10 Rules for Good Medicine

The recent discussion of the appropriateness of bringing patients back to the office has really gotten me thinking about my overall philosophy of practice.  What are the rules that govern my time in the office with patients?  What determines when I see people, what I order, and what I prescribe?  What constitutes \”good care\” in my practice?
So I decided to make some rules that guide what I think a doctor should be doing in the exam room with the patient.  They are as much for my patients as they are for me, but I think thinking this out will give clarity in the process.

Rule 1:  It\’s the Patient\’s Visit

The visit is for the patient\’s health, not the doctor\’s income or ego.  This means three things:

  1. All medical decisions should be made for what is in their interest, including: when they should come in, what medications they are given, what tests are ordered, and what consults are made.
  2. Patients who request things that are harmful to themselves should be denied.  People who ask for addictive drugs or unnecessary tests should not get them.  Patients who are doing harmful things to themselves should be warned, but only in a way that is helpful, not judgmental.
  3. All tests done on the patient should be reported to them in a way that they can understand.

Rule 2:  Minimize

Many doctors and patients have a \”more is better\” mentality.  This not only costs more money to the system, but it can cause harm to the patient.  Here\’s what I think should be done:

  1. Patients should only be seen when a visit is appropriate.
  2. Use as few medications as possible, and when necessary, use the cheapest one that will do the job.
  3. Order as few tests as possible.  No test should be ordered for informational purposes only; the question, \”What will I do with these results?\” should always be answerable.  If it is not, the test should not be done.
  4. When changes are made, make only a few at a time.  Many simultaneous changes make it hard to tell what helps and what hurts.

Rule 3: Relationship = Better Care

Relationship is one of the best tools for achieving optimal care.  This means that the patient knows the doctor and trusts them, and the doctor knows the patient.  This does not happen with sporadic care, but instead with consistent, long-term care by one provider.  The result of this includes:

  1. Patients with long-term significant medical problems should come in on a routine basis.
  2. The best-case scenario for regular visits is that there are no medical problems, in which case the visit will be mainly social.
  3. There is a medical benefit to the social visit, with the doctor understanding the patient better and the patient trusting the doctor more.
  4. There are frequent cases where the patient doesn\’t think there is something wrong, but a regular visit reveals either serious problems, or allows intervention to prevent a serious problem.

Rule 4: Keep Priorities Straight

When a patient comes in with a problem, there are three goals:

  1. Rule out bad things
  2. Make the problem better
  3. Make a diagnosis

#\’s 1 and 2 are of equal importance, with #3 a distant third.  This means that you always should address the fear that caused them to come to be seen (e.g. patients with chest pain should be reassured it is not the heart, if possible).  But stopping with #1 is unacceptable; #2 must be done as well.  Sick people want to feel better, and it is the doctor\’s job to try to accomplish this.

Rule 5: There is ALWAYS a Reason

It\’s very easy to actually believe that people\’s actions revolve around you when you are a doctor.  It\’s not only human nature to take this view, it\’s a natural response to the stress and pressure of the job.  But there are bad consequences to this state of mind:

  • If you can\’t figure out why people come in, then they are just wasting your time
  • If you can\’t make sense of symptoms, then they are not telling the truth
  • If a person is acting in a way that is irritating and annoying, they are doing so by choice to bother you
  • A person who seems emotionally weak is that way by choice

Avoiding these assumptions will make care better, both in the ability to see things objectively and to offer care and compassion.

Rule 6: If the House is Burning Down, Don\’t Cut the Lawn

Focus is one of the most important things in an office visit.  Both doctors and patients can lose sight of the purpose of the visit. I use this line whenever someone asks me about minor issues in the face of bigger things.  Weight loss may be important in the long run, but it is not pertinent when a person is in the office with a heart attack.

There are no quick fixes or magic wands.

Rule 7: Compliance follows Communication

I have a hard time remembering things, so I am not surprised when my patients aren\’t compliant.  In my experience, it is far easier to remember things I think will benefit me.  My job is to help my patients with this, not seeing perfect compliance as the norm.  The best way to do this is to communicate.  I need to communicate in a way that doesn\’t just convince them of my opinion, but gives them reason to change theirs.  This means that I need to know what they think is important (by listening) and then find a way to turn that into motivation.

