A growing culture of hostile dependency toward doctors

An interesting phenomenon is occurring in media circles these days.  No doubt others have seen it, too.

Lately, doctors are being schooled by the media.

From how to learn empathy, to improving communication with patients, the breadth and depth of what we should do for our patients is endless.  Why, some even have our own colleague experts tell us how we should really do things.

These efforts, while probably well-intentioned, are patronizing.  Do doctors tell journalists how to write or what to print?

Why are doctors seeing these mainstream media efforts?  Is it because most doctors are really incapable of the ability to listen and communicate with our patients?  Is it because we must keep a stiff upper lip for what’s coming in 2014?   Or is this not-so-subliminal agenda of social engineering underway for some other reason?

It goes without saying that all of us should communicate better.  (Think how many wars or family fights we could have avoided if we had, for instance.)  And every doctor should turn their head away from computer screens and toward their patients, hold the patient’s hands, look into their eyes, listen to their concerns, put ourselves in their place, do a thorough physical exam, have constant empathy and insight, read back medications, write out written instructions in 5th grade English, escort our patients back to the waiting room, or utilize highly skilled and educated assistants with all of these tasks, too.

But the reality is this: time and ancillary resources are limited these days for doctors.  Helpers cost money.   Productivity must occur before new helpers are hired.  More people than ever are entering health care thanks to intense marketing campaigns and new mandates for care.  And there are so many doctors with only so many minutes in the day.

So doctors have to triage.  Sickest first.  We move as fast as we can to remain productive, because that’s what’s really valued in healthcare these days.  So is patient loyalty because that’s what keeps them coming back.  But in the process of growing loyalty, we increasingly have to document everything or other payers think it doesn’t happen.  So we type.  And click.  And type.   And click.   And print.  To get paid.  Talk about a communication and empathy buzzkill.

Yet for those looking in, we must communicate better.  ”Listen to our experts!” they proclaim.

Medicine was once considered a place where patients could confide in their doctors about their most intimate concerns and doctors had time to listen. Notes were one- or two-line jots in a chart.   We’d spend the extra time because we were valued for our skills and for our knowledge and there was more to it than just pay.  We had skin in the game. We got paid in chickens.  We knew our patients.  Back then, seven-minute appointments didn’t exist.

Now, doctors are cultivated as shift workers.  Patients have Google.  Everyone has information at their fingertips.  Our new story line has become there are no limits to what patients can have in health care.  Perfect data.  Perfect health care access.  Error-free health care with perfect delivery.  Perfect communicating doctors.  Always.  We’re building our medical Utopia.

But this effort to school doctors on our path to Nirvana has a serious downside for health care workers on the front lines.

As I’ve said before, there’s a growing culture of hostile dependency that continues to grow toward doctors  these days.  The theme is like an adolescent who realizes his parents have feet of clay.  He comes out of his childhood bubble and realizes his parents have failures and limitations because they are human beings.  This results in the adolescent feeling unsafe, unprotected and vulnerable.  Since this is not a pleasant feeling, narcissistic rage is triggered toward the people he needs and depends on the most.  None of this occurs at a conscious level.  Most of us understand this behavior simply as “adolescent rebellion,” not understanding the powerful issues at play.  So when we spotlight one side of what doctors should do for patients, be it improve communication or empathy (or whatever) without acknowledging the realities health care workers face like looming staffing shortages and pay cuts, we risk fanning the flames of narcissistic rage against the very caregivers whom we depend on the most - the very caregivers who are striving to communicate, do more with less, check boxes while still looking in the patient’s eyes, meet productivity ratios, all while working in a highly litigious environment.

So be careful.  Maybe we should school doctors less and value them more.

Who knows?  Such a move might make things better for everyone in the long run.

Wes Fisher is a cardiologist who blogs at Dr. Wes.

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  • http://euonymous.wordpress.com euonymous

    Thanks for writing that, Wes, when I’m sure you have plenty of other things to be doing. The phrase “hostile dependency” is a real attention getter. (Dare I mention that I have the same feelings towards our CPA-lawyer-taxguy?) Hostile dependency. Professional practice is too darn complicated in the medical profession. And government has made it complicated. You want to do your job and it is turned into a long, drawn-out effort by the need to deal with insurance companies and often government agencies. (And it’s the government’s fault that I wouldn’t dare try to do my own taxes. Haven’t for years. Flat tax anyone?) Single payer anyone? Universal healthcare anyone? How can anyone focus on patient health when they are forced to focus on paperwork documenting that a human being has consulted with you? Pardon the rant, but unless we make some changes in this country, I don’t see how the medical profession can focus on healthcare.

    I am reminded of a commercial artist I know who is very talented and a great human being. He once confided that the most useful course he took in art school was the one that explained how to run a small business. I get a creepy feeling that individual and small practices are being pushed out of existence by massive overhead requirements. At what point do we have a referendum on how we would like our healthcare system to function?

    As for the media… it’s up to you to use the media for your agenda. Don’t let them bug you. They’re living with the pressures of their own news cycle and will pick up anything “trending”. Use them to get your message out. Build a relationship with your local (almost obsolete) newspapers and TV stations. Hit the national media if you have the energy for it or encourage national medical groups to get the message out. Hang in there.

    • buzzkillerjsmith

      Referendum?!

      At what point do we get a referendum on how our financial system works? Or our energy sector? Or the oil companies? Or…?

      C’mon Euo. this is America. Welcome to the corporatocracy.

  • Daniel

    Perfect healthcare at half the cost. Always low prices. Always.

  • Fat Rasputin

    Three years ago I became critically ill and over the last three years I have seen around twenty different doctors. Things I have learned as a patient is that many doctors need to communicate better. When I say that I find that doctors have lost the art of taking a patient history and its importance as a diagnostic tool. Most of them have pawned these off on forms that I can tell most of them do not read because they ask me what disease I have. Listening to patients is part of communication and it is a lost art. Out of the twenty doctors I would say three actually listen to what I say in proactive manner. When I was first ill I endured many unnecessary procedures because I would not stand up to doctors and they would not listen. I can give you specifics if you would like and believe it or not most of the glaring ones were committed by two different cardiologists. I find your tone condescending, you may not want journalists telling you how to do your job but I do not want doctors telling me how I feel and not listening to me.

    • azmd

      I am really sorry to hear that you had a critical illness that left you needing to see so many doctors. That does sound stressful and I am sure you have had many unsatisfying experiences in which your doctor was not able to take the time to process with you whatever you were concerned about, leaving you feeling unheard and unlistened to.

      However, I think you missed one of the main points of this piece, which was that the practice of medicine has been significantly affected by regulatory requirements for documentation and other administrative tasks that have nothing to do with taking care of the patient or even spending time with him.

      There are only so many hours in the day. If I now spend three of those hours making phone calls and filling out complicated check-box forms documenting my patient encounters, that’s three hours less that I have to listen to my patients. And no matter how efficiently and effectively I try to listen, there are inevitably going to be patients who really needed that extra 10 minutes that I am now spending arguing with their insurance company, or explaining to the pharmacy why they need a particular medication, or filling out a note explaining in excruciating detail what I did and why I should get paid for it, instead of listening to something my patient wants me to hear.

      Patients wonder why we don’t just work later, I think, so that we have that time with them. But what they don’t know is that there is in most cases, no more time in our day. I finished my last admit note for yesterday at 12:15 this morning. I had not eaten or gone to the bathroom all day, but I had a patient during the day who wondered why I couldn’t spend more than 30 minutes with him reviewing his care plan for the third time, and his mother wondered why I couldn’t spend more than 20 minutes on the phone with her, and why it had taken me two hours to return her call.

      I too, wonder about this growing trend for hostile dependency, so clearly described in the piece above. I wonder how much it has to do with our culture, in which we all spend so much time staring at screens, and so little time with each other. I think our patients come to us hungrier for human contact than they used to be, because those needs are not being met in their day-to-day lives. What is sad is that they come to us with greater needs, just at the time when competing demands leave us unable to fully meet them. It is sad for all of us.

      • Fat Rasputin

        I understand your point but I think you have missed mine. Communication with patients is part of medicine that has gone by the wayside. You tell me what I need to do to fix that and I will. From a patient perspective I got get inferior care because doctors do not listen. If I need to call my legislator about some bill that is effecting this let me know. All I know is getting a history and communicating with patients is part of good care, I have not received very good care on this . I sympathize but I will not change my stance I am not WSJ reporter I am a person speaking from experience. If I had died from one of those unnecessary procedures what would be your comment then? They were routine but there is always a chance of death. Not listening is real and I am hostile, not that I am dependent but that I am not listened too.

        • NewMexicoRam

          No, I think azmd heard your point quite well. Read the first paragraph of the response to you. Azmd summed up your points.

          Doctors are human, not divine. Maybe if we went back to patients paying the bill the doctor writes, instead of some 3rd party payer who is trying to skimp at every turn, then doctors can spend the time with patients once again.

          Whoops, now we have ObamaCare, physician shortages worsening, Medicare payments frozen to physicians for another 10 years. Bye-bye patient centered care. Was a good idea, but finances never seem to meet expectations.

          • Fat Rasputin

            I worked at a bank before I got sick, if I said do to regulation I can no longer necessarily get the money you bring to us into your account would you accept that? I am not going to accept that I should get inferior care because of regulation, start a revolt, get a lobbyist, bring it to the attention of citizens. Do not give me inferior care under the pretense I do have time to give you good care because of regulation. That is not a moral position in my opinion. Communication is should be a part of healthcare, do not tell me I should not expect it because the people offering it are human. Humans communicate. I do not ask for perfection I ask for a quality standard of care. You can not tell me it is not possible because I see doctors that do communicate. You would not tolerate that in other spheres so why I am expected to tolerate it in medicine.

