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How to deal with the digitally empowered patient
In November I wrote an article for the Time magazine Web site about an encounter with a demanding and computer-search savvy patient named Susan that touched off a small firestorm in the blogosphere. At least 20 well-read blog sites ran pieces about it with vigorous reader-response on both sides, either pro-patient or pro-doctor. The New York Times blog site alone has more than 300 write-ins, many emotional. At the end of January, CNN still had an article concerning this on the front page of its Web site.
For this Orthopedics Today Round Table discussion, I have gathered together a panel of orthopedic surgeons to discuss how patient empowerment by the Internet as well as other factors such as new commercialization efforts, regulation and the liability threat in medicine is changing their current practice and what they see as their future.
Scott V. Haig, MD
Moderator
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Scott V. Haig, MD
Armen C. Haig, MD
John H. Mahon, MD
Roger N. Levy, MDScott V. Haig, MD: Please relate a personal experience which demonstrates a typical way in which the Internet affects you in the doctor-patient relationship, either in positive or negative ways.
Armen C. Haig, MD: For me, as a “senior surgeon,” the Internet has less effect on my practice because most of the patients I see know me or were sent by my former patients. When I see a patient who has “checked me out” on the Internet, I know I may have a “shopper” who is angry or has resentment issues. Those who see themselves as unaccomplished often have underlying poor self-esteem. This type of patient often will not trust you. They often see you, his or her orthopedist, as the failure they see in themselves. They are hard to help and are sometimes upset by seeing other patients making kind or appreciative comments for past care. After a long Internet search they might feel frustrated by their efforts, because they have given up treating themselves and are now coming to a surgeon for help. If you resist their self-selected diagnosis or treatment plan, he or she can resent you for not jumping onto the Internet “team” that is caring for their problem.
Roger N. Levy, MD: Patients are generally more aware, if not better informed, on subjects that are currently sources of debate in orthopedics such as mini-incision surgery and alternate bearing surfaces. Many patients clearly select their orthopedic surgeon via the Internet. I currently find more patients influenced by direct-to-consumer orthopedic television advertising than any other source of information.
Scott V. Haig, MD: Speaking as a seasoned professional to younger doctors, and especially orthopedists, can you give two or three bits of general advice on dealing with patients with difficult or demanding personalities?
Armen C. Haig, MD: Two or three bits of general advice on dealing with patients with difficult or demanding personalities? Listen ... listen ... listen.
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Levy: Doctor/patient communication can be a problem. Several years ago, the American Academy of Orthopaedic Surgeons (AAOS) conducted a survey of patients’ views of orthopedic surgeons and found that the public saw us as excellent technicians but poor communicators.
However, like physical examination or surgical technique, communication with our patients can always be improved upon. I do not think it is a matter of being a smooth talker. The core values that are the foundation of our profession provide an excellent guide. An atmosphere of compassion, empathy and understanding are easily transmitted and usually recognized by the patient, even the more difficult one. Likewise, a borderline hostility and disregard, detachment and pomposity are just as easily recognized.
For the patient who arrives with a bundle of reports of studies from prior consultations, I have found that after introductions, the phrase, “How can I help you?” sets a proper tone. “Let me try to put your normal common-sense language into a scientific framework” will often satisfy the patient who begins a circuitous history with many irrelevant twists.
The overly demanding patient is something else. We are committed to the patient’s interest but we should neither be exploited nor taken advantage of. We are obliged to take the appropriate amount of time with each patient to deal with the problem at hand, even if that does not match the time scheduled. However, excessive demands on time beyond that required needs another appointment. Office staff should not be harassed to prioritize one patient’s needs over all others.
John H. Mahon, MD: With a particularly difficult patient, like the subject of Dr. Haig’s Time article, I would probably send her for therapy, treat her with NSAIDs, and hope she ultimately will find a more compatible medical champion in another town.
Scott V. Haig, MD: Outside of the personality issue, what do you do when you think a patient is just not hearing you, is always going to be noncompliant, is seeing you only for tertiary gain or is looking for someone to sue?
Armen C. Haig, MD: Listen, then simply state that you are unable to answer all of his or her questions. But say that you will try to get more information by obtaining the proper diagnostic tests and consults. Sometime in the future if the patient returns, you might bridge the personality problem by being candid and straightforward. Occasionally, they turn around and become nice patients when they sense your competence and concern.
Levy: If I feel a patient is not hearing me, I stop and ask, “Am I confusing you?” I have always tried to explain the problem and the possible solutions to the patient in understandable terms and use radiographs or models to assist in this. For that reason, if the patient has disengaged, I usually assume there is an emotional problem. Attempting to get the patient to relax can sometimes work. Elderly patients may benefit from printed or written material.
