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:
- 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.
- 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.
- 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:
- Patients should only be seen when a visit is appropriate.
- Use as few medications as possible, and when necessary, use the cheapest one that will do the job.
- 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.
- 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:
- Patients with long-term significant medical problems should come in on a routine basis.
- The best-case scenario for regular visits is that there are no medical problems, in which case the visit will be mainly social.
- There is a medical benefit to the social visit, with the doctor understanding the patient better and the patient trusting the doctor more.
- 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:
- Rule out bad things
- Make the problem better
- 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 and you wind up make assumptions:
- 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 care.
Rule 9: The Buck Stops Here
I believe in primary care. I believe 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.