          • azmd

            Our responses here are an attempt to “bring it to the attention of citizens.” Too frequently we find that we are not being heard–look at your own responses here. I think perhaps people do not want to hear that they are receiving care in a system that rations its resources, because that’s a scary and depressing prospect to contemplate. It’s easier to blame doctors and believe that if they really wanted to, they could do better.

          • Fat Rasputin

            If this is not rhetorical I will ask the doctors I have that do spend the time how they do it. I know it can be done, I have three specialists that spend enough time with me no matter how much time that is. One is a Critical Care specialist originally a pulmonologist by trade, the other is an ENT who specializes in vertigo and the other is an opthamologist. I am currently in search of rheumatologist and a dermatologist since the last pair refused to listen or even acknowledge they did not know answers to center questions. If I always received bad care I would agree to your thesis but the fact that I do not always receive bad care tells me there is something missing. If you really want the answer my doctors give me hit me up on twitter with a DM.

          • azmd

            I think when you’re talking about specialists, it’s slightly different. They are typically under less time pressure and have more ability to give the patient time, or should.

            In those cases where the patient feels unheard by a specialist, I think personality issues can be in play, on both sides. I am glad you have found some specialists you feel heard by, and wish you good luck in finding some more.

          • Fat Rasputin

            The doctor that wrote the article is a specialist, he is a cardiologist. I only see specialists, the doctors that have failed have all been specialists. I think the thesis has failed.

          • Suzi Q 38

            I will say that two of my doctors were excellent.
            If they can do it, why not others?
            You make a good point.

          • Suzi Q 38

            Agreed. You are right.

            It is a given that doctors serve their patients.
            Other professions have problems and time constraints, but death or bodily injury is not the result.
            Accountants know that there are new tax laws that make filing difficult, but they still have to serve their clients.

            Can you imagine a medical malpractice lawyer saying: Doctor, I’ll take your case, your $10K retainer, but I do not have the time to listen to the relevant components of your case? How could h/she defend you properly? You would surely lose with this form of behavior. How about if h/she said,
            “I had 30 clients that I saw today….cut me a break. I have to go home and I don’t have time to review your case before our court appearance tomorrow.”

          • azmd

            We do not “serve” our patients. We help them. A waitress “serves” you. I think that’s a critical distinction that a lot of people are missing. Treating doctors as though they are there to “serve” you is part of the culture of hostile dependency that the writer above is describing.

            It’s a real problem, because once you start feeling, inside yourself, that a doctor is there to “serve” you, you tend to behave like a customer, and to have unrealistic expectations of what level of “service: you should receive. You wonder why the doctor doesn’t call you back within an hour after you call, for example, and you call the nursing staff multiple times over the course of a couple of hours to complain about it, distracting them from emergencies and creating a dangerous situation for staff and other patients. This is an example that happened on my unit just the other day. Hostile dependency.

          • buzzkillerjsmith

            Hostile dependency and the serve mentality was the culture at No. CA Kaiser in the early to mid-90s. So I quit. Pts in every practice I have been in since treat me much better.

          • Suzi Q 38

            “We do not “serve” our patients. We help them. A waitress “serves” you. I think that’s a critical distinction that a lot of people are missing. Treating doctors as though they are there to “serve” you is part of the culture of hostile dependency that the writer above is describing.”

            I disagree. You don’t “serve” me in the same sense as a custodian, food server (waitress/waiter) or mechanic for my car “serves” me. Yes and no. Yes in the sense that I hire and PAY a physician for a service (to provide health care) this is on a much higher level than a custodian or a food server, although I feel that all careers have importance. I can skip lunch or having my office cleaned, but I can’t skip my hysterectomy if I have uterine cancer. I guess I could, but the result might not be positive.

            Your use of the word “serve” is an over simplification of my intended use of the word.

            I still say that my doctors provide a very important “service” to which they are compensated for. Nurses, PA’s, PT’s all provide different “services.” Doctors do as well, only at a higher level, depending on their specialty.
            My PCP providing the service of taking charge of my general health care and my neurosurgeon providing the service of my anterior dissection (c-spine) are two different services, but both very important to me.

            I don’t care if you take offense to my usage of the word “service,” I know it means “providing payment for services rendered.”

          • azmd

            “I hire and PAY a physician…”

            Here’s the problem with that entire premise, and why there is such a mismatch between patient expectations and the care they are receiving.

            You are not, in fact, paying the doctor for your care. An insurance company is paying your doctor, or a healthcare organization like Kaiser. So although you feel that you are entitled to demand a certain level of service from the doctor you think you are paying, that doctor is, in fact, actually obligated to spend a lot of his day doing the things that the entity which pays him thinks he should be doing. These days, those activities are more likely to involve telephone calls, regulation compliance and form completion than they are spending time with the patient. None of us likes it, but until patients start paying their doctors directly for their care, they will continue to have less say in how their doctors spend their day than they would like to have.

          • Suzi Q 38

            “You are not, in fact, paying the doctor for your care. An insurance company is paying your doctor, or a healthcare organization like Kaiser.”
            In my opinion, you are wrong.
            I am PAYING for my care. I get together with my employer and WE PAY 50%-%50% of the insurance premium, whether I use medical services or not, during any given month.
            WE (my employer and I) PAY $2,000.00 per month for PPO insurance, plus whatever fees that have to be paid if I should have to have surgery at a hospital. I also pay a measly co-pay of $15.00 per office visit. For 10 years we paid $1,850.00 a month without using it for any physician care other than yearly check-ups, pap smears, and a mammogram. I am not sure that I even went once a year for the mammogram and pap smear. We had the higher level insurance because I liked being able to choose my doctors and hospitals.
            Yes, my insurance company pays, but it collects premiums from many other patients like myself. We indirectly pay our physicians, you are right, but we are the end recipient of whatever services (or lack thereof) that the physician chooses to provide. Your loyalty or lack thereof should not only be to the insurance company, it should be to patients like myself, who, without us, you would be working elsewhere.

            I have a gyn that has just informed me that he will be charging $25.00 for his phone consultations, and $30.00 for a copy of my medical records. I am fine with that. If he is always charging me for this and that all of the time, and I don’t think that his care is any different than another doctor that wouldn’t charge me for this and that, I have choices.

            I sense that this is part of the reason that he is not as busy as others. Maybe he would rather charge a little more and provide better SERVICE rather than do what he used to do and be hurried and stressed all of the time.

            Yes, it is a given that you say that you help, rather than “serve.” Fine. I say that my doctors serve their patients. Of course they help their patients as well.

            On the outside of any California police car it says: “Protect and serve.” Who? The public that does not pay them directly, but is considered the end recipient of their services.

            I have met doctors that felt that they served the people that they came into contact with each day. Some were everyday, others were celebrities. The truly great did not say: “The insurance company pays me, NOT you.”

          • azmd

            At the end of the day, you are not paying your doctors for their work. It doesn’t matter a bit that you are paying your insurance company a lot of money. You are not paying directly for the care, and that creates huge implications for the care you receive.

            I am sure that you have sought out doctors who are highly professional and would never dream of telling you what they think, but I can promise you that at one point or another, all doctors these days think to themselves about the fact that patients’ expectations of the medical system would be more realistic if they had to pay for their care directly.

          • Suzi Q 38

            That would be fine with me. I have always had insurance from the time that I graduated from college. The insurance paid the doctor back in the 80′s as well as now. Somehow, those doctors cared more.
            I still pay the insurance company premiums. For us, nothing has changed except for the escalating amount of the premiums and some doctors that have a poor attitude.This is the USA. If you don’t like the way things are done at your hospital or group, work somewhere else.
            Don’t punish the patients for not being savvy enough to know the present day system.

          • azmd

            I was around back in the 80′s and the insurance did not pay the doctor. The patient paid the doctor directly, then submitted the claim to the insurance company for reimbursement. A completely different situation.

            In fact, having your doctor’s office submit for payment directly to your insurance company was a professional courtesy sometimes extended to us patients who were physicians.

            Once physicians’ practices began to be expected to submit directly to the insurance company for every single patient, our entire system of medical care began to change inexorably. And not for the better. It really doesn’t take a very high degree of savvy to stop and think about the different ways in which this system could be adversely impacting care. You have had many of these ways pointed out directly to you over many months on this blog. Continuing to believe that “nothing has changed” except that doctors are now bad is a choice that you are making of your own free will.

          • EmilyAnon

            I remember those days too – paying the doctor directly, getting the paperwork from the office, then submitting the claim myself. That was before my big cancer operations though. Maybe I could handle the operation bills up front, but I couldn’t handle paying the $20,000 charge for each chemo treatment (total 9x) at time of service, then waiting for insurance reimbursement? I’d be in my grave now.

          • Suzi Q 38

            “I was around back in the 80′s and the insurance did not pay the doctor. The patient paid the doctor directly, then submitted the claim to the insurance company for reimbursement. A completely different situation.”

            Yes, it was different, but not completely.

            Most of my doctors billed the insurance, and they got the checks. Maybe it was a courtesy, but it was done. Moreover, when both our children were born, I asked the OB/GYN if he would accept my insurance as payment.

            He gladly agreed to do so. I don’t recall writing out huge checks to my doctors and hospital.

            I remember paying the doctor directly for fees that the insurance would not pay. I also remember calling the insurance to get them to pay more than they initially did. Sometimes they would pay, other times they would not.

