One of the ways a doctor can document the value of an office visit is by keeping track of the number of symptoms the patient has and the number of items included in both the review of systems and the physical exam of the patient.
This way, for example, we can get paid more if we do an extensive evaluation of a dizzy patient by looking for both inner ear, cardiovascular and, for example, cerebral and psychiatric causes, rather than zeroing in on the most common cause while immediately disregarding the less common ones.
The other way we can charge is according to how much time we spend on “counseling and education” of our patient.
I reflected on that a lot this week. It seems most of what I do is counseling and education.
I have been working with a nurse practitioner student the past few months. I make these “externships” a mixture of independent work and observation with collaboration.
In my view, an almost-ready clinician needs to both hone their clinical skills and develop their own style of communication during these rotations.
In some cases, I introduce the student, leave the room and then get briefed on history and physical findings. We then wrap up the visit with me just reinforcing the plan and supporting the student and the patient in how this is supposed to work.
In some cases, I conduct a good portion of the visit myself and then include the student in a three-way conversation with the patient about the disease or the treatment. This allows students to see me and their other attendings’ way of diagnosing and different ways of sharing information or suggesting treatments to patients.
With an extra person in the interaction, I constantly reflect on my own style.
I usually talk a lot. In many cases, I explain a great deal about how the body works and how diseases manifest. I also talk about the history of how they were discovered or how we used to treat them. I think that is a reflection of my own love and fascination with medicine. It is also an expression of my fundamental belief that I shouldn’t tell my patients what to do but instead empower them to choose between options and direct their own care.
Coming from another continent and, by now, another era, I can tell patients firsthand that there are and have been many ways of thinking about even the most straightforward seeming medical problems. I think this depth and context works for many patients. Only once in a while in my career have I had a patient say, “I wish you would just tell me what to do.”
I try very hard to “read” how each patient approaches their health problems, and over the years I have learned who wants a quick “here’s what we’ve got and here’s what to do” visit and who enjoys and grows from knowing the bigger context of what they have.
In some visits, I say a lot less. I sometimes emulate Dr. Marty Samuels or my own Dr. Wilford Brown and use my silence to draw out the patient’s history. And sometimes I use open-ended questions disguised as reflections to get more information – statements like “I wonder why you noticed this while…” or “I don’t know exactly how this is connected with that.”
When I teach clinical practice, I try to share my repertoire of ways to connect and ways to convey, not just how to diagnose and what treatment to choose. You can read that in a book or online. But you need to see how other people do things so you can choose how to behave yourself in the role of healer we are asked to live up to.
I don’t often save lives by performing sophisticated or intricate medical procedures. But I do think I change lives every day in small and subtle ways through how and what I communicate.
I believe in my heart that I need to fill different needs in different situations where my patients are looking for certain aspects of the archetypal “doctor” we all carry in our consciousness and our culture.
“Doctor” is derived from “docere,” a word for “to teach.” “Doceo” means “I teach.” “Ergo sum” means “therefore I am.”
That is really why am here, in this clinic, in this community, and on this planet. I could probably bill 80 percent of my visits as time spent on counseling and education and forget about how many “bullets” I checked off from my history and physical exam. Those things seem rudimentary in comparison with the personal connection that allows my patient to take my explanations and my treatment options and make their own choice of how to proceed.
Orthopedic surgeons probably do most of their work in a form of silent solitude in the operating room.
I do most of my work in conversation.
All of it, really.
“A Country Doctor” is a family physician who blogs at A Country Doctor Writes:.
Image credit: Shutterstock.com