The job of the modern doctor is to convince

The job of a doctor isn’t to diagnose, prescribe, or examine.  It isn’t to be well read, efficient, or punctual.  The job of the modern doctor is to convince.

We now have radiological studies whose theoretical discernment limit is subcellular.  We can not only map clear and obvious genetic errors of metabolism, but also minor variations of the normal.  In a few years, the majority of codes in the procedure manual will probably be laboratory evaluation codes.  There are few disorders left that given enough money and studies remain elusive.

Patients walk in my door with their diagnoses.  They have COPD, or hypercholesterolemia, or degenerative disc disease.  They come bearing boxes of records from dozens of doctors.  They provide me lists of treatments, some effective, most not.   Occasionally I add a few diagnoses, or parse out which of their problems is the culprit, but for the most part I know what they have when I first see them.

Once the patient and I agree on a diagnosis, the doctoring begins.  Based on nothing other than my words, I have to convince the patient to take poison, do something that may hurt a lot, or go see another doctor who will cut them with sharp objects.  Based on a single conversation, I expect strangers to change their lives, expose themselves to unknown dangers, and then usually not see me again for a month.

I enter all of my patients’ medications from all of their doctors using my electronic medical record system.  Almost every prescription is flagged, usually with 3 or 4 interactions.  If drugs weren’t poisons, they wouldn’t be useful.  Their purpose is to change what your body naturally. Medications that won’t kill you if taken in bulk are rare.  Many of the drugs that I write for have unpleasant side effects that are worst when started.  All of them come decorated from the pharmacist with dire warnings on the outside of the bottle and written instructions reminiscent of the fine print of the Affordable Care Act.

I am a rehab doctor.  That means I often decide that the best treatment is exercise, usually of an unpleasant variety.  Musculoskeletal pain frequently promotes avoidance behavior with consequences in posture and activity that must be trained out, through the restrictions and pain that produced the problem.  Frequently, I’m trying to get the patient to accept therapy to improve the problem, not eliminate it.  After all of the painful therapy they still will have some of the pain.

Sometimes, it’s my job to tell the patient that what they’re afraid of the most is the right thing to do.  The patient comes in after years of injections and therapy and medications, determined to avoid the surgery that their brother said ruined his life.  Then, it’s my job to tell them that all of the failed therapy to avoid surgery increased the chances that they would need surgery, and that now they need surgery.

After telling the patient all of this, I send them out the door with my instructions.  They may or may not fill the prescriptions, or go to the therapist, or go to the surgeon.  They certainly will ask their pharmacist, friends and family their opinions of the treatment.   They will then do what they want.

Bureaucrats paid and unpaid need to understand the fundamental limitation of research based guidelines.  That limitation is that people who are paid behave differently than those who are not.   All of the instructions and electronic monitoring will change nothing if the provider can’t convince the patient to do the recommended treatment.

If the job of a doctor becomes that of a data entry clerk who matches the recommended diagnoses with treatment guidelines, how effective will the doctor be at convincing patients?  I have enough trouble getting patients to do what I actually think should be done, much less providing instructions that are changed yearly by committees who never see patients.

“Tiredoc” is a physician.

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  • dpeelmd

    Maybe if your relationships with patients were collaborative and private you would not have to “convince” them to do what you recommend.

    Physicians start with enormous unspoken, coercive power: people desperately want our help, they are at our mercy, and they wait and pay to see us. We are very, very important to them and they want us to treat them. These are HUGE advantages that make patients want to connect with us, want to believe that we care, and will do our best for them. It’s up to us not to blow it.

    But we do blow it by using EHRs that don’t allow patients (or us) to keep anything private and by “convincing” them, rather than collaborating with them and helping to protect their privacy.

    US health IT systems are coercive. They were designed to serve institutions and payers, not patients and physicians. Patients can’t have privacy even if they pay cash, because the technology systems weren’t built to enable data segmentation or meaningful, informed patient consent and control over disclosures. Patients can’t stop the hidden use and sale of their PHI. Physicians are also coerced and rewarded with funds to buy privacy-destructive EHRs.

