Breaking Up With Your Physician
He doesn’t listen. She won’t take your phone calls or return them. She’s distracted and rushed. He always keeps you waiting. He doesn’t seem interested in you and can’t seem to remember important details of your life. She repeatedly interrupts you. She called you by the wrong name. He got mad when you didn’t take his advice. He’s cold and dismissive.
Sounds like the complaints of a husband or wife headed for divorce court, right?
In fact, the same accusations are frequently leveled by disgruntled patients against their doctors, often as they are about to dump the physicians and find someone new.
Although few relationships between doctors and their patients involve the two most loaded subjects in marriage--money and sex--there are other aspects of what social scientists call “the clinical encounter” that closely mimic the dynamics of marriage. To succeed, both relationships require trust, intimacy and honesty.
“In a lot of ways it’s tremendously like a marriage,” said Frederic W. Platt, a Denver internist who has written several books on doctor-patient pairings. “For one thing, it’s a very important relationship, and very important relationships get into trouble easily, precisely because they’re important. When things aren’t good, the intensity of the emotional response is much greater. And the truth is that neither party has been trained or educated in conflict resolution. There is a fear of what will happen if a conflict is brought out into the open.”
Platt and other experts who have spent decades studying what goes awry between doctors and patients say that, just as in marriage, many problems can be traced to a single source: communication difficulties.
Although statistics are elusive, studies have documented that one in four adults will “divorce” his or her doctor because of communication problems. Dissatisfaction with a doctor’s clinical skills or unhappiness with referrals is a far less common reason patients leave.
These departures have accelerated in the last decade, experts say, because patients are more assertive and because managed care has brought new and intense competitive pressures to medicine, a field that had been largely immune to them.
Executives of health plans, alarmed by “disenrollment”--the departure of 10% or 20% of their subscribers annually--are seeking ways to attract and retain patients and to understand the reasons many leave. At the same time, patients--who are being forced into new relationships with physicians whom they often choose sight unseen off a list--are more likely to dump a doctor they don’t like than their parents were.
“The No. 1 reason patients dump their doctors is that they don’t feel listened to or cared for,” said Terry Stein, an internist who is director of clinician-patient communication at Kaiser Permanente Medical Group in Northern California.
“Sometimes it can be as small as whether the doctor has a concerned look on his face or recognizes an emotionally laden moment, by saying, ‘It sounds like you’ve really been worried about all this,’ ” Stein said. “It’s those kind of details that can determine whether someone is going to stick or dump.”
The problem often starts within seconds of a consultation, noted Vaughn Keller, associate director of the Bayer Institute for Health Care Communication, a nonprofit group headquartered in Connecticut that sponsors workshops for physicians.
The scenario goes something like this: A patient starts talking about a problem, which is usually not the most important issue because patients tend to save the things they are most worried about for the end of the visit. Within 18 to 24 seconds, the doctor interrupts and begins firing a series of specific questions at the patient.
“And frequently that’s the only thing that’s discussed,” Keller said. The big issue about which the patient is most concerned never gets addressed, and the patient leaves feeling unsettled and dissatisfied.
But if the physician begins with an open-ended question, such as, “What brings you in today?” and doesn’t interrupt, researchers have found that patients will speak an average of about 2 1/2 minutes and will talk more candidly about what’s bothering them.
Developing communication skills is regarded as something of a frill in medical education, which emphasizes more concrete skills--the “find it and fix it” approach. Yet communication is emerging as an issue of paramount importance in health care.
“There are a lot of studies showing that communication is strongly related to patient satisfaction, health outcomes and even malpractice litigation,” Keller said. Patients who feel they can talk to their doctor are happier with their care, fare better medically and are much less likely to sue their doctor, even if he or she makes a serious mistake.
They are also more likely to stay with their health plan. Studies have shown that dissatisfied patients are not only more likely to divorce their doctor, but also more likely to dump their plan in the process. And that finding has made patient-doctor communication a buzzword in the ferociously competitive world of managed care.
“HMOs typically lose 10% to 20% of their patients every year, and most businesses could not survive with that kind of turnover,” said Mack Lipkin Jr., director of primary care at the New York University School of Medicine and a consultant to several major health maintenance organizations. “Managed-care plans are very concerned about retention, and they study these things a great deal.”
“As plans are less able to compete on cost,” Lipkin said, “they are increasingly competing on satisfaction with the doctor-patient relationship.” Many health plans give doctors report cards based on patient-satisfaction surveys, a practice pioneered by Kaiser Permanente in 1994. At Kaiser, doctors with low grades may be required to attend an intensive, weeklong retraining course designed to sharpen their communication skills.
Experts say that these skills are teachable but that changing behavior is difficult in the high-stakes, high-pressure world of medical practice.
“These are very entrenched behaviors,” said Stein, who oversees Kaiser’s physician communication retraining course. Pleasing patients requires entirely different skills than those prized, or even observed, during the long, grueling years of medical training, she noted.
“Doctors are selected for being aggressive, for being good test-takers,” said Los Angeles pediatrician Barbara Korsch, who has spent 30 years studying and writing about doctor-patient relationships. “They go through the whole brutalizing experience of medical education where being too sensitive is actively discouraged, especially in women, and where a certain suppression of feelings is required in order to function. Some of those doors you close early in your education may be difficult to open later.”
