One Dozen Things
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 done some research and presents the physician with a proposed alternative drug 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, you must become accustomed to being questioned or challenged with respect to your knowledge or judgment. These challenges should not be taken as personal or professional insults. In dealing with all patients, you 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 may come to the physician having done research. It is important to recognize that this is not a challenge or threat to your authority or expertise. Instead, 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 information you believe to be inaccurate or proposes alternatives you think are unacceptable, carefully acknowledge the patient's interest and initiative while pointing out why the proposal is not viable. When the patient presents information you are not in a position to evaluate, state that honestly and advise the patient that you will research the issue as soon as possible after this visit. Obviously, this requires that you follow through on this 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 is therefore not very likely to enter into a productive discussion of treatment options.
