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Why Do you Come...
Why do you come to my office to see me?
At least once a week I see someone who comes to me for my opinion about what's wrong with them and what to do about it. We always have a discussion before that person leaves the office about what I think is wrong, why I think that, and what I think should be done. Sometimes, like many health care providers, I'm not absolutely sure what's going on, but I've got a differential in my head. This is a list of possibilities about what's wrong, prioritized from most likely to least likely.
If I'm a little torn, I may think out loud to them, and say, "I think it's this, but here's why I'm not 100% sure. We're going to do X, Y, and Z, and then I'm going to see you again in a very short time to see if this has helped. If you're better, we'll keep up this plan. If you're not as well as I would expect at that point, we'll reassess and make another plan." People are Ok with that. They know you're being thoughtful in your approach, they know you're not throwing them to the dogs, and they know that you care enough to check on them again.
Egos aside, I don't honestly think that anyone expects me to be 100% right, 100% of the time, the first time I evaluate a problem. Before they leave, I always say to them, "I've given you a lot of information; do you have any questions for me?" We talk about any questions or concerns that the individual has and I send them on their way, with a plan for when the person is to come back. They leave knowing when and why I want to see them again, and they have stated that they agree to follow that plan.
At least two or three times a month I see one of those people back for the follow-up. Sometimes it is for the scheduled visit that is supposed to occur from the visit described above, but often it goes like this...
Me: "So, when I saw you last you were having symptoms 'A,B,C' and we made a plan for you to do 'X,Y,Z' and come back in two weeks to see how you were doing. Here it is three months later and you're back with the same symptoms, only now it seems as though they may be worse. Tell me what happened."
The Patient: "Well, I started to feel better, and by the time I finished up the medicine that you gave me I felt so good that I thought I didn't need to come back."
Me: "Do you remember me saying that this medicine would take a few weeks/months to completely heal your problem?"
The Patient: "Well, yeah, but since I felt better, I thought maybe I just healed more quickly than you thought."
Here's another one:
Me: "So, I see that last year at this time you were here for an infection and we noticed that you had very high blood pressure. We talked about how you might lose some weight and get a little more exercise. When I saw you the next time a couple of months later you had not had much luck with losing weight or getting out to walk. We talked about how it was pretty tough at that time for you to meet those goals. I recall that we agreed that you would take medicine until you were actually able to exercise and lose some weight. We were both worried because you didn't want to have a stroke like your dad did. Is that about how you remember it?"
The Patient: "Yeah, well I took that medicine for awhile, but I didn't like the way it made me feel."
Me: "Well what brings you in today?"
The Patient: "I've been feeling really tired, and having a lot of headaches, so I thought I better get that checked out."
Me: "How long has it been since you took any blood pressure medicine?"
The Patient: "A couple of months now."
Me: "Well your blood pressure's pretty high today, 240 over 136. I think if we get that under control you'll feel a whole lot better. But we need to do some blood work today, because I'm concerned about what your high blood pressure may have done to your kidneys." (Because I see that he really hasn't had a medication refill in 8 months, and I know that we found his hypertension when he was in for a sick visit, so at a minimum he's been a year with high blood pressure, probably more). "So tell me about how that medicine made you feel, and I'll see what I can do to pick one that won't give you those side effects."
Which brings me back to the question, "Why do you come?" If you think medicine is a one-way street, where you don't have to let me know that something isn't working for you, think again. You're an adult. Take some responsibility for your health. There are a lot of medicines out there, lots of other options if you don't feel well on the first choice prescribed for you. When I tell you that I need you to come back, I'm serious. Even if you feel better, it doesn't mean you're cured. You might actually need several months of medicine, or you might think you're better, and not actually BE better. When you get your license to practice medicine you can decide that. Until then, I'd appreciate it if you'd follow my advice regarding medication and treatments and come back to see me when I ask you to. Either that or don't bring your problems to me for my advice.
