Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Monday, August 10, 2009

What Patients "Know"

A set of three cautionary tales:

TALE THE FIRST

What the doctor says: Happy Hospitalist gives non-compliant diabetics his "lecture" on the dangers of not taking care of their disease, because the patient never heard it from the lazy-ass outpatient primary care doctor.

What the patient says to him: "No one ever told me that before."

What you can't possibly expect the patient to say: "I've heard all that stuff from my family doctor so many times before, I just tune it out. I wasn't really paying any attention to you either."

What the outpatient primary care doctor really said: Every visit for the last 10 years has included a documented discussion of the importance of managing diabetes, including lifestyle issues, medications, and complications.


TALE THE SECOND

What the patient says: Doctor, the surgeon says I need an operation, but he didn't tell me anything about it.

What I do: Spend forty-five (uncompensated) minutes having an extensive discussion about the need for the surgery, the possible ramifications of not having it, and so on.

What you can't possibly expect the patient to say: I was too nervous to pay attention to what the surgeon was telling me, so I have no idea what he said.

What the surgeon really said: Pretty much the same things I did.


TALE THE THIRD

What the surgeon says: The hospitalist sent you here for a surgical procedure that didn't need to be done while you were in the hospital, but can be done as an outpatient now that you've been discharged.

What the patient says: What?? Dr. Happy never said anything about an operation.

What you can't possibly expect the patient to say: That guy talked about all kinds of things, I couldn't make heads or tails out of most of it. I tuned him out after the first twenty-four hours.

What the hospitalist actually did:
Reminded the patient every single day about the unrelated problem that wasn't keeping him in the hospital but would have to be dealt with once he was well enough to leave. Made a special point to discuss it in detail at the discharge visit, and carefully documented it both in the medical record and the patient's discharge instructions.


WHAT WE SHOULD LEARN FROM THESE TALES:

Assume that patients really have heard the basics already. Whether or not they understand what they've heard is of course a completely differently pigmented equine. But all of us -- and I do admit my own not inconsiderable guilt in this matter -- need to give our colleagues the benefit of the doubt in terms of what patients have been told. Remember that it's far easier for the patient to claim they've never heard what you're telling them (and oh-so-flattering for us as well) than to admit that they've either forgotten or ignored the same material in the past.


12 Comments:

At Mon Aug 10, 05:38:00 PM, Blogger Ambulance Driver said...

Alternate version of Tale The Third:

The Surgeon Says: Happy Hospitalist sent you here for a surgical procedure that didn't need to be done while you were in the hospital, but can be done as an outpatient now that you've been discharged.

The patient says: Huh? I only talked to that guy once, and the only other time I saw him, he was standing outside my door eating a popsicle while the nursing staff coded my roommate.

What you can't possibly expect the patient to say: Well yeah, I spoke to him several times, but every time I did he spoke to me like I was a retarded fourth grader and kept making those "finger quotes," so I tuned most of it out. Then he showed me pictures of some anorexic dogs wearing sweaters.

What Happy Hospitalist actually did: Spoke to the patient condescendingly, used lots of finger quotes, and then strolled to the vending machines for an Eskimo Pie while the nurse explained it to me.

 
At Mon Aug 10, 05:44:00 PM, Anonymous Anonymous said...

Nurses rock! (see last sentence above)

My doc makes me sign a paper saying he recommended that I do something - a colonoscopy, mammogram, etc. so I cannot come back and say I wasn't told. If he wasn't so busy I'd ask what happened to him that he feels he must cover his behind that way.

Airedalelover

 
At Mon Aug 10, 10:05:00 PM, Blogger medicine girl said...

Amen!

 
At Mon Aug 10, 10:17:00 PM, Blogger medicine girl said...

And @Ambulance Driver: I'm sorry you've had some bad experiences with physicians, but I hope you'll consider that many physicians spend their days busting their tails to do right by patients despite ever-increasing obstacles to doing so.

It's well-documented that patients tend to tune out what they don't want to hear and focus on what they do want to hear. They are more likely to retain information about a treatment's potential benefits than about its potential adverse effects.

Most physicians I've known try hard to effectively communicate with and listen to patients. In these litigious times a physician's livelihood may depend on it -- good communication decreases the incidence of lawsuits. But more important, poor understanding worsens both patient compliance and outcomes. Not even arrogant docs want that.

 
At Mon Aug 10, 11:05:00 PM, Blogger Ambulance Driver said...

Medicine Girl, I wasn't making sport of physicians in general. I know plenty of good ones.

I was just having a bit of sport at Happy Hospitalist's expense.

 
At Tue Aug 11, 07:55:00 AM, Blogger Resident Anesthesiologist Guy (RAG) said...

I try to tell the medical students I work with that you can't trust in entirety what a patient tells you. When I was an intern we'd have transfers where the patient had no idea what they'd had done, or told us of things that seemed outrageously incompetent. Easy to think badly of the transferring physician until you looked through the records and understood more of what was done and what was needed. Patients just can't be expected, like you said, to give you what you're asking for.

Though, there were a few times when the patient was dead-on and I wondered how the doctor who transferred the patient was still working.

 
At Tue Aug 11, 10:47:00 AM, Blogger Ambulance Driver said...

"I try to tell the medical students I work with that you can't trust in entirety what a patient tells you."

I used to get highly insulted when I'd drop off a patient at the ER, and the doctor or nurse would ask exactly the same questions I'd just given them the answers to in my handoff report.

Then one day, I hung around long enough to hear what the patient told them, and I'd have sworn that aliens abducted my patient and replaced him with an exact duplicate with an entirely different history.

Now I know that patient history rarely repeats itself.

 
At Tue Aug 11, 03:26:00 PM, Anonymous Anonymous said...

It's also very hard for a patient to hear anything said after a life-threatening diagnosis. I can attest from personal experience that despite my outwardly calm yet concerned demeanor, after my doctor told me I had ovarian cancer pretty much all I heard was my own mind screaming "Omigod I'm gonna die!" It took me most of the weekend to collect my scattered wits after that.

 
At Tue Aug 11, 06:49:00 PM, Anonymous 4th year vet student said...

Trust me, it doesn't only happen in human medicine.

I'm constantly amazed at how well clients make me look like a bumbling idiot when the history they give my attending is completely different from the history I presented to my attending two minutes earlier.

And this is for things like, "When did your dog last get his heartworm medication?"

 
At Wed Aug 12, 11:47:00 AM, Blogger suzanne said...

AD, can you please explain this to your colleagues?

I get soooo frustrated when I directly ask an ambulance patient questions, only to have the paramedic interrupt and answer for him/her.

I once (very bitchily) snapped "I heard YOUR report; now I want to hear what SHE says." Now I just wait until the paramedic is out of earshot before I ask.

Patients rarely tell the same story twice. The tell the medics one thing; triage something else; the nurse a slightly different version; the doc something else; and, if they get admitted, the floor nurse and admitting physician will get different stories, too.

Somewhere in all of that lies the truth.

 
At Sat Aug 15, 11:14:00 PM, Anonymous Anonymous said...

Now you are getting it Dino. Aftermany previous posts complaining about lab,ER, hospitalists, rads, pharmacy, etc etc. You have come to the conclusion it takes all of us and in reality most of us our doing the best job possible. Kudos

 
At Sun Aug 16, 03:26:00 PM, Blogger Hal Dall, MD said...

Anon:
"after my doctor told me I had ovarian cancer pretty much all I heard was my own mind screaming "Omigod I'm gonna die!" It took me most of the weekend to collect my scattered wits after that"

I was taught in training to say everything important to the patient before I used the word "cancer" for that very reason.

 

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