Managing your doctor

Patient, heal thyself

It's not supposed to be like this.  When you're sick and need help, you're supposed to be able to rely on a doctor - a doctor who is knowledgeable, who really cares what happens to you, and who will leave no stone unturned in seeing that you get exactly what you need.

Unfortunately, having such a "model" doctor is becoming rare. Patients are on their own much more often, and to a much greater extent, than they used to be - and it's getting worse all the time.  

If you've glanced at the Understanding It section of this website, you're acquainted with our contention that patients are feeling abandoned by the healthcare system because they really have been abandoned; and that (because widespread covert rationing is systematically destroying the doctor-patient relationship,) the abandonment of patients is happening by design rather than by chance.  

When you're sick and find yourself engaged in a hostile healthcare system, you need somebody in your corner who knows what she's doing, and who cares about you.

Choosing the right doctor for yourself, and nurturing a good relationship with him, is one of the most critical steps you can take in becoming an effective patient. With the right doctor at your side, the path to good healthcare becomes clear and wide. Without that doctor, you're lost and alone in the enchanted forest.

Qualities to seek

The following discussion pertains mainly to choosing your primary care physician (PCP).  Your PCP is the one who will get to know you the best, and for the longest period of time.  When you become sick she will have the best notion of your values and desires regarding your healthcare.  Your PCP will be the gatekeeper to the wider world of medical care.  She's the one with whom you'll decide on the details of your healthcare, and the one who will negotiate on your behalf with the broader healthcare system. She will recommend specialists to you when you are in need of one. Her actions (or possibly, her inactions) will do more to determine the adequacy of your healthcare than those of any other doctor you may see. Thus, when it comes to choosing a doctor, picking your PCP is generally the most important decision you will have to make.

Rule # 1: You hired him; you can fire him.

Choosing a doctor is different than, say, choosing a car.  When you buy a new car, you can shop around to your heart's content, but once you plunk down your money and bring that baby home, you're pretty much stuck with it. If it's not everything you hoped it would be, you can't just get rid of it - why, it lost 50% of its original value the minute you drove it off the lot. Besides, it's not life and death, it's just a car. So if your new car turns out to be a disappointment, you'll usually shrug your shoulders and resolve to live with it for a few years, at least until you can justify buying another one.

It's different with doctors.  For one thing, it's harder to shop around before you make your move.  For another, starting with a new doctor doesn't require an up-front investment of tens of thousands of dollars. Early on, all you've invested is some time and inconvenience. And finally, choosing the right doctor potentially is a matter of life and death.

Many patients have the same attitude when they're dissatisfied with their doctors that they would have if they were dissatisfied with a car - "Oh, well, guess I'll just have to live with it."  This is the wrong attitude, since, indeed, in this case you may not live with it. Doctors are serious business.

Choosing a doctor is an important decision, but it's not an irreversible one. It's not uncommon for discerning patients to run through two or three doctors before finding the right match. And there's nothing wrong with doing it that way. So if you've tried a new doctor and you're not satisfied with him, get another one.  Remember: You hired him; you can fire him.

The most important factor in choosing a doctor

That would be communication.  

If you can't communicate well with your doctor, you're in trouble.  This is the person, after all, who will need to understand your wishes and values regarding your healthcare.  She is the one who will need to explain to you, so that you can understand it, the nature of your medical problems - the causes, the testing that may be needed, the potential treatments, the pros and cons of the various therapeutic options, and why she's recommending one option over the others.  She's also the one who has to convince your insurance carrier that the course of action you and she have decided upon is the right one, that it's medically necessary, and that they - the insurance carrier - ought to pay for it. Communication has always been important in medicine.  Now it's vital.

Is your doctor really listening to what you are saying?  Does he show he understands your concerns by responding meaningfully to them?  When he explains medical issues to you, does he make them understandable?  Does he have more than one way of explaining a difficult concept?  Is he patient with you, waiting for you to grasp what he's saying, or does he try to embarrass you into saying you understand, with shakes of his head or rolling of his eyes? Do you like him, and more importantly, does he seem to like you? (This may become very important when it's time for him to go to bat for you.)

The inability to communicate effectively with your doctor is sufficient reason to move on to someone else.  Without communication, you've got nothing.

 

The second most important factor

Does your doctor know what she's doing?

Sometimes it's hard to know for sure how knowledgeable your doctor is.  But at a minimum you should check to see if your doctor is board-certified in her specialty.  (Note: there are board certification exams in the primary care fields of general internal medicine, family medicine, and geriatrics.)  Two sources can help.  The Directory of Physicians in the United States and the Official American Board of Medical Specialties Directory of Board Certified Medical Specialists list doctors who are board-certified.  These books are available in most public libraries, and your doctor should appear in them.

Perhaps more importantly, does your doctor seem smart to you?  When you ask a question about a health problem, are the answers quick, logical, and cogent?  Do the answers match with what you know to be true? Are his answers given confidently, or is he dissembling?  Keep in mind that it's often fine for a doctor to answer, "I don't know," as long as he promises to find out the answer, and then follows through on that promise.  And pay attention to whether your doctor's "smarts" are merely of the book-learning variety, or whether his academic knowledge seems tempered by experience and common sense.

