Why patients have lost trust in their doctors

I came across a really good post on the Daily Beast written by a pediatrician in New England, griping (appropriately) about parents who were unwilling to trust his judgment about vaccinating their children.

Why have so many patients lost trust in their doctors?

You might challenge the assumption that patients used to trust their doctors more, and that would be a fair question.  I haven’t found any peer-reviewed studies on this, but if television is any guide to changes in culture over time, I refer you to Marcus Welby, MD vs. House. Rather benign, certainly caring and competent, thoughtful and ethical, Dr. Welby seemed to represent how most folks viewed their personal physician back in the late 60’s.  Dr. House, on the other hand, came across as brusk, uncaring, addicted, untrustworthy, willing to violate his patient’s rights on a whim, a real 21st century smartass.  Accept for the sake of argument that the premise of this blog is generally true.

Did physicians in this country merit this transition in cultural perception from caring to untrustworthy (or at least indifferent) over 40 years, or were we the victims of cultural ambush?

You can certainly point to a lot of possible reasons why many patients no longer trust the physicians who care for them.  It is certainly difficult to maintain this trust when other physicians publicly recommend that people should not trust their doctor.   Dr. Rost makes the argument that “most doctors are businessmen first and doctors second,” meaning that medical practice has transitioned from a profession to a crass, me-first money making operation.  I personally spent a lot of time working on keeping my ER group from sinking under the weight of our mission to care for the uninsured; but I never felt that this focus on reimbursement was more important that the mission itself.  Most of the docs I know care about caring, and serving the best interests of their patients; but I have to acknowledge that for more than a few docs, money matters a lot.

The most obvious things that have changed the perception of medicine over these last forty years include high profile cases of physician fraud, drug abuse, drug pushing, malfeasance, gross malpractice, even murder.   What in the past was often hushed up, or discounted as highly unusual, have now become grist for the media mill.  To say that physicians’ images have been tarnished by these instances would be an understatement.

However, there are undercurrents that have also impacted public opinion, in a more subtle but powerful way.  Physician advertising probably reinforces the view of physicians as business entrepreneurs rather than caregivers.  The whole concept of capitation, not fully understood by the public but felt by patients every time their HMO provider hesitates about ordering a test or treatment and does it in a way that creates a sense of unease rather than confidence; this hits right at the heart of trust between doctor and patient.

Stories about physician researchers compromising their integrity at the behest of pharmaceutical companies; advertising by trail lawyers drumming up business by pointing to horrible outcomes from what initially seemed to be great medical and surgical breakthroughs; pontification by opponents of vaccination, birth control, Obamacare, virtually anything negative having to do with physicians or healthcare:  all of these reach into the fears and concerns of our patients and stoke them.

We are all exposed to a lot of negative press and adverse opinions about the practice of medicine, and some, frankly, is deserved; but there is not a lot of recognition for the positives in what physicians do. Even TV shows like MASH and ER temper the good in medical practice by acknowledging, or even showcasing, the human side to physicians and caregivers, i.e. the tragic failings of these “heroes of health care.”

I admit that even firefighters and paramedics get similar treatment nowadays in the media, and yet they continue to retain a favorable image in the public’s eye; which raises the question:  Are physicians doing something wrong here?

It is possible that we are.  If physicians sell their practice and go to work for a hospital or a large corporation; whose interests are they serving, especially if the interests of the corporation and the patient aren’t aligned?  Do you really need to be admitted to the hospital, or is the doctor just following the directive of the for-profit institution?  Is my doctor getting incentivized to push this drug, or that test?  Are doctors spending more time doing paperwork, and less time in the exam room, because it is in doctors’ best interests, or for the patients?  Do templated EMRs accurately reflect the individual patient’s responses and exam findings, or just help the doctor “move the meat”?  I think it is not as much that patients are having these concerns, per se; but that these kinds of activities and practice patterns have an impact on the way doctors think about themselves, and their work.  Perhaps we don’t trust ourselves as much anymore.

But didn’t a Gallup poll recently reveal that trust in doctors moved to an all-time high of 70% over the last ten years?  That’s true.  Perhaps all of this hand wringing I just went through is based on an incorrect assumption:  we still have the trust of our patients (especially compared to the public’s trust in lawyers, stockbrokers, and members of Congress).  Great.  I hope this poll is accurate:  but members of Congress are at the bottom of the poll at 7%, and yet they all keep getting re-elected.   Perhaps those polled were thinking “I love my doctor, but I’m not sure about those other guys.”

Regardless, I think it is incumbent on physicians to recognize they need to earn this trust, and not take it for granted; to watchdog their profession and those who practice it; to monitor themselves and how incentives impact their behavior and their care; to promote respect from the public and the media; and to guard against the insidious intrusion of the business of medicine on the practice of medicine.  As someone who advocates actively for fair payment for physician services; I can assure you this is no easy task.

Myles Riner is an emergency physician who blogs at The Fickle Finger.

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  • drwes

    With the adoption of the sentinel medical ethic document published in the Annals of Internal Medicine in 2002 (“Medical Professionalism in the New Millennia: A Physician Charter” http://annals.org/article.aspx?articleid=474090 ), professional societies and physicians officially abandoned the ethic of caring for the individual to the requirement for caring for the collective. (See see the ethical requirement entitled “Commitment to a just distribution of finite resources”)

    This ethic officially makes it impossible for physicians to serve as true advocates for their patients in an increasingly hostile health care environment hell-bent on profit for everyone except the patient. Doctors have seen their ability to advocate unequivocally for their patients morph to advocating for their employer, central planners, and third parties with very different motivations than patient care.

    If you wonder why patients don’t trust their doctors, maybe we should start here. Instead of blaming it on everyone else, doctors should probably first look at ourselves and what we’ve allowed to transpire in the name of the “collective” good.

    • RocK8Doc

      Unfortunately it’s the same collectivists/pseudo patient advocates who are spearheading the movement to breakdown the residual trust and eliminate those doctors who would still like to be the real patient advocates.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        Every time you read some seemingly virtuous rant from a famous “patient advocate” wearing a $1,000 suit, you should start digging beyond credentials and non-profit affiliations, and every time you will discover Wall Street, big corporations or politicians pulling the strings.

  • Anthony D

    One other reason is the stigma attached to medical doctors saying that they are greedy and only care about their HUGE bank accounts, instead of the patients well being!

    Plus you have the media that likes to vilify physicians (like the New York Times), is it any wonder why many distrust these healthcare workers!

    • Suzi Q 38

      Just like anything else, we are hearing of more problems with I am glad you are doing well and keeping up with your studies.

      You can do it.

      You are still young and energetic.

      I had to take the year off, but I am doing a little better.

      I have gained 10 pounds OMG!!!

      I feel heavy but realize that part of it comes from less exercise, pain meds, and food.

      My two neurologists are fantastic physicians that care and are hopeful as I am that I will get better.

      It feels good to trust them.

      One is 80 and tells me that “He hopes to still be here for our next appointment,”LOL.

      The other one is a feisty female who just moved to to a large teaching hospital in Los Angeles.

      It is a hassle to drive in to the L.A. area, but worth it. She is a colleague of a friend of Drew’s friend, and that person knows my son.

      She was so good that I had to bring Olivia in to see her work during my examination, she was that good, LOL.

      I like to bring Olivia in sometimes so that she can learn and also help me remember what the doctor told me.

      She is my neurology “quarterback.” I do everything she tells me to, because she makes sense.

      She is fairly young, just in case the elder doctor “kicks the bucket” on me. Sounds mean, but he said it, I didn’t .

      Olivia will hopefully be graduating with her NP in June, then she has to take an exam.

      Take care,

      Sharon

    • Suzi Q 38

      Just like anything else, there are doctors who are less than reputable.

  • David Gelber MD

    Perhaps doctors are mistrusted as a whole, perhaps not. But, should an individual become ill and require medical attention, then the trust inherent in the doctor patient relationship must be present. Lack of trust in a one on one doctor patient relationship leads to bad outcomes, at least in my opinion.
    And, there is nothing better from a business perspective than doing what is right for one’s patients. I know of one surgeon who consistently put his monetary needs ahead of those of his patients. He is no longer practicing surgery, or medicine of any type.
    One can never argue against doing the right thing.

    • rbthe4th2

      If a couple surgeons I know weren’t propped up by the health care conglomerates they work for, they would be out too. Its not always someone elses’ job to put them out of business.

  • guest

    Let’s not forget that the President’s wife was, for some period of time, a highly paid hospital administrator, making over $300,000 one year, a salary that was “in line with the compensation received by the not-for-profit medical center’s 16 other vice presidents.”

