Your voices

Compiled by Jeff Forster, Editor

On learning simple phrases—and building a practice

"In my military days, I made it a point of simple politeness to learn at least five basic phrases in any country I visited: Hello, Goodbye, Please, Thank you, and You're welcome. This usually went a long way toward smoothing relations with the locals.

Ten years ago, I began practicing in Newport News, VA, amid the largest concentration of military posts in the world. Because of service personnel who'd married overseas and former military people who've tended to settle in this area, there are many folks here whose primary language is Korean, Vietnamese, Japanese, Spanish, or Tagalog (Filipino). I try to greet each patient in his or her own language, and it has become something of a ritual to ask every patient who speaks a 'new' language to teach me a few words. I've even learned enough Spanish to conduct a mini-history and exam.

These patients know that I can't really speak their native tongue, but it's remarkable how much goodwill a single phrase can promote. After I had seen one Filipino patient and thanked him (salamat po), it wasn't long before I was seeing several of his friends and family. The same happened with Korean, Vietnamese, and Russian patients.

Even those foreign-born patients who speak English well appreciate my feeble attempts at their language. The modest effort of learning a few phrases pays great dividends in patient satisfaction and practice-building. Give it a try."

—Brooks A. Mick, internist, Yorktown, VA

On providing patient-focused care

" The doctor-patient relationship is the most important therapeutic intervention we can offer. I greet my patients with a smile, a handshake, good eye contact, and the question: 'How are you feeling today?'

I listen and observe while allowing the patient to tell me his or her story. I also try to evaluate the patient's degree of worry by asking, 'What concerns you most about your symptoms? What do you think it could be?' (If I could ask only one question, it would be, 'How are things at home?')

I employ therapeutic touch by putting one hand on the patient's shoulder while listening to the lungs, and shaking hands while assessing the radial pulse. I try to respond to the patient's need for comfort by placing a pillow on the exam table and asking permission to undress one portion of the body at a time for examination.

Oh yes—I wear a beanie-copter hat every Monday to give my patients and staff an excuse to laugh during this most stressful day of the week.

Two codes of conduct guide my patient-focused care: 'It is more important to know what sort of patient has the disease than what kind of disease the patient has,' and ' . . . to cure sometimes, relieve frequently, and comfort always'. I also live by the credo, 'I'm not just here to make a living. I'm here to make a difference.' "

—Gary S. Kodel, FP, Canyon Country, CA

The ideal "marriage" of physician and patient

"Everyone, it seems, is publishing lists of the 'best' doctors these days. What's your disease? Here's the best doctor for you. Wow! We'll be healthy forever if we can just find the best doctor.

But consider the patient who wrote to a medical magazine about her experiences with one of the 'best' doctors. She traveled a great distance to see him, but he spent very little time with her and didn't really answer her questions. He just said, 'Trust me. I know what's best.' He refused to get to know her, to tailor his treatment to her needs. He was arrogant, unloving, unkind.

Now consider the patient who finds a doctor she can talk to. He's not a Nobel Prize winner, but he's smart, he works hard, and he continues to learn. And he cares about his patient. If she has a question, he finds the answer. When she's sick at inopportune times, he's available for her. She can call him up to discuss her concerns. He'll work her into a busy day.

This doctor is good 'marriage' material. He's faithful, caring, and knows how to show it. The ideal doctor is the one who knows the patient well and is committed to the relationship."

—Louis L. Constan, FP, Saginaw, MI

Adapted with permission from the Saginaw County Medical Society Bulletin

On getting financial advice sooner rather than later

"As medical school graduation nears, my loan amounts are skyrocketing while incomes for primary care physicians are dropping. Two weeks after graduation, I will marry and then start a residency, at a salary that will make it necessary to scramble to survive. But I've had an experience I'd like to recommend to all doctors in training, regardless of their school loan situation or expected changes in lifestyle.

My future wife and I had the opportunity to meet with a financial adviser, who gave us a measure of tranquility by developing a plan. Hiring a financial adviser early in our careers will enable us to develop a respected relationship with a professional who will help us with each big change in life. Now is the time for us to make smart investments and strategic decisions for our tax returns.

Our financial adviser met with us twice to obtain the information he needed—including our goals and financial priorities—to create an extensive report that we reviewed at our third meeting. The report not only discusses our current financial status, but also provides a blueprint to help us achieve our goals.

All medical students and residents should invest a modest amount of money to hire a financial adviser to create a long-term plan. It's worth it!"

—Roberto Cardarelli, fourth-year medical student, Arlington, TX

On finding success in practice

"There are no failures in medicine. Anyone who would fail at medicine would probably fail at anything. As members of a four-generation medical family, we offer some tips for building and maintaining a successful medical practice:

• What's the worst thing you can say about another doctor? That he's incompetent, lazy, dishonest? No—the worst thing you can say is 'I never heard of him.' Building your own practice means developing effective relationships with your colleagues in the community.

