We should be careful to get our of an experience only the wisdom that is in it - and stop there; lest we be like the cat that sits down on a ho stove-lid. She will never sit down on a hot stove-lid again, and that is well; but also she will never sit down on a cold one any more.Mark Twain
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My 10 Rules for PCPs
Primary care medicine is intense and chaotic, a constantly mutating kaleidoscope of data, emotions, goals and obstacles. It is designed to confuse and distract, and will find and magnify any tendencies towards ADD in even the most organized clinician. During my 30+ years as a family doc, I’ve come to depend on some core principles and concepts to stay grounded and maintain focus. Here are Ten Rules I have found useful, with some comments and exposition.
1. It’s always about the patient
Never forget that the health of the patient is at stake. The patient, who lives both the process and the outcome, owns the appointment.
Meeting patients’ needs requires acknowledging and addressing their agendas, even if only to reflect it back and suggest dealing with parts of it at another time or in another way.
When possible (and it is almost always possible), let the patient decide which of similar treatment options, what to talk about (first or altogether), when to return for follow-up...etc. Limit your control to offering choice within a suggested range: “I usually see people back for this after 4-12 weeks. What works best for you?” or “There are several ways to approach this. Let me explain them and answer your questions before we decide what works best for you.”
Because you are obligated to do no harm, you are not obligated to give the patient everything they want. But you are obligated to be honest about it and explain why.
Patients have better outcomes and feel better (even with bad outcomes) when they perceive themselves as having significant control of the process.
2. Patients are people
Person and people are words that refer to individuals and groups of individuals. Patient refers to a role people play and the concept of patienthood, and should not used to turn an individual into a generic stereotype. I cringe when I hear a provider say: “The recommended treatment for hypertension in a patient like you...”
Use the word patient only when talking about them generically, never when talking about them individually.
We aren’t all doctors, but sooner or later we will all be patients.
3. People are neither rational nor predictable
People are complex and unpredictable with limited and fallible memory, heterogeneous math and language skills, different cultures and life experiences, different and often inconsistent value systems, and are programmed to make decisions primarily with (inherently biased) heuristics and snap judgements. This applies equally to patients AND to physicians. Accept this and learn about the limitations that beset both patients and providers. Here are three resources I have found useful:
• Judgement under uncertainty by Kahnemann and Tversky is the bible
• Inevitable illusions by Piatelli-Palmarini is a fun and easy read and will get you started
• Predictably irrational by Ariely is the current fave, and deservedly so.
There is no such thing as the correct way to deal with life.
EBM and algorithms are based on a theoretical (and non-existent) average or idealized patient. Doctors take care of individual and unique patients. Don’t let the protocol be an excuse not to think about what is best for the individual person you are treating.
4. It’s the relationship, stupid
People need relationships, form them when they can, and imagine or fake them when they can’t. You have a relationship with every one of your patients. To the degree that each patient is unique, each relationship is unique. For example, every patient (and every provider) has to find their own solution to the built in and therefore inevitable conflict between the need for autonomy and the need for connectedness. Expect to be surprised.
Diagnosis and treatment depend on the relationship. You ask all manner of intrusive questions, to which you expect honest and reliable answers. You subject the patient to experiences that are embarrassing, humiliating, frightening, painful, strange, and at time dangerous. You expect the patient to trust you - and even pay you - for this. The relationship between you and the patient is what makes this possible.
Every patient is unique: education, style, history, needs. You have some control over what you bring to the relationship and expect out of it, but none over what the patient brings or expects. You don’t own the relationship. It is shared. What’s more, it is not static, but created and modified on the fly, by both parties and both intentionally and unintentionally. A true and respectful relationship demands that you understand this and become comfortable with adapting to and nourishing different kinds and depths of relationships, and letting them evolve. This is tremendously hard work. Get used to it. It is also one of the great joys of practice.
Forming and maintaining relationships takes time, of which there is never enough. No amount of time is too small too be insignificant. Every interaction counts. Conversation with patients about their families, jobs, hobbies, fears and goals may be ‘small talk’ but has big results. (See also the discussion of listening, below.) (Sharing about yourself can be powerful, but only in moderation. Remember rule one: it’s about the patient. You should be able to explain how a person will benefit from what you tell them about yourself.)
