No matter what your age, gender, or position, you are the weaker sex in the doctor's office. The whole operation reeks of inequity. You're naked under a paper sheet, he's dressed. You call him "doctor," he calls you by your first name. You speak English, he wields a technical vocabulary that's impenetrable to all but those of his own tribe. You have the power to take your business elsewhere, he has power over sickness and health.
We want to trust our doctors and believe they are superb at what they do. The alternative is too unnerving to consider. Yet the thriving medical malpractice industry proves that our doctors don't always deserve our devotion. Sometimes they disappoint us, endanger us, treat us like children, and ignore our input. Or do they? Maybe the problem is with us. Maybe we just don't know how to talk to them. Whoever is to blame for the miscommunication, both sides pay dearly in health and money: 70 percent of all medical malpractice suits are filed not because of technical negligence but because the patient misunderstood the doctor.
Medical schools have been paying more attention to this problem lately, and the new generation of doctors is supposedly trained to listen, be empathetic, and look beyond the most obvious diagnosis to see if a patient's problems might be more complex. But while doctors are trying improve their bedside manner, reality is undermining them. Doctors today have far less time to spend with patients than they did twenty years ago, mostly because of the paperwork demanded by HMOs and insurance companies and the patient load required to make ends meet. In the typical practice, a visit with the doctor lasts 7 to 15 minutes—and is interrupted within the first 27 seconds by a nurse or a telephone call.
Meanwhile, doctors who think they are improving their communication skills are often mistaken. One study asked physicians how much time they spent educating their patients. "Nine to ten minutes" was the most likely response. In reality, it was about one minute. And patients clearly need the education. Another study highlighted the sorry state of patients' "medical literacy": more than 40 percent couldn't understand instructions that indicated they should take a certain medication on an empty stomach.
Even the most well-meaning doctors regularly fail their patients by overestimating their knowledge of medical terminology and rushing through the exam. Patients complain that doctors don't ask their opinion, don't explain the side effects of drugs, don't take an adequate medical history, don't warn them properly about the difficulty of recovery, don't take their pain seriously, and discourage questions—and that's just a short list of grievances.
Complaining is useless. Waiting for your doctor to change is futile. Your only choice when it comes to dealing with doctors is to change your own behavior in order to influence theirs.
Behind the Scenes: We're Not Gods, We're Overworked Humans with Godlike Powers
As a group, doctors don't inspire much sympathy, yet in order to get the best treatment you must be able to see things from their point of view. Like all of us, doctors have feelings and fears that influence their work.
First, consider your doctor's mission: to heal you. If he can do it, he is a success. If he cannot, he thinks he is a failure—and doctors hate to fail. You may feel powerless in his presence, but in fact his self-esteem depends on you. Will you heed his advice or ignore it? Will you refuse his treatment? Lie to him about your symptoms? Snub him for another doctor? Occasionally, even if you follow the doctor's instructions, you won't get well. His skills will fail you. This is a doctor's greatest fear and a source of constant anxiety.
Next, contemplate the typical doctor's training. Doctors are schooled to diagnose illnesses and prescribe treatments as quickly as possible. With most internists logging about 150,000 office visits in their careers, speed and accuracy are highly valued. Being right is important, but being right fast is the mark of a real pro. In surveys, medical literature, and interviews, doctors repeatedly admit to diagnosing the typical patient within just 30 seconds of walking in the examining room. "It is subsequently quite easy to go on autopilot," writes Victoria Maizes, M.D., in American Family Physician. Instant diagnoses, followed by formulaic, half-interested questions, thus become their normal mode of operation. Maybe it's not the way Marcus Welby would have done it, but it effectively propels them through their overpacked days.
Another more troubling aspect of doctors' training is the well-known desensitization that takes place in medical school and during a physician's internship. It is a grueling trial by fire as the student is thrust into a world of pain, suffering, and death with very little emotional support. Barbara M. Korsch, M.D., who has devoted much of her career to studying doctor-patient communication, wrote a book on the topic: The Intelligent Patient's Guide to the Doctor-Patient Relationship (Oxford University Press, 1997). In it she explains that in medical school the emphasis is on anatomy, chemistry, and other hard sciences, with little or no attention paid to the human aspect of attending to the ill. "When third-year students have their first intense encounter with real patients, they are faced with sickness and death in very large doses." As the years of training continue, "students' inner conflicts with facing illness and death become more and more acute. Their role models, the attending physicians, often behave toward them (and their patients!) in ways that are not very human....One of the goals in the education of physicians is to 'professionalize' them, to toughen them up."
When the training is finally over, relatively few doctors emerge with their empathetic equipment intact. Korsch says that doctors "turn away from emotion. They are not trained to deal with feelings." This detachment is very hard to unlearn. It doesn't have anything to do with a doctor's talent, but it does affect the way he treats his patients and the success of his practice. On the one hand, doctors with lousy people skills have trouble keeping clients and attract more lawsuits; on the other, doctors who aren't emotionally tough are likely to burn out and become unable to function.
Today's physicians, then, are constantly grappling with opposing forces. They want to solve your problem but must do it quickly, which automatically increases the likelihood that they will make a mistake. They depend on your compliance but you can defy them at will, which undermines their chances of success. Theirs is a people-oriented profession, yet they learn few social skills and have much of their natural empathy squeezed out during medical school. They must operate within ever-shrinking time and money constraints, even as patients are becoming more proactive and demanding more attention. They are expected to take control but are constantly being second-guessed by insurance companies, HMOs, and the patients themselves.
The result is that doctors are under a lot of stress. The power, respect, and money that once compensated for the tensions of the job are eroding. They spend more on insurance and keep less for themselves than they once did. Some doctors are even forced to change specialties because they can't afford the malpractice insurance. These healers, who at one time held themselves above the fray of commerce, are now neck-deep in it—resentful, frustrated, and concerned about the level of care they are able to provide their patients. So when the doctor walks into the examining room and you're laid out on the table like a piece of pastry, remember: underneath the trappings of power, he too may feel anxious and vulnerable.