8.31.2007

Asshole doctors...why is it so?

Ass. Hole.

"Why are doctors such ass-holes?"

I have a couple of friends and family members discuss with me their recent interactions with their physicians. I've had many patients thank me profusely for "listening more than any doctor has so far...". You've got to be kidding, right? *I'm* listening to you more than any doctor to date...in the emergency room? That's sad.

Then, a close family member told me how frustrated she was with her doctor because he wouldn't give her...basically what she wanted. And instead of making her understand why what he was doing was 'better' or 'more appropriate'...he just (in her words) flat out refused to give "this" antibiotic over "that" antibiotic. Actually, it wasn't even the antibiotic they disagreed upon, it was merely the dosage (which were both appropriate dosages in the clinical setting). How stupid. This family member is a 30 plus year RN...and has been in clinical medicine longer than that. No, she's not a physician...but she probably does know about her particular issue (and her particular body) much better than this physician. Dear Doctor, why not just listen, and if you want to get rid of the patient fast...as long as what they're asking for is reasonable...just give it to them and be done. Especially since, really, this wasn't that significant.

I've gone to the doctor, armed and ready to plead my case. I'm sure many other doctors have done the same thing themselves. I actually choose my family physicians based on, not how smart they are...but rather who will allow me access to the ancillary testing I feel is appropriate. There's nothing worse than being denied a possibly helpful diagnostic exam to allow the HMO to save money. If I have a headache, and I feel I need a head CT...I want a head CT. And unless the doctor explains to me why this may not be the best course of action...I want a head CT. Or, like the elective c-section I wanted....(and got, thanks to a listening OB who understood my concerns and agreed to my completely appropriate although 'unprotocoled' birth plan).

Because I've been blessed with really great doctors (after switching, and switching, and switching...until I find people I connect with...and who listen to me), I haven't had to argue much (knock on wood). And, yes, I've absolutely been talked out of all sorts of things "I thought I (or my kid/husband) needed." And even if things "go wrong" I feel that together we all made the very best decision possible with the information we had available to us at the time. And that decision is made by mutual understanding of expectations, explanation/education, and the overall feeling by both parties that the desired outcome is the same...which is that of health and happiness.

If what has been happening to my friends and family is the normal operating procedure of most docs...then it's no wonder we're getting sued so much. People are unhappy, and feel docs don't listen, and don't care. They don't educate, and aren't personable. This is a problem.

I understand the system is all fucked up...and this is why many (otherwise very empathetic, listening, caring) docs seem harried, unfocused, uncaring, and don't explain anything. This is why they come across short tempered, and basically rub people the wrong way. But, this is why the physicians should be the grassroots organizers for change. This is why they (I mean *we*) need a unified voice...because as it is, no one is listening.

I saw a nurse practitioner the other day. She had over 30 minutes with me. She seemed focused, and interested. She was rested...and her room was decorated with all sorts of cute pictures and informative posters and such. Her room had so much personality and I was completely absorped and put at ease. Then she came in, smiling, sat down, and looked at me. She had time to actually come in. sit down. and look at me. I felt like...I was the only patient on her schedule for an hour (and I probably was).

This is interesting since the PAs and nurse practitioners see the 'less complicated' patients, you would think that it would be they who had only 15 minutes per patient...with their easy patients and all. And the physician would be graced with over 30 minutes per patient....to decipher the nuances of the more complicated patients, and make more difficult medical decisions. Besides, there are (theoretically) more physician extenders than physicians...so it seems that the physician could busy herself with more 'doctor things' (i.e. things that require that a doctor do them) while the extenders saw the routine things which comprise the large majority.

But...this is not how it seems to be.

Physicians need a louder unified voice....lest our patients continue to think we're insensitive and uncaring, and suing us as a result. We need to be nicer. We need to listen more...and explain more. We need to change the system to encourage (or in some instances *allow*) us to be physicians...and really 'help people' and not simply stress them out and piss them off....

27 comments:

L.B. said...

You reminded me of a recent tragedy in my small town. My neighbor's daughter, a 31 year old popular teacher and a mom, had a persistent cough. She saw her primary many times and was given many different asthma meds. She felt that she needed a chest film but was told repeatedly by her doctor that it was not necessary.

