Thursday, November 4, 2010

A Physician's 10 Commandments

The Holy Bible's Ten Commandments were given by God to Moses, so he could teach them to the human race and they would be able to live better lives. It is the first and most basic moral code for us - mere mortals.

So, here I am. A sometimes not-so-patient patient, looking for the perfect doctor. As someone who is chronically ill, what compass do I want my new doctor to follow? It's not so hard. Let's see if I can sum the basics up in 10 easy points:

#1 Thou shalt have no other patients before me. When you are in my room, concentrate on me. Thou shalt spend whatever time is necessary to complete the task at hand. Thou shalt have focus. For this precious few moments, treat me thus - as if I am your only patient. Read my history with care, and ask questions about it. Do not interrupt me. Respect me and understand that I am the expert of my body. Use that to our advantage for best results. Thou shalt keep in good contact with me. Be timely in sending records, ordering labs and giving results, and replying to messages, for my time shalt be valuable also.

#2 Thou shalt not create in your mind, the version of the patient you'd like to see, but be content with the patient that is before you - flaws and all. Thou shalt check thy ego at the door, for thou art human. I am human. You shall know thy textbooks, but I shall know my body and my symptoms and my disease, for it never leaves me. I will listen to you, so you shall listen to me and we shall conquer. For we can be a team - I'm willing, but thou must be willing also. Together we can be extraordinary!

#3 Thou shalt not speak of me or my situation in a derogatory manner. Thou may think it amusing. Thou may think it relieves stress, but in doing thus thou hast created a negative atmosphere toward me, my family, and my condition. Yea - every time thou speaks ill of a patient no matter the reason, thou shalt ingrain those negative feelings in thy mind and those minds of the staff with which you work. Surely this shall show in thy attitude and the attitudes of thy staff. Verily, it also will be heard by other patients and their families and thy staff, who will wonder what you are saying behind their backs as well. Beware, as stress and distrust is created thusly. In the words of Bambi's mother: "If you can't say anything nice, don't say anything at all."

#4 Thou shalt be available to patients by providing them staff available to help them, as well as the most up to date, easily accessible methods of communication possible, so when thee must take necessary and healthy time for thy well being and that of thy family, thy patients will not be left by the roadside - sick, hurting, scared and confused.

#5 Thou shalt keep up to date in thy field of expertise. Thou shalt set aside time to read thy journals and attend continuing education so thou shant order antiquated lab tests or prescribe outdated medication protocols. Because thou art observing Commandment #4 this shall be easy. Thou shalt acknowledge that the availability of information online means thy patients will try to be proactive and bring thee journal articles or ideas about their treatment/disease of which thee may not be familiar, and thee shall practice due diligence in reviewing material thusly before tossing it in the trash or breaking Commandment #3.

#6 Thou shalt always do thy very best for each and every patient, even if that means making late night calls or extra time researching a condition, or scheduling fewer appointments for the day so thy patients receive the very best thee can offer them. Thou shall treat based on how thy patient feels, seeking more clues when the labs seem "normal", remembering there is a difference between designated "normals" and thy patient's optimal. Thou shalt give carefully researched and timely referrals when necessary. Thou shalt at all times remember that "do no harm" applies to the patient's mental, emotional, and physical well-being.

#7 Thou shalt not use cookbook medicine. Thou shalt glean new ideas and patient care by discussing with others, including physicians of thy specialty and outside thy specialty, pharmacists, psychologists, caretakers, etc. Thou wilt base thy treatments and diagnosis based on what the patient feels and desires.

#8 Thou shall not steal from patients by ordering unnecessary testing, unnecessary office visits, treatments you doubt will be successful, expensive drugs when a less expensive alternative will suffice, selling at exhorbitant costs those products which can be purchased elsewhere for less, or referring a patient thou art capable of treating. Thou shalt consider thy patients also as consumers and clients and continue the diligence you used while initially building thy practice.

#9 Thou shalt not give up. Thou shalt dig however long 'tis necessary to diagnose and properly treat a mysterious symptom or ailment, always seeking out the root cause for treatment. Thou shalt never tell a patient they are hopeless or there is nothing more you can do for them. Thou shalt dig just as hard for proof for a diagnosis of a psychologic/psychogenic disorder before placing that scarlet letter on the person of your patient. Thou shalt acknowledge that pain can be deadly and thou shalt treat it accordingly while looking for its source. Thou shalt realize there are other physicians who may be at times more qualified to diagnose and treat thy patient and thee shall refer them accordingly, always taking into consideration that true psychogenic disorders are comparatively rare. Thou shalt consider complementary and integrative healing. Thou shalt guide me by educating me on my disease and its impact on my life, and encouraging me to be proactive... or employing someone who can.