            Our children were born in ’84 and ’86.

            Recently, I remember paying cash at a rather large hospital for two colonoscopies. One for my husband and myself. We paid cash for a discount, and the hospital billed our insurance as a “courtesy.” The year was 2010.

          • Suzi Q 38

            “You have had many of these ways pointed out directly to you over many months on this blog. Continuing to believe that “nothing has changed” except that doctors are now bad is a choice that you are making of your own free will.”

            I have not said that all doctors are bad.
            I have a few good ones, one that I have had for 12 years. I also have had some bad ones, but not all doctors are bad, as evidenced by some of their blogs. Some of you vilify and mock those doctors that do care.
            You have been the one that has given excuse after excuse for any given doctor’s bad attitude or care.
            Your mantra over the last few months has been to blame the SYSTEM, not the doctor.
            I agree with some of what you say, but at some point in time a bad doctor is a bad doctor.
            A bad attitude is a bad attitude.

          • azmd

            Again, I think you are mistakenly assuming that I am speaking for myself and my own practice when I point out things that I see that concern me about our healthcare delivery system. I am not. I have a good job where overall I feel that I am able to spend adequate amounts of time with my patients, although I do see a trend, which I resent, towards more of my time being devoted to data entry tasks, at the expense of spending time with my patients. I do feel that my patients receive excellent care.

            In a previous job I felt that my patients were not receiving the best care I could offer, because of the culture of the hospital where I worked, where I saw many of thing things going on that I write about here. So I found a better job and left, after some very fruitless attempts to speak up. It’s quite amusing that you call me a coward. Those who know me know that couldn’t be further from the truth.

            I do feel that unless more of us start to speak up, that the future of medicine is not a good one. This concerns me more as a patient than anything else. And I don’t feel that the type of speaking up we see patients doing here is constructive. Lambasting individual doctors for being greedy and lazy is just not productive, when there are so many things about our healthcare system that need to be fixed. Such angry venting may make you feel better, but it doesn’t add anything of value to discussions about how we can improve our healthcare delivery system.

          • Suzi Q 38

            “Again, I think you are mistakenly assuming that I am speaking for myself and my own practice when I point out things that I see that concern me about our healthcare delivery system. I am not….”
            At least you clarified that your complaining for the last few months has not been the problem of your present job. Since you had not pointed this out before, what is the general public supposed to think? Are we clairvoyant?

            “…I do feel that unless more of us start to speak up, that the future of medicine is not a good one. This concerns me more as a patient than anything else. And I don’t feel that the type of speaking up we see patients doing here is constructive…..”

            I agree. You think it is O.K. to complain about patients that are demanding, etc., yet patients are not allowed to complain about doctors….Maybe your complaining without solutions are not constructive not productive either. Interesting.

            I don’t recall saying that doctors were greedy or lazy, you just accused me of such.

            I have said that I don’t believe that a PCP would only net $37K when all bills were paid, or that my specialist gets paid $400K (give or take $100K). This would be a sufficient salary with which to call patients when they need to be called. When it is important. It is a salary. It is more than a usual job. Many jobs are more than 40 hours. I have a neighbor that is a lawyer that works 60 or 70 hours a week.
            My daughters room mate is a CPA and works 80 hours a week during the tax season.
            Both work for a salary.

            “Such angry venting may make you feel better, but it doesn’t add anything of value to discussions about how we can improve our healthcare delivery system.”

            Maybe, but I could say the same about you and your venting.

          • Fat Rasputin

            Do you work in fascist part or AZ where you are unable to set what insurance you choose to take? Is there someone holding a gun and telling you must take medicare? or any insurance for that matter? I read this interesting blog post on kevinmd about concierge medicine where only cash payments were expected no insurance. Is there a small part of AZ that is run by a dictator and that is not a choice for you? I have doctors that don’t take medicare and that is their choice. What goes on that you are not allowed to make choices like other doctors?

          • Cyndee Malowitz

            azmd probably doesn’t own his/her own practice and doesn’t have a choice in the matter.

          • Fat Rasputin

            We all make choices the fact he does not own his practice is a choice. There is freedom in the US even for doctors.

          • HJ

            I have a high deductible insurance plan and I do pay for medical care and I still get ripped off.

          • disqus_f4OBIScMpr

            Ditto. In fact I get charged MORE than most patients who have comprehensive all-you-can-eat low-copay health insurance.

            Paying doctors directly doesn’t buy you any advantage, as least not from where I sit.

          • Suzi Q 38

            It depends on what the doctor charges for any given “service” that h/she provides…ditto for lab fees or hospital costs and medical personnel.
            I think my anterior dissection on my c-spine would have cost anywhere from $60K-$100K without the negotiation of my Blue Cross PPO insurance company.
            Maybe doctors in private practice and group clinics need to go back to the patient submitting all of their claims. We could pay 50% of the bill UP FRONT, then wait to get reimbursed. Of course, there would be exceptions.
            It would be hard, but then the burden would not be as much on the doctor.

          • NewMexicoRam

            Right on.

          • azmd

            The difference is that a malpractice lawyer is a lawyer. Lawyers have been much more clever than doctors, partially because their profession is not based on helping sick people, and so society has given them more lattitude to enact legislation that has allowed them to retain more professional autonomy. than doctors have now.

            What this means is that my malpractice lawyer, (if I ever have to have one), has control over how many cases he takes on, and what fees he charges. If he feels that he doesn’t have time to give my case the attention it deserves, he refers me to a colleague who does. I get the legal help I need, and the lawyer is not too burdened to do a good job for his other clients.

          • Suzi Q 38

            You don’t have to work for a teaching hospital.
            You can choose where you want to work, just as any lawyer can.

          • NewMexicoRam

            You think ALL malpractice attorneys give their ALL to their doctor clients? What world are you living in?

          • Suzi Q 38

            Did I say that? Maybe you said it for me. Don’t speak for me, as I don’t speak for you.
            I am living in the real world, one that is constantly changing. I don’t agree with the changes, but they are what they are.
            P.S. I never said ALL. You did.

          • NewMexicoRam

            I’m asking you “what do you think?” Do ALL attorneys give their ALL? Yes, or no? This has NOTHING to do with your perception of how I’m trying to interpret your words. It has everything to do with the question I’m asking. Are ALL attorneys at the top of their game?

          • Suzi Q 38

            You know the answer to that.
            Some are greedy and lazy. Some are tired.
            some are bored. Some are not all that bright.
            They are not the “sharpest” of the “lot,” nor do they care about you or your case.
            Herein lies the problem.
            You hope and pray that you haven’t hired one of the lawyers I have described.
            If you want to compare these characteristics to physicians, go ahead, “knock yourself out.”
            Just don’t ask me to hire one of the above to care for me or my family.

          • NewMexicoRam

            I was trying to get you to see that you are lumping people together, unfairly, need I add.
            I have patients who nearly think I am a god, always there, always right, and always on top of things.
            I have (or should I say HAD) patients who thought just the opposite–that I’m a moron, miss things, never answer their questions thoroughly enough, and can’t get them in fast enough.
            Now, which kind of doctor am I? Good or bad?
            You only get to pick one. And no matter which one you pick, you’ll be wrong by someone’s standards.
            Now, if we change the tone a bit and realize I am human, meeting some people’s needs while missing it at times, but overall really trying to serve while realizing I have my own needs, then we can get somewhere. That’s all any health care provider can do, and patients as well.

          • Suzi Q 38

            Sure, I can agree with you in a humanistic sense.
            On the other hand, If I am depending on you to manage my health, and you miss an obvious spinal stenosis after listening to my complaints PLUS requests for additional testing for almost 2 years, then I have something to be concerned and complain about.
            I would not expect my dermatologist to figure it out, but I do expect my neurologist to do so.
            It depends on what the situation is as to whether or not you are a good doctor or not.
            You know, based on your medical knowledge and academic expectations, plus empathy whether or not you are a good doctor or not.

            In my case, two doctors made huge errors.
            Do they know that they made huge errors?
            I am not sure. I think that they should know, if only to make corrections in the way that they view patient’s complaints about troubling symptoms. We don’t complain to be a “pain in the @$$,” we do so because something is wrong.

            I can not walk properly, stoop to pick up a dime quarter, sit for longer than 30 minutes and experience pain every night. I can’t exercise for longer than 30 minutes at a time. My hands and feet are cold and numb 24/7. I can no longer run or dance, and I can’t stand for more than a couple of hours at a time. I can no longer wash my car or clean my house. Standing and cooking a meal is a delightful memory of the past.

            Before their care I had no restrictions. They kept telling me I was fine, maybe a psych consult would be helpful. I knew that the jerks were talking about my case together and thought I was a hypochondriac.

            Do you know what it is like to know that your own doctors think this about you?? To offer to give you a referral to a psychiatrist?
            Well, it doesn’t feel good, especially when you know something is wrong medically, and you feel the symptoms everyday.

            When the diagnosis came down, two years later that it was spinal stenosis in my c-spine, it was devastating, but a relief. I knew that the two doctors that were not good to me, had some major explaining to do. They also owed me an apology at the very least.

            So, let’s get back to your question:
            Are you a good doctor, or a bad one??

            It depends. We know you are human, and you are going to make mistakes. It just depends on your specialty and how you treat patients every minute of your workday. If you give it your best,
            every moment of everyday, be content that you are a good doctor.

            If you had a bad attitude that day, or you have a patient that you just don’t like that come in with a myriad of medical problems, refer h/her to someone else if you don’t like their case. If you ignore or put off care for that patient, you are NOT a good doctor for h/her that day. Maybe the case is too complex for you. If so, get help.

