Physician

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Patient-Doctor Relationship

shoes

Tonight I pulled together all the posts we have on the patient-doctor relationship into one page.  Please let me know your reactions.  This is a journey I am really grateful to travel with you.  Keep on.

 

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No One is Choosing For You – Know Your Choices For Health

Yesterday we asked some pithy questions re: Why Psychiatry?  Your responses were received with gratitude and humility.  It takes courage to understand our connection with psychiatry considering ongoing stigma.  Today we’re reviewing that some and taking it one bit further.

When referred to a psychiatrist for medical care, we can feel confused.

Why is my physician sending me away?  Does this mean I’m at my last resort?  Does this mean I’m that sick?, or,

Does he think I’m crazy?  I’m not insane!, or personalizing with,

Does my physician not want to work with me?  I’m that bad of a patient?  Cast off?

Our expectations when we first see our psychiatrist are often also similarly reactive.  Maybe,

I’ll give this one chance but if she doesn’t fix whatever it is that’s going on, I’m out of here. 

I am not going to be dependent on medications!

I do not want to be made into a zombie!

Are we looking for a cure?

Also, we might be confused by the amount of time that she spent with us the first appointment as compared to our follow-up appointments.

I need to talk about my problems!  I need time!

There’s a lot to take in.

Unfortunately, when we are referred to a specialist, often our referring physician hasn’t effectively communicated as to why we are being sent there.  This is for many possible reasons, including Me not hearing him.  Many other reasons are also understandable with insight but we aren’t always given the opportunity to hear the inside story of why our physician does what he does.  That doesn’t mean we have to accept it.  But if we do, we did and it’s our choice.

Choice

Image by Scarygami via Flickr

We have choices.  Before accepting the referral, we can ask, Why?  Keep asking why until we are satisfied with our level of understanding.  Schedule a follow-up appointment with the referring physician if necessary to gain more time if we think we need it.  Sometimes, despite our physicians best efforts, we won’t understand as well as we’d like and we have to make our choice with the information we have.  We can read up on our symptoms ourselves.  I read in Twitter from @NathanBransford,

The 11th Commandment: Thou shalt not ask someone a question thy could easily Google thyself.

That’s ridiculous although I cracked up.  The World Wide Web comprehensively and including Google or any other source within that World Wide Web are not designed to practice medicine.  When we read something, we need to ask for qualifications behind the author of the print, references and so forth.  The Internet is a tool worth our attention but you decide how far you are willing to take what you read before you consult with your own physician.  I think if Doctor Seuss were alive today, he’d write a book (or many) about health care; Oh The Tools We Can Use!  (Maybe Carl and Thysleroux will do a series or a post on this?  Should be fun.  – Asking, “Why?”  Becoming our own friend.  Connection.  Going towards shame, pain, anxiety.  Growing bank – and more.)

And so that brings us to today’s questions:  What choices do you perceive you have in referrals like these?  In your continuing medical care?  In your ability to collaborate with your physician?  In obtaining an understanding of your illness(es)?  Please tell me your story.

Self-Care Tip – Grow your understanding of your choices for your health and medical care.

Related Articles:

  1. Stay Connected For Your Sake and For Theirs
  2. Connecting To Others Is a Condition of Freedom
  3. Safety in Connections
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Reworking Choices With Your Physician as Part of Your Team

What do you want? 

It is one of my challenges as a physician when someone comes to see me for reasons I’m not able to accommodate.  I can’t validate them.  I can’t tell them what they want to hear.

What can I do?  Help them “realize” that they came to see me for another reason.  Another way to say it is to help them “choose” another agenda.  A part of them realizes their need for help; they came.  A part of them believes I am a person that can help; they came.  A part of them.  A part that I and the patient are responsible to find and shift agendas deliberately or by any wiles possible.

Hands touching

Image via Wikipedia

We are an unusual team in this.  How often do you find another so awkwardly paired?  Yet these are some of my best patient-doctor relationships.

What do you want?

When there is a meeting up, a connection and everyone is working for the same “want,” both presence and movement are natural responses.  It’s like we’re standing still in the moment, senses taking it in, and moving all the while.  The process of moving itself brings pleasure and healing.  It is not always about arriving.  It is not always what we think we want.

Self-Care Tip – Enjoy your re-choices and what you will get from them.

