A Talk on Topical Therapy: Dermatologists’ Experiences in Practice

Dr. Keller:
Welcome to DermConsult on ReachMD. I’m Dr. Matthew Keller, and I’m back with my fellow ReachMD host Dr. Michael Greenberg for part two of our discussion on bedside manner. Michael, welcome back, and would you mind giving our listeners a quick refresher on your experience?

Dr. Greenberg:
Sure, Matthew. Let’s review a little bit from Part One. We discussed that presence is the greatest gift that we give to our patients. That the way to patient’s satisfaction and your own happiness in practice is to make yourself present. Actually be in that room, be listening to patients’ fears. Be aware of what they’re going through, and make sure that you respond to all the questions they have that start, “I’m scared that…” even if they’re actually not asking them, but put yourself in their place.

Dr. Keller:
100%. It was a great segment, and I think you summarized it really well. So now I’d like to begin by focusing on difficult patients. How do you deal with them when they are angry or frustrated?

Dr. Greenberg:
Well, first of all, we have a lot of patients while we’re in this pandemic who are angry and frustrated, and I think unless they’re angry with us specifically because we’re running 40 minutes late, I think you need to take time to acknowledge that. Say, “Listen, you seem upset. You seem angry, you seem scared.” Whatever it is, give them a chance to express it, because it gets them out of their head. And half the time, you’ll find that they’re not really angry with you. So that’s the first thing. It’s not about you. And the second thing is, let them tell you why they’re angry. Let them tell you why they’re frustrated, listen carefully, and don’t be defensive. Don’t try and defend yourself. If you’re running thirty minutes late and they’re angry, say, “Yes, I am. I’m terribly sorry. This is why. And you know I won’t rush you.” And once in a while when I’m really running late, I will waive patients’ copays. I’ll say, “You know what? You’re not paying a copay today.” 

Dr. Keller:
I talk to my residents a lot, my trainees, about when a patient is angry with you, 95% of the time it’s not you.  They’re projecting that on you or onto the visit or they just need to get it off their chest because there’s something else going on. And I can’t tell you the number of times I invite people to tell me why they’re angry or frustrated, and it’s not involving anything to deal with their visit or their disease. It’s because their mom’s in the hospital, they’re going through a divorce, their child is having trouble with school. Whatever it happens to be, as you pointed out with coronavirus, that’s another layer on top of it.

I always tell the residents that until you invite them to share those frustrations with you, neither of you can really be fully present with the visit.

Dr. Greenberg:
Right. And it’s interesting, sometimes what they’re frustrated or angry about, you may be too. When patients come in, we have to remember, we’re the only human face they see in the whole healthcare system. They don’t see anybody from pharma, they don’t see anybody from the hospital, they don’t see anybody from the lab. They see us. So when their medications run $400, we’re the ones who get blamed and yelled at. And I think it’s really important to tell my patients, “You know what? I’m a patient, too, and I have the same situation when I go to buy my medications.” So acknowledging their anger and acknowledging that they may be projecting their anger at other things going on in the healthcare system, I’m going to say, “Yep, I agree. I’m a patient, too. This is not my fault, and I wish I could change it for you.”

Dr. Keller:
Yeah, I think those are spectacular points. Now on the flipside, what do you do when you’re frustrated with a patient during a visit?

Dr. Greenberg:
Well, the first thing I do is I continue to take deep breaths because I often get frustrated with a patient because they’re not listening. Here’s an example. They’ve got eczema and a patient will ask, “Well, does food have anything to do with this?” I’ll go, “Probably not.” And they’ll say, “Well, does the fact that I have a dog when” whatever the questions are, they keep asking them, over and over again, and I keep answering, and finally after the third or fourth time they ask the same question, I go, “Hey, stop. Let me ask you something. I’ve answered this question four times, which tells me that I’m either not giving you a clear answer that you understand, which is my responsibility, please help me. Or you’re not listening. Which is it? Because I’m really not going to answer this a fifth time, until we clear that up.” I say it lovingly, I say it direct, but it’s the truth. I’m sure you’ve had that experience with the same question that’s asked twenty times, over and over again. So that’s the first type of frustration I have.

The second type of frustration I have is when patients just are dead set on not listening. They went to Google, they know that what they have is psoriasis, even though it may be something totally different, and you have to talk them out of it. And at that point, I’ll say, “Listen, here’s the deal. You have a choice – you can see me or you can see Dr. Google. But Dr. Google’s not going to get you the prescription you need, so really, I don’t want you going there, because all you do is build up fear.” And, by the way, whatever the problem is, let’s say they have rosacea, I’ll say, “There is a place I want you to go to the internet. National Rosacea Foundation, or the Psoriasis Foundation, or WebMD. These are places where I think you should go, but please stay away from that.” Those are my two biggest frustrations with patients.