Laurie
Related Topics: WebMD Survey: The Lies We Tell Our Doctors, Managing Hypertension
Technorati Tags: healthcare, preventivemedicine, hypertension, heartdisease
At least once a week I see someone who comes to me for my opinion about what's wrong with them and what to do about it. We always have a discussion before that person leaves the office about what I think is wrong, why I think that, and what I think should be done. Sometimes, like many health care providers, I'm not absolutely sure what's going on, but I've got a differential in my head. This is a list of possibilities about what's wrong, prioritized from most likely to least likely.
If I'm a little torn, I may think out loud to them, and say, "I think it's this, but here's why I'm not 100% sure. We're going to do X, Y, and Z, and then I'm going to see you again in a very short time to see if this has helped. If you're better, we'll keep up this plan. If you're not as well as I would expect at that point, we'll reassess and make another plan." People are Ok with that. They know you're being thoughtful in your approach, they know you're not throwing them to the dogs, and they know that you care enough to check on them again.
Egos aside, I don't honestly think that anyone expects me to be 100% right, 100% of the time, the first time I evaluate a problem. Before they leave, I always say to them, "I've given you a lot of information; do you have any questions for me?" We talk about any questions or concerns that the individual has and I send them on their way, with a plan for when the person is to come back. They leave knowing when and why I want to see them again, and they have stated that they agree to follow that plan.
At least two or three times a month I see one of those people back for the follow-up. Sometimes it is for the scheduled visit that is supposed to occur from the visit described above, but often it goes like this...
Me: "So, when I saw you last you were having symptoms 'A,B,C' and we made a plan for you to do 'X,Y,Z' and come back in two weeks to see how you were doing. Here it is three months later and you're back with the same symptoms, only now it seems as though they may be worse. Tell me what happened."
The Patient: "Well, I started to feel better, and by the time I finished up the medicine that you gave me I felt so good that I thought I didn't need to come back."
Me: "Do you remember me saying that this medicine would take a few weeks/months to completely heal your problem?"
The Patient: "Well, yeah, but since I felt better, I thought maybe I just healed more quickly than you thought."
Here's another one:
Me: "So, I see that last year at this time you were here for an infection and we noticed that you had very high blood pressure. We talked about how you might lose some weight and get a little more exercise. When I saw you the next time a couple of months later you had not had much luck with losing weight or getting out to walk. We talked about how it was pretty tough at that time for you to meet those goals. I recall that we agreed that you would take medicine until you were actually able to exercise and lose some weight. We were both worried because you didn't want to have a stroke like your dad did. Is that about how you remember it?"
The Patient: "Yeah, well I took that medicine for awhile, but I didn't like the way it made me feel."
Me: "Well what brings you in today?"
The Patient: "I've been feeling really tired, and having a lot of headaches, so I thought I better get that checked out."
Me: "How long has it been since you took any blood pressure medicine?"
The Patient: "A couple of months now."
Me: "Well your blood pressure's pretty high today, 240 over 136. I think if we get that under control you'll feel a whole lot better. But we need to do some blood work today, because I'm concerned about what your high blood pressure may have done to your kidneys." (Because I see that he really hasn't had a medication refill in 8 months, and I know that we found his hypertension when he was in for a sick visit, so at a minimum he's been a year with high blood pressure, probably more). "So tell me about how that medicine made you feel, and I'll see what I can do to pick one that won't give you those side effects."
Which brings me back to the question, "Why do you come?" If you think medicine is a one-way street, where you don't have to let me know that something isn't working for you, think again. You're an adult. Take some responsibility for your health. There are a lot of medicines out there, lots of other options if you don't feel well on the first choice prescribed for you. When I tell you that I need you to come back, I'm serious. Even if you feel better, it doesn't mean you're cured. You might actually need several months of medicine, or you might think you're better, and not actually BE better. When you get your license to practice medicine you can decide that. Until then, I'd appreciate it if you'd follow my advice regarding medication and treatments and come back to see me when I ask you to. Either that or don't bring your problems to me for my advice.