  • Lisa

    I think the reason patients don’t trust their doctors is more basic than a distrust of the medical/pharma/insurance industries.

    I do not trust doctors, in general. How come? I’ve been misdiagnosed. I’ve been to too many appointments where the doctor didn’t review my records before hand. I’ve been to too many appointments where the doctor didn’t bother to listen to me or discounted what I said. They don’t answer direct questions. I have had too many doctors fail to give me test results. I have had too many treatments proposed without a discussion of the benefits versus risks. I have had too many doctors dismiss complaints of side effects. I swear my fist oncologists favorite sentence was “that is not a listed side effect.” I have had too many doctors who won’t back off an incorrect statement, who won’t acknowledge an error.

    I trust my pcp. He tells me what he thinks is wrong and what his treatment plan is. He answers questions. And if he doesn’t know something he will look it up. He makes sure I get copies of test results and will set an appointment to go over the results and treatment implications if necessary. Simple things really,

    • RocK8Doc

      Lisa;

      The underlying problem is the lack of relationship and the barriers that have been created between patients and doctors.

      You have given us the perfect examples.

      1) With your PCP you had established a good doctor patient relationship which is the foundation.

      2) With other doctors it seems it was more like a PROVIDER – CUSTOMER relationship.

      The trend is more towards the later which is unfortunately beyond the control of physicians.

      • Lisa

        I know that doctors are under a lot of pressure these days and have limited time to spend with each patient. But the problems I have had with doctors don’t have anything institutional barriers that have been created between us. The problems have to more to do with communication – the tendency of the doctors to think they are always correct and that I should go along with their treatment plans without any questions. I find it irritating when doctors are condescending.

        Yes, I have a good relationship with my PCP. In large part that is because of his style of communication.

        • RocK8Doc

          Lisa;

          I can safely assume that relationship was not built in one visit.

          Please look at the attached pictures and you may find some answers.

          The green ones are positive effects.

          When physicians are focused on tasks and they are under stress due to the institutional barriers, they are emotionally/socially impaired.

          This leads to impaired communication and strained relationship and all the ills you described earlier.

          • DoubtfulGuest

            What can patients do?…those of us who are not happy with the customer service model and who want good relationships with our doctors? I’m very sympathetic with Lisa, had some of the same bad experiences, and did not know what I was getting into, in terms of the institutional barriers. We get treated like adversaries even when we go in with complete trust and respect for our doctors.

          • RocK8Doc

            What can patients do?

            Identify a doctor who can work with you as a partner. It is a two way street. :-)

          • DoubtfulGuest

            I have that now, thanks. But really, that’s just a nicer way of saying “change doctors” if you’re having problems with the current one. Is the relationship important? Or not? Let’s compare it with other important relationships – friends, family, coworkers…it’s not quite like any of those. But in most cases, when people have problems with one another in these important relationships, they try to work it out before ending the relationship. People who end relationships very easily are widely considered to be kind of…shallow. So, does the doctor patient relationship matter, or not? I’m sorry to get so frustrated, but you all keep giving me the same answer on this blog. Do you want everyone to change doctors when problems develop? Will all you doctors take a new patient who has done so? Can you imagine the cost, the time, labor, and health care resources in all these “find a new doctor” scenarios? Or, should we learn to work things out with one another, with the idea that changing doctors is further down on the list of options? With the doctor who made the mistakes and threw me under the bus, we had an agreement that he was going to get me to a more specialized person in his same specialty and I would need long-term care from them. The problem is when and how the relationship ended. Not how he and I agreed it would, not on good terms. Does the doctor patient relationship matter? Or not?

          • RocK8Doc

            The doctor patient relationship really matters and is very important.

            Unlike other relationships you mentioned there is a significant difference in the DocPt Relationship especially in the context of the barriers between the Doc and Pt.

            Inspite of several barriers and stresses evoking PEA still works. It just takes time and may not work with everyone. When it doesn’t work then you have to change.

            No I am not advocating changing or doctor shopping.

          • DoubtfulGuest

            I understand, and no, those other relationships aren’t a great comparison. It’s just hard for patients to be sure how hard we should try with PEA. Because one doctor might say the relationship should have ended long ago, but another might say the patient didn’t try hard enough. Many doctors seem to feel manipulated by a patient who is purposefully nice and polite. You’d think it would make their jobs easier, but I’ve had doctors respond very poorly to kindness. Like I must have something worse up my sleeve. I don’t disagree with you, it’s just much harder in practice than you might think.

          • RocK8Doc

            Check my other pictures on the emotional contagion.:-)

            Kindness- It depends on if it is sympathy or empathy. Symapthy may back fire while empathy helps nurture the relationship.

            I didn’t say it was easy. It is hard but it’s worth it in long term.

            You are not alone, we are in it together. Unfortunately too many people positioned between us( patients/Physicians and other clinicians) in the name of helping us they are harming more than helping.

            There are outliers amongsts us ( Bad doctors and Malingering patients) but vast majority of us just want good outcomes.

          • DoubtfulGuest

            Is sympathy the condescending one? I always get sympathy and empathy mixed up. Whichever way is right, is what I was *trying* to do.

          • RocK8Doc

            I Hope this would help

            ” SOCIAL AND EMOTIONAL LEARNING

            Resources for Learning About Empathy on Valentine’s Day

            you http://www.edutopia.org/blog/valentines-day-learning-resources-empathy-matt-davis

          • RocK8Doc

            We can further refine empathy;

            “Two forms of empathy.

            1) There is a form of empathy, that starts in the medial prefrontal cortex in which you’re engaging somebody else through a reflection of yourself. You are understanding the other person by going inside of yourself, in a sense, how would I be feeling if I were in their shoes? They actually label this as a more self-centered version of empathy.

            2) The other version of empathy happens further back in the brain’s networks, in a part of the default mode network, the social network. This is a part centered around the posterius center of the cortex in which the person genuinely opens themself up to the other person, in which the person actually is focused on the other. And it ends up being a very powerful, a much more genuine form of empathy. “

          • DoubtfulGuest

            Could definitely work on 2) some more. It seems the empathy gradient in our society is directed away from doctors, so they are always trying to give some but receiving very little. It shouldn’t be that way and anyone would find it hard to function under those conditions.

          • DoubtfulGuest

            Thanks for adding this second part. The doctor I’m talking about also does a fair amount of worker’s comp and other medicolegal stuff, even though it’s not his main job. I suspect he used to be very idealistic and then got taken for a ride very badly, more than once. I picked up on that during the visits, and I was willing to do anything within reason to help him feel confident that I wasn’t taking advantage of him. I think patients should understand there is some burden of proof/honesty on our end. Trouble is, not all of you have specific endpoints of, what objective information do you need to make this determination about a patient either way? I didn’t even have any nonorganic signs, on exam, and I’m aware those can show up for reasons other than faking (anxiety, old age). I only know this stuff because I had to go look it up to understand what was happening to me.

          • RocK8Doc

            Yes you can have non-organic signs in addition to faking due to several other well non organic conditions.

            We need to look behind that curtain. In order to do that successfully we need a good rapport. Unfortunately sometimes vast majority of us are affected due to the sins of few outliers.

            There are physician innovators who try different approaches when it comes to dealing with chronic pain and pain related conditions that may not be organic.

            “Back in control: Taking charge of your chronic pain treatment.

            Don’t live in pain

            Pain is a perception – nothing more, nothing less. Understanding pain allows you to gain control of your care. Freedom from pain is not possible – with the right tools it is probable.

            Taking Back Control: The 5 Stages”

            http://www.drdavidhanscom.com/

          • DoubtfulGuest

            Very interesting, thanks. I agree we need to get away from the finger-pointing, because stress can make symptoms worse for any of us. I just had no objective indicators whatsoever, that I was faking. I feel that doctors can empower themselves to avoid being manipulated and improve their diagnostic instincts, by always asking themselves “What objective information do I need to determine whether or not this patient is honest?”

            The doctors who finally diagnosed me correctly also considered faking, they went through all the standard exams for that. But they made it clear to me that it was way down at the bottom of their list of possibilities. This made me so much more comfortable with them, less fidgety, better able to explain what was going on. So they got higher quality information in less time with lower “background noise” from anxiety.

          • RocK8Doc

            Unfortunately there is no Objective way to determine honesty. I wish we have a real pain measuring device. Yes there are some psychological tests to determine malingering but that can’t be deployed in the earlier stages and every day interactions with the patients. As I said earlier we need to look through the veil (faking and other issues) to make sure there is nothing significant that we are missing with reassurance if needed.