For specialists you will be seeing only once or twice, or who you are going to for some complex or esoteric medical procedure, their experience, knowledge and ability are often much more important than how well they communicate.  If I'm having a heart valve surgery, I care much less about how warm and fuzzy the surgeon makes me feel during the pre-op interview, and much more about how many similar procedures she's performed, and what have been her surgical results.

The third most important factor

Is your doctor respected by his peers?

Doctors watch each other perform in the trenches, and in general, are pretty good at sizing each other up.  If you can get a recommendation on a PCP from a doctor you know you can trust, that's likely to be a good starting point.

If you know some doctors, ask them what they think. Would they send their own patients to your doctor? Or, better yet, do they send their own family members to him?  Do they use him as their own doctor?  

If your doctor is invited to participate in the training of medical students or medical residents at the local university, that's a reasonably good sign that he's held in high regard by his peers.

Other factors to consider

Where is your prospective doctor located?  Is her office convenient to you?

Which hospitals does she have admitting privileges to?  Are these hospitals convenient to you, and do the specialists there (since the specialists in those hospitals are the ones she will be referring you to) have a good reputation?

What are her practice arrangements?  Who covers for her when she is away?

Is her age, gender or race important to you?

What is her office staff like?  Are they reasonably competent, friendly, and helpful, or is their main job to keep you out?

What are her office hours and office policies?

What insurance plans does she participate in?  This may be especially important if you are likely to be changing jobs (and thus changing insurance carriers.)

Where to look

Make yourself a list of potential PCPs.

Start with your family and friends - people whose opinions you trust. Find out who their PCPs are, and whether they are happy with them. Find out why they like them.  Also, talk to medical specialists, and especially to nurses and (if you know any), physicians' assistants.  See which doctors they respect and admire, and why.

 

There are several sources on the Internet that can help you in your search for a good doctor.  A good compilation of these resources can be found at diagKNOWsis.com.  Here's the link.

 

Once you have made your list of doctors, check for them in the Directory of Physicians in the United States or the Official American Board of Medical Specialties Directory of Board Certified Medical Specialists in your public library.  Make sure they are board certified, which is good evidence of at least a minimal level of competence.

Finally, call the office of one or two of the doctors still remaining on your list. See what you have to do to get an appointment.  See whether the office personnel seem friendly and efficient, or whether they're obstreperous and obstructive.  Remember that you need to deal with these people fairly often, and that before you ever get in to see the doctor, you've got to get past them. And remember that the doctor's front office is a reflection of his own personality.  If his receptionists and nurses are difficult to deal with, you've got to assume that the doctor likes it that way.

 The remaining step is to pick one of the "finalists" on your list, and make yourself an appointment.  If after meeting with the doctor you decide this isn't going to work out, remember Rule # 1.

 

Why the doctor-patient relationship needs nurturing

If you've spent any time with our Grand Unification Theory, you know that the traditional doctor-patient relationship is in deep trouble. And you know there's a good reason it's in trouble.

The traditional doctor-patient relationship requires physicians to always advocate for the best interests of their individual patients. When you are sick, the traditional doctor-patient relationship guarantees there is at least one knowledgeable professional who is looking out, above all, for your interests - not the interests of the insurance plan you're in, or of your demographic group, or even of society at large, but the interests of the individual, you. The loss of such an advocate, especially at a time when the interests of all the other parties within the healthcare system have never been less likely to coincide with your own, can be catastrophic.

 

The problem, of course, is that the healthcare system simply can't afford the traditional doctor-patient relationship anymore. There's no way that HMOs, hospitals, insurance carriers, or federal regulators can allow doctors to continue directing the spending of healthcare dollars as if the only important consideration is the welfare their patients. In thousands of ways doctors are being coerced into giving the needs of each of these other parties a higher priority than the needs of their patients.  The methods being used to apply this coercion are extremely heavy-handed, and are proving to be utterly overwhelming.  No matter how deep their professional integrity, doctors simply cannot continue advocating for their patients' best interests as vigorously as they want to, or as their professional mandate requires them to.  For many doctors, this circumstance causes far more than merely frustration - it causes a sense of utter defeat. The medical profession, many feel, is being totally destroyed. Thus, the systematic destruction of the doctor-patient relationship is bad for everybody. It gravely threatens the professional survival of doctors, and the physical survival of their patients.

The effective patient's strategy

In becoming an effective patient, you've got to take the weakened state of the doctor-patient relationship into account.  Simply assuming that your doctor is always going to be acting in your best interests - no matter how good a doctor he is, or how ethical - is a big mistake.

