"Too Christian" to be a Doctor

I have gathered a collection of insults over the course of my 25 years as a physician. I have been called stupid, old, racist, arrogant, ignorant, too young (okay, this was a long time ago), unkind and once I was even called "a threat to children." This week I became the recipient of a new label. I heard that a specialist colleague told a potential patient that I was “too Christian” to be his primary care doctor.

I was taken aback by the news, surprised that a colleague would view my faith as a negative for my practice. In response to his words I stopped and considered the ways in which my faith has entered into my interactions with patients. I wondered if there were times I had crossed that an invisible line and gone too far, if I had gone from encouragement to offense. I discussed the topic with my staff, not all of whom share my faith and perspective. I realized that there are many ways in which I allow my faith to influence patient care but that these ways have for the most part made me a better person and doctor.  I have described many of them previous posts but decided to take the opportunity to share some the things I do differently because I am a doctor who is a devout Christian.

1-      I pray for my patients, and when appropriate, I pray with my patients. When I do pray in the office, I intentionally avoid denominational or theological lingo. Unless I am certain that the person has a Christian faith, I do not use the name of Jesus (He knows who I am talking to anyway!) I try to carefully assess the patient’s openness and then always ask for permission. Since studies have shown that half of patients actually want this, it seems reasonable. My experience is that patients are grateful for the additional expression of concern.

2-      I try to be more forgiving. My staff says I do this too often, but because of my faith, I intentionally extend more grace when patients are late, non-complaint, or unhappy. The Golden Rule requires it of me. I find my patients are more forgiving of me as a result.

3-      I give more hugs. I continually pray that God will help me love my patients more and serve them better. Overtime this has led me to listen better and care more, which leads to hugs, which seem to be appreciated!

4-      I stand up for my patients more. Since my faith is more concerned with doing right than being accepted, I find myself defending my patients and standing up for their rights. This means going the extra mile in fighting to get medications or therapy approved.

5-      I am more available. My office hours have become more of a suggestion that a rigid rule. When it is truly needed I come in early, stay late or work through my lunch hour. Just this last Saturday I met a patient at the office to suture a hand laceration. I did it because I could.

6-      I am more respectful of my patients time. My faith teaches me that I am no better than anyone else, that my medical degree does nothing to change my standing before God. I am a wretched sinner just like anyone else. This has led me to be more respectful of the time and needs of my patients, and is in large part why I give away Starbucks gift cards when I fall behind schedule!

7-      I often refer to Biblical passages when I talk. Some might call this risky but I have seen it have a powerful impact in my counseling with patients. Truth is truth and wisdom is wisdom and I see no reason to avoid either just because they originate from Scripture. The passages I refer to the most have common applications. I use Adam and Eve to illustrate the truth that people in trouble tend to hide their problems and run from help. I quote the wisdom of Romans 12 to people dealing with depression or addiction as a reminder that we are all broken in our thinking and that trusting in our own thoughts can lead to trouble. Passages such as these are often a source of encouragement to patients.

I am not boasting in this post. None of the behaviors I describe come naturally to me, and for the most part were not a part of my early practice. These things came about through a lot of prayer and a lot of work. I am not by nature a very nice or kind person. I am a Christian who asks God to change me every day, to allow me to be His hands to touch and heal others.

After thinking about it, I have decided that being “too Christian” is a criticism I can willingly accept. It is far better than someone saying I am not Christian enough!

-          Bart

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The Day I Learned Not to Trust Doctors

When I entered medicine I believed I was entering a field comprised of noble professionals committed to taking care of others. I did not expect to encounter doctors who would put personal convenience before the needs of a patient. When I did, I did not handle it well.

I remember well when I first learned that not all doctors put the patient first. It was 1991 and I was an intern working on the OB floor. It was a Saturday and I was responsible for managing the residency program patients who were in labor. There was an experienced obstetrician supervising me, there to observe and provide guidance and to be available should a c-section be necessary.

I had been managing the care of a young woman whose labor had not been progressing well. There had been no significant change for a few hours and we were debating giving up and performing a c-section. The decision was made for us when the woman developed a significant fever and the fetal monitor showed early signs of distress. I went to the charge nurse to make arrangements for the surgery and was told that we could not go to the operating room, that a doctor had scheduled a c-section for another patient who had presented in early labor with the baby in breech position. As both patients “needed” surgery and the other doctor had asked first she told me that I would have to get the other doctor to agree to being “bumped” if I wanted to take my patient back to the operating room.

I asked a few questions about the woman with the breech baby and learned that she was in very early labor. Her cervix was only dilated 1-2 cm, which meant that there was no urgency in performing her surgery. As it was clear to me that my patient’s need for surgery was more pressing I sought out the other OB for what I assumed would be a simple and collegial conversation. I was wrong.

