‘Looks older than stated age’

Pity the young, pretty blonde doctor who’s constantly mistaken for being less accomplished than she truly is.

“Sexism is alive and well in medicine,” Dr. Elizabeth Horn lamented in a guest post this week at Kevin, MD, wherein she describes donning glasses and flat heels in an attempt to make people take her more seriously.

As someone who used to be mistaken for a college student well into my mid-20s, I certainly feel her pain. But let’s be fair: Doctors judge patients all the time on the basis of how old they appear to be.

It’s a longstanding practice in medicine to note in the chart whether adult patients appear to be older, younger or consistent with their stated age. Doctors defend it as a necessary piece of information that helps them discern the patient’s health status and the presence of any chronic diseases.

According to theory, patients who look older than their stated age are more likely to have poorer health, while those who look more youthful than their years are in better health. But does it have any basis in reality? Well, only slightly.

An interesting study was published a few years ago that examined this question. The researchers found that patients had to look at least 10 years older than their actual age for this to be a somewhat reliable indication of poor health. Beyond this, it didn’t have much value in helping doctors sort out their healthy patients at a glance. In fact, it turned out to have virtually no value in assessing the health of patients who looked their age.

Other studies – and there are only a few that have explored this issue – have come up with conflicting results but no clear consensus, other than the conclusion that judging someone’s apparent age is a subjective undertaking.

When there’s such limited evidence-based support for the usefulness of noting the patient’s apparent age, then why does the habit persist?

I’ve scoured the literature and can’t find a good answer. My best guess is that doctors are trained to constantly be on the lookout for risk factors – which patient is a heart attack waiting to happen, which one can’t safely be allowed to take a narcotic, which one is habitually non-adherent – and assessing apparent age vs. actual age is one more tool they think will help, a tool they may have learned during their training and continued to use without ever questioning its validity.

Appearances can be deceiving, however. A patient who looks their age or younger can still be sick. Someone who looks older can still be relatively hale and hearty.

And beware the eye-of-the-beholder effect. One of the studies that looked at this issue found that younger health care professionals consistently tended to overestimate the age of older adults. When you’re 30, everyone over the age of 60 looks like they’re 80, I guess.

Whether you’re a young physician fighting for the respect your training commands or a patient fighting against assumptions in the exam room, the message is the same: You can’t judge a book by its cover.

When the patient becomes the doctor’s caretaker

In a video interview, the anonymous doctor’s frustration comes through loud and clear. She takes care of complex patients with many health needs, often working 11 or 12 hours a day, sacrificing time with her family. Yet the message she constantly gets from administrators is that she’s “dumb and inefficient” if she can’t crank patients through the system every 15 minutes.

In a word, she’s abused.

And patients ought to care enough about their doctors to ask them if they’re being abused, according to Dr. Pamela Wible, who raised the issue recently on her blog. “The life you save may save you,” wrote Dr. Wible, a primary care doctor on the West Coast who established her own version of the ideal medical practice after becoming burned-out by the corporate model of care.

This is one of those issues that’s like lifting a corner of the forbidden curtain. Many patients probably don’t think too much about their doctor’s challenges and frustrations. After all, physicians are paid more than enough to compensate for any workplace frustration, aren’t they? Isn’t this what they signed up for?

The problem with this kind of thinking is that it ignores reality. Medicine, especially primary care, has become a difficult, high-pressure environment to be in. One study, for example, that tracked the daily routine at a private practice found the physicians saw an average of 18 patients a day, made 23.7 phone calls, received 16.8 emails, processed 12.1 prescription refills and reviewed 19.5 laboratory reports, 11.1 imaging reports and 13.9 consultation reports.

And when physicians are overloaded, unhappy and feel taken advantage of, it tends to be only a matter of time before it spills over into how they interact with their patients.

The million-dollar question here is whether patients can – or should – do anything about it.

Dr. Wible advocates taking a “just ask” approach. Compassion and advocacy by patients for their doctors can accomplish far more than most people think, she says.

One of her blog readers agreed, saying the pressures “must frustrate them beyond endurance. I’m going to start asking.”

Another commenter sounded a note of caution, though: “I feel there is a risk for a patient to ask such a question to a dr. who might be hiding how very fragile he/she is.”