            Unfortunately there is no silver bullet :-(

          • DoubtfulGuest

            By objective, I mean consistency of findings and patients’ complaints. We’re coming at different sides of this issue since pain is not a major feature of my disease.

            1) If you test for non-organic signs and find none, that seems like points in favor of *not faking*.

            2) If patient complains of e.g. muscle weakness and you detect clinical muscle weakness on exam –> not faking.

            3) If the patient tells you things that sound unusual/unlikely but they can be checked and verified, then you check and verify –> not faking.

            This is not your problem or your fault. I’m just trying to figure out how I managed to pass every test with no objective indicators of faking, and still be accused of faking.

          • guest

            If you are female, you are more likely to have encounters with doctors in which they think you are faking, at least doctors who are male. I have no idea why this is, but I have experienced it myself, and it is quite traumatic, so I can relate.

          • DoubtfulGuest

            In my travels through the medical literature, I found weird stuff about hysteria. I read it, thinking, “No…just…no…”. Seriously creepy and unscientific.

            On a more humorous note, when I was a kid I once saw something about “wandering uterus”. I thought they meant *outside* the body, roaming around, causing trouble (like in gangs?), and I thought “Surely someone would have had to see that? It doesn’t quite add up…” :)

          • Suzi Q 38

            I agree.
            Having had a hysterectomy, it is my belief that they thought I was “hysterical” and making it all up.
            I think that women who are older and going through menopause are at times given a “bad rap.”
            Sad, because I was telling the truth all along, and they looked rather sheepish and contrite when my MRI did all the “talking.”

          • RocK8Doc

            I agree and understand your ordeal.

            The reason I brought up pain was, it is much more complex and complicated to deal with as it is very subjective. Faking is more likely to happen in a pain setting rather than weaknees setting.

            Can people fake weakness in clinical exam, yes. Can someone fake weakness consistently- No.

            Faking is not a diagnosis, Malingering is and can be made only after psychological tests.

            We as physicians have the obligation not to dismiss the complaints, but to look for the consistency of symptoms or signs and document accordingly and take appropriate action including reassurance, re evaluations or referrals/second opinions.

          • rbthe4th2

            Hmmm that’s not what I got, but I’m glad you said that.

          • rbthe4th2

            Doctor bias. No offense, but that’s what it is.

          • DoubtfulGuest

            Just between you and me, I agree completely. Shh!… ;)

            I keep trying to appeal to their better natures and remind them that they’re scientists, not little kids ganging up on a weaker kid after school.

          • Suzi Q 38

            Agreed.
            Doctor bias is dangerous. No surprise here, but some think that they know everything, so your opinion about your own very real symptoms must be your imagination.
            I agree that they know a lot about medicine, but for some their superior attitude is sad.
            I don’t mind their attitude if they use it to treat me properly. I dislike it when they are so arrogant to assume you don’t have a clue as to what is happening with your own body.
            All they have to do is listen, apply their knowledge and trust that I, their patient is intelligent in my own right.

          • rbthe4th2

            and some don’t, because they seem to have forgotten the ability to read medical literature. I’ll agree with all of the above.

          • rbthe4th2

            No it doesn’t. Its we’re a limited resource, we have all these problems with the system, or whatever, so its ok to crap on the people who aren’t a simple code. GOMER. That’s the majority of the attitude I get. The fact remains, a doctor can make the best of the situation. We patients try and have to do it, just because ‘we’re a limited resource and we have an advanced degree’ mentality just doesn’t cut it any longer. I’ve seen greater problems from the medical profession in terms of attitude and education and ability to handle people than I have with patients who are sue happy.

            I’ve held up helping docs out here, as has DG. Lots of times the answers we get to that are not what they could be in terms of helpfulness to make meaningful dents in terms of attitude & education for docs. When you ‘have a go’ at people who are trying to do the right thing, its time for doctors to truly police their own with something other than a handslap so things get better for everyone.

            Because one way or another, not policing is going to bite you.

          • DoubtfulGuest

            Well put. I, too, am running out of gas with trying to care/understand. Still trying, but running on fumes, actually. Unlike other relationships, patients don’t have a choice. Unless choice means forgoing medical care and dying earlier. Doctors used to acknowledge this difficulty by upholding an ethical obligation to us. Not….seeing that…much..anymore.

          • NPPCP

            Keep looking – there are plenty of providers out there who will treat you with honesty and respect. Keep looking.

          • DoubtfulGuest

            Thank you, I’m all set. I’m just still dealing with the ethical and emotional ramifications of the past experience.

          • RocK8Doc

            Look for a physician/doctor/clinician.

            Unfortunately the term” Provider” dehumanizes and evokes negative emotions and does not contribute to emotional connection.

          • DoubtfulGuest

            Exactly. How about “health care professionals”? I said “provider” once and it sounded weird so I stopped. :)

          • NPPCP

            Well, that is a topic for another discussion and not here I would say. I use provider when physicians use mid-level or extender. You use Nurse Practitioner, I use physician. So – the term “provider” is moot here.

          • RocK8Doc

            No I am not using it in terms of turf war. The term provider and ot Mid level provider/extender are the creation of forces beyond our control.I am using it in term of emotional impact. I agree with you and the negative emotional impact of using extender or mid level. We should use the terms just who we are , Physicians and Nursepractioners or use the term health care professional which is more inclusive and less dehumanizing.

            I despise the terms provider, mid level provider and extenders.

          • NPPCP

            Whoa!! I hope you know you are in the minority. I greatly respect your feelings and thank you for acknowledging each profession for who they are. I guess you can see by my initial response that I am somewhat of a “casualty of war” in this ridiculous battle to call us all who we are. Sorry for shooting first! Yes -provider is demeaning and denigrating for a physician or any other primary health care clinician. We can all fight that nasty term – we can start with physicians not using the term mid-level or extender. So degrading and demoralizing. Terms to stop using in the healthcare field “provider, mid-level, and extender”. Thank you for the kind response.

          • RocK8Doc

            NPPCP; I am not surprised by your reaction- shooting first :-)

            It just reflects your NEA was evoked just like the term Provider evokes Negative emotions from Physicians.

            We didn’t coin those terms it was imposed on us.

            I do have some choice terms, politically incorrect terms for the outliers both for Physicians and NP/PAs’ and others.

            That’s for another day and another discussion.

          • Patient Kit

            I hate the terms provider, mid level and extender and never use them. Doctors, NPs, PAs, etc all worked hard for their titles and deserve to be called by and referred to by their titles. As a patient, I also hate being called a consumer or customer because it connotes a pure business relationship that is mainly about money. Money is an issue to both doctors and patients, of course, but it should not be the core reason for healthcare.

          • querywoman

            Yuck! “Primary Care Provider!” I takes fewer syllables to say DO, MD, NP, or PA than PCP!!!

          • rbthe4th2

            I personally don’t care if they’re an MD, DO, NP, or LVN, if they give good care, I’ll say so and if they don’t, I will say that too. Its the individual that counts.

          • SarahJ89

            No. But its very dehumanizing does remind me we’re in the same leaky boat, me and this doc. I wonder how long before they start referring to me as the Providee. Actually… Widget would most accurately describe what’s going on in the hospital-owned practices in my area. It would apply to both doctor and patient, too. The doctors are like factory workers and we’re just little widgets on the assembly line. Nobody better slow down the profits, either.

          • rbthe4th2

            and then “doctor shopping”, why should I input in this person when they’re going to leave mentality sets in.

          • DoubtfulGuest

            Nice graphics, but why is the PEA/NEA box so small for the physician? Maybe I’m misunderstanding, or distracted by the pretty colors, but where’s the physician’s knowledge, social support, and possible depression on here?

            It looks like PEA/NEA would include those factors, but if doctors really want us to understand what you go through, you’d need to give yourselves bigger/more boxes, so to speak. Otherwise, it looks like it’s all the patients fault, all the baggage we bring to the relationship. With only a token acknowledgment that doctors are people, too? That’s not how it plays out in real life. :)

          • RocK8Doc

            I am not blaming the patients or physicians. The graph shows how it works and what we need to do to get better outcomes.

            The green color is positive correlation. Grey boxes had no correlation or effect.

            I adopted the graph from this study https://etd.ohiolink.edu/ap/0?0:APPLICATION_PROCESS%3DDOWNLOAD_ETD_SUB_DOC_ACCNUM:::F1501_ID:case1283995516%2Cattachment

            Masud Khawaja from Case Western Reserve University, in his PhD thesis, who is also an MD, studied the degree of treatment adherence for type 2 diabetics.