    What happens when physicians can’t or won’t protect their patients’ best interests? Patients act by avoiding or delaying treatment, or hiding information–actions that put their health and lives at risk.

    Coercive health IT systems and data exchanges seriously damage the patient-physician relationship. Learn more about why we need to fix HIT systems andrestore patients’ rights to privacy, so collaboration and trust in the patient-physician relationship can be restored–see: http://www.patientprivacyrights.org

    • Tiredoc

      I agree that physicians have an advantage in convincing patients to follow our instructions. I see that advantage being eroded by the current obsession with treatment guidelines determined by committees. More and more, the collaborative decision making that I do is trumped by the collective wisdom of the nameless bureaucratic sludge.

      As for the right word to use for the collaboration, when your patient’s true belief is that the only thing that works for their neck pain is Esgic, Xanax, Lortab and Soma, despite having an overnight sleep study demonstrating 982 central apneic events per night, what word would you choose?

      I choose the word that matches my experience.

  • Peter Elias

    You lost me with this: “Based on nothing other than my words, I have to convince the patient to take poison, do something that may hurt a lot, or go see another doctor who will cut them with sharp objects. Based on a single conversation, I expect strangers to change their lives, expose themselves to unknown dangers, and then usually not see me again for a month.”

    If the plan were based on you sharing the medical information, the patient sharing their perspective and goals, and then a collaborative decision-making process of which the patient felt some ownership, you would not describe yourself as something that sounds more like a car salesman than a physician.

    “I often decide that the best treatment is…” “…getting patients to do what I actually think should be done…” “I send them out the door with my instructions…”

    I think the job of the physician is to help the patient understand and decide.

    Peter Elias, MD

    • Tiredoc

      First, there is no possibility of me equalizing the educational deficit between my patients and myself in ten minutes.

      Second, patients’ medical decisions are frequently not based on rational analysis of relevant studies and available treatments but by intuition. Intuition is notoriously weak in determining relative risk.

      Third, even if you dispute my assertion that my job is to convince patients of my selected treatment, your collaborative treatment requires an equal amount of convincing. You’re convincing them that you care about their perspective and goals and can modify your recommendations to suit their wishes.

      As for comparing the job of convincing patients to follow my prescribed treatments to a car salesman, I can only say I hope not.

      I tried selling cars for a month after college. Didn’t sell a single one.

      • http://psychcentral.com/ DocJohn

        When you start from the false premise that a doctor or physician is the expert in the condition that’s facing the patient, it’s not a surprise you end up believing a doctor’s role is to “convince.” Many patients know more about their disease or condition than the doctor they’re seeing, and that’s only going to be more true in the future.

        A physician who believes they alone can keep up with the dozens of new studies published every week in their specialty (or worse, if a general practitioner — hundreds of new studies!) is not connected to the reality of the vast amount of medical information being published each year.

        A doctor is there as a partner with the patient to discuss the condition or disorder, and together, find the best treatment plan that works for the patient. If you find that your job is to “convince,” you may be doing it wrong.

        • Tiredoc

          If you are talking about rare conditions, certainly the patient often knows more than the doctor. However, on common conditions everyone thinks they know everything. Hypertension, diabetes, high cholesterol, arthritis, and back problems are so ubiquitous that my illiterate patients have a preconceived notion about cause, effect, and appropriate treatment. They are frequently wrong for anyone or just wrong for them.

          If that is the case, I have to either convince them to trust me and try something different, or convince them that they are wrong about what they believe about their diagnosis.

  • Elizabeth Rankin

    You sound very tired Doc! Maybe you’re right if what you say is what you experience…patients need “convincing.” But your patients don’t listen to you,instead they ask their friends, ignore your advice and so on.What you sound off on is more a reflection of who you are as a doctor and it sounds as if the tired Doc is in need of life support, Discouraged or disinterested Docs are not likely effective with their patients.

