disease managed.  I don\’t fix hypertension or high cholesterol, I help get them under control.

Do I personally prevent disease?  No, again I give people the tools with which they can prevent disease.  Some use this tool, while others do not.  I am not laying on hands or frightening off cancer.  It\’s not me doing the work.

What is the role of the patient in this process?  The patient\’s job is to make decisions about their health.  Should they take this medicine?  Should they lose weight and start exercising?  Should the child be given the immunization?  It is their body, and they are the ones who ultimately bear the consequences of their decisions.  My role in this is to give them the best information with which to make these decisions.

The Right to Decide

I am listening to the audio book The Anatomy of Hope, by Jerome Groopman.  It is excellent; I highly recommend it.  In it he tells of a colleague who develops a very aggressive form of stomach cancer with a near-zero chance of survival.  This person is a world authority on stomach cancer, as he works as the chair of the department of pathology at a large academic institution.  Groopman and other physicians on the medical staff are appalled when this man chooses to use a very aggressive form of chemotherapy and radiation.  How could this intelligent physician choose to ruin the remaining days of his short life with terrible chemotherapy?

It turns out that this man survives, and Groopman gets a chance to talk with him about his decision.  Did he know that most of his colleagues were in sharp disagreement with his decision?  Yes, he explains, he did know of those feelings from his colleagues, and frankly it made him angry.  Who were they to make his decision for him?  He knew the prognosis.  He knew how terrible the chemo would be.  Isn\’t it his right to choose to be treated?

In hindsight it would seem that he was right; but what if he had died a painful death from the treatment he chose?  What is the duty of the physician in this type of circumstance?

Knowledge and Experience

There are two main things a physician brings to the table in an encounter with a patient: knowledge and experience.  We are trained with incredible intensity, nearly doubling our vocabulary in medical school alone.  We are then tested in our knowledge through residency, both through patient encounters and through intense questioning by attending physicians.  It\’s very hard.

The experience physicians bring is through our daily occupation.  I see many people with diabetes, depression, ear infections, and ankle sprains; so I have a lot of perspective when someone new comes along.  This is amplified over time, as my 15 years in practice makes me approach things differently than I did when I was just starting.  Back then I relied on my knowledge and a small bit of experience; now I rely on experience (and do my best to keep up with the latest knowledge).

Many physicians, however, are offended by the fact that they are not the ones who decide things.  Either through overt disagreement or passive noncompliance, patients have the power to derail the best thought-out plans.  The wealth of information from the internet has made this all the more significant.  Some physicians adopt a \”my way or the highway\” approach, discharging patients who won\’t follow their plans.  The patients\’ attempts at gaining knowledge is an affront to them, as it seems to imply the patient can duplicate a physician\’s education by looking up things online.  Some patients believe this; but in my experience, most don\’t.

Putting them Together

At the end of a patient encounter, I move on to the next patient.  The decisions made during the encounter have very little impact on me.  The patient, on the other hand, carries the decision and its consequences home with them.  It is only fitting that they try to make the best decision possible.  It probably is better that people question their doctors.  It is a good idea for them to get their information from more than one source, meaning that they should double-check decisions with large consequences and not take their doctor\’s words as God-inspired.

Which brings me back to the issue of patient record ownership.  I am surprised at my very strong reaction against the suggestion that the records I keep should be public.  Why should a physician who is very much a patient-advocate have such a visceral reaction against others seeing all of my notes?

It comes down to trust.  If I am to advise people and give them the best information possible, I want to know that they trust me.  I like to know that they value my knowledge and experience.  Somehow the idea that people want to read all of my notes makes me feel less trusted.  But I don\’t think this is the point.  Since patients are the ones making decisions, they don\’t want to be left in the dark.  While I make a point to explain as much as possible and send people their results, many physicians don\’t.  There are still some who believe that we hold \”special knowledge\” and are the ones to decide for our patients.

What do I want from my patients?  I want some acknowledgement that my knowledge and experience are worth something.  What do they want from me?  They want me to share that knowledge and experience (as well as the information they generate) so they can make the best-informed decisions.  My job is to put things in perspective and explain what\’s important and what\’s relevant.  Those doctors who don\’t do these things aren\’t doing their job.  But those patients who don\’t value that experience and knowledge make the relationship irrelevant.

