Tuesday, February 14, 2006

"Learning how to deal with helpful patients"

From the archives of NHS Blog Doctor:
Patients often bring Dr Crippen articles from newspapers or from the 'Daily Mail'. He just doesn’t know how he would manage without them. He only spent six years at medical school with four years post-graduate training and then another twenty years in practice, so obviously he cannot be expected to know everything.

It so refreshing therefore that helpful patients never cease to remind him how many areas of undiscovered ignorance he still has, and can back this up with newspapers cuttings not just from England but from all over the world.

It really helps.

If any patients are reticent about proffering advice to their doctor, and wonder how best to approach him, Dr Crippen always advises trying to help a pilot first. Be guided by his reaction in making your decision as how best to help your doctor...
Addendum: One commenter is very angry about this post (see below). What do you think?

Adding to the addendum: Dr. Crippen comments! I'm sorry that I only pulled a few of his quotes out of context. Go, read the whole post. (And the one he suggests, below. Dr. Crippen's tongue is firmly in cheek.)


Blogger jw said...

The good NHS doctor seems a bit snooty to me. No one person can know everything.

I had the misfortune to know several doctors who are more than willing to swear on a stack of bibles that women never sexually assault men and that female child molestation is very rare. It seem to me that those doctors needed a wake up call. Mind you, when dealing with the bigoted doctor no newspaper clipping will create a change of mind.

That's the thing, a degree doesn't mean Godhood.

2:02 AM  
Blogger bp_hockey_chick said...

What a stack of crap.

That article sounds like it could have been written by my pdoc.

I guess I should just sit and take his advise without any comment, without any input?

The doctor who wrote that has severely pissed me off. Arrogant, self-serving @*#&^

The docto

5:51 AM  
Blogger shrinkette said...

We do feel like this sometimes, when patients bring in little clippings from the news. But we can't talk about these feelings, except in our blogs. (And in doctor's lounges, of course!) It has to do with feeling misunderstood and devalued by our patients. It reminds us of the wide gulf between us.

In Dr. Crippen's Grand Rounds post this week, he tells us how to suggest a diagnosis to our doctors, without triggering this kind of reaction.

8:21 AM  
Anonymous Anonymous said...

Hi guys....er oh dear, it is me, I'm afraid.

I'm not quite sure why Shrinkette pulled those few words out of all my scribbles........

....do you ever advise pilots?

Actually, I prefer this more:




8:24 AM  
Blogger Bardiac said...

Arguing by analogy is always interesting, but bad analogies lead to bad arguments.

The pilot analogy suggests that there's one person who knows practice/skill X because s/he has training and familiarity with practice/skill X. This comparison is what the NHS guy is after. Thus far, the analogy works.

I think the analogy prompts us first to think of commercial pilots of large planes, to whom most of us have no access while in flight, for good reason. We also tend to think of pilots as being super busy in flight, but in fact, most pilots aren't super busy in flight most of the time.

I've actually discussed flying with pilots when they weren't actually flying, and when they were flying, but we were the only two people in a small plane. I've even steered and stuff.

When you make the comparison with human medicine, then you should be thinking in terms of being one on one with a pilot in a small plane because that correlates more closely with the doctor/patient situation, where, indeed, you're likely to be one on one, and not in an emergency situation.

NHS doc may not want to take time to discuss questions or issues with his patients, especially if he perceives himself as overworked or underpaid for his time.

Another area where the analogy breaks down is that X is not an airplane with which most people are radically unfamiliar. Instead, X is a human body, and if you're reading this, you have a good deal of experience already in your embodiment. You probably know if you usually feel well and suddenly don't.

Further, because most medical care is not emergency care, people CAN take the time to learn something about their bodies and potential care, and that something might actually be helpful to them. (This is just as well, since many doctors seem so rushed that they don't actually explain things.)

Maybe, indeed, NHS doc does know everything about human experience, and any patient contribution is unhelpful. But I suspect that at least sometimes, his patients know more than his analogy here credits. (I also suspect, based on his writings, that he balances curmudgeonly and caring decently.)