When I presented him with the details of the cases, he replied, “You will have to wait. My patient is breech and in labor!”

“She 1 cm and contracting irregularly! Why not get her an epidural, keep her comfortable, and wait the hour until our case is done? There is no risk to your patient but there is risk to ours!” I was incredulous.

He repeated his same assertion. I was dumbfounded. I was just an intern, but I was a good intern who was knowledgeable in the management of labor. This was not even a close call. It was a no-brainer. Good medical care demanded that he allow our case to proceed. I went to the charge nurse and asked her to tell him that he had to wait. She refused. She might have agreed with my position but in a debate between an attending and an intern she knew who was going to win. It wasn’t me.

I was overcome with anxiety. A million agonizing thoughts and questions were racing through my mind. Was I supposed to just give up? How could I? I was supposed to advocate for my patients, to fight for there care. But how could I fight when I had no power? The obstinate obstetrician was an established member of the medical staff and a faculty member in the residency program. What would happen if I pushed back to hard?

I decided that personal consequences were irrelevant. It was about my patient and her baby. I went back to the resistant obstetrician to again plead her case. I asked him for details about his patient and why should could not wait. He got angry and told me I was out of line. I wish I could say that I took it well. I didn’t. I told him in no uncertain terms (and with significantly elevated volume) that he was willfully and knowingly putting my patient at risk and that if anything happened to her it would be on him. Defeated but realizing I had done all I could I went back to check on my patient.

I walked away disillusioned. I had honestly believed that the other doctor would do what was right. I later learned that his recalcitrance was based on the fact that he had family plans that would have been disrupted if he waited. Knowing that a patient was put at risk out of convenience was unfathomable to me. I had looked up to this doctor before, had sought his counsel and learned from him. My trust and confidence were permanently damaged. The fact that my patient was not ultimately harmed by the delay did little to ease my frustration.

My frustration increased a few days later when I was called in to the office of the Residency Director. He sat me down to lecture me on my impertinence, telling me how inappropriate it was for an intern to challenge an attending physician. In typical Barrett fashion I did not back down. I apologized for my tone but made it clear that regardless of my standing or level of training I would always put the patient first.

As we talked, I realized that he didn’t really disagree with me. He knew that the attending was in the wrong. He also knew how the world worked. In order to run a residency program he needed faculty, and the only source of faculty he had was the medical staff at the hospital where we were located. Not all of them were noble and excellent but they were all we had. He admired my convictions but wanted me to understand the need to carefully choose my battles.

It was a difficult lesson for me to accept and it is one with which I continue to struggle. I have lost many battles that I should have known to be futile, died on too many hills trying to do what I believed to be the right thing for my patients. I have also saved lives by speaking out. I have learned that most doctors are good people but we are still people, with all the selfishness and inconsistencies personhood brings.  The learning process that began 24 years ago on that OB floor continues to shape me. Although I use less anger and volume one thing that has not changed is my commitment to doing the right thing.

- Bart

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Poisoned by a Doctor! (And other Accusations)

“You doctors just want to give me poison and I am not going to take it!” I have been accused of many things in my 20 years of practice but intentional poisoning was something new and the patient's words surprisingly harsh. He was angry from the moment I walked into the room. He was first offended when I questioned his reasons for not taking the medications his cardiologist had prescribed. He had experienced some slight swelling of his legs, decided that this side effect was too severe and made the decision on his own that the medication was unsafe. He was convinced that the doctor had put his health in danger and that I wanted to do the same.

When I explained that this was a relatively common side effect with this medication he became angry. “Why would you prescribe a medication when you know there are side effects?” He was nearly shouting and his faith was contorted in anger. He was MAD!

“Because it is an effective drug and the side effects only happen ten percent of the time!” Was my reply.

He would have none of it. It was his opinion that no doctor should ever prescribe any medication if there were any side effects. I tried to explain to him the nature of side effects and how they were outweighed by the benefits of treatment. I spent the next 20 minutes trying to explain to him the nature of heart failure and why medicines were crucial for his health. I explained how the medications worked and why the side effects were reversible or manageable. He argued with me every assertion I made. He told me that doctors were dishonest people who cared more about money than they did people, unscrupulous individuals who would just as soon poison someone as treat them.

I finally gave up. As calmly as I could I told him that if he was going to refuse care for his heart failure that I would not be his doctor. If he didn't trust me it would be impossible for our relationship to continue. I explained that my preference would be for him to remain a patient and be healthy but that remaining a patient and being healthy would mean following my instructions. He continued to argue with me so I opened the exam room door and gestured for him to leave. “You will need to find another doctor,” I told him, and sent him on his way.