            They found in addition to Physician’s knowedge and all other basic stuff- that a number of the things in the doctor-patient relationship, as the medical literature predicts, do affect treatment adherence, but they are fully mediated through the patient’s experience of the degree of the PEA to NEA in his or her relationship to the physician. Specifically the degree to which the patient experienced a perception- of Information Exchange, of compassion/empathy, of trust/empathy, in the relationship to the doctor.

            What that means statistically is if you were going to work on one thing to improve treatment adherence, You’d work on the experience the patient has in their relationship to the physician.

            Physicians PEA and NEA also matters in the relationship.

            “Specifically, this research hypothesizes that a patient’s positive/negative emotional states, represented by the Lorenz attractors of Positive and Negative Emotional Attractors (PNEA), mediate the relationship between psychosocial correlates of doctor-patient relationship and treatment adherence.”

            http://weatherhead.case.edu/departments/organizational-behavior/workingpapers/wp-08-05.pdf
            http://gradworks.umi.com/34/97/3497554.html

          • DoubtfulGuest

            Thanks for the explanation. I had a somewhat different experience, but the graphics certainly make more sense now.

          • RocK8Doc

            Please share your experience I will try to explain in the Emotional Intelligence paradigm I described above.

          • DoubtfulGuest

            That’s really nice of you. This doctor seemed very focused on risk management through the whole relationship. He was very kind at times, but his interaction style changed every few minutes in each visit. He would be very nice and then the look on his face would change suddenly (to a suspicious angry expression). Then he’d take on a police-like tone of questioning, and the questions would start to be more leading, as though to trap me in a lie. It was like he was playing good cop/bad cop but doing both roles by himself. :/ He sent me to a teaching hospital and made a mistake with the referral. He tried to send me to a friend of his who loves complex cases. But he sent me to the wrong hospital (maybe from tired forgetfulness? I could easily forgive that) and the doctor there accused me of malingering based on no evidence. I turned out to have a mitochondrial disease instead, but I didn’t get diagnosed for another four years (I went to other docs). This first doctor (let’s call him A) told me to come back after the teaching hospital visit and was very angry and dismissive then. Completely turned against me. So, he ended up misdiagnosing me too. Tried to get him to talk to me, just explain/apologize, and he sent me a nasty termination letter. If I sound like I’m making assumptions, I’m just trying to be brief. Also, I’m not allowed access to any factual information about what happened even though I’ve asked for it repeatedly. Thanks for your time.

          • NPPCP

            Something I have never understood as a primary care provider and clinic owner – Why are there charts and graphs to discuss the physician feeling about the relationship as much as the patient feeling about the relationship? I have never seen a chart for another profession providing “patient/customer” services. Psychologists, electricians, babysitters, daycares – whatever – they have to be happy like I am for them to provide a service for me? I see thousands of patients a year – and I treat each and every one of them like a customer and human being. I take each complaint seriously and carefully explain why their concerns are founded or unfounded. Then they agree or disagree. This is called a mutual relationship. It is all so simple. I am just not getting all of the push back from the medical side on them being happy too. Some are happy some aren’t. Same with any other profession.

          • rbthe4th2

            So this is a reason to “crap” on patients? I’m sorry but there is a defense and there is going all the way to justify behavior that there isn’t excuses for from professionals. The oath was taking to help us get better, not to make everything about the paycheck, the doctor, the system. I’ve worked in the system and the fact remains is that good care can be provided, appropriate care. A doctor can set the tone. They’re the trained professionals. I expect them to act like it and those that are, are the ones I do all in my power to make things better. Its the ones who have threatened me with putting things in my record so that other professionals would see it and then it would cause problems that makes my blood boil.

            It should out of every other doctor because things like that are the professional trust eroders. The fact that it doesn’t is why there is a wholesale distrust of the medical profession. Among other things …

        • guest

          Unfortunately, it is likely that your PCP is going to go out of business at some point, or burn out and retire sooner than you would like, precisely because he does take the time to communicate well with you and do a good job of coordinating your care.

          • RocK8Doc

            Absolutely;

            Primary care physicians are being eliminated systematically.

          • Lisa

            I have a hard time thinking that any doctor I have seen, even ones I don’t care for, are viewing the interaction only in terms of risk/liability.

          • DoubtfulGuest

            I can believe it, unfortunately. You’d know best about your own doctors, but I was just glad to see RocK8Doc admit this happens! I had that experience, where every single interaction from day one was strongly influenced by the doctor’s risk management fears. At times it *appeared* there was genuine caring on the doctor’s part, and he was fighting these other influences in his head. But ultimately those fears won out and he threw me under the bus after he made a mistake. I tried to reason with him, preserve the relationship. I meant to show him I didn’t mind the mistake, I just needed him to keep trying to help me. He just got more angry. He didn’t care at all, it turned out.

          • Lisa

            It sounds awful, DoubtfulGuest.

          • guest

            Yes, I have had those experiences as a patient myself. Very discouraging. Thanks for maintaining hope and good humor in spite of it all.

          • DoubtfulGuest

            You, too! I always learn so much from your posts. Just your willingness to explain things means a lot.

          • guest

            :-)

          • rbthe4th2

            looking at lawsuits and how many are won by the patient, I dont see the numbers in it. If someone starts off by thinking you are a liar, someone looking to sue the doc, then it will come across in one way or another and people are going to not offer the olive branch.

          • Melissa McKibben

            This seems to be the crux of it, all in the context of a sick system where big pharma and the medical-industrial complex are calling the shots and pulling in mind-boggling profits as a result.

          • Lisa

            I doubt my PCP is going to go out of business soon or retire early, but we will see.

            I don’t think my PCP spends any more time with me than any other doctor I’ve had. But I don’t leave his office feeling irritated, like I have been talked down to.

            Right now I am seeing three doctors on a regular basis. My PCP, my oncologist (second one) and my gyn. I also like my oncologist and my gyn for the same reasons I like my PCP.

          • guest

            A lot of people think that, precisely because the PCP is very good at interacting with his or her patients in a way that does not show the stress that he or she is under. So it is always a big bad surprise to the patient when the doc retires early, or sells his or her practice to a hospital, or decides to go into direct-pay or concierge medicine.

            Also, your PCP may come across as less condescending because you ask him or her fewer difficult questions than you do your specialists–not that there’s anything wrong with that, but they may not feel that they have time to adequately address your questions. This is a situation in which the doctor generally (although it’s not fair) feels irritated with the patient (although they are trained not to act irritated) and in turn the patient leaves the office feeling irritated with the doctor….

          • NPPCP

            Okay, have to jump in here. I read each response by “guest” to Lisa – each of them were retorts giving some reason for Lisa’s doctor being nice and not degrading to her. Perhaps Lisa’s doctor is nice and not degrading because they are “nice and not degrading.” Then “guest” says, “well, if they spend time with you and are nice and not degrading, then they are going to go out of business and sell their practice.” What? They just can’t continue to be nice and continue successful at the same time. What? In my opinion, this is a very tortured frame of reference. Be nice to patients, sell or go out of business. Be condescending and mean to patients and make them understand you are always right – stay in business.

          • guest

            I think you have misunderstood the implications of the conversation here. My responses are in no way intended to justify the fact that doctors are not always nice, can be condescending, etc. I have had plenty of those interactions myself as a patient.

            My main point was to encourage Lisa to be appreciative of the level of care her PCP is providing, because in today’s healthcare climate, that level of care is increasingly only valued by the patients, who may not be aware of how little influence they have on the healthcare system, since by and large they don’t pay directly for their care.

            In terms of your own responses about how you run your practice, I think it would be important for you to be upfront about the fact that you are running a direct-pay practice, so you have already opted out of the system that Lisa’s PCP is probably trying to work within.

          • NPPCP

            We are not all direct pay. Still take private insurance – just slowly converting. Lisa would be welcome in my NP clinic. Thank you “guest” for your kind responses as well.

          • rbthe4th2

            and therein lies the rub – what you don’t see is that we are expected to be “bow down and low” when the level of care she’s getting should be the standard and norm and not the exception. I dont know one patient that isn’t appreciative of great care. My hematologist’s office gets it, and I’ve bought food and cards and other things, a 2 page email to the docs’ boss (which was shared with higher ups) with specific instances about the outstanding care I received. I go over and above. They do.

