A Patient gets what She Deserved... she had it Coming to Her!

Being a doctor can be hard, and giving patients what they deserve can be even harder. Patients can be needy, demanding, hard to deal with and harder to please. We have many more patients than we do patience. How we respond under stress says a lot about us.

Long hours, job pressures and difficulty communicating can stretch doctors to the breaking point, especially doctors in training. Work hours for doctors in their years of specialty training are pretty intense. When I was a resident physician, it was common to spend over 100 hours a week at the hospital. We were “on call” every 4th night, and call days typically ran from 7 am until at least 5 PM the following day. On that day after a call night, most residents passionately worked toward a single goal- getting done with their work and going home to bed.

This explains the intern's response when, as a senior resident, I paged him to discuss the care of a woman who he had admitted the night before. As the senior resident it was my job to oversee all of the patients cared for by the hospital team. It was 4 Pm, and I had just finished reviewing the admission notes for the elderly woman who he had admitted to a bed on the medical floor. In the intern's notes he had listed hyponatremia (low sodium in the blood) as one of the patient's diagnoses. Typically this notation would have been followed the cause if known, or if unknown possible causes and the tests ordered to identify the cause. Instead his explanation of the low sodium was simply- “cause unknown.” Nothing more was written.

While he may not have known the cause at the moment he wrote the note, a list of possible causes was available in any reference book, and it includes a number of potentially serious conditions.

Perturbed at the lack of thoroughness on his part I got him on the phone. I remember the conversation vividly.

“Hey Scott, what's with this “cause unknown' garbage in your note?” I asked with my trademark tact.

“I didn't know what the cause was!” was his reply.

“So look it up!” I said

"Okay, I'll do it tomorrow."

"No, you will do it now."

"But, I am post call!'

"Not my problem. This woman is in our hospital and deserves the very best medical care. If that means you stay until 10 o'clock, then you stay until 10 o'clock. We don't cut corners!"

"Fine!" he bellowed as he hung up. Boy was he mad.

At the end of the year at the graduation ceremony he sought me out. He shook my hand and said with a smile, "Thank you for making me good." I still get a warm feeling inside remembering the moment. I am still a demanding teacher, harder on students and even harder on myself. People deserve our best effort.

Doing our best and giving our all is a value that seems to be vanishing from society, even from the medical profession. I pray it will always remain a part of my practice.

6 things you know that your doctor doesn't

We doctors may be intelligent but we are not always smart. Some things that are obvious and well known to our patients completely escape us. Here are some important things you know that we probably don't.

1- Our explanations are so confusing that you have no idea what we are talking about.

We think you understand us, but we are often wrong. We are so accustomed to using big words and medical terms that we can talk for 10 minutes and not say anything that makes sense. I recently observed a student interview a young patient about migraines. She asked, "Do you have an aura?" The patient replied, "No." I then asked the patient if he knew what an aura was- "Nope!" He had no idea! This kind of  poor communication is common. Tell us when you don't understand. You deserve an answer that makes sense.

2-How much your medication costs.

Medication costs vary widely and many doctors have no idea how expensive a prescription is. I have seen patients pay $115 for a prescription at a major chain pharmacy that could be purchased for $10 at a discount store. I have also seen dermatologists prescribe an expensive brand name acne antibiotic instead of a generic version of the same medication. The difference in cost- $900 a month! The dermatologists had no clue! Tell your doctor when your medication is expensive and ask for other options.

3- How rude or nice the office staff is.

Doctors are often very poor business managers. They are frequently unaware of the customer service provided by their staff. They probably don't know how long you were on hold, how abrupt the staff was when you arrived, are how long you waited before your needs were addressed. Before leaving and finding another doctor (with equally rude staff), let your doctor know how you are treated.

4- Your Name

This one is embarrassing. I frequently encounter patients while out at the movies or shopping. Many times I am better at remembering diagnoses and medications than I am a patient's name! On more than one occasion I have made my wife hurry down a different store aisle to avoid seeing a patient whose name I could not recall! Be kind and reintroduce yourself!

5- What your insurance covers

Most doctors contract with multiple insurance plans, all of which have different rules, provider networks and conditions for coverage. We just can't keep up with it all. You may be more likely to know which lab to use, what hospital to go to or what your co-payment is than we are. It is wise to confirm with your doctor or insurer before getting tests or X-rays done or before seeing a specialist.

6- How worried and frightened you are

We deal with illness every day. You don't. As a result we may forget how frightened you are of a serious diagnosis. We sometimes say things like, "We want to make sure it isn't cancer," and think we are being reassuring. What the patient hears is-"You might have cancer!" Fear and panic may set in. Cancer may be low on the list and we may just be being thorough, but our words cause needless worry. If you are worried or fearful, tell us! 

 We are doctors and we are educated, but we are still people, with all of the limitations that come with being human. Communication is a common weakness. Our patients are uniquely equipped to help us do better, because you know things we don't!

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An annoying patient... how should I respond?

I received an email from a patient over labor day weekend. It read, “It is totally my fault for not scheduling sooner, but my son needs a sports physical so he can participate in workouts this week. I don't want to take him out of class, so I would like an appointment after 3:15.”

My initial response was. “Seriously?”

The schedule was already packed. I only had 3 afternoon appointments left for the short week, which would certainly quickly fill with patients who had unexpected needs such as illness or injury.

I issued a prompt denial via email saying I did not have any openings, defending my stance by reasoning, “It's her fault, she failed to plan!”