She finally got the chest film after her husband went with her and insisted. Diagnosis- Lung cancer (stage 4) in a young non-smoker. She died less than 6 months later.

So you are right to insist upon the testing that you need for yourself and your family. I do.

Anonymous said...

True as that may be, I don't believe PA's should treat patients in 15 minutes either. The point is to avoid errors.

Happyman said...

l.b.:

tragic, but are you implying that every 31yo non-smoker with a cough should have a chest xray? 20-20 hindsight is great, but that's not reality.

Anonymous said...

A CXR for every 31yo, a head CT for every headache, and a spine MRI for every LBP! Emergency Medicine-style testing for all!

Seriously, this is why the system is going bankrupt. Enjoy your head CT now, but recognize that in 15 years you will only be able to receive a head CT if the proper flowchart has been followed to ensure cost efficiency. And you wait in the queue for a while.

marcello said...

A chest xray is indicated in adults with new onset asthma and in patients with persisting symptoms, etc.

So, indeed, listening to patients is key. Often they provide you with the diagnosis on a silver plate if you can see it (easier said than done, though). Also IMHO miscommunication is a leading cause for litigation. Patients perhaps can forgive you for making a mistake, never for being arrogant or unpleasant.

Anonymous said...

"and in patients with persisting symptoms, etc." Really marcello. You would be zapping alot of young people with asthma then.

L.B. said...

A chest film is less than $100 and is indicated in that situation. I don't think anyone can really argue that one.

ER doctor said...

anon said: "you will only be able to receive a head CT if the proper flowchart has been followed to ensure cost efficiency. And you wait in the queue for a while."

And this is better?

anon said: " and in patients with persisting symptoms, etc." Really marcello. You would be zapping alot of young people with asthma then."

Who are you, and what are you talking about?

CXR is absolutely indicated (obviously) for persistent cough in a young woman with no h/o asthma. Could be lymphoma, pneumotx, cardiomegaly, PE, etc. etc. It is therefore indicated in *new* onset asthma (to properly r/o other potentially life-threatening causes...and this is what marcello wrote). Once a dx of 'asthma' has been established, and as symtoms recur, most docs wouldn't repeat CXR with each simple asthma exacerbation....

If a patient presents with a new persistent cough, and no diagnosis....
....most 'competent' physicians would do a very simple, cheap, readily available, completely appropriate CXR.

HCT is also appropriate w/u for a HA depending on the clinical circumstances. And since I shared none of the 'clinical circumstances,' it's quite presumptuous of you to assume it was not clinically indicated (and would therefore fail to fall into a flow-chart or clinical pathway of some sort.)

Get the facts first...before spouting off what's clinically indicated in a particular situation. That's what good doctors do! That's what smart people do.

Mike said...

Botoom line, what does "seeing their primary doc for awhile" mean? A month or two? Because if you can see a tumor on CXR, its too late anyway.

Also, did everyone NOT know that CXR is ABSOLUTELY NOT INDICATED for lung cancer screening? It would have been found by accident.

The case is a sad reminder that medicine isn't perfect. But the anecdote changes nothing. And this article above is pure blather. Just becasue this ER doctor ahs a lot of friends who think doctors are "a**holes" makes me think she has a lot of friends who are asllo "a**holes' who think they know mroe than the doctor, so don't like when they are told otherwisde

Christine-Megan said...

I couldn't agree with you more. I prefer to see the NP at a specialist center I go to simply because that insures continuity of care. If I don't specifically request to see the NP, I see a different doctor every time.

Happyman said...

ER doc says "CXR is absolutely indicated (obviously) for persistent cough in a young woman with no h/o asthma. Could be lymphoma, pneumotx, cardiomegaly, PE, etc. etc. "

A couple of points from someone who actually sees OUTPATIENTS:

1-lymphoma is a TISSUE diagnosis, not diagnosed by cxr

2- cardiomegaly is a radiographic finding (even often artifactual, especially on portable films e.g. ones used in ERs) and doesn't alone cause cough in absence of CHF, unlikely in a 31yo

3- pneumothorax doesn't usually cause a cough lasting 2-3months

4- cough is one of the MOST COMMON presenting complaints to an outpatient office, & asthma is one of the most common causes. it therefore is often (even USUALLY) treated empirically, without imaging, and without the infamous ER SHOTGUN I-HAVE-NO-CLINICAL-JUDGMENT PANEL (cbc, cmp, ua, troponin, d-dimer, ekg, cxr, head ct, spiral chest ct, surgery/cardiology consults)

Also, I think it's arrogant to state another doctor is incompetent in this situation, particularly with your relative inexperience.