• Good doctors are colleagues, not competitors. When they give you advice, it is usually sincere and should be considered. Remember: When three people say you're drunk, it is best to lie down.

• In designing an office, add one foot to every room, and you'll have it right. Especially in the hallways. Insist on five foot hallways so that two people and a wheelchair can pass easily. Also, just as no diamond can be too big, the nurses' reception area cannot be too large.

• When you enter a patient's room, sit down. We guarantee you will be out in one-third the time. When you stand, the patient senses you are anxious to leave and will try to keep you in the room. But if you sit immediately, the patient will conclude you are there to listen and will then proudly tell others, 'My doctor would have stayed all day if I'd wanted him to.' If the doctor will just shut up long enough, the patient will share what's wrong.

• Never tell a patient that his or her problem is due to 'old age.' Rather: 'It's because you are older.'

• The more you write on the chart, the better. About 30 percent of complaints to medical boards are based on inadequate records.

• If you're awakened by a phone call from a patient around 1 am, you may or may not have to leave your house. But if the call comes in at 4 am or after, start putting on your shoes. Any call at 4 or 5 in the morning signifies a true emergency. Otherwise, the patient would wait until the office opens.

• After you've finished the examination, made your diagnosis, and, if appropriate, given the patient a prescription, watch intently as the patient reaches for the doorknob. Often he will turn to you and say, 'By the way'—and out will come the real reason for the visit."

—Martin H. Zwerling, otolaryngologist/allergist, Aiken, SC, and his granddaughter, Jennifer Almy, internist, US Navy

Creating a "safe space" for the patient

"Thirty men and women moved around the floor of our hospital auditorium. Some hopped like kangaroos, and others pretended to be monkeys, scratching themselves and eating bananas. Emus bobbed up and down, hunting and pecking for food, while crocodiles slithered on the carpet, sweeping the room for prey.

These people, all dressed in suits and dresses, were some of the most respected members of our medical community. What on earth were they doing?

We had invited a visiting healer, Tjanara, to discuss ancient traditions. She had begun the grand rounds presentation by inviting us all to participate in an Aboriginal healing ceremony. She pointed out that, for Aborigines, the healer places great value in honoring the patient and creating a "safe space" for him to speak his truth and become completely vulnerable.

We all enjoyed the animal role playing, which was but one part of the healing ceremony. It was a wonderful relief from our busy schedules, but none of us considered it useful for our own practices. Nice for the Outback, but can you imagine explaining to a plaintiff's attorney why you had your patient hopping when he experienced cardiac arrest? What's the CPT code for 'healing ceremony'? Who has time to create safe space?

Three months later, I was working the evening shift, doing physicals on new admissions and responding to problems on the hospital floor. I was three admissions behind when I got a call from the coronary ward: A patient scheduled for a pacemaker insertion the next morning was leaving against medical advice. He was schizophrenic and had refused medication. As I ran up three flights of stairs, I realized that my gasping was more from not knowing how to handle the developing situation than from climbing the steps.

Theodore was in the hallway, already dressed and carrying his bags. The nurse persuaded him to return to his room so we could talk. Wildly grasping for solutions, all I could come up with was Tjanara and her idea of creating safe space. It was worth a try. As we both sat down on the bed, I smiled and attempted to look with some warmth into his eyes and to create an attitude of openness and welcome.

At first there was only silence. But then Theodore began explaining his situation. He'd felt betrayed by his sister, who'd brought him to the hospital. He knew she'd done this so she could steal his meager belongings. As he talked, he began to relax. He seemed to appreciate the fact that I hadn't come just to give him an ultimatum or a shot.

By the time he'd finished his tale, I'd had time to leaf through the chart and understand why he was there. I explained how his syncope was related to his second-degree heart block and how the pacemaker would help. To my amazement, he accepted my explanation. Then he said, 'Your tie is crooked,' and very gently straightened it. When I thanked him, he volunteered to stay for the pacemaker, if he could go outside for a smoke.

Fair enough! We struck a deal and shook on it. At the nurse's station, as I was furiously writing chart notes, Theodore approached. Oh, no—he's going to change his mind, I thought. But as he neared me he smiled, reached into his pocket, and gave me a penny and a dime. I keep those coins on my desk as a reminder of the art of medicine I learned from an ancient healing tradition.

There are many ways to practice medicine. Even in our high-tech system, there are times when the sensitivity and caring of ancient healing practices are the most efficient, cost-effective, and humane approach."

—David von Weiss, FP, Eden Prairie, MN

 

Jeff Forster. Your Voices. Medical Economics 2001;4:96.