More doubts were voiced at Kevin MD, where Dr. Wible’s blog entry was cross-posted this week. A sample:

- “Abused is a very emotionally loaded word that brings up powerful emotions and feelings like shame. I think if a doc is asked by a patient whether he/she is abused, they might actually end up feeling accused.”

-  ”I’m having a hard time imagining most docs responding well to their patients asking them if they are abused and I doubt that most docs would respond ‘yes, I am being abused’ to patients who do ask that no matter what was going on in their workplace. Nor do I think most patients want to spend a big chunk of their doctor visit talking about the doctor’s problems and issues.”

- “And what could I do if the answer is ‘yes’?”

I’m not sure what to think. At its core, health care is a transaction between human beings that becomes most healing when all the parties are able to recognize each other’s humanity.

Yet reams have been written about doctor-patient boundaries and the hazards of too much self-disclosure by the physician. Can it ultimately damage the relationship if the doctor shows vulnerability or emotional neediness? What are the ethics of a role reversal that puts the patient in the position of being caretaker to the doctor?

What do readers think? I’d like to know.

Needs to be seen

You need a refill for a prescription that’s about to run out. You’ve taken the medication for years without any problems and can’t think of any reason why the prescription can’t just be automatically continued. But the doctor won’t order a refill unless you make an appointment and come in to be seen.

Is this an unfair burden on the patient or due diligence by the doctor?

Dr. Lucy Hornstein, a family practice physician who blogs at Musings of a Dinosaur, was up against the wall recently with a patient who needed refills for blood pressure medications but wouldn’t make an appointment, despite repeated reminders.

“What to do?” Dr. Hornstein asked her blog readers.

First round of analysis: What are the harms of going off BP meds? Answer: potentially significant, in that patient is on several meds which are controlling BP well, and has other cardiovascular risk factors.

Next, anticipating the patient’s objections to a visit: Why exactly do I need to see her? We call it “monitoring”; making sure her BP is still controlled, and that there are no side effects or other related (or unrelated) problems emerging. “But you never do anything,” I hear her responding, and it’s hard to argue. It certainly seems that the greater benefit comes from continuing to authorize the refills.

What’s the down side? This: What if something changes, and either the BP is no longer controlled, or something else happens as a result of the meds (kidney failure comes to mind)? I can just hear the lawyer bellowing, “Why were you continuing to prescribe these dangerous medications without monitoring them?” causing the jury to come back and strip me of all my worldly goods.

So what to do? Refuse the refill and risk having her stroke out from uncontrolled blood pressure? Or keep on prescribing without seeing her? If so, how long? Four years? Five? Ten?

It’s a good summary of a dilemma that puts the doctor between a rock and a hard place no matter which course of action she chooses.

Patients don’t necessarily see it this way, though, judging from many of the online conversations about everything from seasonal allergy medications to antidepressants. Sometimes it ends up being a source of conflict, as in “Why are you making me jump through all these ridiculous hoops for a routine refill?” Sometimes they’re running out of medication but can’t get in for an appointment right away – what then? In some cases they’re genuinely worried about the cost of an office visit, especially if they have a large copayment or lack health insurance.

Dr. Hornstein’s readers (most of whom seem to be health care professionals) didn’t mince words on the need to crack down on this patient.

“No more refills until she sees you in person. Period. You are not a refill machine,” was one person’s blunt assessment.

There seems to be room for debate on how often patients should be required to see a doctor for a prescription refill. Is twice a year excessive for someone whose blood pressure is well controlled with medication and minimal side effects? Is once a year enough for someone who has complex health issues and is taking multiple medications? What about prescription narcotics? Should it make a difference if the patient is someone the doctor knows well?

Truth be told, I don’t enjoy the hassle of getting a refill. But after reading Dr. Hornstein’s side of the story, it’s easy to see why doctors don’t like reauthorizing prescriptions willy-nilly. After all, it’s their name on record as the prescriber if something happens to go wrong. Sometimes the patient really does need to be seen.

Providers by any other name

Guilty, guilty, guilty.

That was my reaction after reading Dr. Danielle Ofri’s take at the New York Times Well blog on the use of the word “provider” to refer to people in health care.