            You are a doctor. You are supposed to heal instead of do harm. You are highly adored and respected because of your medical expertise.
            If I come in with something as boring as tingling in my thighs, neuropathies in my hands and feet, maybe the end stages of these symptoms are devastating. I could end up in a wheelchair for life needlessly.

            This is the nature of your work. This is what you wanted and worked so many years to do.
            This is what you are good at doing, so remember that our expectations for you regarding our care are very, very, high.

          • azmd

            Of course patients don’t complain about symptoms to be a pain in the ass. But many patients come in with multiple complaints, most of which are not related to any disease. Other patients come in and relate to the doctor in a hostile or needy fashion. Still other patients are very dramatic in describing their symptoms. Other patients are disrespectful of the doctor’s time during the appointment.

            All of these are not things that they do on purpose, of course, but they are things that can distract the doctor, since he or she is a human being. Think about the last time someone got in your fact and was confrontational, or made you feel uncomfortable in some way. Did you still have the same level of reasoning ability? Most likely not, since when the parts of your brain that deal with intense emotions are activated, the parts of your brain that think things through methodically tend to shut down.

            Doctors are people and they have feelings, and until we figure out how to replace us all with robots, we will continue to have feelings that influence how we function. Sometimes doctors will be distracted by a difficult patient, and will miss a diagnosis. Is this right? Of course not, but it happens. And it tends to happen more when the doctor is rushed, stressed and/or burned out.

            Much as we would all like to, we cannot expect doctors to be perfect, and to have superhuman brains. They are just human, like the rest of us.

          • Suzi Q 38

            “…….Think about the last time someone got in your face and was confrontational, or made you feel uncomfortable in some way. Did you still have the same level of reasoning ability? Most likely not, since when the parts of your brain that deal with intense emotions are activated, the parts of your brain that think things through methodically tend to shut down…..”

            Of all of your defensive posts, this part of your paragraph makes the most sense to me. I can certainly understand your explanation.

            Just consider this: If a patient gets in your face and was confrontational, or made you feel uncomfortable in some way, it must be important to that patient. No one does this “for sport.” You are only dealing with them for 15 or 20 minutes. They may have been feeling the odd and troublesome symptoms for a few months, 24/7. They are concerned and worried. Maybe they see that you are not, and moreover, you do not understand how bad it all is.

            Hence, the “get in your face” meeting.

            If you have the “get in your face” meeting, the patient truly admires you, maybe even likes you, but realizes that you have not been getting the message or doing a good job with them. It is survival. They realize that they first are giving you the courtesy of helping them or correcting the problem by vehemently complaining. If you do not get the message, or have no intention of helping them, they have to go elsewhere. It may be to another doctor on staff, or to another hospital.

            If it is between ruffling your feathers or hurting your feelings, patients will have no other choice but to choose their own health. In doing so, the repercussions of that decision may be embarrassing for the first doctor.

            If the doctor has a private practice and is solo, it may just mean that the patient should find another doctor. If the doctor does not value the relationship or loyalty that the patient has shown over the years, he/she may just allow h/her to leave without a discussion.

            My PCP of 12 years just sat and listened, found out what tests I wanted, then ordered them. For once, he was not the ten minute doctor. He gave up. He knew I was angry. He knew that he may have missed something. I knew he was human. He understood that I was frustrated enough to fight for myself, plain and simple.

          • Suzi Q 38

            “Much as we would all like to, we cannot expect doctors to be perfect, and to have superhuman brains. They are just human, like the rest of us.”

            I don’t expect doctors to be perfect nor clairvoyant. All of the above is true.
            Understand though, you are in charge of your patient’s medical care. This is a “tall order.”
            There is not another thing more important to people than their health. Not all doctors are equal.
            Some are better than others, and in different ways.

            I am not unlike other patients in that I need good doctors at this point.

          • NewMexicoRam

            Sorry, but banks can freely charge what they need to in order to stay in business.
            Medical practices are strictly limited by what Medicare pays. Doctors aren’t paid like hospitals.

          • Suzi Q 38

            Are you allowed to have your own practice and limit your medicare practice, or decide not to accept medicare at all?

          • Fat Rasputin

            Doctors choose whether to take medicare or not and my insurance does not pay medicare rates. I do not know what you are talking about. Doctors are forced to except medicare? That is news to me.

        • azmd

          Let me ask you this, what do you think is the solution to doctors not having enough time to spend with their patients? I agree that it’s a problem, and that both sides are frustrated. But insisting over and over again that doctors need to spend more time with their patients, when that time does not exist, is not moving the discussion forward.

          • Suzi Q 38

            Maybe it is more time that actually helps the patient.
            The time does exist if you give the patient the direct time h/she needs. Some patients will need more time than others.
            Just because we are not yelling at you and angry does not mean that we are getting the proper treatment from you.

          • azmd

            Of course it’s time that helps the patient. But our healthcare delivery system does not wish to provide patients with that time with their doctors, and so doctors are snowed under with an overwhelming array of tasks, all of which must be accomplished in any given day, the time for which comes out of time with the patient.

            I am not sure what influence you think we have on the time-space continuum, but I can assure you that we are just humans, and we have the same number of hours in the day as anyone else. Saying “the time does exist if you give it to the patient” is simply not logical.

    • Suzi Q 38

      “I find your tone condescending, you may not want journalists telling you how to do your job but I do not want doctors telling me how I feel and not listening to me.”
      I empathize with what you are saying. I have the same complaints.
      Doctors would be better able to treat us if they would only take the time out to list to what we have to say about our symptoms and ailments.
      I sense that they do not want to listen because that might mean that their control is not there.
      They want to tell US how we are supposed to feel and what we have.
      I have realized over the decades that the more skilled physicians listened and watched, then took a few moments deep in thought, then spoke.
      It also helps if the doctor is not viewing my EMR information while I am already in the exam room. I find that not very efficient and unprepared. It would be akin to a divorce lawyer not knowing the relevant facts of your case or situation during any given legal conference meeting. If h/she sat there for 10 minutes and was just reading your file and was barely looking up at you, you would probably realize h/she is just not ready and walk out.

      If you say that you don’t have the time in a day, well make the time. It is important. Lives, mobility, progressive disease states and other things are at stake. Your salary is more than most, so this makes up a little for the inconvenience.

      • azmd

        The reason a lawyer has already reviewed your file when he or she walks into a room is that they bill by the hour for any activity they undertake on behalf of their client. So they are able to bill for the time it takes to review your file before they meet with you. The doctor is not paid for any activity that does not take place in your presence and so they review your files with you in the room.

        • NYC Patient

          This is true. However, in the academic setting doctors in a FPA/hospital affiliated practice have salaries and benefits similar to that of most attorneys, plus the other opportunities for consulting, etc.

          The reality is that health care is at a place that unless something extreme is done, we are just going to go round and round.

          The system is broken. Hospitals tend to simply create more low and mid level positions to fill this void or that but FAIL to mesh these roles (that look great on paper) for improving patient care and support physicians.

          The only way this will change is by doctors leading the way. Unfortunately that will mean possibly missing the ADMIN set benchmarks for patient volume for a season, missing a few conferences, declining a few offers to consult, etc.

          Many doctors have “made the best’ of the system and thus by tolerating it have inadvertently enabled it.

          • azmd

            I realize that’s true, since I practice in an academic setting and before I walk into the room to meet with the patient I have generally spent about 20-30 minutes reviewing any documentation I can find about their history. It is, however, different for physicians in private practice, which is where I think most patients are feeling frustration.

            However, I can tell from your suggestions on how change could be made that you are not really that familiar with how medical systems work. A doctor who “leads the way” in protesting our current system by “missing a few conferences” is typically identified as a problem employee and marginalized within the system he or she is trying to change. Our culture really doesn’t tolerate physicians pointing out that various changes have an adverse impact on patient care. You can read up on the literature on how the term “disruptive physician” is being used to silence those doctors who try to speak up and effect change, if you are interested.

            I think that change is going to have to be a joint effort between physicians as well as patients who are more interested in recognizing the need for systemic change and less interested in blaming the individual practitioner.

          • NYC Patient

            Actually, azmd, I have quite a bit of experience in academic institutions. As one who “worked their way up” hospital admin from a physician’s secretary, to surgical coordinator, academic coordinator, credentialing, contract negotiation, Admin Mgr to an administrator between Mount Sinai and MSKCC, I am very familiar with how medical institutions work. Plus, prior to hosp admin, I worked for a health insurance company. I moved to non-medical higher ed a few years ago because I couldn’t tolerate constantly being between admin and doctors, especially since I typically sided and advocated for the doctors. A few doctors actually offered to pay me large “gifts” if I would continue to work for them or open a private practice…with the saturation of medical academia in NYC, private practice, even for highly sought after doctors, is very…um….hostile…

            However, you are correct in that patients to play a vital role as well and my intentions were never to minimize the role of the patient in all of this.

            However, at the hospital level, especially considering many of the policy “influencers” (whether it be prominent physicians, their trustees, etc.) so to speak are at academic institutions, physicians are the only ones the can truly drive the change. It sucks. It’s not fair for physicians to bare the burden, but from within the walls of hospitals, where much of the precedent for healthcare in general is set, it can only come from physicians.

            The reality is that the majority of patients go to a hospital they trust. The hospital only truly has and or maintains it’s reputation because of the physicians there. Therefore, physicians are a hospital’s revenue and need to be vested in every aspect, which means overriding many of the counterproductive counterintuitive and inadvertently non-patient-centered things put in place by admins and or doctors who haven’t practiced in over a decade.

