Boy is this a pertinent quip from Medical News Today .

In today’s world of very educated patients, most would be insulted if the physician even mentioned anything to do with depression. And yet, the universal presence of depression in the U.S. is phenomenal. Many people do not know that that is their diagnosis though. And therefore, they think that there "must be something wrong with me" - something that enough "tests", enough "diagnostic studies" - enough something - would show. The somatic symptoms of depression are multiple. And it should be considered in most scenarios. AND most patients should not be so resistant to the screening process. This resistance is what keeps physicians from even considering it as a diagnosis.

Providing a voice to an often silent disease, Epocrates, Inc. surveyed 500 clinicians to identify trends in depression diagnosis, prevalence and treatment. People dealing with stress, whether in the workplace or at home, should take note; nearly all clinicians identified stress as the leading contributor to depression.

The majority of clinicians reported seeing an increase in depression in the past five years, and believe this increase may be driven by greater disease awareness, and ultimately more patients seeking help. However, clinicians reported that many more patients may be experiencing symptoms that are going undiagnosed. More than half of survey respondents felt that physicians are hesitant to diagnose depression, primarily due to resistance from patients and lack of societal acceptance. Clinicians also reported uncertainty about diagnosing depression, as patients may present symptoms differently based on gender and ethnicity, or may be a product of another medical illness.

"In today’s digital age, the increasing pressure to get it done yesterday can lead to more stress and potentially depression. Early recognition and intervention are important to prevent the loss of jobs, damage to relationships or suicidal thoughts," said John Luo, MD, Assistant Clinical Professor of Psychiatry at UCLA Semel Institute for Neuroscience and Human Behavior.

The vast majority of clinicians reported recommending prescription therapies for their patients experiencing depression. Beyond pharmacotherapy and psychotherapy, 60 percent of respondents believe lifestyle changes such as diet, exercise and meditation may also be helpful in treating depression, depending on the patient’s individual situation.

Additional key survey findings include:

– Gender makes a difference when diagnosing depression

– Thirty percent of clinicians reported being less likely to discuss depression with men.

– Clinicians reported it is often more difficult to treat men because they are less "open" than women, and symptoms such as anger or addiction may not be immediately linked to depression.

– Clinicians may be more likely to experience depression

– More than 50 percent of clinicians reported experiencing depression at some point in their lives, which compared to the National Institutes of Health data, could make them more than twice as likely to experience depression as the general public.

– Additionally, 12 percent of clinicians reported missing work because they felt depressed. Clinicians are not alone-a national study revealed that depression is the leading cause of missed work days, and lost productivity due to depression is estimated at $83 billion a year.

For more about depression, including a podcast with UCLA psychiatrist Dr. Luo, clinicians’ comments and comprehensive survey results, please visit http://insights.epocrates.com/depression. Comprehensive dosing and drug interaction information for anti-depressants can also be found at http://www.epocrates.com.

I found an article the other day that discussed use of the ER for non-emergency conditions. I thought it would be a good discussion topic so here it is:

Overuse of Emergency Departments Among Insured Californians

October 2006

One of the key challenges facing emergency departments (EDs) nationwide is a marked increase in use, driven primarily by insured patients who do not have true emergencies. With the troubling trend in California of emergency room closures, it is important to examine the factors that lead to inappropriate emergency room use.

A recent Harris Interactive Inc. survey found that nearly half of recent ED patients felt their problems could have been handled by a physician’s office visit, had one been available, rather than using the ED.

CHCF commissioned Harris Interactive to conduct two sets of surveys, one of emergency room patients and one of primary care physicians and ED physicians. The patient survey found four key factors that drive increased ED use by insured patients who are not critically ill:

• Lack of access to medical care outside the ED (e.g., same-day appointments with a primary care physician, or evening and weekend appointments);
• Lack of advice on how to handle sudden medical problems;
• Lack of alternatives to the ED (e.g., nurse advice lines or urgent care clinics); and
• Positive attitudes about the ED as a site of care.

The lack of options for Medi-Cal patients, who have even more trouble with access to primary care than privately insured patients, is especially severe. The study also noted that patients with chronic conditions made more ED visits, suggesting that their primary care providers may need to improve their methods of chronic disease management.

This issue brief summarizes the key findings of the survey, recommends strategies to increase alternatives to ED use, and calls for streamlined ED processes, as well as improved communication between physicians and patients.
 
