Patients routinely treated disrespectfully?
Nov. 9, 2011 — Countless times every day, a patient is made to wait long past a scheduled appointment time to see a physician or other medical professional, or is given only 10 or 15 minutes when he is seen, or is seen less as a whole person than as a set of symptoms, or can’t get straightforward answers to his questions, or is faced with the overwhelming task of negotiating a complex medical system on his own.
How does it feel?
We recently took a look at the fact that, despite innovative efforts at a number of medical schools, the medical community as a whole still has far to go to enhance doctor’s communication with and empathy for their patients. That reporting included candid comments made by experts leading efforts to reshape medical education acknowledging that there are profound structural barriers within the medical care system that inhibit the effectiveness of reforms made at the training level.
Oftentimes, advocates for more humane interactions between doctors and patients focus on the medical benefits of doing so: better communication has been found to result in the patient providing more complete and accurate information for the doctor to work with. Furthermore, patients whose subjective experiences are positive have been found to have better outcomes.
But we wanted to put those (very significant) benefits to the side, and explore an additional aspect of everyday medical interactions: how are “inconveniences” commonly seen as “just the way things are” actually psychologically and emotionally harmful to patients?
— Editor
Are these reasonable costs to pay for the benefit of eliminating any “inefficiency” in the medical system related to patients getting “too much doctor time”? Are they mere inconveniences, or something worse?
Powerless, frustrated, and “disrespected”
Having to wait past one’s appointment time is a persistant problem, albeit one that is not often discussed. Press Ganey, a company that conducts patient satisfaction survey research and describes itself as providing “health care improvement services” to the health care industry, reported in a 2009 white paper that “one important aspect of the patient encounter that tends to be overlooked is time spent waiting before a patient sees a physician.”
The paper cites survey data the firm collected that showed the “average wait time patients spend waiting to see their provider is 24 minutes,” and that, “at some practices, patients are made to wait significantly longer, in some cases hours.”
According to Press Ganey’s white paper, “when a patient is waiting to see a physician,” the delay can cause not only “mere annoyance,” but also, “physical and emotional discomfort and anxiety.”
Carolyn Marsh, spokesperson for the Picker Institute, a non-profit that advocates for and promotes patient-centered care, agreed that the habit of physicians and other health care providers of keeping patients waiting for their appointments was “too common,” and that the patient in those circumstances is “made to feel unimportant, overlooked and — if she or he happens to ask how much longer the wait will be — presumptuous.”
From the point of view of patients, March continued, “if they are sick enough to go see a doctor, the doctor should have the decency to treat their illness seriously and with dispatch.”
Julia Hallisy is the founder of the Empowered Patient Coalition, a patient advocacy group, and has worked on patients’ rights issues for the last 10 years. She identified long wait times to have blood tests conducted as “another common experience” faced by patients. “I hear patients say over and over again that they were waiting in the lab for an hour and a half after their appointment time to get blood-work done,” she said.
Patients, Hallisy observed, “are already stressed…often they have to get back to work, and can’t afford to take 2 extra hours out of their day, especially in this economy. Patients feel disrespected and extremely frustrated.”
According to Hallisy, the impact is not limited to a single interaction: “Because this happens over and over again,” she continued, “patients develop this low-level chronic anxiety about having to deal with the health care system. They wind up worrying that the long wait time just to see the doctor is just the tip of the iceberg, and that there’s real uncertainty about what will come next.”
Ready, set, go
Scheduling patients for short appointments — perhaps only 10 or 15 minutes long — is today’s medical status quo. But, for patients, it is a status quo with serious consequences.
Dr. Elizabeth Rider, director of academic programs at the Institute for Professionalism and Ethical Practice at the Boston Children’s Hospital, pointed to a frequen occurance: appointment time is limited and the patient either is not aware of the constraint on time or simply is not monitoring the time remaining in the appointment. That circumstance combined with what she described as the tendency of many doctors to latch on to the first concern that a patient voices results in many patients coming away from their appointment feeling as though they have not been treated well.
“A patient can come in and say ‘My child has a sore throat and a runny nose.’ It’s the physician’s job to ask, ‘Is there anything else?’” Most physicians, she said, “are loath to do that, because it takes time.” But this willingness to hear all of a patient’s concerns is crucial, she noted, because “you have to know what’s on a patient’s plate and what they care about.” The patient, she said, “might wind up saying, ‘well, [my child] has been having headaches,’ which is a crucial piece of health information and allows the parent to convey something that has been a concern.”
When the doctor has not taken the time to “ask a patient for their full list of concerns,” the doctor ends up either missing something entirely or having the patient “say something as they’re walking out the door, when you don’t have time to respond,” something that actually was the most important thing on the patient’s mind.
The patient, she said, leaves “feeling dismissed and not cared for by the physician.” It is, according to Rider, “absolutely essential for the patient’s emotional health and well-being” for doctors to be “present in the moment, with the patient,” even when feeling rushed or overwhelmed by their patient load and other responsibilities.
Dr. Nancy Cochran, a professor at Dartmouth Medical School who teaches a course on shared decision-making between doctors and patients, agreed with Rider that doctors “often assume that the first thing that a patient reports is the most important thing.” The problem, Cochran, said, is that “data have shown that that’s not true; it’s often the second or third thing a patient mentions that is the most important. Initially, the patient is trying to figure out if they can trust you as a physician, so the most sensitive issue won’t even be raised unless the doctor responds positively, empathically and warmly to the first encounter.”
Patients also suffer, Cochran said, when doctors “communicate a sense of time urgency to the patient, asking closed-ended questions like ‘You don’t have chest pain, do you,’ shaking their head ‘no’ as they ask the question, making it clear it’s not permissible to say ‘yes.’ Those kinds of questions leave most patients with only one acceptable answer.” The effect on patients? “There is no question that patients feel devalued,” Cochran said. “We hear that anecdotally all the time.”