Dr. Ofri dislikes the term intensely:

Every time I hear it – and it comes only from administrators, never patients – I cringe. To me it always elicits a vision of the hospital staff as working at Burger King, all of us wearing those paper hats as someone barks: “Two burgers, three Cokes, two statins and a colonoscopy on the side.”

“Provider” is a corporate and impersonal way to describe a relationship that, at its heart, is deeply personal, Dr. Ofri writes. “The ‘consumers’ who fall ill are human beings, and the ‘providers’ to whom they turn for care are human beings also. The ‘transactions’ between them are so much more than packets of ‘health care’.”

I suppose this is as good a time as any to confess I’ve used the p-word – used it more than once, in fact.

It’s not that I don’t know any better. I’ve been aware for quite some time that many people in health care don’t really like to be called providers. I deploy the word rather gingerly, and have increasingly taken to calling them something more specific – doctors, for instance, or nurses, or clinicians.

Frankly, it’s hard to know what the right word should be. Once upon a time it was pretty safe to use the term “doctor” to refer to those who provide (sorry!) care. This is no longer a given; many of those engaged in patient care these days are nurses, nurse practitioners, physician assistants, medical assistants and… you get the picture. (For that matter, “doctor” and “physician” aren’t interchangeable either, but I digress.)

“Clinician” seems a little closer to the mark, and it has the merit of distinguishing those in health care who are engaged in the actual care of patients from those who aren’t. But it’s a catch-all term, not particularly descriptive and somewhat lacking in personal warmth and fuzziness.

Similar minefields lurk in terms such as “health care professional,” “mid-level professional,” “allied health professional,” “health care worker” and the like. They’re lengthy, cumbersome and stilted. It can be inaccurate to call everyone who works in health care a “professional,” because many of those who toil behind the scenes in disciplines such as medical records management and central distribution aren’t professionally licensed, even though their work is just as essential. On a more politically correct note, many allieds don’t like being called mid-level because of the hierarchy this implies.

Don’t even get me started on the varying levels of “health care organizations.” Hospitals, medical clinics, outpatient surgery centers, community health centers, public health agencies – each occupies a special place in the ecosystem and can’t easily be lumped into generic vagueness.

And if you really want to get technical, shouldn’t we consider health insurance, pharmaceutical companies and medical device manufacturers as part of the “health care system” as well?

What’s a writer supposed to do? It’s a constant challenge: trying to be accurate and descriptive yet not allow oneself to become bogged down in multiple syllables.

Language does matter. There’s a case to be made for the importance of being aware of cost, quality and medical necessity – for behaving as a consumer of health care, not solely as a patient. But I view myself first and foremost as a patient, and I’m not sure I like it when patients are urged to “shop around” for good care as if they were kicking the tires at a used-car lot. There’s a relationship aspect to health care that goes beyond pure consumerism and that needs to be recognized and valued.

If we’re debating about the language, perhaps it’s because everyone’s role is shifting to a greater degree than at any other point in history. Patients have more information and are being asked to take more responsibility, as well they should. The people who care for patients are being pulled in more directions than ever before. We don’t know what to call ourselves anymore, and reasonable alternatives don’t seem to have been created yet.

So here’s the deal: When I use the term “providers,” it isn’t because I think of them as burger-makers at a fast food restaurant. It’s generally because the word is short, to the point and encompasses the range of individuals and organizations I’m writing about. As far as I’m concerned, my doctor and nurse are still my doctor and nurse and I’m still their patient. Sometimes I’m a consumer, but only when consumer behavior is what’s called for.

If anyone has suggestions for new terminology other than “provider,” I’m all ears.

This entry was originally published Dec. 30, 2011.

Flipping the clinic

Advocates of patient-centered care talk of “flipping the clinic” to create an environment in which everything, from the sign-in process to how patient-provider conversations are conducted, is designed with the patient experience foremost in mind.

So here’s a really radical thought. What would happen if we took this one step farther and flipped the flip? What if patients also became more mindful of the provider experience and, by extension, more supportive and understanding of their doctor, their nurse and others involved in their care? What might we gain as a result?

