No one wants to be sick, especially when no one can tell them what is wrong. In the US, we live in a culture where we want instant results; we want easy answers for complex problems. However, in medicine, there are often no easy fixes. Bad medical events happen, despite our best efforts. For example, a young child was recently diagnosed with Type 1 diabetes mellitus. While he and his family struggled for many months to get this under control, they eventually did. Then, a few months later he was diagnosed with leukemia. Why? No one can answer this because the two diseases are completely unrelated. Is it unfair that one child should have two dreadful diseases? Absolutely, but that doesn’t change the fact that it happens.
How can doctors address patients’ expectations?
- With honesty. Patients need to know the truth, good or bad. If we feel they are expecting something unattainable, we must balance their hope with reality. When we fail to do this, we take away the patient’s ability to make informed choices about their healthcare.
- Providing enough information. I often see patients come and tell me that the specialist didn’t explain anything to them. We must do a better job explaining exactly what we think is causing their symptoms and the treatment plans. How can patients know what to expect without this discussion?
- Through compromise. If a patient is requesting a test that we think may be unreasonable, we should explain our reasoning. Maybe another test will give us the same results or maybe the patients should really have the test done that they are asking for. We must listen to their reasoning before making hasty decisions.
- By discussing options. Often, there may be more than one way to treat a given disease. We may know which one that we think is the best, but we should present all available options to the patient and let them make their own decisions. Yes, we need to make sure they understand all the options and potential outcomes. However, when we don’t give them all the options, we are making the decision for them.
- Telling patients when their expectations are unrealistic. If something is not going to work, patients need to know that. Why give chemotherapy to a terminal cancer patient if we know it is only going to make a patient sick and do nothing to treat the cancer?
- Direct patients to further resources. Patients may need to time to make their decisions. Give them good references where they can study it on their own time and not feel pressured to make a decision.
Not only do patients sometimes have unrealistic expectations, doctors do too. We expect our patients are going to to take the medications that we prescribe for them or do the tests we recommend. Maybe there is some reason that prevents them from doing this; perhaps, the pills cost too much or they are afraid of the complications of a procedure. If we don’t listen to what are patients are experiencing, we will never be able to get a handle of our own expectations. We must listen to what our patients have to tell us. We need to give our patients the opportunity to tell us what they feel and expect. And we must not be afraid to tell them the truth, even if it hurts.
Copyright secured by Digiprove © 2019 Linda Girgis, MD, FAAFP
Despite our best efforts, there is a certain appeal to the easy answers to that bugaboo of all disorders: “I don’t feel good and the last four doctors couldn’t tell me why.” There are Lyme and fibromyalgia centers run by physicians. At one time people got treated for chronic esophageal candidiasis until the NEJM accepted a rigorous research study confirming the condition bogus. The people labelled as adrenal fatigue got their hydrocortisone prescriptions from somebody with a license to prescribe it. And a look at the tongue, the only muscle not hidden by skin and people who can get more our of a radial pulse than I can accept the option of some minor cutaneous punctures in a quest to feel better. And we have the chiropractors. All licensed by the state government to assure the imprint of capable. With the ultimate irnony that these backups for when we mainstrea clinicians fall short pay less in insurance to protect their errors than we do.
As a referral source, I also depend on inheriting other colleagues’ unsuccessful treatments. Tapping specialty resources generally corrects things that have a clear relation to the specialty but too often the endos and the ID people compete as Dr #4. It’s either Wilson’s Syndrome or Parvovirus, depending on who #4 MD is.
One of the real challenges, both that I inherit and that I contribute to, is bypassing some of the options by way of my own training related imprinting or sometimes just wanting to have good relations with patient and referrer. There are oodles of ways to treat diabetes but for any patient they are not equivalent. So what they saw on TV that gets their weight down will not correct insulin deficiency if that is what they have. When the lab says it’s not Low T, it’s not even if that they feel like the guy on the screen. And sometimes I’ve been the guy to offer Zoloft when nobody else did or to tell them that statins are better worth the potential side effects. After about 4 reasonable assessments, though, some things just don’t have a good means of reversal. Whether illusion of reversal which will satisfy some patients is really good enough, has no clear answer either.
Very well written. In psychiatry, it gets very tricky because we often have to ask our patients to give it time…..whether it’s medications or psychotherapy. I try to write down a quick summary of our goals for treatment and any options that we’ve discussed because patients don’t always remember or understand everything when they’re not feeling well (outpatient setting). Emergency room situations and inpatient therapy can get even more complicated! Patients are discharged even if they’re suicidal or psychotic if they aren’t pointing a gun to their heads! I have had frantic calls from primary care physicians, internists, psychologists and social workers who are overwhelmed because their patients are unstable but “not sick enough” to be hospitalized according to criteria set by third party payers. The most heartbreaking cases I have dealt with include young adults who have been diagnosed with both a mental illness and substance abuse/dependence. “Why?” family members ask. “What happened? Are we at fault?” I try to focus on helping one patient at a time. Otherwise, I would become overwhelmed. I am however, able to be honest and realistic with my patients to the best of my knowledge. Dr. Linda, please keep what you’re doing with your patients and together, I believe we can achieve the goals which we set for ourselves and our patients.
Thank you so much! I appreciate your thoughts on this article and always. Hope you are doing well!
Dr. Lunda