A Doctor's Point of View on the Doctor Patient Relationship

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Many of our questions and comments on MS Health Central illustrate the growing strain between doctors and patients.   Perhaps this is due to the fact that patients expect more from their doctors nowadays.   And add to this the plethora of information anyone can glean about their medical conditions from books, magazine articles, television shows, and of course the internet.   We see several episodes of "House" or "Scrubs" and we think we too can possess the medical knowledge of a doctor.   In some ways patients feel more confident and assured to take charge of their medical conditions.   But somewhere along the way, it is my opinion that we have lost trust in our doctors and in the medical profession.

If you have a disease such as Multiple Sclerosis or even if you are in limbo and awaiting some diagnosis to explain your symptoms, it is essential to have a good relationship with your doctor or neurologist.   Let's face it, you are going to be seeing the doctor for a very long time.   It is critical that you find someone who you can work well with and with whom you feel a certain degree of trust.

I have asked Doctor Nitin Sethi to contribute to this discussion through an interview about this very topic of the doctor-patient relationship.   Doctor Sethi will discuss this relationship from a doctor's point of view and in part two of this series we will examine the same relationship from a patient's perspective.   The patient will be me.     I do encourage you to offer your viewpoints through the form of comments to these articles.

I introduce to you:   Nitin K Sethi, MD who is the Assistant Professor of Neurology at New York-Presbyterian Hospital of Weill Cornell Medical Center located in New York City.

What do you feel are some of the personal qualities which are important for a doctor to develop rapport and trust with patients?

A lot has been written about doctor patient relationship and what qualities define it. Nowadays in medical school itself there is a thrust not just to produce smart doctors but also to produce more humane doctors. A study had shown that student doctors (medical students) have the highest levels of empathy. As they go through their long training (residency and at times fellowship), this empathy progressively decreases. One may argue that "experienced" doctors become less humane. I do not buy that argument. I feel the empathy gets replaced by knowledge. You know what you are dealing with and you understand disease pathology better. This might make a doctor sound aloof and like a "machine".   He is very good at what he does but he is cold and aloof.

My patients frequently tell me that they left their previous doctor because he would not hear them out or he was not caring enough. They rarely say I left him because he was incompetent. I want to make this point to answer your question. Some of the smartest doctors I know (people I would go to if I had a neurological problem) do not have the greatest bedside manners. They are not most suave. But as a patient I would rather go to a competent doctor than to one who says all the right things in the right way but is not the smartest light.

So to end I feel a doctor should be competent with a sound knowledge base, that inspires confidence in the patient. A sick patient is at his most vulnerable self, he needs to know he can trust the doctor to heal him back to health. If the doctor can go about doing this with empathy and humanity, he is my ideal doctor.

From a doctor's perspective, why do you feel that so many people do not ask questions of their doctor?

I see all types of patients and caregivers/ family members. Some shall ask tons of questions, many not even relevant to their medical condition. As a physician I have learned to be patient and answer their questions to the best of my knowledge. I realize they are worried and seek reassurance.

Then there are others who seem unconcerned about their health problem. You are telling them they have a potentially fatal condition and they shall still pick up their cell phone to answer a call. So to answer your question, everyone is built differently and handles their medical problems differently. For some knowledge is power, the more they know about the medical condition that plagues them, the more empowered they feel. Others would rather not know or are in denial or maybe they just trust their doctor to do what is best for them.

From your perspective is it good for the patient to have researched their disorder on the internet before coming to see you?

I wrote an article on this on my website and blog.  I titled it "Paging Dr. Google". The Internet has revolutionized the way medical information is disseminated. You type in the name of any disease or just type in your symptom like for example twitching in the arms and legs and lo and behold pages and pages of information is available for one to review.

But one has to use this power correctly and responsibly. First of all one needs to know what plagues them, you type in a wrong disease and you shall get the wrong information. You type in twitching in arms and legs and the first page that comes up is about amyotrophic lateral sclerosis (ALS). You shall understandably panic thinking you have a potentially fatal neurological condition. The Internet is not a doctor, it shall not be able to refine your history and examine you thoroughly before reassuring you that you do not have ALS, rather you have benign fasciculations.

I encourage people to research their disorder on the Internet but I guide them how to go about doing so. Random Google searches is not the right way. There are many reputable websites which offer information which has been written by health professionals especially with patient information in mind.

In your opinion what is the most common topic for disagreement between doctors and patients?

Doctors and patients may disagree on a whole range of topics if their relationship is not based on trust and mutual respect. I feel conflicts can be avoided if information is conveyed to the patient and their caregivers in a timely manner. As a physician I always outline my plan of care to the patient clearly in a language he or she understands. I try to keep medical jargon to the minimum. Moreover I am always honest; I do not give a false sense of reassurance to a patient suffering from a fatal disorder. I tell them how things stand as of now, what can be done and what shall be the outcome in the future. I feel patients always feel better once they know what lies ahead. This is also very true for patients who suffer from chronic disabling neurological conditions like multiple sclerosis. It helps them prepare for the future; it helps them accept their diagnosis. It is not easy but a good doctor patient relationship sure can make it easier.

How do you feel disagreements between doctors and patients should be handled?

I try to avoid the disagreements in the first place. I am not confrontational in my approach. I give the patient time to have their say and listen to their concerns and complaints. The philosophy which has always guided me in my life has being to remember that it is the patient who is suffering. They are the ones who feel vulnerable and hence may be defensive or confrontational at times. As a physician I have learnt not to take it personally. The idea is to work as a team towards a common goal of getting back to health and not to be at each others throats.

