By Anna Reisman
Not long ago, I got this plea from my medical students: Can't these patients stop with all the questions? The questions — about procedures and Googled findings and alternate treatments — were getting in the way of providing good, efficient medical care, the students said.
-- One student described a young woman with advanced breast cancer who was so persistent in asking for tests and procedures that the team dreaded seeing her on morning rounds.
-- Another student recalled a busy orthopedic clinic where he and his resident would see up to 60 patients a day. There wasn’t any extra time for patients to ask anything that strayed even remotely outside the orthopedic zone, and so any such patient was branded "difficult."
-- A third student spoke about a very old, dying man hooked up to a ventilator in the ICU whose family refused to consider a Do Not Resuscitate order.
The 'Difficult' Patient
There is a difference between difficult and "assertive," I pointed out to the students. It's good for patients and family members to ask questions, speak their minds and not dutifully accept every recommendation. It's great that they advocated for themselves or their family members. But to the students, these patients were impeding their own best interest, and this, it seemed, was making them feel burned out even before they received their medical school diplomas.
Another young man raised his hand. He’d spent a month working in a government hospital in South Asia. There, he told us, no patients were difficult. Patients listened. You told them what they needed to do and they did it. Simple as that.
The students pondered this for a moment. Then one asked, tentatively, whether the reason we have so many patients like this in the U.S. — the kind that ask a lot of questions -- might be our focus on "patient-centeredness." Could we be giving our patients too much room to speak? At some point, he wondered, shouldn’t our knowledge, expertise and experience trump those endless questions?
I almost fell off my seat.
Not to say I don’t understand this perspective. I do. After all, these students were about to become doctors, steeped in newly acquired knowledge and eager to apply it.
I believe there’s a certain yearning in many medical students for the age of the paternalistic physician who knew what was best for his patients and just did it, basically leaving the patient out of the decision-making process.
I also understood this perspective because I, too, am guilty of it at times. On a busy day, any patient with more than a few issues or questions becomes by definition difficult; when things are less hectic, the same patient might merely come across as complicated.
In my early years as a primary care doctor, I didn’t mind questions from my patients but hated the feeling of having my recommendations challenged. Those discussions could be time-consuming. I wished my patients could just accept my recommendations at face value.
No More Cringing
As a middle-aged doctor who has practiced medicine more than 15 years, my perspective has changed, thanks in large part to having been on the other side. I question my doctors and my family’s doctors. I expect them to be willing to engage in conversation, answer my questions, and provide good reasoning. I can’t imagine accepting everything that a doctor tells me with nary a raise of an eyebrow. And so now, when my patients tell me that they’ve Googled their symptoms or read about some new approach on Facebook, I no longer cringe; I welcome their input.
One of my colleagues urges medical students to view difficult patients as visiting professors, there to teach. Assertive patients fit that description: It’s like having a coach in the room who will blow a whistle if explanations aren’t clear or pipe up if there are options that haven’t been discussed.
Is there evidence that assertive patients have better health outcomes? My take is yes. In the medical jargon du jour, listening carefully and appreciating the patient’s perspective is called “shared decision-making.” Shared decision-making increases patients’ knowledge and decreases the number of patients on the fence regarding medical decisions. That’s what’s so great about assertive patients: They ask questions, express their beliefs and values, and oblige their doctors to have a give-and-take conversation.
Easy? Not So Fast
For those doctors -- and students -- who have trouble making room at the shared decision-making table, assertive patients will pull up an extra chair and wiggle right in.
The alternative? The “easy” patient who nods and has no questions, but on the way out tosses the prescription or never schedules the colonoscopy. Don’t dread patients bearing questions, I told my students. Welcome them. They’re some of the best teachers you’ll encounter.
Anna Reisman, M.D., is an associate professor at Yale School of Medicine and a Public Voices Fellow with The OpEd Project.