After he left I composed a letter summing up what had happened (detailed documentation is required when a patient is dismissed) and put it in the mail. I reviewed our conversation and concluded  by saying,

“You made it clear that you do not trust doctors, myself included. The physician/patient relationship has trust as its foundation. Your good health and medical treatment is dependent on you following expert medical advice. Our lengthy conversation today proved to me that you are unwilling to do this.

If you wish to remain a patient in my practice, you will need to accept and follow my recommendations, and schedule appropriate follow up visits. If you are willing to follow my recommendations and respect my judgment and opinions, please schedule a visit to move forward with your care.

If you plan on continuing to argue with my recommendations and refuse to comply with treatment plans, I must insist that you seek care elsewhere.”

I had my staff send the letter via certified mail, convinced that I would never see him again. Which is why I was so taken aback when I saw his name on the schedule 5 weeks later. I entered the room cautiously, prepared for another conflict.

It never came. He was incredibly apologetic from the outset. I asked him what changed his mind. He told me it was the letter! He realized that I was serious about his health and decided right then that he didn’t want to see anyone else. 

His dramatic change of heart was something else I had not seen in 20 years of practice. I was truly impressed with his humility and told him so. We agreed on a new medication plan for his heart and blood pressure and arranged a follow up visit. It was a very pleasant encounter.

It was also educational. He taught me that people can change, even those who seem intractable and unreasonable. He reminded me of the power of forgiveness and the beauty of a fresh start. I am actually looking forward to our next visit.

- Bart 

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Medicine is Changing. Are you Ready?

Medicine has changed and many patients did not get the memo. Electronic record keeping and computerized data bases have made it so every aspect of a patient's health is now monitored, tracked, and analyzed. There is no longer such a thing as a simple office visit as third parties are telling doctors what to do, how to do it and who to do it to. 

When I started in practice 21 years ago the business was pretty easy. Most patient visits could be divided into three categories- routine check-ups, follow up for chronic diseases, and sick visits. Check-ups were straight-forward, uneventful reviews of overall health. Chronic disease visits were also easy, encounters focused on the problem in question- check the blood pressure, review the cholesterol or blood sugar, and make medication adjustments and order appropriate tests. Sick visits were easiest of all, as most of them were upper respiratory illnesses that could be handled quickly. 

Another characteristic of that era was that patients were responsible for their own care. We told them what they needed to do to be healthy, recommended screening tests such as colonoscopy and mammograms and encouraged appropriate diet and follow up tests. Whether or not they wanted to follow instructions was up to the patients. Being human beings, many patients didn't. Some forgot, many simply had other priorities. It was frustrating when patients did not do what they should for their health but we accepted the reality of the situation.

There was another reality that eluded both doctors and patients, and this reality led to changes in the way health care is delivered. The bad decisions patients made did not just effect them. When illness occurred as a result of these poor choices someone else, the insurance company, had to pay the bills. Insurers decided they wanted healthier patients and determined that reaching this goal required a dramatic change in how doctors practiced. The change came in the form of quality measurements. Doctors were to be held accountable for the decisions patients made, graded and financially incentivized based on the percentage of their patients who did what they were supposed to.

A new era of accountability has dawned. Doctors are now bombarded with forms and scorecards showing the percentage of patients who had mammograms, Pap Smears and colonoscopy. Reports pour in every week with the names of patients who have not been filling prescriptions on time, asking doctors to confront their patients about their non-compliance. Hours and hours of staff time are spent tracking chronic disease such as diabetes, with patients being reminded again and again to get eye exams, control their blood pressure and cholesterol and get their sugars under control.

The rules haven’t only changed for disease management. MediCare wellness guidelines are so arbitrary that we are required to annually discuss incontinence, fall risk, memory loss, ability to care for oneself, end of life issues and control of chronic pain with every single patient above the age of 65 regardless of health status. We have to check the same boxes for a debilitated 88 year-old as we do for a vibrant 65 year-old who plays competitive tennis, which is a bit puzzling to the 65 year-old!

The result of all of these metrics, reports and guidelines is that patients who come in for one problem find themselves being bombarded with instructions and questions for multiple other conditions they didn’t come in for. This can lead to defensiveness and a breakdown in communication, encounters that leave both the patient and the doctor feeling frustrated or dissatisfied.

So what to do? We start by understanding the new paradigm. I have begun educating my patients about the changes in healthcare. I explain to them the standards to which I am held and how their compliance has a dramatic impact on my practice and I am asking them for their help. The result? Increased cooperation, better understanding and decreased frustration. Medicine has changed  but if doctors and patients truly partner together we should be able to find a way to make it work for all of us.

- Bart

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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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