Medical patience

Doctors feel pressed and stressed. Patients feel frustrated and ignored.

Patients often think they are allowed too little time in the office — especially for a routine physical examination — and aren’t given enough information about medicines or tests prescribed. Many physicians complain about patients showing up with a shopping list of talking points instead of focusing on their most important concerns.

Pressure on both sides is affected by health maintenance organizations’ guidelines, which may restrict appointment times and limit reimbursement for some preventive health practices.

About 200 patients, physicians and health care professionals came together to air these and other grievances during a weekend session last fall sponsored by Johns Hopkins University’s Outcomes Evaluation Program, headed by Dr. Frederick Brancati, a Hopkins professor of medicine and epidemiology, and American Healthways, a disease-management company. The result was a report, “Defining the Patient-Physician Relationship for the 21st Century” (www.patient-physician.com), that suggests ways of changing matters in the future.

“The over-reliance on tests makes people believe the fundamental part of being a physician is less valuable and contributes to the techno feel of the relationship,” says Dr. Roy Ziegelstein, vice chairman of medicine at Johns Hopkins Bayview Medical Center and associate professor of medicine at Johns Hopkins University School of Medicine, who was not present at the meeting.

“There is a real concern that we are training physicians in a climate that romanticizes the technical and devalues the ability to view the patient in a sociological context.”

Also, nearly half of all American adults have difficulty understanding and acting upon the medical information available from doctors and other sources, such as the Internet, according to a report on health literacy issued in April by the Washington-based Institute of Medicine of the National Academies.

Dr. Ziegelstein suggests that psychological factors are at work as well. One is the problem of the unequal relationship that exists in the examining room, where the usual scene is a white-robed doctor standing above a skimpily clothed patient sitting on a cold, sterile, paper-covered table. The situation hardly is conducive to a free flow of conversation.

“[Other] studies show physicians spend little time listening,” he says. “Not only is it bad for medicine, but it doesn’t give the physician any information, and it sets up an unequal relationship.”

A physician who keeps quiet while the patient tells his story will learn more in less time, he believes.

“If it is a normal physical exam and a new-patient visit allows more than 15 minutes, which is normal, why not find out about his or her family, occupation — the whole person?” Dr. Ziegelstein asks rhetorically. “Getting the story out completes two things at the same time.

“It would be interesting to do a research study that involves giving the patient a form in the waiting room that says in effect, ‘We know you may be nervous, but we are sure you are here for some reason. Could you spend a couple of minutes thinking about what it is you would like to say to your physician?’ It also would be nice to have a similar set of instructions for the doctor, reminding him that the patient is in an unfamiliar environment and asking him to consider being quiet the first minute they meet.”

Even in an optimal doctor-patient relationship, though, there can be a price to pay.

Many years ago, Tammy Matthews of Salisbury, Md., a longtime migraine headache sufferer, called Johns Hopkins’ main number looking for help. She was referred to a special headache unit run by Dr. Brian Mondell, an assistant professor of neurology. He regularly spent at least three hours with new patients and 45 minutes on subsequent visits — the time necessary for an evaluation and correct diagnosis. He says he sees his job as a partnership with a patient, who he believes also has a responsibility to seek out information independently.

Ms.Matthews, a nurse, was delighted. “I’m not used to doctors being that thorough,” she says, praising Dr. Mondell for his attentiveness and thoroughness.

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