ER doctor said...

Don't you just hate dealing with people with overcompensation issues (i.e. the need to overcompensate for something that's lacking)?

Mike,
No one said CXR = CA screening. Seeing tumor on CXR may or may not = “too late” depending on the type of tumor. And when something is missed because asshole physicians think they know everything…I guess the defense that ‘medicine is not perfect’ makes everything okay? Many people are frustrated with medicine. The main gripes that people have with doctors is their inability to listen, their arrogance, and their lack of interpersonal skills. Apparently you fall into this category if you believe that the doctor always knows better than the patient…just because he is the doctor. That’s ridiculous…and is partly the reason medicine is all fucked up.


And to you Happyman:

Tsk. Tsk. Typical post of a guy with overcompensation issues….

No shit that lymphoma is a tissue diagnosis…and cardiomegaly is an xray finding. CXR findings can suggest a pathologic process which would warrant additional evaluations. This is the point. But you knew that.

We can fight over an imaginary patient, with an imaginary cough…and argue about when a cxr is indicated (changing/expanding on slight variations in the clinical history and such to validate difference in opinion)…but that completely misses the point. Not what the post was about, really.

Likewise, to use this post as a springboard to attack the ED/ER doctors…and me personally…misses the point. Reading comprehension at its finest.

It doesn’t take ‘experience’ to realize that someone who allows a person to die because they are too arrogant to consider that…they just. might. be. wrong., is incompetent.

Besides, it's your 'experience' that has royally fucked up medicine...and as far as I'm concerned.
***

It’s interesting, this position I’m forced to take by these two guys with ‘little men complexes.’ As a physician who sees *both* outpatients (because anyone who has completed an internship in the state of California can work as a primary care doctor in outpatient clinic…so Happyman, you’re actually not as special as you’d like to believe) *and* ER patients, I am frequently frustrated myself with patients who think they know more than me about everything simply because they watch HouseMD or ER on TV. Antibiotics for viral infections…ENT referral for simple otitis externa…Demerol for sprained 4th digit…

…I believe that most physicians who are practicing clinical medicine understand this. It’s a given. I know about difficult and demanding patients…and have had many discussions with equally frustrated colleagues in the doctor’s lounge.

But, there is a balance between being the ‘knowledgeable physician’ and the ‘listening physician’. Realizing that sometimes people actually do know themselves better than a stranger does, is something to consider (even if it’s later dismissed as the patient proves they are just crazy). As smart as we (you) think you may be…you are not omniscient…and a bit of humility may, not only keep us out of trouble…it may save some lives.

Happyman said...

ED doc says "It doesn’t take ‘experience’ to realize that someone who allows a person to die because they are too arrogant to consider that…they just. might. be. wrong., is incompetent.
"

So you equate not getting a USELESS cxr to "allowing her to die". Wow, I wonder how long before you're out of the ER & into the courtroom as a "professional" plaintiff's "expert witness.

girlvet said...

ER doctor you have it right: "people have with doctors is their inability to listen, their arrogance, and their lack of interpersonal skills". The childish interchange in this comments is an example of the above statement

Mike said...

I have no idea what "overcompensation issues" means or its relevance here. If you dont like my comments, simply say so.

As for your main point, there are indeed doctors who I think are reprehensible human beings, and are nasty on the phone, in person, and have secretaries who are also nasty. But this is who they are, It has nothing to do with being a doctor. And you completely useless and banal advice that they have to "listen more" is utter garbage, as is your column.

If a patient tells an ER doctor "You listen more than my PCP", that should be a warning to any doctor that the patient is probably not on the level. As a doctor, I'm surprised you aren't aware that the system does not pay enough to spend as much time with patients as we'd like. And you can't even explain it to a patient, because with all the patient "empowerment", now they are just "customers" and we're providing a "service" and need to do so always with a big smile on our face.

So if you want to write a follow up column about "Why patients are such a**holes" and give them the same boring advice about how they should be nice to their doctors and understand that practicing medicine ain't easy.

