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What is a good doctor? Patient perspective

Sheryl Martin, BS

Salt Lake City, Utah

When I was 3 years old, our pediatrician removed mytonsils and adenoids. In those days it was done in thephysician’s office. After the procedure I was taken home.Later that evening I began to hemorrhage. My mothercalled our pediatrician, Dr. Leslie Smith, who came toour home and attended to me for over an hour until hewas certain the bleeding had stopped. During anotherwinter, he made 13 house calls to check on my sister whohad scarlet fever.

Of course, that was the olden days. Dr. Smith had pro-vided pediatric care to our family for years because mymom thought he was the best in town and not because hewas one of the approved physicians on an insurance list.The surgery was done at the physician’s recommendationbecause Dr. Smith thought my numerous sore throatsand ear infections warranted it. It did not need to wait ap-proval from the insurance company, nor did the subse-quent house call. Dr. Smith was always spoken of veryhighly in our home, respect he won because of the ser-vice he provided and the care and concern he showed forour family.

During the 18 years that I worked for Dr. James Scottwhile he was chairman of the Department of Obstetricsand Gynecology at the University of Utah, letters andphone calls from patients were frequently directed to meexpressing songs of praise or their frustrations and dissat-isfaction about the care they received. I have interviewedhundreds of patients and solicited anonymous commentsfrom others about what they consider most important inphysicians.

In my current job, genetic research, I speak daily withpatients who frequently share feelings about their physi-cians and health care experiences. More than once I tooka university class titled “Health Concerns for Women” justto keep informed about what women want and what theyare concerned about. Comments are always focusedaround the qualities of physicians—their abilities to prac-tice the humanistic part of medicine.

We want the same thing today that my mother wanted

50 years ago: a physician who is caring, someone who lis-tens and is sensitive and kind, a physician who followsthrough and is available. However, health care today,from our viewpoint, is frequently complicated by roadblocks, detours, and numerous restrictions, just as manyof those of us who drive Interstate 15 in Salt Lake Citymust keep informed daily about new ramp closures andlane changes because of constant construction delays.

In the health care arena many frustrations occur, in-cluding fine-print insurance plan guidelines. Theseoften cause annoying delays. Do I want to see a physicianon my insurance company’s “approved list”? Do I have tosee a primary care physician for a referral to see a spe-cialist? We have to wait for insurance company approvalbefore procedures can be performed. We not only faceregulatory frustrations but internal barricades as well.

Humanistic treatment of patients should begin withthe first phone call. In 1984 Medical Economics pub-lished a list of 20 patient pleasers. They reminded us that“since the phone is the patient’s first contact with youroffice, insist that the staffer who answers address callersby name. That reinforces the patient’s feeling that youroffice is aware of [her] as a person.”1 In contrast to thissuggestion, often the human voice has now been re-placed with a recording that allows the patient severaloptions from which to pick.

Just a few weeks ago at our university a Wyoming cou-ple with a 3-week-old infant born with some birth defectswere misdirected to the genetic research building. Theyhad called for an appointment several times only to beconnected to voice mail. In spite of their messages, theyreceived no return call, so they drove for more than 1hour to schedule an appointment in person. The volun-teer at the information desk in the front of the hospitalwasn’t sure where to send them. Instead of calling andchecking, she sent them on a quarter-mile walk throughthe hospital and the medical school to the EcclesInstitute of Human Genetics, a facility dedicated to ge-netic research. A coworker of mine attempted to getthem an appointment. However, this clinical office hasone person that does all of the scheduling and she wasunavailable. So they left without an appointment but ona list and hoping that someone would call them. Of moreconcern is that the physicians in charge have done noth-ing to correct this situation. This is only one of many in-cidents that I have observed in our institution, and I sus-pect similar situations have occurred in your “IvoryTowers” that are not user friendly.

From the Department of Obstetrics and Gynecology, University of UtahSchool of Medicine.Panel Presentation, presented at the Sixteenth Annual Meeting of TheAmerican Gynecological and Obstetrical Society, Victoria, BritishColumbia, Canada, September 4-6, 1997.Reprint requests: Sheryl Martin, BS, Division of Reproductive Genetics,Department of Obstetrics and Gynecology, Room 2B200, 50 N. MedicalDr., Salt Lake City, UT 84132.Am J Obstet Gynecol 1998;178:752-4.Copyright © 1998 by Mosby, Inc.0002-9378/98 $5.00 + 0 6/6/89544

Volume 178, Number 4 Martin 753Am J Obstet Gynecol

The current philosophy of hospital and clinic adminis-trators is “no down time,” “keep everyone busy,” and thebottom line is finances. This philosophy often results inpolicies and procedures that are not always in the best in-terest of patients. Complaints that I have frequentlyheard from patients that demonstrate these frustrationsare listed in Table I.

