Patients Want It Tangible
- A pediatric back surgeon told us today that he has a harder time convincing parents that their children with lower back pain shouldn’t have surgery than he does convincing them to undergo surgery. (This is back surgery, notoriously full of complications and risks, as you’re potentially messing with the spine and spinal cord.) He says he believes in educating parents about surgery and the chronic nature of back pain–even in kids. But, he adds, sometimes it’s much easier to give the parents a referral for physical therapy (which he doesn’t support for kids).
- A pediatrician told me she finds that parents are much more reassured and comfortable taking care of their children with fever when she actually writes out a prescription for Tylenol (an over-the-counter medication anyone can buy) than when she just tells them to go buy it.
What is with this? Why do we want some sort of tangible intervention when we leave the doctor’s office? Why is education and discussion not enough, and how can we do a better job of both increasing patient satisfaction while decreasing unnecessary medications and other treatments? I’d be especially interested to learn if this is an American or Western concept, or whether this sort of expectation exists throughout the world–or even if this has only come to exist recently?
I wouldn’t be surprised if there’s a monetary “value for your money” component to it; either you pay a co-pay or a ridiculous amount for your health insurance, so you carry over the expectation of money exchanged for goods (arguably you don’t get “service,” as your doctor may be running late).
I think there’s also a degree of discomfort with “just watching” someone’s condition–either from an impatience standpoint or a worry factor. Or maybe the feeling of the physician abandoning the sick patient, or not showing the patient some sympathy or empathy. “You want me to what? Go home, rest, and drink some liquids? I’ve felt awful for 3 days already, and you’re not going to give me anything for it?” (I’m definitely guilty on this count.)
It looks like physicians as a whole are pretty clueless about patient expectations; perhaps figuring out what a patient wants to get out of the visit will help to head off some patient disappointment at the end of the visit. I also like the concept of not downplaying a person’s illness; I’m guilty of telling patients “it’s just a virus” many, many times.
A cursory Pubmed search didn’t turn up much, but I wouldn’t be surprised if patient satisfaction increased if all patients were just given a little one-page handout on their condition. It would satisfy the tangible need, reassure them that they have information–including when to expect to feel better, or medication side effects, or when to return for a follow-up appointment–and wouldn’t lead to excess antibiotic usage. It’d be simple to customize the handout with the patient’s name and some other personal info to make it feel even more individualized; anyone know if this has been studied?
Dear Mr. Walker,
I found your website through US News, and thought I might ask you something. I love biology and anatomy and I want to persue a premed college, but unfortunately I’m really horrible at math. I’m in advanced but i’m pulling a B-, do you think I could ever get into medical school with those kinds of math grades?
Dr. (Almost) Walker,
As a mother of 5 children, let me just say that I think you’ve hit the nail on the head. I also know of parents that will leave a pediatric practice because the dr. wouldn’t prescribe something. Preposterous! This is a major problem, in my estimation.
I believe your first assumption is accurate: the exchange of “buying” and “selling”. No one likes the idea of going to the dr’s office, only to pay $25-35 (or higher) for nothing in return. I know I don’t prefer to do it, and many times, I simply don’t take my children in for many things that other parents run to the ped for.
Yet, I’m also the type of parent that doesn’t give out tylenol like candy, consider every ache to be pre-terminal, or poo-poo minor abrasions. All because I’ve been educated. I’ve educated myself. There’s no manual for taking care of your kid, however, so it’s probably in a physician’s best interest to jump into educating with both feet. I believe most parents would respond appropriately to these medical situations if only their trusted doctor would inform them–making them part of the team.
Another facet you may not have considered: I believe (when it comes to peds) that the pressure for a parent to go back to work is a huge driving force for overuse of antibiotics and unnecessary medical intervention in general. This may also apply to the adult population. It’s the “Give me/little Johnny something Doc, so I can go back to work—I’m running out of sick leave!” Sound familiar?
Kelly–thanks for writing; I’m glad to have some validation!
I’ve definitely dealt with the parent going back to work/sick days/threat of losing health insurance thing. Another important point to consider, most definitely.
The pointy heads in academe may not be doing patient satisfaction surveys, but the hospitals and payors are. Why don’t you look there?
I never, I repeat never do nothing when a patient comes to my office. I take a history, perform a physical, develop a differential, make a diagnosis, formulate a plan, educate and give instructions.