    That you say: “prescribed medications are poisons”, I concede, they often are not well prescribed, overprescribed, or inappropriately prescribed, and often with little surveillance but as a doctor to suggest they are “poisons” is somewhat disingenuous when we know drugs can and are helpful and sometimes essential. We can’t always accomplish ourselves, what the carefully selected drug can do for us if we need one. It’s true we don’t always need a drug and we should often allow the body to do “what it can naturally with proper nutrition balanced with exercise and finding meditation and yoga, something you might like to consider if you’re into taking any advice?

    I sense you are tired of a system that prevents docs to have the type of practice that could be more focused on working with patients to accomplish better patient outcomes through focusing on the needs of the patient, encouraging dialogue that sparks interest in the patient. Both need to feel there is a compassionate doctor listening to his patient so the patient understands the doctor cares and is willing to work with them to help the patient achieve their goals, whatever that might be. The doctor must recognize their own limitations, so they don’t need to feel they need to ‘convince” patients but rather they need to recognize the patient’s strengths and point out benefits and risks for each problem or concern and weigh the preferences of the patient.
    The doctor’s first goal should be to help the patient by”listening” to their needs and attempting to find a balance to do so.
    The modern doctor and modern patient want this type of engagement.
    Patient privacy issues could be handled, less by “code” and more by ” a patient recorded narrative” that they share, something that escapes the eyes of the EHR. Perhaps patients need to “fight back” and charge EHR corporate systems for all data entry about them since it is that is rightfully theirs, not that of any corporation.
    Would you need to convince your patients if you asked them:
    1. To take a stand and sign a petition to keep their data private?
    2. Have access to all their data?
    3. That they first review their data to see if it is correct, whether anything important has been ignored or misinterpreted?
    4. That Corporations who use their data must pay them for that data since it is rightly theirs?

    If you and others don’t like the system, including your patients, maybe you and they will have something to work together on?

    Elizabeth Rankin

    • Tiredoc

      I am tired, but not of patient care. I tire of the bureaucracy. I tire of formulating collaborative plans that are trumped by insurance companies. I tire of committees that produce guidelines that are useless. I tire of codes and notes.

      As for drugs, they are poisons. The list of drugs that wouldn’t kill you if taken by the bottle is quite short. That doesn’t mean they’re not useful, but it does mean that I as a doctor should always recognize that patient fear of drugs is both logical and intuitively correct.

      Knowing that drugs are poisons also means that frustration with non-compliant patients is misplaced. It means, to me, that non-compliance means that I haven’t enlisted the patient effectively in the treatment plan. It means back up, educate, change the plan or try again.

      As for your feelings about patient privacy, I respectfully disagree. In my opinion, objective non-identifying data should be freely available for anyone to analyze. Your advocating for a patient-entered and corrected EMR is interesting, but with over 100,000 codes scheduled to hit with ICD-10 unfeasible.

  • Thomas D Guastavino

    What about the issue of secondary gain, a problem much bigger then most realize.?

    • DoubtfulGuest

      Right you are, but, docs, please check the functioning of your secondary gain-o-meters. If they go haywire, you can hurt someone. A good starting point is to ask yourselves, is there *evidence* that the patient has ulterior motives?

      • Thomas D Guastavino

        The only problem with my “secondary gain-o-meter” was not turning it on earlier in my career. Any patient that I see initially gets the benefit of the doubt that they seeing me for legitimate reasons, that they are there because they want advice and guidance for a medical complaint. A short list of problems that have gotten much worse in just the past few years:
        1) Limitations on health insurance and poor job prospects coupled with litigation leading to an explosion in workers compensation claims
        2)Lessening of welfare requirements leading to exaggeration of medical complaints for greater support payments
        3) Lessoning of requirements for social security disability
        These are just a few along with the ever present drug seekers, family dynamics, etc…etc.

        • DoubtfulGuest

          Maybe the optimal setting is that meter should always be humming along at a low level? I try to tell myself that the most jaded docs were once the most idealistic and eager to help.