#10 Thou shalt be a learned friend - Despite thy time constraints (which can be altered), know thy patients well and treat them with respect and trust so they shalt regard you as beloved amongst your peers, for thy white coat does not impress us. Thus were the healers of generations past held with reverence and appreciation. In so knowing thy patients, thee will make better and more appropriate judgments for them, for they are much more than their disease, but human souls in need of healing and compassion.

Okay, so this is perhaps a serious subject handled in a not-so-serious way. There are so many other things I could have added.

What do you think? What did I miss? Feel free to give me your ideas here or in this conversation.
Comment by Ellen S on November 4, 2010 at 3:11pm

Thank you Anthony! You know, my Facebook pal Denise added to the post and made me laugh so hard. She said:

"I LOVE THIS!!! Though Shall NOT Make us WEAR PAPER ROBES...or ANYTHING that Says PEEK-A-BOO either!!!
Comment by SickMomma on November 4, 2010 at 4:55pm

Fabulous post, Ellen!! So hilarious, and yet, sadly, so truly on the mark.
Comment by Debby on November 4, 2010 at 6:37pm

Dear Ellen. I know that this comes from the heart, from a place of pain, a place where you are searching for acknowledgeable, understanding, compassion and to be treated with respect. As I continued to read through the commandments, I felt the burden heavier and heavier upon the physician. My thought, if I were the doctor, being this tells me to take fewer patients, leaving many stranded. Usually, I am on the patient's side, and certainly we should not feel belittled, taken advantage of (financially, time-wise), in a partnership relation where both search for potential answers to problems, but why did this feel so one-sided?

Like, sure, go take time off with your family, rest up, but during that time you can study and bone-up on all the latest research; and oh, by-the-way, hire some staff to take care of me too. And, while you're at it with the telephone cue of patient calls, please spend more time getting back to me ASAP.

You know, as a person suffering from an illness, how you can take hours upon hours researching and reading; well, something tells me doctors are busy 'caring' for patients and don't always have the opportunity to spend on the internet, etc.

just saying....

all the best.
Comment by Ellen S on November 4, 2010 at 11:15pm

And my FB friend Michelle adds:

"I have been chewing on this all day - finally came up with what I wanted to add - I AM AN EDUCATED PATIENT DO NOT LET THIS THREATEN YOU - it irritates me to no end"
Comment by Debby on November 4, 2010 at 11:19pm

What irritates you?
Comment by Ellen S on November 4, 2010 at 11:49pm

*Sorry* Debbie, that was part of what Michelle said. She is irritated because her doctor is threatened by her knowledge of her condition, and that irritates her.
Comment by Debby on November 5, 2010 at 12:07am

The patient must be a good advocate for their own welfare. If the physician is not willing to listen and learn, then may be time for new doctor.
Comment by Ellen S on November 5, 2010 at 1:32am


Agreed. Hence, the reason for this semi tongue-in-cheek list of 'commandments'.

Tell me, all other things being equal, which doctor would you choose for your own - one that follows these ten commandments, or one who doesn't?

Thanks for the thought provoking comment. This post actually was written mostly as a result of years of experience watching patients struggle each day because they need more from their doctors and aren't getting it. It's so difficult to hear about patients needless suffering and not be able to help. I've even seen a few die as a result. For me, that's the toughest part about being a Health Activist.

This post is of course one-sided. It is from the perspective of a chronically ill patient (read: sick every day) looking for the "perfect" doctor. There are few of them out there, but shouldn't these all be things one would want to strive for? Thankfully I can say that I have had 3 doctors on which I actually based this post, each manage the fine balance it takes to be effective as physicians and maintain a life of their own. They believe in and follow these 'commandments'. None of them are broke, and all of them that I know of following these 'commandments' are happier than any of the doctors I have seen who don't. I would encourage you to read each 'commandment' number separately, as each of them do contain parts that I think address the concerns you mentioned, and are perhaps not quite as one sided as one might expect from the bolded first sentences.

I have seen similar posts made by physicians that paint a picture of the 'perfect' patient as someone mighty hard for most of us to live up to also. I have posted some of my own as well. That doesn't mean they're not right however, it just means we have some work to do. Unless you're very lucky, health does not equal being passive.

Yes, the burden is high on the individual physician. It is also high on the patient. Our lives are forever altered by the course we take with our chronic health conditions. When a mistake is made we cannot walk away from it. We live with those mistakes every day for the rest of our lives. Some people die because of them. This is why it's so vitally important for us as patients to be responsible for our own health care and be proactive in it. Part of our jobs as Health Activists as I see it, is to encourage that. The burden shouldn't be all on our doctors, that's not fair to them. It's our lives, not theirs. The burden is also high on physicians as a whole because there are already so few doctors in ratio to the patients that need them. Please see this post
Staggering physician/patient ratio for the United States and the ch...

