As a rheumatology fellow, I have learned to appreciate the sanctity of the doctor–patient relationship. Within the confines of a small room, I invite a stranger to share intimate details of his or her life, hoping to improve the patient’s quality of life. When I first began medical school, the doctor–patient relationship intimidated me. How could I impact a patient’s life in one visit? Over time, I have learned that listening, addressing the need for the visit while focusing on the patient’s primary concerns, and relating to the patient brings trust in the doctor–patient relationship.
As the healthcare landscape changes, work-relative value units (wRVUs) are increasingly important, and the amount of patients being seen in one day can be dizzying. Listening to the patient seems like a simple task. However, this is indeed a huge task to accomplish in a short period of time. Walking into a patient visit, doctors have to set an agenda. With new patients, we generate a differential diagnosis and treat the patient appropriately. If the diagnosis is established, we need to monitor disease activity and progression. Truly listening to the patient allows us to hear the needs of the patient. Unfortunately, there is a minority of patients (e.g., narcotics seekers) who will not be satisfied and can also become aggressive if the physician does not treat with a certain medication or pain prescription. These patients are the exception, not the rule, but still need to be heard. The ability to listen brings about an action to address the needs of the patient and to develop the subsequent treatment plan, thereby leading to patient satisfaction.
Truly Hearing Patients’ Concerns
Some patients are not model patients, even after extensive discussion of their illnesses. They leave the office and do not comply with their medications. One of my patients, a 25-year-old African American woman with systemic lupus erythematosus and severe Raynaud’s disease with gangrene, is a perfect example of a complex patient. I first encountered the patient as an urgent case. She presented crying out in pain from her hands. She kept repeating, “nobody is listening,” and, “no one will help me.” Looking at her medical record, I saw that she had missed multiple appointments, went to the emergency department multiple times, and previous notes had labeled her as noncompliant. The patient was admitted for an alprostadil infusion and during the admission, pain management was consulted. In the outpatient setting, she was treated with sildenafil and continued to follow with pain management in a multidisciplinary approach. At a follow-up appointment, she thanked me profusely for listening. I wasn’t the first person to listen to this patient. But, it appeared that this time, the patient’s concerns were addressed. Therefore, she felt better about the experience, and her compliance with medication and follow-up with appointments has improved significantly.
There is no place for pride in medicine, and even the best doctors can miss a diagnosis because they weren’t listening to the patient. Often, patients may appreciate the diagnosis, more so than the treatment plan.
Admitting When You Don’t Know
The most challenging patients “don’t trust” doctors or have been told “different diagnoses by multiple physicians.” I am simply another “doc” who has no idea how to help. It’s in these difficult encounters that honesty is the best policy. Instead of generating a sense of false security in a patient with a complicated history and a difficult diagnosis, I have learned to admit if I don’t know the diagnosis yet. There is no place for pride in medicine, and even the best doctors can miss a diagnosis because they weren’t listening to the patient. Often, patients may appreciate the diagnosis, more so than the treatment plan. Consistently, most patients want a doctor who listens and cares, more so than a doctor who knows everything all the time. In the doctor–patient relationship, trust begins with a listening ear.
Practical Applications for the Doctor–Patient Relationship
1. Set expectations for each appointment. In a limited period, there may not be enough time to address multiple concerns that the patient brings up in the appointment. Allow the patient to identify the most important needs. It is easier to address those issues and still perform your agenda. This may require having the patient come back for another appointment to address the other issues that can wait or making contact with the primary care doctor about a concern that is out of your scope of practice.
2. Clearly address the patient’s concerns. It’s not good enough to set expectations, but in the appointment, the concerns actually need to be addressed. For example, if the patient with rheumatoid arthritis is preoccupied with a ganglion cyst on the hand and he or she clearly has synovitis of the ankles bilaterally, you may want to address the synovitis. However, the patient may feel as if the ankles are “not a big deal.” It is important to set up a treatment plan for the ganglion cyst, which is the patient’s primary concern, and obviously address the synovitis in the ankles. This is the best scenario—it is a win–win. The patient feels like his or her needs are being addressed, and the doctor is treating the underlying disease process. If the ganglion cyst is not addressed, the patient may walk away grumbling and upset, only to ask the next doctor about the same concern.
3. Relate to the patient. Rheumatologists are physicians who can really get to know and develop great relationships with their patients. We ask intimate, personal histories, and we need to know the answer to have the complete story. The medications that we prescribe can have devastating consequences, and it is up to us to educate the patients about the risks, benefits, and side effects. Relating to the patient can be as simple as asking the patient about a hobby or home life. It creates a sense of connection beyond the disease process that allows a patient to feel that we care. Anecdotally, patients are more likely to make the follow-up appointments, take their medications, and listen to their doctor if they feel like the doctor actually cares.
Dr. Cobb is a second-year rheumatology fellow at the Case Western Reserve University/MetroHealth Medical Center Rheumatology Fellowship Program in Cleveland.
