The current structure of the medical establishment in the United States provides a well-known obstruction to patient care – it’s not structured to allow patients and doctors to actually communicate with one another. This paper is intended to provide a doctor’s perspective and to make some suggestions that doctors can implement to provide a positive change toward quality patient care. First, I shall look at the difficulties in the health maintenance organization (HMO) situation that keeps making the headlines (especially in an election year, when it makes for fine political fodder). Second, I will look at the medical training regimen and how it lacks the ability to create or improve communication skills between doctors and patients. Finally, I suggest some ideas that may help both doctors and patients circumvent the dominant paradigm and feel more satisfied with their work. After all, the best sort of revolution is one that starts with the individuals involved.
The hegemony of the HMO system works against human interaction between physicians and patients. It is a well-known fact that American HMOs are usually for-profit. What does this mean for the consumer of medical services? How do other businesses make profits in this country? By my reckoning (my apologies to the economists out there, for I am just a simple doctor), most businesses amass profits by maximizing the intake of money and minimizing overhead and other expenses. For some reason, the people in health care who actually provide medical care service (and thus make money for the HMO) are the ones who are viewed as the biggest source of overhead. Who are those nefarious characters? They are the doctors, nurses, physical therapists, occupational therapists, nutritionists, social workers, and others – the very people who allow the HMOs to remain in business. Yet, the people who provide no medical service and make no true money for the HMO, such as CEOs and other financial officers, are paid large salaries and bonuses and tend to live in fancy houses. A case in point: the president of a hospital where I once worked was recently given a new office space for his personal use, totaling approximately 1200 square feet (which is about the same size as my current house). Now, that president may need that space for whatever important fundraising and business he needs to do, but the sad irony is that two floors down in the new building are unacceptable clinic rooms for doctors to work with patients. The rooms are about 10×12, contain a large sink and have closet-sized entry doors. This is all located at a rehabilitation hospital, a place people in wheelchairs need to enter. In case you are wondering, it is extremely difficult, if not impossible, to maneuver a wheelchair through a narrow door and into a room the size of the proverbial closet. It is this sort of contrast that becomes so troublesome in medicine. The focus of this new building and the people who run it is obviously not on patient care since the very people they are charged with caring for don’t have effective access to the building.
A second part of the HMO problem is the capitation system and other incentive/punishment schemes designed to make patient care more efficient. In the relatively common capitation system, a doctor is paid a set amount for each patient that he or she sees for the year. If doctors spend more on clinic visits than is allowed, then the extra money comes out of their own pockets. This system was probably designed based on actuarial statistics. Not all patients will require services that exceed their yearly allotment. However, people are not statistics and doctors I have spoken with have described multiple times where they get “hit” with a string of sick patients that quickly deplete their allotted money. Morally, doctors are obligated to continue to care for these patients; the Hippocratic Oath still governs what we do. But financially, this can cause a doctor to have to beg, borrow, or steal money to stay in business. What this means to the general consumer of medical services is that your average doctor will have to take on tons of patients to make up for the excessive costs of a few sick patients. It should be noted that I’m not blaming the patients – being ill and needing medical care is not something that should be blamed – but rather the capitation system that forces us into taking on more patients than we can reasonable handle. Practically all of us have experienced the fallout of this system: long wait times in the office and very short “face time” with physicians because they are swamped.
A more insidious system is the incentive system. Primary care doctors, the so-called gatekeepers of the medical system, are sometimes given bonuses for keeping costs down. An example how this works is that for a set amount of patients that have not required referrals to specialists or extra tests, the doctor is given a share of the profits from the HMO at the end of the year or some other time period determined by the HMO. The implications of this “reward” system should be obvious: there exists a clear incentive for the doctor not to refer the patients onward. Primary doctors are pressured or encouraged to try to manage as many medical problems on their own as possible in order to minimize the HMOs’ costs. There are excellent primary doctors, but no one can know everything about medicine. In addition, a typical family practice doctor or internist only spends three years learning their craft during residency. How are they supposed to learn some of the subtleties of stroke management, sleep disorders, heart conditions, back pain, etc., in that time period? The truth of the matter is that they cannot. Yet, in the particular example of back pain, primary care physicians are subjected daily to one of the most common patient complaints in the USA. I seriously doubt that many primary physicians know that sometimes back pain can be caused by a capsular tear in the hip joint or the spasm of a deep muscle of the buttocks, so they would not know to look for these issues when doing their workup. This leaves patients in the position of suffering needless tests or not being given the relief of an appropriate diagnosis or correct treatment. If the primary care “gatekeepers” were allowed to refer their “interesting” patients onward without the threat of losing a bonus or overspending an allotment, the patients would receive better care. It is as if the HMO industry has forgotten that the average doctor spends 11 years of post-secondary training learning their craft (more on that in a few moments).