          Family dynamics…to my knowledge most doctors have little training in this area. In my experience, some doctors act as though any less-than-ideal family situation somehow conveys a protective effect against all sorts of organic diseases. Wouldn’t that be nice –there’d be lots more healthy people running around…but that assumption is not supported by evidence.

          I actually agree with you in general. To doctors at large, I ask, please define “initially”? It’s just that “secondary gain” gets thrown around a lot, even with no evidence. Potential for secondary gain ≠ the patient actually doing anything dishonest. Trouble is, once doctors see it several times, or even once with serious negative consequences for the doctor, it’s easy to start “seeing” it everywhere. Which means blowback for some innocent patients. I have not found anyone willing to address this.

  • Carole Staveley

    I agree with your objection to the use of guidelines that turn doctors into data entry clerks. I also agree that many of the solutions to patients’ problems require taking some unpleasant actions. I think the issue lies in doctors’ belief that it’s their responsibility to “convince” patients to take action. In my view, physicians are there as resources to patients. Patients are in the driver’s seat (as you’ve noted), and the only person who ultimately decides what action to take is the patient. If doctors accept this fact and behave as partners and advisors to their patients, the “convincing” part will not be necessary. Empowering the patient to be informed and ask good questions in order to have productive, problem-solving conversations with their doctors and other health care professionals is the only way.

    • Tiredoc

      convince: To bring by the use of argument or evidence to firm belief or a course of action.

      You can’t convince someone who isn’t in the driver seat. Convincing requires patient participation and ownership of the treatment plan and requires collaboration between the physician and the patient.

      Perhaps I should have used the word persuaded.

  • Tiredoc

    Fair enough. As a paramedic, your interaction with patients fairly closely matches their preconceived notion of what you should do. As a rehab doctor, I often have to leave the script. Of course it requires a relationship and collaboration with the patient. It also frequently involves convincing the patient the change their mind.

  • Tiredoc

    I don’t underestimate intuition. I do recognize its limitations. Intuition is excellent at identifying motivation and absolute danger. It is quite useless even for physicians at choosing between two dangerous alternatives.

    • rbthe4th2

      You were spot on with that one Tired. I had a doctor who used “intuition” on me. It was quite a life changing impact I’m paying for to this day. My question is why the “captains” or “pilots” of the ship aren’t taking the responsibility for it? Or why the other ship captains and pilots aren’t getting them to do so?
      Maybe that would help explain what some of us patients are trying to get across to health pros. :)

      • Tiredoc

        In inpatient rehab, we had weekly meetings where the PT, OT, Social Worker, RN, Speech Therapist, patient, family and MD would meet. “Captain” was appropriate for those meetings. I’m not sure why a doctor-patient relationship needs a captain.

        In the end, the patient is responsible, because the patient must live or die with the consequences of the treatment decision. I don’t say this to insulate doctors from the consequences of bad advice, but to encourage patients to advocate for themselves.

        There are going to be more and more circumstances in which patients don’t have a choice in doctors. The advice of “find another doctor” isn’t always going to work. Thank you for reminding me that this is hard from the patient end as well.

  • Shirie Leng, MD

    It seems to me that if the patient has made an appointment we can assume that he or she wants our help. This is arguable, I know. So that person who took time out of their day to see us is likely to at least listen to what we have to say. We listen and recommend, but what a person does with their own body and health is really not up to doctors. All the guidelines in the world don’t change human behavior.

    • Thomas D Guastavino

      Clearly patients make an appointment because they are seeking help. The unanswered question is, help with what?
      During my first year of residency we ran a very busy pediatric orthopaedic clinic. One day for no apparent reason there was a big increase in the number of mothers bringing in their children complaining that their childrens feet were crooked. Doing our due diligence we did a thourough exam the vast majority of the time finding nothing wrong. Despite our reassurances to the contrary the mothers persisted at times practically their children upside down by one foot while pointing to the other. It took us a while to figure out that a rumor was started that if your child had crooked feet they could get free shoes.
      The point? Several of these patients filed complaints against us. Once we found out what was going on we all had a good laugh and dismissed the complaints. These days Im not so sure what would happen.