            Just because the work conditions are crappy doesn’t give the health care provider a right to shoot down the patient. Make the best of it as you can.

            Let me also point out that the more direct pay/concierge practices are something that many people can’t afford, making it so that those doctors who have to stay in the system are overworked because they’re taking care of the extra people that those who can’t afford it have to use. Its tough when your own brothers sell you out. Its harder on them – maybe its easy for you, but everyone else takes the hit.

          • Lisa

            I actually think doctors who are able to communicate with patients have a better chance of staying in business than doctors who are unable to communicate with patients. Doctors develop reputations within the community they practice in.

          • DoubtfulGuest

            I agree, I just think they need less oversight, not more.

          • rbthe4th2

            The ones I’ve seen do need more oversight – patient care would be better because they’d drop attitudes and get appropriate education. Its the kind and type of oversight needed that is the issue.

          • DoubtfulGuest

            I definitely have a problem with no accountability. They’re unfortunately being held accountable for stupid stuff while major ethical violations get swept under the rug. I can see the point that most of them (sometimes I have to use my imagination) are kind-hearted, mature folks who would handle their own patient relationships very well without so many other parties breathing down their necks. I like to think I’m a pretty nice person, but it’s not a major stretch to think I’d function very poorly under those conditions. Most of the “communication expert” types targeting doctors for “improvement” have no idea what their workdays are like so their advice is not helpful. What I really think they need to do is listen to patients. Especially those of us who pay attention to what they say, and adjust our expectations based on new information.

          • NPPCP

            I am asked all kinds of complicated questions by my patients – I stop and listen. There are no excuses for being able to be irritated with or rude to a patient if they are not doing the same to you. And in many cases, you still should not return the attitude.

          • DoubtfulGuest

            I think it’s okay for them to say when they are out of time. But if I can only get doctors to change one thing, it’s to quit getting mad at patients so easily. No need to fuel the downward spiral…

          • RocK8Doc

            I agree.

          • SarahJ89

            Agreed. And I have to say, I get tired of tugging at my forelock in appeasement each and every time I ask a question.

          • DoubtfulGuest

            Yes! Funny story, about one of my really good docs. She has a listening posture that she adopts every time you say “And I was wondering…” or “May I ask you something please?”. She leans forward in her chair, and places one foot more forward. She does this so deliberately it’s almost a stomping motion. Then she turns one ear toward me with a pained expression, and answers “Mmmph?…”. LOL, she is a great doctor, this is just her “I really want to help but I’m so pressed for time so please make it quick” expression. It’s quite amusing, and the message comes across without her ever getting angry. :)

          • DoubtfulGuest

            I think we should care about their stress and take it into account during visits. It’s much easier to do that when we’re not having our heads handed to us. :)

          • guest

            Yes, I agree, but doctors are socialized to internalize their stress, so they tend not to handle it always in the most productive way, and certainly not in a way that makes it apparent to the patient. Also, the vast majority of patients feel, with justification, that the doctor should be there to help them with the stress of being ill, not the other way around…..

          • RocK8Doc

            In the end doctors are humans to. You can’t internalize stress for ever.

          • rbthe4th2

            I’ve had them take it out on me. No longer internalization, so I’m wary. Yes, they’re there to help me feel better, and there comes a point where that is their job to do. Its part of the territory, if they don’t want it or deal with people, then go to another field. Its the power, money and prestige. Lets face it if it was all about patient care, we’d see tons of people going into primary care, direct patient care, not opting for specialities because they make more money and can pay the bills off sooner.

          • rbthe4th2

            I did that and got fried for it. So I’m wary over who I stick my neck out for.

          • DoubtfulGuest

            It’s amazing the big, sharp teeth some of them have.

          • DoubtfulGuest

            And sometimes, we get small, not-scary-appearing cookie cutter sharks for doctors:

            (scroll down for some science-y awesomeness)

            https://teacheratsea.wordpress.com/tag/cookie-cutter-shark/

            “The cookie cutter’s mouth can be very destructive. While biting its victim, it rotates its mouth taking a “chunk” of flesh.”

          • Lisa

            It will be interesting to see what happens. My PCP is in a group practice and affiliated with a network of independent physicians. My other physicians are also affiliated with the same network.

            I have seen direct pay or concierge practices come can go in our area. I am not sure how many the area can support.

            I don’t know why my pcp comes across as less condescending but he does. If it is a matter of training, then doctors need better training on how to communicate.

          • guest

            Well, you can go on thinking it’s just “bad” doctors, or “bad” training in communications, or whatever. A lot of people have that outlook. The problem with that mindset it that it eventually translates into all of us being subjected to increased regulatory and training attempts to make us all stop being “bad.” This annoys and burdens those of us who are already doing a good job with our patients, and does nothing to improve the ones who aren’t, since it doesn’t address the underlying problems that led to the deficiencies you are complaining about.

          • Patient Kit

            Who should a cancer patient ask difficult questions, if not their oncologist? Thankfully, my GYN ONC has listened to and answered all my questions and answered them respectfully and compassionately. He has even said “Good question!” to some of them. By the way he communicates with me as a patient, I think he must be an awesome teacher to the residents who work under him. I’m always appreciative of him and respectful of his time. I approach appointments or phone conversations very prepared with a prioritized list of well researched questions. I may have an advantage there because I’m a professional researcher (though not a medical researcher). Now that we’re past the initial crisis of surgery and dx (early stage ovarian cancer) and almost a year into routine monitoring for recurrence, I’m a less time consuming patient. But when I needed him to help me understand what was happening, he was communicative and compassionate. And I trust him with my life.

          • guest

            Of course a patient should be able to ask his or her oncologist difficult questions, and I am glad you have found doctors who have taken such good care of you. Not every patient is able to manage their doctors well, but it sounds like you have a gift for it.

          • Patient Kit

            Amazingly, I was able to get such good care even though I had to jump down the rabbit hole into the world of Medicaid in order to get the life-saving surgery I needed. Believe me, given the demonization of Medicaid patients around here, I hesitate to disclose (or should I say admit or confess?) that I’ve been on Medicaid for almost a year for the first time in my life.Yet I’ve never been a no show or even been late to a doctor’s appointment, I’m very respectful and thankful to my doctors and I never go to the ED.

            That said, when I found myself in the frightening position of a cancer dx and no insurance, I did what I had to do. I recognize that I have some advantages though as I quickly learned to navigate new (to me) healthcare system territory. I’m in NYC with some excellent teaching hospitals and many excellent doctors. I’ve spent many years advocating for other people (though not for medical issues) so I quickly learned how to advocate for myself. I had an angel on my shoulder that guided me to good doctors. I can honestly say that I was never once treated like a second class citizen because I was on Medicaid. My doctor earned my trust and, going forward, as I get off Medicaid (now that pre-existing conditions are no longer an issue — I hope), I will choose my new private insurance so that I can continue being treated by the doc who treated me so well while I was on Medicaid because I trust him. He earned my trust with successful state of the art robotic surgery, no complications, plus communication and compassion and respect.

          • guest

            I am sorry that you feel like Medicaid patients are demonized. In academic medical centers, it’s actually considered fairly good insurance for patients with serious illnesses. You absolutely did the right thing by getting enrolled when you needed it; that’s what it’s there for. I am glad it worked well for you.

          • querywoman

            Student doctors see a lot of Medicaid patients. Medicaid patients need other options than the medical schools. It also wouldn’t hurt the medical schools to train on more employeed people.

          • Patient Kit

            Thank you. I do feel like the Medicaid safety net worked well for me when I really needed it. I have seen some real contempt for Medicaid patients coming from some doctors who post here and elsewhere, which kind of scared me. However, thankfully, I personally experienced great and compassionate care from doctors who treated me under Medicaid. I was pleasantly surprised at the level of care I received because I’ve heard some pretty horrific stories from other Medicaid patients and have no reason to doubt them. Condescension is bad enough but contempt is even worse coming from doctors toward their patients and it leads to, among other things….well-earned mistrust.

          • SarahJ89

            I have found most doctors in my experience are pretty arrogant in their assumptions. And, while some of them are pretty good at explaining things, most of them become angry if you ask the simplest of questions. God help you if you disagree.

            I’ve noticed doctors now seem to think differently than they used to. They get to a certain point in the process and the next step is… to order a test, usually imaging. The next step nowadays is not to take another look at the patient or gather more information from the patient, it’s expensive imaging if you have insurance and out the door (with a broken ankle, in my friend’s case) if you do not.

            I wonder if these folks would be able to practice medicine in a third world country, where fancy imaging is not available. What would they do? They don’t seem to have any Plan B.

