Best to Hear It From a Friend

While there are reasons why physicians may not wish to be too emotionally attached to their patients (as it may impair their abilities with bias or undue emotional burden), it is hard to resist the analogy of the ideal doctor-patient relationship as a friendship. As with good friends, both the doctor and the patient should be able to trust one another: the patient trusts the physician to provide him with the best medical care and information while placing the patient’s interests as the top priority, and the physician trusts the patient to be honest and compliant with her treatment regimens and recommendations. Both are grateful to the other: the patient is grateful that his physician is doing the best she can to keep him healthy and happy, and the physician is grateful to her patient for giving her a chance to make a substantial difference in another person’s life. Their interactions are congenial and are marked by displays of care, concern, and private expressions of fear, grief, and strength.

However, there is another important aspect to this friendship-like relationship: constructive criticism. Some people go through their lives without accepting meaningful critiques from friends, and similarly, they lack the ability to appropriately criticize people they are close to with hopes of encouraging improvement or intervene when self-made situations have become dire. Good physicians know how to critique a patient’s behavior or beliefs without offending. For example, my preceptor (whom I follow in his clinic and hospital), an interventional cardiologist, is a highly charismatic and amiable man who is well-liked by his patients. However, he is often placed in the position of laying down the ground rules for new diet and exercise regimens for his post-myocardial infarction (heart attack) patients who may be obese or diabetic. Even patients who are very conscientious about their health status tend to overlook certain aspects of their health, and physicians are ideally suited to identifying these loopholes. Some patients fail to reach set goals (that both he and the patients agreed to at a previous checkup), and others slip in a lapse of discipline. At these times, he must be stern and sometimes unforgiving in his critique, sending the message that he truly cares about the patients enough to break the usual lightness of their interactions in order to drive home the message that they need to modify their lifestyle behaviors.

At the same time, patients should similarly practice constructive criticism with their physicians. This doesn’t happen nearly as often as it should. Usually, dissatisfaction with the doctor-patient interaction festers and grows until the patient is sufficiently malcontent to seek malpractice litigation. Perhaps contrary to popular belief, malpractice lawsuits don’t just happen because doctors make mistakes: they usually happen when the doctor fails to defuse the growing discontent of a patient after a poor outcome occurs. Malpractice litigation thrives on the faulty assumption that the science of medicine is perfect, and therefore the practice of medicine and its outcomes should also be perfect. As such, some patients are fooled into thinking that if a poor outcome occurs, they deserve financial compensation because it’s the doctor’s fault. Most of the time, however, doctors are able to bridge the gap in understanding and apologetically take responsibility for the outcome, even if it wasn’t the doctor’s mistake in judgment or action. Malpractice litigation has a terrible influence on doctor-patient relationships. Patients, in most cases, may be better off telling their doctors why they are unhappy with their performance or interactions rather than seeking retribution. After all, the doctor is the patient’s foremost advocate with respect to the facts that they have the patient’s interests at heart and have the greatest ability to help the patient. Physicians are generally good people, and there is a good chance that they will modify their behaviors to provide the best care for their patients. At least, this is an emphasis in the training of younger physicians: to listen, to truly understand, to reflect on one’s performance, and to constantly improve.

[This is most difficult in emergency care situations that are often targets for malpractice litigation. In these cases, the physicians have no prior relationship with the patient or chance to develop one, and so there is an emotional disconnect. Patients need to understand that poor outcomes are not always the result of mistakes, and furthermore, mistakes that do result in poor outcomes are not often indications that the physician is a bad doctor.]

On a final note, not only should physicians and patients practice constructive criticism on one another, but it is also very important for physicians to learn how to properly critique their colleagues. Physicians, as a professional group, love autonomy, and they despise and vilify the external influences that increasingly impinge on their independence (insurance companies, pharmaceutical companies, personal liability lawyers, etc.). However, in order to shake off these influences that are damaging for both patients and physicians, physicians must learn to better police and rein in their own. It is probably true that the vast majority of malpractice incidents are the result of a very small number of physicians. However, those physicians are often not the ones who are targeted and whose careers are buried by malpractice lawsuits. There are a number of things that could be done to fix this problem, including instituting physician or joint physician-lawyer committees in each state or city that screen all malpractice cases for validity (i.e. true indications of improper practice, not just poor outcomes). Physicians, however, need to constantly strive for improvement (just as they encourage their patients to improve), be willing to accept the constructive criticism of their colleagues, and also know how to give the same sort of meaningful critique when they see that a colleague could do something better.

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