Laurie
Formerly, when religion was strong and science weak, men mistook magic for medicine; now, when science is strong and religion weak, men mistake medicine for magic.
Thomas Szasz, The Second Sin (1973) "Science and Scientism"
Related Topics: WebMD Survey: The Lies We Tell Our Doctors, Managing Hypertension
Technorati Tags: healthcare, preventivemedicine, hypertension, heartdisease
14 Comments:
people come for hope,they r afraid,
they need a support to hang on & that seems to be u...
I guess that all health care providers don't need to exist because if patients diet and exercise, they would have no health concerns.
(I am looking for a provider who is not completely self-actualized so my concerns will be taken seriously. I would like to meet a provider who has significant cognitive dissonance so my immediate concerns will be taken seriously.)
Providers, whether they be MD, ANP's, or PA's might get off their high horse and note that they would have no business if people did not want to see them. They might have to change specialties to Orthopedics, where they can see marathoners with ligament problems; OB/GYNS, for procreation problems; or others with legitimate concerns.
I would LOVE to see more doctors (like you) that feel their paients need to take some responsibility for their own health. I would LOVE to think there is a PILL for EVERYTHING, but there isn't. I would appreciate the fact that you care enough to tell me EXACTLY what you suspect that I have & what I should do to get better. YES, if I felt your diagnosis or recommendations are incorrect/or maybe I need to explain myself a bit better, I would tell you that before leaving. Your desire to see me again for a follow-up, is AGAIN, another clue that YOU are CONCERNED about my health. It is unfortunate that the avg time spent talking with your health care professional is (what) less than 2 minutes...(after spending 30-45 mins once you walk in the door). NOTE: I am quoting time est. based on info I heard "somewhere" lately. I would just have my list prep'd while sitting in the waiting room! Wish there were more DRs like YOU!
s. M. C FLORIDA
Sounds to me like you should consider another profession. Whether you like it or not, this is how many people handle their health issues. You do the best you can in the limited amount of time you have, and you move on.
Consider having patients buy home blood pressure cuffs, weigh themselves and document it themselves. Give them a sheet when they leave the office so they can document it. Have your staff call them one week after they visit to make sure they started.
Then, let it go.
It's tricky, really - sometimes people have to get to the point where they are really ready to take control and do something, and up til that point you can talk to them for hours and they won't do anything.
I speak from the patient side - I've been flirting with high blood pressure for years, and just hadn't really tackled the diet-and-exercise bit. However, this spring when I was in for my annual gyn exam, my BP was quite high (150/90), and the nurse practitioner said that I would need to go on medication if I didn't do something about it. That scared me, and it was coinciding with a critical point in my career that was putting me under a lot of stress, too.
Fortunately, she referred me to a good preventative cardiology program at a local university hospital - I got tested (blood, ekg, etc), and they decided that nothing was really wrong except the weight and no exercise stuff. So this time, I was ready to dive in and change my life - diet, exercise, AND the career things. 8 months later, I've lost 40 pounds, exercise regularly, have gotten my blood pressure down to an average of 112/75 (I have a machine at home I use to check it regularly), and have a new job offer!
But it took me a lot to get to this point - a year earlier, maybe I wouldn't have been willing to take it all on. I know it's frustrating from the practitioner perspective, but if you keep trying, eventually it will get through, at least to some people.
I do suggest making sure that those followup appointments get scheduled before the person leaves the office: if you let them wait to schedule, they may never happen. Even if people aren't sure of their schedules, have them schedule something, and they can always call in to reschedule.
There has to be some balance of trust between a practitioner and his/her patient. It's wonderful if you really do give that much concern to your patients, but why is it so difficult for doctors to realize that you may have the degree, but that doesn't make the rest of us idiots.
I've been living in my body for a very long time. All my life, in fact. So I know my body better than you do. For instance, I know how long it will take my body to deliver a baby, because I've done it four times. But that wasn't interesting to my doctor who induced my last delivery, insisting that I wouldn't be ready to deliver for at least 24 hours after starting the pitocin. He wouldn't even check my progress until, lo and behold, two hours later, I was crowning. So, no epidural...sorry, ma'am.