On the other hand, doctors can be somewhat dense when it comes to being savvy about their ability to deal with these problems. In order for the HMO system to be maintained, it requires doctors to passively accept the demolition of the Hippocratic Oath in favor of the amassing of profit for the HMO. If doctors as a group agreed to ignore some of the asinine rules set up by insurance companies and government agencies, then those rules would no longer be able to function. The only unfortunate part of all of this is that the old joke of ask three doctors their opinions and you will get three different answers applies. Even the American Medical Association (a huge lobbying group for physicians) only represents about 30-40% of all doctors in the USA; not even a simple majority belong! Doctors need to work together to help subvert this problem and remember that one of our jobs is to be a vociferous advocate for our patients. Recent lawsuits filed by physicians against HMOs represent to my mind only the beginning of our work to get away from bean-counting and back to doctoring.
This brings us to the second aspect of the problem: the hegemony of the medical establishment in America prevents doctors from learning how to effectively communicate with their patients. If one looks in the medical literature for references to communication and patients, one will find thousands of articles. The basic message of these articles is that doctors seem to have a great deal of difficulty getting their message across. It has been my experience in reading medical literature that whenever there are a large number of articles on a particular subject, there is both a keen interest in the subject and yet a great deal that is not known about it. The sum total of this literature search: the amount of research on doctor-patient communication shows that we don’t really know how to communicate with our patients.
In my brief career, I have known of a good number of physicians with diverse interests and backgrounds. There are doctors who are skydivers, hang gliders, musicians, motorcyclists, rock climbers, and, as in the case of Beck Weathers, mountaineers. But how many doctors are able to take these hobbies and sports – or even the doldrums of everyday life – and dovetail them into talking with their patients? From what I have seen, not many. One reason for this inability to bridge the gap is the way people are trained to be physicians in our country. A brief aside for the uninitiated follows.
When one becomes interested in attending a medical school and making a career out of medicine, one quickly learns there are a lot of hoops to jump through. At the university level, one must complete one-and-a-half years of chemistry and organic chemistry. It is also considered important to have a thorough understanding of biology, math, calculus, biochemistry, and physics. Now, I will be the first to admit that these subjects, on the surface, all can come in handy in medicine. However, if you add up the time taken by all these endeavors, you realize that there is not much time for dance, drama, art, and other humanistic courses. When one reaches their junior year of college, a test needs to be taken. This is the MCAT (Medical College Admissions Test), consisting of three multiple-choice sections and two writing samples. The writing samples are two basic essays that are then graded by a high school English teacher. I have nothing against high school English teachers, but it does seem a bit weird that a doctor only needs to be able to write and express their ideas at a high school level. To my mind, this is the first problem in the communication skills of many physicians – it’s clearly not seen as an important part of the testing required to even get into medical school.
Assuming one gets into medical school, you are then sent into a strange time-warp reality. Medical school, like the army, seeks to break you down and reshape you in its image. A college graduate, used to having their own schedule and deciding what classes to take, is suddenly plunged into a world that is far more regimented than the strictest high school. One is told which classes to take and when, and is assigned a cadaver to dissect with a group of complete strangers. One is subjected to frightfully boring lectures on each and every stage of embryo development. It is required to learn each enzyme and product of the Krebs cycle (how our cells produce energy to function). The classes, terminology, and sheer volume of stuff medical students are required to memorize floods your brain for two years straight. At the end of this period, another standardized test: the USMLE-1 (United States Medical Licensing Exam, part 1). This test, after two years of sweat and studying, is a multiple choice test. Yes, your doctor and your friends’ doctors are where they are now because of several educated guesses. Here’s the real kicker: to pass this test, most of the time people only need to get fifty percent of the questions correct.
