A Doctor's Life

You're probably wondering where the long, brilliant, and eye-opening post for this week is?

Well, this week Dr. D worked 72 hours in the ER. I realize for some docs this is a light week, but as someone who doesn't actually like medicine this kind of week kicks my ass. I only saw my son awake once this whole week.

Ah, the glamorous life of an MD!

But enough bitching by Dr. D... I have a great post I'm preparing for you. I want to take the time to write something brilliant rather than giving you a crappy rough draft.

Stay tuned!

Teaching Empathy (Fit Doctors and Sick Patients)

A reader asks:

My doctors are all very fit. It would seem that being a doctor is so demanding that it requires good health. Can doctors ever really understand what it's like to be ill?

Of course, doctors understand illness! We spend our whole lives studying it! ...but if you mean personal understanding of what it is like to feel your body betraying you, or the dread of approaching death, or the strained relationships created by severe illness—actually, most of us have never been there.

With a few notable exceptions, most people able to dedicate a dozen years of their prime to the punishing ordeal of becoming a doctor have always been pretty healthy in body and mind.

The worst Doctor D ever felt was a moderate case of sinusitis. I have no idea what how it feels to be in daily pain, to be unable to walk, to face death.

The Need For Empathy

So how do doctors, who are rarely sick, relate to ill patients?

Often poorly ...but if we do relate well it is through empathy: the emotional intelligence that allows us to experience the feelings of others. Doctors must learn the true experience of illness from our patients. Doctors may teach patients the science of disease, but in the experience of illness patients are the teachers and doctors are the learners.

Unfortunately, life in the medical business strains one's empathy. The sheer volume of suffering we see can make us numb. There is also the professional objectivity that we fear will be compromised if we care about your pain too much. Empathy may atrophy till a fit physician can diagnose and treat all day long without connecting with a single ill person in a humane, healing way.

Teaching Empathy

You—the patient—must teach the doctor. Empathy is a lesson physicians desperately need to learn. But how can you teach your MD?

The Direct Approach: Speak directly to your doctor about how uncomfortable your symptoms are and how miserable your illness makes your life. Remind your doctor about how horrible it is regularly, just to make sure they don't forget.

Hate to break it to you, but the direct approach doesn't work. In fact, it has the opposite effect. The more someone talks about their suffering the less we identify with it. Yes it's cruel, but it's human nature.

Remember when you were a kid and that elderly relative complained incessantly about their horrible bowels or joints? Chances are your grandmother really was miserable with those symptoms, but how much did you really empathize with her? Not much right? You just wanted her to stop complaining. It's called “compassion fatigue” and it has infected every doctor by about the 2nd year of medical school.

(By the way, I'm not saying you shouldn't tell your doctor your symptoms and how they affect you. Just don't expect compassion as the natural response to your discomfort.)

The Indirect Approach: Tell the doctors your symptoms and cooperate with them to diagnose and manage your disease. Only mention your miserable experience in passing. Instead, ask about how your physician is managing the stress of his or her life. Your doctor likely has a lot of frustrations despite their healthy body. Even if the doctor's problems seem petty compared with yours try to act like you care that it sucks to miss sleep or leave family dinner to care for a patient.

Believe it or not, this is the best way to teach empathy to doctors. The doctor will empathize with you instinctively.

We all naturally focus on our own sorrows and minimize the suffering of others. We awaken to empathy when we see that others care for us.

Doctors are educated in a system that only cares about how much they know and how hard they work. Few of their teachers care how they handle our rigorous training or the suffering they see. Doctors learn that feelings don't matter.

A caring patient's interest in a physician can teach more empathy than watching a whole world of suffering.

Doctor D has been told by patients that he is a caring physician. If so, it isn't because he has ever been ill himself, or any illness he's seen. It was because my first year of residency a patient with a miserable disease actually made an effort to find out about young D and encourage him. With an education like that how could I not want to understand the experience of every patient I met from then on?