(sorry to go on so long)

8:31 AM  
Anonymous Anonymous said...

Hi bardiac,

"curmudgeonly and caring" - yep, after 20 years in the NHS, I can live with that.

my journalist friends say "never explain an article" ..... well, blogs are for fun, for letting off steam - and occasionally for serious points.

did you read the article I referenced? Seems a reasonable approach to the increasing numbers of unmarried mothers with unruly children


8:46 AM  
Blogger shrinkette said...

Hi, Dr. Crippen...I pulled those few quotes because I don't like to lift entire posts from other blogs, and because those quotes seemed pithy. Sorry your remarks are out of context. It's something that we feel, and that patients wouldn't necessarily know about, unless we blogged. (And because I've felt that way myself, more than once...)

But anyone who felt that their doctor was misguided or arrogant, or who felt that their doctor honestly needed some help (if not from the Daily Mail, then from somewhere), would obviously have a lot to say about this one.

8:56 AM  
Anonymous Anonymous said...

I think there is a fine line between sharing information versus cramming it down the physician's throat. Dr. Crippen was, perhaps, referring to the latter? Because I can see why a physician would tend to become defensive when patients aren't very, um, diplomatic.

Although I respect physicians' knowledge and skills, I know they cannot possibly know everything. It would be foolhardy for me not to educate myself or take some initiative if the physician seems to be veering off down the wrong track. If you want to be a partner in your own care, it comes with the territory. Just my opinion.

9:20 AM  
Blogger Joel said...

I always read up just before going in on a visit. I also find discussing things with my support group members to be helpful.

What does this do for me? First, it prepares me for what the doctor might be ready to do as a next step. If there are rights and wrongs involved due to my particular symptomology, I am prepared to explain my reservations. I don't know everything that is going to happen: the doctor may well know another effective treatment that gets around my concerns.

Second, it allows me to recognize symptomology. Example: a few weeks ago, at a support group meeting, a woman spoke of her hearing voices and messages in fans and the buzz of electrical appliances. It floored me because I have had that symptom and just brushed it off as weirdness. The more I talked and looked around (bp_hockey_chick mentioned it on her blog recently), the more I realized that I had been plagued by this. The good news is that fans sound like fans and buzzes sound like buzzes. It affirmed my faith in my psychiatrist's diagnosis and my improvement.

I can't expect my psychiatrist to tell me everything in our sessions: I've got to root things out.

3:21 PM  
Anonymous Amy said...

Doctor's are not the only ones who get input. I support computers and when I let them know what we need to try next some people will question me. "Are you sure?" "I don't think that will fix it." And then I have to explain why we following this route, the process of elimination, all the while prolonging the process. And there are others out there who really want my help.

4:46 PM  
Anonymous nursenancy said...

Hi Shrinkette. I'm a frequent drop-in to your site, enjoy your diversity and humaneness.

I read this post shortly before going to bed. where I lay and thought about it. and thought some more. I was glad to see some responses when I checked back this AM.

One of my jobs as a nurse is to encourage people to take responsibility for their health (Not as in 'this-is-all-your-fault') and to implement successful self-care practices. Of course it's not as easy for an MD to act in collaboration as it is to take charge. That's what doctors have done historically; this is, in a way, what the NHS pays Dr John to do.

To complain about patients gathering information that might be relevent to their condition, even from the Daily Mail, is to reinforce that potent and popular stereotype of Doctor as God: "If there's something to be known, I know it." ie, I am Omniscient. How can any one know all there is about every condition? And how can a patient feel confident in a 15" NHS visit that there's been enough time to consider what's actually going on? Even with a nice, caring, non-curmudgeonly doc? Especially knowing that most of medical continuing education is sponsered by pharmaceutical companies.

I'm into my 3rd year with Chronic Fatigue Immune Disorder Syndrome. And the effects of two best-selling pharmaceuticals helped damage my immune system to the point it is now. If I didn't manage my care I would still be worsening. While I was still seeking consultations I heard the phrase "heart-sink patient", maybe in this very blog. And I realized that just by walking into the office with a complicated, highly personalized condition that doesn't respond to some medication, I was just such a person. Ms Heartsink, here again.