It’s a novel idea raised  by Natasha Gajewski, a patient advocate and innovator who recently blogged about attending a Flip the Clinic symposium hosted by the Robert Wood Johnson Foundation and hearing some of the success stories about patients who were empowered to become full participants in their care. Seeing how rewarding it was for clinicians to help make this happen, Gajewski reflects:

… [J]oy and satisfaction are apparently in short supply amongst care providers, particularly those on the front lines. So I find it curious we focus so much attention on salvaging the wellbeing of the patient, when studies and the emerging crisis in primary care suggest that more attention needs to be given to improving the wellbeing of clinicians.

Then she asks the million-dollar question: “Could patients cure clinician burnout and other problems in our healthcare system?”

In one of those moments of synchronicity, I came across Gajewski’s online posting at the same time I was reading Dr. Danielle Ofri’s new book, “What Doctors Feel,” about the undeniable – and sometimes overwhelming – role of emotion in the practice of medicine. Then, to clinch it, New York Times contributor Dr. Pauline Chen wrote this week about the growing problem of clinician burnout and how to lessen it.

It would be hard to find a health care provider in the U.S. these days who isn’t under tremendous stress at least part of the time. Although stress is inherent in the health care professions, it’s being ratcheted up and up and up by constant change, increasing demands on people’s time and energy, and resources that are becoming ever more strained.

While most Americans are probably aware of this, one has to wonder how well the average person understands the connection between frazzled, exhausted, unhappy clinicians and unsatisfactory patient experiences.

Dr. Chen lays it out for us:

Research over the last few years has revealed that unrelenting job pressures cause two-thirds of fully trained doctors to experience the emotional, mental and physical exhaustion characteristic of burnout. Health care workers who are burned out are at higher risk for substance abuse, lying, cheating and even suicide. They tend to make more errors and lose their sense of empathy for others. And they are more prone to leave clinical practice.

Do patients care? More than a few people might react the same way as one of Dr. Chen’s online readers who called it professional narcissism: “Enough about how physicians and other medical professionals’ lives are so difficult. We all have jobs that are hard to do.”

But I would hope this is a minority view. At its core, health care is about relationships between human beings. It’s hard for the parties to truly engage with each other when one of them is physically and mentally overloaded, frustrated and on the verge of burnout.

This isn’t to say that provider satisfaction should be the sole responsibility of patients. Patients often have enough to handle without also worrying about managing the morale of their health care team.

But patients do have a stake in this, whether they realize it or not. So, to go back to Gajewski’s question: Is there something we can do about it?

Medicine’s privilege gap

Have doctors become increasingly removed from the everyday struggles of their patients, especially patients who occupy the lower rungs of the socioeconomic ladder?

A letter to the editor in the July issue of Academic Medicine raises some thought-provoking questions about a “privilege gap” that’s opening up in medicine.

It starts at the very beginning, with the selection process into medical school, writes Dr. Farzon Nahvi, an emergency medicine resident at New York University’s Bellevue Hospital:

Data from the Association of American Medical Colleges show that over 60% of medical students come from families in the top quintile of household income, with only 20% coming from families who earned in the bottom three quintiles. Similarly, the median family income of American medical students is over $100,000. In other words, the average medical student comes from the upper 15% of America.

This is anything but reflective of the patient population, Dr. Nahvi goes on to explain: “They are all of America: rich, poor and in between.”

And it has an impact, he maintains:

The unfortunate consequence of this is that patients sometimes struggle to be understood by well-meaning but, ultimately, privileged doctors who sometimes cannot relate to patients of other backgrounds.

Being privileged does not necessarily make a physician incapable of understanding the daily lives of his or her patients, of course. And many physicians resent (often rightfully so) the stereotypes that portray them as money-grubbing, golf-playing, Beamer-driving plutocrats who consider themselves above the masses.

Yet the statistics cited by Dr. Nahvi don’t lie. And they’re a problem for a society in which the health gap between the well off and the not so well off has been extensively documented. As Dr. Nahvi points out, how can doctors be aware of the issues their low-income patients face – unable to afford prescription drugs, for instance, or unable to take time off work to get to the pharmacy – when “it often doesn’t occur to the more privileged that such issues even exist”?

