For those who greet doctors with snarls
You should go and read Dr. Charles
He writes with both thought and compassion
And his stories can really be smashin’

And if there’s a poet inside you
But accolades have been denied you
Then send him your very best verses
You patients and doctors and nurses

This contest should give motivation
Your sonnets could win acclimation 
The verse should be healthcare related
And still be poetically stated

This contest is not for the slackers
He’s giving up five hundred smackers!
For those who don’t need him to pay dough
He’ll throw in a cherry tomato.

It’s not our fault

Getting Along (Part 1): Doctor Rules

Favorite

Shame

Dear Insensitive Person

How to Be A Good Patient

Ask Dr Rob: Resilience

Joi De Vivre

An Open Letter to Consultants

These are a sampling of older posts that highlight the fact that I feel the patient, not the doctor, is the center of the universe in the exam room.  I have always said that in this blog, and those who are new here need to hear it again.  I am a primary care doctor who loves his patients (most of the time) and hates to see them treated poorly.  The last post in particular is one I wrote out of total frustration at how my patients were being treated by other doctors.

Thanks for visiting.

Dear Patients:

You have it very hard, much harder than most people understand.  Having sat for 16 years listening to the stories, seeing the tiredness in your eyes, hearing you try to describe the indescribable, I have come to understand that I too can’t understand what your lives are like.  How do you answer the question, “how do you feel?” when you’ve forgotten what “normal” feels like?  How do you deal with all of the people who think you are exaggerating your pain, your emotions, your fatigue?  How do you decide when to believe them or when to trust your own body?  How do you cope with living a life that won’t let you forget about your frailty, your limits, your mortality?

I can’t imagine.

But I do bring something to the table that you may not know.  I do have information that you can’t really understand because of your unique perspective, your battered world.  There is something that you need to understand that, while it won’t undo your pain, make your fatigue go away, or lift your emotions, it will help you.  It’s information without which you bring yourself more pain than you need suffer; it’s a truth that is a key to getting the help you need much easier than you have in the past.  It may not seem important, but trust me, it is.

You scare doctors.

No, I am not talking about the fear of disease, pain, or death.  I am not talking about doctors being afraid of the limits of their knowledge.  I am talking about your understanding of a fact that everyone else seems to miss, a fact that many doctors hide from: we are normal, fallible people who happen to doctor for a job.  We are not special.  In fact, many of us are very insecure, wanting to feel the affirmation of people who get better, hearing the praise of those we help.  We want to cure disease, to save lives, to be the helping hand, the right person in the right place at the right time.

But chronic unsolvable disease stands square in our way.  You don’t get better, and it makes many of us frustrated, and it makes some of us mad at you.  We don’t want to face things we can’t fix because it shows our limits.  We want the miraculous, and you deny us that chance.

And since this is the perspective you have when you see doctors, your view of them is quite different.  You see us getting frustrated.  You see us when we feel like giving up.  When we take care of you, we have to leave behind the illusion of control, of power over disease.  We get angry, feel insecure, and want to move on to a patient who we can fix, save, or impress.  You are the rock that proves how easily the ship can be sunk.  So your view of doctors is quite different.

Then there is the fact that you also possess something that is usually our domain: knowledge.  You know more about your disease than many of us do – most of us do.  Your MS, rheumatoid arthritis, end-stage kidney disease, Cushing’s disease, bipolar disorder, chronic pain disorder, brittle diabetes, or disabling psychiatric disorder – your defining pain -  is something most of us don’t regularly encounter.  It’s something most of us try to avoid.  So you possess deep understanding of something that many doctors don’t possess.  Even doctors who specialize in your disorder don’t share the kind of knowledge you can only get through living with a disease.  It’s like a parent’s knowledge of their child versus that of a pediatrician.  They may have breadth of knowledge, but you have depth of knowledge that no doctor can possess.

So when you approach a doctor – especially one you’ve never met before – you come with a knowledge of your disease that they don’t have, and a knowledge of the doctor’s limitations that few other patients have.  You see why you scare doctors?  It’s not your fault that you do, but ignoring this fact will limit the help you can only get from them.  I know this because, just like you know your disease better than any doctor, I know what being a doctor feels like more than any patient could ever understand.  You encounter doctors intermittently (more than you wish, perhaps); I live as a doctor continuously.

