Teaching your Patients How to be Good Patients

Time is limited and the patient keeps talking and talking. What can you do? I realize that patients aren’t taught how to be good patients. So it is up to us to teach them. I have three recommendations for you.

Recommendation #1 Have them write out what they want to talk about before their appointment. Now I am sure you have heard this before, but the part that most doctors miss is to get them to prioritize their questions. I tell them to circle the most important 2 questions they want to discuss with you. Otherwise you just get a long list of random questions without any sense of what they truly want you to focus on. Patients understand that you can’t answer all of their questions but they will be satisfied if you take care of the most urgent issues. I have a questionnaire form, Viki Kind’s Office Form that you can download to help you help the patient. I encourage you to give copies to your patients to keep at home so they can fill them out before their appointment. If they haven’t filled one out before they arrive, then have them work on it while they are in your waiting room. In the medical practice I used to manage, we had a clipboard and form all ready for the patient when they checked. This is an easy way to be more efficient and to increase patient satisfaction.

Now some of you might be thinking, “Good, I don’t have to spend time listening, I can just read their list.” Well, you can if you want but your patient will be angry and non-compliant. If your patient doesn’t trust you or trust that you care about them, they won’t heal as fast or follow your instructions.

Here is Recommendation #2. It is up to you to build a caring relationship with them and you do that through compassionate dialogue, not a monologue. The act of listening has its own healing properties.

Recommendation #3 The other thing you need to educate patients about is to stop asking you the, “Oh by the way…” question as you are about to walk out the door. You need to tell them up front to ask you the most important questions at the beginning of the appointment or else you won’t have to time to address their concerns. Of course, this is a hard habit to break for patients and you will have to give them time to learn to be more direct with you.

Bonus Information: Unfortunately, some of these techniques will not work with certain cultures as they use a form of indirect communication which dances around the topic and takes longer as the only way they know how to communicate. But for most of your patients, these techniques will help you manage your time while caring for your patients.

Have a kind and respectful day.

3 Secrets to Getting the Most Out of Your Dr.’s Appointment

Do you feel like the doctor doesn’t have enough time to listen to your complaints? Is it frustrating to leave the doctor’s office and realize you didn’t get your questions answered?

Let me tell you what is going on and you aren’t going to like it. The doctor has about 12 minutes to listen to you, exam you, figure out what is wrong with you and put together a plan to help you get better.

I can hear you saying, “But 12 minutes isn’t enough.” Of course not, but that is the reality of medicine today.

You can complain but if you are smart, you can learn the three simple steps below to get the most out of your doctor’s appointment.

Here is Secret #1. You have to think like a doctor. Doctor’s think in an organized manner, so we have to give them our information in an organized way. Doctors usually play a guessing game with us as they try to figure out what is our “chief complaint”. But these questions are just wasting our precious minutes. The more organized and prepared you are for your appointment, the better.

Here is Secret #2. The doctor will make more time for you if he likes you better. And if your doctor likes you, you will get better care. I know it doesn’t seem fair but that is just the way it works.

Secret #3 is to make sure you are nice to all of the office staff. They can make it easier or more difficult for you to get in to see the doctor. They control his schedule. So, be kind to them and say, “Thank you.”

Now let’s make it easy for the doctor to help you.

Step 1. Write down all of your medications, occasional cold medicines, vitamins, herbal medicines, natural supplements, etc. And I mean everything. Even things you don’t think are important may be very important to your health. The doctor can’t protect you from things that he doesn’t know about, so write them down. If you don’t want to write them down, then bring all of them to the appointment with you.

Step 2. Write down how you are feeling. Why are you coming to see the doctor? Tell him what is hurting you, bothering you or any other physical complaints? Write down the new symptoms first and then write down the problems that are ongoing.

Step 3. Write down your questions and then circle the 2 most important questions. The doctor doesn’t have time to answer all of your questions so it is up to you to keep the doctor focused on what is most important to you.

And a Bonus Secret, if you want to make the doctor angry, keep your most important question a secret until the end of the appointment, and as the doctor is walking out the door say, “I have one more question …” If you wait until the end for this “Oh by the way” question, the doctor will only have one minute left to answer it. Please, write down this most important question so the doctor can spend time helping you.

If you would like, I have created a form for you to use each time you go to the doctor, Viki Kind’s Office Form for getting more from your doctor. Sign up for my newsletter and I will send you new support tools once a month.  Print out a couple of copies so you have them ready before your next appointment.