What do you think? Is Doctor D too cynical about human nature? Have any patients out there had success with the “indirect approach” for teaching doctors to empathize? Healthcare people: Has a patient ever taught you empathy? Doctor D always loves to hear your thoughts and stories!

Why Do Incompetent Doctors Flourish?

Last week Doctor D answered this question in a way that made him sound like a frickin' hero:

How do doctors deal with colleagues that they know are incompetent?

Now that you all think I'm awesome, I have to make a confession: I have looked the other way a lot more often than I have saved the day.

Doctor D has known some bad doctors over the years. I don't mean doctors that make errors—we all do that sometimes—but doctors that flagrantly disregard patient safety and don't give a damn about right practice. And Doctor D usually kept his mouth shut.

The code of silence started early...

Doctor D's first run-in with reckless care was as a first year med student. D was working with Dr. Subethical who happened to teach the medical ethics class. Dr. Subethical who seemed so cool in class spent most of his clinic time screaming at patients and dictating physical exams he didn't perform. Lowly Medical Student D thought that this didn't seem right, but he never confronted Dr. Subethical or filed any complaint. Young D figured he must have just misunderstood the situation. Also Dr. Subethical was an honored professor while D was just some lowly student who didn't want a target on his back.

MD's usually have more power and more knowledge than their patients and other healthcare providers. This often keeps patients, med students, and nurses from confronting doctors. So it falls on other doctors to keep an eye out for bad care among our colleagues.

Unfortunately, we doctors do a terrible job policing each other.

Young D always kept his mouth shut in medical school, but he told himself that when he got that MD with some power and knowledge he would set the world right. He would stamp out crappy care and save the world from low-life doctards! Yeah, well old habits stuck around. D's been out of medical school for a long time now, and has seen quite a few doctards, and his number of confrontations thus far is a grand total of... one! To be honest, Doctor D only whooped some doctard ass at Crayzee Clinic after having incompetent care shoved in his face month after month till he couldn't ignore it anymore.

So in this anonymous blog Doctor D confesses:

"Hi I'm D, and I have turn a blind eye to bad medical care."

Doctor D's readers all gasp and shake their heads.

"But wait, I can explain!"

There are lots of reasons good doctors are always letting the bad ones off the hook:

• Nobody Likes Tattletales: You might assume that Doctor D's heroic battle with Crayzee Colleague looks good on his resume. Nope! D has a big FAIL stamped right across his forehead. Nobody wants to work with a goody two-shoes who rats out his buddies when they break the rules. Even the excellent docs got kinda distant while I was fighting Crayzee Colleague. If I called out bad doctors wherever I worked before long I wouldn't have a job.

• Nobody's Perfect: Our culture expects perfection from doctors. Of course, we all make mistakes, and many of us live in dread of errors. We want people to forgive our mistakes so we are willing to accept that other docs make errors too. Now there's a big difference between understandable human error and the doctard who makes a habit of flagrantly and willfully doing stupid shit. Unfortunately, this unspoken "culture of forgiveness" in medicine protects the guilty as well as the innocent

• Everybody Hates Lawyers: Every MD lives in constant fear of a malpractice case, which is a professional and personal catastrophe. We usually keep our mouths shut about bad care because discussing possible malpractice is taboo. If you accuse a colleague of malpractice you might as well send the poor schmuck in front of a firing squad. There just isn't any safe environment where we can confront other physicians. It's ether shut your mouth or throw your colleague to the dogs.

• There's More Than One Way To Skin A Cat: Every doc remembers that abusive attending in medical school that yelled that there was only one right way do do medicine, which happened to be his way. Later we learned there are a lot of different right answers in medicine. Every doc has a different treatment style. Nobody wants to grow up to be that jerk that attacked others' legitimate care because it wasn't the way he did it. So sometimes when we see obviously bad care we shrug and say, "Well that's not what I would do, but maybe it's just a different approach?"

• Second Hand Information: Most of the bad care I know about is hearsay. I usually don't have time to sit around and watch my colleagues practice. I hear things from patients or read charts that sound concerning, but I wasn't there. I tend to give other doctors the benefit of the doubt: "Maybe there's a good explanation for this?"

• We Expect Lawyers To Do Our Dirty Work: Every good doctor can probably think of an incompetent doctard who they secretly hope will get destroyed in a malpractice lawsuit. (Yep, Doctor D is thinking of one right now.) Malpractice is horrible, but some doctors deserve it. Why should we waste our time confronting bad care when lawyers will take out the garbage for us? Unfortunately, this is a total cop out. Malpractice does a terrible job policing medicine. First of all, the lawyers and juries don't understand medical care very well. Second, lawyers don't bring malpractice cases to improve medical care. Lawyers bring malpractice cases to hit the jackpot. The malpractice system creates a mad scramble where big money gets awarded or denied based on the lawyer's cleverness or the jury's mood, rather than the doctor's competence. Good doctors are often screwed while bad doctors get off on legal technicalities. Malpractice doesn't really improve medical care—it just makes doctors afraid to discuss bad care.

Of course, all these are just lame excuses. Doctors should step up and call out the bad ones who are endangering patients. Doctor D can think of a couple that need to be set straight, but after his adventure at Crayzee Clinic he isn't too eager to try any more heroics. He's keeping his mouth shut and venting anonymously on his blog.

So Doctor D has taken the first step: he admitted he has a problem. Any ideas for 11 more steps that could motivate D and the other good doctors out there to remove the incompetent doctors from their midst? I've got no answers on this one.

This is an intervention!
Your favorite blogging doctor has a serious apathy problem, but he is totally unmotivated to change. Use the comments section below to convince Doctor D why he try to be a hero again when the first time was a big fail!

The Battle Against Incompetence

A while back Nurse K asked a really good question:

How do doctors deal with colleagues that they know are incompetent? Keep your mouth shut? Frank discussion with the medical director? Anonymous letter?

Doctor D has two ways of answering this question. One makes him look really awesome, and the other exposes him a part of the problem. Doctor D will start out all the heroic stuff and then tell you more in the next week:

Doctor D once worked at a place called Crayzee Clinic, because he really wanted to practice primary care in an underserved community. (What a saint! Let's give Doctor D a Nobel Prize or something!) Unfortunately the clinic came with a partner we shall call "Crayzee Colleague."

Now Crayzee Colleague was pleasant enough, but the medicine she practiced didn't even remotely resemble proper standards of care. Doctor D, being the totally nice dude that he was, thought maybe Crayzee Colleague was just behind the times and hadn't heard of the cool new stuff doctors have been doing for these last fifty years. D mentioned his concern in the gentlest possible way, but would you believe it, Crayzee went nuts! She called D a "young doctor who doesn't know shit."

So Doctor D printed out some info for Crayzee Colleague on how medical care is done in this century to prove that he isn't the only one who believes in things like vaccines, mammograms, and such. Unfortunately nothing changed about Crayzee Colleague's incompetent care.

Doctor D was worried because he shared patients with Crayzee Colleague and the stuff she did wasn't exactly safe. From time to time he sent her pleasant little notes reminding her about sensible medical care as he was cleaning up her disastrous work. After a few months of this our hero realized Crayzee Colleague had no interest in changing anything.

Since Crayzee Clinic was federally funded, Doctor D figured he should go up the ladder and speak to "The Man." The Man isn't a doctor, but he has a fancy title, sits behind a big desk, and supervises a whole lot of doctors. D figured his colleague would surely listen to The Man. So D informed The Man that he was very worried about Crayzee Colleague's care. The Man said "Doctor D you are right. Crayzee should step up her game."

And then nothing happened.

Crayzee Colleague kept providing downright dangerous care, ignoring D's still friendly but increasingly firm reminders to at least try to practice something resembling primary care.