  • http://www.mightycasey.com/ MightyCasey

    You’re attempting to cast yourself in the category of Magical Being, wherein “convincing” (casting a spell?) a patient to do [whatever] is your role in the play called “Illness or Condition.”

    Sorry, TireDoc, but you’re just another human working to use the knowledge you have to offer a best-guess – evidence-based, but still a guess – on what will circumvent said illness or condition. There are no guarantees in medicine, other than that there are no guarantees in medicine. We’re born, we die, what happens in between is equal parts luck and art, with a sprinkling of science.

    I’m more of an expert on my corpus than any clinician I work with to manage said corpus. Admittedly, the clinician’s education is an advantage for him or her, but that does NOT give that clinician expert status on MY specific issues. For that, you need MY input. Sorry to hear you find that input so tiresome.

    Rather than whinge about becoming a data-entry clerk, why not partner with your patients to work on making the system work better for all of us? Or is it just too darn easy to whine … ?

    • Tiredoc

      There is nothing magical or egotistical about convincing. if you think you are logically right, you present objective evidence and information to change someone’s point of view.

      Your opinion that you are an expert on Corpus Casey is precisely what I would attempt to convince you otherwise.

      The human body is notorious for providing its owner with vague symptoms unconnected with pathology and pathology unconnected with symptoms. If the body provided everyone with expertise in themselves, there would be no need for diagnostics.

      As for complaining about the input my patients provide, my thesis was a complaint about treatment guidelines that fail to include either the patient or the doctor in their metric.

      • http://www.mightycasey.com/ MightyCasey

        I’ll grant a doc the right to share scientific evidence that might show the symptoms I’m displaying are coming from something not on my own awareness radar. I will remain unconvinced, however, if that doc fails to treat me as a partner in working on [whatever]. Nothing you’ve said so far has moved me from the belief that most of what you’re saying comes purely from ego: “I’ve got MD after my name, so shut up.”

        • Tiredoc

          In some doctor-patient relationships, there reaches a point where the patient and the doctor have a difference of opinion. In that case, argument and convincing no longer apply. In that case, either the doctor defers to the wishes of the patient, or the doctor says, “No.”

          I’m not overly concerned with the M.D. after my name, but there are many circumstances in the collaborative relationship where the correct scientific and moral answer is, “No.”

          • rbthe4th2

            Agreed. I think what patient advocates are trying to get across is the reception we get, the attitude and behavior, the life long lasting damage, that comes when there isn’t a collaborative relationship and the where the correct scientific and moral answer is Yes.
            If the health professionals want us to buy into them, they need to buy into us. Trust is a two way street.

          • Tiredoc

            True.

        • Tiredoc

          So you expect your doctor to produce scientific evidence to prove that your symptoms aren’t on your awareness radar?

          How would such a study even be designed? You state that you want to be an equal partner, but your feelings can only be contested with peer reviewed thesis.

          Perhaps your beam needs adjusting.

  • Tiredoc

    I prescribe controlled substances, but I spend a large portion of my education time in those cases convincing patients of the very real limitations of the treatment, both in terms of tolerance formation and how to manage treatment failure.

    Your amputation is an excellent example of the need to convince on both sides of the doctor patient relationship.

    I have on two occasions convinced patients that amputation of a crushed foot would relieve their pain, with excellent results in their pain level and function. Both times required at least a year of the relationship forming. I stated my case on the first visit, but the convincing took much longer. Once I convinced the patient, both of us then needed to convince the surgeon.

    As for drug seekers, they don’t exist. There are drug dealers or patients. Dealers are easy. They’ll wait for hours, tell you you’re wonderful and bring you presents. Patients are hard, because they have actual problems and need help. Addicts shouldn’t be treated the same as pain patients, but they’re still patients and should be treated with respect. It’s just a different problem.

  • Tiredoc

    My biggest problem is not with patients who know more than me about their condition nor with those who know nothing whatsoever about medicine.