Have a kind and respectful day.

How to help your patient understand what you have told them.

The conversation with the patient should be a dialogue, not a monologue. But we are in a hurry and forget to make sure they understand us.

Here a few easy solutions:

1. Use the explain back method. After you tell the patient about their disease, have them explain back to you what they heard you say. This will allow you to confirm that they have understood correctly and it will allow you to clarify anything they got wrong.

2. Same thing when you give them instructions. Have them repeat back what they heard you say. Again, you will be able to make sure they got it right. If they got it wrong, just repeat the instructions again and then have they explain back what they just heard.

3. If this isn’t working, then you will need to write down the instructions for them or have them write the information themselves. Ask them which they would prefer, you writing or them writing.

4. Have them bring a tape recorder and record the instructions and information about their disease.

5. Have them bring a helpful loved one with them. A second set of ears can help them both remember the details.

6. Tell them that if they have questions when they get home, have them call back and your nurse will explain it to them again or they can make a follow up appointment and go over it with you again.

Yes, it shouldn’t be this hard to communicate, but it is. It is normal for people to only hear part of what we say. The explain back method is a great way to solve this problem.

Have a kind and respectful day.

What did the doctor say?

Dear Viki,

Sometimes when I go to the doctor, I forget what they told me to do. How can I make sure that I understand what the doctor says?

So many times we get overwhelmed by our visit to the doctors. Either they tell us too much information or they tell us information we don’t quite understand.

Here is an easy set of solutions.

1. Use the explain back method. After the doctor tells you about your disease, explain back to him what he has said. This will allow you to confirm your understanding and for him to clarify anything you got wrong.

2. When you’re the doctor or nurse gives you instructions, repeat back or explain back what they just said. Again, they will be able to make sure you got it right.

3. Ask them to write it down for you or you write it down yourself. Have them check to make sure you wrote it correctly.

4. Bring a tape recorder and record the instructions and information about your disease.

5. Bring a helpful loved one with you. A second set of ears can help you both remember the details.

6. If you have questions when you get home, call and have them explain it to you again or make a follow up appointment and talk it through again.

Yes, it shouldn’t be this hard to communicate, but it is. It is normal for people to only hear part of what is said. The explain back method is a great way to solve this problem.

Have a kind and respectful day.

Doctor Desperation = Doctors are disappearing – Part 2

I know I hold healthcare professionals to a high standard. But I also have tremendous respect and compassion for them. They have a difficult job and sometimes we make it worse for them.

I was in Las Vegas last week lecturing and there was a commercial on television. It showed two doctors caring for a patient in the hospital. The voiceover reminded the audience that if we don’t support education, then in the future there may not be enough doctors to care for and support us. And as this was said, the two doctors disappeared from the hospital room. It was a rather dramatic visual moment. What if people stop wanting to become doctors? What if it becomes so burdensome to become a doctor that the best and brightest students started going into other professions? What if it becomes so difficult to practice medicine that the doctors we already have begin to leave?

This is already happening. Doctors are leaving the practice of medicine.  How many months would you work if you weren’t getting paid?  Would you work for 1 month for free?  No, but the doctors are.  They keep working even though they can’t afford to stay in practice as the insurance companies pay less and less. The increasing use of electronic medical records is making it difficult for the older doctors who don’t type well to keep practicing. Malpractice insurance costs keep skyrocketing. And most importantly, the respect and appreciation they used to receive from patients and families is disappearing. No money, no significance, not worth it.

Medicine has always been a profound profession. Doctors knew they were making a difference and that it was worth all the years of training and the long daily hours. But now, they aren’t as sure. Just after I wrote this doctor piece, I went to give a lecture. I asked the first doctor to arrive, “What type of medicine do you practice?” He said, “I retired early. The healthcare system broke me. It became too difficult to practice anymore so I gave up.” He wasn’t an old man. He was broken man. Did he still love medicine? Of course. He was still attending a continuing medical education class. But medicine had become too difficult.

We better be careful. Our doctors are leaving us. I doubt medicine will ever pay well again, but maybe as patients, we can still let them know that our doctors are making a difference. Tell them that we appreciate and respect all of the sacrifices they make for us. Tell them that they matter.

Have a kind and respectful day.

Should a doctor treat their own family members?