I'm not suggesting patients should be be left out in the cold. Does this mean we should be okay with a lesser quality of care though?

I think the problem is how we are thinking about this. Of course the burden on our doctors is much too high. No wonder they are so stressed and soon become jaded. It doesn't help that there are so many 'bad' patients out there either. However, the trouble is not that we are asking too much of our physicians, the problem is that there are too few doctors out there able to share the load of what patients need. On one hand, doctors often chide us and even shame us for looking up our own information, yet they they become frustrated or don't take the time to give it to us when we ask for it. As a patient or a doctor, you can't have it both ways. I have no problem with a doctor handing me printouts telling me to read up on it and call with questions, or one that gives a few helpful websites, or refers me to a support group. All are ways to disseminate information - it's just another way of educating the patient. But to leave patients empty-handed and expecting us to do as we are told without question is unrealistic and not good medicine/healing. It's certainly not what the 'perfect' doctor would do.

My perspective is different than many. I'm old enough to remember what it was like to visit the town doctor. You know the type - they deliver you and care for you your whole life - or theirs. They live around the corner and knew you by first name. They gave you a graduation gift, and a wedding gift when they watched you get married. They took whatever time was necessary for you during a visit, and planned accordingly. The bottom line was not the bottom line. Their patients were. Our doctors were respected for their knowledge and their compassion, not because they wore a white coat. They encouraged us to take an active part in our health, and helped us when we did. They asked questions and literally listened. Most of them died still practicing this art. (A local doctor passed away recently. He worked out of his home and charged $35 for an office visit - if you could afford it.) Somehow, somewhere along the way we began to assume that health care was like taking our cars in for a tune-up, and that doctors are not to be questioned or treated like normal people. Doctors are encouraged now to remain distant from their patients. In fact I think blindly leaving our health decisions up to our doctors puts added pressure on them, not the other way around.
Comment by Debby on November 5, 2010 at 2:39am

I hear what you have to say. I've said the medical system IS broken for a long time. There are NOT enough physicians and it is because of the system they have built and refuse to change. There is a way to support educating many young people or even older compassionate educated and capable people who would love to be healers.

Unfortunately, they charge $250,000 to get training and limit the numbers intentionally. There has to be a better way even if that includes training and accepting alternative medicine as support for people in pain and with conditions that can be helped in other ways.

We have to accept the mind/body connection for one thing. Well, I took this off-topic. But, I do know where you are coming from. Being a doctor is certainly not an easy job. It has gotten much more complicated and demanding than ever before, with little support in some cases. While in others, money matters and that's it. Besides having a belief system that does not jive with some free thinkers.

I enjoyed reading your post here.
Comment by Ellen S on November 5, 2010 at 10:03am

Debby, I think we are really on the same page :) So, what do we do about it? We are, after all Health Activists, and we can use our voices...
Comment by Alicia C. Staley on November 9, 2010 at 12:17pm


Your blog post was a writing prompt for me! I think this is a great list. These are great rules to follow - as patients and physicians. Here's my post for a patient's version: A Patient's Decalogue
Comment by Debby on November 9, 2010 at 12:24pm

Hi Ellen. I do believe these stimulating discussions make us think about the issues. Each of us can only do our little part individually, which adds up as more participate. Thank you so much. #gratitude.
Comment by Ellen S on November 9, 2010 at 12:44pm

Alicia - once again you eloquently, and I must say brilliantly show in your post that there is more than one side to any issue. Your post is definitely worth the read and due consideration by anyone who is a patient - especially those suffering from chronic illness.

No matter how flat you make a pancake, it still has two sides. :)
Comment by Debby on November 9, 2010 at 12:47pm

This is for all of us. I do not see a place to enter Videos on Wego. Someone direct me.
Get up and dance! 

Love, Debby
Comment by Ellen S on November 9, 2010 at 12:49pm

This post is my entry for the Patients for a Moment blog Carnival for November hosted by Health Activist SickMomma. The topic is: What do you look for in a doctor?

