One piece of feedback that patients give all clinicians is that they want to "feel really listened to." They don't want clinicians to spend time questioning whether they are being honest or mis-representing themselves.
Imagine yourself in the scary situation of a new onset of pain in your neck, and beyond just the horrible pain, you are worried that the pain is just the tip of the iceberg and may indicate evidence of a more serious condition. Because of your concern, you go to the Emergency Room. Tell me which of these situations you'd prefer:
Situation A: You are immediately evaluated by Clinician A, who assumes that everything you are saying is true, and assumes your only motivations are to be assessed by a skilled clinician and get steered efficiently toward an appropriate treatment
Situation B: Clinician B, who has the same basic skill set, but before they can speak to you, they saw 2 patients with similar symptoms, but who had a long history of drug abuse, and have histories of using the ER to obtain opiates. Clinician B needs to take seriously that these patients may actually have real pathology that needs to be treated, but is appropriately concerned that they are abusing the ER to obtain drugs.
I'd obviously be seen by Clinician A.
Thinking about this, what is the difference between the two clinicians? There is nothing intrinsic to the physician that is different- the difference is all things outside of their control.
So, if you are are the patient, it would be ideal to create a social environment that allows people stuck in the situation of Situation B, and allow them to practice in an environment more similar to Situation A. This would allow the clinician to be a better listener.
Unfortunately, that is NOT the current healthcare environment we have created. The excellent blog KevinMD.com had a wonderful post this week called The ER Demonstrates the Inverted Priorities of American Society. In this blog post, Dr. Edwin Leap details how our current healthcare structure creates a Moral Hazard, where patients no longer have societal checks in place to prioritize their own health.
My experience with blog posts like these is that people react to this as follows:
- Clinicians- read it, and feel "At last! Someone is getting the word out about what we have to deal with!"
- Some patients - read it, and feel "I get what they are talking about, but this doesn't explain ALL patients, and I'm a little bit uncomfortable with the 'blame the patient' mentality."
- Other patients- read it, and feel "This jerk hates patients! Proof that doctors are evil!"
Clearly, there is a disconnect. I think the main disconnect is related to how many unreasonable patients there are. If the unreasonable patients described in Dr. Leap's post accounts for 1 in 5000 patients, then I'd agree that he may not be sufficiently prioritizing empathy.
But what if the % of unreasonable patients is much higher? Speaking with colleagues who work in Emergency Room settings, the % of unreasonable patients can be very high, often over 50%. I feel for the patients, but also feel for the physicians treating them.
Ideally, I like to work in one mode, which is "get patients better" mode. I don't like having a second gear of "let me figure out if this patient is telling me the truth" mode
Therefore, creating systems where patients have some "skin in the game" is a necessary measure to make sure that patient's spend effort prioritizing their own health.
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