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In the rush of daily practice it is easy to miss what patients are feeling. But often just a few minutes of mindful attention can make all the difference.
Patient's home after a sleepless night:
Another night of fits and starts - the pain in my back woke me every time I turned in bed. I am finally getting in to see my doctor - it took three weeks - and now the pain is interfering with everything I do, from getting out to bed, to driving, to work, to spending time with my family. My wife and I are arguing more - I don't seem to have much patience these days. And I am snapping at my kids. People at work notice that I am irritable too - my boss called me out on it the other day.
This is a common scenario - we need to recognize that often patients are compromised, to some degree, before even stepping foot into our office.
The doctor's office - take one:
I arrive at the doctor's office for my appointment and there is a line of patients at the front desk. My back is killing me and it hurts to stand. I can feel my anger starting to rise. It's finally my turn and the receptionist greets me, but then answers the phone. "Listen, I've been waiting for over 10 minutes and now you take a call ahead of me," I say with an angry tone. But she's busy dealing with the call and gives me an irritated look. "I'll be with you in a moment. Please just be patient." (Patience is the last thing I feel). When she finally finishes the call, she gives me a meek apology and I am sent to the waiting room.
There are now numerous factors that add to the distress of the patient - pain, having to wait, being put "on hold," and not being seen on time. All this creates a threatened state in the brain, making it very difficult to self-regulate, thus the impatience and the angry tone in his communication. The patient is likely to be more inwardly focused on his own needs and level of distress, making it extremely difficult to focus on how he might be impacting others (like the office staff).
Finally, it's my turn to be seen. I am taken back to an exam room and the assistant lets me know the doctor "will be right in." Fifteen minutes pass - still no doctor. Don't they realize how much pain I am in! At 10:30 a.m. the doctor finally comes into the room. I blurt out that I have been waiting almost an hour since I arrived at the office. "I am sorry," he says, sounding defensive, "but it has been a really busy morning. I was delayed earlier at the hospital seeing patients." He listens to my complaints, does an exam, then suggests that I get some physical therapy and prescribes me some pain medication. The visit is over in 10 minutes and I am rushed out the door. I don't really understand what is wrong with my back, but I am relieved to get some medicine for the pain. I have such a busy schedule I don't think I can fit in physical therapy. The doctor told me I should come back if my pain does not improve over the next three weeks. So I will wait and see if the pills work. I am feeling a little hopeless and wonder if my back will ever get better.
A lack of certainty and predictability (not knowing when he will be seen by the doctor) creates even greater threat and distress for the patient. He is likely not listening well and will try to seek some form of control so he feels less helpless. In the absence of sufficient information, combined with his anger and frustration, he is unlikely to be open to anything that he perceives as making his life more difficult (like finding time for physical therapy). This sets up a situation of non-compliance with medical advice.
The doctor's office - take two
I arrive at the doctor's office and there is a line of patients at the front desk. There is a sign-in sheet that indicates name, time of arrival, time of appointment, and doctor's name. The receptionist apologizes to everyone waiting and lets them know she will get them checked in as quickly as possible. She tells people they can take a seat if they are uncomfortable standing. I am thankful as it aggravates my back to stand. Within about 10 minutes, the receptionist calls my name and, once again, apologizes for the wait. Then her phone rings. "I am sorry," she says, "please allow me to answer this call and put it on hold." She quickly gets back to me - "I see you are here to see Dr. Henry. Please have a seat in the waiting room. Someone will take you back as soon as possible. Please help yourself to some water or hot beverage."
Recognizing that patients frequently come to the office somewhat compromised, there are some simple strategies that can help make them more at ease. Communication is one of the primary strategies - by letting patients know you recognize that having to wait can be frustrating, you communicate care and concern. Telling them how long they will have to wait gives them a sense of control. A sign-in sheet gives patients an opportunity to do what they need to get as comfortable as possible (like sitting down), while assuring they don't lose their place in the line. Offering a beverage is another simple way to express consideration. All this helps the patient feel that his needs matter, which creates a positive state in his brain.
The medical assistant brings me to the exam room and explains that the doctor has been a little behind with his patients. She apologizes for the wait and offers me some reading materials. She stops in the exam room after 10 minutes and lets me know that they have not forgotten me, but the doctor is finishing up with another patient. At 10:30 a.m. the doctor comes in the room and immediately apologizes for making me wait. He asks me how the pain is affecting various areas of my life. He explains how it is easy to get into a pain-spasm-more-pain cycle and that is important to both relieve the pain and get my back and core muscles stronger to prevent more pain. He suggests that in the short-term, some pain medication can help me, but for the long-term, physical therapy has the advantage of providing me with exercises to make my back stronger.
Then he asks if I have time in my schedule to go to a few sessions of physical therapy. I explain that my work schedule is pretty hectic. He asks me how much the pain is interfering with work. "Quite a bit," I respond. "By taking time for physical therapy, your ability to work productively will improve, so perhaps it would be worth your while." He's right. That was a helpful explanation. Before ending the appointment, he asks if I have any further questions. I do have a couple of questions, which he takes the time to answer. We decide that if I am not getting better within three weeks, that I will come back to see him. I leave feeling a sense of hope.
Frequent communication and a brief explanation lessen the feeling of uncertainty and help create some predictability. When the physician takes time to understand the patient's situation and then becomes his partner in health, there is a much higher likelihood of compliance. The patient feels heard, understood, and cared about.