Satisfactory Patient-Doctor Communications

[JTB]

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[JTB]

This is my first attempt to start a discussion and I’ve already bungled it, hitting send when instead I wanted to correct something. Since I can’t remove the title of the post, I guess I’ll just continue on.

I think most everyone has had challenging communications with physicians at one time or another. At the same time, it’s important to realize that physicians in general realize good doctor-patient communication has a significant effect on healthcare management and outcomes. On another thread it became evident that a number of posters have a lot of experience in achieving good communication with their physicians. So hopefully we can have a discussion that may be useful to WSB readers.

I thought I’d start with the last comment in an article about Doctor-Patient Communication from 2010 in the Ochsner Journal, a publication by a healthcare system.

“Doctors with better communication and interpersonal skills are able to detect problems earlier, can prevent medical crises and expensive intervention, and provide better support to their patients. This may lead to higher-quality outcomes and better satisfaction, lower costs of care, greater patient understanding of health issues, and better adherence to the treatment process.29,32 There is currently a greater expectation of collaborative decision making, with physicians and patients participating as partners to achieve the agreed upon goals and the attainment of quality of life.”

In the article itself, communication problems are addressed, with an emphasis on physicians’ limitations. In the subsequent Strategies for Improvement, the following items are discussed:

1. Communication skills; emphasizing listening and empathy.

2. Communication training.

3. Collaborative communication.

4. Conflict management

5. Health beliefs (patients’)

So if we presume most physicians are positively inclined to have good communication with their patients, how do we as patients relate to that in a way to contribute to our own health management and optimize the results?

The most important thing to me is determining if a particular physician is in fact interested in having respectful, informative communication with me. In a few instances, I’ve had to press a bit to establish that basic foundation, but in a few instances where I’ve concluded it’s not likely to happen, I’ve moved on to find another doctor. I cringe whenever I hear someone describe an interaction with a physician where there is clearly an absence of respect for the patient’s need to understand what’s going on. Don’t accept it.

Of course, there are important things we can do as patients. Those include being as informed about our medical issues as possible, being clear about our concerns and our goals, being ready for an appointment by having information ready (written down) about medications, any recent changes in symptoms or new problems, and of course the front desk will have already taken the insurance info.

I’m always amazed when talking with someone and learning they didn’t get a clear diagnosis from their doctor. “Doctor, what is the actual name for what’s going on?” Also, ask for a clear explanation of what to expect—- that ranges from medical conditions to tests, to treatments. It’s important to routinely discuss options for treatment. Your physician may well have a preferred recommendation, but there are almost always alternatives, and it’s good if they know you want to be involved in coming to a final decision.

Anyway I could can go on at length, but I hope this starts a worthwhile discussion

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[wakeflood]

It’s all good, JTB. This is a fine topic for us to share.

I still remember an interaction I had with my chosen primary physician from a number of years ago. It was only a few years into the HMO phase and I had been getting something like 5-10 minutes max with my doctor over several appts. I could tell he wasn’t happy about having to move through patients at breakneck speed but I also sensed he felt helpless about it.

The incident that sticks most significantly was this. After mentioning a nagging sinus/ear issue several times and being told it wasn’t something to worry about, I purposely scheduled an appt. with another doctor in the practice who specialized in E/N/T. (My doctor was on vacation and I told myself this was good cover even though I knew my plan didn’t include specialist visits without referral.)

Well, I had the appt. – had a different set of questions and exam, and got a scrip for something and it cleared up, thank you very much.

I ALSO got a call from my doctor upon his return telling me to NEVER do that again – it was bad for both of us! – which was followed shortly by a note from my insurance company that I had just used my first strike up. Which, coincidentally, was the only strike I was allowed. Next stop was policy voiding.

I really felt bad that I’d put my doc (who I generally liked) in a bad spot. I’m not actually sure what “bad” meant for him in this scenario?? What was at risk for him??

I’ve been lucky ever since to have the option to choose to pay extra to get “no referral required” for specialist visits but I know that’s not readily available nor affordable for many.