After two years, the new medical student, fresh from lectures and the USMLE-1, is sent to a hospital to put their knowledge to practical use in an internship. In the hospital setting, the student is shown the standard format for taking a patient’s history, doing a physical exam and reporting their findings. All of this knowledge is again tested with a multiple choice question format at the end of the year, the USMLE-2. Just in case the medical student had trouble figuring out how to get stuff right 50% of the time, they again get to test their knowledge after their first year of residency with the USMLE-3. Put another way, for American medical students, the one time communication skills are examined is before one even enters med school. The only time communication skills are ever tested is with those few people lucky enough to graduate from a foreign medical school. These folks are required to take the ECFMG test with English speakers saying things on a scratchy tape over a loudspeaker. In this test, the foreign medical graduate has to use a list of available answers to determine what the speaker meant when they said “Dude, that really sucked.” From this explanation, it should be obvious that there is precious little time or inclination to learn to communicate in medical school. In my personal experience, we had a grand total of three formal lectures on how to treat patients, and another week spent on general medical ethics. Beyond that, it was up to the individual to find a mentor and learn from them how to talk with people. When I have asked people from other medical schools, their lack of experience in doctor-patient communication was similar.
It is the basic and sometimes boring experience of daily living that seems to escape a doctor when he or she needs to impart some critical knowledge to a patient. All too frequently, doctors are too absorbed in the esoteric language of medicine to know that their patients have no idea what they are talking about. Sometimes, unfortunately, this is done deliberately. For example, on typical medical rounds in a hospital, doctors will frequently use technical jargon right in front of the patients in order to keep them from worrying about their illness. Other times, doctors do try their best to communicate, but without the ability to relate well to the mundane, things get a little confusing. One example that I have seen is the vain attempts of a surgeon to try to “talk basic” to his patients by continuously using the word “O.K.” in both the form of a question and an answer. It reminded me of some bizarre twist on valley-girl speak. Needless to say, his patients were completely lost by the end of the visit. I often had to return and translate this doctor’s explanations into more sensible language like: “you have a flat foot and it cannot and should not be repaired by surgery because you will most likely end up with more pain and scarred feet.”
Another example is the typical conversations that go on at dinners with colleagues. They frequently revolve around rumors at the hospital, gossip, and discussing various patients’ problems. I am the first to admit that I indulge in these conversations and I have learned much about other people’s views on medical problems and diagnoses. Although these “shop-talk” conversations are informative, I do have a twinge of sadness when I consider that my friends and colleagues don’t know and don’t care who won NASCAR, who threatened whom with nuclear attacks, who succeeded in scaling Mt. Everest lately, who just went to number one on the pop charts, who wrote Crime and Punishment and so on.
Even more pathetic are some professionals who have strong (generally negative) opinions about people with tattoos, multiple divorces, different skin colors, different religions and other basic facets of modern American culture. When I see reactionary bumper stickers on cars in the doctors’ parking lot I feel concerned that they might be unable to be an effective advocate for a particular patient’s care. Even more alarming are some of the comments I have heard about an unconscious patient while they lay in the emergency room or on the operating table. How can a surgeon who voices their opinion that Black crack addicts are worthless, then perform an accurate procedure with attention to reducing suffering and helping mend that person’s wounds? Or, how can a doctor make incredibly crude comments about a cheerleader’s body at a football game and then have to treat her for a strained muscle five minutes later? The last time I checked, the mind is connected to the body and can determine its actions (or lack thereof). Medicine has no room for racist or misogynist views. Whatever our personal hang-ups might be, as doctors we need to leave those opinions at home. If a college-educated, medical-school trained individual is unable to do this, then they should consider another line of work.