            As an example:

            When I joined MSKCC in 2008 it was as an Admin Mgr – supervised 30 support staff of varying levels for 2 surgical services and a surviorship program that was at that time still in beta. Before I go further, I will say that of all the hospitals in NYC, the doctors in MSKCC do have adequate support and the overall structure there is a bit better compared to most. Still there are tons of decisions and expectations developed and enforced by admin that, well, put more pressure and inconveniences on the doctors. This happened when MSKCC built a new OR…

            The new OR was finished in 2007-08. Yes, doctors were “a part” of the process. But what exactly does that mean?

            Well, it means that they attended a few committee meetings where things were presented to them, they weighed in on decisions based on what was presented. But since they really were not enabled to be fully vested and integrated to that process, the finished OR was missing a few…CORES!

            This resulted in several OR clusters not being able to store customary equipment. I vaguely remember there were only 1 or 2 clusters that actually had a core…

            So, one of my services, thoracic surgery, had some challenges….nothing like being elbow deep in a patient’s chest that has been cracked open without STANDARD equipment the surgeon had used for decades.

            As a result, a committee was formed and in roll the carts…carts and checklists and way too much time of nurses spent on ensuring doctor X had what s/he needed for that case…

            You can argue that doctors were on the committee that approved the plans..but had they been more vested in the process, which would’ve meant likely reducing patient volume for a season, they likely would’ve realized such a basic necessity was MIA. When things look pretty on paper and admins have all the right lingo and it is presented to doctors in a monthly or quarterly 1 hr meeting, of course many things will be overlooked.

            This is pretty much how things have been done for decades and it needs to change. Unfortunately, only doctors can drive the change. Doctors, who are the PROVIDERS of CARE to PATIENTS, are the only ones that can in good faith change things with medical CARE in mind….

          • azmd

            So….what do you think kept the docs on the committee from being more “fully invested or integrated in the process?”

            Because that’s exactly what I’m talking about.

            I have sat on the governing committee of a hospital which had serious deficiencies in processes and procedures which impacted patient safety and I have a few thoughts about what keeps docs from driving the train. I do think it’s the kind of thing you can only be aware of if you’re actually a doctor sitting on one of those committees.

          • NYC Patient

            i hate to say it but decreasing patient volume..a furlough of sorts…something.

            Admittedly, a doctor doesn’t become a doctor to be on committees. But when such committees govern and directly affect patient care, I believe doctors should be DRIVING the committees and not just attending, voting, etc.

          • azmd

            I couldn’t agree with you more. Unfortunately, sitting on committees is not a reimbursable activity, so hospitals are very reluctant to reduce the duties of salaried docs in order to free up real time for them to fully engage in committee work.

            To me the closest thing we have to an answer so far is the physician-led healthcare system, but it’s been my observation that those are effective ONLY if the physician leaders continue to engage in at least a little bit of hands-on clinical work.

    • http://barefootmeds.wordpress.com/ Barefootmeds

      The reason a doctor asks you about your disease even though it is in your file is because we need to hear it straight from you. I work in a large public hospital where the patient I see today was probably seen by another doctor when they came in last month.

      So I read in the notes, for example, “patient is HIV-positive” but for some reason the previous doctor hasn’t written whether the patient has been informed or how it was diagnosed (rapid test? ELISA?) So I ask because I want to give the patient the opportunity to tell me on his own terms.

      My own GP, who always sees me, often misreads or missunderstands his own notes about me. So I would much rather he ask me than pretend he can remember when clearly he can’t.

      • Fat Rasputin

        Sorry did not see your reply until now. The diagnosis is not in my file. It is in the form the doctor has asked me to fill out, that is done instead of the doctor taking a history. If I have written my diagnosis I probably know about it.

        • http://barefootmeds.wordpress.com/ Barefootmeds

          That’s fair

  • buzzkillerjsmith

    What people want from doctors knows no bounds. It’s getting worse now that the internet has allowed all and sundry to voice their thoughts on that small part of the elephant that they have felt, and the all and sundry include the mediadocs, many of whom could not diagnose and treat their way out of a wet paper sack.

    Two axioms of life:

    1. The farther you are away from them, the easier things look.

    2. Those whose expectations are unreasonable will be disappointed.

    • medicontheedge

      Correct. Patients want their healthcare delivered like fast food: cheap(we know it’s not), fast(no matter what the problem), and without much effort on their part.

  • Jason Simpson

    This topic so spot-on. I read the link from the Wall Street journal about “poor communication” by doctors. There are 19 quotes from so-called health “professionals” in that article, all of them complaining that doctors dont communicate well. Guess how many of those health “professionals” were doctors? Answer: not a single one of them. They are all consultants or selling some stupid communication training that they want people to buy. Not a single one of those idiots has ever treated a patient in a clinic or hospital. Not a single one of them knows anything about healthcare or medicine.

    What is really scary is that the federal government is hammering doctors with all this crap regulation based on what these idiot ivory tower “consultants” are telling them about doctors.

  • Dr. Pamela Havekost

    Big compliment – I think you hit the point. The problem occurs on the layer of expectations people have – and that is beyond costs, and comfort – it is about illness and death. A system increasingly unresponsive to these concerns will loose credibility. People say doctor, but they mean the system as a whole. In Germany we face this kind of “hostile dependancy” since at least 15 years, and now we have a shortage of doctors in the rural area and in hospitals. I linked your contribution in our discussion network Hippokranet, thanks for your input.

  • southerndoc1

    Sad.

    Medicine today is run for the benefit of and controlled by the big corporate interests. Both patients and physicians suffer as a result.

    Doctors are beginning to understand this. Many patients still have no sense of how much they’ve lost.

    • Suzi Q 38

      So true.
      I am 57. I remember when doctors had more time.
      I remember watching doctors interact with their patients in the hallway. They were calmer and less rushed.
      I recall when doctors would ask you why you came in for any given day, and then take the time out to listen, then reflect on the best treatment strategy. The acted as if they cared, instead of acting as if I was a huge inconvenience because I was not an easy case.
      Now, in order to get better care, I have to “get in my doctor’s face” a bit. My life and health depends on it.

      I hate doing that. I think that h/she would want to do a good job just because h/she chose the profession for the right reasons.
      Like they would do their profession regardless of what it paid. That caring for patients was what they were born to do.
      For anyone else it would be a chore, drudgery, or mentally improbable career. For those that do the job and are caring for me, I can feel comfortable that they are the chosen ones, LOL.
      I learned that with this new generation of physicians, this ideation of them is rather elevated and naive on my part.

      I am so glad to be “set straight” on these blogs. At least I know what I am truly dealing with. I am sympathize with you all, but there comes a time when the job is what it is.
      Either do it well or be honest and tell the patient that they really need to see someone else. “I really am not paid for X,Y, and Z, so I have no intention of doing this or that to better care for you.”
      Most of my specialists get paid $400K in the state of California, at the teaching hospital. Am I off base on this?
      That is $33,333.00 a month. I don’t think that if I am a difficult case that my specialists should be complaining about reading my EMR on h/her own time. Also, if I am seeing a specialist, my case is not going to be easy.

      My PCP doesn’t get paid that, and I understand this. I called the insurance company on my own behalf when they denied his request for my MRI on my right knee. I bring the guy fruit and foods from his country. I offer to come in for minor things so that he can bill my insurance company. I offer to pay a little more co-pay.
      Because of all of you, he gets better treatment from me. I still sense that after 12 years of being his patient, he would still care for me to the best of his ability.
      I don’t get that feeling from some of the other doctors, even though they are specialists.

    • azmd

      I think they have a keen sense of how much they have lost. I know that I, as a patient, do. I have lost track of how many times over the last decade I have had encounters with physicians who are just “cranking me through” and giving whatever problem I am there for the barest, most superficial consideration. It is maddening, and also frightening. You really feel like you are alone with whatever medical problem you have.

      The difference for me is that I recognize that it’s a systemic problem that will not be fixed until we have the kind of reforms in place that Dr. Reznick described above. Many of our patients choose instead to blame the individual practitioner, I think because it’s less frightening to think that you got a “bad” doctor than to think that an entire system will let you down when you are sick.

      • Suzi Q 38

        “I think they have a keen sense of how much they have lost. I know that I, as a patient, do. I have lost track of how many times over the last decade I have had encounters with physicians who are just “cranking me through” and giving whatever problem I am there for the barest, most superficial consideration. It is maddening, and also frightening. You really feel like you are alone with whatever medical problem you have.”

        Yes, at times, I do feel that I am alone.
        You feel this way, and YOU are a physician with a certain amount of medical knowledge and training. You can also identify yourself as a physician and get a certain level of treatment. Not only do I lack the knowledge and training, but I do not get VIP treatment as a physician.
        I don’t mind if the physician is my dermatologist and I have minor urticaria, but I DO mind if the physician is my neurologist and passes off the cold and numbness in my hands and feet as Renaud’s rather than spinal stenosis in my c-spine.

        • azmd

          Sorry to burst your bubble, but we physicians do NOT get VIP treatment. The prevailing belief is that since we are physicians we should tough things out and so unless I come in missing a leg or something, my concerns about other less acute issues typically get glossed right over. Also, since I am a physician, other docs are quite quick to assume I’m being neurotic because I have more medical knowledge than lay people. It’s quite annoying, but again, I recognize it as a systemic issue and also as a generational one. Doctors these days are just not trained to provide the type of thoughtful care that I was trained to give. They just don’t have the time to spend thinking things through that thoroughly any more.