This is another sweet spot: the doctor whose goal is to offer their abilities for the patient\’s use, and the patient who values those abilities.

12 thoughts on “Another Sweet Spot”

  1. Ken O

    As I’ve already said, I don’t want to read and understand every last word of my notes (and suspect I can’t read some of the early pages anyway 😉 ). What I do want is the right to audit them to make sure they’re all physically there, because that’s something you can’t do for me if I’ve only just moved to your practice. If I don’t do that from time to time, I might not even know myself. As I’ve also noted, my notes do (or should) include pages I wrote my self but which you might need to know for diagnosis.

  2. Ken O

    As I’ve already said, I don’t want to read and understand every last word of my notes (and suspect I can’t read some of the early pages anyway 😉 ). What I do want is the right to audit them to make sure they’re all physically there, because that’s something you can’t do for me if I’ve only just moved to your practice. If I don’t do that from time to time, I might not even know myself. As I’ve also noted, my notes do (or should) include pages I wrote my self but which you might need to know for diagnosis.

  3. tiffany

    I really like this post. I am having trouble with family and friends telling me that I should be questioning and arguing with my daughter’s doctor more but the thing is, I trust his decisions. I need to trust someone. I can research and find alternatives but that just seems to cause tension between the paed and I. I do honour that he is a hard working doctor, even if I feel worried about some of his choices. In the end, he is the doctor and I am putting the health of my children in his hands. I need him to help me improve my daughter’s wellbeing. I can’t do it alone.

  4. tiffany

    I really like this post. I am having trouble with family and friends telling me that I should be questioning and arguing with my daughter’s doctor more but the thing is, I trust his decisions. I need to trust someone. I can research and find alternatives but that just seems to cause tension between the paed and I. I do honour that he is a hard working doctor, even if I feel worried about some of his choices. In the end, he is the doctor and I am putting the health of my children in his hands. I need him to help me improve my daughter’s wellbeing. I can’t do it alone.

  5. Pattie, RN

    Thanks for articulating the frustration I often feel when patients will NOT “follow the plan of treatment”. I know it is their life, their body, etc. That I can respect. I guess my frustration rises when people make bad choices…missing dialysis, smoking as a diabetic, piling on the salt with their CHF….and then frantically expect–no, DEMAND-that we as the medical team “DO SOMETHING” to make them all better. My tongue gets bloody from biting it so hard…..

  6. Pattie, RN

    Thanks for articulating the frustration I often feel when patients will NOT “follow the plan of treatment”. I know it is their life, their body, etc. That I can respect. I guess my frustration rises when people make bad choices…missing dialysis, smoking as a diabetic, piling on the salt with their CHF….and then frantically expect–no, DEMAND-that we as the medical team “DO SOMETHING” to make them all better. My tongue gets bloody from biting it so hard…..

  7. Tex Bryant

    I appreciate the honesty of Rob in this blog. It seems that the involvement of the patient is becoming more and more important, especially since the IOM’s “Crossing the Quality Chasm.” As I recall, in that book the IOM recommended that the patient has ownership of his/her medical record. Some of the history, though, would not make sense to the patient, as Ken O. stated. I have not asked to see my own medical history from my primary care physician but I do make sure that he has received reports from my urologist each year I have a physical. I also am very involved with him in planning my care. I believe that if I am involved in planning my care along with his advice and experience, the outcomes will be better as I will be more motiviated.

  8. Tex Bryant

    I appreciate the honesty of Rob in this blog. It seems that the involvement of the patient is becoming more and more important, especially since the IOM’s “Crossing the Quality Chasm.” As I recall, in that book the IOM recommended that the patient has ownership of his/her medical record. Some of the history, though, would not make sense to the patient, as Ken O. stated. I have not asked to see my own medical history from my primary care physician but I do make sure that he has received reports from my urologist each year I have a physical. I also am very involved with him in planning my care. I believe that if I am involved in planning my care along with his advice and experience, the outcomes will be better as I will be more motiviated.