    My biggest problem is with patients who know all sorts of things that happen to be wrong. Not wrong in some intangible sense, or wrong for everyone, but wrong for them, and wrong for the goals that they express.

    For those patients, in order to change the disease process, the patient must change their mind. That changing of mind requires…convincing.

    My point is that this convincing is necessary for all of the most common preventable disorders, precisely because most people are educated by everyone before they walk through my door. The problem is that this education is not specific to the patient and their life and needs at a minimum modification to work.

    Collaboration is necessary. Patient ownership of the plan is necessary. Convincing, or persuading if you hate the word convincing, is vital and is being undermined by treatment guidelines.

    I guess I need to work on my ability to be convincing as a blogger.

  • Tiredoc

    Thank you.

  • Tiredoc

    I do work with that problem. Again, I am a rehab doctor, almost by definition at the end of lots and lots of doctors and tests. I do occasionally diagnose things that have been missed, but not usually.

    I will say that my approach is very objective, in that I support and expect my patients to demand measurable results. If the treatment plan is ineffective, that by itself is reason to revisit diagnosis.

    • rbthe4th2

      What could we, docs and patients, do to foster this in “the system”?

      • Tiredoc

        I have a few truly complicated patients bring in medical summaries they did themselves. About half are way too wordy and include non-medical detail. “I was visiting my cousin Sally who is going through a divorce…” The others are sometimes brilliant. I have one patient who leads with a bulleted
        agenda on their sheet, and never gives me a sheet longer than two pages of 12 point. I let her ask twice as many questions as I otherwise would, because I know there’s an end point. It’s on the agenda.

        • DoubtfulGuest

          Great suggestions. I suspect many patients are simply unaware of what the doctor needs. Docs might also consider:

          Communication styles/preferences vary.
          -I had one doc angry at 1-page, 12-pt. list.
          -Pts. often don’t find out doc’s prefs until too late
          -Try telling us early, please?

          Different factors –> Pt. communication efficiency
          -Medical (e.g. cognitive difficulty, anxiety)
          -Before frustrated at windy pt, try gently redirecting?
          -i.e. help pts. “back to Earth” if we go off track

          -Cultural/social/media influence
          -“Tell the doctor *everything*, let her figure it out”.
          -Vague awareness of mind-body connection
          -Sense of entitlement*
          * (please consider other factors first)

  • Tiredoc

    True. By job I meant what a doctor actually does, not who the doctor is.

  • Tiredoc

    The reason most doctors shy away from using food and supplements as drugs is the absence of universal rules. Just the percentage of dietary fat, protein and carbohydrate required is highly variable depending on genetics.

    Your vegetarian diet works well for you, but make someone who looks just like you miserable. You can be highly allergic to a common food and spend years just determining which one. Using food as a drug also requires a level of compliance far in excess of what most doctors expect from a typical patient.

    That isn’t to say that your doctor shouldn’t work with you to find a solution. I have patients who I spend the time necessary to fine tune medication, exercise, diet and supplements to achieve an objectively measurable goal (weight, mobility, diabetic control, cholesterol, etc.).

    In those cases, the convincing mostly works along the lines of insisting as a doctor that the goals are more important that the treatment. The science behind the goals is just a lot better than the science behind any diet or supplement regimen. I’m all for alternatives, but I do insist on evidence that the regimen works for the patient as an individual.

    • DoubtfulGuest

      There you go, getting back to the original topic. :)
      I agree with this 100%. I just think it bears noting that many of us do want your help, getting well is our priority #1, and we want to do it by reasonable means. That’s often true even if it’s not immediately apparent. Perhaps it would be a post for another time, but it would be nice to see a doctor address what can happen when they mislabel or misunderstand a patient’s reasons for scheduling a visit. What would be really great, is to look at ways to resolve these issues before they have serious consequences for either party.

      Nice post, and I thought the word “convince” was just fine taken in the right context.