Questions:  Have you every found yourself being “helped” to have a different agenda that improved your presence and movement in your personal journey?  Please tell us your story.

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Stop! Don’t Stop! – Affecting Our Practice Of Medicine and Other Agendas

Self-Care Tip #281 – Be aware of how your “Stop!  Don’t stop!” behavior is interfacing with your agenda.

One of the challenges in practicing medicine is the inevitable “Stop!  Don’t stop!” petitions.

stop & go

Image by Joseph Robertson via Flickr

It’s similar in a few ways to being a shoe cobbler who receives clients that don’t want her to use leather.  Ms. Cobbler spends 40-60% of her time with clients persuading them of her capacity to use leather, the objective and subjective evidence behind the use of leather and empowering her clients to wear their leather shoes despite public opinion.

This sounds silly and is not meant to be disrespectful to patients, including myself as a patient of physicians and my own difficulties being a patient.  It is only to describe the forces we are all working with when we work together in medical care – physician and patient.

Quenn came in reminding me of this.  Quenn was a 32 year-old married mother of three, who complained of trouble swallowing, sleeping and ability to feel pleasure over the past two months.  She had struggled with this after her mother died nine years ago, but the problems went away over the following year.  However nine years-ago, Quenn was not a mother.  Nine years-ago, Quenn could shake, stay in the house with the shades down, silent or crying loudly, not eating lying in bed for days and if she wanted, nine years-ago no one would know.  This time however, Quenn told me she was desperate.

I have to get better!  This time, I’ll do anything!  But please start with something natural.  I don’t want to get addicted!  I’m someone who never does meds.”

Quenn, why are you seeing me?  

This is challenging for everyone.  Together, the physician and the patient work with this influence on their agendas.

My brothers and I used to play a game on each other when we were kids.  Maybe you did this too.

Stop!  No don’t!  Stop!  No don’t! Stop!  Don’t!  Stop! Don’t! Stop! Don’t stop! Stop! Don’t!  Don’t Stop!  Don’t Stop!

And for some reason that was hilarious to us.  I like to remember this when I’m in the office and smile despite being played by the “Stop!  Don’t stop!” behaviors and emotions.

Questions:  How about you?  How are the “Stop!  Don’t stop!” behaviors and emotions playing on your agendas?  Please tell me your story.

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Our Patient-Doctor Relationship Improved by Self-Care and Back At You!

NICU Nursery

Image by EMS Shane in Portland via Flickr

I am writing a series of blog-posts outlining self-care in which we examine the tenets of self-care:

Self-Care Tip #265 – Use your connections to help yourself and use your self-care to improve your connections (such as your patient-doctor relationship.)

Damaged and premature, my niece was born needing help to live. Now, one year later, I am playing ball with her on the floor. Her intelligent smile, thriving body, and especially the lovely nape of her neck with that baby-curl of hair lipping up makes remembering her near death-dive into life surreal. I don’t want to remember it anyway. But when I can’t help myself, what I like to think of is how my brother and sister-in-law were treated.

The clinicians at UCSD were unbelievable, my brother said. They included him in their decision-making and informed him of medical study results. If you don’t know, if you’ve never been sick or been in a medical setting otherwise, this doesn’t always happen. It isn’t traditional to share medical information directly with patients (such as x-rays, laboratory results, differential diagnoses, and to ask their opinion. Can you imagine?!  “…Um. Yes PLEASE! Can I be your patient!?” Sounds like fantasy.)

I’ve also struggled to collaborate. Hovering over charts and laboratory results, many of us practitioners behave as if our patients were at any moment going to throw us into court. It’s embarrassing, even though the truth is, too many of us clinicians are stalked by litigious intentions, whilst the truly awful practitioners seem to sail away on unsinkable malpractice without pursuit.

I have not enjoyed myself when I’ve done this. When I’ve acted suspicious of the very people I’m meant to team up with, work was not good for me. I don’t think my patients felt comfortable with the doctor-patient relationship either during those times. Hearing my brother talk about how he was treated has emboldened me to engage with more trust in the care I offer patients. Moreso, being friendly to myself has helped me be a better physician.  It’s tail chasing but with productive and enriching effects.

Making a choice to choose trust and transparency with patients and clinicians, even being present with the fear, is self-care although high pressure. With people’s lives on the line, clinicians and patients know mistakes will happen. The self-care will grow our ability to forgive each other.