Being able to discuss professional issues via blogging is a great opportunity. If you don't want Us to be privy to that whinging, then create a members-only site. Otherwise, why not be open to actually understanding where people's responses come from. And I reread the original post, and Shrinkette's quote doesn't seems out of context to me. She adds, "It has to do with feeling misunderstood and devalued by our patients. It reminds us of the wide gulf between us." Yes, that's just what we patients often feel like, misunderstood, devalued, depersonalized, trying to communicate across a wide gulf.

4:56 PM  
Anonymous nursenancy said...

PS: Anecdote, true story:

Visited my GP requesting further labwork and referral for endocrinologist. A few hours later I phoned GP asking for additional referral to consultant internist, to be sent to me. When I hand the new doctor the sealed envelope, he opens it, stares at it, then at me, saying "she says she doesn't know why you've come to see me."

I found another GP who actually believed we could do something for my health. But what, too, of the doctor who reads these confidence-boosting words to me?? On the one hand, I'm grateful to see so clearly what my doctor thought of me. On the other, what if consultant said something more like,"so tell me what's going on with you." maybe this is way off topic.

6:00 PM  
Blogger Kim said...

I'm lost here.

When I have a question about a new medication or have heard of a new treatment or read something in the papers/magazines I simply ask my doctor/dentist about it.

I might write it down so I don't forget the name of the new "thing" but (1) usually the doc HAS heard of it and has an opinion that he shares or (2) had no idea what it is but will look it up and have an answer/opinion at my next appt.

It surely has never been an issue, as far as I know. Perhaps because I ask for two reasons (1) in terms of how it will or will not affect me and (2) its effect on patients I may come across...

I don't know. Guess I just have been lucky with my doctors...

6:17 PM  
Blogger Kim said...

Oh, and John is not "snooty", check out the entire blog and you will find much more "care" than "curmugeon" : )

6:18 PM  
Blogger David said...

"Dr Crippen always advises trying to help a pilot first"...does Dr Crippen think that if a passenger pointed out to a flight attendent that smoke was coming out the the left engine, this data would be ignored because it was not coming from a certified pilot?

Aviation safety in recent years has focused on the concept of "cockpit resource management" which include a conscious attempt to avoid arrogance on the part of the pilot in command and to ensure a climate in which other members of the flight crew feel free to advise him. I have heard it suggested that CRM concepts could be beneficially applied in medicine.

7:58 PM  
Anonymous Anonymous said...

At the risk of having physicians roll their eyes at me, I will continue to do research on my own. When I was struggling with depression the dr. prescribed Effexor at a pretty high dose, consequently I started getting urine retention. I called the dr., who never called back, so I lowered the dose on my own. My bladder went back to normal. I did some research on it and found it can cause urine retention in some patients. I went to my next appointment and after a scolding for "trying to treat myself," the doctor told to me to continue taking it at the higher dose and that Effexor didn't cause urine retention. I shared with her what I had read and it pissed her off. I wasn't trying to be obnoxious, I just like to be able to pee. So, I started taking it as prescribed again and ended up in the ER having to have a catheter put in. I was referred to a urologist who said antidepressants at that high of a dose sometimes cause that to happen. My point is that doctors don't know everything about everything. I think it is in a patient's best interest for them to do the research on drug side effects - they need to know what to look for. I did switch physicians after that and found one that really worked with me and didn't take it personally that I wanted to know everything about the medication I was taking. There is a very limited amount of time the physician spends with the patient, if they don't have time to go over all the potential side effects or the pharmacist doesn't do it, then the patient needs to.

12:03 AM  
Anonymous Anonymous said...

Regarding my last comment - I don't want it to come across that I'm blaming the physician for the side effects of the medication. I realize that anytime I take a medication there is some risk involved, and I'm willing to accept that risk. However, I accept that risk only after reading the potential side effects. I will listen to the physician, but ultimately it is my decision what risk I am willing to take. I hope that patients don't get labeled as being difficult for simply trying to make the right decision for themselves. Let's face it some of the side effects of psych meds really suck. It's not an easy decision.