  • rbthe4th2

    This comment, “More educated patients who realize that expertise varies require sound reasoning before accepting a treatment plan.During initial visits, both doctor and patient are somewhat at a disadvantage with no established track record. But if doctors miss the mark with their diagnosis, prescription or treatment, patients are likely to become circumspect of future suggestions.” just hit the nail on the head so completely!
    Tiredoc, you might want to ask those “doctor shopping” and those who don’t do what you want them to do, “non compliant”, and the like (and maybe all other docs reading posts here) that this might be a huge factor in why you are having problems.
    I had a doctor prescribe Boost/Ensure. If you review the ingredients on the label, sugar water that is more than a soda, with a few vitamins thrown on top of it (and not the ones I need/am low in) probably isn’t as healthy and nutritious as one thinks. It also went against another doctors’ recommendations. So of course, I’m going to be “circumspect of future suggestions”. That was after I looked into the data/information, and not just TV ads.
    Now was the patient bad/wrong or was there another explanation? I know some docs who dislike my posts and thoughts, but this is a doctor complaint about patients that we’re telling you how you solve it: ask the question of us what the data is behind why we won’t do something. This would make a major headache for you all go away, wouldn’t it? As DG has said, we’re actually looking to try to find ways to work with you, if you are willing to do that.
    I think you’d find the difference between your patients who rely on TV or their friends, or relying on ClinicalKey, UpToDate, and an MD/PhD for their resources. Dr. G. wouldn’t need to have to turn on his “entitlement/drug seeking” radar for these people, would he?
    Randy

    • Tiredoc

      The problem isn’t so much “doctor shopping,” but the “Burger King” patient. (“Have it your way.”). If a patient lies to the doctor about their symptoms, expectations and goals, it becomes a different sort of experience for everyone.

      • rbthe4th2

        Excellent point! 2 things then come to mind: what would be “medical thinking” behind a patient on a treatment regime that wasn’t working? Also, how can you tell the difference between a BK patient and one who has something a bit obscure but no one wants to test for what the problem might be?
        I guess probably what we’re trying to get across is we understand you all have different classes of patients, so how can we do or say the right items so that you know who you can trust (someone who sticks their nose into appropriate material) and those who read Oprah (or whoever she has a doctor)?

        • Tiredoc

          A BK patient is one who walks in the door thinking that they know what they have and what they need, and don’t really want to talk to the doctor at all.

          I guess bad patients and bad doctors have the same problem. Failure to listen.

          I will say that I don’t move to a treatment plan unless the patient and I agree on a diagnosis, or at least the problem to be treated.

          Just like everyone, Oprah and her doctor are sometimes right. The trick is figuring out when.

          • rbthe4th2

            I can agree with you on the failure to listen. The problem is that the doctor has the upper hand in the relationship: the power and control. When things go wrong, where should the responsibility lie? Tiredoc, you and a fairly good portion of docs on here are that way. I’ve met too many though that aren’t. That’s what you see – and hopes that maybe those, like you, would be willing to start making the change. If you don’t – guess who will? Oprah and her doctor …

  • DoubtfulGuest

    Exactly. Hey, maybe a few of us patients could help with video evaluations for docs to work on how they come across during history-taking and exams:

    “Oh, that’s waaaaaaay too much side-eye! You think that’s not going to make people nervous?”

    • rbthe4th2

      With all due respects to the docs here, I had one doctor that after a number of meetings, I finally had enough. I interrupted them and said (not shouting but forcefully) “can I get a word in edge wise please?”. They literally jumped back.
      I understand you all need to control the situation, but a full sentence might be helpful to diagnosing an issue. :)
      Randy

  • buzzkillerjsmith

    Over many years of beatings, some self-induced, I have learned that pts very rarely follow unsolicited advice and rarely follow the advice they ask for. Trying to convince someone to do something in 15 minutes is doomed to failure. I don’t even try it anymore.

    You are trying to square the circle and you will fail to do so.

    What do I do? First I try go get more than 15 minutes. Sometimes that happens, sometimes no. Then I smile and nod agreeably, try some motivational interviewing, and expect that changes will not happen, at least in the short term. Sometimes in the longer term, yes, and there are some pts that surprise me by coming around soon, but those are the minority.