          • guest

            In a third world country, doctors would not be under the relentless pressure to be “efficient” that has developed in the healthcare industry in the U.S. in the last decade or so. “Efficiency” is generally speaking a euphemism for not engaging too deeply, or at all, with your patients. Doctors who are “inefficient,” i.e. take the time to really listen to and talk with their patients, are routinely penalized by the system in ways that their patients are not aware of.

          • DoubtfulGuest

            Besides working within the time constraints, are there other not-so-obvious things we can do (or avoid doing) so as not to create headaches for our doctors? (i.e. not subject them to ridiculous system penalties?)

          • guest

            I think just being understanding is a good thing. :-)

          • DoubtfulGuest

            You’re right, there are really no resources or framework to do anything else but move on, except through the legal system which in most cases won’t get patients what we want anyway. The doctor I had problems with, I’ve been out of his hair for quite a while now. I just think there’s a whole decision tree involved in moving on that sort of encourages patients to devalue physicians. It’s a philosophical conflict for me. Like with step 1: label the doctor a dud…well, some are duds, for sure, as with any segment of the population. But it’s harder when there were several visits and the doctor was trying to help. You have to decide, is this a good doctor or not, and would I recommend him/her to other patients? Surely no worse than your experience, but perhaps different. To some extent I’ve had to hold out hope of explanation and apology from that doctor in order to build trusting relationships with the new ones. I thought it might be encouraging for doctors here to see how deeply opposed some patients are to the institutional barriers and overwhelming influence of the legal system. I do understand this stuff happens to lots of people, and there’s no time for doctors and patients to really work things out. The time constraints are probably the worst contributing factor anyway, because the risk management fears could be handled better given enough time to understand one another’s motivations.

          • rbthe4th2

            so the dud doctor never improves? That’s what I see from the monopoly here. That attitude. So how does that further patient care?

          • DoubtfulGuest

            Thanks, R. You are on a roll today! :) I understand what guest is saying, with the best intentions…I’ll do pretty much anything within reason to get along with doctors…but “move on” isn’t sitting well with me. Next, do we sit quietly by and watch some people rob a bank? Or beat up a little old lady? Are doctors people with feelings, who have good days and bad days and can learn from mistakes? Or not? It throws the moral compass out of whack to treat doctors differently. Also, if we didn’t talk about our own experiences, Dr. Kevin would find it mighty quiet around here. We all make connections between the bigger issues and our personal reference points.

          • rbthe4th2

            Sort of, I think I upset the apple cart with a link I posted. http://economix.blogs.nytimes.com/2012/01/18/what-the-top-1-of-earners-majored-in/?_php=true&_type=blogs&_r=0 says that the highest # of the 1% earners are docs.

          • rbthe4th2

            Yep. Exactly.

          • Patient Kit

            I sincerely empathize with doctors re the relentless push for efficiency and productivity. It’s a pressure that I think most working peeps can seriously relate to. When we went through several waves of layoffs at my former nonprofit employer, each time, those of us who remained got extra hats until 50 peeps were doing what 200 did a few years earlier. I went through many meetings in which those of us who were left were praised for “giving 500%” and accomplishing “more with less”. The meetings always ended with us being told that they needed 1000% from us.

            Our entire culture is contaminated with this push for more and more efficiency and productivity, which benefits the few who profit from it. In journalism, for example, speed and being first is valued way more than being accurate.

            But at the end of the day, there are still only 24 hours in a day just as surely as there is a limit to how fast the human arm can throw a baseball. And in medicine, the price we all pay for this so-called efficiency and productivity can be huge for both patients and doctors. There is always risk and sacrifice in pushing back against the powers that be. But the alternative isn’t risk-free either.

          • guest

            Exactly. We are all in the same boat, doctors obviously at a higher pay scale than a lot of other workers, but we are all workers nonetheless, being squeezed by a system in which a few elite players have most of the power, and use it to profit from making us all do more and more work for less and less pay. I honestly think that unions are the only answer.

          • rbthe4th2

            Oh really? I’ve got people who have come over here and say in India if you are not good or efficient, the word gets around and no one goes to you. Also, the criteria for getting in medical school is worse than it is here. I had one tell me that if she were treated by an Indian doctor back home the way a specialist treated them here, they would have slapped them and it be legal.

            After what they did to them, I agreed. Might have knocked some sense into the doctor. Not only did this specialist cause damage the friend had to fix by going out of the area to get it done, they had other visits because of this problem doc.

          • rbthe4th2

            I have several doctors from third world countries. I have no problems with them, and they’re actually better than all but the best Americans. No offense, but the attitude and what you talk about above there, the ability to think past a lab result, and to talk and really work with a patient is there.

          • SarahJ89

            I think you misunderstood what I was trying to say. I was saying that US doctors who have been trained “the next step is imaging” would be lost in a setting in which an expensive imaging machine is not available. They don’t seem to be teaching “the next step is to look more carefully at and get more information from the patient.”

            I have lived in nearly third world and in third world countries and I agree the medical care, especially for the kinds of routine things most of us need most of the time was fine. Actually, often better than fine since home visits still were offered.

          • rbthe4th2

            Actually I was agreeing with you. I’ve had doctors who come from 3rd or 2nd world nations and have had great luck with them. Its the Americans who are the problems. The no offense part was to any one, not just you, who felt like I was saying that non American doctors aren’t that good. I guess I should have said that straight out. The ones I’ve had problems with: all Americans. They can’t seem to get past a lab result or know how to LOOK at a patient and give a H&P past listening to the heart. Don’t get me started on the ability to take a blood pressure without pushing a button.

            US doctors don’t seem to be able to think thru a CBC or CMP. To be quite honest, I learned how to read it and can sit there and say – changes here, drops here, here is what is happening and put it together for them. That basic information is no longer taught in medical school. At least it doesn’t appear to be it.

            The other item: when a patient is told its all in your head and nothing wrong with you because the lab says do, what do you think you’ve told that patient in that response? That the patient is dumb, doesn’t know their own body, and that you don’t take them seriously or think they lie to a doc. Not all people are like that. Those people who are honest with docs, and do this straight up and get the responses like DG and I and others have gotten, is why there is so little support for docs. If you don’t support the good people like us out there, do you think we’re going to support you? Think about it.

          • SarahJ89

            Thanks for the explanation of what you were saying. Yes, we agree. You’ve also shed some light on what I’ve been seeing in the past 15 or so years–that doctors now seem to think differently than they used to. There’s something missing now that used to be there. And it’s something that was vital to the crucial task of diagnosis.

          • rbthe4th2

            Yep. That attitude is telegraphed, along with proponents of “tort reform” instead of “diagnosis reform”, medical boards not disciplining doctors, etc. When you spend time denying the problem, vs. fixing it, things will never be right.

          • rbthe4th2

            Then they tell you that. I had my PCP tell me they couldn’t address everything at one time. Ok, made another appointment. I’m still with them. Yes it is bad but if that’s what it takes …

            its better than the emergency room.

          • Deceased MD

            Very insightful. I don’t have this name simply as a joke. There is a phrase that a joke is the most seriously thing.
            I feel like I am being systematically killed off as someone earlier said. I do try to push back with patients about having limits with their endless requests for paperwork etc. but I am really weary. Direct pay would help but probably solve maybe 60 percent of the problems.

          • Lisa

            My orthopedic surgeon’s office charges for paperwork. I think it was 7 dollars for my leave of absence paperwork. I paid and the paperwork was completed and sent to my employer in a timely manner. Seemed fair to me.

          • guest

            Family leave paperwork takes about 10 minutes for the MD to do. You do the math. $70/hour likely doesn’t even cover the doctor’s overhead.

          • Lisa

            The PA did the paperwork, surgeon signed. I had to complete a good deal of the paperwork, give it to the PA who added a few items and had it signed. I doubt the practice lost money on the deal. Nothing is gained by having the surgeon actually complete the paperwork.

            Decreased MD was complaining about endless demands for paperwork etc. – I just was trying to suggest there ways to handle the demands.

    • SarahJ89

      Lisa,
      I used to have that kind of relationship with my PCP. No longer. She’s just a cog in the corporate wheel now, unable to advocate for me effectively. All of the things you list now happen routinely. I do not view my PCP as any able to be on my side, nor do I trust her at all. I trust her as a person.

      But I know whatever I tell her goes into the EHR, straight to her corporate owner and I’ll be getting profitable tests pushed at me by letter or intrusive telemarketing phone call from the hospital soon, with no context or regard for my health.