Dr. Keller:
Yeah, I completely agree. I think I try to fight the frustration, and I think in my life, I’ve only ever had a couple of patients that I’ve had to sort of fire because we weren’t able to come to an understanding of a patient-physician relationship, and it wasn’t so much because of my frustration, it was just I felt like I couldn’t give them good care, because we did not have that connection. But I also have to say that, “You know, I’ve done this for quite a while, and I’ve seen a lot of patients, and I think I’m giving you the best advice I possibly can, in this circumstance.” And 95% of the time, the patient comes around. You know, 5% of the time, they want somebody that’s going to tell them what they want to hear, and that’s not going to be me.

Dr. Keller:
So for those of you just tuning in, you’re listening to DermConsult on ReachMD. I’m Dr. Matthew Keller, and today I’m speaking with Dr. Michael Greenberg about bedside manner. So switching gears a bit, Michael, I’d love to dive into some key strategies that can help us improve our bedside manner. Can you tell us what professional intimacy is, and how it plays a role with your patients?

Dr. Greenberg:
Sure. I learned that you’re supposed to have a professional distance from patients in medical school, and I think that that’s just nonsense. The more human I am, the more patients can relate to me, the more patients really do better in my practice. So for instance, I had prostate cancer fourteen years ago, and I had seeds and I am just fine. But when a patient comes in and says, “I just got diagnosed with prostate cancer,” I go, “Yeah, I had that. Do you want to hear about my experience?” And I share that with them. Or I’ll share issues about my having some eczema, or my having another medical problem. And patients love it, and the most intense one was a patient who came in one time, and he had this terrible rash along his inguinal fold, and he said, “I had prostate surgery and I leak urine, and the rash is from that.” And he goes, “I just feel awful.” And I looked at him, and I said, “Hey. Did you ever see me wear tan pants to the office?” And he got the message. I go, “Every guy who’s had prostate surgery, or even guys over a certain age, yeah, we leak urine. Guess what? Me, too.” And the patient started crying, and we had that bond of intimacy. I’m not scared to say I’m human and I’ve had the same problem as you. Patients love it, and that’s when they really get peace of mind, when they know that you’re going through the same thing they are, and you’re okay.

Dr. Keller:
Yeah, I think that’s a great point, and I sort of try to relay that to my trainees as well is that there’s a difference between being close with a patient, having them see you as a human person, and losing your ability to be objective or their ability to see you as the physician in the kind of relationship, right? And I think that’s a really important point that you sort of make sharing things about yourself is a great way to create a greater bond with your patient. And they’re not going to see that as, “Oh, now I’m equal to you.” Or “You’re not going to be able to be objective with my care.” So I think that’s a great point and really a great thing to relay out, especially physicians out there that struggle with that, or come up in a training environment where there really is a lot of professional distance.

So as we close today, do you have any final thoughts on how we can improve our bedside manner with patients?

Dr. Greenberg:
Sure. I think the first thing that we need to look at is, are we really willing to do this? You know, what are we in here for? I would review, as I do all the time, my career in medicine. I go over the past 43 years, and I’m stunned by the number of patients I was able to help. A lot of my patients have been asking me lately, “Well, you’re 72, are you going to retire?” And I go, “No, why would I do that? I get to come to work every day in a clean shirt. I get to take care of people like you, I genuinely care about. I get to help you. And I get paid for this. This is insanely good. Why would I want to quit this?” And so the first thing is a focus on why you’re practicing medicine and what a privilege it is.

And the second thing that I think is really important in improving our bedside manner is to realize that we can’t fix a lot of things. I can’t fix the price of medicine. I can’t fix people’s insurance issues. I can’t fix their deductibles. And most importantly, I don’t care what people see on TV, with advertisements or on television shows, I can’t do the impossible.

And the last thing I think in improving our bedside manner with patients is to admit our humanness that we make mistakes sometimes, we’re not perfect. So when I am going to do, for instance, a cosmetic shave of a nevus, I’m very careful to tell a patient, “Listen, I don’t have an eraser here. I want you to have a realistic expectation. I’m going to make you better. You’re already perfect. I can’t make you perfect.” And they love hearing that, so it’s really a matter of presence and honesty. That’s how we improve our bedside manner with patients.

Dr. Keller:
Well those are all great things to keep in mind when interacting with our patients. And as that brings us to the end of today’s program, I want to thank my guest and fellow ReachMD host Dr. Michael Greenberg for speaking with me and for sharing his approach to bedside manner. As always, it was a pleasure speaking with you.

Dr. Greenberg:
I feel the same way, Matthew. Let’s just keep the conversation going. We’re here to be physicians, we’re not here to be businessmen.

Dr. Keller:
That’s great. So for ReachMD, I’m Dr. Matthew Keller. To access this two-part discussion on bedside manner or to find other episodes in our series, visit ReachMD.com/DermConsult, where you can Be Part of the Knowledge. Thank you for listening.