Overuse of Emergency Departments Among Insured Californians - CHCF.org  –  http://www.chcf.org/topics/hospitals/index.cfm?itemID=126089

The one good thing from this (remember, I’m an ER doc) is the last bullet - that people had positive attitudes about the ED as a site of care. They may complain about the wait they have to get the care and to complete the care, but it’s apparent that people do think that ED physicians and staff are on the cutting edge. That’s a very important point but not a good reason to use the ED.

Not only is it bad for you when the EDs are so crowded but it’s bad for everyone coming in. Fortunately the ED staff is used to getting the story quickly and barking off orders for this bed or that bed and they all get done. But this is NOT a good way to get personalized care. I hope that physicians look at this brief and say to themselves that they need to look at the services they offer. As I talk about in "Your Doctor Said What?", we have to get sick on the doctor’s schedule and I can tell you from expeirence on both sides of the fence (as a doctor and perhaps, more importantly, as a patient, that rarely occurs. The Urgent care clinics have been a great boost there but a greater review of the situation is needed.

Terrie

If you have Ulcerative Colitis or know someone who has it, read this…. 

This shows that it is a good thing to have those ads on TV that talk about Ulcerative Colitis - just as it is good to have the ads about erectile dysfunction - we need to raise awareness about these conditions for those who know nothing about them - and it helps people know they are not alone and there are treatments out there for them.

Ulcerative Colitis (UC) Sufferers Find UC Quite Disruptive to Many Aspects of Daily Life

UC’s Overall Psychological Toll Is Greater Than for Asthma, Rheumatoid Arthritis and Migraines

WAYNE, Pa., May 17 /PRNewswire/ — Nearly three out of four ulcerative colitis (UC) sufferers (73 percent) responding to a new nationwide survey say not feeling well has become a normal part of life. Furthermore, they describe UC as disruptive when it comes to their relationship with a spouse (64 percent), their sexual relations (75 percent) and their emotional state (82 percent).

UC patients "normalize" aspects of their experience to the point that they resign themselves to these burdens. The majority say that there is not much they can do beyond what they are already doing to feel better (70 percent) and they have learned to live with the disruptions that UC causes (83 percent).

"The findings sound an alarm because a diagnosis of UC shouldn’t mean patients are settling for the level of burden reported in this survey for the next 50 or 60 years. UC is a manageable disease with the appropriate therapy," says David Rubin, M.D., a gastroenterologist and assistant professor of medicine at the University of Chicago Medical Center who helped design the surveys.

UC is a chronic autoimmune disease that causes inflammation in the intestine and can lead to symptoms such as severe abdominal pain and cramping, uncontrollable bloody diarrhea several times a day, fatigue and weight loss. It is typically first diagnosed in people between the ages of 15 to 30 and is estimated to affect nearly 700,000 Americans.

The objective of the surveys was to understand how UC affects patients’ lives, including definitions of what’s normal, the threshold for letting the disease disrupt life, and how patients manage their condition. The surveys, titled "UC: NORMAL (New Observations on Remission Management and Lifestyle)" were sponsored by Shire Pharmaceuticals, a specialty biopharmaceutical company which markets UC medications LIALDA(TM) and PENTASA(R) (mesalamines). Please see Important Safety Information included below.

UC patients generally report more stress/depression compared to other diseases

The findings illustrate that UC takes a heavy psychological toll, which is further brought to light when comparing UC patient responses to the survey responses of people with three other chronic health conditions — migraines, rheumatoid arthritis (RA) and asthma, who were also surveyed as part of UC: NORMAL. Eighty-two percent of UC patients said their condition made life more stressful versus 75 percent of migraine patients, 69 percent of RA patients and 46 percent of asthma patients. Furthermore, 62 percent of UC patients reported feeling sometimes or always depressed about having their condition, versus 49 percent of migraine patients, 52 percent of RA patients and 25 percent of asthma patients.

More than four out of five people (84 percent) with UC say they worry about the long-term health effects of having UC, compared to 45 percent of migraine patients, 72 percent of RA patients and 58 percent of asthma patients. Specific worries most commonly mentioned by UC patients were developing colon cancer, having their colon removed, requiring surgery and public fecal incontinence.

