Brian Goldman makes an impassioned personal case for changing the culture of medicine by admitting errors of judgment.
I think that the most important step in making that change is recognizing the relationship between physician and patient for what it really is: a partnership.
Doctors don't cure diseases.
At our best we help patients heal. In extreme cases, our interventions are necessary for healing to occur. No matter how strong the medication or how advanced the surgical technique, no matter how expertly they're applied, their success depends upon the ability of the patient's body and mind to heal itself.
This is not the way doctors are taught. When I applied for a residency at Bellevue Hospital many years ago, the chief of medicine assured me that Bellevue was a great place to train. "When you've worked on city hospital patients with multiple diseases and multi-organ failure," he explained, "then the University Hospital patients, who only have one thing wrong with them, are a piece of cake."
I've analyzed the social implications of this statement in my book, Power Healing. The bottom line: This is the vision of the biomedical mechanic.
My experience at Bellevue taught me a lot about medical complexity, but it also taught me that my professor had used the wrong preposition: "work on" instead of work with." The distinction makes a huge difference.
Working with patients requires a special set of skills and behaviors that must be taught and encouraged if the culture of medicine is to change. Not only do these skills increase humanism, their application has consistently been shown to result in better health outcomes.
1. Listening. Patients are typically given about 20 seconds to express their concerns before being cut off and redirected by the doctor. Yet patients who are allowed to present all their concerns in their own words cooperate more fully with medical treatment and show a greater improvement in health status, losing less time from work and experiencing less limitation of function.
2. Acknowledging. Every patient has his own ideas and feelings about his illness and his own goals. In most medical consultations, the patient and the doctor are not in full agreement about the nature of the principal problem. Unfortunately, physicians are loathe to recognize the patient's perspective, even when it is presented to them.
3. Explaining. People have intense need for explanations about the causes of their diseases. Doctors are usually content to name the disease and treat it. Patients want to know how they came to be sick, so that they can attach some meaning to the illness. They want to know what to expect from the illness and what they can do to relieve symptoms or speed recovery. The amount of information given by physicians correlates with the degree of satisfaction patients express concerning the treatment they have received. Yet studies show that doctors consistently underestimate the amount of information patients want and grossly overestimate the amount of information they actually give.
4. Encouraging self-care. Advice about self-care practices enhances a patient's confidence in his or her ability to recover. Eliciting the patient's active participation in developing a therapeutic plan improves satisfaction, cooperation and level of activity for patients with a wide range of chronic diseases.
5. Asking for feedback. This may well be the hardest part, but also the most enlightening. Sports educators have discovered that novice athletes progress fastest when they are given positive feedback ("this is what you did right"), whereas experienced athletes learn best when given negative feedback ("this is what you did wrong").
In medicine, we do it the opposite way. Students and interns are constantly reminded of what they don't know, but senior physicians are allowed to focus on their successes. Our practices consist of the patients who keep returning to see us. We lose the opportunity to learn from those who don't come back. When I left academic medicine and went into medical practice in a small town, I started calling patients I hadn't seen in a while to find out how they were doing. Their responses taught me as much as I'd learned in 12 years of training and teaching. To really change the culture of medicine, feedback from patients should become part of continuing medical education.
Now I'd like to hear from you:
Please share your experience with the health-care system.
How do you feel about your medical care?
What obstacles have you faced in communicating your illness?
Please let me know your thoughts by posting a comment below.
Leo Galland, M.D.
Important: Share the Health with your friends and family by forwarding this article to them, and sharing on Facebook.
Leo Galland, MD is a board-certified internist, author and internationally recognized leader in integrated medicine. Dr. Galland is the founder of Pill Advised, a web application for learning about medications, supplements and food. Sign up for FREE to discover how your medications and vitamins interact. Watch his videos on YouTube and join the Pill Advised Facebook page.
References and Further Reading
Beckman DB, Frankel RM "The effect of physician behavior on the collection of data." Annals of Internal Medicine. 1984; volume 101: pp 692-696.
Marvel MK, Epstein RM, Flowers K, Beckman HB. "Soliciting the patient's agenda: have we improved?" JAMA. 1999 Jan 20;281(3):283-7.
Roter DL, Hall JA. "Physician interviewing styles and medical information obtained from patients." Journal of General Internal Medicine. 1987;vol 2: pp 325-329.
Fredidin RB, Goldin L, Cecil RR. Patient-physician concordance in problem identification in the primary care setting. Annals of Internal Medicine. 1980. vol 93: pp 490-493.
Sanchez-Menegay C, Stalder M. Do physicians take into account patients' perspect¬ives? Journal of General Internal Medicine. 1994; volume 9: pp 404-406. No, at least in Switzer¬land.
Korsch BM, Gozzi EK, Francis V. Gaps in doctor-patient communication. I: Doctor-patient interaction and patient satisfac-tion. Pediatrics. 1968; vol 42: pp 855-871.
Williams GH, Wood PHN. Common-sense beliefs about illness: a mediating role for the doctor. Lancet. 1986; 328: 1435-1437.
Hall JA, Roter DL, Katz NR. Meta-analysis of correlates of provider behavior in medical encounters. Medical Care. 1990; vol 28: pp 657-675.
Brody DS. Physician recognition of behavioral, psychological, and social aspects of medical care. Archives of Internal Medicine. 1980. volume 140: pp 1286-1289.
Lorig KR, Mazonson PD, Holman HR. Evidence suggesting that health education for self-management in patients with chronic arthritis has sustained health benefits while reducing health care costs. Arthritis and Rheumatism. 1993;vol 36:pp 439-446.
Waitzkin H. Doctor-patient communication: clinical implica¬tions of social scientific research. Journal of the American Medical Association. 1984; vol 252: pp 2441-2446.
Greenfield S, Kaplan S, Ware JE. Expanding patient involvement in care: effects on patient outcomes. Annals of Internal Medicine. 1985; vol 102: pp 520-528.
Kaplan SH, Greenfield S, Ware JE. Assessing the effects of physician-patient interactions on the outcomes of chronic disease. Medical Care. 1989; vol 27: S110-S127.
Power Healing: Use the New Integrated Medicine to Cure Yourself. Leo Galland, M.D. 384 pages, Random House
The Fat Resistance Diet Leo Galland, M.D.
This information is provided for general educational purposes only and is not intended to constitute (i) medical advice or counseling, (ii) the practice of medicine or the provision of health care diagnosis or treatment, (iii) or the creation of a physician--patient relationship. If you have or suspect that you have a medical problem, contact your doctor promptly.