12:33 AM  
Blogger Bardiac said...

Wow, lots of interesting responses while I was off doing stuff.

It seems that while I was writing my rather long missive, Dr. John Crippen and Shrinkette both posted, which means that my response looks like it's responding to them, but was meant to respond to the ones above. Sorry about that. I should have checked.

I'm confused about pointing me to Swift. Yes, I've read Swift, but I don't get why it's posted here. Are we to compare the NHS blog with Swift's satire? Or the state of NHS personnel with the state of the Irish under British colonial rule in 1729?

I find this discussion (and blog generally) fascinating. Shrinkette, why do you think you're undervalued? And how does a patient trying to learn something and bringing it to a physician contribute to that?

6:32 AM  
Blogger Bardiac said...

Sorry, devalued, not undervalued.

6:34 AM  
Anonymous Allison said...

Reading all of this (fun, since I just "found" Dr. Crippen's blog yesterday), I realize how entire blessed/lucky I am to have the pediatrician I do. She quickly understood that I'm "the mom who reads EVERYTHING," and she's okay with that. For her, it saves time in our appointments, because she knows she can skip much of the soft talk and go straight for the bones.

The second thing I've realized (also since just finishing "The Real Age Makeover") is that I need to take more charge of my own healthcare. Even though I'm fairly healthy and much more informed than the average American (not that that says much, LOL), I don't see a doctor unless I'm sick, and there are questions about day-to-day things about my body that I probably should ask.

On the passenger/pilot analogy...I'm not quite satisfied with how that lines up. In my opinion, it's almost more like the patient is the pilot and the doctor is the co-pilot or perhaps even the mechanic. I'm the one flying this body day in and out. When I talk to the mechanic (the doctor), I should be able to explain what rattles I'm hearing and what lights I see on the dash -- then the experienced mechanic will better recognize the problem underlying. If the pilot happens to have read about a common airplane failure, what's the problem with telling the mechanic, "I think we have an oil leak."?

At least, that's how I see it. While a doctor knows vastly more than I do about medicine in general, I'm the expert on my own body. For best results, shouldn't it be a team effort of the two experts?

11:32 AM  
Anonymous mchebert said...

It is difficult for doctors and patients to realize how different their perspectives are. Whenever a patient suggests a medical treatment I try to remind myself that the patient is just trying to help himself, not impugn me. It is important not to internalize remarks by patients. Patients are often very fearful and this is the motivation for the news clippings. We doctors need to be tolerant.

On the other hand, in medicine we have a running joke about the N=1 experiment. All research studies report out their results by stating the number of patients enrolled in the study, so a N=2,345 study means 2,345 patients were enrolled. An N=1 experiment means we drew conclusions off of one patient only. Usually this means we tried a treatment on ourselves, and it worked.

Patients need to understand that if a friend of theirs tried something and it worked, or if a newspaper article reports about a small study with promising results, that this does not necessarily make the information valid for them. It is human nature for us to draw parallels between others' experience and our own, but it is not always valid. Research is only valid when it is drawn from a large number of people in a wide variety of contexts. When N is a very big number.

A patient cares for one body, his own. N=1. A typical doctor sees 2000 - 5000 patients a year, N=5000. This means the doctor has a much broader perspective on medical problems and can see them in contexts the patient cannot see in themselves. That is why, for instance, a psychiatrist can diagnose a mental illness in a patient in 30 minutes that the patient could not see in herself in her entire lifetime. The patient knows herself, N=1, but the psychiatrist has seen the illness in hundreds of patients in different settings, N=500. This gives the psychiatrist a huge advantage.

A patient may know his disease in and out, but a doctor, having treated many similar illnesses in different circumstances, can see and understand things about the context of illness that even the most well-read patient can never understand.

That is why, when I go to the doctor, even though I am one, I generally take his advice and don't argue. A doctor, with a broad experience and a detached point of view, often sees things that the patient does not.