So let me be so bold as to give you advice on dealing with doctors.  There are some things you can do to make things easier, and others that can sabotage any hope of a good relationship:

1. Don’t come on too strong – yes, you have to advocate for yourself, but remember that doctors are used to being in control.  All of the other patients come into the room with immediate respect, but your understanding has torn down the doctor-god illusion.  That’s a good thing in the long-run, but few doctors want to be greeted with that reality from the start.  Your goal with any doctor is to build a partnership of trust that goes both ways, and coming on too strong at the start can hurt your chances of ever having that.
2. Show respect – I say this one carefully, because there are certainly some doctors who don’t treat patients with respect – especially ones like you with chronic disease.  These doctors should be avoided.  But most of us are not like that; we really want to help people and try to treat them well.  But we have worked very hard to earn our position; it was not bestowed by fiat or family tree.  Just as you want to be listened to, so do we.
3. Keep your eggs in only a few baskets – find a good primary care doctor and a couple of specialists you trust.  Don’t expect a new doctor to figure things out quickly.  It takes me years of repeated visits to really understand many of my chronic disease patients.  The best care happens when a doctor understands the patient and the patient understands the doctor.  This can only happen over time.  Heck, I struggle even seeing the chronically sick patients for other doctors in my practice.  There is something very powerful in having understanding built over time.
4. Use the ER only when absolutely needed – Emergency room physicians will always struggle with you.  Just expect that.  Their job is to decide if you need to be hospitalized, if you need emergency treatment, or if you can go home.  They might not fix your pain, and certainly won’t try to fully understand you.  That’s not their job.  They went into their specialty to fix problems quickly and move on, not manage chronic disease.  The same goes for any doctor you see for a short time: they will try to get done with you as quickly as possible.
5. Don’t avoid doctors – one of the most frustrating things for me is when a complicated patient comes in after a long absence with a huge list of problems they want me to address.  I can’t work that way, and I don’t think many doctors can.  Each visit should address only a few problems at a time, otherwise things get confused and more mistakes are made.  It’s OK to keep a list of your own problems so things don’t get left out – I actually like getting those lists, as long as people don’t expect me to handle all of the problems.  It helps me to prioritize with them.
6. Don’t put up with the jerks – unless you have no choice (in the ER, for example), you should keep looking until you find the right doctor(s) for you.  Some docs are not cut out for chronic disease, while some of us like the long-term relationship.  Don’t feel you have to put up with docs who don’t listen or minimize your problems.  At the minimum, you should be able to find a doctor who doesn’t totally suck.
7. Forgive us – Sometimes I forget about important things in my patients’ lives.  Sometimes I don’t know you’ve had surgery or that your sister comes to see me as well.  Sometimes I avoid people because I don’t want to admit my limitations.  Be patient with me – I usually know when I’ve messed up, and if you know me well I don’t mind being reminded.  Well, maybe I mind it a little.

You know better than anyone that we docs are just people – with all the stupidity, inconsistency, and fallibility that goes with that – who happen to doctor for a living.  I hope this helps, and I really hope you get the help you need.  It does suck that you have your problem; I just hope this perhaps decreases that suckishness a little bit.

Sincerely,

Dr. Rob

Post Script: This post has generated a huge amount of conversation and interest (as witnessed by the large number of comments!).  I very much appreciate the dialogue it has spawned both here and across the web.  I’ve subsequently written follow-up posts explaining my thoughts in more detail – largely in response to the comments here.  One of them discusses in more detail my own experiences as a doctor and the second talks of the importance of  knowing and being known.  Reading these will give you a better picture of my thought process and perspective on this.
Dr. Rob

I have no single thing I want to write about today.  I am weary of the obvious topic: the “passage” of the 6-month extension on the SGR, but do feel I need to comment.

I am tired of this.  I am tired of being jerked around by congress.  I am tired of congress hitting the 6-month snooze button and somehow feeling that they are doing something good.  This is procrastination, not a solution.  Reassurances that something will be done are starting to be irrelevant.  The problem is becoming the frustration, anger, and exhaustion that congress is thrusting upon doctors and patients, not the pay cut itself.  The idea of no longer having to deal with the passive-aggressive tactics of congress is becoming increasingly appealing – and if it is this way for me, I am sure it is the same for PCP’s across the country.

At some point the promises of the unfaithful spouse ring hollow.  Yes, things may get better, but that’s starting to not matter any more.  Eventually you just have to break off the relationship, and congress’ recent (in)actions are making a lot of us consider that possibility.  The consequences would be great, but to enable the pathology in Washington may have greater consequences.

