Friday, August 26, 2011

What do Patients Want?

What do Patients Want?

I looked at the question and thought. Well that is simple. Isn't it?

Patients have acquired a disease or illness. So the first thing they want from their doctor is:

  1. Understanding of their malady: They want to know what the doctor understands about their signs and symptoms and what will he/she do about it. They want the doctor to listen to their relevant complaints before he/she decrees a treatment. If it satisfies the patient then all is well. But herein lies a problem. Even if the patient is agreeable to that interpretation, is that the right one? And that is where modern medical care gets hung up. Trying to define “interpretation” is a subject du jour  of great debate. So in the academic and political world of medicine, where medicine is not practiced, a physician’s judgment must be exact, correct and to the point. But, but… There is a thousand page reference book of “Differential Diagnosis,” which seems to suggest that what is manifest does not have an exact answer, but is merely an algorithm to get to a fragment of the truth. Therefore outlining issues for the patients by the doctor, in tabulated form, is a good measure of prioritizing time and helping the patient understand the nuances of their medical care and the disease itself. It is in this vein that the facts about the disease, its curability or lack thereof must be discussed. Humans are not robots and even with all the advances of science and knowledge of genetics and cellular function, life remains a terminal disease!

  1. Time: The patients want to spend time with their physicians so they too can understand the process of their disease, its treatment and the potential benefits of therapy for their malady. Here is the biggest bugaboo in the land of medicine. Time is in short supply for both the patient and the doctor. A patient desires less time in the waiting room and more time with the doctor - a worthy reasoned argument. The question that arises is does extra time equate to better care? Most doctors don’t think so, and data on this subject is equivocal at best, while most patients think so. This conflict appears to be a perceptual issue, doesn’t it? If the doctor who understands the malady is able to communicate the entirety of the case in short form and render good care for all his/her patients in the long run, isn’t that a better outcome for all? In the United Kingdom where universal healthcare exists and money is removed from the equation, the preferences for 1000 patients scaled from “thoroughness of visit,” “doctor who knows and treats them with warm and friendly manner” with “less waiting time and flexibility of appointment scheduling,” are the main desires. (Jennifer Warner, @WebMD 2008) Different strokes for different folks. But one must not forget where the patient most wants to spend time is with his or her family and not in the bowels of an inner city or outer rural hospital, or in a stranger's office (even though it is a physician). So lengthen that time the patient can spend with their loved ones is a consummation devoutly to be wished by the physician.

  1. Communication: Patients want their doctor to treat them as one of their own. Through the years, I have heard this question asked many times, “What would you do, if this was one of your own family members?” A valid question that has a simple answer. The best possible therapy that is available. This satisfies most of the patients, because it is the truth. But unfortunately it does not satisfy the industry, which is at odds due to expenses involved. So the best possible treatment is neither going to be the best nor is it possible in today terms. And that has both the patient and the doctor frustrated. One thing that physicians must not do is to wear their harried-existence patience thin to the detriment of communications. Take the time to listen and explain. Take the time to be human. After all, we have all suffered the whips and scorns of time.

  1. Costs: Depending on the medical insurer, the patient wants to be oblivious to all discussions related to costs. If discussions regarding costs are brought up by the physician, this implies to the patient that the doctor cares about money more than the patient. Media constantly states that doctors should work for the goodness of humanity and society takes that as gospel. Some have come to believe that medical care is a right. Others do not think so. The battle continues at least in the US. This discussion will occupy more patient care time in future. Those with limited insurance usually go to doctors that will accept their limited insurance claims and there the patients find less time, less communication and less thought. The times, they are a-changing. But in the realm of “costs” is a pesky minimally uttered cry from the patient that the doctors need to listen for; the cry to understand, how the disease will impact their lives. Not I used that in plural and that signifies that disease impacts more than the patient, it effects the whole family. It affects their dreams and desires, their vacations planned or soon to be, their mortgage payments, their daily living. The physician needs to be cognizant of these unexpressed wailings in the voice of his or her patient. There is always more to "it" then a “hello” and “goodbye.”

  1. Decision Making: Do patients actually want to share in the decision making process of their care? That is akin to asking of a passenger in a commercial aircraft, which flight-level he would prefer to fly at. The pilot like the doctor has the key information and knowledge, not the patient. However discussions regarding the quality of care are an important discussion to have. The pilot shares his by saying, “We will descend to a lower altitude to prevent further turbulence,” and the doctor says, “We will avoid that therapy due to the risks of complications inherent in the treatment.” Those are information-sharing decisions rendered for the knowledge, comfort and safety of the individual/patient. These communications are necessary where marginal survival benefit relating to the coincident complications from a certain treatment exist. The act of making a decision between Treatment A and Treatment B should be shouldered by the physician and communicated to the patient in simple terms and be based on good, solid and verifiable clinical evidence. The “Shared decision making” is not to my knowledge a patient deciding therapy based on his or her understanding of what the internet/or their research has yielded but the richness of conversation between him/her and their physician regarding the fully understood choices available and what would suit that patient.

  1. Comfort: Some physicians have the ability to provide comfort with their words and others not so. Not all physicians are alike. It is in that comfort level that a patient has a choice to stay with, or make a change from their physician. Should a physician strive to be a comfort giver and sacrifice the mandate that he has undertaken to cure the disease? The answer is a simple, No. Is comfort rendering a teachable process? Only by example and a desire to learn.  Rendering “false-hope” is not the answer either to garner that emotion from a patient, it is the care to listen to the patient complaint in building the road to healing. I have known many a patient say, “He (the physician) has terrible bed-side manners but he is an excellent doctor.” And “I would go to him in a heartbeat.” Yet the best honor a physician can elicit from a patient is, “he is a good doctor and a decent man.” This dichotomy is worthy of another discussion at a later time. Since the three-pound flesh housed behind the pale thick walls of the cranium controls the remainder of that which lies beneath it, must give pause to the physician to make sure that he or she  gingerly handles the input to this most extravagant and auspicious of all nature-made living things, so that the output from the patient's brain is always a positive defiance to disease.

Aside from a warm “hello,” an “empathic conversation” displaying “concerns through eye contact,” and “sitting down” that ease some issues, do they address the “compassionate concerns” that are much bandied about these days, what is it other than that, that patients want doctors to deliver? The answer might be a simple; maybe the media-impressed society demands everything, including immortality and cannot find satisfaction from anything short of it! And that is sad. It is “madness most discreet.” 

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