If medicine in the U.S. is becoming a bastion of privilege, it’s probably because it increasingly takes privilege to survive the rigors and costs of becoming a doctor.

The cost of a medical education is a significant burden for aspiring doctors; a report from the Association of American Medical Colleges puts the median amount of medical school debt at $170,000 for the Class of 2012 (and this doesn’t include any debt students may have accumulated from their preceding four years of college).

Then there’s the protracted training time to consider: four years of undergraduate education, four years of medical school and, at a minimum, three years of residency before doctors actually start earning real money. Once they’ve arrived, they can start acquiring the trappings of an upper-middle-class lifestyle – but this is small comfort to the bright young high-schooler from a low-income family who dreams of being a doctor but lacks the financial wherewithal to even get a foot in the door.

One could also argue that the medical school admission process itself tends to favor students with the “right” kind of background, i.e. those who already possess strong socioeconomic advantages.

So what’s the solution? Dr. Nahvi writes:

The stopgap fix is to better train all students to deal with all types of patients. A true long-term solution, however, is to steer more representative slices of America – individuals from all income levels – into medicine. There are many ideas for how to do this, from special recruitment strategies to arrangements for financial aid. Fundamentally though, for change to occur, admission committees need to recognize the importance of getting more middle- and low-income students into our medical education system.

Doing so won’t be easy, because it’s not just about money. Many other ingredients come into play: a solid grade school and high school education, parents and teachers who encourage careers in medicine and hold aspiring students to high expectations, and even local role models who can show young people that someone like them can successfully become a doctor.

There doesn’t seem to be much public discussion about how to narrow the privilege gap in medicine. Since part of the solution likely will lie at the community level, maybe this needs to change.

Every move you make, the patient is watching you

Patients have a way of hanging onto every nonverbal cue they notice, no matter how small.

Was the doctor frowning as he/she entered the exam room? Did the nurse at the hospital bedside seem harried while checking your vital signs? What was up with that brusque welcome from the receptionist? Was that an eye roll behind your back?

In any setting, body language is a big deal. The fact that people are watching, interpreting and judging, especially when it comes to leaders, is illustrated vividly by New York Times columnist Adam Bryant in his latest piece, “Are You Mad at Me?”

One day a colleague pulled him aside and asked to speak privately with him in the conference room. The question, wrote Bryant, “came out of the blue. ‘Are you mad at me?’”

He goes on to explain:

I was puzzled, but I realized later what was going on. As an editor, I faced a lot of tight deadlines, and I would often have just a short window to get a story into shape for the next day’s paper. I’m guessing I was thinking hard about some story as I walked through the newsroom one day – probably furrowing my brow, my mind a million miles away – when I briefly locked eyes with my colleague, who was startled enough by my body language to later pull me into a conference room to wonder if the air needed to be cleared between us.

Bryant writes, “I learned a memorable lesson that day about how people can read so much into subtle, and often unintended, cues.”

How much more so in health care, where patients often feel vulnerable, needy and at the mercy of a system that may or may not be responsive – and where misinterpreting the cues can have very real consequences.

The literature on the role of body language is varied and fascinating. One study carried out in the Netherlands found that people had a positive physiological response to pictures of happy facial expressions. But they showed signs of higher anxiety in response to facial expressions that were fearful or angry – and their reaction to angry signals was heightened when they were already anxious. Other studies have found people are quicker and more accurate at detecting angry faces than happy faces.

Less is known about the impact of nonverbal cues in the health care setting. For just one example of how body language can influence the doctor-patient interaction, however, consider a study, published last year, that examined the differences in nonverbal communication between white and African-American doctors when talking to older patients.

The study found that white doctors tended to treat all their older patients the same way. But black doctors often gave contradictory nonverbal cues to their white patients – smiling, for example, while crossing their arms or legs.

Other studies have found a similar pattern among female physicians interacting with male patients.

Most of these studies are fairly small and don’t really explore the impact of the doctor’s body language on quality of care or outcomes. Disparities in health care are well known to exist, however, and unconscious social bias can be very difficult to root out and change.

Meanwhile, patients notice these subtle cues and draw their own conclusions, accurately or not.

“How do you say, ‘I don’t give a damn’?” asks Kristin Baird, owner of the Baird Group and a consultant on improving the patient experience.

