Friday Reflection 42: Patient Approaches to a Doctor’s Visit

PT is a 62-year-old man referred for an initial clinic visit by the medical center president. He is an executive at a Fortune 500 Company, a large donor to the University, and a member of the hospital board of directors. He is healthy, comes to the visit impeccably dressed, and knows exactly which tests are warranted – some which the doctor also recommends. At the end of the visit, he asks if the phlebotomist can come to the exam room so that he does not have to wait to have his blood drawn at the lab.

There are transactional and non-transactional relationships. Commercial relationships are transactional. When you get your car fixed, or pay your rent, or buy groceries, the transaction is simple: one person pays, the other delivers a good or a service.

Although there may be transactional aspects to our personal relationships, these are far more complex, involving human needs and emotions.

The patient doctor relationship sits somewhere between the commercial and the personal. The patient is looking for a service - a diagnosis, prognosis, or treatment – but the exchange is more complicated than that for cash.

Our modern healthcare system has made the relationship much less transactional. A patient almost never pays the doctor personally.¹ Long gone is the exchange of cash (or a hen) for a consultation. If any payment is made at the office, it is made to “the staff” and usually for less than we consider the service to be worth – the “copay.” In the United States, most care is paid for with money taken surreptitiously. It is deducted from our paycheck as health insurance and as state and Medicare taxes. It is also raised indirectly through employer contributions to health insurance premiums.

Without a direct payment, what incentivizes the doctor to provide care? There remains, of course, a financial incentive. Each patient served enables the doctor to keep her job and burnishes her reputation, leading to future patients. A fear of being charged with malpractice and the desire to please also motivates the doctor.

The incentive we rely on most is professional obligation. Because this is so intrinsic to good healthcare, we take it very seriously. Students are accepted to medical school only if they seem likely to develop a sense of this obligation. We train students and residents in the definition and practice of professional standards. We admonish and discipline doctors for unprofessional behavior. Part of what worries us about medicine becoming a job rather than a vocation is a fear that this will lead to doctors feeling less obligated to their patients.

Because the professional obligation is so amorphous, and because the patient doctor interaction is so like normal human interaction, patients have a role in securing good care for themselves. Patients behave during their visits in ways they think – usually without realizing it – will lead to the provision of excellent medical care. This is not unreasonable. No matter how professionally obliged a doctor is to her patients, patient behavior affects care.

How a patient manages the doctor during the office visit is a product of their socialization – what enables him to get what he wants and needs in other aspects of his life. How a patient approaches the visit is something I only notice on one of my forest days — a day when I am particularly relaxed and mindful. What I am about to write is a gross oversimplification. Not only is our behavior at a doctor’s visit driven by our socialization; it is affected by everything else happening at a given appointment.

What are we hoping for?  A pat on the back, or an important diagnosis?

How are we feeling? Fine, or are we on day four of a horrible gastroenteritis?

Are we feeling empowered or powerless? Sitting in a jacket and tie, or donning a paper gown, in the lithotomy position, waiting for a cystoscopy?

Are we seeing a doctor who treats us as a peer or as just one more name on a busy schedule?

The behavior of most of my patients, even on forest days, does not even register with me. These are either people who expect from me what I expect to provide or long-term patients with whom I share an established rapport. I think these visits are collegial -- I hope my patients see them in the same way.

Then there are the behaviors that stand out. Two are easiest for me to identify.

There are the bullies, entitled “Masters of the Universe.”² These are the people, like PT, who are accustomed to telling people what to do and are used to getting exactly what they want. A doctor’s office is a particularly uncomfortable space for these people, one in which they are not in charge – none of us can control our health. These patients make demands. Some of these are reasonable, some are not.

A classic teaching in clinical medical ethics is that the patient/doctor relationship works best when the doctor sticks to what she knows – the medicine – and the patient weighs the possible decisions based on their values.³ Visits with PT and his ilk are often trying because the patient, feeling like he has mastered one thing – often demonstrated by the accumulation of wealth -- believes he has mastered the complexities of medicine as well.

At the other extreme are the disenfranchised: people who feel as powerless in a doctor’s office as they do in the rest of their lives. Experiences have taught these people that they are unlikely to get what they are entitled to unless they work for it. They navigate doctors’ visits by expressing excessive appreciation and respect. They may even be solicitous and deferential. My experience is that trainees often comment on how “wonderful” and “thankful” these patients are, often missing the injustices that underlie the behavior.

As doctors, we are professionally obligated to provide the best care to each patient, irrespective of who they are and how they treat us. As an insider, I know that we strive to meet this obligation and usually do. However, it would be foolish to argue that we are unaffected by how we are treated. Our treatment may not affect the care we deliver and only affect how we feel at the end of the day. It is probably impossible to know.

As patients, we respond to our doctor in a way that we hope (or expect) will make the visit tolerable and productive. How we behave is affected by past experiences and our previous interactions with medicine. Some of us are lucky enough to expect to be treated fairly, and with respect. We interact with the doctor collegially. Others have succeeded by being demanding and entitled. These people often bring this to their visits. Still others are accustomed to mistreatment, to getting less than deserved. These patients often resort to ingratiation and solicitousness.

1. Though maybe in the future the doctor will accept Apple Pay.

2. I use this in the Tom Wolfe Bonfire of the Vanities sense rather than the action figure one.

3. To reference one of my critical appraisal pieces, you could see this as doctors overseeing the decision node and probabilities and patients controlling the utilities.