Your column just makes me think you're part of the whole problem with lack of repsect towards the medical profession and the whole "give patients what they want" syndrome. Shame on you.

Anonymous said...

Dear new EM doc:

I was the one who stated

"and in patients with persisting symptoms, etc." Really marcello. You would be zapping alot of young people with asthma then."

I don't argue that depending on the circumstances (which none of us know) the pt would be served with a CXR (which was I did NOT include it in my statement, if you read it carefully). I do state that by getting a CXR on every pt with a persistent cough you will be zapping a lot of young people with asthma, which is what marcello WROTE. Simply a fact.

"As a physician who sees *both* outpatients (because anyone who has completed an internship in the state of California can work as a primary care doctor in outpatient clinic…"

Because you have done an internship, that says nothing about your competence in the clinic setting. As an example, IMO today's graduating IM residents are usually very competent to become hospitalist's. However, most don't have the strong clinc experience needed and it shows. Let alone the typical american grads pathetic physical exam skills. Most FMG's blow new US grads out of the water from what I can see, very simply because they don't have the technology to prop them up that we have. I assume as a fresh ER attending your clinic experience is less than IM docs correct? Remember, it is one thing to be sitting in an ER/hospital with every modern medical lab test/imaging test at your fingertips. It is a little different to be in a clinic in the middle of nowhere that probably has no onsite imaging and very likely no stat lab capabilities. I am saying this as a doc with decades of experience. I have worked extensively in ER's, clinics, and hospitals. Remember, us lowly non-ER docs were the ones who staffed many/most ER's before the specialty became sexy. From experience I will state that treating asthma or COPD exacerbations in the ER/hospital is easy (even if they end up intubated). It is a little tougher managing these issues in the oupatient setting and thereby preventing them from seeing you. Maybe Mike et al have overcompensation issues, however I also think you suffer from the same problem.

Lastly, I have always lived by the words of Sir William Osler who stated "A physician who treats himself has a fool for a patient.". I am alot more experienced than my PCP, but I let him treat me as he is not nearly as biased. Food for thought.

ER doctor said...

Thanks guys...for proving my point exactly!!

Mike said...

"Thanks guys...for proving my point exactly!!"

No, thank YOU EM Physician!!! Without the gifted prose and fresh insight, we never would have known some doctors are, as you say, A**HOLES!

(By the way, do you kiss your children with that mouth? Sheesh)

Anonymous said...

Nascent ER doc:
The only thing you have "proven" is that you can't listen to other points of view (ironic considering your thread).

PS: That "little man" with "overcompensation issues" who stated "A physician who treats himself has a fool for a patient". Does his name ring a bell? Even a thud?

Anonymous said...

Wow. Flaming blog.

I used work with USC & OHSU Med Schools to teach 1st year med students to take histories. A complete and relevant history CAN be taken in fifteen minutes--even allowing ample time for the patient to express her concerns.

But it cannot be done without listening!

My recent experience: After 4 months ABX and 4 medrol packs for a refractory sinus infection, I began to suspect atypical "walking pneumonia" caused by Chlamydia P, which can present as sinusitis, and which is almost by definition refractory due to the microbe's dual life cycle.

I suspected this because my onset was acute, and it was the one class of ABX I hadn't tried.

Went to urgent care center with apparent relapse, acute facial/eye pain, plus some symptoms of steroid withdrawal--any of which might be emergencies in someone with my history.

This visit was a pageant of arrogant incompetence: My ears were not examined. My throat was not examined. My glands--which were swollen and painful--were not palpated. My nose was not examined. My mastoid processes were not examined. My lung function was not tested. My heart was not listened to.

A chest x-ray was taken, but never discussed.

A blood test was taken, but never discussed--and it was only on demanding a copy that I discovered my RBC was very low and my WBC elevated, suggesting infection consistent with my report.

Instead, this woman ignored the differentials and my symptoms and my history, and the fact that I was on steroids that suppress allergy symptoms, and marching into the examining room to announce, "All your other doctors were wrong." Then she asserted I had "asthmatic bronchitis" and prescribed albuterole and an antihistamine that, with my daily dose of benedryl, might have stopped my rbeathing in my sleep.