My journey with self-care has brought me to see people differently. I look at them from the self-care angle. I look for those sticky bits where we can connect and collaborate. I expect things from them. I ally myself with their self-respect, with their intuitive desire to be friends with themselves. I am bored at work when I don’t do this. I am bored at work when my patients don’t do this too. Without self-care for myself and without my patient’s interest in self-care, medical practice becomes everything that the negative reputations advertise about the physician and the patient.

Yes. My quality of practice has definitely improved.

Who isn’t blessed when she sees the courage to face stigma, shame and bewildering illness? Who isn’t more informed every time someone chooses the freedom to do self-care, chooses to live, fights hard like my niece did and shows what that fight is worth?

Who doesn’t learn from that? When someone loses her identity to the defacing ravages of disease but still knows she is worth the fight, like PattyAnne, working beside her is one of the best places in the world to be. For Me. It starts and ends with Me.

Building trust in a patient or a clinician starts with us staying connected to others in our personal circle and along the ripples as the circle widens. We have to have a voice and hear their voice and we do this by maintaining a community of people.

Connection is part of self-care for both clinician and patient. In the case of PattyAnne, (yes, she’s still in our story,) she could take an action toward her self-care with the intention of gaining stronger connection to her community and to me. She could ask herself about her intentions. In fact, we both would do better self-care approaching each other this way.

Connection via the patient-doctor relationship is self-care and then back the other way too!

It starts and ends with Me.

Questions: Has your patient-doctor relationship been a friendly part of what you’ve given yourself?  What are some examples or in what ways have other connections you’ve chosen improved your self-care?  How has self-care inversely improved your patient-doctor relationship?  Please tell me your story.

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Choose The Learning and The Teaching You do, and That is Done To You: Patient-Doctor relationship

I'll Give You All I Can...

Self-Care Tip – Choose the learning and the teaching you do, and not be passive to it, when in your patient-doctor relationship.

Hearing a physician tell us when we can and cannot take medications is somewhat private.  In our culture in our “advanced” and liberated age it isn’t so easy to feel handled like that.  But feeling handled verses helped is our choice.  It is all the more reason to dig in our fears and see what scares us.  If what we find there is that our fear is playing into keeping us from receiving this information, and decide actively if that is really in our best interest.  Emotion has it’s own activity, different from a muscle in our arm.  When we respond to the emotion, and especially if we respond before we do this kind of digging into the fear, we might not actually be doing protective behavior, like our fear would have us believe.

We have talked a bit in previous blog-posts about the patient-doctor relationship being a team effort.  It quickly became apparent that some of us don’t perceive that we have the luxury of working with a physician who see’s their patient as a person to learn from and influence their treatment decisions.  But it is still important to know that this exchange is critical for us and then to let that knowledge progress to a wanting in us to have this dynamic relationship with our physician.  The knowledge and the wanting will have their way in us and in our communities subsequently.  We do not know how long that will take but it will happen.

The marvelous scientist, Deb Roy, from MIT talked about his research on language development.  It was of course extremely endearing as it began with his work with his own infant baby and hooked us both by the intimacy of it and the marvelous discoveries.  Then after we were oohing and ah’ing (most appropriately because this is AWESOME stuff!) he moved us into our cities and media and showed us with his data and eloquence that in order for learning to happen, the professor and the student, the sales rep and the client, the physician and the patient, the parent and the child, both learn and teach simultaneously.  Whether it is subconscious or conscious.  The baby teaches the parent to teach him better and the parent learns this from the baby.   The physician teaches the patient and the patient teaches the physician to teach him better.

Both roles of instructor and student you see requires humility to learn and teach.  They both push into private spaces of the other.  Without consent, either conscious consent or subconscious consent must be there, it will not happen.  So this is consensual, even when we do not realize it.

Now what do you think the friendly thing is for us to do for ourselves, considering this growth in our knowledge?

Of course.  We will be more effective if we embrace this knowingly, willingly, humbly.  Move this learning process from the subconscious to the conscious level.  Make it as deliberate as possible.  For both physician and patient, this is good self-care.  Accept that when we engage in a patient-doctor relationship, we are giving that other person admittance, by our will and choice, admittance to that private space inside of us and not feel the victim when they enter.

Questions:  How has feeling like a victim sabotaged your patient-doctor relationship?  How have you worked past it in a positive way for both of you?  Please tell me your story.