100% compliance is not expected, but it is nice to see motivated patients; it\’s my job to encourage, not judge.

Rule 8: People Come to the Doctor\’s Office

When people come to see me, they interact with more than just me; they interact with my staff.  They deal with our system that we have set-up, good or bad.  A bad experience in the office usually has nothing to do with the quality of medical care, it usually is because of a poorly run office encounter.

A big part of taking care of patients is running the office efficiently (which was one of my biggest frustrations in a practice run by the hospital – they didn\’t care about the patient encounter, they cared about the referrals).  This takes a lot of work that doesn\’t seem to be reimbursed and doesn\’t seem pertinent to medical care, but patients who are frustrated and upset don\’t listen as well, and frustrated healthcare workers don\’t give as good of care.

Rule 9: The Buck Stops Here

I believe in primary care.  I believe it is I am the one who my patients call \”my doctor,\” and I see this as a big responsibility.  I need to know as much about them as possible, getting information from anywhere else they get medical care.  My problem and medication lists need to be as accurate as possible.

I am advocate, doing what is in the best interest of the patient, not the drug companies, hospitals, or specialists.  I am confidante, listening to anything the person has to bring to me and knowing as much about them as anyone on the planet.  I am advisor, collecting medical information and giving them an opinion as a trusted person with their best interest in mind.  I am comforter, shutting up and listening when that\’s appropriate to do.

Rule 10: Enjoy the Good Stuff

There\’s a lot to complain about in our system.  There are a ton of stressful things and a lot of bad stuff we see.  The simple fact that so many of us keep going back to work is witness to a lot of benefits.  Remembering what\’s good about being a doctor is key to maintaining the energy to face the rest.  Here are some of my favorite things:

  • I have a lot of patients who I really like, enjoying my interaction with them.
  • I see a lot of inspiring people, getting up when they are knocked down time after time.
  • I get to play with babies and tickle kids (and get paid for it!).
  • I save people\’s lives and make them feel better.
  • I get to say the right thing at the right time, really making a difference when it counts.
  • People openly tell me how much they appreciate what I do.
  • I work with a bunch of folks who are good to be with and like-minded in their desire to help our patients.

These things are what get me up in the morning.  They are what make dealing with insurance companies, stupid government policies, and rude doctors and patients possible.  They are the balance to the suffering and pain I see.  No, they greatly outweigh all of that stuff.  Really.  I wouldn\’t do the job if that weren\’t the case.

16 thoughts on “10 Rules for Good Medicine”

  1. It's assuring to see the things you've listed are all very ethical and exactly what we as patients should expect from our physicians. I'm very glad! Good for you.

    Now, on another note, I have a friend who once asked her doctor for a prescription for an ADD medication she was already taking illegally. She asked him for the script because she preferred not to acquire the drug illicitly but would have continued to do so had he refused. Knowing this, he agreed to give her the prescription. What would your protocol be in a situation like this?

  2. I would only prescribe it if I thought it was medically justified. This is an unusual and tough situation, given her honesty about doing something illegal. On one hand, you have to encourage the honesty and openness. On the other hand, getting something illegally is obviously a bad thing. Where do you draw the line between enabling that person and scaring them off? There is no easy answer except to say that I would not give anything I didn't really think she needs.

  3. I wish all docs had this philosophy. As a renal transplant recipient, I have been through more PCP's for different reasons than I care to mention. I believe a person is her/his own best advocate in that one needs to know her own disease and body. I have had PCP's ask me which kidney was transplanted! I also feel a doctor can only be as good as his office staff. If the staff is irresponsible, the doctor is ineffective. To save money, many doctors opt for cheap, undereducated @%#$&**s. I see this too often. I lost my first renal transplant (14 yrs post-transplant) to inferior insubordinate inactions. I hope doctors read your blogs, too.

  4. These are the ten commandments of genuine patient care. My friend's daughter had a liver transplant in Little Rock, Ar., my father had an exploratory operation in his chest in Springfield, Il, and I myself had a physical therapy in Dallas, Texas and I would say, from what I learned, that the care were all excellent ranging from 8 and up of these rules. Good service comes not only from the doctors but also from laboratory technicians and nurses. I suggest all healthcare providers read them, too.