I’m sure others have even more egregious interactions to share…

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[JoB]

JTB..

i suspect that the ease of communication with a doctor is somewhat dependent upon the nature of your medical issues.

if they are relatively straightforward and easily verifiable by tests then communication is more likely to be equally straightforward.

However, if your straightforward medical condition is complicated with a chronic condition.. especially one involving pain..

communication becomes more complicated as well

because that which is subjective is filtered through both the patient and the physician’s personal biases and experiences.

If i answer honestly on a pain scale, I vary between a 7 and 10, with 7 being a good day.

But conventional wisdom says that continuous pain in the 7+ range should leave the patient unable to function and I not only function, but within my limitations I thrive.

This has led many a physician to assume that i exaggerate unless they explore further.

i once walked into the office of a doctor that i knew well from advocacy work … for one of those consult visits.

He asked how i was doing that day and i hopped up on his table and told him i was doing pretty well. Since he had seen me barely able to walk.. he joked about why i was wasting his time ..

until he did an examination and found that every tender point was severe flinch active with minimal pressure and that i had an additional 11 active trigger points.

That made him ask what it took to make me unable to walk. it turns out the answer to that was adding sciatica … but even that was more pressure on the nerve than inflammation…

now my osteoarthritis has reached an ugly stage and complicates thing further :(

the point is that communication of subjective symptoms is difficult at best…

i under-report and physicians assume i over-report…

this is actually pretty common among chronic pain patients… and can have deadly consequences..

the black humor joke in the chronic pain community is that if we had a heart attack we would die before we figured out we had a REAL problem.

it’s likely true.

Last year or maybe the year before when i had a bad reaction to a scent and my tongue swelled i took benadryl and only headed to the emergency room when i realized it was getting worse, not better.. i drove myself.

Not the smart move when your tongue is rapidly filling your mouth:(

To say i got a lecture from the emergency room staff after they saved my life is an understatement.

The built in assumptions we all have about how a person should react if they are experiencing a certain level of pain or discomfort colors the patient doctor relationship

as do the assumptions chronic pain patients have while experiencing the warning signs of pain that send most running to the doctor.,,

or those we have about how another new symptom will be received :(

it’s easy enough to say that you should just find another doctor if the one you are working with does not seem to be communicating well with you…

but that too becomes complicated if you are a chronic pain patient dependent upon medication to function..

The current assumption about chronic pain patients who change doctors is that they are seeking a doctor who will give them narcotics..

even if they don’t ask for any increase in the amount of medication they have been using.

since the AMA cracks down pretty hard on doctors they suspect of over-prescribing,

doctors are reasonably very careful about prescribing anything at all to new patients…

So.. you do your best. You hope your doctor sees you and hears you and once you get past that magic marker where a life threatening emergency gives them the opportunity to measure your reactions next to other “normal” patients in similar situations you hope they never ever retire or change jobs and that they stay within your insurance program .. and that neither of you moves so far away that you can’t manage the occasional appointment.

i speak to the difficulties chronic pain patients face because i know that community and it’s issues very well.. but chronic pain isn’t the only medical condition measured by subjective results…

take bowel disturbances for instance

i am having a little trouble can mean anything from passing a little gas to alternating swings of constipation and severe diarrhea… not something any of us really want to dwell on or talk about in any great detail ;-0

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[JanS]

I have been so lucky with doctors. When I had a hip replacement in 2004 (no insurance), my PCP showed me how to have it done through patient assistance. When she suggested I get a free mammo while recovering from the surgery, I jumped at it…and they found cancer.(hadn’t had a mammo in 4 years). When she eventually left the practice to go to New Mexico, we both sat in her office and cried when she told me. The resident who was sitting in thought we were nuts – lol. The doc who replaced her? We’re on a first name basis, and he helped me to get the right tests to discover my kidneys had failed because of a rare disease. He referred me to a kidney doc who likes beer and good food..usually our main topic once the medical stuff is out of the way. He brought me a box of goodies from Bakery Nouveau when I had my kidney transplant. And all my docs lay it on the line for me.And let me ask questions, and spend time to talk. And don’t even get me started about the Swedish Transplant Clinic. They’ve been wonderful…even down to little things like hugs.