The parents who want goodies instead of good medicine don’t stay long with me. Frankly, they’re better off elsewhere.
best,
Flea
For a contrarian view: I’d say that the “something for your money” theme is actually secondary for doctors, because their *social* position is not that of mere merchants.
In a social/anthropological context, doctors are an example of a priestly caste, dealing with the Great Unknowns on behalf of their client. I would say that a good deal of patient dissatisfaction probably traces back to the doc muffing that priestly role. So does a lot of the doctor’s frustrations with the patients, who reflexively expect the doctor to handle everything *for* them, since it’s the doc who’s “authorized” to face down the powers of disease….
This sort of thing is an issue in several professions (notably my own, computer programming). The problem is that the patient expectations are coming from the “deep social structure” they learned in childhood, so just *telling* them “no, I’m just a doctor” isn’t going to help. The real answer is for the doctor to learn the proper methods (ritual, “theater”) to both fulfill their expected role, and imbue their instructions (at least the important ones) with the “holy authority” that the patient wants to hear from their “priest of medicine”.
Some doctors pick this up naturally, others seem to need more effort. This is of course a major aspect of “bedside manner”, but it applies just as much in the examination room.
I like the idea of a one page summary regarding the condition, side effects, ways to alleviate symptoms, and most important, how I know if it’s getting better or worse. I get something like that every time I take my dog to the vet, and I feel it really helps me when it’s time to take care of whatever condition he does have. After a long day in which I’ve dealt with many other things, it’s comforting to have that sheet to look at to remind me of what I need to do or look for. This saves me from having to go on what I remember, since what I remember may or may not be the most important information I truly need to know.
A good EHR will have this component. “Discharge Instructions” are mandatory for someone being discharged from a hospital, but not so in the outpatient or clinic setting. I just took my 4 year old for her annual physical yesterday and left with a piece of paper with her height/weight, immunizations and two words, “doing great”. It’s better than nothing, but how much better would it be to have a sheet of paper telling me what developmental milestones to look for this next year, basic treatments, what’s the tylenol dose now, etc. (I worked with a pediatrician who wrote something like this out for every physical exam, no matter the age, 20 years ago. I miss that.)
It’s not terribly difficult, just not mainstream yet.
I think this is part of the problem with how medicine has become in the US, and is related to the popularity of (mostly bogus) alternative therapies.
People go to the doctor because they see doctors as having expert knowledge (esoteric even, as in your ‘miracle workers’ post), and a rational explanation plus saying “go take some Tylenol” doesn’t satisfy that need to be “cured.” So people go to the alternative therapist, who talks at them in big words and gives them vitamin B and knee magnets, and they go home happy.
It’s a placebo treatment effect. Patients want to be told that there’s something that the doctor understands that they dont – that’s why they payed that $30 copay. Tell them it’s “dihydrogen oxide” and water could be a miracle cure.
I’m not supporting this, or even really ripping on alternative medicine (I’m actually a big fan), but I think that something is changed (maybe lost, maybe just changed) in the current practice of participatory medicine.
There’s also this aspect: if you leave the doctor’s office with a prescription, that’s written proof that you were justified in making the appointment, taking time off of work, monopolizing the doc for whatever length of time, and (if you have insurance) paying the co-pay, and having the insurance company billed. Those are the tangible justifications. There are also the intangibles. For many people, the simple statements of “I feel sick” or “This hurts, and it keeps hurting, and I’m afraid something’s wrong” are not easy for everyone to make. I’ve had (and heard of) plenty of employers who typically view claims of illness as malingering. I recall one guy sending around a memo in which he said that he expected us to “play hurt” if we had colds or the flu.
Obviously I’m not in favor of prescriptions for every visit, but a short written summary of the findings and/or instructions and verbal acknowledgement of the patient’s discomfort may alleviate the guilt many of us feel after showing our neediness. Even leaving the “just” out of “It’s just a virus” is a kindness.
Certainly the case in Australia too – people don’t feel they have their money’s worth if they don’t leave the doctor’s office with a nice juicy script for some antibiotics..
That really validates their illness!
How do you think we got in such a mess with antibiotic resistance?!
I know there’s too often an expectation that you’ll walk out of a doctor’s office with at least one prescription. It’s the 21st century’s answer to ancient healing rituals, in the form of a 10 pill instead of a potion or pointed chicken bone.
