Early & Late Career Collaboration #1

Lilian White, MD is in her first year of practice after finishing her family medicine residency. I am in the 40th year of my journey. This is the first post where we both write about our experiences…

…from the opposite ends of a life in medicine

A Matter of Fit

By Lilian White, MD

Sometimes patient-physician relationships feel a little like shoe shopping.

My brother is getting married in June. As a bridesmaid, I’ve tried on, bought, and returned a growing number of shoes. Some were too big, some were too tight, and some were the wrong color. Others, I didn’t even try on - I could tell they were just not the right fit from the shelf.

In residency, we were handed a panel of patients that had been passed down from a combination of graduating residents. Graduating residents could choose who a handful of patients were assigned to, attempting to personalize their care and match them to an incoming resident they thought would be a good fit. Many of the patients had been going to the residency clinic for years, so they were used to being assigned another physician every few years. In the end, it generally meant the patients were content to remain with their assigned physician, knowing if the fit wasn’t perfect, it would only be temporary anyway.

.

As physicians, we’re often playing this balancing act of investing in the patient-physician relationship, while also not investing too much of ourselves that it becomes unhealthy. Perhaps some more learned on the ego than I am would also comment on the importance of the ego in offering top-notch care: that it’s important we’re invested personally in the relationship, but how that can also be our downfall if we invest too much of our ego. Our ego cannot depend on the health or strength of the patient-physician relationship. So we balance. Or at least attempt to.

.

Growing and building my own practice has offered a unique lens to view the patient-physician relationship. My panel was not handed down but rather chosen to see me or join my practice specifically. I’m even more invested in the relationships because I care as a person, as a physician, and now as a practice owner.

A milestone I knew was inevitable, but was not looking forward to, was the first patient to leave my practice voluntarily. As humans, we all have those people we don’t get along with as easily as others - there might be differences in style of communication, personalities, or opinions. So naturally it makes sense this principle would extend to the patient-physician relationship as well. It is not immune to the intricacies of relationships.

And yet, even knowing this was inevitable, the part of me that was invested in the relationship felt a bit hurt when I received the news. The ego was involved. I reviewed our last few conversations in my mind. I considered if I had treated her any differently than other patients. If I had been empathic enough or lacking in clinical acumen? Was my ego too involved?

At the end of the day, sometimes it’s like shoe shopping. Sometimes I’m just not the right fit. For that person or problem or phase of life.

As a practice owner, this is why I’ve chosen not to require long-term contracts for my patients. It may not be the most financially-savvy way of running a business, but I only want patients on my panel who feel that I continue to be a good fit for their needs, which may change with time.

So I wished the patient well and offered to connect her to other physicians that may be a better fit.

A size 8 shoe will not do for size 6 feet and vice versa.

Fit matters.

____________________________________________________________________________

Getting Fired is Often Just Parting Ways

By Hans Duvefelt, MD

As a busy physician in an underserved area, you never have to compete for business, but when somebody decides that they no longer want to be your patient it can trigger some emotional responses.

It hasn’t happened all that often in my practice that patients have chosen to switch providers in any kind of demonstrative fashion. More often, someone may have seen a colleague of mine when I wasn’t available and more or less drifted in the direction of that other provider. In those cases I barely even reflected about it, we were in the same practice, and patients had a chance to assess which one of us they worked better with.

I used to be more sensitive when patients indicated they would seek a second opinion from another primary care provider (rather than request to see a specialist in a matter I felt I could handle as a primary care physician). When I was young and a little hotheaded, I preferred to fire patients who did that. Now that I am more seasoned, I roll with the punches.

Some of the few instances I can remember when a patient has openly told me that they were switching providers include a woman who seemed to have no tolerance for me explaining that many things in medicine are not completely straightforward. I remember explaining to her that a sore throat with a negative rapid strep test was more likely viral, but could still be strep, and that it was a judgment call whether to start an antibiotic or not. “I wish you could just tell me what to do”, summed up her assessment of my clinical prowess.

I also remember that I have had an occasional patient leave my care because they thought I was ignoring their stage three kidney disease. But on the other hand, I have also had a couple of new patients who left their previous doctor for the same reason. I have patiently explained in those cases that stage three kidney disease is the first one that is detectable by standard laboratory testing. I tell people more or less jokingly that nephrologist are crazy people who invented a classification where stage one and stage two are essentially undetectable.

One of the aphorisms I have claimed as my own is “Osler said, listen to your patient, he will tell you the diagnosis. Duvefelt says, listen to your patient, he will tell you what kind of doctor he needs you to be”.

I try to meet people “where they are at”, and approach their clinical situation in a manner that I believe will meet their needs, while still letting me hold to my standards of care for lack of a better word.

I have had very few situations in my career where patients have left my care because I missed, or was slow in making, the correct diagnosis. The reason for this, I believe, is that I try very hard to have a personal flavor to our relationship and that I think out loud, so that patients don’t believe I make snap decisions, but work through the logic of a clinical diagnosis. The standard of care in malpractice situations is that you must do what a reasonable physician in the same circumstances would have done.

I’ve had a few patients come to see me just to find out if I would provide the controlled substances they were looking for, and I have had a couple of patients who were drug abusers leave my care rather than let me help them with their addiction. In those situations I haven’t felt insulted, but certainly sad that I could not offer them a way out of the situation they were in.

Healthcare these days is a little less personal and a lot more fluid because doctors move around more and patients’ insurance companies may switch, even if they don’t change jobs, because employers sometimes change plans on an annual basis.

So, when my young physician friend, Lilian White, suggested this topic for our first early and late career perspective post, I couldn’t think of a single dramatic instance of being fired in my 40 years as a family medicine doctor.

I guess that’s a good thing.