Dear Viki,

What is your take on doctors who take care of patients with whom they have a personal relationship including families and how should hospitals deal with this?

Thanks for asking this question. This is an ethical problem that is regularly ignored and has always bothered me. The quick answer is that doctors shouldn’t treat loved ones unless it is an emergency and no other doctor is available or if the patient is in an isolated place and no other doctor is nearby. This would never be the case in a hospital setting where another doctor is readily available. Hospitals should have a policy against this behavior.  This may be more difficult to deal with in rural communities but every effort should be taken to protect the patient.

I have heard doctors tell me that they can be objective. They may think that they are able to be objective, and maybe one or two can, but they can’t change what the patient is experiencing. Patients may not be willing to tell the whole truth to their family member, may be embarrassed to be examined by the family member and may feel pressured to do what the doctor/family member says even though they disagree with the plan. And it doesn’t have to be only with family members. It can also be a problem with friends who are healthcare providers. Doctors should hold themselves to the higher standard and live by their own professional code of ethics.

Here is what the American Medical Association has to say about it in the physician’s Code of Medical Ethics:

E-8.19 Self-Treatment or Treatment of Immediate Family Members

Physicians generally should not treat themselves or members of their immediate families. Professional objectivity may be compromised when an immediate family member or the physician is the patient; the physician’s personal feelings may unduly influence his or her professional medical judgment, thereby interfering with the care being delivered. Physicians may fail to probe sensitive areas when taking the medical history or may fail to perform intimate parts of the physical examination. Similarly, patients may feel uncomfortable disclosing sensitive information or undergoing an intimate examination when the physician is an immediate family member. This discomfort is particularly the case when the patient is a minor child, and sensitive or intimate care should especially be avoided for such patients. When treating themselves or immediate family members, physicians may be inclined to treat problems that are beyond their expertise or training. If tensions develop in a physician’s professional relationship with a family member, perhaps as a result of a negative medical outcome, such difficulties may be carried over into the family member’s personal relationship with the physician.

Concerns regarding patient autonomy and informed consent are also relevant when physicians attempt to treat members of their immediate family. Family members may be reluctant to state their preference for another physician or decline a recommendation for fear of offending the physician. In particular, minor children will generally not feel free to refuse care from their parents. Likewise, physicians may feel obligated to provide care to immediate family members even if they feel uncomfortable providing care.

It would not always be inappropriate to undertake self-treatment or treatment of immediate family members. In emergency settings or isolated settings where there is no other qualified physician available, physicians should not hesitate to treat themselves or family members until another physician becomes available. In addition, while physicians should not serve as a primary or regular care provider for immediate family members, there are situations in which routine care is acceptable for short-term, minor problems.

Except in emergencies, it is not appropriate for physicians to write prescriptions for controlled substances for themselves or immediate family members. (I, II, IV) Issued June 1993.

Your Patient’s Just Not That Into You

Are you the difficult doctor? Are you making things better or worse for your patient and their family? You might be perceived as a difficult doctor if:

– The nurses hide when you come onto the floor

– You will not return phone calls

– You will not listen to the patient/family

– You appear too busy and in a hurry to demonstrate compassion

– You will not respect the patient’s wishes or the patient’s advance directive

– You will not transfer the patient to another doctor who would be a better fit

– You have a bias against the patient’s culture, religion, gender, sexual orientation, etc.

I had a doctor tell me that the nurses hide from him but he was sure he wasn’t the problem. I just smiled as he went on to defend his rude and aggressive behaviors. I tried to explain to him that how you treat a patient affects the medical outcome. Research has shown that if a patient trusts you, they will heal faster. And trust comes from good communication. I told him that I understood that he didn’t mean to be difficult and that he may just be misunderstood because he is so busy.

If your patients aren’t that into you, then here are some strategies to help your patients reconnect with you.

Here is the most important point: We want to turn judgment into compassion. When a person comes into your office, you don’t know what just happened in their life. They may be grumpy, angry, frustrated or sad because they are in the middle of a divorce, their brother just died or they just had a car accident. Whenever I see someone in a bad mood, I give them the benefit of the doubt. I try to be compassionate and give them extra support. Usually, just showing them some kindness turns the situation around and I become a trusted ally.

Other ways to rebuild the relationship:

1. Be aware of your negative expectations. If you walk in expecting the worst, you will get it.

2. Avoid making assumptions. Your assumptions may be wrong. There may be a good reason this patient is being difficult and if you can find out what it is, you can help resolve their issues.

