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It’s hard for doctors, but even harder for patients

What should be the relationship between doctor and patient?

Hippocrates of ancient Greece, known as the “father of medicine”, made indelible contributions in explaining the mechanism of many diseases and interpreting the professional needs of medicine. He coined the word “cancer” and described many of its manifestations, suggesting that the correct treatment for cancer is “the best thing to do is to leave it alone, the more it is treated, the faster it grows”, which now seems absurd. The Hippocratic Oath is taken by every one of our medical students at the time of admission.

Hippocrates was not only the father of medicine, but also the father of paternalistic medicine. When it came to the doctor-patient relationship, he wrote unabashedly, “Doctors should hide most things from their patients.” He insisted that the patient should not be informed about the treatment, and that only the physician community should have the relevant medical knowledge and information.

Patient (patient) originally meant “one who suffers pain,” “one who is not anxious and patient,” from the ancient Greek verb “pashkin,” which means that it has been believed since ancient times that the physician is to be admired and worshiped because of his scientific or religious knowledge, and that he is a god-like person who must be obeyed unconditionally, while the patient, as long as he is “able to endure,” is all that is required.

The 1874 Code of Medical Ethics also mentions that the physician is the most learned man and the best judge of human nature; that the patient should obey the physician’s prescriptions punctually and absolutely, and that any immature ideas about health should not affect this; and that the patient should not consult the consulting physician without the consent of the medical caregiver.

I once had a visit with a well-known veteran specialist in the same afternoon, in the same office, with a partition screen drawn between us to separate us. Once a patient came in and I explained the situation in great detail to the patient, who left satisfied and kept praising me as the clearest doctor he had ever seen. After a while, I suddenly saw that the patient was sitting at the old specialist, whispered the symptoms to the old specialist again, and turned his head away awkwardly when he left, pretending not to see me.

In China, we seem to understand this matter very easily, after all, the level of doctors in each hospital varies, and specialists are more trustworthy than small doctors, and sometimes the problem of misdiagnosis is inevitable even in the big tertiary hospitals, let alone local or community hospitals. Patients no longer have the absolute trust in doctors. Patients may think, “I am a consumer, what’s wrong with spending almost the same amount of money to see a few more doctors? I can’t wait to see all the specialists in the hospital!

But in the United States, this is not accepted. During the visit, the doctor will go through the patient’s medical history, and if he/she finds that the patient has been to multiple hospitals but never followed the doctor’s recommendations and prescriptions, he/she will simply refuse to be seen. This is because the stereotypical American perception is that the patient does not trust the doctor and is a potential medical malpractitioner. A patient with an overdrawn credit limit is like a family car that has been in multiple accidents, and the cost of seeing a doctor will get higher and higher.

In fact, “paternalistic medicine” does not mean that the doctor takes a paternalistic attitude in medical treatment, but rather refers to the relationship between the status of the doctor and the patient in the medical process, that is, the doctor takes the main responsibility as a parent and is the dominant party, while the patient mainly performs and obeys, even if he has his own subjective opinion, he is not allowed to take action without permission, but should communicate with the parents and then let them decide.

In China, the doctor’s emotional intelligence is very important in terms of informed choice, and the doctor’s parental status is actually tacitly accepted by the patient and the family: the doctor chooses a reasonable way to communicate with a reasonable person, which is in fact exactly what we feel is “comfortable and normal”.

The “informed consent” form that we must sign with the patient or family before every invasive procedure or medical decision is made may seem like a bullying clause, but in fact its main function is to inform, not to exempt. In other words, the doctor has to let you know how the procedure will be performed, what the risks are, and even what drugs and devices will be partially paid for out of pocket. I have been both a doctor and a patient’s family member, and people with this dual identity are always very quick to sign. Because I know very well that even if I sign it, if something goes wrong, the doctor will not be able to get rid of all the responsibility. The value of this list for the doctor is that if a problem occurs but is not signed, the hospital is solely responsible.

Patients are often anxious and fearful like children, filling out whatever the doctor tells them to, choosing to give up their initiative in the complete unknown of the disease and handing it over to a knowledgeable looking doctor in a white coat. This transfer of initiative is often a good thing, because on the one hand the patient often really doesn’t know, and on the other hand the doctor doesn’t want the patient to have too much initiative, and patients who do have initiative often have poor “compliance” (the degree to which they strictly obey the doctor’s orders).