Despite all of the troubles that the system can give doctors, there are still opportunities for those of us involved in point-of-care service to make a difference. Part of my personal duties involves caring for patients at a local Veteran’s Administration Hospital. The stereotype of this organization has been that is it a morass of red tape and that the veterans get shuttled around so much they don’t know which way is up. True to form for most government-run organizations, some parts of this stereotype are correct: the place is indeed a morass of red tape. However, the people I work with are very dedicated and do try their best given the limitations of staff and time. In addition, at the VA one has a certain amount of freedom that is unavailable to people in the civilian world. In my specialty of rehabilitation medicine, we are able to order special equipment for people with physical impairments. It is a joy to be able to order the correct wheelchair for a tetraplegic patient and not have to worry about fighting an insurance company. On the other hand, the VA has strict written rules as to who qualifies for various pieces of equipment and it is sometimes my duty to deny patients access to some things that they want. The VA does this because they are constrained by severe congressional budget cuts (and the cuts get larger every year since the VA monies come from the shrinking defense budget). As in all systems, there are pluses and minuses to the VA. Being open to new ideas and people of differing backgrounds can make a big difference in this arena. First, you have the opportunity to give people a positive representation of a government institution. Second, you have the opportunity to learn about the people who have worked to defend this country. There are few places in the world where people are willing and able to be honest about things and a doctor’s office should be one of them. When I approach this particular patient population with respect and an open mind, I am often surprised by what I learn both medically and in the realm of trivia. For example, did you know that several days after Nagasaki in WWII, the ground was like powder and you could shove a stick two feet into the ground without resistance? Or, did you know that some vets in the Gulf War were in foxholes and dove for cover under sniper fire (doesn’t sound like the Gulf war most folks saw on television). These are some of the mundane facts I’ve learned through taking the time to listen to patients who served their country – and for me, this is the real benefit of being a physician.
In other arenas, I have also noticed that an open mind has helped. I was fortunate enough to grow up in San Francisco where there was plenty of opportunity to experience a wide variety of differing opinions and therefore I am rarely surprised by people’s interesting backgrounds. When I encounter people with tattoos, I have found that being honestly interested in the design and the background of why they got them has really helped in treating them. Plus, you do get to hear some really interesting and sometimes funny anecdotes. (For people interested in tattoos, I recommend Vale’s edited volume, Modern Primitives.) I personally have found that reading for pleasure and interest has helped immensely in dealing with patients numerous times. When I hear that colleagues don’t have time to read for pleasure I am saddened that they are really saying that they don’t have time to learn about life outside of medicine. Reading about different people in our culture and others has been a benefit to my style of practice as it allows me to reach my patients as people instead of as “cases.”
Another way I have tried to subvert the dominant paradigm of the HMO culture (which does, as I’ve hinted before, infect the Veterans’ Administration) is to actively pursue friendships outside of the medical arena. As I have jokingly told people both inside and out of the medical profession before: I like to date outside my species. This has occasionally resulted in some interesting encounters with girlfriends and friends who don’t understand the idea of being “on call”, or why you have to stay in the hospital until late at night. In fact, the idea of meeting people out of one’s bailiwick is probably a good idea for anyone in any profession. I feel lucky to have wife who works in the school system and friends from the humanities, computer industry, and other areas of life. However, on some level I have tried to do this deliberately in order to learn about life and what it has to offer. Plus, when I apply some of the things I have learned from my friends to my work, I find that my ability to relate to patients has improved significantly. One example I can think of is from my wife: she is a school psychologist. When I worked on the head injury unit of our local rehabilitation hospital, she provided some insight into the younger patients that I had not known about. All public schools are obligated to provide services for learning disabled students. For our teenage head injury patients (and unfortunately there are many), just providing a sketch of how the system works has been a great help for them and their parents. My wife has taught me about the proper jargon to use in the school system to get the services one needs. I have been able to pass this information along to my patients’ families to their child’s benefit, but only because I know people outside the establishment.
In sum, then, the biggest problem physicians and patients alike face in our current health care system is, when it comes right down to it, time. The impulse from the medical establishment, be it HMO or government-run, is to, as is often said on the show ER, “treat ‘em and street ‘em” – in other words, to treat as many people as possible in the most efficient manner and with the fewest resources necessary. The financial incentives provided to doctors by HMOs are frequently too tough to resist, so doctors take on more patients than they can really deal with, leaving us overworked and patients with almost no time to develop a rapport with the person in whose hands their life is frequently placed. Physicians are then left resorting to their basic language (medical jargon), and patients are left not really knowing what is going on with their treatment. What this amounts to, then, is a factory-floor model for treating people, ensuring that they leaves healthy, productive lives, and leaves everyone involved on the front lines of medicine unable to truly develop what counts in medicine – the doctor-patient relationship.