Don’t be trapped by the physician role and think of yourself as limited to medical activity. Communicate as a person. Read the local paper to see what your patients are doing and talk about it at the next visit. Call to express condolences when you hear about a death in the family. If the office screws up (billing or appointments), call personally and apologize - separate from any process to fix the error.
5. Use the right tool(s) for the job
Mr Natural sez, get the right tool for the job (R. Crumb):
The best and most expensive chisel is useless for fixing a leaky pipe. Understand the job and then pick the tool(s). Don’t forget that the right tool may not be the one in your hand, the one you use best, or even one you know about. Encourage patients to share in finding tools.
The web is a fantastic and powerful tool. Don’t fear it. Learn to understand it and use it correctly. Encourage patients to use it and use it safely and productively to help themselves and to help you help them (and others). (Learn more from ePatient Dave and the Society for Participatory Medicine.)
Listening (offering your time and attention) is one of your most powerful tools. Master it. Practice every day. Test yourself. Ask yourself and your patient if you are listening effectively.
You are trying to understand the patient’s story in the patient’s context. (Medicine is all about stories.) History originated as a term for what was known about people and events, and their meanings, and was passed along orally long before written language existed. Past history, family history, social history, and of course the history of presenting illness are all parts of what the patient has experienced and knows, all of which you need to learn about if you want to help.
You have two ears but only one mouth. This is a clue. Spend at least twice as much time listening as talking.
Encourage your patients to give you feedback, about the care they get, about your office, about whatever THEY think you need to hear about. NEVER punish them for giving you their opinion, even if it is disagreeable, said disagreeably, or something you disagree strongly with.
Be humble or be humbled. Admit what you don’t know. More important, admit that what you ‘know’ could be wrong today and will probably (definitely) be wrong at some point.
Ask the right questions: Is there anything else? Do you feel like you understand? Do you have any questions? Is there anything else we should talk about? How was/is that for you? What do you think? How did/does that make you feel? Does that make sense? Do you think that will work for you? Should we set up a separate appointment to talk about this some more?
Silence is a kind of question and a vital part of listening. Pausing prods. Wait, be patient. The patient may only need time (and the encouragement of eye contact, leaning forward and a nod) to volunteer more information. Sometimes the specific details of what you get is less important than the context, how it relates to what came before, how it is phrased.
7. The doctor is the drug (see Balint)
This is a corollary of the human need for relationships and getting the right tool for the job. Sometimes ‘doctor’ is the correct drug to prescribe, with an impact related to time and intensity of intention.
Like any drug (and especially like the potent drug it is), it can be over prescribed, prescribed for the wrong condition, It can result in overdose, dependency and addiction. It can have side effects and interactions.
8. It isn’t the patient’s fault (even when it is)
Don’t blame the patient. If you don’t like (or dread) a patient, ask yourself why.
When things aren’t going well, focus on finding a solution rather than looking for a scapegoat. When the patient returns every 3 months with poorly controlled diabetes, telling them that their diabetes is out of control because they eat the wrong foods, forget their medicine, don’t exercise, drink too much, don’t check their sugars or have bad protoplasm is not helpful. Instead, note that we are not making progress, which is frustrating to both of us, and ask what they think we might do differently to have better results.
9. It’s about time (and there’s never enough time)
Doctors don’t sell widgets. We sell our time: time to listen, time to teach and explain, time to help decide.
It’s not just quantity. How much time you spend with a patient matters but is hard to control. Quality trumps quantity, and is something you do control. Being physically present is not enough. You must be cognitively and emotionally present and available. Attending physician is an old fashioned term but accurate. Attend to your patient. Eye contact. Reflecting and validating what you hear.
There is never enough time. It isn’t your fault that there isn’t enough time, but it isn’t the patient’s fault, either. Don’t be angry, especially at the patient.
10. Enjoy yourself
If you don’t love what you do, you won’t be able to love - let alone like or respect - the people who trust you with their health or the people with whom you work. If you aren’t having fun, find something else to do. YESTERDAY. You and your patients will both be better and happier for it.
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