I think the most common explanation for the patient disengaging is that I have offered a conclusion that does not match his or her preconceived ideas. Such patients can be helped in their own decision making by pointing out that the alternatives are to take an action to improve their quality of life, but which may carry some degree of risk vs. continuing to live with the current, or worsening, level of life quality. In other words, what is more important to the patient – to improve upon their current situation or to avoid an operation?
The patient who is primarily seeking tertiary gain is a different kettle of fish. Fundamental to the doctor/patient relationship is honesty and mutual self-respect. One needs to act politely and with courtesy, but not take part in such affairs.
Occasionally, you can have a run of difficult patients. This can lead to considerable frustration. At such times it is best to ventilate with colleagues in the surgeons’ locker room or at the next friendly get-together.
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Mahon: Patients vary in the level of information they need to feel comfortable with their diagnosis and treatment plan. The physician can almost always satisfy the patient within the time allotted for a routine visit, and it is usually enjoyable to interact with him or her about their condition. Everyone loves to talk about their medical problems, and usually just letting the patient explain and re-explain his or her complaints will satisfy them that they have been heard out. Even if the physician knows everything he or she needs to know after the first 30 seconds of the interview, the ensuing conversation is a valuable time to bond with the patient and make sure that he or she feels you are listening.
Susan (the subject of Dr. Haig’s article) was different. She was not interested in telling her physician what her complaints were; she wanted to recruit her doctor to her cause, and get him to agree with her treatment plan and execute that plan to which she was already committed. This rallying round the flag can also be enjoyable — but not when the patient turns out to be committed to a cause that you can’t adopt. In this instance, when the patient is just not hearing you, the physician probably has a lot more to lose than gain.
I have had this problem several times, and I have approached it from several angles. I tried direct confrontation, which has not worked well for me. If I tell patients that I don’t think they have the condition they are blaming all their complaints on, or even that it doesn’t exist (did I hear fibromyalgia?), I alienate them and make it unlikely I will be able to help them. We are obligated to tell our patients the truth as we see it, but if the interview turns hostile, no one will be listening to anyone else and it will all be a waste of time.
I know, because I have entered into this losing battle. I have told patients that they do not have anything wrong with them, that the operation they want will not help them, or that the condition they think they have cannot possibly be responsible for their complaints — and I have sometimes been dead wrong. I haven’t been filled with professional pride when an Internet-educated patient comes to me with the correct diagnosis and reasonable expectations, but I don’t reach the same proper conclusion. So I avoid the confrontation, say what I think to be true, encourage second and third opinions and give the patient the time to come to a better understanding of his or her condition.
Scott V. Haig, MD: Do you have any advice that you give to patients regarding use of the Internet in their own medical/orthopedic care?
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Armen C. Haig, MD: Ignore the “Best Doctor” reports and to remember that the information that they receive from the Internet is all bought for a price — it is public relations and advertising. These are not vetted by concerned people worried about your health. ... They do it for the money. The last great asset that we have in medicine is the doctor/patient bond, not informational empowerment or a contract. If a physician is paid enough to be independent, as we once were, this bond can survive. It is the only effective way to ensure good health care.
Levy: Patients need to use ordinary common sense when using the Internet. There are many reliable sources for understandable patient information from the Web, including the AAOS. Everyone needs to remember that the true purpose of advertising is not to inform but to persuade. I advise patients to try to distinguish general information from brand-name advertising as well as most sponsored hyperlinks.
Mahon: A well-educated patient is easier to treat. A badly educated patient is very difficult to treat. In the early ‘90s, I had difficulty treating college professors. I found them to be terribly demanding of my time, overly skeptical, and generally dissatisfied with anything less than an excruciatingly thorough review of all the medical information available. Now, I love seeing college professors. Is it because of the Internet? Maybe it’s because they come in with a fairly good understanding of their condition and they leave with enough information to continue their research on their own time. They are less demanding of my time because they know that they can do their own research, and they only need direction from me. But they still have a low pain threshold.
For more information:
- Armen C. Haig, MD, can be reached at 700 White Plaines Road, Scarsdale, NY 10583-5013; 914-723-4244.
- Scott V. Haig, MD, can be reached at 700 White Plains Road, Scarsdale, NY 10583; 914-723-4244; e-mail: scotthaig@gmail.com.
- Roger N. Levy, MD, can be reached at Mount Sinai Med Center, 5 East 98th St., Box 1188, New York, NY 10029; 212-241-7080; e-mail: roger.levy@mountsinai.org.
- John Mahon, MD, can be reached at Northern Colorado Hand & Wrist Center, 2121 E. Harmony Road, Suite 260, Fort Collins, CO 80528; 970-221-2827; e-mail: hwestlund@hotmail.com.
Reference:
- Haig SV. When the patient is a Googler. Time.com. http://www.time.com/time/health/article/0,8599,1681838,00.html.