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Which is Best for the Patient?: A Patient Patient vs An Impatient Patient
I put this question up on my Bioethics Discussion Blog, March 22, 2010
http://bioethicsdiscussion.blogspot.com/2010/03/which-is-best-for-patient-patient.html but I thought it would be of general interest for all of us real or potential patients, that I would reproduce it here on Medpedia under Questions and Answers. I await an answer. Remember, the answer should be related to "which is best for the PATIENT?"
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If the title of this thread started with "Which is best for the Doctor", my general opinion would be easily answered with "a patient with patience." Doctors know that diagnoses are not made easily and treatments do not always give instantaneous cures. So patient patience is the most comfortable patient behavior looked for by the doctor. However, answering the question from the viewpoint of what is best for the patient, the one who is ill and symptomatic, ah! there probably are different responses. And it is from that viewpoint that I would like my visitors to respond. First, though, let's look at a list of what writers and philosophers had to say about patience and impatience and which I culled from the Thinkexist.com website.
http://thinkexist.com/quotations
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First, patience:
"All human wisdom is summed up in two words - wait and hope” ...Alexandre Dumas Père (French Writer, one of the most prolific and most popular authors of the 19th century, 1802-1870)
“Patience is the companion of wisdom.”...Saint Augustine (Ancient Roman Christian Theologian and Bishop of Hippo from 396 to 430. One of the Latin Fathers of the Church.354-430)
“The two most powerful warriors are patience and time.”...Leo Nikolaevich Tolstoy (Russian moral Thinker, Novelist and Philosopher, notable for his influence on Russian literature and politics.1828-1910)
“Patience and fortitude conquer all things”...Ralph Waldo Emerson (American Poet, Lecturer and Essayist, 1803-1882)
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And now, impatience:
“In all evils which admit a remedy, impatience should be avoided, because it wastes that time and attention in complaints which, if properly applied, might remove the cause”...Samuel Johnson (English Poet, Critic and Writer. 1709-1784)
“Perhaps there is only one cardinal sin: impatience. Because of impatience we were driven out of Paradise, because of impatiencewe cannot return.”...(English born American Poet, Dramatist and Editor who achieved early fame in the 1930s as a hero of the left during the Great Depression. 1907-1973)
“Patience is the support of weakness; impatience the ruin of strength”...Charles Caleb Colton (English sportsman and writer, 1780-1832)
“All human errors are impatience, a premature breaking off of methodical procedure, an apparent fencing-in of what is apparently at issue.”...Franz Kafka (German Writer of visionary fiction, 1883-1924)
“Experience has taught me this, that we undo ourselves by impatience. Misfortunes have their life and their limits, their sickness and their health.”...Michel de Montaigne (French Philosopher and Writer. 1533-1592)
“Impatience is the mark of independence, not of bondage”...Marianne Moore (American Poet, 1887-1972)
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So now considering the uncertainties and burdens of a patient who is ill and in this age of patient autonomy where the patient has become more responsible for their own decisions and treatment, which behavior, patience or impatience, would be the most productive for a better outcome? Which behavior would you classify yourself as demonstrating? ..Maurice.
http://bioethicsdiscussion.blogspot.com/2010/03/which-is-best-for-patient-patient.html but I thought it would be of general interest for all of us real or potential patients, that I would reproduce it here on Medpedia under Questions and Answers. I await an answer. Remember, the answer should be related to "which is best for the PATIENT?"
________________________________________________________
If the title of this thread started with "Which is best for the Doctor", my general opinion would be easily answered with "a patient with patience." Doctors know that diagnoses are not made easily and treatments do not always give instantaneous cures. So patient patience is the most comfortable patient behavior looked for by the doctor. However, answering the question from the viewpoint of what is best for the patient, the one who is ill and symptomatic, ah! there probably are different responses. And it is from that viewpoint that I would like my visitors to respond. First, though, let's look at a list of what writers and philosophers had to say about patience and impatience and which I culled from the Thinkexist.com website.