My challenge to others in the medical profession is that there needs to be a greater understanding and translation into the doctor-patient relationship of the more mundane aspects of life and the dominant culture. If you see a tattooed, crack-addicted, divorcée, are you going to be able to talk with her about the quality of her tattoo, the local conflicts with crack dealers, the schmuck who wont pay her alimony? Or are you going to dismiss her as another crack head with a broken hand? It is by learning to be open-minded about your patients’ backgrounds and accepting of their adventures and their reality that you can truly learn to get what you need from them: information. I have had a somewhat diverse background and have often been accused of knowing something about everything (or at least sounding like I do). But I relish this accusation, because it has saved me many times. By paying attention to someone’s background, it is possible to use little bits of knowledge picked up in life to try to form a bond and thus get a more honest answer. Yes, patients lie all the time to their doctors; most of the time it is done to try to please the doctor, while sometimes it is because they are embarrassed and do not feel that their doctor would understand. But when you know who Jeff Gordon is or the difference between a single-wide and double-wide trailer, you can often ally yourself with your patient and find out all sorts of interesting things – and this is the point of the doctor-patient relationship. Another mistake that I have seen several doctors make is forgetting to ask their patients about their interests. Have you ever been curious about collecting garbage and what people throw out; have you ever wondered what it’s like to work in a coal mine; have you ever wondered what it is like to take sniper fire? The world is your oyster in a doctor’s office, because if you are interested, all of this and more are available just for the asking. When you do ask, all of a sudden the white-coat intimidation disappears and it becomes much easier to talk about the real problems and complaints that a patient might be having.
Another difficulty for doctors in communicating with their patients comes when it is time to dispense information. Like the poor surgeon mentioned earlier, if you cannot connect with the people your care for, you cannot correct their problems. I was told long ago that the word “doctor” is a Greek derivation from a word that means teacher. In this light, I think it is important for doctors to think about that line from the movie Philadelphia: “explain it to me like I was a child.” I do not mean to imply that patients are simpletons – far from it, for it has been my experience that most Americans I have met have rather good street smarts. It’s just that fancy terms like ependymoma, anterolithesis, scoliosis, malignant, urological, and bowel movements can sometimes confuse and intimidate people. It is sometimes necessary to play the role of teacher. Rather than just tell someone they have supraspinatus tendonitis preventing abduction, one could instead add that they tore an important shoulder muscle that helps them lift their arm away from their side. It can even help to grab a piece of paper and diagram things. I realize that many of these ideas take time, but it is that extra five minutes that can make the difference between a well patient and one who continues to suffer from illness or impairment.
Unfortunately, much of the medical establishment does not allow for the extra five minutes that can come in handy sometimes. As I mentioned previously, the pressure on most doctors is to add as many patients to their rosters as possible. The current mentality appears to be based on the model of industrialism. People are expected to be more “efficient” in their jobs whether it’s in a factory or a doctor’s office. In a factory, there may be some arguments to be made for efficiency and timely production of things like cars. Of course, there have been unintended consequences of that mentality (can you say Corvair?) outside of the medical business. But, in medicine, the factory model is particularly insidious. There are such concepts as “standard of care” and “treatment algorithms” that sound nice on paper and make things very easy for insurance companies and the government to regulate, but they are potentially harmful. Take, for example, a person who comes to a doctor with a cancer. The “standard of care” for this patient might be a particular surgery followed by a particular chemotherapy. This can be very expensive and painful for the patient and may, as in the case of someone I spoke with recently, only provide a 5% improvement in the person’s survival. The problem arises when the doctor is pressured to move fast and get on to the next patient and doesn’t have the time to listen to the first patient about their fears, worries, and concerns. Perhaps the patient would rather give their money to their children instead of the hospital; perhaps they don’t really care about an potential extra 5% survival; perhaps they don’t like the idea of being nauseous their remaining days for a small overall improvement. The inability for doctors to really understand their patients, though, would prevent them from realizing the real wishes of the patient – and isn’t that what medicine is really about? Unfortunately, until doctors return to the old fashioned model of the “art of medicine”, the chance for patients to really connect with their physicians and vice versa will be diminished.
Vale, V. (ed.) Modern Primitives (RE/Search 12). San Francisco: RE/Search, 1989.
Author: When he is not climbing or reading books about tattoos, Dr. Jackson Maddux is a third year resident in the department of Physical Medicine and Rehabilitation at the University of Kentucky, and was one of the lucky ones who had to talk about what the scratchy voice meant by “Dude, that really sucked.” As a recently married man, he will most likely stop complaining so much about things he cannot change, unless it’s poor medical practices.