  9. Anne Marie Cunningham

    Dear Rob
    I picked up this book by Annemarie Mol a few months back. She is a Dutch philosopher and she spent many months observing the practices in an oupatient diabetes clinic. Her book is about how choice and care can work against each other at times.

    I hope you have time to look through it because I think you will enjoy it and I am very curious about what your thoughts might be. I saw her speak at a conference on Saturday and she is very charismatic… a real live-wire. Although you start my foregrounding choice I think care is in your heart and the rest of this post. And when I read the comments I sense that these people are looking for care. I certainly do when I am a patient.

    And I do think we heal our patients, or we try to. Healing is very different to curing.

    Anne Marie

    http://books.google.co.uk/books?id=QBuaNun81eAC&dq=annemarie+mol+logic+of+care&printsec=frontcover&source=bl&ots=vj-qtxVAXp&sig=SQXG85kaFCbqSxT-DPKlsB5-_Y8&hl=en&ei=41JJSrWtKtHRjAeTx81k&sa=X&oi=book_result&ct=result&resnum=1

  10. Anne Marie Cunningham

    Dear Rob
    I picked up this book by Annemarie Mol a few months back. She is a Dutch philosopher and she spent many months observing the practices in an oupatient diabetes clinic. Her book is about how choice and care can work against each other at times.

    I hope you have time to look through it because I think you will enjoy it and I am very curious about what your thoughts might be. I saw her speak at a conference on Saturday and she is very charismatic… a real live-wire. Although you start my foregrounding choice I think care is in your heart and the rest of this post. And when I read the comments I sense that these people are looking for care. I certainly do when I am a patient.

    And I do think we heal our patients, or we try to. Healing is very different to curing.

    Anne Marie

    http://books.google.co.uk/books?id=QBuaNun81eAC&dq=annemarie+mol+logic+of+care&printsec=frontcover&source=bl&ots=vj-qtxVAXp&sig=SQXG85kaFCbqSxT-DPKlsB5-_Y8&hl=en&ei=41JJSrWtKtHRjAeTx81k&sa=X&oi=book_result&ct=result&resnum=1

  11. Linda

    Dr. Rob – you have no idea how unusual you are. I’ve been the least important person in the room with each of my encounters with physicians. I have a lot of respect for my current doc, I think she’s great. But even she occasionally asks questions, then interrupts when I’m answering. And tells me to start doing things I’ve already said I’m doing. (She always tells me to begin exercising and eating more fruits and veggies even though I walk every morn and eat mostly fruit, veggies and whole grains. Maybe she just thinks I’m fudging things to sound better.)
    FWIW, I think the doctor’s notes are the doctor’s notes. I don’t think you need to detail your every thought process for your patients to see. That’s just my personal opinion – I understand why Robin and others feel they need to know everything little thing but I don’t. The healthcare system I use only gives access to current and former test results and recommendations and the like. I guess if you want to know what your physician is thinking, you are supposed to ask them in the eight min. you spend together.
    No one will know what you are or are not concealing unless you tell them you’re censoring your notes anyhow, will they?

  12. Linda

    Dr. Rob – you have no idea how unusual you are. I’ve been the least important person in the room with each of my encounters with physicians. I have a lot of respect for my current doc, I think she’s great. But even she occasionally asks questions, then interrupts when I’m answering. And tells me to start doing things I’ve already said I’m doing. (She always tells me to begin exercising and eating more fruits and veggies even though I walk every morn and eat mostly fruit, veggies and whole grains. Maybe she just thinks I’m fudging things to sound better.)
    FWIW, I think the doctor’s notes are the doctor’s notes. I don’t think you need to detail your every thought process for your patients to see. That’s just my personal opinion – I understand why Robin and others feel they need to know everything little thing but I don’t. The healthcare system I use only gives access to current and former test results and recommendations and the like. I guess if you want to know what your physician is thinking, you are supposed to ask them in the eight min. you spend together.
    No one will know what you are or are not concealing unless you tell them you’re censoring your notes anyhow, will they?

Comments are closed.

%d bloggers like this: