When the Patient Suffers From a Fear of Speaking Up

The waiting room was full. I was working the treadmill--seeing a packed schedule of patients assigned to me in a managed care clinic. I only had 10 minutes to see my next patient. That was ample time, however, to help Helen (not her real name) with her concerns about her skin.

For her mild acne, I prescribed two creams that helped dry the oily areas on her face. For a few patches of eczema on her arms, I prescribed another cream and gave her instructions to moisturize, moisturize, moisturize.

Helen seemed satisfied with the treatment plan. And we still had a few minutes left--enough time to explore and answer Helen’s additional questions about her seasonal allergy symptoms and to prescribe an antihistamine that wouldn’t make her sleepy.

Summarizing the visit’s advice, I tucked her chart under my arm and stepped toward the door, extending my other hand to her with a warm smile.

“Thank you for coming, and please come back and see me again if things don’t improve.”

I had barely reached the door before I heard the three words that spell chaos for a busy physician’s schedule.

“By the way . . .”

I turned, mentally calculating how I would juggle my afternoon schedule to keep my waiting patients from mutinying. For I knew that, as always, those three words would lead me and my patient toward the real reason for her visit--the problem she had not mentioned until now, the reason we needed those valuable minutes to explore.

”. . . I collapsed last week.”

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Helping Helen that day took me and my associates over an hour. The differential diagnosis (the list of possible causes) was long and serious, including problems with the brain and nerves such as seizures, heart rhythm disturbances and abnormalities in metabolism such as low blood sugar. The evaluation eventually led to a relatively more comforting conclusion. Helen was suffering from exhaustion and stress. Her treatment plan included counseling services and rest. Unfortunately, the stress levels of my waiting patients were magnified by the delay.

Helen wasn’t alone in her reluctance to bring up her most critical concerns at the beginning of the visit. It’s understandably difficult for most people to bare their feelings and worries to a stranger. It’s even harder when the doctor is perceived as a figure of authority, who, patients fear, may criticize and judge them. It takes time to build the trust that allows folks to comfortably share their innermost thoughts and secrets.

Often much longer than 10 or 15 minutes.

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Even with a familiar doctor, it’s tough for patients to know what to ask. When I take my car to the dealer for repairs, I haven’t the foggiest idea whether the rattle in the thingamajig is more serious than the clang in the whatchamacallit. I list my questions for the service manager and hope that he’ll be able to keep the vehicle running--for a not too unreasonable cost.

My goal as a doctor is to do the same for my patients’ “vehicles,” though I do wish that our bodies’ Manufacturer had provided us with an owner’s guide or repair manual to aid in the task. I encourage my patients to mention all of their concerns, since I don’t always know at first which of them may turn out to be serious or related to the reason behind the visit. If I sense discomfort in discussing sensitive or potentially embarrassing subjects, I try to reassure my patients that, like most doctors, I’ve “seen and heard it all,” and have been trained to help, not judge.

Then, my patients and I agree to an “action plan” for diagnosis, treatment and follow-up. I prefer to work alongside my patients as a resource, rather than be expected to provide authoritarian direction (common in generations past, less so today). Together, my patient and I can address his or her needs, and make arrangements for further evaluation and follow-up visits if indicated. Even in the most demanding managed-care settings, some of which allow as little as five to six minutes of contact time per visit between doctor and patient, similar efforts to prioritize concerns and temporize the less-acute issues can allow for reasonable health care service.

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But it is you, the patients, who can have the most immediate and effective impact on the services you receive. As health care consumers, you should be assertive about your needs and expectations, and take advantage of your voting and buying power when choosing and working with health care plans.

Help your doctor help you by prioritizing your concerns before your visit. If you think your issues will need a substantial amount of time to address, ask for more time when you make your appointment. Most doctors can make advance arrangements for longer visits. When you and your doctor finally do meet, bring up your most important worries first--and if you’re not sure what’s most critical, let your doctor help with the list.

And, please, don’t hesitate to be open about worries and concerns, especially in the arena of emotions, feelings, sexuality and psychology.

Mindful of my experience with Helen, I now follow my greetings to my patients with an honest, “We only have 10 minutes. Please tell me how I can best help you with your most important concerns.”

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Claire Panosian Dunavan is on vacation.

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Linda Reid is a pediatrician currently practicing primary care in Los Angeles. Doctor Files appears the fourth Monday of the month.