- The Washington Times - Monday, May 24, 2004

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.

Such customized treatment plans usually are not very remunerative, and Dr. Mondell, who admits that he is something of a “dinosaur” for his approach, was forced to close the unit late last month after 19 years. He is in the process of reorganizing his practice.

However, patient complaints elsewhere are widespread enough that several doctors have gone public in recent years in print and online, addressing how to improve matters. One book, co-authored by Pennsylvania internist Marie Savard, is titled, dramatically, “How to Save Your Own Life.”

Dr. Savard also has produced a Web page that includes a tutorial on the subject available through Merck, the pharmaceutical company. Called “Preparing for a Doctor’s Visit,” it offers extensive advice at www.mercksource.com.

Her solution overall is urging patients to break bad habits and learn new ones because she believes the patient, as the person most concerned about the situation, must take action while the medical profession catches up.

“Even doctors finally are getting the word,” Dr. Savard says in a telephone interview. Also, younger patients are less inhibited about taking the initiative, she and other primary care physicians say. “Since the 1970s, it’s been shown that the more engaged the patient is, the better is his or her health. I’m glad managed care provided the impetus to let patients realize they can’t sit back and wait.”

She advises a patient to think of the annual exam as an important business meeting and realize that the time frame is short and probably does not allow for covering every aspect of one’s health. If remembering is a problem, she suggests the patient bring in a friend or advocate to be a witness. For the doctor, she advises having a visual image of the patient tacked to his or her medical chart or records to help with rapid identification.

Both Johns Hopkins and Georgetown medical centers make special efforts to train residents to be aware how attitude and emotion can affect their relationships with patients.

“One difficulty is that residents get so caught up in worry about missing a diagnosis they are not getting across information about [prescribed] medicines,” says Dr. Deborah Kasman, an assistant professor of medicine in charge of supervising residents at Georgetown. She also researches medical ethics at the university’s Center for Clinical Bioethics.

“The economic pressures to move patients out of hospitals make it more important to have an understanding of [post-operative] care. [The pressure] has changed the pace at which medicine is practiced.”

She cites the example of a woman in her 80s who showed up at the clinic for internal medicine complaining of pain five days after she had had an abdominal operation. It turns out that she had constipation from the painkillers prescribed for her, but she had not been told the medicine could have that effect. Nor had a doctor asked whether a relative could look after her during recuperation. Better discharge planning would have saved the woman anxiety and pain, Dr. Kasman says.

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