Compliance is a challenge

The survey found that 32 percent of UC patients are not currently taking medication to treat their UC. For patients who are taking medications, compliance is an issue. Of those UC patients taking aminosalicylates (5-ASAs), the first-line therapy and most commonly prescribed class of medication for UC, only about half (54 percent) reported that they have taken all of their 5-ASA medications in the past seven days.

Past studies confirm compliance challenges and report that patients who are noncompliant with their prescribed UC medications have a five-fold greater risk of flare-ups than compliant patients. Traditionally, 5-ASA therapies required two to four times daily dosing and up to 6 to 16 pills a day.

"It’s troubling that almost one-third of UC patients are not taking medication because the standard of care is that all patients with a diagnosis of UC should be on medication to maintain control of the condition and reduce the likelihood of relapse," says Dr. Rubin. "The other challenge we need to address is compliance. More convenient dosing regimens such as once-daily dosage formulations may be part of the solution."

Bridging the physician/patient gap

Patients are also normalizing their experiences with flare-ups, a serious worsening of UC symptoms. UC patients reported an average of eight flare-ups per year. Four out of five (81 percent) of those surveyed say they consider the number of flare-ups they experience to be "normal" for their condition. On the other hand, in a survey of gastroenterologists also done as part of UC: NORMAL, physicians reported that a "typical" number of flare-ups per year on average is three among all patients (2 flare-ups if condition is mild; 4 if condition is moderate; 5 if condition is severe).

UC patients admit that they do not report all of their flare-ups to their physicians, making it difficult for physicians to understand the impact of UC on their patients’ lives. One-third (34 percent) said they are sometimes reluctant to tell their doctor about flare-ups.

"If patients are experiencing multiple flare-ups a year, they should feel empowered to talk to their physicians openly about their disease and ask if their current therapy is appropriate for them," says Dr. Rubin. "As physicians, we need to ask questions to encourage patients to be forthcoming and open with us about the challenges they face and the concerns they have."

As a company committed to educating patients and working with physicians, Shire is developing a program that will launch this fall and is designed to help foster increased discussion between physicians and patients about UC and its management.

Low public awareness

Further confounding the challenges for UC patients, their disease is relatively unknown among the general public. According to UC: NORMAL’s survey of a cross section of the general public, 74 percent of Americans have either never heard of UC or have heard of it but know little about it, even though UC’s prevalence approaches the numbers for HIV/AIDS and Parkinson’s in the United States.

More than two-thirds of UC patients report that having UC is embarrassing to them (70 percent) and that they are reluctant to tell people about their condition (66 percent). With low public awareness and this hesitation to talk openly about their UC, feeling isolated is a risk for UC patients.

"This survey highlights the need to raise awareness and engage the public in a discussion about UC," says Richard Geswell, president, Crohn’s and Colitis Foundation of America (CCFA). "There’s a scarcity of data relating to patient experience and opinions of UC and its treatment, so I hope these findings will help bring this disease to the forefront and assist the ulcerative colitis community in identifying areas to focus our efforts."

"Like many other chronic diseases, there’s no medical cure for ulcerative colitis, but with better management of quality of life issues, improved patient communication and by getting patients on effective therapies, we can help patients live more normal, fulfilling and productive lives," concludes Dr. Rubin. "I hope the survey will spark a national dialogue about UC. I know I’ll use it as a conversation starter in my practice."

The surveys were conducted by Richard Day Research and included a total of 1,975 people: 451 UC patients, 300 gastroenterologists, 309 RA patients, 305 asthma patients, 305 migraine patients and 305 adults from the general U.S. population who may have chronic health conditions. All patient surveys and the general public survey were fielded through an online panel that closely reflects the U.S. adult population overall. Physicians were recruited from a list of all board certified gastroenterologists in the U.S. Assuming no sample bias, the margin of error for the sample of 451 UC patients is +/- 5 percent; assuming no sample bias, the margin of error for a sample of 300 (the other surveys) is +/- 6 percent.

For more information about the survey, visit http://www.ucnormal.com/. For more information on ulcerative colitis, visit http://www.managinguc.com/.