3. Listen more so you can understand the patient’s perspective. Listening itself can be an act of healing. When you listen, the patient feels cared about.

4. When we deal with someone who is difficult, our frustration makes us pull away from them. What we really need to do is to monitor our emotions and reactions so we can continue to be empathetic and compassionate.

5. If the patient continues to be non-compliant, work on maintaining the relationship through an ongoing dialogue. If the patient can rebuild their trust in you over time, they may begin to take your advice. You have the power to change it from a conflicted relationship into a collaborative one.

Your Doctor’s Just Not That Into You

Do you get the sense that the doctor doesn’t seem to care about you? Does the doctor seem rushed? Are they not listening to your concerns? Do they not return your phone calls? If so, you may have a difficult doctor as your doctor.

The reality is that all doctors are rushed now. Doctors have a lot of financial pressures as the insurance companies pay them less and less every year. I know doctors that can barely pay their bills but they love medicine so they keep practicing. So, if it is just that you don’t get enough time, that might happen with any doctor.

But if it is more than that, you may have a doctor who is judgmental and won’t give you enough care. Research has shown that if a doctor doesn’t like a patient, they will spend less time with the patient. They might not like you because you are overweight, from a different religion, from a different culture, or you aren’t following their advice. Doctors get frustrated when patients won’t listen to them. You come to them for help and then you don’t take the medicine, go get your x-rays done, stop smoking, eat healthy, etc. Doctors shouldn’t get frustrated but they are human. They want you to get better and when you become a non-compliant, problem patient, then they treat you as a problem. I am not saying this is right, but this is what happens.

Your goal is to have a good working relationship with your healthcare team. And it is up to you to be a good team member too. You don’t have to agree with everything the doctor says, but you should be respectful and at least consider what the doctor is saying.

So what can you do if you have a bad relationship with your doctor? If you truly don’t like your doctor or think the doctor is the wrong doctor for you, then you should change doctors. You are allowed to fire a doctor at any time. Don’t let them tell you differently. Your insurance has to provide you other options. How do you fire a doctor? You can just tell them or you can write a letter. The doctor is obligated to give you a copy of your medical records and they are allowed to charge you a reasonable fee for this. Even if you are in the hospital, you can still fire your doctor.

One more thing to consider. Doctors are real people too. They have personal problems just like all of us. So if they are just a problem at one visit, then maybe they have just had a death in the family or are dealing with a problem teenager. Give them the benefit of the doubt and understand that they are doing the best they can. If they continue to be distracted, disrespectful or uncaring, then change doctors right away.

Helping the Family Make the Difficult Decisions

Doctors tell me all the time that they struggle with families that aren’t respecting the patient’s wishes or are not making wise decisions for their loved ones. Over the next months, I will give you many techniques you can use in these situations. Here are two to help you begin.

A dear friend of mine was sitting at the bedside of his wife after her massive stroke. They had been married for over 50 years. As I sat with him he said to me, “The doctors keep asking me what I want them to do. Well, what I want is for them to keep Ruth alive no matter what.” I nodded and listened as he continued. “If they asked me what Ruth would want, she would say, “Let me go, I don’t want to live like this. But the doctors don’t ask me what she wants, just what I want.” I was so surprised that in his grief he understood the difference.

So here are two techniques you can begin to use to improve end of life decision conversations. First, stop asking, “What do you want us to do?” And instead ask, “What would (the patient’s name) want us to? What would (the patient’s name) be telling us to do in this situation?” And if the family member responds, “What I want is …” you stop them and re-clarify that they are supposed to speak as if they are patient. You can always use the classic question, “If the patient was able to wake up for 5 minutes and understand what was going on, what would the patient say?” The trick is to keep silent after the question and let the family member struggle with the question. The silence in the room helps the person understand the significance and the weight of the question. Don’t rush them as they haven’t been thinking about what the patient would want; only what they would want.

Secondly, you need to educate the family about their role as the decision maker early on. Explain to them that they are supposed to make the decisions based on the patient’s values, not what they would want. Tell them that they are supposed to speak with the patient’s voice and wishes, even if it’s hard to do. I think we need to acknowledge how difficult this job is for the family member and to validate their struggles. “I know this must be very difficult for you, but it is important that we respect your loved one and follow their wishes.” If we can begin the conversation with the right questions and to educate families regarding their role, it will provide a good beginning to improving end of life communication. More to come on this topic later.