          • Suzi Q 38

            Do you identify yourself as a physician when you go to a physician? If you do and you say you do not get extra care, why do you identify yourself as such at all?
            There is a difference, and you know it.

          • azmd

            I have tried it both ways. The response I get seems to vary quite a lot depending on the individual. Overall it seems to be a negative so mostly these days I don’t bring it up at all.

          • Suzi Q 38

            I have friends that are physicians, and another childhood friend that is married to one.
            All of them identify themselves as physicians or the spouse of one when they see their doctors. When I ask them why, they say that they have to. I say that they do not have to at all. Why not experiment and see what it feels like for a change?

          • Noni

            Suzi, I am a physician and have experimented both with identifying myself as a physician and with not. There’s no upside either way.

            What I can assure you of though is that physicians and their families do NOT receive any kind of special treatment or higher quality treatment. The only advantage we have is being able to choose higher quality practitioners due to access to inside referrals.

            It’s not like we’re in Congress or something!

          • Suzi Q 38

            I appreciate your response and explanation.

            “What I can assure you of though is that physicians and their families do NOT receive any kind of special treatment or higher quality treatment.”

            I simply do not believe it. Most doctors that I knew were more careful if the patient was a physician or the spouse of such.
            Not that I blame the clinic or doctor for being more careful, that is just the way that it is.
            My point is that doctors would not be identifying themselves as doctors in their personal medical situations if there wan’t something in it for them.
            I don’t begrudge you this “perk,” but it exists.

            “The only advantage we have is being able to choose higher quality practitioners due to access to inside referrals.”

            I appreciate this information. You say this as if it is no big deal. This is a big deal. Imagine getting the less experienced doctors rather than the more experienced ones.

            This is a huge advantage.

          • Noni

            I didn’t mean to minimize the advantage of the inside referral. It’s a huge advantage. For my family I’ve been able to make sure they get the most skilled practitioners in their field. This has been especially useful for my kids.

            However, when it came to surgeries or hospitalizations (including my own) I can honestly say that the fact that i was a physician didn’t seem to make much difference with regards to receiving special treatment. Sometimes this was good, other times it was very frustrating. There was a blog post earlier about a surgeon who had cancer surgery with tracheostomy and literally had no voice. He documented mistake after mistake after oversight. I saw similar mistakes, miscommunications, and a missed diagnosis.

            With doctor’s visits my physician-ness didn’t get me or my family earlier appointments, shorter wait times, or better treatment by medical staff. Some doctors were respectful to me; others were arrogant and condescending. Same as for any patient.

          • Suzi Q 38

            Thank you.
            I am of course talking in anecdotal generalities of what I have heard. I also am making my own decisions based on common sense.
            Why disclose at all that you are a physician when you are one? The perks. The hopes of better treatment and the desire to get assigned the more experienced physicians.

          • EmilyAnon

            Dr. Noni, I’ve always appreciated your comments here, especially when replying to patients. In response to your being able to choose higher quality practitioners I think is more than “the only advantage” hospital workers have. This includes the opportunity to avoid the failed ones.

            On one of the nursing forums there was a thread where OR nurses told disturbing stories of witnessing incompetent or careless surgeries, often performed by the same doctor over and over again, and never reported. Survival of their jobs or fear of blacklisting encouraged a blind eye or obfuscation when documenting. My thought was, wow, what an enviable opportunity insiders have to be able to avoid terrible or mediocre doctors or choose brilliant ones when they or their families are in need of medical treatment. The unconnected patient has no chance of tapping into such vital information. We just have to trust, where caregivers have the advantage to verify before trusting. This is a huge perk.

          • Suzi Q 38

            Emily,
            I agree with everything you said.

      • drgh

        Wow this thread is very telling. As both a doctor and a patient, it is frightening how system problems play a large part in preventing doctors from giving adequate care. To start, I had a serious problem and had to wait several months to see a specialist. I could not even make an appt without a PCP referral which delayed matters even longer. In the end I ended up diagnosing the problem myself given no one took the time to step up to the plate no matter how much symptoms were progressing. For one thing if you can only get a follow up every 6 weeks at an academic institution and they did not allow more than 1 consultant visit at a time which is crazy. The system problems definitely played role in delaying my care although I don’t excuse the specialists. For example, when I had serious systems, there was really no way to communicate that to the doctor. It would go to a NP who would disregard your concerns. Without an adequate system there is no way to have the time and thought to put into a patient.

        • Suzi Q 38

          Finally, an honest assessment of what us patients sometimes have to go through.

          Are you really a physician?
          If so, did you identify yourself as a physician when attempting to get sound medical treatment?

          I had to do all of the above and more.

          I am sorry this has happened to you, too.
          Much less that you are a physician and it still happened.

          How did you finally get the proper help, did you have to fire a couple of doctors along the way, and are you O.K. now?

          Do you have any suggestions for patients like us, attempting to get proper care in “the “eye” of a perfect medical storm??”

    • Ray

      No, it’s run by and for bureaucrats and politicians. It’s Big Government and it will only get worse.

  • Steven Reznick

    I think this is a meaningful and important essay and it clearly defines the angst of patients and practitioners. I believe we need to establish a new dialogue within the profession and with our patients on how to communicate information and concerns. It was much simpler 40 years ago when an academic physician handed me an article during my training entitled ” The Ten Commandments of Consulting and Communicating.” As a primary care physician I am often disappointed when I call and send over the patient information asking a specific or several questions of a specialty colleague and I never hear back from them until I pursue it. Receiving a computer generated note that doesn’t address the questions or an unreadable handwritten note through the fax machine is not the answer either. At the same time I realize my specialty colleagues are equally disappointed when one of my patients shows up for an appointment at their office and isnt sure why I sent them and no records have arrived. Often it is because the patient has self referred themselves and I am unaware of it or because the records were sent and misplaced or because I requested the records be sent and they were not or because I just goofed and didnt send them. When I started practicing specialty physicians spoke to the referring physician in non life threatening situations before they spoke to the patient about the choices and options. We established a care plan that we were both comfortable with and then presented it to the patient and family for their consideration.That rarely occurs today.

    Not listening to patients complaints face to face is problematic and does require attention. The problem is time and non patient care related issues. Each year the physician is required to see ” 2.5 ” more patients per day to cover the new overhead and costs so they can meet their payroll and pay their bills. Tragically the longer the physician is in practice and caring for his or her patients well the older and more complex and chronically ill they become. They see more doctors and are on more medicines and require more time to listen to and examine and to develop a care plan, not less time? Eventually mom and pop small community practices see their overheads climb towards 70% and they choose to leave practice or become an employee of a hospital or health care system that has another agenda namely making money ( there is little difference between community non profits and for profits today in my community) That is like jumping out of the frying pan into the fire.

    I have made proposals to fix this. Pay family practitioners and pediatricians and internists at a higher rate for the non procedural evaluation and management components of a visit. Let government both federal and local pick up the cost of a medical education if the practitioner stays in primary care in your area for fifteen years. Provide subsidies for office overhead costs and housing costs and childrens educational costs of PCP’s like they do in the UK. Limit federal funding for specialty training so that it covers the number of doctors in each specialty we need from year to year and base these decision on manpower needs. Instead of cutting medical school from 4 years to 3 , use the time to teach communication skills between patients and doctors and doctors and doctors and doctors and administrative personnel. Establish a national health service with each physician and nurse required to devote a year to public service before they go out in the world and practice or start their specialty training. Assign them to community health centers, senior facilities, childrens day care centers , schools as nurses and health care educators. If we are going to rebuild the health care system we need to do it right from the ground up beginning with education in the schools.
    Medicine is being run today by insurers , employers and big pharmacy. Self proclaimed academic gurus receive far too much input and have made the formerly representative professional societies impotent and worthless in advocating for practicing docs and patient well being

    • EmilyAnon

      Hi Dr. Reznick, re the complaint that patients arrive without previous records of medical care because they were misplaced, were never sent or other “goofs” is precisely the reason I request copies for myself of labs or other important reports to put in my own files. Then when I see a new doctor, I make copies and personally hand them to the doctor upon first visit. One time I handed them to the receptionist upon arrival thinking that the doctor might want to read them before meeting me, but I don’t even trust that anymore. The first time I tried that they were never put in my file and the receptionist later claimed to have misplaced them – in just 30 minutes! So that important first meeting lacked my carefully documented medical history. Live and learn.

      • Steven Reznick

        I much prefer to get the history first from the patient and do the exam and then review old records to supplement what the patient has told me and I have seen. As a primary care physician this is somewhat different than a specialty physician who the patient is referred to for the purposes of addressing a specific issue. The hope is that as electronic medical records systems and patient portals become more useful and communicate with each other you or the specialty care giver will be able to access the data with a user ID and password

        • Eleanor D.

          EMR isn’t working out that well. Too much boilerplate and propogation of error, and they are ridiculously hard to page through, it seems.

          • Steven Reznick

            You can customize most programs and if you have voice trained the dictation software or touch type you can make it work. It doesnt excuse the fact that in the hospital setting these computers are now replacing ward clerks and administrative personnel and the doctors are being asked to perform those tasks on the computer once taken care of by non medical administrative personnel.

          • medicontheedge

            And patients are complaining that we spend more time on the computer than looking at THEM….quite the conundrum.

      • Suzi Q 38

        Emily, good suggestion. I just did this the other day.
        I handed my doctor my pertinent medical information in a small file, maybe a dozen pages.
        He read a few pages while I was getting undressed for my pap smear. When I got dressed to go home, I noticed he was in his office reading more of my records. Before I left he came back out to let me know what lab tests I should get before our next visit.
        Since I value this type of care and SERVICE, I will definitely pay him the extra if he decides to charge me for it. It is my choice. IF I think otherwise, I can move on.