    Getting upset about normal human behavior, even if it is self-destructive, is about as productive as raging against the sun coming up in the east and going down in the west. It won’t help your pts but will grind you into dust.

    Perhaps some will not like this comment. Perhaps some, in and out of the medical profession, cling to the idea that we can help everyone,. Those folks are deluded.

    But you already knew this, Tiredoc.

    • Tiredoc

      Yes, I did.

    • T H

      Amen, brother.

  • Tiredoc

    Generally, guidelines put out by government bodies include physicians, pharmacists, administrators and random humans whose job it is to be a layperson voice. These guidelines are then voted on. This is a stupid way to come up with guidelines.

    The guidelines put out by the various specialties are usually 100% physician votes, but are notoriously corrupted by financial interest (orthopedic surgeons and meniscus surgeries, cardiologists and stents). These are also votes, and are biased toward the viewpoint of senior members.

    The current trend is to make guidelines for everything, even if the guideline specifies a treatment that ls known to achieve goals in less than a third of the target population. (ACE for blood pressure.)

    The trend to guidelines is based on an academic bias against community physicians. It is based on the presumption that if doctors and patients would just do what they were told, then tens of thousands of lives would be saved.

    Every patient and doctor should be resistant to medicine by distant bureaucratic votes. They aren’t scientific. They’re arrogant and usually wrong. We know less than 10 percent of what we need to know before medicine can be a cookbook. The science isn’t there yet and we need to tell the bureaucrats to go back to their changing tables where they belong.

    • rbthe4th2

      Very interesting. Thank you. I’ll have to muddle over this one. I know I pay attention more now than I did 10 years ago to any conflict of interest statements. This will help me more to look at what the doctors are (academic vs. practice) also. I’m not as much a guideline person as I am in reviewing the data itself and seeing it against any guidelines.
      Can someone alert Kevin Pho and tell him we need to put some of the comments on this page on a separate “help sheet”? Good food for thought.
      Randy

    • DoubtfulGuest

      Yes, Tiredoc, I really appreciate all your thoughtful responses to these comments and questions you’ve received. It’s been a great read and very informative.

      • Tiredoc

        Thank you.

  • Tiredoc

    If the diagnosis is in doubt, I will provide an abbreviated differential diagnosis. Most of the education that I provide is translating medical speech into English. I find that just about all of my patients do better with pain and dysfunction if they understand the natural process.

    I caution strongly against relying overmuch on new treatments and new research. A general rule of thumb is if your medical problem isn’t killing you, wait a year before taking a new drug, three years before having a new surgery, and five years before accepting a new implant. Let someone else be the guinea pig.

    I have had patients provide me with useful medical information based on their own research. It usually isn’t new research, but old generic medications that aren’t funded that come by that path.

    I’m probably going to get negative votes on this one, but I only send patients to diabetic classes when I am starting Insulin. The ADA guidelines for diabetics who are only on oral medications are a prime example of the nonspecific guidelines that I detest.

    • rbthe4th2

      I gave you a thumbs up because I know diabetic people and detest the food pyramid or whatever crap it is they tell them to eat. They’ve gotten better at it but it still needs some work.
      I also don’t believe that “eat what you want and pop a pill” is on that list, and if it was, it would probably be a one time a week thing.

  • Tiredoc

    The day I stop looking to improve my performance is the day they plant me in the ground.

    • rbthe4th2

      Thank you!
      Would a synopsis be better? For example: I have a paper from Dr. Z, a fellow in the American College of Derm, saying that Treatment P works for D. The paper describes the symptoms, which I have. Any thoughts?
      Or would a Medline/PubMed synopsis be better than the full write up?
      Randy

      • Tiredoc

        The problem with dermatological problems is that they have a tendency to look alike. A synopsis would likely be better received, but most difficult to diagnose derm problems need a piece of you cut off and put under a
        microscope.

        • rbthe4th2

          Thank you. Most helpful – appreciate it.

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