Thursday, January 24, 2008

Are you an obnoxious patient?

CNN recently did a writeup on how to approach your doctor with your own research on a health condition. This seemed really timely in light of a previous set of comments I had previously written and some of the topics that have been recently discussed.

The question being asked is: Are you an obnoxious patient? I wonder how many of us can admit it if we are. In my case it becomes especially difficult to be objective since I feel like I have a vested interest in getting better, unlike my doctor to whom I may be just a patient. I also feel like I have learned a lot about my specific condition and I know which symptoms specifically apply to me. Yet, on the flip side, it is important to realize that the physician has probably seen a thousand patients like me and probably knows more about the progress of the condition and what I should expect. I guess its difficult being a partner... and trusting your partner.

6 comments:

Kelly Hills said...

I think it depends on doctor perception as much as anything else. I know some doc's have considered me obnoxious for taking the time to understand my (somewhat obscure) chronic pain condition, but the vast majority of my primary medical providers have always left complimentary notes in my files - including expressions of relief that I actually make an effort to understand my condition and treatment.

Part of it, I think, is that few people shop around for doctor's that they actually click with and share similar personalities with - they just take the first name they pick in the list of providers and stick with it, no matter what. And it's important, for good medical care, that you and your physician have a similar view of medicine and how you should be treated.

Daniel Goldberg said...

Why shouldn't I be an obnoxious patient? Howard Brody advocates the transparency model in doctor-patient communication, which asks healers to think out loud, such that the healing process becomes more of a collaborative enterprise between physician and patient.

It's not clear to me how taking advantage of the (fortunate) fact that I am health literate, and wanting a more active role in formulating a treatment and management plan that fits with my understanding, goals, and overall life-plan is something I should eschew.

It's true that many physicians probably are not used to such conduct, and many may not like it.

But that's too darn bad, IMO. The best healers are the ones who are interested in participating in a joint partnership, to borrow Paul Ramsey's term.

Jennifer Emily Cochran said...

I think the point being made is that some "healers" are not being looked at as "partners" but merely conduits.

The perception that you are being "used" is not something a physician, or anyone for that matter, likes.

Add to that the feeling that physicians complain is characteristic of many of their patients: i.e. "I am an informed consumer. Hear me roar." can be trying at times. This is especially difficult when, as in the vast majority of cases, the information received is incomplete and only tends to upset physicians who now must not only deal with treating you and educating you, but also convincing you that you are wrong because you hadnt considered several important factors that were relevent to your condition but could not be mentioned in the 3 page internet article you brought to the Doctor's Office.

I think Kelly's point is well made: Much of it can depend on a physician. However, I would also add that a lot of it can depend on a patient, and as a partnership, we , as patients, must learn to shoulder the blame just as quick as we are to blame our partners.

Kelly Hills said...

The problem I have with your analogy, Jennifer, is that as patients, we are typically wrong when we see the doctor. We are, after all, self-diagnosing ourselves as being sick, determining something is wrong and that we need to be treated. So the doctor is already in a position of having to treat, educate, and possibly dissuade - the furor over parents wanting antibiotics for every viral infection their children had is a great example of this. Nothing in the internet has made that triple role of the doctor a new thing.

A physician *is* being used. They're being used for their expertise, just like anyone with an expertise in an area can be viewed as being used by the person who comes to mine that expertise. At least, if that's your definition of being used. But the physician is also compensated for their time and knowledge, and for playing that triple role of educator/diagnostician/dissuader.

And I'm just not certain patients should have any blame to shoulder here. A truly obnoxious patient - one who any physician sees as obnoxious - is probably that obnoxious in all their life, not just their medical issues. And just as there are polite, kind, and genuinely friendly people out there, there are real and obnoxious jerks. After all, it takes all kinds.

But in an era where physicians are increasingly viewing themselves as providers of a service, and the patient as a consumer, I see no problem at all with the consumer taking charge of the situation and making sure they are receiving their perceived value for their money. It's the same thing we would expect a consumer to do at a department store, isn't it? To insist for value for money, and to make sure their questions are answered? Consumers who have educated themselves might take more time to sell that HDTV to - but we consider that consumer to have been smart to do their homework, and it simply part of the salesperson's job to share their own knowledge with the consumer prior to a sale.

Daniel Goldberg said...

Well, if physicians as healers are rooted in the priest tradition, which they are since the period of the Hippocratic corpus (and Richard Selzer and others are good contemporary sources), then the physician is obviously a conduit in some sense.

The whole point of the quasi-shamanistic notion of the priest-healer is that the healer can commune with a body of knowledge that is inaccessible to the supplicant. the healer is the medium for translating that proto-sacred information to the patient.

thus, the idea that physicians are not conduits is unconvincing. kant never said we cannot treat people as a means; he said we cannot merely treat them as a means.

so, i absolutely treat my physician as a conduit. they are much more than that, of course. ideally, they are a partner as well. but partnerships is by definition a joint venture, and not all people make good partners together.

i see no problem with assessing whether the physician's attitudes and practices cohere with my life plan, and if they do not, finding a healer better-suited for my needs.

We're not talking about respect, either. Respect is always due a professional, unless they behave unprofessionally.

As for the "informed consumer" point, I do not feel sympathetic to physicians who are certainly professionals but are also workers. Part of the problem with U.S. health policy is that because we mix market-based delivery and financing mechanisms with public schemes, we cannot decide whether it is appropriate to refer to patients as consumers or not.

If health is to be subject to market forces, why should I not be a consumer, or at least identify as a consumer in some encounters?

Bear in mind I am not for a moment saying I think health care should be allocated by market-based mechanisms. But in the world we live in, it is. And in that world I am regarded as a consumer by payors, and even by health care professionals at times. Why should I or anyone else feel chagrined at playing that role, even while agitating for change?

Ultimately, I seek out my physician for his/her phronesis, for his/her practical wisdom and judgment. If they think I am wrong, I need to know that. But I do not agree that searching for a healer who understands his or her roles as a conduit for information and as a partner is questionable.

Anonymous said...

Call me strange, but I prefer if a patient has done some reseach on their problem before they come in for a dietetic consult with me, because it suggests a degree of engagement.

Even if they have gone off on a totally inappropriate tangent towards the quackery end of nutrition, I would rather this than someone who doesn't even give an damn and has only attended because they were referred.

I chose to go into a paramedical field so I could be *used* by my clients who need to make lifestyle change - I consider it a privelage to be able to work in partnership with people and make a substantial difference to their life.

Interestingly, I have a low follow-up appointment defaulting rate - I guess this suggests I am doing SOMETHING right!

Sometimes I wonder if these obnoxious patients are the ones who object when the physician (or other health worker) tries to fit the patient to the diagnosis, rather than the other way round.

As someone who has been on the receiving end of this I can understand the frustration of not being treated as an individual, merely as someone who is a disease