http://thinkexist.com/quotations
________________________________________________________
First, patience:
"All human wisdom is summed up in two words - wait and hope” ...Alexandre Dumas Père (French Writer, one of the most prolific and most popular authors of the 19th century, 1802-1870)
“Patience is the companion of wisdom.”...Saint Augustine (Ancient Roman Christian Theologian and Bishop of Hippo from 396 to 430. One of the Latin Fathers of the Church.354-430)
“The two most powerful warriors are patience and time.”...Leo Nikolaevich Tolstoy (Russian moral Thinker, Novelist and Philosopher, notable for his influence on Russian literature and politics.1828-1910)
“Patience and fortitude conquer all things”...Ralph Waldo Emerson (American Poet, Lecturer and Essayist, 1803-1882)
_______________________________________________________
And now, impatience:
“In all evils which admit a remedy, impatience should be avoided, because it wastes that time and attention in complaints which, if properly applied, might remove the cause”...Samuel Johnson (English Poet, Critic and Writer. 1709-1784)
“Perhaps there is only one cardinal sin: impatience. Because of impatience we were driven out of Paradise, because of impatiencewe cannot return.”...(English born American Poet, Dramatist and Editor who achieved early fame in the 1930s as a hero of the left during the Great Depression. 1907-1973)
“Patience is the support of weakness; impatience the ruin of strength”...Charles Caleb Colton (English sportsman and writer, 1780-1832)
“All human errors are impatience, a premature breaking off of methodical procedure, an apparent fencing-in of what is apparently at issue.”...Franz Kafka (German Writer of visionary fiction, 1883-1924)
“Experience has taught me this, that we undo ourselves by impatience. Misfortunes have their life and their limits, their sickness and their health.”...Michel de Montaigne (French Philosopher and Writer. 1533-1592)
“Impatience is the mark of independence, not of bondage”...Marianne Moore (American Poet, 1887-1972)
________________________________________________________
So now considering the uncertainties and burdens of a patient who is ill and in this age of patient autonomy where the patient has become more responsible for their own decisions and treatment, which behavior, patience or impatience, would be the most productive for a better outcome? Which behavior would you classify yourself as demonstrating? ..Maurice.
asked Feb 02, 2011 at 05:11PM in Other
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0Votes
answered Feb 03, 2011 at 12:29PMMaurice,
As a patient my policy will be to be impatient with incompetent doctors- those who give wrong diagnosis, little time to explain, ready to bill, under stress, wrong medication prescription and then charge for their time. patients should have the option to walk out and cancel the appointment at spot without paying. On the other hand highly competent doctors, university professors and lecture circuit stars have always had time to listen to their patients, time to explain, answer questions and reassure patients. Patients must have lots of patience with such competent doctors. -
1Votesanswered Feb 03, 2011 at 01:30PMI might be impatient either as another physician or as a patient with "know-it-all" "lecture circuit star" physician who is paid by a pharmaceutical company for those lecture circuits when he or she is advising me or prescribing to a patient the "unique lecture circuit drug" . Perhaps, I am too cynical about those particular doctors but there is mounting evidence that someone should become impatient with their pharmaceutical advice or behavior. ..Maurice.
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answered Feb 03, 2011 at 03:36PMI don't see a place in medicine for a physician that does not spend time and listen to the patient. The listening and looking develops the relationship necessary for the Doctor / Patient relationship. The patient develops a confidence in mileau as does the physician.
Impatience does not satisfy the responsibilithy of the physician.
Michael Derechin, MD -
1Votesanswered Feb 03, 2011 at 05:48PMBut Michael, patients may feel, realistic or not, an imbalance in power between them and their physicians. They may feel by the physician's knowledge, privileges granted by society including diagnosing, prescribing medications, even examination of the patient's body along with the patient's own illness and symptoms and bearing the associated physical and emotional incapacities,that they are the weaker party. This may encourage an apparent appearance of patience on the part of the patient in that the patient may not speak or "speak up" to the doctor about the patient's personal concerns or about some unwanted behavior on the part of the physician. The physician may not be aware that the patient's apparent patience could be an illusion due to that power imbalance. ..Maurice.
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0Votesanswered Feb 03, 2011 at 09:37PMWhat is your suggestion and advice for patients in the following examples : be patience, follow advice or be informed and challenge the diagnosis/treatment. Some doctors openly say that they do not like aggressive patients. Good doctor-patient interaction is important in building a relationship of confidence.
An endocrinologist repeatedly ignored complains of frequent leg pain from an overweight type 2 diabetes patient. The leg pains are well known labelled adverse reaction of glitazones: Avandia. The patient was continued for 3 more months on Avandia leading to persistent leg pain.
When the patient presented him a copy of the US prescribing info with the FDA Black Box warning (the local official French info had no such warning), this was dismissed as American and media obsession with ADRs. After 3 months, the patient was switched to another drug for T2D and leg pains ceased. Here Maurice your point about some doctors in league with the pharmaceutical industry seems justified.
Once during a routine Friday afternoon first consultation, a specialist performed minor surgery on a new patient without informing or seeking consent from the patient. After the surgery, patient was told to rest at home for 5 days. The sudden surgery resulted in cancellation of weekend plans with the family, medical leave from work and cancellation of a business trip. After patient complain and protest, the specialist (the local media star) informed the referring family doctor that the patient was aggressive and non cooperative?