      I no longer tell her anything, nor do I view her as any sort of ally. We’re just two people caught in the same fishnet. It’s sad, really, for both of us. There’s no other option in my area because the hospital has bought up every practice in a 30-40 mile radius.

      • Lisa

        Funny story, somewhat related: Several years ago, I started getting calls from my pcp office reminding me about my annual mammogram. Only thing is I’ve had a bilateral mastectomy so I don’t need mammograms any more. About the same time, I saw my pcp for an annual physical. His nurse asked me when I had my last mammogram while she was weighing me, etc. I reminded her of my history. Then while the nurse was doing an ekg, we discussed my scars. Two seconds later, she asked me about my last mammogram. When my pcp came in and went through his checklist of annual physical exam questions, he had the good grace to look abashed when he started to ask me about my last mammogram.

        I still get mailings from the local breast center about mammograms; I also get mailings from my insurance carrier. It is almost impossible to get these things turned off.

      • NPPCP

        Was she in private practice and then sold out to a corporation? This is exactly what happens when one sells out. I pray it never happens to me.

    • rbthe4th2

      AMEN! All of the above. It is an attitude and education issue. I don’t know any one these days that isn’t exasperated by being able to look up and find their own diagnosis in medical literature, and then get zilch from the doctor when they talk about it. At least test for it, check for it, and if it looks like it, give it a shot for treatment. You can’t know everything and that’s fine, but if you are the “educated expert” then you should be able to review medical literature and “get it”. Stop whining about oh someone is going to sue me. If you’ve tried everything else and the symptoms fit, document it, document what the patient wants and have them agree to the treatment and go on.

      There is a difference in pain meds and antibiotics, but seriously, when the majority of med mal is due to delayed and missed diagnosis, its time to use the computer to help both the doctors and the patients get better and get appropriate medical care.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    That’s different. These are working people doing a job. I was talking about the folks on the lecture circuit who have never done any hands on work, but for some reason anointed themselves as the ones speaking on behalf of “patients” or “consumers” during public debates, policy hearings, conferences, etc. My guess would be that most of them have never even met a person on Medicaid, other than maybe in a gas station or something like that.

    • dontdoitagain

      Thanks Margalit. I should have known after reading other posts of yours that you weren’t getting all defensive about having an “outsider” coming in with the patient.

      You talk about Medicaid patients as if they are treated badly by providers. I am treated like I’m a waste of time, even though I have private insurance that I pay dearly for, and I work hard at a physically demanding job. It’s a health care thing. I was made to feel unworthy and like a malingerer that was looking to get on disability. I have paid into my health care plan for decades, using it for a doctor visit every two years. (condition of employment). I don’t like the feeling that when I need to use it, that somehow I am a bad person.

      • Patient Kit

        Please clarify because I don’t think I understand — you’ve paid dearly into your private health insurance plan for decades (via your employer?) but are only allowed to see a doctor once every two years? I didn’t realize there are plans that are that limiting. Of course you’re not a “bad person” for using your health insurance when you need it.

  • elizabeth52

    There is no doubt medical coercion keeps many women away from doctors and it’s seriously damaged the way many view the profession. Such conduct would amount to medical misconduct and possibly assault in some countries, but it seems American and Canadian doctors can demand anything and call it standard of care. Elective screening is considered mandatory for women.
    I’ve spoken to many women online who’ve been sacked as patients because they don’t want non-evidence based and unnecessary exams and tests or have chosen not to have cancer screening. Legally and ethically, informed consent is required for all cancer screening.
    Women are routinely denied the Pill, other meds and non emergency medical care unless they comply.
    So we have women ordering pills online, “managing” their asthma or diabetes with a pharmacist or naturopath, others make trips to Mexico to pick up their meds over the counter.

    The forums are also, full of women harmed by tests and exams they did not want. The routine pelvic exam is a good example, an exam scrapped in many countries, it is not evidence based, is not a screening test for ovarian cancer, is of poor clinical value and carries risk, even unnecessary surgery.
    For all of the absurd emphasis on the female body, American women have poor outcomes…a lot of hysterectomies, 600,000 are performed every year, 1 in 3 will have one by age 60, more than twice the number performed in countries that don’t do this exam. Same thing when you consider the loss of healthy ovaries after false positive pelvic exams.
    Excessive and inappropriate pap testing, often forced in exchange for the Pill, leads to excess biopsies and over- treatment. Adding HPV to pap testing, which generates the most over-investigation, the HPV test should stand alone.

    So hardly surprising many women do not trust and respect the medical profession. We have our issues here in Australia, but I’m still able to decline excess and cancer screening and receive medical care.
    I know some doctors fear legal liability and many are just as concerned about the situation, but more needs to be done to clean up women’s “healthcare”. Too many women are being harmed.

  • DoubtfulGuest

    Good point, yes. What I would like from doctors is 1) suggestions on how patients can best handle changing doctors when necessary and 2) what steps patients can take to repair a damaged relationship. To some extent, we all prefer relationships in which people tell us what we want to hear (we all generally want kindness, for example, and to feel understood in our relationships ). The only question is whether or not people are trying to deceive themselves or others through that preference.

    • Myles Riner

      For 1): make it about the relationship not working for either of you, not about the doc, and for 2): first identify the problem, and indicate your wish to improve the relationship, then assess from your perspective, and ask the doc what he thinks the problem might be from his or her perspective. That will get you started.

      • rbthe4th2

        Not any more. Docs just want you to move on.

        • Suzi Q 38

          Believe it or not, maybe that is the safest thing to do. Why stay with a physician that doesn’t listen or thinks what you have to say does not have merit?
          It would be far better to move on.

          • rbthe4th2

            Here’s the problem: you get labeled with doctor shopping, and the problem never gets fixed with the original doctor. Lose lose on both sides.

          • Suzi Q 38

            Yes, that is a problem.
            I still say that moving on is better than risking yourself with a physician that doesn’t want to do the right thing. You could get worse, which would be far worse than not fixing the problem with the original physician.

  • Lisa

    I find it interesting that you mention that it helps to know what I am looking for in a physician. I’ve thought about that and realize I do want different things from different doctors. The only consistency about what I want from doctors revolve around communication. A hugh topic….

  • Rhonda Love

    I know this is true in my community in Eugene, Oregon. Peace Health owns this community. They cannot even get drug reps to stock their shelves with samples for patients anymore because honest Doctors want to give us generics. I have a PC I have seen for 25 years who has never seen an MPN patient. I had to teach her about my PV after begging her to give me a referral to a hematologist for 7 months that ended up leading me to have a TIA to get my diagnosis. No. I do not “trust” Doctors. I immediately learned everything about MPN’s and have even taught my Oncologist a few things he wasn’t aware of. He still doesn’t believe it is familial. Even after having him go through all my identical blood counts from 1989. My insurance company refused to pay for the proper EXON testing to prove my JAK2 status. I had a Bone Marrow Biopsy that came back “inconclusive”. A second sleep study forced my Oncologist to diagnose my PV as primary even with all my blood counts already proving it for 7 months. My sleep study Doctor knew all about PV and diagnosed my PV primary. My TIA Doctor knew all about PV and did not force me to go through all the usual required testing. Only the Doctors who actually know about MPN’s do I TRUST.

    • NPPCP

      Funny to hear you say that….we have no drug reps at our clinic either. They don’t come in anymore. I won’t prescribe their expensive medications – unless I have to.

  • guest

    As a physician who has had more experiences as a patient than the average physician probably has had, I think we as a profession need to be careful about passing judgement on patients who “doctor shop.” There are a lot of valid reasons for patients to do that these days, but I think many doctors are quick to pass judgement. I personally experienced this bias when one of my children began to have episodes that were clearly partial complex seizures. Astonishingly, there were no pediatric epilepsy specialists in our (large) metropolitan area at the time, and neither of the pediatric neurologists we consulted appeared to be able to answer my questions about the long term risks vs benefits of putting a child on anti-seizure medications for intermittent episodes that were not showing up on EEGs. One neurologist actually implied that I was presenting factitiously for my child. The fact that a medically educated, upper middle class mother asking reasonable questions about her child’s condition and treatment could be labeled this way gave me a lot of insight into why people don’t trust doctors. The fact that it was a “red flag” that I had taken my child to one other neurologist before that one was interesting, and I think speaks to some underlying condescension in how many doctors view their patients.

    Interestingly, the doctor we consulted at MGH during a family visit back East was respectful, interested and helpful.