She relates the experience of accompanying her sick sister to see the doctor. The doctor barged into the exam room, stood with one hand on the door handle and informed her sister there was nothing he could do and that she should go to the hospital.

“Everything about his demeanor, both verbal and nonverbal, screamed: “I don’t give a damn about you. You’re not worthy of my time, so don’t bother me,’” Baird writes. “This was hard enough for me to witness, and I wasn’t the one in need of his care.”

Maybe it wasn’t personal. Maybe the doctor had just had a terrible encounter with the previous patient, or was distracted by a family crisis or suffering from burnout or depression. It leaves a mark, however, and it can become one more piece of baggage for patients to tote around and unpack in their next visit to the health care system.

There seem to be a lot of angry patients these days, and at least some of it stems from the nonverbal cues that shape people’s perceptions of how they’re treated: “The person at the front desk barely made eye contact with me. “The doctor just sat there and looked at the computer.” “The nurse/physical therapist/radiologic technologist seemed in such a hurry.”

One consequence might be heightened anxiety that prevents the patient from communicating honestly and allowing the doctor to reach the right diagnosis. If patients perceive that their participation in their care is met with annoyance or secret eye rolls, they may become frustrated or outright hostile. Perhaps they’ll take the opposite route and decide it’s better to be passive and uninvolved, even if none of these approaches are beneficial to their health.

Like hawks, patients are watching every move their clinician makes and levying their judgment, whether it’s fair and accurate or not.

A clinician who looks like me

The face of America, and the people who seek health care every day at clinics, hospitals, urgent care centers and emergency rooms, is becoming ever more diverse. But you’d never know it by looking at the average U.S. medical school, where the faculty remains resolutely white and male.

The Association of American Medical Colleges recently examined this implicit bias in an article that takes a look at the situation and what medical schools are doing to cultivate a leadership that is more diverse.

It matters because when medical school leaders and faculty come from varied backgrounds, they bring a more inclusive approach to how medical students – the physician workforce of the future – are trained, Dr. Hannah Valantine, senior associate dean of faculty affairs at the Stanford University Medical School Office of Diversity and Leadership, told the AAMC Reporter recently.

“We are facing complex problems that will require diverse perspectives to solve,” she said. “The extent to which we can retain diverse faculty will drive our excellence in education, research and patient care.”

Disparities in health and in health care unfortunately are pervasive. They’re manifested in many ways: how people live, whether their environment is safe, whether they have access to health insurance and affordable care. At least some of the disparities, however, seem to be rooted in a health care system that doesn’t always recognize or appreciate the differences, both clinical and cultural, that make human beings so diverse.

Take, for example, a cardiovascular health initiative that was one of the topics of discussion last month at the 10th annual national summit on health disparities. The initiative, now in its second phase, is aimed at giving doctors more knowledge about treating minority patients and improving their cardiovascular outcomes.

Speakers at the event said physicians often are unaware of the nuances in treating patients of diverse ethnic and racial backgrounds, hence may fail to recognize heightened risk or important early signs of chronic disease. One of them is the so-called triglyceride paradox, or the fact that blacks can have high levels of high-density lipoproteins (“good” cholesterol) and low triglycerides yet still be at high risk of cardiovascular disease.

To what extent does the failure to see these nuances reflect assumptions that “every patient is like me,” i.e. white? Some studies have noted that black patients are referred for cardiac catheterization or bypass surgery less often than white patients, even when their symptoms are the same, which suggests at least some level of inequality.

“Clearly there is some subconscious bias that is going on,” Dr. Conrad Smith of the University of Pittsburgh Medical Center told MedPage Today last week.

Physicians need to be aware of the differences in how they approach patients of varying backgrounds and the impact this has on outcomes, Dr. Smith said. “The education of physicians is going to be paramount if we want to close that gap.”

This isn’t to say prejudice and discrimination are rampant among health care professionals. The vast majority are skilled and well-intentioned. Yet their training and background may not necessarily have equipped them to recognize their own assumptions.

Consider, for example, the implications this may have for conducting end-of-life discussions. Americans strongly favor telling the truth to patients when further medical care is futile; other cultures view this as harmful and believe the patient should not be told.

