Another indication that health care is sick—doctors are being told to stop asking patients open-ended questions like:
“How are you feeling?”
“What worries you?”
“What’s on your mind?”
Today a physician just e-mailed me:
“I am really, really overwhelmed right now. What happened to me at work this week was grim, even before our dreaded production meeting. I can feel tears welling up. Reason: Many times I have tried to incorporate friendly pick-me-ups like a smile, a handshake, a ‘thank you for coming in to see me today,’ an ‘it was wonderful to see you today’ at the end of patient visits. My standard opening line has always been some version of ‘What brings you in today?’ I’ve always felt a source of pride that I can ask open-ended questions and still get to the bottom of most issues in a short visit. My production meeting yesterday pretty much squashed all those niceties out the door.
We are now to be double-booked [two patients per appointment slot] to ‘make our production quotas.’ Our regional director (not a doctor) reinforced the decision by our medical director (an MD under the thumb of the regional director) that we are NOT to ask open-ended questions in our visits but to let the medical assistants who room the patients identify the SINGLE issue that they are coming in for and THAT’S IT. So we basically need to shut down to whisk them through the door.
You know as well as I do how ridiculous and futile that is and how fast care like this destroys what’s left of the therapeutic relationship. I now have to figure out a way to work even faster while still being caring and compassionate. I am in a really shitty position.”
My plea to doctors: please stop taking this shit.
Pamela Wible, M.D., is a family physician and founder of the ideal medical care movement. Watch her TEDx talk on ideal care. If you’re a doctor, join the physician teleseminar and learn how you can stop suffering and start practicing real medicine. Photo by GeVe.
Luckily, I’ve never been told what I can and can’t ask patients, but I have been told to focus on a single issue per visit and ask the patient to come back, at increased cost to the patient, and endless frustration.
When I was leaving that practice, my previous employer threatened to sue if I told patients I was leaving (despite it being my ethical duty and obligation to notify patients of my departure) because I would “damage his business.”
I let him know that he was doing that without my help already by thinking of it only as a business. I get it that there are costs to manage and time constraints to balance, but one CAN see patients, do a good job, be ethical and still make a living.
RE 1 visit 1 problem.
Fortunately, I had this advise from an admin physician when I worked at an HMO; it lasted 1 visit, and I never returned to that model.
Unfortunately, you may be faced with this question in the future if you do not work for yourself.
Good for you that you had the strength to walk away.
Hope for those who are thinking the same thoughts.
Dr M in Western PA
Solo since 2004
FP residency completed 1988.
6 years staff model HMO.
8 years hospital owned practice (which has had 5 docs in the last 10 years since I left).
2 years working in a physician owned practice when I started out, which dissolved when the doc didn’t want to collaborate with the 2 of us “employed” docs.
That should add up!
I left my residency program after 1 week. I left every job I had feeling that I had failed.
I now have a private practice. I enjoy my work. I take care of patients the way they should be taken care of, like a human being. I realized that I was not the problem. The system is not only broken, it is antithetical to good patient care. It is focused more on making money. Do what is right, quit your job, start a practice. So you will not be rich but you will be happy.
You can also be rich and practice medicine properly and ethically if that is your goal. Most doctors are not driven by money. They are driven by meaning and caring for people.
As a physician in practice for 20 years, I am grateful every day for the courage of folks like you who stand up for what makes medicine a mission worth pursuing. We only allow our patients to be victimized when we allow ourselves to be victimized. My generation rolled over. I’m confident yours won’t!
I told my healthcare org that I was burnt out and could only see 20 pts per day. I had no resistance, thankfully. The decrease in my pay is incremental when you calculate taxes. My patients, staff, and I are happier. So thankful for your Tedtalk, maybe one day I’ll get my own place. Today- so much better! Thanks for caring and speaking up.
RE 20 pts a day “requirement”
Sad.
I hope you feel better for taking a stand.