Physician-patient relationships Business Editors/Medical Editors BOSTON–(BUSINESS WIRE)–May 17, 2007–As part of its ongoing commitment to patient safety, ProMutual Group, a leading provider of medical liability insurance in the Northeast, is pleased to announce that on behalf of its insured physicians, it has negotiated a discount on annual subscriptions to EmmiPrep(TM), an innovative, web-based, patient education and risk management tool. The reduced cost of Emmi will be effective immediately for all policyholders that purchase an annual subscription.

Developed by Emmi Solutions, LLC, the innovative Emmi system is designed to help healthcare providers improve the quality and reduce the costs of healthcare. At the heart of the Emmi system are engaging, interactive programs that help patients and their families understand what to expect before, during and after a medical procedure. The Emmi program’s interactive nature allows patients to ask specific and confidential questions of their physician and alerts physicians to specific concerns the patient may have. This important attribute further enhances communication and strengthens the physician-patient relationship. The program also provides detailed documentation of each patient interaction with the program and provides physicians with a powerful risk management tool to ensure patients understand their role in ongoing care before and after a procedure. 

We are constantly looking for new and innovative ways to promote patient safety," said Maureen Mondor, vice president of risk management for ProMutual Group. "Emmi provides an excellent means of educating patients, improving the informed consent process and mitigating risk. We think Emmi will be an ideal complement to ProMutual Group’s ongoing efforts to provide superior risk management services to our insureds so they can better meet the needs of patients and the challenges of healthcare practice today."

Studies indicate that patients who fully understand what to expect from medical procedures are more satisfied with the outcomes and less likely to file medical malpractice claims. Not surprisingly, a 2006 survey conducted by Emmi Solutions found that of the 18,000 patients who had viewed an Emmi program, 96 percent developed a better understanding of their procedure. Additionally, 79 percent of patients found that the program provided new and important information and 85 percent reported that the program increased their confidence in their doctor and comfort level with the procedure.

"I want to do everything I can to increase patient safety and reduce risk in procedures that I perform," said Dr. Murray Goodman, an orthopedic surgeon in Salem, Mass. "A large part of that is educating patients and helping to bring their expectations in line with reality. I always have an informed consent conversation with my patients, but using Emmi helps many of my patients more fully understand the proposed procedure, the reason behind it, and its risks and benefits."

By utilizing Emmi in their practices, ProMutual Group policyholders will be able to build relationships with patients, further improve patient satisfaction and increase patient safety.

"We are pleased to be collaborating with ProMutual Group in introducing Emmi to the physicians they insure," said Jordan Dolin, vice chairman of Emmi Solutions, LLC. "Emmi is a unique, innovative system that has been adopted by some of the most progressive healthcare providers in the country. We think it’s a great fit for ProMutual Group and its insureds to enhance the healthcare experience for everyone involved."

For more information about the Emmi Solutions program, to schedule an interview with a ProMutual Group representative or speak with a physician currently utilizing the system, please contact Nina Akerley at ProMutual Group via telephone number (617) 946-8665 or by email at nakerley@promutualgroup.com.

About ProMutual Group

ProMutual Group is the largest provider of medical malpractice liability insurance in New England, insuring more than 18,000 physicians, surgeons, and dentists as well as a large number of hospitals, health centers and clinics. It is one of the top 10 medical liability insurance providers in the country based on direct written premium. ProMutual Group has more than $2 billion in admitted assets, over $500 million in policyholder surplus, and nearly $340 million in direct written premium. ProMutual Group has a Best’s Rating of A- (Excellent), and is a leader in providing risk management and claim services.

Based in Massachusetts, ProMutual Group member companies also operate in Connecticut, Maine, New Hampshire, New Jersey, Pennsylvania, Rhode Island and Vermont. ProMutual Group distributes its products through independent agents. For more information, visit ProMutual Group’s web site at www.promutualgroup.com.

About Emmi Solutions

Emmi Solutions, LLC is the producer of the Emmi healthcare communication system, helping health organizations connect more intimately and effectively with patients and their families. In a field where trust and good communication is critical to quality and safety, Emmi is highly regarded as a one-of-a-kind intervention that clarifies complex information using a conversational voice to engage patients and affect behavioral change.

Created in 2002 by a surgeon and a computer game designer, Emmi facilitates physician-patient communication by providing multimedia programs to help patients understand what to expect. Whether it’s preparing for a procedure, living successfully with a medical device, or helping people manage a chronic disease, every detail of the Emmi system is designed with a single goal in mind: to improve quality by helping patients, their families and caregivers take an active role in their care. Better-informed patients who are engaged in their care drive benefits that cascade across all healthcare organizations and interests.