Come and join me - write your own blog post then let us know where we can go to find it!
Comment by Ellen S on November 9, 2010 at 12:57pm

Debby - I love you! I use that saying a lot, and now it's going to make me smile every time I say it! Thank you for putting the video here - I grinned from ear to ear, and now I'm so durned hungry for pancakes I'm going to make some for lunch, LOL!! Oh yes, I'm a butter and pure maple syrup girl... if there's no strawberries and whipped cream to be had :)
Comment by Amy K on November 9, 2010 at 3:41pm

This post truly describes the "perfect" physician. I love how Alicia has counter-balanced it with her post. And I love how you are so good at expressing the needs and desires of the chronically ill patient.
You all have said a lot, I'm afraid I don't have great words to share in response, but I really enjoyed the post. Thanks Ellen!
Comment by epatientGR on March 18, 2011 at 4:47pm

This discussion thread comes were timely for me, as I finish reading "how doctors think" by Dr. Jerome Groopman. It's a phantastic book, that I heartily suggest to all health activists to read, because it sheds light into the practice of medicine and explains a lot of things. What is crucial is that reading the book, you are guided both as a doctor and as a patient to avoid all assumptions, obstacles in practising true medicine. The last chapter is devoted to what patients can do, how they should work with their doctors to help him/her come up with a good diagnosis and therapy.

You may believe it or not, most of what Ellen has written in her 10 commandements stands in "How doctors think". So, I come to think that most probably she has read the book or articles on it. I also agree with her list, even though this might mean less "productivity" for doctors.

Medicine is not a production line to process a given number of patients per shift (although this is also what happens in Greece, a doctor has to see in 5.30hrs 25-35 patients, 25 fixed appointments plus emergencies, in 10min. appointments!). Doctors need to think and consider besides the main ailment that brings in the patient, any other chronic conditions he might have. I appreciate my homeopath doctor who tells me that he will research my case and will call me up to discuss his diagnosis and proposed therary and I am suspicious of the oncologist that he hardly has a look on the mammogram and says OK without properly seen it.

So what Ellen proposes sounds all right to me.
Comment by Ellen S on March 18, 2011 at 11:40pm

Thanks so much epatientGR :)  I wish I  could say I've read the book you're talking about, but I haven't.  This just comes from personal experience - lots of it unfortunately.  I have had some really truly awesome doctors, and some really bad ones who really shouldn't even be seeing live patients.  When looking for the "perfect" doctor, you glean the best of what you see and experience and your wants when care is lacking, and voila - a list.  It seems if this doctor is writing about it too, that once again, I am pretty normal then - Yay!
Comment by epatientGR on March 19, 2011 at 7:37am

I had given the book to an orthopedic surgeon, very good friend of mine, who is director in one of the clinics of a large public orthopedic hospital. He read it in one shot, he told me. why? because he found in what Jerome Groopman writes too much of his everyday practice in the clinic. So, last week I visited him at the hospital for a foot problem and he was there with his two interns and a former intern now director of orthopedic clinic in another city.
He let the interns examine my foot, say what they thought it might be the problem, then the former intern intervened with his diagnosis of the problem, finally, my friend summed up the discussion and the course of action. We went on discussing the issues you tackle, which are also those tackled in the book. It seems that how medicine is practised is universal, there are only very little differences in how doctors think. Maybe also because most Greek doctors are trained in the anglosaxon world, differences tend to be very small...
I plan to write a post about this book and "Tracking Medicine" by Prof. J. Wennberg on practice variation. Both books address how medicine is practised and in a way they complement each other. Definitely, I will include the discussion since it reverberates the contents of the two books, and shows the understanding of the issues discussed from the side of the patient.
Have a nice week-end! We have a phantastic spring day in Athens today!

Comment by Ellen S on March 20, 2011 at 2:57pm

epatientGR,  This is all very fascinating to me.  I am so impressed that you have doctors who are taking this school of thought so seriously.  My usual experience is more that which you likely have already read here in this discussion - most doctors are so busy with the business of running their practice that they forget the patients.  "Good enough" has replaced "optimal".  Again, this isn't across the board, just the usual school of thought I've found personally.

The thing I've noticed with my doctors who were very patient focused - those that gave me the inspiration for this post in the first place - they are so much happier as people than the doctors I've had that don't want to be bothered with making our experience better.  They are more relaxed, their families are happy, their practices run like well-oiled machines.  They're never late, phone calls are always promptly returned, and encouragement is given to patients to be active in their care as well as the means and education to make that happen.  Everyone smiles, including the patients who uniformly know how lucky they are to be blessed with these doctors and do hold them in very high esteem.  When you have a doctor like this, it makes me as a patient want to try harder to go out of my way for them too.  I am more prompt and easier to get along with.  I find I can even joke around and have some quick fun with staff because we all know each other and care about each other.  Appointments go faster because I don't have to spend so much time explaining background to tell about a new issue.  My doctor already knows all this.  I wish every experience with a doctor could go according to these "rules".

I loved visiting Athens years ago.  Today I can still see the intensely blue sky that welcomed us, and have many warm thoughts about our experience there.  Enjoy your beautiful city!!!

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