Patients need to contribute to help their doctors

“Be a fountain not a drain,” an expression used by baseball announcer Rex Hudler, is one that has motivational content particularly in terms of an individual included as part of a team.

I would suggest that this expression would be appropriate when considering a basic team in medical practice: the doctor-patient relationship. It is critical in most clinical situations that both the doctor and the patient assume responsibility for making progress toward the goal of diagnosis and therapy and hopefully a cure. The doctor-patient relationship is not one of the patients simply “taking” or “draining” the knowledge and skills of the physician or one of the doctor simply “spouting” those capacities to the patient.

Each member of this team has a responsibility to contribute and not just “take.” That means that the patient must realize that the doctor can usually fail to make a diagnosis without a full history provided by the patient. It also means that to examine the patient, a certain degree of patient cooperation is required for the exam to be of value. And when it comes to treatment, patient compliance is also essential.

On the other hand, the physician should understand that looking at the patient simply as an “object” of a disease and a resource to demonstrate one’s skills for an income is not what the doctor-patient relationship is all about. It is not about “taking” but is about considering the patient as a “subject” of physical and mental concerns giving the patient not only a chance to be physically healthy but also a feeling of comfort in the relationship and support of the patient’s emotional health.

Now, one may argue that the doctor-patient relationship is not really a equally balanced one in that it is the patient who is sick and may be ignorant of the facts of the illness and treatment whereas the doctor is not. Therefore, it should be only the doctor who should be required to be the “fountain” and, well, the patient receiving and taking the results, the “drain.”

Which view do you hold?

Maurice Bernstein is a physician who blogs at Bioethics Discussion Blog

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  • http://twitter.com/shotzie52 RCK

    There are many informed patients out there and many doctors who refuse to accept information from those patients.  Maybe it is just the area I live in but I saw it both as a patient and while working in several family practice offices.  The older generation seems to want to be spoon fed but those of us in the computer age seem to have our act together and the ability to question. 

    Sure some patients can be ridiculous with thinking every minor symptom is some major disease but many come in with legitimate concerns and because the provider didn’t come up with the idea it is dismissed. 

    Those of us with complicated multisystem problems get the “trainwreck” or PITA label and aren’t even listened to.  I had two serious conditions missed this way, I even was able to find that unprovoked low serum K and increasing uncontrollable BP could mean Conn’s Syndrome by a simple internet search.  Took that to my provider and was told no way and it was not considered…Guess what, I had it and was cured with surgery once I found a provider willing to do proper testing.

     

  • http://twitter.com/ConversasVadias CarLoS

    Is this a matter of “view”? I mean, does one´s  view defines the results? Or rather is this a matter of *what is*, meaning that there is some kind of  EBM for every particular situation and, in this view, both - patient and doctor – have is own and irreplaceable paper?

  • Anonymous

    Patient-centered care is built upon the notion that the patient is no longer an empty recipient waiting to be filled by the all-knowing doctor. You correctly describe how an involved patient will receive better care because the doctor can’t do it alone. Like most professions, medicine also medicine also needs active patients who bring valuable assets to the table. These assets may take the form of information, time and most always actions outside the hospital.

    After all what’s the value in a patient who is a drain?

  • Steve Wilkins

    Yes patients need to accept more responsibility and actively contribute/participate during the medical interview.  The problem is that since the early 1900′s patients have been “socialized” into being passive where the doctor does the talking and patients simply respond to questions.  Today even the most empowered patients ask very few “important” questions during the typical office visit. The literature is very clear on this issue. If physicians want patients to behave differently they have to tell them that the rules have changed, invite their participation, and them behave as if the patient’s input really matters. It is unreasonable to otherwise expect that patients will become “fountains” of information without doing this.

    Steve Wilkins
    http://www.healthecommunications.wordpress.com     

  • http://twitter.com/DoktorMo Maurice Bernstein,MD

    The question is what should society and the medical profession do to encourage patients that their job in furthering their quest for relief and cure is beyond the now fully ethically and legally supported autonomous decision-making but to feel free to speak (not “speak up” but speak) to their doctors as a person who also “knows facts” that the doctor should be made aware.  The facts will be their own personal history but also the facts that they have gathered through their own research. Sadly, what can be done about this is inhibited by the way medical practice is practiced these days: rush and no time to LISTEN. Who spends an hour with the patient.. how about a half hour?  And can the patient say “wait! I have something to say”? Time, yes, the looking at the time and readying for the next patient is the current medical practice “spigot” which is turning off the patient to become a “fountain”. ..Maurice.

    • Steve Wilkins

      Maurice,

      Surprisingly one way that has been shown to “get the patient more involved” is for the physician to given them permission to “speak.” To invite questions. I am not being facetious or flippant here.  Older patients in particular are afraid to interrupt the doctor once the medical interview starts.  Beyond their opening statement there really is no place for them to speak up.

      Steve Wilkins

      • http://twitter.com/DoktorMo Maurice Bernstein,MD

        Steve, you used the expression I was seriously trying to avoid: “speak up” and I think that this expression exposes the problem in the communication between patient and doctor. Once the patient sees the doctor as above his or her social class, above his or her education, above his or her financial level, someone who has potential control over the patient’s illness and someone considered “untouchable” but is permitted to “touch” the patient, then to speak is to “speak up” not simply “speak”. And therefore many patient.are inhibited to do so. Yes, your suggestion is correct for the physician to encourage the patient to speak but also for the doctor to promise to listen. ..Maurice.  