Finally, Doctor D had enough of Crayzee Colleague doing dangerous shit to his patients. He blew the whistle as loud as he could. He warned every healthcare bureaucrat he could find, "Look, if Crayzee Colleague keeps doing this stuff that endangers patients I will resign from Crayzee Clinic and tell every patient I see on my way out that I'm leaving because the care here is a treat to public safety!" And still nothing happened.

So Doctor D did exactly as he had threatened he would.

At the end of our story The Man's bureaucracy remained intact, Crayzee Colleague was still at the clinic, and Doctor D had all his principles but no job in the middle of the Great Recession.

...but Doctor D is still proud he opened that can o' whoopass on medical incompetence as well as The Man and his Crayzee Clinic.

Please feel free to praise the fearless Doctor D in the comments section! Get his ego good and inflated because next week he has to make some confessions that will disappoint you.

Who Determines Quality Of Life?

This is an interesting question Doctor D found in a discussion going on at the Serenity Now Hospital blog.

Quality of Life is the concept that medical care should focus not just on the number of days our patients live but the amount of meaningful and fulfilling health within those days. Patients will often sacrifice length of life for improved quality of life. Some patients also decide that in the face of a life-threatening illness they will not have further treatment once their quality of life falls below a certain level.

Reflecting on quality of life helps doctors recognize the humanity of their patients. It helps us realize that that longer life isn't always better. At its best, quality of life allows the patient to decide how they approach illness and disability, while the doctors respectfully relinquish control to the patient's wishes.

Doctor D believes that quality of life cannot be determined apart from the patient's personal values and preferences. Many doctors, however, make quality of life judgements about their patients. Often physicians embrace the concept of quality of life without acknowledging that it is a personal decision that belongs to the patient not them.

On the post "Compassionate Death?" Doc Sensitive relates the story of an attending that decided not to treat an elderly man with dementia due to the attending's belief the man had no quality of life. The attending allowed the patient to die comfortably and untreated without ever trying to find out the old man's desires or contact the man's family. Doc Sensitive wonders if this was the right way to handle this patient?

The discussion after the post is also interesting. (Doctor D threw his 2 cents worth into the conversation too--It's the 3rd comment down.)

What do you think? Would you be comfortable with a doctor making a quality of life decision for you if you couldn't speak for yourself? Do you think Doctors are the right people to be making quality of life decisions? Do accounts like this make you more likely to get a living will or discuss your wishes with your family?

Doctor D will be back soon with more answers to your questions.

Picking a Doctor (Finding a Doctor: Part 2)

Now that you have some idea what style of doctoring will work for you, it's time to actually get an appointment.

This is not Doctor D's area of expertise since he is usually on the "getting picked" end of such things, but he has tried to find doctors for enough of his own family to appreciate that this can be a tricky step. Usually you are stuck staring a a long list of unfamiliar names from the phone book or insurance company. The best way to pick a doctor is to consult the experts in your community: retirees and soccer moms.

These people know stunning amounts about every doctor in a 5o-mile radius since they spend several hours a day discussing every doctor visit they or their friends have had in the last few years. So just saunter up to an Oldsmobile or minivan and show them your list. You'll have to sit through long stories about constipation or little Johnny's ear infection but you'll hear a lot about the names on your list.

A couple things to remember about the advice you get:

• The doctoring style that worked for Harold or little Johnny may not work for you. (Like Ms. Smith from last post) Pay more attention to what they say the doctor said/did more than how they liked or disliked the doc.
• Even the best of doctors (even Doctor D) will sometimes have patients that dislike them. A complex doctor-patient relationship sometimes doesn't work even with good doctors and patients. Don't avoid a doc just because one person hates them. (But if everyone hates them don't go, unless you just want another jerk in your life.)
• Be careful when you hear effusive praise being poured on a doctor. Don't take it too seriously. Anyone who thinks their doctor is the best thing since sliced bread probably has a few screws loose. Doctor D's weirdest patients have sometimes been the ones that fell all over themselves saying he was the answer to all life's problems, when he hadn't done anything for them.