A commercially minded GP diagnosed a a skin rash as invasive Candida fungal infection and prescribed topical anti fungal treatment. Another specialist surgeon agreed with the fungal infection and recommended the same treatment. A few weeks later a dermatologist identified the rash as a generalized allergic reaction and the prescribed anti allergic treatment resulted in resolution of the problem. The patient was billed by the GP for diagnosis and consultation. Although the patient paid the bill, I think he had the right to refuse to pay? -
1Votesanswered Feb 03, 2011 at 10:08PMYes, Krishan, a voluntary conflict of interest by a prescribing physician especially for self-gain demands patient impatience and complaint if the patient is aware of the relationship.
"Blacklisting" an impatient patient is not fair especially when the problem was inadequate communication in the first place between the surgeon and patient so that both knew each
others duties and responsibilities.
In your last scenario, it is not clear that the GP or surgeon's misdiagnoses represented conflict of interest. Patients usually have to pay for services by a physician whose initial diagnosis, made in good faith, was later found in error, particularly if that physician has followed and monitored the patient and at a point that would be consistent with standards of practice to refer the patient to a specialist for the condition. Sometimes, in non-critical circumstances, patience on the part of a patient is necessary to allow time for observation of the course of the symptoms in a patient started on empiric therapy for a condition as yet not fully proven. ..Maurice.-
I agree with your opinion about the last case, that is why despite initial hesitation, the patient paid the bills of both the GP and surgeon. The first 2 examples unfortunately exist in several EU countries although not very common. Europe lags behind the US in clear declaration of conflict of interest and ethical conduct.Krishan Maggon PhD commented Feb 05, 2011 at 01:03AM
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1Votesanswered Feb 04, 2011 at 09:14AMRatul,
The categorization of patients was probably one of the earliest system of classification. It is mentioned in Ayurveda, Traditional Chinese Medicine, ancient Greek and Roman era. Ayurveda devotes a whole chapter to qualities of patients and another one to duties of patients. Its aim was to prepare future doctors to be ready to deal with diversity of patients and their behavior. These days the same purpose is served by rounds of clinical wards.
I believe that the wrong or stupid question is the one which is never asked. As a patient I would like to go a qualified and experienced doctor and who has sufficient time for me and resolves the problem in minimum time. -
2Votesanswered Feb 04, 2011 at 10:03AMRatul, I was not classifying patients as "best patients" or "not the best patients". The word "best" in my introduction was to emphasize which would be in the BEST INTEREST FOR THE PATIENT by either the patient or the doctor to demonstrate to the other patience or to demonstrate impatience. Yes, the patient IS A PATIENT and not a machine with the doctor not simply a technician. Because both are human beings and both can demonstrate their emotions and feelings and understandings or misunderstandings of the other, the expression of what either feel can be shown as patience or impatience. And I am not insisting that a patient who shows patience under one circumstance should not under some other circumstances show impatience.
What I am concerned about is that because of the possibility that some patients might feel that the playing field is not equal and they may be the weaker party they may feel it would not be to their benefit to appear impatient and thus not speak up and challenge the doctor if they find that the doctor hasn't communicated adequately or because of some other issue with the doctor's action and behavior.
Actually, I think that the playing field is should not be perfectly level in the sense that the field should be slanted toward that of the PATIENT'S BEST INTEREST and not that of the doctor. ..Maurice. -
2Votes
answered Feb 04, 2011 at 02:15PMI have had patient family physicians the last two years (the first one was promoted to another position). That said, a family physician previous to those ones had the habit of continually looking at her watch, and looking impatient if I, or a family member with cancer, went over "the limit". She was into making as much money as possible by plowing through patients by the numbers. She had no tolerance for anyone who had difficulties speaking, or complex medical issues that needed a longer explanation. Unbelievable, but true. We left her practice, after she told me that she didn't want me as a patient, because I complained about her demeanor.
Thank God, physicians like that are far and few between......
Some physicians appreciate advocacy for best care, and others don't, it seems. -
3Votesanswered Feb 04, 2011 at 04:52PMKim, do you realize that you presented an example of a patient's impatience with the physician's impatience in which you as the patient "spoke up" and which turned out to your own best interest!
Imagine what would be the consequences if you were not impatient and therefore failed to "speak up". A wonderful clinical example of exactly what this Question was all about! ..Maurice. -
0Votesanswered Feb 04, 2011 at 08:11PMI inadvertently stumbled on that one. I am aiming for "best answer". Just kiddiing!