    • azmd

      Brilliant suggestions. I completely concur. I wish I could practice in the system you have just described.

      • Steven Reznick

        Thanks for the kind words. I sent the suggestions to Bruce Berenson MD during the Hillary Clinton health care reorganization attempts and never got a response. I tried again with the Obama administration, Don Berwick MD and K. Sebelius and did get a beautiful form letter from the White House.
        We need a comprehensively trained primary care work force that understands and can care for their patient in an outpatient and inpatient setting without having to worry if they are losing money each time they leave the office and go to the hospital to see one of their patients. There is lot to be said for knowing your patient and longitudinal care. Part of the comprehensive training involves knowing how decisions are made by physicians in other specialties. You learn that by practicing with them in those areas of medicine during your third year rotations and fourth year electives and residency elective rotations. Creating a national health service composed of doctors and nurses who have not yet stepped into practice or their specialty training under the direction of their residency program and rotating through outpatient community settings for seniors and children and schools exposes them to the real world. Educating the public at a young age how to shop and prepare for healthy affordable meals including growing it if necessary should be part of the national agenda. Teaching children and young adults how to care for simple injuries and illnesses that past generations learned how to treat from their families or while earning Cub Scout and Brownie merit badges would hopefully keep some of the minor injuries out of ERs. Putting new physicians and nurses in senior facilities to care for simple injuries and illnesses without mechanically calling 911 and copying the chart for transfer as happens daily at these institutions could improve home compassionate care and reduce overall health care spending.

        • Eleanor D.

          To me, it sounds like a centralized nightmare. The way to get health care out of the grip of employers, insurers and big pharma is to encourage tax-sheltered private accounts for individuals and families to cover the costs of routine care, minor illness and procedures and tests, combined with private policies for catastrophe to prevent bankruptcy and personal ruin.

          • Steven Reznick

            I believe the high deductible health savings account health plans were supposed to do that. They are extraordinarily expensive anyway with insurers not able to justify why two healthy sixty year olds with a $10,000 deductible pay $1400 a month for a group plan through their medical society.

  • Anthony D

    “Lately, doctors are being schooled by the media.”

    Healthcare “inflation” is a sham. The hospitals continually inflate the cost of care to try to push the insurers to raise reimbursements. The reimbursements remain essentially flat but the insurance companies use these inflated costs to demand higher rates. People paying the premiums and people paying for their own care are the ones who get screwed.

  • Cyndi F

    Each week I look forward to reading the stories shared on this blog as well as the resulting responses. Today I feel the need to share my experiences.

    As an improvement specialist for a large healthcare organization in the midwest one of my main focuses is to shadow physicians and their nurse/medical assistant to discover potential communication and process issues. I don’t take my job lightly. Rarely do I originally encounter a physician who is originally thrilled to have me shadow them. But once I do and then provide them with suggestions based on my observations as well as patient survey data and comments, our physicians have embraced what I have to share and their practices have excelled. Our medical practice system has gone from 29% patient satisfaction a year and a half ago to over 85% today.

    I’m only saying this because physicians I’ve spoken with are frustrated when it comes to patient satisfaction. They mean well, and are highly intelligent and competitive professionals. But what physicians often don’t understand is that they may be great clinicians and diagnosticians, but the small things they do or don’t do during patient interactions are what patients are evaluating them on. I often say to my docs that a patient can’t tell if you’re listening to their lungs correctly, but they can tell if you read their file before walking in the exam room. They can tell if you: appear rushed, don’t listen, ask a question that was previously answered, didn’t knock before entering the room, didn’t acknowledge delays, didn’t sit down during the encounter, didn’t tell them what you saw during their medical exam, didn’t look them in the eye when asking questions, didn’t acknowledge a major life-changing event, and the list goes on.

    Several physicians in this blog have stated that they walk into an exam room, even though they have spent time reading a patient’s file, and then ask their patient what brings them in? I see this every day when I first shadow a physician. Please understand what this brief statement says to a patient. It says you didn’t read their file and didn’t talk to the nurse or MA who roomed them even though they were left to wait for a long period of time. I know physicians do this because they want to hear what the patient is concerned about in their own words.

    The better way to enter a patient’s room is to say something such as, “Hi Mr. Smith, nice to see you this morning. Thank you for waiting. I read that you’re here for your three month check-up and also said to my MA (insert name here) that you’re also concerned about (insert problem here). Before we discuss these issues, do you have any additional concerns?” I always suggest that you get all issues on the table and then work with your patient to address the main concerns.

    This method allows you to inform your patient that you read their file prior to entering the room, spoke to your MA (which says we coordinate and listen to one another), all while involving the patient in their care plan. Yes, I have a nice way of dealing with patients who come in with the laundry list and how to work with them to ensure you still maintain the original visit time. There are also communication techniques for providing information about medications, problems/conditions, follow-up care, and so on.

    Patients do have a choice where they can go for their care. With our current economy, a lot of patients have very high deductibles from $6000 to $12000 out-of-pocket before their insurance company even pays a dime. That’s on top of the hundreds they pay each month for their catastrophic health care coverage.
    On the best day of a patient’s life they will recall 20% of the information that is verbally given to them. So why are we surprised when patients are non-compliant? For instance, the main reason patients don’t fill their prescription is because they don’t understand why they need to take their medication. Cost is secondary. We need to do a better job communicating, listening and getting patients involved in their care plan. Patients are paying for their care and we need to be respective of that.

    • azmd

      As a patient, my opinion is that this highly scripted, patient-satisfaction-oriented, corporate-bottom-line driven approach is one of the many things wrong with medical care today, because all of these directives on how to communicate with your patients ( and jack up patient satisfaction scores) create a huge distraction for the physician, who ends up concentrating more on the style of the encounter than the substance.

      On a recent visit to a well-trained specialist at the local children’s hospital (translation, the doc is an employee of the healthcare system) with a child suffering from exercise intolerance in the context of a chest wall deformity, I was annoyed to note that most of the doctor’s attention was visibly focused throughout the visit on not appearing rushed, checking in with us to “make sure I answered all of your questions,” making excellent and soulful eye contact, not entering our information into an EMR while we spoke, and very ostentatiously “including” my child in every question.

      Meanwhile, after the visit, a quick Pubmed check (which I should have done before the visit, probably) revealed that he had failed to perform the correct pulmonary function testing during the visit, had ordered a very generic and probably ineffective treatment (inhalers) and had failed to recommend appropriate followup (with a cardiologist).

      I am sure that many patients would have left that appointment feeling extremely satisfied. I left feeling like I wanted to scream and tear my hair out. And that’s the problem with practicing medicine as dictated by patient satisfaction surveys. I think if your average physician is routinely given enough time with patients so that he or she is not burned out, and has time to think critically about the problem that the patient is coming in with, they will give better care than if they are squeezed for time, but given relentless input on how they can create the appearance of providing good care in the limited time they have.

      • Noni

        + 1. Could not agree more.

    • southerndoc1

      “Hi Mr. Smith, nice to see you this morning. Thank you for waiting. I read that you’re here for your three month check-up and also said to my MA (insert name here) that you’re also concerned about (insert problem here). Before we discuss these issues, do you have any additional concerns?”

      And do you want fries with that?

      To talk to anyone like that, not just a patient but any fellow human being, is phony, insincere, and condescending. My patients know me well enough that they’d tell me to shove it where the sun never shines if I pulled that crap on them.

      This is the pure, unadulterated voice of bigcorpmed speaking here.

      • kjindal

        Yes I bet this guy even has studies on wha color coat and tie are perceived in a more positive light by patients
        (Oops, I mean “clients”). He’s probably the same guy who picks the actors in the cialis commercials

    • azmd

      Also, the correct word for the usage you intend in your last sentence is “respectful,” not “respective.”

  • jlynnor

    I contine to see many things going on in the health industry today that remind me of education. Teachers have been told how to do things by the media, parents, and administration since about the 70′s, and we’ve steadily lost trust and respect since then. In addition to our jobs, we have been expected to be moms & dads to our students, as well as psychologists, behavior specialists, nurses, motivators, mind readers, disciplinarians, counselors and social workers. Cramming 30 or more patients a day into a schedule? We are told the ratio should be 20-25 students per teacher, but often have to manage 30-35, or even more. Need to engage and communicate better with patients? We have to model grace under pressure, and respond calmly when under verbal attack by either kids or parents. Worried about liability and lawsuits if there is one little misstep in the exam room? We are told if we touch a student, we could be in for physcial abuse accusations. Never mind that to break up a fight, it doesn’t do much good to say “Now you kids stop that!” If we have a kid coughing his guts up in our classroom, we do not dare to give him/her a cough drop. If we speak sarcastically, or if we admonish a kid who won’t do work, talks back to us and continually disrupts class, we can be harrangued by parents in front of administrators, who then frequently back the parent. The current push to punish doctors for patients’ readmittance to a hospital is similar to being held for blame when kids fail. It doesn’t matter if the kid has strung zeroes like beads, if he sleeps through class or is frequently absent, just like it doesn’t matter for doctors if those patients leave the hospital and go home to consume alcohol with their meds, get surgical incisions wet, eat the wrong things, smoke, forget to take medicine, or begin activities before being released. Welcome to the blame game. Teachers are told, “then you did not work hard enough to inspire that kid! Tell us what you did to reel that kid in.” Really?

