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We all know that patient and physicians are an integral part of the doctor-patient relationship. Yet, this partnership isn’t always as balanced as one would hope. There are simple rules that we can follow to make a positive impact of this relationship. When primary care physician shares his insight on helping doctors and patient build a stronger rapport.

You are listening to ReachMD XM157, The Channel for Medical Professionals. Welcome to the Clinician's Roundtable. I am your host Dr. Jennifer Shu, practicing general pediatrician and author. Our guest is Dr. Rob Lamberts, sport-certified internist and pediatrician and author of a popular blog called Musings of a Distractible Mind.

DR. JENNIFER SHU:

Welcome Dr. Lamberts.

DR. ROB LAMBERTS:

Good morning.

DR. JENNIFER SHU:

Thank you for joining us. Now let’s just start talking about your golden rules for physicians. How did this all come about? Why did you decide to write rules for physicians?

DR. ROB LAMBERTS:

Well, Tara Parker-Pope who works at New York Times and actually does health blogs with the New York Times, she actually has been a reader of my blog and she was doing a piece on doctor-patient relation and she asked me if she could interview me and I said that was fine and so she asked all these questions about, you know, why is it that doctors and patients aren’t getting along. You know, I honestly have fairly good relationship with most of my patients, but I had some insight at least enough to get put in the article, but it got me thinking about what it is that doctors need to know to be able to facilitate a good relationship with their patients and what it is that I do when I am seeing my patients that make by patients feel more comfortable and the times that I don’t.

DR. JENNIFER SHU:

Is there an underlying reason why patients might not feel comfortable coming to a doctor in the first place or why they might get frustrated with that?

DR. ROB LAMBERTS:

I think, there is a whole bunch of reasons, but I think the biggest reason that I know of is simply that it’s very uncomfortable when the spotlight is on you. It is very uncomfortable when it is all about you were very good at rationalizing things and not thinking that rules of thumb apply to us or that the warnings about this drug or that drug or cancer or whatever, we figure it doesn’t apply to us, but when you are in the doctor’s office, the light is shined on you and it is uncomfortable.

DR. JENNIFER SHU:

Let’s talk a little bit about these rules for doctors. Your rule #1 is that the patients don’t want to be at your office. What do you mean by that?

DR. ROB LAMBERTS:

Well that is pretty much what I just described. You know we assume as medical professionals that I come into my office every day; it is comfortable, it is pretty normal for me when I interact with patients and I have gotten very comfortable with that interaction. But, putting myself in the shoes of the patient, the patients don’t get comfortable because we are writing down their weight, we are talking about what they are doing in their life. The focus is on them and I think that there is a lot that people are uncomfortable about. It’s kind of almost the no-win situation from a patient’s standpoint, either you are doing everything you should do which is, you know, expected or you are not doing what you should do and you kind of have to apologize to your doctor, I’m sorry I haven’t quit smoking, sorry I haven’t gotten on the diet and lost the weight. Very few times do you come in excited that you can tell your doctor, I mean some times people do, but I think the majority of times patients are uncomfortable and would do what they can to avoid it plus they have to pay. There is cost associated with it. So, I think there is a lot of reasons but overall just getting the idea that you have to understand that it’s not like they are excited about being there.

DR. JENNIFER SHU:

What about rule #2, patients have a reason to be at your office.

DR. ROB LAMBERTS:

When I was early in training and, you know, even during residency and such you kind of thought that patients were kind of morons at times, you know that why would they come in for that? Oh, that’s just ridiculous and there are times when they come in with little problems. You know, it’s just that jaded attitude, I think that residents some times get and I think doctors even some times carry into their practice, although I don’t think those doctors are very successful in primary care at least, but you know you get the idea that some times these people are trying to waste your time or you think about it from your perspective, but the truth is that when somebody comes in for what seems like no reason at all, you always have to ask yourself, I will have to ask myself what is the real reason they are coming in to see me, what are they nervous about? You know even if it some times, you know, is it meningitis that I have got or is that brain tumor because I have got this headache or I am having this other problem and the idea is that they are worried about something and something worries them enough to finally show up. You know, I think about that also when people have chronic problems that, you know, I have been coughing for the last 3 months and then they come into your office. I say, well what made you decide now that you would come in. Something had to finally get you to decide after the course of 3 months or longer a lot of times that it is time to go in and get seen and I think that is a helpful question to try and get to the root of the reason that the person is coming into the office and then it gives the patient a whole lot more satisfaction to turn around and address that problem, make sure you answer that reason why they came in. They had screaming child, mom wondered if it was an ear infection. You can say okay, I don’t think it is an ear infection and they walked out saying good, not an ear infection.

DR. JENNIFER SHU:

So, excellent reminder to figure out exactly why the patients are there in the first place.

DR. ROB LAMBERTS:

Yes.

DR. JENNIFER SHU:

Now, rule #3 of yours is that patients feel what they feel. What do you mean by that?

