Doctors prepare to partner up with informed patients

A doctor examines a patient at the UCSF Women's Health Center in San Francisco, Calif.


Tess Vigeland: Good communication skills are essential when dealing with patients. That's why Dr. Dennis Novack teaches seminars about it to first-year residents at the Drexel University College of Medicine here in Philly. He says doctors are being trained differently to care for the "informed patient" who is armed with questions and Internet research.

We dropped by one of his classes earlier this week to see how these doctors-to-be are preparing.

Dennis Novack: O.K. so this is one of our classes in our doctoring curriculum, and actually we were speaking about patient education and counseling. And certainly we want our patients to be partners in their own healthcare, and we want to empower our patients. And it's not all that unusual that patients will come in and know something about their illnesses or even have looked them up. It's just a question of what we do with that and how we respond to it. So what do you guys do now when patients ask you for things that you think are not quite indicated?

Vigeland: In other words, the patient thinks that he or she is informed, and perhaps is, not.

Dr. John: I think that this skit was actually an excellent depiction of how we've really fallen from true bedside manner where the doctor is kind of glorified as this well-knowing guru, let's say, of medicine to the patient being a consumer. And I think that that really is where the distrust really comes into play. I think the problem is when you have a "consumer" who's coming into your office, the issue is they're really looking for is what they want; they want a bargain, if you will, not necessarily in terms of price but rather in terms of what they can -- I don't want to say weasel out of you because that puts me in a bad light -- but if I can be so dramatic, I would put it that way. In terms of what they want from their health care. And I think that's where the distrust comes into play. I mean, blame that on our economy, blame that on the way advertisements would blame that on insurance companies, but I think the only way to fix that is by creating a genuine relationship from the very beginning that promotes a team-like mentality between you and the patient, where you are both on the same page and you both have the same treatment goals in mind.

Vigeland: It's really interesting to hear you talk about that shift in the relationship, because we are now consumers, not patients, and you are a service provider, not a doctor.

John: Exactly.

Vigeland: Dr. Novack, when did that change?

Novack: It's been changing, and I think the HMOs have probably had a lot to do with it. And the demands on our time and you know, it used to be we would make the decisions and now we have all sorts of people looking over our shoulders, telling us what decisions we should make, how many patients we should see. So we have a lot of pressures on us, and the Internet had provided people with free information, so it's true, we have a lot of patients looking up things and thinking they know things. And I think because doctors have had less time to explain things to patients and to create relationships, patients have sort of filled in that gap and are trying to get the most out of the time they have with doctors.

Amit Deshpande: As well as being someone who treats disease, makes people feel better, we're also educators. Obviously the job is made infinitely harder when, you know, everyone has access to the Internet more or less, so there is going to be a lot of misinformation out there, and it's our jobs to sort through that misinformation and give them the right information as best we can.

Novack: So that's what we're trying to promote: patients who are true partners in their health care, they'll just do better. One of the goals of this course is to talk about some of the psycho-social interventions, or some of the ways of approaching people's emotions, fears, concerns, beliefs and so on. So I want to ask, a patient comes in and says, 'This rash, I'm really concerned, it's a fatal disease.' What do you say to them?

John: I think what we would do in that situation is really go from a broader perspective and ask the patient what's going on in their life in terms of stressors, etc., what their home environment is like. Because for a patient to present with such a strong concern of a "fatal rash" is a clear depiction in my mind, or red flag if you will, that they're obviously other stressors that are coming into play.

Novack: O.K., but a little role play here. 'Doctor I have this rash and I'm really, really worried about it. I think it's a fatal disease.'

John: 'What is it about the rash rather that is so concerning for you?'

Novack: 'Well I looked it up on the Internet and it's this epidermal, necrolysis or something, it's the same thing. It really, really looks that way.'

John: 'Hmm.'

Novack: 'It seems to be spreading and I'm scratching it all the time.'

John: 'I see, O.K. And when did you first start noticing this rash?'

Novack: 'Well, just a couple days ago.'

John: 'Just a couple days ago?'

Novack: 'Yeah.'

John: 'How's everything else been going on? Anything else change a couple days ago? How are things been going at home and at work?'

Novack: 'I don't know what that has to do with my rash.'

John: 'I just want to get a sense of --' [laughs] Touche. Yes, I mean, I guess I could be going with exposures.

Novack: I'm thinking of an empathic comment at this moment might be good. Legitimize their concerns.

Vigeland: So what can your informed patient take away from this? What words of advice would you have for them as they interact with you?

John Gain: I think that a lot of times the physicians are human and it's easy to get the feeling as if patients coming in with information are somehow supplanting your role. You know, you can react to that in a couple different ways: you can be angry, you can get upset with a patient, you could acknowledge their efforts and to work with them, be a partner with them.

Alex Schlachterrman: So I think the informed patient is actually a great opportunity for the physicians to stay on top of their game. You know when someone's coming in prepared that you're not just going to get by with saying, 'Do X, Y, Z,' and the patient's going to go ahead and do it. So it's give and take.

John: I actually say welcome to the informed patient, and if I can be even more cheesy, I would say, you know, help me help you. I think this is definitely the future of medicine and I think that this is the kind of mindset that generally speaking we all need to adopt.