Once I was on surgical duty, a female family member came to me and said that her father’s drainage tube was blocked and asked us to open it immediately. I went over and found that the drainage fluid was very clear, the patient’s temperature and blood picture were normal, and the drainage tube could actually be removed. I reassured her that it was okay, and that we could just pull it out in the morning after the doctor in charge looked at it. But the female family member said very rudely: “This is a blocked tube, can’t you see it? Can’t you see it? There will be bacterial infection inside the blocked tube. I’m also a medical student, so hurry up and open up the tube!” Later I learned that the female family member was indeed a medical student, but she studied veterinary medicine.

As doctors, we are not afraid of “too knowledgeable” family members, but we are afraid of this kind of family members who think they know everything, which will greatly increase the cost of communication.

When we were studying, our teacher told us that as a doctor, we must follow our own judgment, the patient can propose, but the doctor must adhere to his own principles, not listen to the patient. If you listen to the patient and the treatment goes well, the patient will misjudge: “The doctor is not up to par, he is not as good as me, it’s bad if you don’t listen to me.” If the treatment does not go well, the patient will immediately say, “Are you the doctor or am I the doctor? I don’t know anything, why should you listen to me!”

It’s not the right thing to say, but as a doctor, especially in the current state of medical care in China, from a doctor’s standpoint, he definitely likes a well-behaved and obedient patient, which is not the right thing to do, but you have to understand that this is indeed a common phenomenon.

Information is not fully liberalized without reciprocity

Adoptive families keep this secret for a long time until the child becomes an adult, because once the child learns that he or she is not biological, it may cast a shadow on the child’s childhood and make the child have low self-esteem and be closed off, which is called a “gentle lie”.

Once there was an operation, the patient hemorrhaged during the operation, several doctors on the stage to rescue the back wet, but the patient eventually turned to safety, the total amount of bleeding is not too much. When the director came out of the operating room to explain his condition, he looked at the eager eyes of the patient’s family and said, “The operation went well and was successful, there was some bleeding but it was stopped. Wait a little longer, the patient will be out soon.” Such a sentence, lightly put everyone’s anxiety, tension and worry a sentence carried.

Have you ever wondered if it would have been better to handle the situation differently by installing a monitor for the operating room so that the family could see the patient’s procedure all the time, like an open kitchen in a restaurant, open and transparent?

My mentor always did things that made people feel dangerous during surgery. For example, if a patient has a lymph node stuck next to the most dangerous aorta, a normal surgeon would probably just slice off a piece and send a pathology to prove that he cleared the lymph node. But the fact is, you slice off a metastatic lymph node to fool the patient and deceive yourself, which is certainly the safest, but you leave a potentially metastatic lymph node in the patient’s stomach, which is bound to recur after surgery. The only way you can give this patient a chance of survival at this point is to take the most dangerous path and detach this lymph node intact from the patient’s aorta. The difference in risk between these two options is huge, but it makes no difference in the eyes of the patient because the patient doesn’t understand it. If you do a good job, the patient may be able to walk out of your operating room unscathed, but the patient is bound to relapse and die soon, and you will never walk away from the nightmare. An experienced and conscientious doctor will choose to take a chance and put up a fight, after all, even if the bleeding, he will have a proven program to save the day.

However, assuming that the doctor’s operating room is transformed into a transparent glass room, and even the doctor’s surgery and operation videos can be copied by patients at will, it will be a disaster for medical treatment. It would look like everything is open and transparent, but in the end it would evolve into a pathological medicine where the doctor would lose his comfort zone and be under constant surveillance. At this time, the doctor would choose not to actively involve himself in the risk, he would rather not move that potentially metastatic lymph node than let the patient take a single risk, but in the end the patient would bear the consequences of metastasis.

So I don’t think surgery should be pinned down. It is a technique and a work of conscience. Monitoring with the best monitoring may not solve the problem, but rather exacerbate the tensions in the doctor-patient relationship.

Should the choice be left solely to the patient?

When volunteering for college entrance exams, children will consult with their parents whether they have their own ideas or not. Why do we consult parents when applying for a volunteer position? Are parents industry ombudsmen? Have parents done market research? Probably not. Parents just “have eaten more salt than we have eaten rice” and can prevent their children from making a choice that they will regret in the heat of the moment when they apply for a job.

So, it is a very bad idea to let patients make choices about their own bodies when they do not know about them. It is tantamount to a hooliganism for us to crown the patient with the possible benefits and risks of surgery and then leave it up to the patient or family to make the decision.