I may be anomalous, but I find it reassuring when the doctor tells me “you don’t need a prescription,” or prescribes a non-pharmaceutical treatment. It means my condition is less worrisome– and it’s good not to contribute to greedy pharmaceutical company executives and their filthy marketeers and lobbyists.
This has been studied, and in the Emergency Medicine field is emphasized over and over again…by the defensive medicine folks. (Because dissatisfied/angry people sue.)
What patients are looking for is your TIME. Any behavior that increases PERCEPTION of time spent increases satisfaction. Spending time explaining the disease process, test results (if performed) or explaining why no tests were necessary correlate with greater satisfaction.
Some studies have shown that a prescription may correlate with LESS satisfaction, because those visits may be characterized by less time spent with the patient.
Sit down, lean forward, listen, put the prescription pad away.
kerock is right. What patients want and expect is meaningful time spent with the physician. However, the time a doctor spends with the patient has decreased dramatically in the past few years. Thus the patient expects something, i.e. a prescription, if he/she can’t get more than five minutes with the doctor. It is often easier for the doctor to write a prescription for the patient than it is to spend the time talking to the patient that is really necessary. This is especially true when a patient has a viral URI. Unfortunately, patients have come to expect a prescription for an antibiotic in these cases and rather than taking the time to dissuade an adamant patient that he/she doesn’t need such a medication and that it won’t help them.
The decreased time spent with the patient is largely an economic factor. I have heard of large HMO’s that tell the doctors that they can only spend a certain amount of time with any given patient.
I’ve written a book, just published, which — among other things — gives some insights into a surgeon’s point of view regarding patients. I think any med student would like it. It’s written with lay readers in mind, but all the healthcare folk who’ve read it have liked it, too. It’s called “Cutting Remarks; insights and recollections of a surgeon,” and it’s available at amazon and bookstores.
I suppose I might be one of those patients that you’re talking about.
I wanted something tangible when I went to the doctor’s office because “I don’t know” and “try not eating tomatoes” wasn’t going to make the crippling headaches (so bad that I was unable to finish high school) go away.
I wasn’t paying for a diagnosis and a scrip, but that’s what I was hoping for, every time. I think that’s very reasonable. I think that being disappointed when that didn’t happen was also very reasonable. I felt bad; I wanted to feel better. I even hoped I had a Chiari malformation like my mom because I wanted there to be something that could be done.
Why are you discounting that? It’s so obvious.
I finally found a neurologist about a year ago who was able to help. He was late to the appointment and spent about ten distracted minutes with me before prescribing a medication for me to try. It worked. /That’s/ the most satisfying doctor’s appointment I’ve ever been to, not the visits to the attentive doctors who would talk to me about my problems for an hour and then not know what to do.
It’s a difficult call, kutsu–a doctor can’t just give out a medication if he or she doesn’t think it’s indicated–they have lots of side effects. I’m sorry it took so long for you to find someone that could help you.
Though I have no scientific evidence to back me up, I can offer you personal experience on the issue. A couple of months ago, I came down with a fever and scratchy throat, and was forced by my mom to go to the walk-in clinic. After my evaluation, the doctor left for a while and came back with a single sheet of paper with a big and bold upper respiratory infection title. On the sheet of paper was a list of the common symptoms and a short description of the virus, followed by what I can do to treat it. He told me I should be feeling better in the next couple of days, but he’d give me a prescription to use if my symptoms still persisted. My mom thanked him and we left. Thinking anything called a respiratory infection was something serious, she stated that I wouldn’t be going to school tomorrow, as we pulled out of the parking lot. I decided to actually read the sheet of paper, and found it hilarious when discovering that my suffering was due to the common cold. When I showed my mom, she laughed a little and sent me to bed, stating “all that for a little cold”, but I know from past experience if the doctor had just stated that to her in the first place, she would want to take me for a second opinion. I think it’s because of parent’s protectiveness of their children, and them wanting to know that their child is going to be taken care of (“certainly a cold couldn’t put my baby in bed for 4 days”). As a patient, I really enjoyed the handout given to me about my illness, mostly because it made me feel like the doctor took time out to make sure I completely understood what was happening to me, not shouting directions while he sent me home. Plus, it was a great way to remember everything that he said…