Argue all you want that this is “politics as usual,” but I am starting not to care.  Blame the conservatives, the liberals, or the president.  Blame the AMA, the drug companies, lobbyists, or those pesky muskrats.  Pointing fingers won’t make us any less jaded by the process we are enduring.

It has to stop.  Things have to change.

That’s all I have to say about that.

On a brighter note, I just celebrated the first anniversary of my podcast, the House Call Doctor’s Quick and Dirty Tips for taking charge of your health.   Episode 52 was another “mystery diagnosis” podcast, dealing with the common complaint of dizziness.  If you haven’t checked it out, please do.  This blog is not aimed toward patient education (unless they want to learn about llamas); it is a personal perspective on being a doctor.  That is, by the way, why I don’t have guest columnists (except for Dr. Val when she had no URL to call home).

The podcast, on the other hand, is all about patient education.  It is an entirely different medium aimed at an entirely different target.

If you have any suggestions/critiques regarding the podcast, I’d love to hear them.  I don’t get a lot of feedback (except on my Facebook page, but they tend to be “fans” of the podcast).

Finally, let me once again say how disappointed I am in my readership in their inability to come up with pictures of “llama man.”  The few attempts so far have been great, and will earn recognition.  But I must say that I expected more out of you.  Your mother and I are quite disappointed.  We will have to consider just how to deal with this falling-down on your part.

But let me give you another opportunity.  I have recently discovered the blog: Awkward Family Photos, along with its sister site Awkward Family Pet Photos. There was a picture that especially caught my eye, and I want to share it with you:

I want you, my readers, to come up with either a back-story that explains this, or a clever caption.

This should be easy for you guys.

I was going to call this post “shout outs,” but I didn’t want to infringe upon others’ copyrighted material.  This is basically the same thing for me – it’s a post to highlight some great stuff going on elsewhere and to thank people for their kindness, graciousness, and for simply not slapping me.

A String of Great, Nifty, Awesome, and Oblong Adjectives

First, let me give a nod to a few nuggets on the web that I have found.  The first is a blogger named Fizzy (will have to explain the name to me sometime) who has a blog called A Cartoon Guide to Becoming a Doctor.  It is chock full ‘o great cartoons that are very close to what I remember during my torture by humiliation…uh…I mean training.  For example:

Ah, the memories.  Great stuff Fizzy!

Sticking with the adjective theme, the second is a blog about a kitten named Flimsy.  Flimsy is quite enjoyable to young and old alike; my whole family was laughing aloud (LA, as we cool folks on the Internet write it).

I am showing this as an example.  Go over to Flimsy’s website and support this fine artist! Maybe she could do a llama-man.

One more adjective-orented person…or is actually a lobster, Zippy is back!  Hopefully you all remember Zippy, the lobster who is trying to raise money to save kids from brain tumors.  One of the finest writers out there in the medical blogging universe is Intueri, a doc in NYC.  Well, she’s been running a very nice series of posts featuring our dear lobster friend.

Here’s ol’ Zipster in Times Square.  He has secretly communicated to me that he’s very excited to get to see Grand Central Crustacean.  Go over and support Zippy’s cause!  Give generously.  Perhaps he can visit you.

Unsolicited Inclusions

That would be a good band name: And now, back from their world tour in which they grossed more than Kenny Rogers and Slim Whitman Combined, it’s the Unsolicited Inclusions!!!!

I always forget to send submissions to grand rounds, the blog carnival for the medical community.  Yet somehow I have been nicely included in several grand rounds, including one by Grunt Doc and Dr. V’s 33 Charts.  My most recent unsolicited inclusion is on David Harlow’s Blawg Review, a review of law related blog posts!  At first I was afraid I had done something against the law, like included something in an unsolicited manner, but then I realized I was a recipient of the unsolicited inclusion. Imagine my relief.

A Question to the Smart Folks out There

Besides the obvious question: what the heck are you doing wasting your time reading this drivel??? I have a serious question to ask – especially to those who are reading this via RSS reader (freeloaders).  What is your opinion about doing complete posts in the RSS feed.  I have heard conflicting opinions.  I have always sent out my entire posts and have not worried about making money or having people barter with chickens to support me in doing this blog.  I just figure if enough people get hooked on my (llama) subliminal messages, I’ll be able to cash it in eventually and crush (llama) Oprah with my awesome power.

Seriously, I have heard it’s better to send partial feeds to get lots of readers at your blog, but others say it just annoys people to get partial feeds.  Both are probably true, but I’d be interested to hear what smart people think.

A Plug

Don’t forget (llama) to buy some Drug of Choice Coffee for Dad for this upcoming Father’s day.  What better gift can you give than consciousness?