What women want from physicians can be summarizedinto three big “Cs”: competence, concern, and communi-cation.

Competence

Although patients want a physician who is competent,they do not select a physician on the basis of Council onResident Education in Obstetrics and Gynecology resultsor their board scores. Patients who do not work in themedical environment don’t know which residencies pro-vide high-volume gynecologic surgery experience. Theydon’t know which medical schools are considered amongthe best in the country. When seeking a new physicianwomen turn to peers and friends for suggestions.

A study reported in 1994 in the Journal of the AmericanMedical Association concluded that “physicians who hadnever been sued were more likely to be seen by their pa-tients as concerned, accessible, and willing to communi-cate.”2 Patients judge the quality of care by the timeli-ness, accuracy, courtesy, and outcomes of the service andinformation provided.

Concern

Simply stated, women want a physician who is con-cerned about them as individuals. Patients judge thatconcern by how long they have to wait in the waitingroom for appointments. Long waits communicate anoverbooked schedule and suggest that the physician willhave very little time for the patient once she does get inthe room. A presentation at the thirty-third annual meet-ing of The American College of Obstetricians andGynecologists cited waiting time as the number one com-plaint from patients across the country.3 Our lifestyles aredemanding and busy. Many women have careers and weconsider our time to be as valuable as yours.

Patients want to be called by name and not just treatedas a number. We want a physician who has reviewed thechart and knows our history. Recently a patient told methat she was switching physicians because when she re-turned for her 6-month checkup as the physician in-structed, he greeted her by saying, “Why are you heretoday?” She said, “If he doesn’t know why he asked me tocome back in 6 months, then I will find a physician whowill.”

Communication

Recently I asked 40 patients to list the three qualitiesthat they thought were most important in a physician.

Nearly everyone listed communication in the top three.More specifically, they want a physician who will listen tothem, be honest with them, and take time to explainthings on their level. Keep the lines of communicationopen: in the office, on the telephone, and in writing. Acommentary that appeared in The Washington Post stated:“The CT and MRI scans, the lasers and the laparoscopies,the chemo-cocktails and DNA codes—all the advancesthat make modern medicine so effective (and expensive)have isolated physicians from the patient as a person. Inthe process, the ancient therapeutic art of listening isbeing ignored, much to the dismay of many physicianswho recognize the limits of technology.”4

In general, patients share two features: (1) They have aproblem or they would not be seeking medical care; (2)they are afraid, tense, and apprehensive. We need to feelthat our physician is supportive and sensitive to our feel-ings. If a patient is given unexpected news during a visitto the physician, the patient frequently has questions thatarise after leaving the office, when she has had time tothink about what was discussed. Patients appreciatephysicians who are available and return phone calls.Follow-up from the physician’s office on laboratory re-sults either by mail or telephone reinforces your interestin the patient and her medical needs.

Criteria have been established to monitor the techni-cal skills of residents and medical students. Hundreds ofevaluations are collected and statistics are kept to docu-ment numbers of procedures that residents perform.The Resident Review Committee establishes guidelinesto ensure that residencies provide technical training inessential areas. Medicine has made many technologic ad-vances and research discoveries that benefit patients. Asimportant as these advances are, they cannot replace thehumanistic approach to patients.

I challenge each of you to ask yourself: What are youdoing to ensure that residents leave the program compe-tent not only in technical skills but equally competent inthe art of medicine?

Table I. Common complaints from patients

Long waits in waiting rooms without ever being given a reasonfor the delay.

Additional long waits in the examination room, often in a skimpy patient gown.

We’re rushed through like cattle without enough time for questions.

Poor bedside manner. The physician was abrupt and insensi-tive.

I can’t reach the physician by telephone. I always have to talk to the nurse.

I pay for expensive tests but never hear the results.With so many specialists and subspecialists I feel like nobody

is really in charge and knows the whole picture.Complicated billing systems that generate stacks of statements.

754 Martin April 1998Am J Obstet Gynecol

REFERENCES

1. Brandon K. 20 Patient-pleasers you can start using today.Raritan (NJ): Medical Economics; 1984. p. 141-5.

2. Hickson GB, Clayton EW, Enthma SS, Miller C, Githens P,Whelton-Goldstein K, et al. Obstetricians’ prior malpractice ex-perience and patients’ satisfaction with care. JAMA1994;272:1583-7.

3. Grace K. Building a better mousetrap—marketing from the pa-tient’s perspective. In: Proceedings of the Thirty-third AnnualMeeting of The American College of Obstetricians andGynecologists; 1985 May 14; Washington, DC. Washington: TheCollege; 1985.

4. Trafford A. The empathy gap. The Washington Post 1995 Aug29. p. 6.