There was once a working man who didn’t come to the doctor for many days because of stomach pain, and was brought in by a colleague only after he passed out from the pain. A look at the abdominal CT, a large part of the intestine necrosis, the patient is in a state of severe infection toxic shock, and this patient also has little money. I talked with his wife for a long time about the risks and difficulties of surgery, and that after surgery he might go into intensive care, which would cost a lot, but in the end it might not save his life, or even become a vegetable because of the prolonged shock, etc. If we do not do surgery for conservative treatment, and wait for the patient to get better from shock before surgery, although the risks would be smaller, it is likely that the patient’s infection would be further aggravated If we do not operate for conservative treatment and wait for the patient to recover from the shock, although the risk will be smaller, it is likely that the patient’s infection will be further aggravated. I was in a very scientific mode of conversation, playing the role of a good, calm and composed doctor, rational, restrained, calm and elegant.

But my wife just couldn’t make the decision. She kept repeating the same thing: “Doctor, if it were your own family, do you think the surgery should be done or not?” No matter how patiently I tried to explain, she kept dwelling on herself. I was sure I did what I was supposed to do, but I didn’t dare to help her make that decision directly.

Just then, the chief of that department came running over and yelled at the patient’s family, “What else are you thinking! You are looking for death, but not doing surgery is waiting for death! The patient is so young, there is a ray of hope, so what are you waiting for?” She was blindsided by the yell, but she quickly made up her mind and had the surgery. The operation went well and the patient was back in the general ward after 2 days in the ICU. The patient was soon discharged and the family thanked the director profusely.

However, it was the director who took the initiative to carry the medical risk, and if anything had gone wrong, the family could have complained that the director made the patient undergo a surgery that was unnecessary. But the director’s reason for choosing the surgery was one of his intuition about the patient brought by experience (the patient is saved, I can’t back out) and one of his intuition about the patient’s family (the family doesn’t make a fuss, I can get on).

So in the face of disease, especially in a critical situation, it is a ridiculous bullshit thing to say that the patient is in charge of himself. Doctors must be decisive and take the lead, advise the patient on the right course of action, and do what “parents” are supposed to do.

Paternalistic medicine begins to face serious challenges

As mentioned in The Future of Medicine, Johannes Gutenberg came to Germany in 1440 to usher in the era of movable type printing, and the first work of this press was the Gutenberg Bible, an initiative that appeared to be a simple photocopying technique, but at the time, it changed the entire structure of society significantly.

In the “Age of Hearing”, ordinary people could only read by listening, and only the extremely wealthy nobles and priests had access to manuscripts from the pre-press era, which accounted for only 8% of Europeans. In this era, therefore, reading was the exclusive right of a few people who had access to knowledge and dominated the social machine. But the printing press itself was a revolution in communication, which brought about an explosion of knowledge. The exposure of the general public to information and science meant the enlightenment of the people, which is a dangerous thing in any society.

The current popularity of smartphones and the formation of social networks have made it easier to share knowledge. A person with no medical knowledge can easily learn about the latest advances in the field, as well as information about which doctors have the highest ratings in the field, which hospitals to go to for the highest reimbursement rates, etc.

In the past, when patients walked into the ward, the most common question was-

“Doctor, what should I do for this disease?”

Now the most common question is-

“Doctor, I see that someone on the Internet said …… Do you think that is correct?”

Doctors are gradually walking down the altar, no matter how much doctors boast their skills and experience, patients are gradually learning that doctors are not gods, doctors are also ordinary people who also make mistakes. After understanding the treatment process of diseases and seeing the “mistakes doctors may make” shared by netizens, there are naturally countless pairs of eyes on doctors and try to find those mistakes that may cause harm to themselves.

You will find that during the time of infusion, there are more patients staring at the nurse’s bubble line, more patients taking pictures of the infusion; more patients recording the doctor’s explanation of their condition, and more questions to the doctor; even now when their loved ones are ready to go to the operating table, their families will start squatting at the director’s office door, staring to see if the director did the surgery himself.

The wall between doctors and patients is gradually becoming more transparent and is even being silently removed, and the authority of doctors is being questioned more and more every day.

Technology is still evolving, and the amount of information available to patients will increase every day. Perhaps in the future, patients will be able to know their health status at a glance through a single test, without the need for doctors to attend, ask questions, check and examine them. At that time, the patient will be the one who knows his own body best. Does this mean that healthcare will really change from a doctor-led “paternalistic medical model” to a patient-centered “democratic medical model,” as foreign writings suggest?

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Doctors’ emotions need to be managed and taken care of too

“Why should doctors’ emotions be taken care of? I don’t have anyone to take care of my own emotions, and I’m taking care of him? I’m obviously paying him and I still have to go along with it?” The reason I’m talking to you about this is because we all have a very clear premise that we all want the patient’s visit and recovery to be smooth.