That, to me, was the issue. She made the mistake, and now she was asking my office staff and I to bail her out. I was miffed, and I replied to her message saying we did not have any afternoon appointments available. I marinated in my miffed-ness for a few hours, and then realized that my schedule really was a mess. I looked again at the schedule for the week and saw that I needed to add appointments. I did not have enough openings to meet the normal demands of a short post-holiday week. I told the staff I would give up my Wednesday morning off. Since I then had 10 extra slots for the week I had my receptionist call her and offer one of the openings Wednesday morning, or an afternoon opening the following week. It wasn't what she wanted, but it was really the best I could do.

What I didn't do that I would have done 5 years ago is give her a lecture on how unreasonable she was! (not that the thought didn't cross my mind!).

While my initial thoughts were more annoyed than gracious, I hope my ultimate response was appropriate and reflective of how I would want to be treated in a similar circumstance. Isn't this what the Golden Rule is about? Treating others as we would want to be treated? Grace is difficult, and does not come easily to me even in small matters, but I am learning!

5 principles for parenting a teenager

I see a lot of teenagers for sports physicals. When I do, the actual physical exam only takes about 5 minutes. Most of the visit is conversation about the things that are most likely to threaten the health of an adolescent- sex, drugs, alcohol, smoking and depression.

At a recent appointment, I asked a young girl whether she had become sexually active. When she said, “no,” I asked a follow up question.

“What are you beliefs about sex? Is it something that should wait until marriage or until you have been in a relationship a while?'

I could tell she had not intentionally thought about it before. She replied she wasn't sure, but she knew she wanted to wait a while. I shared my common counsel- if you don't want to have sex, don't be in a place where sex can happen! If you are alone in the living room with a boy and no one is at home, sex can happen. If you parents are there in the living room watching TV, not so much!

We then talked about alcohol and drugs. She did not drink or use, but some of her friends did. She seemed surprised when I suggested she consider finding new friends. I explained that while she may think that she would never do those things, if she had a really bad day someday where she failed a test, broke up with a boyfriend and her dog died, that she might not be as strong in her convictions when a “friend” said, “Try this, it will make you feel better!” I shared with a smile that if she didn't have friends who used, this couldn't happen. Her response told me my words stimulated some new thoughts about how to arrange her life.

Reflecting on conversations such as this one reminded me of the principles my wife and I used as our kids were growing up, rules that worked well as we tried to raise children with values and who loved God.

1- Teach values before rules

In our home we spent a lot of time talking about what we believed and who we wanted to be. We first talked about where we wanted to go in life, then we talked about how to get there. Instead of simply telling kids not to have sex before marriage, we taught our children that being moral was a core value. If children want to be moral, rules become tools and guides helping them be who they want to be instead of arbitrary limits on their behavior.

2- Spent a lot of time with your kids talking about life

When my daughter was 8 we started going out to breakfast together every Saturday morning. She loved the cinnamon roll french toast, I loved the conversation. We talked about her week, her friends, her favorite TV shows, whatever she wanted to talk about. As we did, opportunities arose for me to apply biblical truth to her life and encourage her and praise her. These times laid a foundation for future conversations.

3- Have a plan

When our kids were going to birthday parties and sleepovers, we had discussions about what to do if things went south. We had a plan of how to respond if there was alcohol, or if the parents left. These plans became the standard.

4- Set the example.

This truth seems obvious, but many parents fail to embrace it. As much as possible, we follow the standards that we set for our children. We check the content of movies before we see them. If there is nudity, we don't go. We turn the channel when a TV show gets inappropriate. We talk about making a stand in our workplace and in our personal relationships, and share stories about it when we do. Our children have seen us live out what we believe and have seen it work in our lives. It adds immeasurable credibility to our words.

5- Start young!

It is really hard to start parenting when your child is 16. Begin instilling values at a young age. When our daughter was 11 she became best friends with a girl in the neighborhood whose family did not share our values. We talked often about how, when they reached high school those differences could impact their friendship, preparing her to make a stand for what she believed in. Sadly, this did occur, but our discussions had prepared her, and difficult as it was she was able to stand firm in her convictions.

When the truth hurts, trust builds

We got away with a mistake. A baby came in for his first visit. He was 4 days old and had been home for 2 days. And he was yellow. Really yellow. Put a chiquita sticker on that kid yellow. I sent him to the hospital lab to get a bilirubin level drawn (bilirubin is what causes jaundice. At too high of a level brain damage is possible.)

Every other time I have done this I have instructed the parents to call me if they did not hear a result in 2 hours. This time I didn't. When the results came back 2 hours later, my receptionist, instead of notifying me of the lab's phone call telling me the level was very high, just put the lab results in my inbox.

Since we are an electronic office, my paper inbox is the last thing I look at. On this day I rushed to an evening meeting and did not see the results until I came in the next morning. When I saw the results I was worried and upset. Worried because the child had not been treated in 20 hours, upset because I could not believe the lab had not called me. I asked my staff to call the mom every 30 minutes until we got a hold of her so she could take the baby in for treatment.

My receptionist could have remained silent, and allowed the lab to take the blame. I would have never known. While I was blaming myself for not asking the parents to call back, she spoke up and said that it was her fault, that the lab had called and she had not notified me as she should have.

I was touched by her honesty, and her character.

I did not beat her up over the mistake as I was pretty sure she would beat herself up pretty well on her own.

I did wonder how many people would have been as forthright. Telling the truth when the truth has consequences displays character that is all to rare, but it builds trust that endures.

When it was all over I was left with a healthy patient whose bilirubin had normalized and a healthy respect for my receptionist.