  5. With respect to convincing patients to be compliant. This, too, is a cognitive error on the part of the doctor IMO. This also may be a result of thinking that the world revolves around the doctor. The point of the communication should not necessarily be you convincing me why you are right and why I should “comply.” The point should be you asking me questions that help you figure out why I'm not adhering to the prescribed treatment recommendations and, if there is some reason that your recommendations do not fit into my life, then you can adjust your recommendations accordingly once you find this out. For example, if you tell me to take a pill three times a day, but I don't want to take medicine at work, you might learn this and prescribe a pill that only has to be taken 2 times a day, rather than trying to convince me to make shifts in my lifestyle to accommodate you. Adherence (note that I did not say “compliance”) is far more likely to occur if the treatment fits into my lifestyle than if I am asked to change my lifestyle to fit the treatment. I understand that some treatments won't have alternatives. But I am saying that the communication should not be just about “convincing” me. It should be about the doctor *listening* to me. Convincing is about ego. Listening is about the patient.

  6. Perhaps I didn't express that clearly enough then. I agree 100% with what you say, and in the context of the other rules I thought I said that. We need to put ourselves in the shoes of the patient, listen to them, and work with them. Sometimes we do have to ask them to do things that are hard, but then it's our responsibility to explain why we are asking to do something crazy like taking a medication four times per day (sometimes there is no choice but to do so). It's a two-way dialogue, but in the end the patient needs to hear things in ways that they can grasp and understand explaining the importance.

    I think this post expressed that fairly clearly.

  7. I do, too, but I wanted to put what I see as fine distinctions in the comments section because I think sometimes there is frustration on the part of providers when patients don't adhere to treatment and that
    frustration is not about the patient, it is about the doctor (e.g., thinking in terms such as, “you're not doing what *I* tell you to do…” “I am the doctor, you should listen to what I tell you to do…” “You are not complying with my orders…” “Why should I bother with you if you don't listen to what I say?”). That last one, in particular, is what I am focusing on. It is ego-driven. The question *should* be: “I need to figure out why you are not adhering so we can try to come up with a plan that you'll feel more comfortable with and be able to adhere to.”

    I think the frustration might be lessened (I would hope) if the provider could look at non-adherence as a challenging puzzle that needs to be figured out, rather than something that irritates them and “wastes” their time. The goal is to help the patient get better. Keeping a singular focus on that goal seems like it might lessen the chances of falling into the “Why should I bother with you if you are not doing what I tell you to do?” frame of mind.

    Anyway, I am probably not being very clear. I do think you and I are on the same page, Doc Rob. I just wanted to get into the nitty gritty a little.

  8. Got it. I get very frustrated when I hear docs laying the entire blame of noncompliance at the feet of patients. I get equal frustration when docs are surprised that it's hard to follow some instructions.

  9. Excellent! I'm sure all of these attributes can be easily weighed and measured with the upcoming pay for performance initiatives.

  10. Excellent post, thank you.

    You write of old-fashioned professionalism and common sense.

  11. Are you sure you, Mrs. Rob and the Roblets wouldn't like to move to the midwest?
    A few years ago when I went to have my swollen foot checked after an accident, the dr waved her hand in dismissal about my foot and spent the next several minutes scolding me for being two months late in having my cholesterol checked. Twice I brought up my foot; both times she interrupted me and brought the subject back to my lipid levels. I thought it was quite odd and left with no answer about my foot and a determination to never go back for any reason. When she left the practice, I was assigned a different doc who also seemed indifferent. The next year the second Dr. left the practice as did I. My beloved and I now drive to a neighboring town where we see different doctors at the same practice for whom we have enormous respect. My dr and I don't have a relationship beyond a brief acquaintance and I doubt we would recognize each other outside the office but I trust that she is looking out for my best interests.

  12. doctor sabelotodo

    great stuff..especially #4..a patient wants to know what is wrong, how they can get better, what they can do in the future..i have heard this story a 1000 times–“the doctor just looked at me and gave me a Rx..even in a busy practice, it does not take more than 5 minutes to explain Dx & Tx..sometimes i can only tell the patient what they do not have or what they may have

  13. […] was just gunning for a Golden Llama, but regardless, he said something awfully nice about my post, 10 Rules for Good Medicine.  He wrote: “My quotes and praise do not do this post justice.  I would rate it one of the […]

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