When many people hear that I’m an oncologist, they ask, “Do you get sad when you face all those lives and deaths every day? Or have you become numb to it?” In fact, these scenarios don’t cause any mood swings for most doctors anymore. Instead, it is the small and trivial things during the consultation that disturb the doctors’ mind more.

One of the most common scenarios is that a doctor is seeing a patient and suddenly an old man comes up from the back of the line and says, “Just prescribe a medicine. If the doctor does not prescribe, he will ramble on about how he is in a hurry, either because the train is late or he has to pick up his grandson from school. If the doctor stops to see him and prescribes him medicine, the patient he is seeing will be very unhappy. No matter what the doctor does, there is no way to make everyone happy. This kind of emotion continues throughout the day, even a doctor with a very good temper and attitude may fall into a strange aura, and even end up in a red-faced argument.

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Suppose this doctor is your father’s primary care doctor, when the doctor returned to the ward at 7 p.m. after the clinic to prepare for the end of the day, you rushed up without saying anything and asked, “Doctor, can I talk to you about my father’s condition?” I guess your doctor probably reacted this way: “Didn’t we talk about it? I’ll do what I said before.”

I think you must have known that doctors are more difficult and must have been careful to ask, but you must have felt some aggravation inside in the face of the doctor’s indifferent and even somewhat bored attitude. There will be two different directions next.

Ending A

You and the doctor have a big fight –
“I asked you a couple of questions in a peaceful manner, what is your attitude!”
“What’s wrong with my attitude I!”
“You say what’s wrong with you, you are the attending doctor, I asked you two sentences about your condition what’s your attitude!”
“I have no attitude ah, I have not told you all!”
Next there will probably be some nurses and doctors coming over to persuade the fight.

Ending B

You put up with your grievances, and the next day you see the attending physician in a good mood chatting with the nurses at the nurses’ station. You walk over and ask directly and clearly, “Doctor, I didn’t hear you last time, what day are we coming back for a review?” The doctor replies, “In 3 weeks.” Problem solved.

You may think that I just used two stories to tell you to be respectful and “tolerant” of your doctor. But in reality, this is the most realistic scenario in which most conflicts do or do not occur, and there are two things you need to focus on.

One, have you noticed that in scenario B, the most important thing is to ask directly and clearly. What does this mean? Usually when you want to talk to someone you start by asking, “Do you have a minute?” But for doctors, this question is skipped. In hospitals, especially public hospitals, although you do pay money and doctors do get paid, your money does not translate into doctors’ money in most hospitals. A doctor’s income is related to the volume of procedures, but it’s not that related, so treating one more patient and seeing one more outpatient does not increase a doctor’s income, which means that a doctor’s income is equal to a day and a night of talking to you. So from an economic standpoint, the price of a doctor’s service decreases as the service increases, so doctor-patient chats are usually “intake” – everything moves toward the easiest way to solve the problem, without open-ended questions and answers.

If you want to respect a doctor, you have to respect his or her time. Understand this so you can effectively manage your doctor’s time.

Don’t start an open-ended conversation with “Let’s talk,” which can make the doctor feel like the “talk” can’t end anytime soon. If the doctor is still busy, or is not busy but wants to take a 10-minute break to catch his breath, he will resist talking to you. But if you come up and ask a few small, clear questions, the doctor will give you the most direct response.

Second, it is also important to choose the right time. I have had the experience of the family of the first operation of the day rushing over to ask about the operation when I got off the operating table at 12:00 in the middle of the night. The family members came to ask the doctor even though they had already said “the surgery went well” during the day because they were anxious and wanted to get affirmation and comfort from the doctor. However, asking questions regardless of the occasion and time is disrespectful to the doctor’s time and energy, and will make the doctor think you are an “uninformed” family member, so your attitude will be indifferent.

Patients and doctors are unlikely to become friends in the hospital. I have quite a few patient friends, but basically they don’t become friends at the time of the visit. The friends that doctors can have long term relationships with and help must be the ones who “get it”. To tell you the truth, once at 2:00 in the middle of the night, a patient who was 5 years post-surgery called me and asked me what medication to take for constipation. After I answered, I took special measures for this number. You can certainly take the moral high ground and call me out, but I still want to live well.

Most of the time a patient looking for a doctor is not like picking out goods on a store and picking the one that fits best after looking at all the items. There is a considerable amount of chance in choosing a doctor and the outcome of treatment is a probable event. So to the extent your emotions allow, restrain your instinct to want to talk to your doctor, always remind yourself that your goal is to make the patient’s treatment in the hospital go smoothly, and on that premise, be moderately understanding and kind to your doctor, including his energy and time.

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