Dr M in Western PA
I’m with Nelson! Enough is enough! I too have left the madness behind, but am feeling disheartened by these types of stories that I keep hearing – is there a way for those of us who have “made the leap” to help out those who haven’t yet? While I (and others) have stood up and said “I refuse to accept this for myself,” I’m now starting to wonder if we also have some sort of collective public-health obligation (referring to the health of our colleagues who are still trapped as cogs in the industrial medical “machine,” as well as to that of their patients, who are the vast majority of Americans) to unite and take a stronger stand. How on earth did it come about that some of the most highly-educated people in this country allowed a bunch of bureaucrats with checklists and patient satisfaction scores to bully us (and our patients) into a corner like this? (And then there is this lovely MOC thing on the horizon… More bureaucratic BS… ) Argh. Ok, enough ranting for now. To the person who e-mailed Pam: get out! find a way to start your own clinic! you can do it! and you *WILL* PROSPER!
Yes. We do have an ethical responsibility to save our ailing colleagues. Would you stand by and watch someone jump off the Golden Gate Bridge and do nothing? I know of a doc who lost 7 colleagues to suicide. What other profession loses so many and does nothing? We actually need to go out and befriend our suffering colleagues and help them back from the ledge. Absolutely. Call a few today. Check on them. Take them out for coffee or tea. Talk. For real. Listen to their silent cries. Only we can stop this madness.
OK, thanks for the ideas. You are certainly doing your part by shedding light on this with your blog and keeping the rest of us energized. Thanks for the good work & keep it up – for all of us!
Yes, like Pam has, say hello, watch others, talk with them about their days.
Dr M in Western PA
Solo since 2004
FP finished residency in 1988
A little (but ONLY a little) tangential, but I am still feeling “ranty.” Saw this article this morning about medical errors contributing to patient deaths & I immediately thought back to this blog post and thought to myself that as long as this kind of mentality persists, those numbers will only continue to rise…
That’s why I had to let it go. I was destroying my sense of self worth diagnosing people for profit.
I have seen two of my doctors leave for those reasons. One burnt out , he used to be so nice but all the pressure on him changed that. Then my other female doctor that I loved went to greenfield health. Patients pay a annual fee or 50 dollars a month for no waiting , and access to the Dr. whenever . I am thinking of going there instead of Ohsu where I go now. I usually get 40 minutes with the doctor , which really is about ten and if its a 20 minute appointment , thats about 5. The Dr. that went to Greenfield was the best. Sometimes I was in there an hour , she hooked me up with social services, with counseling , all kinds of things that no one ever mentioned to me before . She cared and that is probably why the powers that be told her to move along .I really love your blog . I sure like to see nice caring doctors here too. I would love to see everyone have a doctor they like and trust , and also doctors who arent pushed for quotas. Loved that goat pic too.
Thanks Maria!! Please share the TED talk –> https://www.youtube.com/watch?v=5cvHgGM-cRI and blogs as people do not know they can have (and deserve) ideal medical care. And the docs often feel so trapped and victimized. It is up to us to change things. No legislation can fix a health care system without a soul.
I am not a physician, I am a patient, and all I can say is “WOW”!! Unbelievable!
This makes me sad. The point of being a doctor is to help people and they’re effectively telling doctors not to do that, or to do it as little as possible per bill.
HMOs are evil to patients.
One turn they say, only one symptom per visit.
Then they turn around and berate you for “ignoring” symptoms. And they ALSO (reason unknown) constrain us to the so-called meds with the most toxins and most side effects and most recall histories. So the clinics and HMOs get kickbacks from pharmaceuticals too ?? If the drugs make patients sicker, then pharmaceuticals gain when patient needs more drugs to counteract bad drugs. Half of those given to also remedy previous bad drugs. And if you call, the desk clerk is ALWAYS a snitface, agitates patient for no reason, answers questions with rhetoric, and insists on an apptmt time that conflicts w patient’s ability to attend.
Then hangs up. When you call back, waits for half hr to pick up, then snits off again at the patient, wont change apptmt, and falsely claims patient is the problem. Cant doctors command better conditions than that ? Are there really so many doctors that staff and pharmacies can treat them that way? Patients too ?
If there are So Many doctors, why is it necessary to continuously import more doctors ? Desk clerks and “managers” really hate patients.