Or when I went in to an internal medicine guy because I know that something's not working in my body. I have every symptom of a thyroid disorder...have had problems since I had my first baby. But he didn't care what my symptoms were, because the one blood test he ran said I was "fine." So forget all my symptoms. He declared that I was just depressed and loaded me with anti-depressants. I knew he was wrong, but I took YOUR approach. Trust the doctor. He has the degree. A month later, when there was no improvement in my symptoms, and I DID go back to him, he said, "You're not taking enough." And he doubled the dose. Four weeks later, when I had NO improvement in my symptoms, I went back again. You know what he said? "You need a stronger dose of anti-depressants than I'm comfortable prescribing. Go see a psychiatrist." And he walked out of the office and never came back.
Doctors (at least, the ones I've been dumb enough to seek medical advice from) are so busy being "smart" and "educated" that they can't be human. And that's why we don't keep going back.
I applaud you and totally agree with your comments, Laurie. There is not much any doctor can do for a patient if the patient is not first ready to help him/herself. If h/she wants to get better, then they need to do what is asked of them AND...no doctor or doctor's staff should call to remind any adult of what h/she has been instructed to do. Some "adults" act like children!
I really enjoyed reading what Laurie posted, and I am not a health care professional. However, I am an educated consumer and I take a proactive role in my own care. I don't believe her point was that she doesn't want people to come see her, she is just a bit perplexed why a patient would see a provider for a problem with no real intent of following through with the treatment.
I do not believe that every MD, ARNP, or PA is arrogant and think they know everything, but these types certainly exist. In fact they exist in almost every profession. If your health care provider is not sensitive to your needs and input then just find another one.
I have bipolar disorder and I have had some wonderful doctors, as well as a couple who felt they knew what was best for me and disallowed my input. In those cases I just found a new doctor. When I was diagnosed I read all I could about the condition (as I do with any health problem), and if I am prescribed a medication I read all the clinical literature I can find. The good shrinks I had not only listened but they also considered my suggestions for possible treatment. Yes, I have actually had doctors follow my suggestions for medication, and in one case he said "I'm surprised I didn't think of that."
Not all providers think they are gods and many really care about their patients. It is beyond me why a patient would ask for a diagnosis if they are concerned for their health then not follow the suggested plan of treatment. Then again, people not following suggestions or directions is not limited to health care, for many people it is just a way a life.
In some cases the doctor may very well know best and/or the patient may be mal-equipped to take part in their own care. In cases like this the provider must make the decisions and if need be may need to make follow-up calls. Adults should be able to take care of themselves and their own affairs, but in an ideal world many things would be different.
Let us not be arrogant and believe that all providers think they know everything and that we as patients are all idiots. If you have a doctor or provider who treats you this way then find another doctor. There are plenty of compassionate providers who will take the time to listen and care. Also, if you are proactive the internet is a wonderful source of information about symptoms, conditions, treatments, and medications. If you are unhappy with your provider then find another one, but let's not bash the caring ones who express honest concerns. And remember that people ask advice of all types of professionals then do not follow the advice. People really DO have to want to be helped, no matter what the issue may be. Thanks for being honest, Laurie.
I have been in practice for thirty years. I have seen everything that has been from the Doctor and patient views. Patients today depend on the Internet for symptoms of their possible conditions. Most of the time they are wrong. They lack one important element--years of experience, people are not text books.
As for current day physicians they do not take the time to listen to patients and their symptoms. Many group practices treat patients as numbers especially after they have seen a specialist, they come to me to interpret the results of their tests. Some patient types that upset me: those that take their blood pressure meds or diabetes meds and usually come back 6 months later instead of their regular scheduled appointments. Then when something happens they come running back for help when they are experiencing a sudden side effect(s) of their disease(s) and wonder why I can't help them. As you see some patients do what they want and its easy to blame the physician. Another problem is that patients tell the phyician what is wrong with them as well as what tests they want to have done!
