Moving beyond non compliance

From: Seto Gary <glseto@mac.com>
Sender: Practiceimprovement1@yahoogroups.com
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Date: Tue, 26 Sep 2006 01:15:24 -0700
Subject: Re: [Practiceimprovement1] appt length
Reply-To: Practiceimprovement1@yahoogroups.com

David,

Several years ago I got involved with teaching medical students at UCLA in a new curriculum they called "Doctoring". It involved learning interviewing techniques, active listening, recognizing body language (the patient's and your own) and using a standardized patient (an actor who played a role modeled on real patients). "Touchy feely stuff", I called it.

At first, I thought it was nice that the 1st year medical students got a chance to learn how to talk to patients and take a medical history without worrying about making a mistake or asking inappropriate questions. But they would wonder, as did I, as they were taking social histories and family histories when they were going to start dealing with "REAL" medical issues and problems. Eventually as I read over the course material, I began to see the utility in what we were teaching the students, especially since I had never been taught these kinds of things before but had to learn them on my own through trial and error. I started to incorporate these same techniques in my busy practice at Kaiser and found that I got to know more about my patients by just letting them talk and forcing/training myself to listen. What I learned is that the more time you spend with a person, the more you get to know them, and they you. What follows is a rapport, a relationship, whatever you want to call it. And when this connection is made, then and only then is when you find out the reason why your so-called non-compliant diabetic is the way he is is because he is totally stressed from his low-paying job and alcoholic wife and ADD son while also trying to care for his mother with Alzheimer's who is living with them. That is when you find out the woman who came in for a cold has also had low back pain for 6 months because she is being sexually harrassed at work and it is causing insomnia and depression.

My point is, that I believe that spending time with patients and making small talk with them and learning what makes them tick is not just "being kind". It is *medically necessary* for me to do my job as a family physician. It is one of my most valuable tools in helping to diagnose (because they won't tell you everything unless they trust you), and to treat (good rapport can help improve compliance rates, exert a positive placebo effect) whatever ails them.

Normally, I'm not this "touchy-feely", but I really believe that being a good doctor involves treating the whole person. I can't adequately treat their bodies without knowing their personalities/preferences/values.

I grant that there are some patients who don't care to share their personal lives with their doctors, they just want to get their physical exam and blood tests and medication refills and get the hell out of there. But people, unlike cars, have souls and spirits which can affect the health of the bodies they share and which require a different kind of attention. Would you rather be treated like a car, or like a person? And how do you treat your patients, like a person or like a car?

I would also like to be paid like a family physician, rather than like a piece-rate worker, but until then, I will abide by the coding rules as established by the powers that be and code correctly and not by a quota.

Gary Seto

South Pasadena, CA