    • DoubtfulGuest

      I wonder, was this neurologist interacting with you as a patient’s parent only or as a parent who is also a medical professional? I’m honestly not sure which would be worse, given the outcome for you. I’ve just read that medical knowledge/sophistication is often considered a “risk factor” for malingering and factitious disorder. It makes me think how challenging it must be for doctors and nurses to get their own health care — on top of the time and cultural pressures to put others’ needs first. It’s as though one can either have medical knowledge OR seek medical care, but not both?

    • Suzi Q 38

      Thank you!
      Here you are a physician and you have experienced what we are talking about.
      Imagine how hard and scary all of this is for us, who are not physicians.
      There is nothing wrong with asking questions
      when you or a family member is concerned.

      Some doctors don’t even listen or answer your question(s). They smile, nod, and walk out the door. My sister had an oncologist like this.
      We had to follow him in the hallway to get him to answer her questions. She wanted to switch oncologists, but the head of the department asked the doctor to “work it out” with her.

      Yes, I will admit to doctor shopping, with good reason. I now view a first or second visit with any physician as an “interview” of sorts.
      I am trying to decide if h/she would be a good doctor for me or my family.

      I found my regular neurologist by consulting a neurology resident and his brother who was a neurosurgeon. The resident was a friend of my son. He said that his good friend, who was also a neurologist, went to medical school with my new neurologist. She is fabulous, and I trust her completely. Being able to trust your physician(s) is everything to a patient who has been through a lot.

      She was so good that I brought my daughter in with me to learn from her. My daughter wants to be an NP.

      If she ever moves from the teaching hospital she works at, I will follow her, if need be.

      She is that good.

  • NPPCP

    Well stated.

  • Suzi Q 38

    I can empathize.

    Our insurance for just the two of us costs about $950.00 a month. Add that to what my husband’s employer pays (1K) and you get close to $2K for medical insurance.
    When I finally did need our insurance, my gyn/surgeon was only too happy to give me a hysterectomy, but not give me assistance on the nerve sensations I felt in my legs afterwards.

    He didn’t believe I could have had problems after HIS surgery. Such hubris.

    As it turned out, I can’t prove it was or was not his surgery that caused it. I just needed treatment, as I had a severe spinal stenosis in my neck area.

    He and his neurology consult thought I was making it all up.

    • dontdoitagain

      Suzy I have a friend who was horribly damaged and has NUMEROUS health issues as an effect of a hysterectomy. She has her own blog about it.

    • rbthe4th2

      I’ve had this a lot. If the computer doesn’t tell us the person is sick, then they’re malingering or its mental. Or, I cant figure it out so everything is fine or I’m not wrong and everything is fine.

  • Lisa

    Employer provided health care is not taxable income, even under Obamacare.

    • Suzi Q 38

      I did hear this was to be a possibility.
      I heard it on the news.
      I hope you are right.

      • Lisa

        The proposal to add a new income tax of employees (35%) for their employer sponsored health insurance is part of the proposed Republican replacement for Obamacare.

        I don’t think that proposal is going anywhere.

        • Suzi Q 38

          Thanks for the information.

        • dontdoitagain

          I’ll call my congressperson and find out about that one. I hadn’t heard about it. The breakdown of what I pay for health care is new for me. It changed because of the “gold-plated” tax contained in Obamacare. The 40% surcharge that’s in the ACA law. The one that’s in there right now. Plus the “taxable income” part of the Obamacare. It’s in the ACA and we “haven’t seen nothin’ yet.” There are a gazzilion new rules and mandates being written even as we speak.

          • Lisa

            There is a excise tax for high price insurance policies (so called cadiallac plans). It does not take effect until 2018. That tax is imposed on employers, not employees.

            I have no idea of what you are talking about when you say taxable income part of Obama Care. The penalty for not having health insurance that is based on your taxable insurance? Right now, insurance provided by an employer is not taxable. Plain and simple.

          • dontdoitagain

            I looked up the tax that you say is being proposed… It’s not a 35% tax on health care benefits like you say. It proposes that 65% of employer funded health care benefits is tax free. The other 35% of the cost would be taxable income. This plan is bad as well. It along with the mis named ACA does ABSOLUTELY NOTHING to bring down the COST of health care. Which cost has gone from less than 6% of GDP to 18% of GDP since 1960, and climbing. A minor outpatient surgery now costs more than most people make in a year. Talking about regular working people, not necessarily health care workers.

            The ACA along with the “proposal” from Republicans is nothing but a shell game. Nothing is being done about the core of the problem and that is EXCESSIVE health care cost. Shifting the burden around and raising taxes isn’t a cure. It makes things worse.

  • Suzi Q 38

    No doctor is worth keeping if you can not talk to h/her.
    Plan to dump him/her if h/she does not listen.
    There is distrust because the patient has been harmed in some way.

  • Patient Kit

    I think some doctors have the unreasonable expectation that new patients should blindly and automatically trust them just because they are doctors. And that mostly just doesn’t happen anymore, for good reason. I realize there are real time constraint issues but trust has to be earned and then, if not nurtured, at least not violated. Starting with a simple thing, I tend not to trust anyone who doesn’t make eye contact with me.

    • DoubtfulGuest

      Sometimes eye contact is just a cultural thing, though. Or not…I used to think the same thing, but then I had a great doctor who was not an eye contact kind of guy (he was just very reserved). But he listened to me, I realized that later when I read his “new patient” letter. This was for a more limited problem than the bigger stuff I dealt with later on, but he took great care of me, did everything he was supposed to do. What with the “customer service” trends in corporate health care, there are lots of doctors undergoing training in things like eye contact and “reflective listening skills”. I’d bet money that some weaselly-type docs can get really good at this style of interaction while others who are great doctors but less socially polished will take a hit in patient reviews.

  • DoubtfulGuest

    I understand, and probably lots of patients feel the same way you do. It’s just that I’ve had one doctor look me right in the eye while lying to me, although most of the other body language indicators of deception were there. I’ve read that sometimes folks use eye contact to appear honest, and to check to see if the other person is buying it. You have every right to your preference. I’m just concerned about external pressure on doctors to *appear* approachable and honest, when the reality may not match up. Yes, trust matters — a lot, and I’m still trying to figure out how to recover when it’s betrayed.

  • rbthe4th2

    More like we got wind of the sexist, racist, thrown instruments, entitlement attitude and it soured us since then. I’ve seen some of that entitlement among the younger crowd: I want my $400K a year job with 9-5 hours and no hospital stuff. Then the diagnosis isn’t right, they just wing it, look at labs and not the patient … it all adds up.

  • Lisa

    Every pay stub I’ve gotten in the last 18 years shows both my contribution and my employer’s contribution to my insurance.

    The Republican replacement for the ACA, aka Obamacare, is not going to happen. In part because of the tax provision. The ‘No New Tax’ party won’t be able to sell it.

  • rbthe4th2

    Here is one of the major reasons: all the complaints about not getting paid enough, and see the results from this. Med school is at an all time high enrollment, it seems that there are lots of pulls to get into the “business”. Not saying people don’t earn some of it, but when you complain about your pay, not want to go into primary care, work a 9-5 job, and then complain about lots of us, it seems there needs to be other criteria to get into medical school.

    http://economix.blogs.nytimes.com/2012/01/18/what-the-top-1-of-earners-majored-in/?_php=true&_type=blogs&_r=0

  • dontdoitagain

    BTW Lisa, do you think hammering my employer, punishing him, for providing an insurance plan that *I* pay for will help the situation? You really think a 40% “excise tax” will solve the problem of high insurance costs? Do you think that this “excise tax” will encourage employers to maintain coverage for their employees? Or will it have the opposite effect? Just askin’.

    • Lisa

      Dontdoitagain – I can’t answer the question. There are a lot of things I don’t know about your employment situation and the insurance your employer provides. But from what you have said, I don’t think your insurance, as expensive is it is, fits the definition of a cadillac plan.

      In general, what the excise tax on cadillac plans (over $27,000/yr) is supposed to do is encourage employers to select lower cost insurance plans. Will it? I don’t know for certain, but I susupect it will have exactly that effect.

  • Lisa

    In part the purpose of the tax is to finance the ACA. And yep some employers are changing plans. I have mixed feelings – the ACA has created winners and losers, but it has to be financed somehow. This is a good analysis:

    http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=99

  • rbthe4th2

    Why have so many lost confidence? When a friend reports that a doctor followed them 3 times, staring at them, etc. you have to wonder why? Especially as this person never contacted the doctor and they know the doc doesn’t like them. Really …