 This is about heart disease from About.com but the info is still pertinent

Getting What You Need From the Health Care System

There’s nothing more frustrating, or more dangerous, than having to solve your own medical problems. No matter how many hours you spend searching the Internet, listening to the accumulated wisdom of your Great Aunt Hilda, or engaging in games of Twenty Questions with taciturn medical personnel, you can never be sure you’ve got the right answer. 

It’s not supposed to be like that. When you’re sick and need help, you’re supposed to be able to rely on a doctor - a doctor who is knowledgeable, who really cares what happens to you, and who will leave no stone unturned in seeing that you get exactly what you need.  Unfortunately, having such a "model" doctor is becoming rare. Patients are on their own much more often, and to a much greater extent, than they used to be - and it’s getting worse all the time.  

If you’ve read Part 1 of this series, you’re acquainted with our contention that patients are feeling abandoned by the health care system because they really have been abandoned; and that (because widespread covert rationing is systematically destroying the doctor-patient relationship,) the abandonment of patients is happening by design rather than by chance. But even if you don’t buy DrRich’s explanation of the problem, the problem still remains. When you’re sick and find yourself engaged in a hostile health care system, you need somebody in your corner who knows what she’s doing, and who cares about you.  And that somebody is supposed to be your doctor.

Choosing the right doctor for yourself, and nurturing a good relationship with him, is probably the most critical step you can take in becoming an effective patient. With the right doctor at your side, the path to good health care becomes clear and wide. Without that doctor, you’re lost and alone in the enchanted forest.  Accordingly, this article discusses two aspects of dealing with your doctor: Choosing the Right Doctor, and The Care and Feeding of your Doctor-Patient Relationship.

Rule # 1. We ought to begin with the first rule of choosing a doctor, to wit: You hired him; you can fire him.

Choosing a doctor is different than, say, choosing a car. When you buy a new car, you can shop around to your heart’s content, but once you plunk down your money and bring that baby home, you’re pretty much stuck with it. If it’s not everything you hoped it would be, you can’t just get rid of it - why, it lost 50% of its original value the minute you drove it off the lot. Besides, it’s not life and death, it’s just a car. So if your new car turns out to be a disappointment, you’ll usually shrug your shoulders and resolve to live with it for a few years, at least until you can justify buying another one. 

It’s different with doctors. For one thing, it’s harder to shop around before you make your move. For another, starting with a new doctor doesn’t require an up-front investment of tens of thousands of dollars. Early on, all you’ve invested is some time and inconvenience. And finally, choosing the right doctor potentially is a matter of life and death.

Many patients have the same attitude when they’re dissatisfied with their doctors that they would have if they were dissatisfied with a car - "Oh, well, guess I’ll just have to live with it." This is the wrong attitude, since, indeed, in this case you may not live with it. Doctors are serious business.  Choosing a doctor is an important decision, but it’s not an irreversible one. It’s not uncommon for discerning patients to run through two or three doctors before finding the right match. And there’s nothing wrong with doing it that way. So if you’ve tried a new doctor and you’re not satisfied with him, get another one. Remember: You hired him; you can fire him.

The most important factor in choosing a doctor: Communication.  If you can’t communicate well with your doctor, you’re in trouble. This is the person, after all, who will need to understand your wishes and values regarding your health care. She is the one who will need to explain to you, so that you can understand it, the nature of your medical problems - the causes, the testing that may be needed, the potential treatments, the pros and cons of the various therapeutic options, and why she’s recommending one option over the others. She’s also the one who has to convince your insurance carrier that the course of action you and she have decided upon is the right one, that it’s medically necessary, and that they - the insurance carrier - ought to pay for it. Communication has always been important in medicine. Now it’s vital.

Is your doctor really listening to what you are saying? Does he show he understands your concerns by responding meaningfully to them? When he explains medical issues to you, does he make them understandable? Does he have more than one way of explaining a difficult concept? Is he patient with you, waiting for you to grasp what he’s saying, or does he try to embarrass you into saying you understand, with shakes of his head or rolling of his eyes? Do you like him, and more importantly, does he seem to like you? (This may become very important when it’s time for him to go to bat for you.) 

