The One Dozen Most Important Things You May Not Have Known, Understood, or Realized About American Medicine
The Doctor-Patient Relationship - Scenario Analysis
These two scenarios are meant to demonstrate patients at the extreme ends of a range of possible attitudes toward compliance with physicians’ management plans.
The first patient is totally compliant, not posing any questions or objections, and apparently completely willing to do whatever his doctor tells him to do. By contrast, the second patient obviously wants to take a much more active role in the decision-making process with regard to her care. She questions the efficacy and appropriateness of the medication that has been prescribed for her high blood pressure and indicates a strong resistance to adding another prescription to her daily regimen. She has been doing her “homework” and presents the physician with a proposed alternative drug she has researched based on a recommendation from a friend. She presents the physician with the material she obtained on-line and asks him to consider changing her treatment to include that drug.
While not all U.S. patients will be like the second patient, IMGs must become accustomed to being questioned or challenged with respect to their knowledge or judgment. These challenges should not be taken as personal or professional affronts. In dealing with all patients, physicians should be sensitive to the degree to which patients want to obtain more information and actively participate in the decision-making process.
Many U.S. patients are interested in receiving information about their diagnoses, potential treatments, side effects, and prognoses, and often want to take an active role in deciding which course of management to pursue. Many will be quite well informed and will come to the physician having done a good deal of research. Physicians need to recognize that this is not a challenge or threat to their authority or expertise. They should express respect for the patient’s willingness to be involved in the decision-making process and commend them for their efforts in obtaining information about their medical conditions, diagnostic modalities, potential treatments, and other aspects of their care.
At the same time, it must be acknowledged that there is a great deal of information on the Internet regarding medical issues, and not all of it is accurate or up-to-date. If the patient presents bad information or proposes unacceptable alternatives, the physician must carefully acknowledge the patient’s interest and initiative while pointing out why the proposal is not viable. When the patient presents information the physician is not in a position to evaluate, that should be honestly stated, and the patient should be advised that the physician will research the issue as soon as possible after this visit. Obviously, this requires that the physician follow through and be able to report back to the patient on the next visit.
Although this scenario was developed primarily to demonstrate the variation in patient behaviors and attitudes, viewers have been quick to note some serious deficiencies in the physician’s behaviors and attitudes. His demeanor is generally quite authoritarian, and his opening question in both scenarios is unnecessarily confrontational. An alternative approach would be to start by expressing concern about the continued elevation of the patient’s blood pressure and then more sensitively pursue why the patient may not have been following the prescribed regimen.
The addition of a drug is always a concern to patients, so it would have been more desirable for the physician in these scenarios to underscore the importance of adequately treating hypertension and the rationale for adding another drug. Perhaps the physician could have explained that the new drug might function differently than the first drug and the two together might be more effective. Obviously, the new drug should be identified by name in the event that the patient is familiar with it and has any considerations regarding it.
Finally, it is apparent from the doctor’s nonverbal communication that, rather than being pleased by the patient’s interest and initiative, he is affronted and feels challenged, and it therefore not very likely to enter into a fruitful discussion of treatment options.