If I had a doctor who couldn’t even tell me what I had? He’d/she’d be fired in an instant. Yes, they are smart people, but they are human, not infallible, and I expect them to be as open and honest with me as I am with them.

Others for sure haven’t had the experiences I’ve had. I hope we hear from them. And I would be glad to refer anyone to my docs. I did that once, and they were not a good fit at all…she wanted him to tell her what she wanted to hear – not the truth..they parted ways.

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[JanS]

JoB…thanks for your post. My affliction is so much more straight forward than yours…and with fibro, among other things, you have to deal with physicians who don’t even think it’s real. My oncologist said to me during chemo that I had to be very honest if I was in pain. He felt no one should have to just put up with it, that they could deal with that. The other things during chemo were a bit more complicated. I really appreciated his attitude towards that.

And your last paragraph speaks to me…anti-rejection drugs have many side effects…and the ups and downs of the gastrointestinal tract are..well…they just are…and I do downplay them when I see my docs. We get so used to things like that (and pain) that we start accepting them as “normal”…and we’ll just deal with it, no need to go into depth about it. Again, not communicating on our part. And it’s wrong, and I know it..but, as you said, who really likes to talk at length about it…with anyone.

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[KatherineL]

I have difficulty with the 1-10 pain scale. What is the ten? If it’s labor pains, everything else is below five. But if I tell a nurse or doctor that this persistent ache is about a three, they think it hardly hurts at all. How do you communicate about pain?

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[Ms. Sparkles]

Excellent point KatherineL (and I think Job’s discussion of bias addresses this too).

I don’t know if I’ve ever experienced a 10 on the pain scale – but I know the placement of the pain makes a huge difference in how tolerable I find it. IMO dental pain is the absolute worst.

How do you rate something on a 1 – 10 scale when that somthing has so many variables and is so subjective?

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[miws]

Yeah, I have trouble with the 1-10 pain scale as well.

Being fortunate, in that with my various health issues over the years that the occurrences of pain have been minimal, and when there have been occurrences, they haven’t seemed overly intense, there’s nothing to compare it to.

What I have found, is when they have a pain scale on the wall something like this….

……with the different facial expressions, it makes it easier for me to relate any pain level to the Nurse/Dr.

Mike

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[JTB]

Wake,

You incident is a great example of “failures to communicate.” In my opinion, the first failure was on the part your physician when you brought up a problem several times and he blew it off.

But the second communication failure was on your part when you accepted the blow off rather than say “wait a minute, this is something that is a problem for me. How is it not something to be concerned about? What do you expect to happen if we do nothing?” Saying “I don’t think you’re hearing me” might be a tad confrontational but worth remembering if the reply to your direct questions was not a direct answer.

You clearly didn’t appreciate his cavalier attitude about your medical problem because you sought out more informed help—a reasonable step.

It’s not clear if he addressed your medical issue when he returned or only the breach of protocol. If he didn’t at least inquire about the medical problem, and was only concerned about the notification procedure, shame on him.

Finally, I would not accept fault from the insurance company or business office. It is the responsibility of the doctor’s office to verify coverage and referrals, etc. If they left everything like that up to the patients, they’d have a nightmare. So I would have pushed back on that point.

In any case, this is a great example of how easy it is to get screwed around and some simple responses that can alter the dynamics. That gets back to my point that patients should insist on being treated with respect and consideration and either keep the discussion going long enough to get it or change providers if it turns out to be a losing cause.

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[JTB]

JoB, Firstly my heart goes out to you. I have friends with less severe forms of fibromyalgia who really struggle with it. No one anywhere has a clear notion of how to manage the constellation of symptoms you describe. It’s all trial basically, with some things helping some patients more and not helping others at all.

On the symptom side of things, I do think it is necessary to determine pretty clearly how various doctors and other providers view the assessment scales before providing your input. Along with that is informing them precisely what you mean when you say “five” or “eight.” There’s still room for a degree of misunderstanding, but it is lessened. If they don’t really “get” your subjective experience, they’re no dealing with all of the necessary information.