For some reason, the search for “dating patients” as come up a lot on my side bar.  Now it seems that it has generated enough curiosity as to what I say on the issue that people are regularly clicking on “dating patients.”  They are disappointed to find out, however, that I have never written about dating patients.

It seems strange to me that this has happened, as I believe strongly that doctors should not date their patients.  This especially applies to those doctors who are married.  I don’t intend on dating my patients, and I don’t recommend that any other doctors do it either.  There are huge ethical lines that are crossed in this circumstance – especially with long-term patients.  The vulnerability of people in the exam room makes taking advantage of their weakness something that is quite bad.

I am glad I got that off of my chest, although I guess I can’t say that I haven’t written about “dating patients” any more.  I guess I will get even more searches.

——–

On another  subject, I need to ask What’s wrong with you, people??? I asked for pictures of “llama man” with the offer of a coveted Golden Llama award, and I have gotten only two submissions!!  Don’t be afraid.  I want to see your talent (or lack thereof).  Since the GLA’s are handed out by my whims, it is not beyond reason that I will reward particularly bad efforts out of pity.

I am just so disappointed.  Where have your mother and I gone wrong??

——–

And with Father’s day coming up, how about buying dad some Drug of Choice Coffee?  It’s the perfect gift – especially if dad does drugs or works in the medical field (or both).

it’s yumsters.

I was in a local coffee shop and noticed a display for a new kind of coffee:

I was most intrigued.  Drug of Choice Coffee is the baby of a fellow Augustan, who actually publishes a medical periodical (which has even included posts by your’s truly!).  Given the fact that I worship at the java altar many times each day, I thought a partnership was in order.

The coffee comes in three blends:

The first is named after the most famous street in Augusta (on which a certain golf club resides).  The others are just cleverly named.  They come in the jars as pictured above.

Pretty cool.

Drug of Choice Coffee will get a special advertising spot on the blog.  Go on over to their web page and buy your own!

I will be the guest tonight on the Blog Talk Radio show of my blogging buddy, Dr. Anonymous.  There’s no specific topic, but I’m sure I’ll talk blog, podcast, llamas, and perhaps some nuclear physics.  I may even give some cooking tips.

Come by and visit the show.  Tonight at 9 PM (Which is 8 AM Tomorrow in Perth Australia and Ulaanbaatar, 1PM Today in Pago Pago, and 1 AM Tomorrow in Oslo, Norway).

Sorry for the hardship for the folks in Norway.

Be there.  You can even call and chat with me if you like.

Aloha

I haven’t been blogging as much lately.  You may have noticed.  I hear there was great celebration in Switzerland.  The main reason for this is a lack of time.  To sit and write something (especially longer posts, such as the physical exam posts) takes a good amount of time and mental energy, and much of the time I would normally devote to blogging, I am spending writing podcast episodes.

This is not all bad, because I really like doing the podcast.  I like it for entirely different reasons than those that make blogging so fun; the focus of the podcast is education.  The audience is the non-medical population.  Blogging, on the other hand, I do predominantly for myself.  I enjoy voicing my opinion, making people laugh, and having people laugh at my opinion.  Blogging is more play than it is work, while podcasting is somewhere in between.

All this is to say that if you are not listening to the podcast yet, please do (subscribing on iTunes is best for me).  It may even be worth listening if you are a physician or other medical professional, as I write these to address common questions patients have.  I want this to be a tool for docs to be able to get questions answered accurately and easily without necessitating a phone call or office visit.  I want to make things easier for myself, and so would as a consequence make things easier for other docs in my position.

I am also working on a possible book through Macmillan that would be somewhere between the podcast and the blog.  The humor I use in the blog is much more natural for me than spoken humor in a podcast – I had to really refine that humor over time.  Writing a book is back to the blog humor I am very familiar with.  We’ll see.

Another thing: March is our social media push.  I am competing against the other QDT podcasters to see if we can get the most new Twitter and Facebook followers.  If you are not following me on twitter, go to http://twitter.com/housecalldoc, and if you are not following on Facebook, please join my fan page.  I want to show the other QD hosts who rules the roost.  Besides, they are giving out a TV set as a prize.

Don’t worry about the blog.  It’s too much a part of me now to ever give up.  I have about 5 or 6 half-written posts (as opposed to my usual half-witted posts).  I like my readers a lot and enjoy the whole process of blogging.  I just need to hit a new rhythm with my writing.

Just thought you needed to know.