This I find very annoying not because the patient doesn't have a medical degree but it is better to discuss symptoms mutally with the physician and if any person can't do that then they definitely found the wrong physician. It's a two way street. There is no right or wrong here, it a case of mutual respect. This principal applies to every aspect of life and in any profession. I have yet to find a solution to this current dilemma!
I agree with Laurie that patients have to do some work to imrove their health, even if it's just taking your medication. If you are not going to follow the Dr's advice then you're wasting your time and thiers.
If you don't like what they tell you or you have doubts about what is recommended, then ask for a second opinion. If you don't trust the Dr find another one because you'll never be satisfied with what they tell you to do.
As a patient with deteriorating health, I have seen some excellent, caring Dr's, some real quacks and others who hit the stopwatch as soon as they enter the room and rush you out after 10 - 15 minutes even if you've booked a longer appointment. Doctors are human too, and they can make mistakes or may need a second or third try before the correct diagnosis is made.
My advice is to enjoy your health while you've got it. Treat your body like your car - see the mechanic when you start hearing things ping, your tires are wobbly, when the carberator is sticking or when your emmissions get out of control. Take care of yourself, and do it before you get sick - because some illnesses don't get better!
It is true that patients should take responsibility for their own health, habits, drugs, etc.
However, the medical professionals should learn a little bit of compassion or at least patience, when people don't follow or comply w/ a program. often, the demands of a job won't allow people to exercise, take medicines, check blood pressures, and so on. There are so many studies on stressful jobs out there! Plus, with a rotten economy, it is harder for a non-medical worker to make ends meet (unless they are CEO's or independently wealthy!) so working our fingers to the bone is inevitable. Have a little mercy.
Sometimes the patient has an unusual problem and has experience of having had standard treatment for a non-standard condition with bad outcomes.. if this isnt recognised by the MD who then prescribes more incorrect treatment, the patient goes away and then starts on the same merry-go-round again; the new doctor isnt trusted so much. Difficult problems in any scenario can't usually be solved in minutes. Some of us can't exercise because of other problems or disabling impairments from past injuries, not because we are slackos. Also, mild exertion usually raises my BP to very high levels for hours, but later it may drop drastically ( I now have a BP machine which I know is accurate)
to something like 108/90 in one arm and 124/75 in the other and a racing pulse.I must rest then due to lightheadedness;
These fluctuations arent evident during the X minutes at the MD's nor the bradycardia I experience or the racing heart and missed beats and sweating at other times,for no reason. I am not anxious.. and no, I wont take meds that I have found woeful and unhelpful in the past, I feel this is indeed taking some responsibility. Some MD's these days dont seem to read one's charts first, so you have to prompt them about the last consultation. Also, if a patient has several problem areas, the doctor will frequently only want to address one per session and tough if you broached the less important one first. All's well if you have standard ailments that respond to good standard treatment without undue side effects, which isnt too difficult to find for the majority, but woe-betide if you dont fit that criteria. Those who practice unhealthy lifestyles
are a different category again, and too often we are all lumped together because of insufficient consultation time.
hi i know this is not consistent with current comments, but i need some help.. I do not have health insurance anymore and i went to pick up test results. test said this, range detects a small amount of myocardial injury and classifies these patience as high risk. umm i looked up the word here and it gave me heart attack. can anyone help. i know this is a long shot but dont know who else to ask. im 33 male.
In response to the Anonymous who posted at 7:21 with this message:
"hi i know this is not consistent with current comments, but i need some help.. I do not have health insurance anymore and i went to pick up test results. test said this, range detects a small amount of myocardial injury and classifies these patience as high risk. umm i looked up the word here and it gave me heart attack. can anyone help. i know this is a long shot but dont know who else to ask. im 33 male."
To get your questions answered, please post to our Heart Failure/Heart Disease:
Laurie Anderson, MSN, FNP message board.
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