Luckily, my wife and I are in practice together and see 10 to 15 patients each and we are done by 12 noon. We can take as much time as we want with our patients. I have friends that work ‘under contract’ etc. for hospitals where productivity is the bottom line. I can’t practice medicine like that and either should you. Take a handle of your own medical practice and do what you feel is ethical and right without the pressures of a bottom line.
I know most of your talks are aimed at physicians, but I am a nurse practitioner who feels the same way you do. I am accused of talking too much with my patients about personal things like how their lives are actually going. I know all about their family issues, what’s stressing them out etc. and they know mine! My heart aches to be able to sit on a couch and diagnose and have a real relationship with my patients like the good old days! I heard a fellow coworker say once that she had absolutely no interest in getting to know her patients and she had no intention of ever sharing any of her personal life with them. How sad and arrogant!
I think this all applies to anyone providing health care. I don’t like the word “provider.” We can all be healers if we can give up being victims.
Yeah, they stared playing the 3 issues per visit game in residency. I explained that I’d limit it to 3 new issues maybe, but I’m not asking a person to have 3 separate visits every 3 months for their 9 chronic medical issues. People simply wouldn’t tolerate it! They’d get 1/3 of their issues or less dealt with every visit. It’s horrid what production line medicine has done to my profession.
I agree will you wholeheartedly but how about the plight of sub-sub-specialists who can only function within a complicated institutional structure. I am a seasoned internist by training and experience and qualified/practiced in 3 continents but my passion was for hematological malignancies and bone marrow transplantation. I am also a clinical/translational investigator; I don’t have a lab but collaborate with basic scientists to develop drugs and complex cellular products and take them to clinical trials. It is extremely demoralizing to see the “institution” being not supportive, and sometimes hostile and antagonistic, not only for revenue but for favoritism and hidden agenda!! I am ashamed to say but if our patients know what really happens in the background, they will be mortified!! I always had been a believer in being a patient advocate, even when I do research, I take their interests at heart and that the doctor-patient relationship is the center of the, so called, “health care solar system”!!! I believe, and sometimes I am gently reminded by patients and their families and other colleagues, friend, and my own personal family, that my “work” is very important! I can’t do my “work” without the infra-structure of the organization that I hate and loathe!! Is there is any salvation for ME? Or am I destined to, consciously, remain locked in that virtual world analogous of the 1999 Matrix movie!!!
I was a Primary Care physician for 10 years, and I was absolutely miserable. I hated my job and the way insurance companies tied my hands. No way one can deliver good medical care in 5 to 10 mins and being a ‘bean counter’ for the insurance company. I left primary care, went into Integrative Medicine, opted out of medicare, started my own practice. I now spend an hour with each patient, and, although I am making less money, am much happier.
Is Integrative Medicine a euphemism for “Concierge Care,” that is not affordable for average hourly wage earners ?
Obviously it cannot benefit the majority. Perhaps instead of rationing patient care with obfuscatory and concrete headed managers, we should be rationing profits. When profits are too high, recognize that pt care will suffer, then suspend the HMO or demand new management,
Integrative Medicine can be delivered at a fair price so not necessarily only for the wealthy. I favor a holistic approach in which people have their needs met body-mind-spirit. Healing is so much more than pushing pills and being a pharmaceutical vending machine!
I feel incredibly lucky, as a patient with several ongoing and tightly intertwining medical issues, to have a wonderful NP at a practice that doesn’t appear to have the absurd notion that it’s possible to address “only one thing per visit,” and yet provide anything whatsoever of real value to the patient.
If only we could make the bean-counters call things what they are:
“From now on, you will be required to diagnose and treat patients without actually seeing, examining, talking to, or asking questions of them. At no time will you be in the same room with them. Should you accidentally see a patient in the hallway, you must look the other way immediately. Failure to do so will earn you five demerits.
“During each five-minute appointment, you must accomplish the following: record in your laptop the presenting complaint. Only one symptom per visit. No more of this time-wasting business of ‘fever AND rash/headache/sore throat/broken arm/nail in head, and the like. Identify the single most important symptom, and ignore the rest. You will probably be surprised at how easy this becomes with no actual patient in the room. It’s the Future! We’ll be rich, I tellya; RICH! No, not YOU, doc, US! Your managers! Business is business! You don’t need actual patients to make money! You just need RECORDS! And the simpler, the better! Geez, how’d you doctors survive before you had us MBA’s to run things!