The effective patient understands this, but she understands something else, too. She understands that her doctor (if she's chosen her doctor wisely) deeply wants to honor the traditional doctor-patient relationship, since honoring that relationship is his first duty as a professional.  She understands that, despite all the coercive pressure to the contrary, her doctor will occasionally go up against an HMO for the benefit of a patient. He needs to do this as a matter of professional pride - just to be able to live with himself.   (The HMOs understand this, too.  Letting the doctors win one now and then - only, of course, after putting up a stiff resistance - costs them some money, but in the long run keeps the doctors mollified.  It keeps the doctors working, and it keeps them quiet.  It's just one of the costs of doing business.)  The effective patient also understands that, as much as he may want to, her doctor cannot go to the wall for every patient, or for every issue that comes up for a given patient. The process would be too grindingly difficult, and fatal to his career. She knows that her doctor must choose his battles carefully.

The effective patient understands all this, and nurtures her relationship with her doctor accordingly. She tailors the relationship in such a way that, when the chips are down, she is likely to be one of those her doctor will go to the wall for.  

To be such an effective patient, consider following these five general strategies:

Strategy 1 - Be empathetic

Doctors need a little empathy too, and will often respond more favorably to patients who express some. Let her know that you understand the frustrating, externally imposed constraints under which she is laboring. You know how hard it is to be a good doctor these days, and you're thankful she's there for you despite everything. Even if you have to reach a bit to express such sentiments, your doctor will appreciate it-and may become more solicitous toward you and your medical needs.

Strategy 2 - Respect the office rules, even the absurd ones

Try to play by the rules the doctor has established for his practice, even if those rules appear arbitrary and restrictive. Do your best to cooperate with the office staff, as surly as they may be, and minimize interruptions and special requests. If you do have to make a special request, be polite to the office gatekeepers even to the point of physical pain, and try to make sure you let the doctor's staff know how appreciative you are for their assistance (even if you think they've been downright mean to you.)

Strategy 3 - Become engaged in your own good health

Especially in the era of covert rationing, few things frustrate doctors more than patients who, they feel, completely neglect their own health, then expect them to pull out all the stops when they get into medical difficulties.


Look, this isn't fair. Try to look at it not from the standpoint of what's right, but instead from standpoint of the modern doctor. Consider two patients who need special permission for some medical service from a recalcitrant HMO, one an obese smoker who has made no visible effort to take care of himself; the other a diabetic who has carefully tried to follow her difficult diet and drug regimens. For which of these patients is a doctor more likely to risk his viability-determining cost profile? Perhaps neither, of course, but he's more likely to jeopardize his professional security to fight for a patient who is fighting at his side for the same thing.


So look at it this way. Here's yet another reason to take good care of yourself (aside from the much better reason that it might help you avoid the healthcare system in the first place.) Your doctor is likelier to fight for you if you are fully engaged in maintaining your own health.

Strategy 4 - Optimize the time you spend with your doctor

For your own benefit you should try to optimize the 7.5 minutes the doctor is going to spend with you. Plan a visit with your doctor the same way you'd plan an important business meeting. Set specific goals for the visit and write down a list of items you'd like to cover. You might even send your doctor an e-mail (if he's not a Luddite) before the appointment to let him know what your goals are. Bring all pertinent information your doctor might need to know, such as a list of all the medications you're taking. Take notes during the visit, writing down the important points your doctor makes with you. Repeat back to your doctor what you think you heard him say. Consider taking an extra pair of ears with you to the visit. A sympathetic spouse or a good friend can later confirm and reinforce the messages your doctor has given you. Finally, after the visit go over your list once again and make sure your issues were each addressed. If not, you ought to consider e-mailing your doctor within a day or so (while your visit is still fresh in his mind), and ask for clarification of the outstanding issues.

Strategy 5 - Trust but verify

Even the best doctors forget and omit things. So always do your own independent study after you see your doctor, just to make sure the information and explanations you've gotten are proper and complete. When you do find inconsistencies - and you will-it's fine to call your doctor's attention to them on the next visit, but try to do this in a non-confrontational way (remember, you're nurturing a relationship, not playing gotcha). Just say that you've found a somewhat different view on one of the matters you discussed on the last visit, and you'd appreciate a chance to explore the topic further with him. Reasonable doctors will suppress their natural defensiveness at such a thing, and will engage in a genuine conversation on the matter. Most doctors are used to this sort of thing now that we are more than a decade into the Internet era, and don't take such challenges personally anymore. If nothing else, your request will remind him of your sophistication regarding your medical condition - you're listening to what he says, but you're also checking things out for yourself.

 

With the right doctor, the right nurturing, and the right strategies, it is unlikely your doctor will attempt to withhold potentially important medical information from you. Not only will you be a more informed patient and a better partner with your doctor in managing your healthcare but also you will be immunizing yourself against covert rationing. If every patient did these things, widespread covert rationing would not be possible.

Summary

By understanding how and why the doctor-patient relationship is under fierce attack, you can "manage" your own doctor-patient relationship to make yourself a more effective patient.

Any doctor worth her salt will respond favorably to patients who seem to understand the duress she faces each day in the practice of medicine, who try to help her keep her head above water while she provides healthcare, and who take an active role in maintaining their own health.  Patients like that are worth their weight in gold, and doctors try hard to provide them with the best healthcare they can possibly manage.

 

Next: Managing your health plan