Monday, July 27, 2015

Shopping for a Doctor Who 'Fits' - The New York Times






All newly minted physicians go through a learning curve. They have learned all the ABCs of medical science, and then some.

Life experience comes to us through dribs and drabs if we are fortunate, or it may hit us in the face all at once.

At times physicians must 'unlearn' best practices, ethics, and other ethereal values or face consequences.

At times bad manners, or poor judgment rather than a medical error results in a medico-legal situation. And there are many attorneys willing to help there, on either side.

Shopping for a Doctor Who 'Fits' - The New York Times

Second opinions are a normal part of my line of work. I specialize in rare diseases affecting the bone marrow, and feel privileged both to practice at a hospital where I can focus on these esoteric illnesses, and to be considered competent enough at what I do that people seek my input on their diagnoses and therapies. At the same time, I never discourage my own patients from seeking the opinions of others, as their conditions are unusual and serious, and frequently deserve advice from more than one doctor. It’s what I would ask for if one of my own family members became sick.

But that wasn’t exactly why this woman was seeing me. She had arranged this appointment because she didn’t like her other doctor, and wanted to see if she liked me better.
These kinds of clinic visits have also become a normal part of my practice.
Decades ago, when physicians worked within a much more paternalistic system, such “doctor shopping” would have been considered inappropriate. Your doctor’s medical opinions were considered authoritative, incontrovertible and often final. Patients who challenged them were labeled “difficult,” and worried about developing a reputation that would influence their care, both with their own doctor and with others – as in the 1996 “Seinfeld” episode called “The Package,” in which Elaine is blackballed from being seen in medical offices and tries to steal her own medical records to erase her “difficult patient” status.
In recent years, patients have become more empowered to demand both good care, and a good attitude. Given some of the stories I have heard, I can’t say that I blame them.
One patient recounted how, when she mentioned to her primary oncologist that she wanted to seek my opinion, he told her to take her medical records with her because if she did see me, he would refuse to ever treat her again.
Another patient called me from his hospital room to give an account of his recent interaction with a doctor who recommended a course of chemotherapy for his refractory cancer.
“When I asked some questions about it, she basically told me it was her way or the highway. This is a big decision,” he told me. “I don’t want to go into it lightly.”
I reaffirmed that he, and not the other doctor, was in control of his destiny and treatment options, and reviewed the possibilities with him so that he could make a decision. I then called that doctor to relay his choice, which happened to be what she recommended – but on his terms, where he was included in the process.
Other times the interactions aren’t quite as dramatic, but represent more of a dissonance of personalities. Patients feel their doctors may be overly confident, or not confident enough; excessively nurturing, or too aloof. Alternatively, they simply may not “click.”
It cuts both ways. Doctors may not like some of their patients.
Years ago, I was asked to care for a prisoner who had just been diagnosed with lung cancer. When I entered his hospital room, he was lying in bed in his prison jump suit, his leg handcuffed to the bed’s footboard, as two guards stood by his side. As I explained his diagnosis and treatment to him, he stared at me, unblinking, with hate in his eyes. Every hair on my body prickled until I left his room. A guard who followed me into the hallway told me why my patient was in jail: He had killed his wife using a hammer.
I did not like that patient. But I put my emotion aside and cared for him, without judgment and to the best of my abilities, because it was both my job, and my duty.
I worry that we are increasingly losing sight of why our patients are seeing us. It is not because they want to, but because they are sick – they are hurting, not us. In their moments of need, we should disregard any feelings of indignation if our patients seek the opinion of another, or our disappointment that they don’t immediately accept our advice. We should support them as they make decisions about their own health – even if those decisions don’t include us.
As I walked into the exam room to meet my new consult, I put on a warm, welcoming smile. I didn’t want her to feel the least bit uncomfortable about the reason for her visit. Because this was about her medical care, and not about anyone’s pride.
Dr. Mikkael Sekeres is director of the leukemia program at theCleveland Clinic.

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