U.S. clinicians might become deeply frustrated, perhaps even angry, with immigrant or refugee patients who refuse testing and treatment for tuberculosis. What they may not understand is the stigma associated with TB in these cultures and differing practices in when and how medication is prescribed.

It’s not hard to see how misunderstandings can arise. Sometimes these spill over into the clinician-patient relationship, not only in how people communicate with each other (Do they feel their perspective is heard? Do they feel their values are respected?) but in the quality of care the patient receives.

Some studies have found that doctors relate better to patients when they share common ground, such as socioeconomic background – in other words, patients who aren’t perceived as “other.” These same studies also have found that when doctor and patient come from similar backgrounds, the doctor is more likely to take the patient’s symptoms seriously and more likely to trust that the patient will follow medical advice.

It argues that unconscious bias in favor of one’s own tribe is very real. It also argues for a better doctor-patient relationship and greater comfort level when an increasingly diverse patient population can receive care from someone with whom they identify.

That the health professions are having robust discussion about instilling diversity and cultural competency within their ranks is an indication of how much progress has been made in the past couple of decades. There in fact have been calls to broaden the definition of what constitutes diversity to include religion, gender identity and sexual orientation. In a newly published study, students in the medicine, physician assistant and physical therapy programs at the University of Colorado supported the value of an inclusive, respectful campus environment – but they also reported that disparaging remarks and offensive behavior toward minorities of all kinds continue to persist.

“According to these students, the institution must embrace a broader definition of diversity, such that all minority groups are valued, including individuals with conservative viewpoints or strong religious beliefs, the poor and uninsured, GLBT individuals, women and non-English speakers,” the researchers concluded.

Few people are without bias in some form and this goes for every walk of life, not just health care. The challenge lies in recognizing it and overcoming it so all patients get the care they need, even if the clinician doesn’t look like them.

When the doctor doesn’t like the patient

It was one of those honest admissions that usually go unvoiced: The doctor didn’t like the patient and felt pretty sure the patient didn’t like him either.

Their introduction didn’t go well and the relationship failed to improve during subsequent visits, Dr. Don Dizon, an oncologist, blogged recently at ASCO Connection. “As time passed, I resented having to see her and take care of her because despite what I perceived as my best efforts, I felt we had no real doctor-patient relationship,” he wrote.

But when he confessed to some of his colleagues that he disliked the patient, they were shocked that he would even say such a thing.

Do doctors have an obligation to like all their patients? Good question – and thought-provoking as well, judging from the amount of traction that Dr. Dizon’s blog entry gained online this past month and the comments it generated (here and here, for instance).

While many patients desire empathy (or, at the very least, some respect), it was clear from the comments that this isn’t the case for everyone.

“We are not teenaged girls and this is not Facebook,” was the response from one person. “I don’t care whether you ‘like’ me, any more than I care whether my plumber or pool guy ‘like’ me. Just do your job.”

It’s about the clinical care, not about who likes or dislikes whom, wrote someone else. “Put aside your ego, do your job, stop labeling and move on.”

The online discussion raised another question: Is it fair for doctors to want all their patients to be likable? “It can be a significant burden to have to be the doctor’s buddy and entertainment when feeling awful,” one person pointed out.

This whole issue of likable vs. non-likable patients (or, put another way, “good” vs. “bad” patients) is one that’s received considerable study. People who work in health care encounter all types of personalities, backgrounds and preferences among their patients, and they often see patients at their worst. Because health care essentially comes down to a transaction between human beings, how clinicians perceive their patients, and vice versa, inevitably becomes part of the equation.

Research seems to support that the quality of the doctor-patient relationship indeed makes a difference. One rather disturbing study, conducted in Canada a couple of years ago, found that doctors tended to underestimate the severity of pain in patients whom they disliked.

There also seem to be expectations on the part of clinicians for what constitutes a “good” (read: “likable”) patient. The Medical Dictionary, for example, defines it this way:

A patient who:

1. Provides reliable history and information.

2. Follows the prescribed regimen, drug therapy, or recommended change in lifestyle, if appropriate for the patient’s condition.