“Now, then, where were we … “
I am making under 100k per year, but it is allowing me to buy my building, have 30-60 minute appointments-12-14 a day-my own quotas. Right now I have one regular staff member and no medical assistant. I see Medicare and Medicaid. I bill insurance. I live in one of the areas that has lower fee for service due to archaic medicare rates for location. I thought I would burn out when I couldn’t find a qualified medical assistant, but instead I am feeling better than I have for a long time. I feel closer to the patients, more confident in my life and though it is weird to be getting less revenue and turning away new patients, the financial dip I had with the assistant is recovering. I have compassion for the providers who must support debt and family commitments with the high salaries this type of assembly line medicine provides. I encourage them to get financial counseling -Dave Ramsey Financial peace university is a resource. This may be better than a high brow financial planner. As a society we need to respect those who choose to make less, live a simpler life, and focus on the quality of their work and the relationships that they have. I still struggle with the pressure of family and society on me to “produce more”. Like many of you, I am a brilliant physician and they think there must be something wrong with me if I am NOT making the big dollars. Unlike dr. Weibel, I only spent one year working with others telling me how to run my practice. But I too have struggled time finding my place, because I thought there was something wrong with me when I didn’t make a lot of money. I realized that I make enough. Once I accepted that, I have really found joy in my work! Sure, I want to learn more and get smarter at this business, but what I’ve learned listening to Dr Weibel and reading her materials is that smarter is sometimes less. I honor her ability to accept us as professionals in whatever way we practice and encourage anyone who is struggling to take the webinar.
All I can say is never let them take away the main reason you chose to be in be in healthcare. That is who you are and once they have that….what is left of you ? Many times the only thing that got me through the day was my dedication to the patients. I had to use that as my excuse to continue on, despite the inner workings and politics of working in a hospital. No one appreciated me or my dedication so I had to find a way to continue for the patient and myself to get through each day. I had to do it for myself and my sanity.
It’s funny I just filed a complaint against my ex pcp because she runs her office like a drive thru and refuses to treat more than one, maybe two issues at any one appointment. As for double booking I am going to start charging a late fee..the same fee the doctors charge for not showing up or very late. My time is no less important that a doctors
Hi my names Hope, I’ve been frustrated lately more and more when i go to a Endocrinology MD doctor who talks to me pretty oddly,shy ask things like about stuff i talk about once when i first went about my living siutation,and butts into my daily life stuff like eating and my weight and excersising ,its annoying like she doesnt think like i have enough to worries about and i dont pay attention to it enough,sure might not to it presisly like they want,but i do enough its,but not always good i have diebtic type 2 and i do take care of it ,but dont waste all my time worrying over it when not needed ,i want to enjoy what life and happiness i have. not to long ago she ask me have i went to the eye doctor lately ,i said no,since last 2 years i havent been ,been longer than that without a visit,but i dont have money to always spare to just check up for diebtic issues in my eyes ,when last time i did said was no issues,i have barely any money for stuff and i already explain my issues of money before when i told about my living siutations and always try to explain and brush off her odd behavior. she didnt stop after that ,she said i need to go and i told her why that medicaid and medicare do take ,but there fee charges are high at walmart and not only i cant drive so i would have to get a lyft back and forth,which transport doesnt support eye appointments that arent eye inguries or something bad enough,she also then went on to tell me to loose more weight and to keep up loosing weight like i did cause of how much its brought up by them lost 6 pounds in a 6months ,but still isnt enough to please them,when i say that i cant always do that and i might always come in with the best they want from me,she said if i dont keep it up them she gonna put me on inseline and i’d need to go to get appointments to the eye doctor. me knowing that was used to scare me or get her way or what ever makes me pissed ,i never rude to them all i go there for in my opinion is to get my metformin and thryriod check ups,but being told how to live my life and then threating to do things like that makes dealing with this even more harder,idks what to do to make it stop all i want is her to not to say anything to me and do her job.where to go to get answer if she even allowed to act this way or is there any other options for me.