Perhaps most importantly, when a patient goes to see a doctor, it is not for drugs, it is for advice. When a person asks another person for an opinion it is best not to put ideas into the person's head to start with. You want an unvarnished opinion, not to hear what you want to hear.

Consider the difference between the two questions:

"Given that a recent study reported in the Times shows that garlic is effective for blood pressure control, would you use garlic for my blood pressure?"

"How would you treat my blood pressure?"

Which question do you think will get the most thoughtful answer?

2:29 PM  
Anonymous Anonymous said...

All I can say to the N=1 joke is thank God the ER doctor didn't look at my distended abdomen and say, well but this only happens to x% of patients so therefore it can't possibly be the case with you. Thank God he had all the extra cc's drained from my body and gave me relief. And thank goodness the next psychiatrist read the insert to the medication and knew that urinary problems, though listed as "less common," do in fact happen and in fact become more common the higher the dose gets. I don't need herbal monthly to tell me when my bladder stops functioning. I can figure that one out for myself.

6:08 PM  
Blogger David said...

"Whenever a patient suggests a medical treatment I try to remind myself that the patient is just trying to help himself, not impugn me"...I'm not trying to be rude, but I think this is an culturally-interesting sentence. Why *would* anyone even imagine that a mere suggestion was "trying to impugn" them? Following up on Allison's analogy above: do you think the mechanic would think the pilot was trying to impugn him by suggesting a potential problem source..even if the mechanic knew much more about engines and airframes (as he almost certainly would) than the pilot?

6:43 PM  
Blogger TBTAM said...

I have nothing to add to this interesting discussion. I just saw that some of my favorite bloggers were hanging out over at Shrinkette, and I wanted to join the party...

8:26 AM  
Anonymous Anonymous said...

I know that a doctor knows all sorts of things that I don't. But I also know that two doctors both know more than me, and yet do not necessarily agree with each other.


8:21 AM  
Blogger Tom Paine said...

Dr Crippen's blog is one of my favourites and I am prepared to write his remarks off as "having a bad day". I have experienced both US and UK medicine, however, and much prefer being treated as an intelligent being with something to contribute to a discussion of his health problem (US approach) to "shut up, you are in the Divine presence" (UK approach).

Recently a colleague of mine was taken ill while on holiday in the UK (she works with me in Russia). She presented at an NHS hospital, reported symptoms and a history of pneumonia and had the temerity to suggest an X-ray. That was enough to infuriate the petty NHS gods who told her "...we decide who needs an X-ray" and sent her home with painkillers. She flew to Russia and - running out of painkillers - presented at the private clinic our staff use. They were surprised at the treatment and insisted on an immediate x-ray. She was diagnosed as having a serious problem arising from her pneumonia and medi-evac'ed back to a private hospital in the UK where she was promptly treated. This cost my firm's health insurers half a million bucks, but I am sure that if she did not have the good fortune to work abroad, she would have been at serious risk.

Most doctors are great, but they are human like the rest of us. A patient who makes an effort to understand his/her own problems deserves respect and encouragement, not a put-down. Socialised medicine does unfortunately lead to the attitude that a patient's health is the State's problem, not his own. As they are "costs to the taxpayers" rather than customers, they should keep quiet and behave.

PS: The UK is so much less litigious than the US that even though both my colleague and her husband are lawyers, it doesn't seem to have occured to either of them to sue the charmer who sent her away with sharp words instead of treatment. Having some experience of the US approach in that respect too, I can't help feeling that personal bankruptcy would have educational value for the petty divinity in question. Unfortunately, liability is socialised too in Britain, so the little s**t can rely on the taxpayer to pick up any bill for damages.

12:08 AM  
Anonymous Anonymous said...

The US vs UK debate would be a bit more credible if 25% of people in the US couldn't afford healthcare thanks to their money-orientated system.

2:02 PM  
Anonymous david b said...

It's a Daily Mail thing, really. Gets a knee jerk response from most UK GPs.

7:35 AM  

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