3. Reliably returns for check-up visits at appropriate intervals.

Being likable or agreeable doesn’t always benefit the patient’s care, however, especially when patients don’t speak up because they fear the doctor won’t like them for doing so.

The challenge, it seems, is how to manage the doctor-patient encounter without letting likes or dislikes become personal or dominate the relationship.

So how did Dr. Dizon work through his dislike of this particular patient? Ultimately he came to the realization that it’s OK for doctors to own their feelings and not feel compelled to like every patient they treat, he wrote. Nor did the patient have a duty to like him in return.

“It dawned on me that I was working so hard to make her like me (and vice versa), that it was affecting my ability to care for her,” he wrote. “Once I admitted to myself that it was okay to not like a patient, I was able to do what she wanted me to do – to be her doctor.”

Hurt feelings: When the patient dumps the doctor

One of my all-time favorite physician bloggers, Dr. Jordan Grumet, is making a big career change, and he wondered this week how many of his patients will be loyal enough to follow him to his new practice.

He’s learned from experience that some won’t – John, for instance, who arrived in his office several years ago with a cancer that had been missed on a CT scan. Dr. Grumet pursued the diagnosis, John was successfully treated and they had a doctor-patient relationship that lasted for several years, until Dr. Grumet moved to an office half an hour away and John declined to follow him.

“Without apology, he explained that he preferred someone closer,” Dr. Grumet wrote.

And yes, it hurt, he admits. “My sense of professional worth dropped a notch that day.”

Patients leave their doctors for many reasons, not all of them personal. Sometimes it’s because the doctor is no longer in their health plan network. Sometimes the patient or the doctor moves to a new location and the distance is too far, or transferring the medical record is an unwanted headache.

Other times it does become personal – when patient and doctor clash over a decision, perhaps, or a negative experience prompts the patient to bail out.

No matter the reason, however, it can be emotionally painful for a doctor to be dumped by one of his or her patients.

Somewhat surprisingly, this issue and its impact on the physician’s psyche have been little studied. One of the few pieces of research to date comes from Israel and contains a couple of interesting findings: Doctors were more likely to experience hurt feelings when the relationship was terminated by someone who had been their patient for a long time. It also hurt more when the patient was perceived to be someone of high social status.

The researchers came to these conclusions after asking 119 Israeli doctors to respond to four fictional scenarios involving a patient who switches doctors. As part of the study, the doctors also were invited to share their own experiences and reactions to being dumped by a patient.

Why would it hurt more if someone who had been your patient for many years decided to change doctors? Physicians feel vested in a relationship of many years’ standing, and a patient who comes back year after year is usually sending a signal that he or she feels vested too, the study’s authors wrote:

Thus, physicians may expect that patients will not end long standing relations for trivial reasons but rather that something serious has happened such as gross dissatisfaction with the treatment, or other serious reasons for extremely negative evaluation of the physician’s competence or behavior. Such thoughts would engender a heightened sense of relational devaluation and hence a higher level of hurt feelings.

That physicians also would be more bothered by the departure of a high-status patient is one of the more intriguing findings of the study. The researchers hypothesized that doctors may assume, correctly or not, that patients who are educated, well off and of good social standing are also better judges of the doctor’s professional competence and therefore more likely to have opinions worth valuing.

The personal stories shared by some of the doctors in the study revealed more nuances. Several of them described feeling hurt at investing great time and effort in a patient’s care, only to have the patient change doctors. One doctor had an entire family leave his practice over a single incident of missing a child’s ear infection; what made it hurt more was not being given a chance to explain. Notably, many of the doctors didn’t learn of the patient’s departure until after the fact.

Should it matter if a doctor’s feelings are hurt when a patient leaves?

These situations aren’t without consequences, the researchers wrote. They can lower the doctor’s self-esteem, accelerate the likelihood of burnout and perhaps spill over into relationships with other patients. Moreover, with increasing emphasis on patient-centered care, the doctor-patient relationship has become much more important and there’s greater pressure on doctors to earn the trust and satisfaction of their patients.

Patients don’t benefit by staying with a doctor when the relationship doesn’t work well or when it breaks down. But it may have an impact on the doctor when they bail out, especially if their departure is unexpected or ungracious. At its heart, medicine is still very much about interactions between human beings, the doctor as well as the patient.