Why is that some doctors dismiss alternative therapies to treat illness?   How can a patient bring up the fact that they may use alternative treatments without feeling dismissed?

That question is easy to answer. The reason why many of us allopathic doctors dismiss alternative and complimentary therapies (as they are referred to now) is because we are not exposed to them during our training. Let me explain with a simple example. If during my training and practice, I have never been exposed to the use of acupuncture or massage therapy for the fatigue associated with multiple sclerosis, how can I trust that it works and recommend it to my patient? Medicine is a science and art honed after years and years of training. One learns what works and what does not and then we as doctors stick to it. I am not saying alternative and complementary medicine does not work, I am saying I do not have knowledge to say if it works or not.

One reason for this skepticism is that many who practice alternative and complimentary therapies have not subjected these therapies to double blind random studies. Let us take an example. Suppose someone says that a herb works for multiple sclerosis, well then prove it. Test it on patients. Give it to patients in a blinded fashion and see if it works. Publish those results so others in the scientific community can review and critique it. But unfortunately there is no effort to do this by people who practice these different systems of medicine.

On a more personal note, I am not averse to my patients discussing alternative options and therapies. I keep an open mind and am humble to realize that is much I do not know. But I try to make sure, that the alternative therapy they try shall not harm them.

What do you feel is the most common reason for a patient to stop going to see their doctor?

Again I feel that every doctor patient relationship is unique. There are multiple reasons patients may be lost to follow up. They did not like their doctor, they did not like what the doctor told them to do, they did not like his office staff, they had to wait too long for their appointment, financial constraints or the fact they are still in denial are among other reasons patients may stop seeing their doctor.

In your opinion, when is it a good idea for a patient to get a second opinion?

This is a topic which is dear to my heart. I wrote about this on my website and reproduce my thoughts here.There are times when a second opinion is not only appropriate, its necessary. This is true both from the patient's as well as the doctor's perspective. Since the patient technically has more to lose, it is imperative that patient's know when and how to seek a second opinion. This is more significant in clinical neurology especially when one is handed down a diagnosis of a neurodegenerative condition like young onset Parkinson's or Huntington's disease. Diagnosis of a disease like amyotrophic lateral sclerosis (ALS) is essentially like signing off on a death sentence. Patients and caregivers are distraught and may not know what to do. Some may trust their doctor and agree to his or her management plan. But what if he is wrong? Maybe there is something out there that may help me. Maybe my doctor does not know about it. Even if the diagnosis is correct some may not be comfortable with the line of care. It is at times like these that the question of seeking a second opinion crops up.

Is my doctor right? Is frequently the first question that comes up in the minds of many patients when handed down a diagnosis of a chronic or life threatening illness. Could he have made an error? Patients and caregivers may approach this in a couple of different ways. Some will inherently trust their physician skill entrusting themselves to his care. Others may seek to reassure themselves of the certainly of the diagnosis in one of many ways either by asking more questions of their physician or seeking information on the Internet. A fraction may decide to seek a second opinion. A question, which arises in the minds of some patients and caregivers, is would my doctor mind if I request a second opinion. Would he take it personally? Most doctors do not get upset if their patient requests a second opinion but some do. Many doctors may actually encourage their patients to get a second opinion especially if they have a rare condition or an atypical presentation. In these times of increased medical litigation, one form of defensive medicine practiced by doctors is to get a second opinion.

Now the question arises whether you want your doctor to suggest a specialist or do you want to do the spadework yourself. Having your doctor refer you to a specialist for a second opinion has many advantages. It may cut down on your time and effort and more importantly ensure that you are seen by someone who truly is a specialist in the malady that plagues you. Your own doctor may be willing to pick up the phone and call the specialist to apprise him of your case history. Relevant investigations can be quickly faxed to the specialist office. This ensures you are seen in a timely manner. Importantly the specialist has all pertinent records including results of tests down at his disposal at the time of your visit. Remember if you go to see a specialist without lab results, his opinion is at the most limited.

One must ask oneself what do I seek from the second opinion? Is it confirmation of my diagnosis? My diagnosis is confirmed but I want to know what treatment options are available or I just want a better explanation for my disease. Stick to what you seek from your second opinion and do not get side tracked.

Go prepared at the time of your second opinion visit. As your time with the specialist is going to be limited so make the best of it. Have your case history summarized. A good way is to have it typed out in a chronological order. When did the problem start, how did it progress and the treatment options that have been pursued. This shall save precious time and ensure that the specialist has all relevant data at his disposal prior to giving a second opinion.

Are there any cons to seeking a second opinion? While there are no real cons to seeking a second opinion, certain issues should be borne in mind. Remember there is no guarantee that a second opinion is right. The specialist may or may not voice the same diagnosis as your primary doctor. One can get side tracked and end up wasting precious time and money. Time and money that could have been used to begin treatment earlier. Do not get into the trap of doctor shopping, shopping till you get an opinion that you want to hear. Too many opinions have the potential for confusing you and leaving you undecided.

Seeking a second opinion is your prerogative as a patient but use it wisely.

**Last thoughts?   How can patients and doctors develop better working relationships?  **

Communication is the key for both parties. Talk to your doctor if something is on your mind or bothers you. As for the doctors we need to be more accommodating too. The doctor patient relationship shall traditionally been built on mutual trust and good will. "Prima non nocere" meaning "first do no harm" has been the ethic on which the medical profession was built. It is time to return to the basics.

Thank you for your questions.