The inability to communicate effectively with your doctor is sufficient reason to move on to someone else. Without communication, you’ve got nothing.

The second most important factor: Does your doctor know what she’s doing?

Sometimes its hard to know for sure how knowledgeable your doctor is. But at a minimum you should check to see if your doctor is board-certified in her specialty.  At least two sources can help. The Directory of Physicians in the United States and the Official American Board of Medical Specialties Directory of Board Certified Medical Specialists list doctors who are board-certified. These books are available in most public libraries, and your doctor should appear in them.

Does your doctor seem smart to you? When you ask a question about one of you health problems, are the answers quick, logical, and cogent? Do the answers jibe with what you know to be true? Are her answers given confidently, or is she dissembling? Keep in mind that it’s often fine for a doctor to answer, "I don’t know," as long as she promises to find out the answer, and then follows through on that promise.

For specialists you will be seeing only once or twice, or who you are going to for some complex or esoteric medical procedure, their experience, knowledge and ability are often much more important than how well they communicate. If I’m having a heart valve surgery, I care much less about how warm and fuzzy the surgeon makes me feel during the pre-op interview, and much more about how many similar procedures she’s performed, and what have been her surgical results.

The third most important factor:  Is your doctor respected by his peers?

Doctors watch each other perform in the trenches, and in general, are pretty good at sizing each other up. If you can get a recommendation on a doctor from another doctor you know you can trust, that’s likely to be a good starting point.  If you know some doctors, ask them what they think. Would they send their own patients to your doctor? Or, better yet, do they send their own family members to him? Do they use him as their own doctor?  And, if your doctor is invited to participate in the training of medical students or medical residents at the local university, that’s a reasonably good sign that he’s held in high regard by his peers.

Other factors to consider. 

• Where is your prospective doctor located? Is her office convenient to you?
• Which hospitals does she have admitting privileges to? Are these hospitals convenient to you, and do the specialists there (since the specialists in those hospitals are the ones she will be referring you to) have a good reputation?
• What are her practice arrangements? Who covers for her when she is away?
• Is her age, gender or race important to you?
• What is her office staff like? Are they reasonably competent, friendly, and helpful, or is their main job to keep you out?
• What are her office hours and office policies?
• What insurance plans does she participate in? This may be especially important if you are likely to be changing jobs (and thus changing insurance carriers.)

Where to look.

Start with your family and friends - people whose opinions you trust. Find out who their doctors are, and whether they are happy with them. Find out why they like them.  Also, talk to medical specialists, and especially to nurses and (if you know any), physicians’ assistants.  See which doctors they respect and admire, and why.

Another place you might consider looking is www.bestdoctors.com.  This is a listing of American physicians chosen through a survey of other American physicians.  For a doctor to make the list, a large number of physicians have to assert that they would want that doctor to take care of them or their family members if they were sick. Best Doctors is a business, however, and currently requires a $35 subscription fee.  A problem with Best Doctors is that it is sometimes weighted toward academic physicians, and there are potential drawbacks to academics - doctors often sing the praises of academics not because they are especially good doctors, but because they have published a lot, or are in positions of power. Some of the most famous university doctors are not especially good clinicians. The bottom line is that while you may find Best Doctors useful, it should by no means become your chief searching tool.  The large majority of excellent doctors in the U.S. are not listed there at all. If you strictly limit your search in this way you may be cheating yourself.

Once you have made your list of doctors, check for them in the Directory of Physicians in the United States or the Official American Board of Medical Specialties Directory of Board Certified Medical Specialists in your public library to make sure they are board certified.  Finally, call the office of one or two of the doctors still remaining on your list. See what you have to do to get an appointment.  See whether the office personnel seem friendly and efficient, or whether they’re obstreperous and obstructive.  Remember that you may need to deal with these people fairly often, and that before you ever get in to see the doctor, you’ve got to get past them. And remember that the doctor’s front office is a reflection of his own personality.  If his receptionists and nurses are difficult to deal with, you’ve got to assume that the doctor likes it that way. 

 The remaining step is to pick one of the "finalists" on your list, and make yourself an appointment.  If after meeting with the doctor you decide this isn’t going to work out, remember Rule # 1.