I’m actually a little hesitant to say much of anything more, because I do appreciate what a difficult situation you have to live with. I know there is a lot of effort being directed at understanding fibromyalgia and related disorders on the part of clinicians and researchers all over which will help with finding useful treatments, the sooner the better.

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[JoB]

JTB

“It is the responsibility of the doctor’s office to verify coverage and referrals, etc.”

unfortunately, this no longer seems to be true.

last summer i was tested and found that i had profound hearing loss. towards the end of the year i finally decided to spend the balance of my flex ben account on hearing aids and made an appointment.

when i made the appointment i made sure that I booked with an in-network provider and at that time i let them know i would appreciate their verifying insurance coverage so i knew what to pay when i picked them up.

i asked about my cost when i went in for the consultation appointment

i asked when i went in to pick them up

in the end, i paid what they thought i maybe would be responsible for but had to sign that it was only an estimate and whatever the insurance didn’t pay.. i would be responsible for…

a month later i still don’t know what the insurance did or did not pay or what i will ultimately be responsible for…

and there is a 5G spread between what i signed for and what i have already paid.

the same was true of my hernia surgery a couple of years ago and of my shoulder surgery this last year.

in my experience, relying on the doctor’s office to inform you of your cost is a huge mistake. Even with pre-authorization you can never be certain of exactly what is and isn’t covered.

and this is with what is considered gold standard insurance. Hubby works for Google and we purchase the best policy available :(

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[JoB]

JTB..

i get the same smiley face pain scale indicators that miws does.. and i mark them accurately.

i tell them the pain is bad enough that i am not able to _______ .

but the plain truth is that doctors are people who have difficulty believing anyone could function if what i and others like me report is true…

add the complication of multiple chemical sensitivity and atypical reactions to medications and what you end up with is a situation where your physician doesn’t want to believe that your conditions could possibly be so severe without them being able to do much about it… so they believe it can’t be THAT bad.. that you must be over-reporting.

i understand what is happening and i know it isn’t just me because every day i talk with people who get the same reactions from their physicians….

but that doesn’t change the difficult process of finding another new doctor and waiting until you get critically ill enough for them to have that aha moment…

and don’t even let me get started with the move to proprietary electronic charts which not only negate decades of medical history from other practices but that from your own practice prior to their latest software update.

and the built in assumption that patients don’t know their own medical history well enough to relate it accurately to you.

I dont’ know how many times i have been told to “just try” a medication that’s reaction has landed me in the ER because some doctor doesn’t believe that that medication could possibly have produced that reaction.

and no.. i am not stupid enough to send myself to the ER again just to validate myself with a new physician. One of these times they might not save me… and no amount of ego gratification is worth that.

What we need is a better way to communicate with our doctors.. and our doctors need to have access to the medical information every insurance company has available to them.

Delivering medical care via businesses that considers your medical information proprietary business data is not best practice medicine.

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[JTB]

I agree, any cost estimates prior to the final adjustment between the providers and the insurance company are simply that–estimates. What I intended to convey about Wake’s situation wasn’t about the cost, it was about the referral or absence of one in this case. Someone screwed up by setting up the appointment without a referral by his primary physician. Unless he misrepresented that he had a referral, the error was on the part of the scheduler. There was a reason his doctor was so exercised about the breach of protocol after the fact. My point is that taking the time to follow up with the insurance company and, if necessary, escalate the discussion in a polite, firm manner would likely get them to back off the threat if for no other reason than to get you off the phone. I admit, it involves a bit of “playing dumb” about not understanding the in’s and out’s of the referral process, but I have no qualms about striking that posture with an insurance company given the way they conduct business. People familiar with the operations of that industry know there is a significant percentage of billing errors (in their favor) that remain either undetected or beyond the capacity of an individual to pursue a correction.

To your basic point, I’ve found the frequency of errors on the part of the provider’s staff or insurance company personnel is surprising. Simple data entry errors result in wrong diagnostic codes, incorrect descriptions, mistakes in deductions, co-pays and other charges. When I see something that raises a question, I start asking questions and typically find a mistake. Again, it is important to be polite, even friendly, but persistent. It’s better to gain a sympathetic ear than to make someone defensive.