DR. ROB LAMBERTS:

I hear patients complaining a lot that doctors don’t believe them and they always apologized to me for their symptoms, that you know it is a weird symptom, I have a hard time describing why this pain feels like or I am really having numbness on the left side of my face and entire body. Again, I think in training you tend to roll your eyes during residency and say, you know, that doesn’t really make sense or that the parent says the kid was screaming all night long and the kid comes into the office and they are playful and happy and you know as a resident I remember kind of thinking, yeah right. You know, but again, it’s one of those things that it doesn’t help us to not believe our patients are telling us the truth. In other words, if they do say that the pain is hard to describe, well may be its just hard to describe pain and we may not be able to make sense of all their symptoms, but they are having those symptoms and you have to work with what they have given you. You can’t dismiss them and I think a lot of times when we do dismiss them, we dismiss them because it doesn’t make sense with the diagnosis we have made. Well, then we should make that diagnosis with caution. You know, we should be very careful to not sit on that diagnosis too hard. I mean you have to come to a conclusion when you are dealing with a patient, but I think a lot of times, people ignore facts that are already in there and again you have to decide, but you have to do that with a lot of caution and explain to the parent or the patient you know this doesn’t make sense, but this is the best solution that I can find out. You know that the child was screaming all night long and I will usually just kind of joke with the parents, say yes you know that’s just the magical effect of the doctor’s office, but always tell them, you know, I believe you. The funny thing is that kid has diarrhea and the parents feel like they have to bring the diaper in to prove to you that they had diarrhea. I believe you, you know, just show me that or just me any sputum to prove to me that you had those symptoms. You really are feeling what you are feeling, I am the one who has to make sense out of it and understand that you may not remember somethings, you may not describe it real accurately, I do have to deal with that, but the challenge is to listen to the patient. You know, the same statement is the patient will always tell you, what’s wrong with them. I think that that is the truism that doctors need to walk into the exam room with.

DR. JENNIFER SHU:

And that kind of ties into your rule #4, which is patients don’t want to look stupid. Can you give an example of how that might play out in practice?

DR. ROB LAMBERTS:

Well, I’ll tell you a personal story on that. I was in Puerto Rico and thought I was younger than I really am and did some body surfing. Well, I got slammed down on to the sand and broke the surgical neck of my humerus on my right arm and it was horrible. It was very, very painful. It didn’t require surgery, but it put me out for a long time and I remember going to the orthopedist and feeling very, very self-conscious about how much pain I was complaining about, that I fell like I was being a wimp may be or is that I wasn’t sure how much was the right amount of pain and again I was fighting with this idea of does he really think, you know, because this is a doctor friend of mine and it just happened that another doc friend of mine had broken his humerus the year before and said well yeah I was doing surgery in 2 weeks and here I was in 2 weeks, I couldn’t even lie down flat in bed, I couldn’t do anything, turned out it had a midshaft humerus fracture and I had it right in the joints, so it made sense, but it just made me feel stupid and I think that patients a lot of time need reassurance from the doctor that it’s okay. You know, you do feel this pain, don’t feel self-conscious and I think that is very important to understand that it’s not just like I didn’t want to be there, but they are embarrassed about their symptoms. You know, the classic story of the man who has been having chest pain and you know for days and never went into the emergency room. Is he an idiot or is he just afraid that he is going to look really stupid going into the emergency room and having it just be indigestion. I think the latter is true. I think if he really knew it was his heart hurting him, he would be in the emergency room quickly unless he had a death wish, but he is just stubborn and saying no, it’s not my heart and just I don’t want be a wimp and you know I think that is probably more true in men, but in pediatrics you see it in the parent, the mother who doesn’t want to be that worried mom, that everybody is rolling their eyes about, brings the child in and it turns out that it is just teething and not an ear infection and they feel a lot embarrassed. You know, again, I always try and tell them, look this is the best case scenario that it is nothing. It’s still worth looking into, but it is the best case scenario that it is just teething and not an ear infection or it’s just indigestion and not chest pain. I would much rather have you come in and have it end up being nothing. You know, my job is to worry more than you do and then if I get that through to my patients, they are a lot less likely to be embarrassed because they don’t feel like I am judging them as to the merits of their manhood or whatever.

DR. JENNIFER SHU:

Exactly. Now, we just have a couple of more minutes for the last 2 rules. Rule #5, patients pay for a plan. If you could quickly discuss about it?

DR. ROB LAMBERTS:

When people come in, they really want to know what to do. So, really when people walk out of the office, they want to have a plan in hand and I think a lot of visits and my wife complained at times that she didn’t really know what to do. The plan of action is really what people are paying for and we just need to make sure that we give them at the end of every visit, here the medicines I am giving, here is the plan. If this test comes back positive, this is what we would do. If it comes back negative, this is what we will do and I think you get a lot more patient satisfaction that way.

DR. JENNIFER SHU:

And finally, rule #6, the visit is about the patient. Doesn’t that seem like it should be obvious.

DR. ROB LAMBERTS:

You know, I find that a lot of times I bring in my own troublesome times and you hear doctors complaining about the state of medicine or about other things. You just need to make sure that the focus of the visit is entirely, you know they are paying for this time. They are asking you for your professional opinion and even though you have problems yourself, it’s really not about you and so you constantly need to be going back to – this is your problem, this is what we are dealing with and again I think some times we use office visits as grape sessions. I don’t think that’s appropriate.

DR. JENNIFER SHU:

Thank you for the reminder about golden rules for physicians. I would like to thank our guest Dr. Rob Lamberts. We have been discussing golden rules for a physician.

I am Dr. Jennifer Shu; you have been listening to The Clinician's Roundtable on ReachMD XM157, The Channel for Medical Professionals. Be sure to visit our website at www.reachmd.com featuring on-demand pod casts of our entire library. For comments and questions, please call us toll-free at (888MD-XM157) and thank you for listening.

I am Dr. Walter F. Lambert from Miami, Florida. You are listening to the first national radio channel created specifically for medical professionals. This is ReachMD XM157.