Seriously, when both patient and physician are impatient, it can result in either a better or worse relationship, but probably not a static one. I don't believe patients should be passive. -
1Votesanswered Feb 04, 2011 at 08:49PMI agree that patients should not be passive when dealing with their physician or others regarding their symptoms, disorders and also personal concerns even the issue of patient modesty. But as I already mentioned many patients feel dependent on the active interest and professional participation by their physicians and other healthcare workers and may fear that "rocking the boat" so to speak may disrupt what should be a smooth and effective journey on the waters of personal recovery. I think what should be done is when a physician begins a doctor-patient relationship, the doctor should communicate with the patient about the doctor's need for patient input in any matter during their working together which is troublesome or uncertain to the patient.
Impatience by a patient in relation to any disorder is actually a symptom about which the physician should be made aware and to be attended to and treated like all the other symptoms.
..Maurice. -
2Votes
answered Feb 05, 2011 at 08:46PMKim, I think your example is an example of advocacy at best. Maurice, I agree that all too often, too many patients are passive in their own medical care. I think a good patient is informed and must have impatience if the doctor is not providing answers or is being rude, as in Kim's example. As a patient, I've been impatient with doctors who were uncaring or rude. I "fired" them. Of course, I "hired" my compassionate, competent, personable doctors. I have also found most doctors to be in the latter category, but to my dismay, have found a number to be in the former. Also, whether a patient is patient is perceived differently, depending on the doctor. For example, I'm sure my excellent doctors would say I'm a very patient person, but the ones I "fired" would say I was not patient at all.-
Thank you, Beth. You are a strong advocate for yourself and others, too.Kim M Robinson commented Feb 06, 2011 at 02:06PM
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2Votesanswered Feb 05, 2011 at 09:26PMBeth, I have a question. You "fired" your doctors after experiencing their behavior and I understand that. But how did you "hire" those doctors who you say are "compassionate, competent and personable" PRIOR to experiencing their behavior. Have you made it a practice, generally, to participate in a "introductory" non-clinical session (that is, while well) with a new doctor to discover how the office works and about the physician's behavior and views? If so, then I would understand how you can decide about which doctor you feel comfortable to "hire". I don't think and it isn't my experience that most patients go for the introductory session, a session which I think is actually very important. I suppose most patients pick a physician (if they have time to do so) by recommendations of their family, friends or neighbors. That can be open to the possibility of personally erroneous selection since such appraisals by others may be specifically related to the other's personality and the specific disease and course. And yes, and perhaps understandably,, patients are regularly evaluated by their doctors for the patient's patience and compliance. ..Maurice.
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1Votesanswered Feb 07, 2011 at 07:46AMHi Maurice,
You pose an excellent question, and I should clarify: I hired them after our first meeting -- if they seemed the right fit for me. I never had a non-clinical session, although I think that's not a bad idea for people looking to hire good doctors. Here's a long answer that just highlights of how I hired doctors.
I hired my doctors in all sorts of ways: there really was no linear path. I hired my PCP pre-cancer, when I needed a routine exam; over the years I had seen other doctors in the group, but felt they were OK, but not what I needed in terms of their demeanor, professionalism, or how long they attended to me. So I randomly picked her name, and she sat down and listened to me during the appointment and really seemed to care. I happily used this doctor for years, and she'd return my calls.
She was what I call the "Gateway Doctor." My philosophy is that great doctors associate with other great doctors, and a great gateway doctor can lead you to great specialists. When I was going through breast cancer diagnosis, she referred me to an outstanding oncologist, whom I wanted to hire. He was optimistic, sweet, kind, caring, and put me at ease. Plus he was thorough and answered my questions clearly. I sought out a second opinion just because I thought it would be a good idea, and that oncologist basically told me coldly that I was going to die and threw out a bunch of scary statistics from the Internet pages he had printed out and was reading from. He also contradicted his statistics.
Needless to say, I hired the great oncologist my gateway doctor recommended, and I was very pleased.
A last example (and I have many) was when I hired my mastectomy surgeon. This was the only appointment where I conducted it like a formal interview. I told her that I had fired a string of doctors who were nasty to me and/or wanted to remove organs that had nothing to do with my mastectomy. I told her that she was potentially the missing link -- all my other surgeons were in place for my DIEP flap procedure. She was wonderful in every aspect -- and she was a breast cancer survivor who had a single mastectomy. So there was this surreal connection there.