So with those things in mind circle one on your list and get an appointment. We'll talk about what to do at that appointment in Part 3.

Read the "How to find a Doctor" Series

Types of Doctors (Finding A Doctor: Part 1)

Magda asked how to find a new doctor on this post. She likes her current Primary Care doctor but wonders what she will do when he retires. This is a big question so I'll answer it over several posts:

First, you need to figure out what style of doc you need. Every MD has his or her own style of relating to patients. Knowing what sort of doctor you would work with best will help you choose the right one for you.

Of course doctor is special like unique snowflakes etc... but Doctor D has broken it down into five basic doctoring styles he sees often. Some doctors may combine several styles. Doctors often don't really know what their style is (Doctor D isn't sure where he fits on the list) but the doctor's patients can always tell you.

Five Doctoring Styles:

1. The Drill Sergeant: Gives orders and expects absolute obedience. The drill sergeant is very confident and knows more about your body than you do. These doctors won't take any crap from you or anybody else. This meanness can come in handy since drill sergeants go ballistic on anyone who messes with their patients.

   • Pros: Some patients need no nonsense firmness to get results. If you trust doctors and need to be pushed to live healthy this doctor might work for you.
   • Cons: They tend to be abusive. Your opinions and feelings really don't matter to drill sergeants.

2. The Parent: A warm, wise parental figure who watches out for you. Parent doctors want to know how you are doing and want the best for you. Parenting style medicine is more common in older doctors. These doctors kindly guide you to the healthcare decisions that they know are best for you.

   • Pros: Parent doctors are often the nicest physicians.
   • Cons: You will likely be treated like a child. The parent doctor will often make your decisions for you.

3. The Buddy: Treats you as an equal, wants to be your friend. The Buddy doctor lets you make your own decisions and just wants to help. These doctors worry a lot about whether you like them. Buddies may give you a treatment because you want it, even if they don't think it is the best thing for you.

   • Pros: Works hard for you and treats you with respect and kindness.
   • Cons: May not give you difficult facts or ask hard questions. Sometimes passive-aggressive.

4. The Consultant: Treats your relationship as strictly professional. The consultant's role is to give you information and provide you with treatment options. You make all the decisions. The consultant is just there to answer your questions should you have any. Consultant doctors may overwhelm you with options and the pros/cons of each. They tend to be neither angry nor friendly, but always professional.

   • Pros: Informative, always professional. Consultant doctors don't get emotionally involved which means less drama.
     
   • Cons: May overwhelm you with facts and options without much guidance. As long as you are making informed decisions it's no skin off the consultant's back if you live or die.

5. The Mechanic: Sees your body as a machine that needs tune ups and repair. The mechanic doctor doesn't really recognize you as a person at all. Your medical issues are all mechanical problems to be solved. Don't expect a mechanic to talk to you much. They may speak about your body, but usually this is the doctor talking to himself in medical Latin that you probably won't understand.

   • Pros: Usually very intelligent in a scientific way. Who needs human interaction when you can have a robot doctor?
   • Cons: No real relationship. You probably won't understand a lot of what the mechanic doctor is doing for you. You could ask but the answer usually won't be in plain English.

Next Post we'll look how these doctors would work with a particular patient: Ms. Smith

Read the "How to find a Doctor" Series

Can you help me with my Doctor-Patient Relationship?

Yes! That's actually why I started this blog.

Think of me as the relational therapist for your doctor-patient relationship! Heck, you can use me as your counselor for your relationship with the medical system in general. Doctor-patient relationships can be full of miscommunication, mistrust, unspoken expectations, and emotional baggage from past relationships. This kind of stuff dooms romances all the time, but when it messes up your medical care it might significantly damage your health.