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Self-Care As it Affects Your Professional Self

Of the patients waiting at the Out-Patient Dep...

Image via Wikipedia

Self-Care Tip #236 – Think about what self-care is doing for your professional self.

When speaking with managing editor of the Journal of Participatory Medicine (JoPM,) Kathleen O’Malley yesterday, I struggled to explain the presumed simple description of what effect self-care has had over the past many months on my professional self.  I realized that I hadn’t spoken much about that yet.  The words spilled out, messy and ungraceful.  I’d like to say it better so I’m going to try again, and then many more times.  Self-care has helped me be a better physician.

I see people differently.  I look at them from the self-care angle.  I look for those sticky bits where we can connect and collaborate.  I expect things from them.  I ally myself with their self-respect, with their intuitive desire to be a friend with themselves.  I am bored at work when I don’t do this.  I am bored at work when my patients don’t do this too.  Yes.  My quality of practice has definitely improved.

Who isn’t blessed when they see the courage to face stigma, shame and bewildering illness?  Who isn’t more informed every time someone chooses the freedom to do self-care, chooses to live when disease is damaging them, fights hard like my niece did and shows what that fight is worth?  Who doesn’t learn from that?  Who doesn’t want more?  When someone loses their identity to the defacing ravages of disease but still knows who they are, is for me, one of the best places in the world to be.

Working harder on myself personally is working harder to improve myself professionally.  One healthy is another healthy Me.  Self-care has helped me find more pleasure at work because I know I am responsible about how I feel when I’m there.  I take care of myself when I’m there and then I’m able to give more to my patients because of it, including just being present.

Being present is really a lot to get and a lot to give.  I sense this in my kids who want me to see them.  They call out for observation of activities; riding without training wheels, jumping super high, running in fast shoes, building awesomeness.  But those are code.  They want me to see them.  I just can’t do that when I’m self-neglected.  It carries over in all spheres of my life, including the office.  Who wants to consult a physician who is half asleep in the chair?  (Now if I need a nap, I just go all the way and sleep! j/k.)

I know my self-care is participating in the practice of this kind of medicine with you.  I’m hoping to get better saying it.

Questions:  What has self-care done for you in your professional world?  How has it helped you work better as a team-member?  How has it helped you receive better from others who have something to give – such as teach you or give directions?  Please tell me your story.

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A Little Bit is Not Enough – Claim Full Health

The good news is, I just ate 3 chocolate chip cookies.  You already know the bad news.  Has nothing to do with my post.  I’m just sharing it for the sake of your own

Schadenfreude 🙂

…Onward.  Question:

Does emotional disease get worse even while on medication therapy?  Sometimes.  It does so more often when the disease process is treated but only partially treated.  Read a little more about this in this post if your interested.  A primary care physician recently told me, “I think the term ‘Partial Responder’ is a marketing gimmick to get physicians to prescribe more medications.  I don’t think it even exists.”

There’s a lot to be said about interview skills in sussing out the partial responder.  If I asked someone if they felt better, many things play into their response. Everyone’s responses are biased of course.  We don’t have sterile minds.  For example there’s the patient who wants to please their physician.  “Yes I’m better!”  i.e. “Yes you’re a good doctor!”  There are the patients who don’t want to be patients and minimize whatever they’re going through.  There is the physician who leads the interview.  “So, you’re feeling better?”  “The medication is helping?”

Partial response means that at the end of a full treatment initiation period, there is some disease remaining but a reduction of disease.  For example, in depression, I may no longer be suicidal, but I still have trouble feeling pleasure in life.  In cancer it means that there is tumor reduction of at least 30%.

Now why would a physician presumably agree that there is a partial response in cancer, but not agree that it happens in mental health?  Anyways….  (Ahem.)  When we partly respond to mental health treatment and don’t push further for full response, about 70% will relapse.  Versus maybe 25% in those who reached their pre-disease baseline emotional health through treatment.

Don’t get lost in this.  The point is, get treated and get fully treated.  Mental illness is progressive and causes changes at the cell level.  The brain is connected to the rest of our body.  The brain is human.  A bit better, is not enough.

Self Care Tip #61 – Go all the way!  Claim health.  Be a friend to yourself.

Question:  Did you find this to be true in yourself or someone you know?  Please tell me your story.