If you’ve read Part 1 of this series, you know that the traditional doctor-patient relationship is in deep trouble.  The problem, of course, is that the health care system simply can’t afford the traditional doctor-patient relationship anymore. There’s no way that HMOs, hospitals, insurance carriers, or federal regulators can allow doctors to continue directing the spending of health care dollars as if the only important consideration is the welfare their patients. In thousands of ways doctors are being coerced into giving the needs of each of these other parties a higher priority than the needs of their patients. So in becoming an effective patient, you’ve got to take the weakened state of the doctor-patient relationship into account.

The effective patient’s strategy 

Simply assuming that your doctor is always going to be acting in your best interests - no matter how good a doctor he is, or how ethical - is a big mistake.  The effective patient understands this, but she understands something else, too. She understands that her doctor (if she’s chosen her doctor wisely) deeply wants to honor the traditional doctor-patient relationship, since honoring that relationship is his first duty as a professional. She understands that, despite all the coercive pressure to the contrary, her doctor will occasionally go up against an HMO for the benefit of a patient. He needs to do this as a matter of professional pride - just to be able to live with himself. (The HMOs understand this, too. Letting the doctors win one now and then - only, of course, after putting up a stiff resistance - costs them some money, but in the long run keeps the doctors mollified. It keeps the doctors working, and it keeps them quiet. It’s just one of the costs of doing business.) The effective patient also understands that, as much as he may want to, her doctor cannot go to the wall for every patient, or for every issue that comes up for a given patient. The process would be too grindingly difficult, and fatal to his career. She knows that her doctor must choose his battles carefully.

The effective patient understands all this, and nurtures her relationship with her doctor accordingly. She tailors the relationship in such a way that, when the chips are down, she is likely to be one of those her doctor will go to the wall for.  To be such an effective patient, consider following these three general strategies:

Strategy 1 - Be empathetic.  Show that you understand the constraints under which your doctor is laboring, and adjust your expectations accordingly. Don’t be too demanding, especially regarding the small stuff. Show that you respect your doctor’s skills, and that having his skills working for you is worth a few minor inconveniences. After all, you make clear, you know how hard it is to be a good doctor these days, and you’re thankful he’s there for you despite everything. 

Strategy 2 - Align your interests with those of your doctor. Remember: you and your doctor are in this together. He feels your pain, and you feel his. You both want the same things. You both want the patient (you) to get good health care; and you both want the doctor’s practice - and professional integrity - to thrive. So while you fully expect to get the care you need from your doctor, you will help him to deliver that care as efficiently and as cheaply as posible.

You will not bother him needlessly, or thoughtlessly. You will make the most efficient use of your time with him. You will learn how his office operates, and cooperate with his office staff in minimizing interruptions and special requests. (For instance, inquire as to the best time to call the office with questions, or to speak with the doctor.) The main idea is: you are interested in making the doctor’s job as easy for him as possible, while still having your own vital needs served. 

Strategy 3 - Become engaged in your own good health. Nothing makes doctors crazier than patients who completely neglect their own health, then expect their doctors to pull out all the stops for them when they get into medical difficulties. The fact is, your doctor simply cannot afford to vigorously advocate for every problem for every patient. This being the case, which patient is your doctor more likely to fight for when they get sick - the obese smoker who has made no visible effort to take care of himself, or the diabetic who has carefully tried to follow her difficult diet and drug regimens?  

Maybe it isn’t fair, but it’s nonetheless true. If a doctor is considering stepping out of line and jeopardizing his own security to fight for his patient’s best outcome, you can be sure he’s more likely to reserve that action for a patient who’s fighting right at his side for the very same thing. 

You greatly increase the likelihood that your doctor will go to the wall for you if you are fully engaged in maintaining your own good health. You need to stop smoking, lose weight, exercise, take an interest in disease prevention, and during your visits to your doctor, demonstrate how involved you are with your own health care. Make yourself into the kind of patient that doctors find it rewarding and fulfilling to fight for.

Summary

By understanding how and why the doctor-patient relationship is under fierce attack, you can "manage" your own doctor-patient relationship to make yourself a more effective patient. 
Any doctor worth her salt will respond favorably to patients who seem to understand the duress she faces each day in the practice of medicine, who try to help her keep her head above water while she provides health care, and who take an active role in maintaining their own health. Patients like that are worth their weight in gold, and doctors try hard to provide them with the best health care they can possibly manage.