To make things worse a lot of doctor-patient relationships are arranged marriages (by insurance companies) or random couplings (the doctor that is on-call the day you need care). You may prefer to stay single, but sooner or later you'll need one of those jerk doctors and Boom! ...you are in a relationship. As Doctor D's wife can attest, relationships with doctors can be tricky!

While he is an excellent physician, Doctor D cannot be your personal physician over the Internet. Long distance relationships just don't work out for him. But he is offering to be that guy that understands both you and your significant other and gives some sage advice.

Is Doctor D doing this out of the goodness of his heart or because he is a glutton for punishment? He doesn't know either. Perhaps Doctor D should see a therapist about this, but until then send in those questions!

E-mail Doctor D

Why Are Doctors Such Jerks?

Let's start with a question I know that you have been wanting to ask:

Why are so many doctors jerks?

Excellent question! As any nurse will tell you, doctors are notoriously difficult to work with. We doctors have a much higher percentage of jerks among us than the general population. Even Doctor D (on very rare occasions) has been known to be downright ornery towards patients. There is a epidemic of condescending, difficult, foul-tempered doctors, and you the patient are the one who suffers!

Some doctors have been jerks their whole lives. Maybe they weren't hugged enough as babies. These docs just love having a position of power so they can make others feel small. Such natural-born jerks can be found in any profession, and just one of them (especially as a customer service representative) can make anyone's day miserable. Such doctors will never change. It is best to avoid them whenever possible (unless you need surgery).

But the relatively few natural-born jerks in the world just aren't enough to explain the over-abundance of jerk doctors. This only leaves one explanation: many doctors become jerks by becoming doctors.

The number one reason everyone says they want to go to medical school is "to help people." Believe it or not, we were all once innocent wide-eyed young medical students who really cared about you.

Then they fed us through the decade long meat-grinder of training involving sleep deprivation, endless memorization, calling patients by their diseases, and getting yelled at regularly by our jerk-doctor teachers. At first we hated those other jerk-doctors, then we felt sorry for them. We worked till we were dead tired, and then got told heathcare is cutting back so we had to do the same work twice as fast next time. Patients expect us to work miracles after watching too much TV, and don't see any reason for dieting or quitting smoking since our purpose in life is to cure everything. Despite our good intentions people keep destroying themselves with bad habits, and nice people keep dying, and everyone is angry we can't turn them back into twenty-year-olds. Add to that lawyers promising irritated patients that they can hit the jackpot, if they just sue jerk doctors--It is enough to turn even the nicest medical students into misanthropic bastards.

As a patient that just wants to get your check-up none of this is your fault, but you are going to bear the brunt of this. Your best bet is to look at your doctor, and try to imagine him/her as the kindly, altruistic, and terrified student that showed up on that first day of medical school. Somewhere in your doctor lurks that annoying humanitarian impulse that doesn't die easy.

Look your doctor straight in the eye and say, "Doc, I really appreciate you taking care of me." Only say this and nothing else! Under no circumstances then ask for something or launch into a list of every odd symptom you had in the last year. Just say something nice and leave. A jerk-doctor hasn't seen human kindness and generosity in years might just feel a warm spark of caring in his/her cold heart. Doctors have a bad habit of forgetting we work on real people. Suddenly you become a real person and not just a patient. Trust me, doctors actually care about real people. You just have to remind your doctor that real people exist.

Who knows, your doctor might even be nice to the nurses after seeing you?

Any Questions?

The Doctor Will Take Your Questions Now

The American Healthcare System can be a bizarre and confusing place to find yourself. It's nice to have a friend on the inside who can help you understand how things work here. Thus Doctor D created this blog to help you navigate the weird world of doctors, clinics, hospitals, and such.

Doctor D can't diagnose or treat you over the internet (so don't even go there) but what he can do is help you make sense of your doctor or help out with that question about the strange world of medicine that has been gnawing at you.

This blog is just getting started and what it obviously needs is questions. So send them in!

Ask Doctor D (at) gmail (dot) com