I hope I answered your question. I do have a great doctor a friend referred me to, but I'm not sure if personal referrals are necessarily the best way to go.-
Great insight and experience, thanks for sharing it with us. It is not difficult to find the right doctors and specialist based on recommendations if one is in a pharma company or medical school. However the few I tried on my own, I had to change within a year or two. Reasons: Business minded, wrong diagnosis, stressed, very busy, breach of confidentiality, late appointments during emergencies etcKrishan Maggon PhD commented Feb 08, 2011 at 11:07AM
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answered Feb 23, 2011 at 01:28AMRogentine showed in 1979 that melanoma patients, who seemed 'less adjusted' to their diagnosis, had beter survival (80% after one year) than patients who seemed 'well adjusted' (30% suurvival after one year). Derogatis, in the same year, published favourable outcome in breast cancer, in psychologically 'symptomatic'patients. Stavraky saw better survival in lung cancer in patients wih more, albeit controled, hostility. Well adjusted, according to the doctor, is a patient who is nice and calm and easy in our consultation room. Everything seems well. Actually, these patients may well repress negative emotions and 'pay a price 'for being nice'. So, an inpatient, emotional,'psychologically symptomatic' cancer patient is more healthy than the silent, complying, 'everything-is-fine-doctor', patient patient.-
I agree; and hypothesize that the visibly angry patient, or one with emotions negative or positive openly expressed, has more of a sense that they are in control, rather than the cancer or even the medical system. Perhaps that "not so nice patient" is less likely to produce stress related inflammatory toxins that promote cancer growth as well, I don't know. Your comments are most interesting.Kim M Robinson commented Feb 23, 2011 at 07:52AM
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1Votesanswered Feb 23, 2011 at 08:34AMJohannes, a most interesting relationship regarding this Question which you are describing. Can you tell us what has been found as the biological mechanism for this cancer-expressive emotion relationship? And from the point of view of what you professionally try to accomplish with a patient, is it literally to try to turn a "patient" patient into an "impatient" one? Also, how do patients accept your attempts at therapy? Even for the goal of a better outcome with their cancer, is it easy for a patient to change emotional behavior that probably has been unchanged of most of their lives? And importantly, what feedback do you get from the patient's families or those who live with and attend the patients regarding their "new" behavior especially during this period when these "others" may be themselves stressed by the patient's cancer diagnosis? ..Maurice.
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1Votesanswered Feb 23, 2011 at 09:07AMDear Maurice,
With regard to mechanismn, I believe that most of it, we don't know. A lot of attention has been given to activation of the cortisol axis in tumor ptomotion. Corticosteroids decrease immune function and, as decribed by Laborit, corticosteroids themselves increase passive behaviour. So, the patient may get 'locked in', in a cycle of passive coping: passive coping increases cortocosteroids, corticosteroids increase passsive coping. But I do not beleve that this is the whole story and it may not even be one percent of it. Immune function in cancer, likely, is less important in humans than it is in animals (where much research has been done in psycho-neuro-immunology/ -oncology). We have studied spotnaneous regression of cancer in humans. Large tumors like mesothelioma measuring 16 cm, may virtually vanish in a couple of months, and I do not believe that mere immuno-activity could account for that. Changes in blood flow, growth factors, growth promoting hormones in estrogen sensitive cancers, promotion of cell differentiation by cytokines; all sort of mechanisms do exist in the body and could be involved. I currently do not focus on psycho-biological mechanisms. Rather, my emphasis is on development of psychosocial intervention. When we reach the stage that psychotherapeutic action reproductively effects tumor growth, we have more 'material' to search fo the mechanisms involved.
Problem focused, active coping may be trained in a course and has been found to slow down melanoma for a period of ten years (Fawzy et al.). Yet, most of a desired psychological change is not achieved by 'direct' mental instructions or cognitive therapy. Actually, so far cognitive behavioral approaches have not been found to affect cancer outcome. Experiential, supportive-expressive intervention, but only by psycho-oncoligically well trained therapists, has (Spiegel et al, De Vries et al, Kuchler et al). The basic assumption is that that experiential intervention -my main approach is psychodrama- leads to re-activation of repressed parts of the personality. When these parts, sometimes after decades of partial dissociation and repression, regain their full presence and role in the personality, different coping ensues. There is more expression, more active coping, personal autonomy, more 'degrees of freedom' in the person and in his behaviour and feeling. This is the sort of change we observed preceding (otherwise) spontaneous regression of cancer: acces to essential activities and experiences, more personal autonomy, expressive behaviour and more 'real' and meaningul social relations. Family members may report that ;'he used to be such a kind man; and now he is more expressive, decisive and willing', and yet, when such behaviour is authentic it will not distort relationships, rather it will boost them.
Sincerely, Johannes Schilder
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The content on or accessible through Medpedia.com is for informational purposes only. Medpedia is not a substitute for professional advice or expert medical services from a qualified health professional.
Read more