    Teachers are also required, by federal mandates, to cater to each kid with a learning problem, from ADD to dyslexia with special lesson plans, alternative testing, preferential seating, and altered grading, even if we might have 8 or more of those kids in a class of 30, which does happen. I’ve spent hours upon hours not only designing all of this, but then documenting it. Of course it’s necessary, but we aren’t paid any extra for the time. The feds, and the districts want proof. Just like doctors have to do all that paperwork, the expectations mount ever higher. We deal with dozens of parental phone calls or emails during the week, which we often have to complete at home, and we are not compensated for that time. It would be a folly to ever expect that we someday will be. Not going to happen. Sometimes we are forced into taking on extra roles, such as being the cheerleading sponsor or the volleyball coach, if we want to keep our jobs. Chalk up another 30 after school hours or so. There might be a stipend for that, but it will be laughable compared to the time invested.

    Teachers have to take a multitude of courses about how to engage their students, but the bottom line is that some of us are good at it, and others aren’t. To me, it was always simply a matter of greeting my high school students from day one cheerfully, and to occasionally take note of something personal about that kid. “Love your earrings, your shirt, your new haircut….” whether that kid was a prize or a pain, those things mattered. Even the crankiest would eventually respond. We could then build on that in the classroom. Eye contact. Questions about weekends. Genuine interest in their after school activities, which can then lead to “how can we help you get your homework done with your busy schedule?” Then when I did have to have that conference with him and a parent, at least we had some kind of friendly relationship.

    Of course, there are always teachers who are very reserved, or who truly want to keep everything business like. And some of them are very, very good at what they teach. Kids don’t like them much. Do they learn from them without all the creative communications? Yes, they do. There will always be good doctors who don’t really like to talk to patients, even while they continue to do brilliant work.

    I’ve been lucky, because even though teacher dissatisfaction with the job and burnout is pretty high, I loved my students and my job even as I retired a couple of years ago. I always enjoyed working with teens, even the ones who challenged me. I never felt more success than when I turned a kid around, form a surly “I didn’t even sigh up for this class,” to a happy participant. Of course there was always job stress, and bad days, and continual pressure from above, but it was still what I was meant to do, and I felt meaningful. I’ve also been lucky with doctors, for the most part. My current primary physician is just the best ever, in my book. He is such a kind human being, and such a good doctor. He doesn’t need anyone to tell him a thing about patient engagement. He was meant to be a doctor, and I think he genuinely likes his job, likes working with the people around him, and has great hopes for the future.

    I would say this to patients who encounter doctors who don’t engage well: remember that it never hurts to treat him kindly, to ask how he/ she is, to be friendly. Keep in mind that he/she is a human being with plenty of stresses both on the job and off. Maybe after leaving a long day at the office seeing dozens of patients, he goes home to fighting kids, a sick parent, a spouse who also had a bad day, a computer on the blitz. It helps a physician to feel that patients are glad that he is their doctor. LIke teachers, doctors don’t really get patted on the back very much. That’s how it is in the service business. But a smile and a laugh can go a long way to building that relationship. It can’t always all be up to the doctor.

    • buzzkillerjsmith

      Excellent post and analysis. We seem to be going down a similar path. I would add that lip service, which was paid to teachers for decades, is now being paid to us. Doctors’ day, how important we are, and so on. But we know the score as you do. Of course the carrot has turned to stick for most of you all and we are seeing that process as well.

      You all have been under the thumb of admin types and government types for a long time. Being an employee is often a very bad situation for a professional. I am very concerned that as more doctors come to be employed by CorpMed our attitude and performance will suffer. Of course this will generate another round of sticks and the feedback loop will grind on.

      You and I both know that where students and pts end up mostly depends on where they start. Of course this fact is willfully ignored by taskmasters.

    • Cyndi F

      I think we all know teachers who are excellent with kids and work really hard. We also know there are a ton of teachers who do the bare minimum and just look forward to days off. The teachers in my kids’ school district have 11 days off for teacher education days (can’t this occur during summer break or one of the two holidays they have?). This is on top of being off for 3 months during the summer, two weeks at Christmas and a week off for March break. I have been working for 20 years and have a total of 26 paid time off days which include stat holidays, sick days and vacation days. Even though I am an exempt employee my boss still docks me for time taken at the doctors and dentist.
      I have a sister-in-law who is a teacher and leaves for work after me and comes home hours before me. Yet she gets paid more, has a wonderful pension and great benefits, as well as plenty of time off noted above. I don’t want to gripe, but I have strict deadlines, statistical expectations that I must meet (with 3500 people working in our system we must have patient satisfaction at a certain level for all reported areas). Can I honestly manage and be responsible for 3500 people? No. But those are expectations placed on me. I also have to educate staff, work with difficult providers and explain to them why they need to properly inform patients about their care plan, conduct rounds to ensure patients are looked after, analyze our system for continuous process improvement initiatives. The list goes on and on. I’m sure most, if not all, of us reading this post can relate.
      No one is out to get teachers or doctors. People want educators and care providers to be caring and include those they are looking after. As patients we have been talked AT for years. Told what tests were being ordered, not asked if we understood and agreed or even able to afford those tests. Patients and students want to be heard, and deserved to be listened to. Are there extremes that expect too much? Of course, but they are a small percentage and the rest of the population shouldn’t have to go without because of them.

      • azmd

        I would suggest that you spend some time considering the possibility that the hostility you are expressing towards doctors and teachers is actually displaced anger towards your corporate employer, who appears to be treating you less well than you deserve.

    • J.M.

      Since the Feds stepped in to healthcare, with Medicare and Medicaid, in the 60s, healthcare has gone down hill. Since the Feds stepped in to education, with the Department of Education, in the 70s, education has gone down hill. I’m starting to see a trend.

    • Noni

      Very well stated. It’s embarrassing how as a nation we have both poor healthcare and poor educational systems. It’s amazing that no one can reconcile the excess of administration and oversight with this poor quality. Clearly those in charge of policy value bureaucracy and administrators (and the vast amounts of money they can extract) more than our children or our health.

  • Alene Nitzky

    You’re learning what it’s like to be nurse!

  • drgh

    A spot on article about what’s wrong in the medical system. When a cardiologist has to step out of his role and start analyzing what is wrong with the medical system, you better believe something is very wrong.

  • UMKCMed

    May I ask a question of the community? If this comment is accepted then I #kindly #thank you.

    What about a medical school that alters transcripts after students leave? ………… This is no #hypothetical “what if” this has occurred in Kansas City, Missouri at UMKC-School of Medicine. #Advice on how to approach such a topic is greatly appreciated. Since they have repeatedly altered the documents I asked them incredulously if they were going to do it again, which they did. So, in addition to commenting on every #article published from the University of Missouri Kansas City School of Medicine, I am sharing this with as many #social #media outlets as possible. Traditional media may follow. #Organizing a #protest for the following reasons. I will be bringing much soda. This protest will be for high healthcare costs and #corruption in healthcare. If there is a particular #sign you would like some of us to carry, please #email me the ideas.

    US Medical School Alters Graduates Documents

    Healthcare #Crisis Risks Decompensation by Bad Docs as Esteemed US Medical School Changes its #Graduate’s Documents

    Amidst the #debates of how to proceed with #healthcare #reform, #documents have surfaced providing #irrefragable evidence that at least one #medical #school repeatedly changed documents for at least one of its alumni. #State #Licensing #Boards rely on Medical Schools to ensure the qualifications of its graduates. A new level of caution is now required as the #University of #Missouri-#Kansas #City #School of Medicine, an innovative six-year #BA / #MD training program founded in #1971, has been found to have repeatedly altered documents related to licensing requirements. Jay Patel, #PhD, has commented that “one way by which a medical school looks excellent is when its alumni look excellent, and the incentive is certainly present for a #medical #school to modify documents related to state licensing requirements”.

    These latest events at #UMKC-#SOM should be a reminder to exercise extra caution when reviewing the credentials of a #physician, especially a physician from #UMKC-SOM.

    #UMKC, #UMKCMED, #med, #Med, #MedEd, #PathGuy, #Ed, #Pathology, #USMLE, #step1, #medicine, #doctor, #physician, #healthcare, #MS2, #MS, #MD, #DIO, #ACGME, #Probation, #transcript, #alterations, #topdoc, #medicalschool, #school, #study, #gunner, #harvardmed, #Kaplan, #usmleworld, #residency, #DO, #osteopathy, #FMG, #kaptest, #plastic, #surgery, #surgeon, #IM, #260, #health #college #university, #student, #pain, #cancer

  • anon3

    Haha!!! You are a major tool. Oh poor you… patients want you to show them respect, be polite, and actually DO the job you were thoroughly trained to do, and if we are annoyed at you for treating us like dirt, and for being unable to solve basic things that we can ourselves with google, we are mentally ill..? And we are mentally ill for daring to USE google! Come on now… ANYONE moaning how they are expected to make eye contact and smile to a “customer”, make them feel welcome and answer their questions about DEADLY DISEASES, let alone brands in a supermarket, is a major tool who is only in it for the money and is more angry about your job than the patients who are doing nothing wrong at all. You all disgust me. It is also not my fault if you spend the majority of the time talking about pointless things and misdiagnosing mental disorders and “reassuring” your patients and giving out wrong information like “young people can’t have heart attacks” and scoffing at them and so on, taking 10 years to diagnose things like celiac disease. If you don’t have enough time to do your job properly, tell your boss ,or get a new one where you can slack off and be sloppy without killing people, oh and where you slagging the people paying your wage, and people for being ill, does not make you look like a heartless, gutless b ….