Novack: Yeah. Wouldn't we all feel great if our patients were true partners with us?

Vigeland: So you can be both doctor, patient and service provider and consumer?

John: Yes!

Class laughs

Vigeland: Thank you all for letting us sit in on this.

Novack: Thank you for being here.

Vigeland: You heard from Amit Deshpande, Cindy John, Alex Schlachterrman, John Gain, and of course Dr. Dennis Novack. Who we found out has a pretty interesting side gig: fronting the Dr. Novack Experience.

Novack: Well first of all, I love being in a band. It's healing for me. And in an odd way, it's a commitment to my patients. If I'm not in balance, I'm not going to be there for my patients. I've been in a band now for 24 years. My bandmates are mostly medical students. So every year there's a few people who graduate, and we have to find some new folks. I think I've had close to 100 people in my bands over the years. It keeps me young. I mean, think about Mick Jagger, he must exercise like six, eight hours a day to do what he does. You know, you have to be in shape.

Josh Rogosin: Do you know how old Mick Jagger is?

Novack: Ah, he's a few years older than I am.

Dr. Novack Experience covering the Rolling Stones' "Start Me Up"

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As a practitioner in the new world of Healthcare Advocacy, I can say that the reason people come to a company like Healthcare Liaison for help is they feel they cannot communicate with an increasingly complex system of providers and insurers. The critical factor here is time (which, of course, translates into money): if physicians had the time to sit and listen, the empathy would emerge more naturally---but they frequently don't have that time, and my clients come to me saying, "The doctor won't listen".
It is cost effective to listen: we just need to create that space to let that happen.

I so appreciate what Dr. Novack strives to teach his residents. Many system problems result in patients not getting what they need in a timely and efficient way, wasting money and producing emotional distress (or potential medical catastrophe). However, attention to building a trusting partnership, whether in a short visit or over many years, can overcome some of the system defects. Caring for the patient involves more than making the diagnosis of say, Hodgkin’s Disease, or providing the correct antibiotic for meningitis. With excellent communication skills, the physician can respond to the specific concerns of each patient, who is then more likely to take the antibiotic or not make the extra visit to Emergency.
The American Academy on Communication in Healthcare (AACH) helps physicians at every level improve their relationship and communication skills. We are distressed that both physicians and patients are trapped by the "miracle cure" -- all patients want one and all physicians want to deliver it, so the focus is too often on the technical and scientific aspects of medicine. Meanwhile, high quality research data shows that better communication results in improved care--not only does everyone feel more satisfied with visits and conversations, but medical outcomes are improved, fewer tests are ordered, no additional time is needed and malpractice suits are lessened. Illness experience is unique, too complicated to find the “right answer” on the web.
One of the Academy "mantras" is that communication skills are teachable and learnable. If physicians put more emphasis on building relationships, especially in complex situations- such as providing clear instructions or delivering bad news or dealing with sadness, fear or anger- everyone would be better off. And patients would not have to choose between speaking up when confused or upset and having to search the web for incomplete information.
Learning resources are available to medical schools, residency programs and practicing physicians. The AACH/ Drexel U College of Medicine web-based curriculum called "doc.com: An interactive learning resource for healthcare communication", is one of them. We wish for more emphasis on practicing these skills in everyday medical encounters, and applaud Dr. Novack’s teaching efforts.

As a healthcare worker, I'd like to point out some FACTS missed by the author(s) and which compound the problems of the entire syste. These omissions also compromise this entire broadcast as basically one-sided and biased against the insurance industry.

Doctors are not teaching, they are pushing pills instead. They "don't have time" and if they do teach, their patients have to wait.

Doctors are victims of managed care, albeit, because somewhere along the line, being a doctor meant making more money than anyone else in which case, the more they see, the more they make -- and managed care programs are not paying them as much (as some deserve) and some just think theya re entitled to. This is why people wait and this is why doctors only pass pills, rather teach toward a cure.

Nurses in the hospital don't have time to teach because they are understaffed and constantly pressured about bed TURNOVER as if they were waitresses rather than professional clinicians. They are forced to pawn for the business rather than advocate their patients. Their voices are being squelched by administrators who demand profitprecedent to good patient care.

Patients themselves, as with most of the American mind set, think they are entitled to everything for free without educating themselves nor practicing prevention on their own health issues.
This is, of course, pathetic.

WebMD and Emedicice are excellent online resources for LEARNING about disease.
Also, most if not all insurance providers offer FREE case management (learned RNs advocating for the patient) to assist people on how to navigate the system and teach them about disease self-management. These nurses guide you toward which doctors to see and WHAT QUESTIONS to pose to your doctor for expediting A CURE. (not much healing going on thse days, just suspending symptoms temporarily).

I hate to say it, but the comments from those interviewed is typical of Philadelphians who appear to be wearing blinders about their own policies. All that information is available from customer service, and if not, ASK FOR A CASE MANAGER. They "don't wanna deal with it", but instead go the ER for everylittle hangnail or cough.

I also thought Dr. Novack's other profession although good for him, was inappropriate to this article and rather highlighted the evident ego of most doctors.

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