  • Anonymous

    I’m a linguist who studies medical discourse.  In my field, we regard all speech and communication styles as being equally valid, and we look at them as reflecting each speaker’s conversational goals, objectives, and understanding of the “rules of engagement” for the conversation.  In the case of a medical interview, the doctor and patient both want the patient to receive quality medical care, but they often have different understandings of how that is to be achieved, which comes out in the way they interact.  It’s important for patients to meet their doctors half-way by being prepared with information about their condition–when, where, how long, how severe, etc.–and to state up-front why they’re visiting.  Yes, more time with patients would certainly be helpful.  Anticipating doctor’s questions can help patients get more out of that brief time they have with their doctor, just as opening the floor to the patient and listening without interrupting can help the doctor receive the information he/she needs to make an accurate diagnosis.

  • http://twitter.com/PatientCommando Patient Commando

    There’s a corny old joke circulating among patients that has 1 patient saying to the other “Have you noticed that doctors only practice medicine. That’s right - Practice. Do you ever wonder when they’re going to stop practicing  and start doing it for real?”
    I don’t have a comparable corny joke about patients. The reality is that when a patient is told they have a serious illness, they don’t get any time to practice. They’re thrown into the game right away.
    So the doctor at this point has a head start of at least 35,000 words – the vocabulary they pickup in medical school. There are many patients who have the ability to take up this unbalanced challenge. Doctors would do well to understand how to identify them. There are existing  patient evolutionary scales such as The Patient Activation Measure developed by Hibbard, Mahoney, et al. Or the 4 groups defined by Von Knoop et al (2003) that divide e-patients by their level of patient engagement characteristics.
    The point I’m making here is that to expect patients as a group to change established behavioral patterns in the patient/doctor relationship is a lofty ambition. Not that I wouldn’t want that to happen. An important step to help that happen would be to equip doctors with the ability to identify at what point in the evolutionary journey a patient might be and then to continue to empower that patient towards a goal of self-managemen.
    Doctors need to recognize which patients have the best prospect to become full partners in their healthcare. It starts with active listening skills. Focusing on building relationships with the best potential partners will affect outcomes.

    Zal Press
    http://www.patientcommando.com

    • http://twitter.com/DoktorMo Maurice Bernstein,MD

      “Practice”
      of medicine represents the reality that diagnosis and treatment outcomes are
      full of uncertainty compared with the outcomes of other work some people
      perform and the uncertainty is a burden on this worker, the doctor.. With
      this uncertainty the doctor is always looking to learn and learning. With
      every change in the patient’s diagnostic workup or treatment or with every
      similar case, the doctor’s knowledge progresses. On the other hand, nothing is
      necessarily “cut and dried” from the ill patient’s point of view either since the issue remains regarding the patient’s learning to cope with the many
      previously unexperienced aspects of their illness and that learning to cope requires
      practice to find the most effective approach. 
      What I am getting at is that, in dealing with a medical illness due to
      its variability in nature and progression, “practice” is not a
      one-sided function.  That is why both
      physician and patient are involved in the “practice” of the illness
      and therefore, pertinent to the topic here,  both should be contributing to each other’s learning.
      ..Maurice.

  • http://pulse.yahoo.com/_JY5FGLSV3JYM77D66PX4ZWAYAU Trinigyal

    I definitely agree that patients need to accept more responsibility & actually participate during their doctors’ visits.  I think that a large part of the problem is that unfortunately many patients aren’t tuned into their own health on a regular basis unless something is going (sometimes terribly) wrong.

    As a former Disease Mgmt nurse I cannot tell you how difficult, not to mention extraordinarily frustrating, it was just to get many patients interested in their own health/knowing their own health status let alone encourage them be more than just physically present during their doctors’ visits.

    To try & get some of them to ‘get it’ I liked to use the analogy that when you take your car to the shop for repairs, the mechanic checks it out & calls you FIRST to tell you what’s wrong, what it will take to repair it, how much it will cost, how long the repairs will take etc. The mechanic calls you BEFORE they do anything else with your car. Then I’d say, so you have all this information, all the details about your CAR, an object that can be replaced but you have no idea why you’re taking these 10 medications? Or if they’re even working?

    The point is that I think patients don’t contribute or participate more at the doctors office partly because they don’t participate more in their own health maintenance at home. For the most part whether things are fine or not, patients feel fine (or lousy as usual) so they pay no attention until they’re forced to. Then when they’re at the doctors office, the mentality is ‘oh the doctor will tell me’ or ‘he/she has my chart/my information’ so they still kinda sit there like a bump on a log.

    I can’t tell you how many times I’ve heard “Oh, I’ll let my doctor worry about that.” I’d have to remind them that their doctor cannot be with them 24/7 so they need to help their doctor to help them. Some patients got it, some did not/would not.

    Maybe one way to get patients more involved is to give them homework. Ask them to check & record their BP (or whatever) for X number of days, once a week, something & then ASK for the results. Impress upon them that you aren’t psychic & need some input, some participation, some dialogue for Pete’s sake to make it happen.

    • http://twitter.com/DoktorMo Maurice Bernstein,MD

      Trinigyal, I suspect that many patient who were well and then became sick have a certaininertia to accept being sick.. I mean, sick enough to warrant personal attention to the details
      of their illness. Patients need education by their doctor about their sickness, what to
      consider and what to do about it.  If doctors think that simply naming the disorder and 
      the treatment without spending time needed to educate and have the patient understand
      what their illness is all about, the doctors should accept their patient’s non-compliance.
      Continuing with the analogy, education and support becomes the turning ON of the “spigot”
      allowing the patient to participate as the fountain and not simply a drain. ..Maurice. 

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