Family as Stakeholder

I had an interesting discussion the other day about what to call the family when they are involved in the patient’s care. Do we call them simply family? Or caregiver? Or stakeholder?

Each of these terms comes with assumptions about the family’s role in the healthcare setting.

If you are a caregiver, you are changing someone’s diapers and helping push their wheelchair. If you are the family, then I would ask, “Are you there to help or are you going to make things worse because of the conflicts already within your family?”

I like the term, family as stakeholder because as a stakeholder you get a voice.

You have a stake in what is happening to your loved one. You have to take off work to go with the patient to their doctor’s appointments. When the patient is discharged from the hospital, you are responsible for their care. When the patient can’t pay their bills, you may feel responsible, even though you aren’t really responsible. While the doctors and nurses may grieve when the patient dies, it is your own deeper pain and loss you will have to deal with. Even though you aren’t the patient, you experience the effects of the situation.

Now, if you are from a culture where the family is more important than the individual, then your family may make it difficult for the healthcare team because the “family as decision maker” isn’t how healthcare works. Healthcare is based on autonomy which means the patient is in charge of making the decisions about their body. Now I am a big fan of autonomy because it is the patient’s body which will feel the effects of the medications, the pain of the surgery and the long term suffering associated with their disease. As the family, we only witness what they are going through. But as much as I love autonomy, I understand how hard it is to be the family and see your loved one in pain, afraid or maybe dying.

The pediatric physicians get this. Pediatricians practice “Family Centered Medicine.” What does this mean? It means they take into account how the patient’s situation is affecting the entire family. The patient is still the primary person that they focus on but they don’t ignore that the family has a role in whether or not the child will get better. But this isn’t how it works in adult medicine. It is only about the patient.

So what can you do if you want a voice? Be cooperative and respectful when you are dealing with the doctors and nurses. Say please and thank you when people help your loved one. Pay attention to what the doctor is saying because the patient may be too sick to listen. And when you see something that is going wrong, don’t threaten to sue but instead bring it to everyone’s attention and ask, “How can we solve this problem together.” You don’t want to become the enemy. You want to be a part of the team.

I had an interesting discussion the other day about what to call the family when they are involved in the patient’s care. Do we call them simply family? Or caregiver? Or stakeholder? Each of these terms comes with assumptions about the family’s role in the healthcare setting. If you are a caregiver, you are changing someone’s diapers and helping push their wheelchair. If you are the family, then I would ask, “Are you there to help or are you going to make things worse because of the conflicts already within your family?”

I like the term, family as stakeholder because as a stakeholder you get a voice. You have a stake in what is happening to your loved one. You have to take off work to go with the patient to their doctor’s appointments. When the patient is discharged from the hospital, you are responsible for their care. When the patient can’t pay their bills, you may feel responsible, even though you aren’t really responsible. While the doctors and nurses may grieve when the patient dies, it is your own deeper pain and loss you will have to deal with. Even though you aren’t the patient, you experience the effects of the situation.

Now, if you are from a culture where the family is more important than the individual, then your family may make it difficult for the healthcare team because the “family as decision maker” isn’t how healthcare works. Healthcare is based on autonomy which means the patient is in charge of making the decisions about their body. Now I am a big fan of autonomy because it is the patient’s body which will feel the effects of the medications, the pain of the surgery and the long term suffering associated with their disease. As the family, we only witness what they are going through. But as much as I love autonomy, I understand how hard it is to be the family and see your loved one in pain, afraid or maybe dying.

The pediatric physicians get this. Pediatricians practice “Family Centered Medicine.” What does this mean? It means they take into account how the patient’s situation is affecting the entire family. The patient is still the primary person that they focus on but they don’t ignore that the family has a role in whether or not the child will get better. But this isn’t how it works in adult medicine. It is only about the patient.

So what can you do if you want a voice? Be cooperative and respectful when you are dealing with the doctors and nurses. Say please and thank you when people help your loved one. Pay attention to what the doctor is saying because the patient may be too sick to listen. And when you see something that is going wrong, don’t threaten to sue but instead bring it to everyone’s attention and ask, “How can we solve this problem together.” You don’t want to become the enemy. You want to be a part of the team.