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[JoB]

JTB

what if your doctor refuses to take your condition seriously enough to set the referral in the first place.. should you be denied care?

and why on earth are we expecting sick people to do battle with a medical system designed in such a way as to benefit the provider by denying them care?

and why would you think that a clerk who is unable to get anything more than a cost estimate from an insurance company would be the best advocate for getting a referral from a doctor’s office that did not believe there was a medical issue worth pursuing…

lastly.. while i agree that the medical information the insurance company compiles on individuals is often full of errors.. as are doctor’s charts by the way… it is still better than no information at all..

in my case it would accurately reflect ER admission for drug reactions…

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[JTB]

JoB,

what if your doctor refuses to take your condition seriously enough to set the referral in the first place.. should you be denied care?

Time for another discussion with your doctor or time to make a change. Seriously.

and why on earth are we expecting sick people to do battle with a medical system designed in such a way as to benefit the provider by denying them care?

Yes, we need to change the system. Until then we have to deal with it. Or roll over and take the beating.

Every specialists’ front desk asks 1) who referred you and 2) what insurance do you have. If you a referred from within the system, there is a simple notification from the primary. If you are referred from outside the system (but in the same network) a referral form is necessary. It’s standard and has nothing to do with cost estimates.

astly.. while i agree that the medical information the insurance company compiles on individuals is often full of errors.. as are doctor’s charts by the way… it is still better than no information at all..

I strongly disagree. Incorrect information can be worse than no information. Unreported or incorrectly reported drug reactions is an obvious example. It can also have other consequences, financial and otherwise. I hassled with my insurance company to get an erroneous condition description corrected because I didn’t want “drug-induced myotonia” on my record. The billing code was correct-for hearing loss and the claim was paid so the insurance folks wondered why I even cared. It too multiple calls, eventually involving a manager to get my record corrected, but the potential problems from having something like that on my data base were too numerous to let it stand. I also pointed out to the manager that they shouldn’t be having clerks manually entering two separate, related fields and that the condition description should automatically download from the diagnostic code in order to reduce simple data entry errors. She agreed.

I tend to think the discussion about dealing with insurance companies and medical/hospital billing staff should be separate from communicating with physicians. Obviously they relate, but there are different issues and strategies for dealing with each.

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[JoB]

JTB

a doctor labeled me drug seeking over 20 years ago because i sought help managing my illness so i could return to work. She was a rheumatologist who “didn’t believe in” fibromyalgia.

At the time i was labeled as drug seeking,

i was not taking a single prescription medication of any kind…

nor did i until i landed in the hospital for emergency gall bladder surgery. suddenly the clinic where i could get medical care through my insurance altered it’s position on the psychological nature of my illness and started offering treatment

imagine that;->

that changed my care at that clinic, but it did not change the erroneous designation on my insurance files… which still rears it’s head with every new physician i see 20+ years later.

the medical database the insurance industry keeps on you is looked at by your insurance company

and even though you have no access to it, the information it contains can be shared without your permission with the clinic where you get your medical care.

i would like to see a more level playing field for patients where they and their doctors not only had access to the information contained in that data base but the ability to challenge any erroneous information it contained.

aside from all that coding..

the insurance database contains the results of every medical test any insurance company of any kind has ever paid for..

whether those results were fully disclosed to you or not.

that information alone would be invaluable in evaluating long term patients with chronic illness…

as for keeping how you deal with your insurance and with the medical/billing staff separate from how you communicate with your physician…

I don’t see how you can since all three factors work together to determine your medical care. without a full understanding of how those three interact to limit your options, i don’t see how you can have any productive communication with your physician.

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[JTB]

JoB, I meant keeping the discussions distinct in the Forum, simply to promote focus and ease of reading through the posts. Of course there are overlapping aspects to those categories but I think the key issues involved in optimizing the conversations are largely different and involve different strategies on the part of the patient. It’s probably a matter of individual sensibilities which determine whether it’s more challenging to deal with the physician communication or the paperwork people. But if things aren’t good with the doctor interaction, everything else is secondary as I see it.