When I queried her, she drew herself up and loudly announced, "I am the doctor and you will listen to me!" Had I not been febrile and barely able to stand, I would have replied, "Then why are you ignoring the differential and the opinion of a UCLA specialist to make a diagnosis unsupported by facts or any standard of care published?"

Time management is not a factor in such arrogant malpractice. Nor is years of experience. It's just pure insecurity and one-upmanship. Some docs seem to feel that listening to the patient diminishes their apparent authority. This seems to be even more the case when the patient is well-informed and has a medical background or vocabulary.

Indeed, when I told this physician that my pain was "periorbital" and seemed to radiate from my ethmoid and sphenoid sinuses, she said, "How do you know that? Are you a doctor? Why don't you speak plain english?"

Um, because it is MY body, and I should think I know more about where it hurts than anyone else. And last time I checked, a working knowledge of anatomy was not a crime. Since when is using the appropriate anatomical landmark to locate pain the sole province of doctors?

The examining room is no place for a pissing contest! But until we teach docs to listen--reward them for listening, and punish them for failing to--we're stuck with doctor shopping and malpractice suits.

I was lucky: I had a pretty good idea what the problem had to be, based on my case report and blood counts. And I had the strength to demand the doxycycline. 48 hours later, I'm tired but much better.

Steven said...

Maybe we should do away with Docs ordering tests in general. That way patients can order the tests that they think they should get and then consult a doc if they don't find what they are looking for.
So, what's the purpose of a doctor anyway. If people can order their own tests and interpret them? Maybe we have gotten to the point that there is enough information out there to inform anyone on any condition.
Maybe primary care medicine is obsolete? Maybe all my training and experience was a waste?

ER doctor said...

anyone who is familiar with my blog knows that i'm absolutely not for patients telling us how to do our jobs. i have entry after entry about annoying patients (some i've decided to unpublish to keep myself out of 'blog trouble'), the demoralization of physicians in this "new age" of medicine/lawsuits. i frequently show frustration with 'know it all' patients.

in this (one) entry, i decided to incorporate another (very valid) point of view. that of many patients who do, in fact, have asshole doctors. i'm sure everyone has encountered them (even you)...and they make us all look like uncaring, arrogant, know-it-all bastards.

and we are not. even if we detest the american medical system, the american 'patient', or are just frustrated with losing our ability to practice - it doesn't mean it's okay to stop listening to our patients. it doesn't mean that personality problems shouldn't be addressed...especially when a few docs make us all look bad.

that's what this entry is about. just another side of my typical..."patients are crazy" rant.

i actually understand what you're saying...and i agree...

residentmedic said...

I just subscribed to your blog. Being an R2 and a paramedic, I feel your pain. I try to pattern my actions after, and I know it seems silly, Dr. Greene from ER because he was understanding and caring and firm when needed. I feel like being a medic has really helped to prepare me for ER medicine. I onlt want to be an ER DOC. I hope to stay in contact with you.

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oobob said...

This post is dead on. I mentioned that I hated CPAP and instead got an oral appliance to treat my apnea. They're less effective but used all night, all the time (compared to 4-5 hours nightly with CPAP that's considered compliance). Worse is that they work best in skinny people. My doctors hate it because the CPAP gives them objective medical evidence and isn't 100%. When I told them about the studies I'd read (from the american academy of sleep medicine, though I didn't mention that) they said a lot of those studies have small sample sizes - while hearing 10 minutes before that I was a graduate student in math at the time and studying to take the actuary exams.

They also missed my sleep apnea completely. I had every symptom (GERD, blood pressure, sleeping all day in my medical record, frequent illness, rising A1C in type 1 diabetes, carpal tunnel from both hypoxia related nerve damage during apnea and diabetes) but I'm not old and fat. So I got to diagnose that one and call the neurologist myself. At least he listened and now I have a PSG confirming this. The diagnosing doctor is amazing, only the ones in the CPAP followup clinic were hostile to the use of the oral appliance. Which is hilarious given that everyone hates CPAP and compliance is around 50%.

Doctors forget that the patients are the data. Some are moronic but others read the research in the original journals. And what I've seen makes me realize that maybe 3 doctors out of the tens I've had over my lifetime as a diabetic know anything at all.

I left math for law school. Turns out most doctors sued for malpractice are seen as assholes by the patients. You can fuck up a lot if you're nice.

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