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[JanS]

oops

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[JoB]

JTB..

what i can’t seem to make you see is that the paperwork end has an influence on both the doctor and the patient which has a huge influence on the doctor patient relationship…

if we want to change the doctor patient relationship we need to give doctors enough time to actually form a relationship with their patients.. to ask the kinds of questions about symptoms and severity that lead to a better understanding of illness impact on patients and to more effective targeted treatments.

The current process doesn’t allow that time. Nor does it allow doctors to make referrals for either tests or specialists without justifying them to both their clinic management and the patient’s insurance company.

There is a simple fix for this.. a system that gives physicians standard guidelines for referrals and access to a patients entire medical chart regardless of where it was generated…

it’s called single payer.

Unfortunately, it’s not even available in insurance form here…

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[JoB]

A few of those tips that JTB hoped i or someone else would start with :)

One way to form a better relationship with your doctor is to see them more often..

don’t wait till there is a crisis and you have no choice but to make an appointment

if you have a chronic illness make regular checking in maintenance appointments…

and try to confine your update to one symptom/aspect of your illness.

try to stay within one clinic so all of your specialists will have access to the same medical information/tests.

which may mean choosing your clinic on the basis of the special services it provides rather than on your choice of primary care physician

and be pushy.. if you think you have a problem that is not being addressed adequately, speak up. Tell your physician how much this problem is affecting your day to day life.

if your physician still isn’t giving your current problem the attention you think it deserves ask what the process is in that clinic to get a second opinion.

THAT gets their attention in a hurry.

Review all of your prescription and non-prescription medications annually.

It’s a good reminder to your physician to review how all of your medications work or don’t work together

and if you travel, you will ensure that you miss the last minute scramble to make sure every prescription is current.

feel free to step in here and add to the list ;->

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[JTB]

Be informed. It helps the interaction with your doctor if you have some basic understanding about the condition or procedure in question. One good resource is the Mayo Clinic’s website section for patient information.

mayoclinicinfo

The information here can also help provide some clarity and reassurance for someone who may be worrying about a condition or upcoming procedure much more than is warranted.

I heartily agree with JoB’s comment about second opinions. It’s a mistake to think of a second opinion as an affront to the initial physician or thought they’ve made a mistake. There are honest differences of opinion between physicians, including specialists, about how to best treat conditions. I recently discovered a hand surgeon was not even aware of a non-surgical treatment for a condition that is widely utilized in Europe and very infrequently used here. Thing is, it’s more successful than surgical options. The point is that even specialists tend to narrow their focus over time and in so doing, may tend to pass over reasonable treatments you’d like to know about. Good doctors routinely and comfortably refer their patients for second opinions.

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[JoB]

JTB

good doctors should routinely refer their patients for second opinions .. and many would do so more often if not practicing within the constraints of insurance oversight that requires justification for that referral.

if only we lived in the land of should

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[Irukandji]

Cool post JTB. I’ve been lucky to have a non-complex med history combined with a general practice MD in the neighborhood who’s known me for nearly a decade. I’ve learned that, when I DO need to see a doctor, it’s worth waiting to see MY doctor than to just see any doctor available within the same office. Why? Solid history of good communication and trust.

When I wreck my neck in dance class (or sleeping) and tell any-doc how badly I hurt, I get swabbed for strep. When I tell my own MD, he knows my regular tolerance, assesses the overall physical function to determine if PT or meds are appropriate, gives me the optimal recovery timeline with specific instructions on what to do if the prescribed course doesn’t work.

I don’t want to be in the doctor’s office any more than he needs me taking up space, so having a good rapport, a personality match, even, makes a difference. I don’t WANT to come for follow-up, I want to move along.

As I age and more things go wonky more often, I’ll be glad to have found THIS physician, and hope that if he retires before I move or die, I’ll be able to rely on him for referral to another good match.

Your initial post also brought back to me a study from a decade ago regarding physician communication and lawsuits. The WSJ article is worth a read.

http://online.wsj.com/news/articles/SB108482777884713711

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[Author]

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