11 Things Good Doctors Do That Can Anger Patients

It’s always controversial to write a post that admits doctors upset patients, but after 15 years in practice, I’ve found it’s important to explain why some things happen with a doctor that drive patients batty. I’m not immune to this either. As a father, husband, patient, and doctor, I’ve been on both sides of these issues. I hope it sheds light on reasons why it happens if it can’t make them any better.

 

11 Things Good Doctors do that Make People Mad

 

  1. Give people antibiotics only when it’s indicated, not just when patients want them
    1. One of the greatest threats in the world of infectious disease is resistance. This means that bacteria are not killed by antibiotics. One of the main reasons for this is the over-prescription of antibiotics. If you have a cold (which is caused by a virus) and you get antibiotics, you increase the risk developing antibiotic-resistant bacteria. When this is done millions of times across millions of patients over many years, we get MRSA, VRE, and other so called “super” bacteria that are very hard to kill and, therefore, potentially very dangerous. It’s not uncommon for a good physician to take a lot of heat from a patient (or very often the parent of a pediatric patient) for not providing an antibiotic even if one is not indicated. A good physician will hold their ground for your benefit and the health of the community as a whole.
  1. Infrequently fall behind in clinic
    1. Good physicians fall behind in clinic, just not often. In this era of medicine, it’s not possible to schedule only 10 people in a day and spend an hour with each and keep a practice open. The average physician office had an overhead of about 61.3% in 2016. This means over 60% of a physician’s day is spent just to cover that day’s expenses. With patients not showing for appointments, ever declining reimbursement from insurance companies, increased paperwork demands, and increased need to meet federal regulations, physicians have to schedule more patients than they did a decade ago. Compounding that fact is that patients now have a harder time getting in to see their doctor and so they try to cover more concerns when they do visit. More issues in less time does not allow a good doctor to consistently be on time.
  2. Make patients get referrals
    1. Just like there are bad doctors, there are bad patients. One form of a “bad” patient is a doctor shopper. You know them. The patient who, regardless of the quality of a physician, bounces from doc to doc or clinic to clinic until they get the answer or drug or surgery they want. Specialists are particularly sensitive to this issue because they are often not aware of what other specialists have done. When a patient shows up in a doctor’s office for a 2nd or 3rd opinion and keeps that information from the doctor (often to prevent the new doc from being biased by previous diagnoses or treatment), the new doctor may prescribe a medicine that could interact with one already received and not documented. In an all too real example, a patient may have been given an allergy medicine by one doctor which has helped somewhat, but then sees a 2nd doc and doesn’t let them know about the first doctor’s prescription. The 2nd doc prescribes another allergy medicine. The patient not knowing better takes both and becomes sleepy behind the wheel of their car. Referrals help mitigate that potential disaster by helping coordinate care among several doctors.
  3. Make patients follow up to get test results
    1. In the world of results from medical tests, no news is not good news. No news is no news and potentially bad news until proven otherwise. Results get lost in cyberspace. A fax fails, an e-mail gets sent to junk mail. A phone call to a patient goes to the wrong number or to voicemail but gets deleted. The best way to know that your results are back and do not indicate the need for more investigation or treatment is to get the results in your hand. You then have a record of the test to show other physicians if needed. Never assume no news is good news. Yes, it does cost more of a patient’s time and money to review results in person, but it sometimes costs a lot more if something important slips through the cracks.
  4. Make patients wait to get pain or other addictive medications
    1. I’ve had a patient ask for a pain prescription prior to their surgery only to receive the Rx and then cancel surgery just to go fill their narcotic pain medication. I’ve even had one ask for it while in the pre-op area already having had an IV placed in preparation for surgery. The patient asked if I could give his wife the Rx. After receiving it, the patient pulled out his IV and he and his wife left the surgery center to go fill their narcotic. Good docs do what they can to prevent the abuse of any medication.
  5. Spend time talking about the risks of surgery
    1. Informed consent, the requirement a doctor has to disclose the risks, benefits, and alternatives of a procedure, is a necessary part of any medical treatment. It stems from an era not too far distant when physicians would submit patients to treatment without disclosing the potential risks. Today, it’s a requirement to have a full disclosure of the potential issues related to a medical or surgical treatment. Sometimes patients get bored with the discussion. Often they don’t pay attention. One study showed that 60% of the informed consent discussion could not be recalled by patients 30 mins after they had a thorough videotaped discussion with their surgeon regarding an upcoming major procedure. A good physician ensures you understand what’s happening, why, what can go wrong, and then asks if all of your questions have been answered.
  6. Do not personally negotiate or discount your bill
    1. For all of the reasons above, a good physician cannot typically involve themselves in the personalized cost of your care based on your means to cover those costs. Do not misunderstand that statement. Indeed, physicians should be cost conscious. They should know what tests to order, what surgeries to do, and what medications to prescribe based on efficacy, risk, and cost. However, if a physician has to compromise your care because they are worried about how you try to negotiate the cost of their recommendations, it introduces a bias that will inevitably compromise care. If you want to negotiate your bill or ask for a discount, don’t discuss it with the doctor, discuss it with the office manager or billing department. Let your physician focus on your health and not your financial status.
  7. Deny surgery when it’s not indicated
    1. This is round 2 of the doctor shopper. I stopped doing cosmetic facial plastics when a 20yo model came to my office and wanted her nose to look like her model friend’s nose. This girl was phenomenally beautiful. I told her I couldn’t make her prettier than she was—that changing her nose would make her different, but not prettier. She insisted on going forward. I refused. I told her that if she persisted, she would not have much of a problem finding a surgeon who would take her money and change her nose, but that this would not improve her appearance, career, or make her happier. She left my office. I don’t know if my counsel made an impact or not, but I couldn’t live with myself if I had to agree to a surgery because a patient demanded it when there was substantially more risk than benefit. I won’t do surgery for someone’s sinuses when they don’t have sinus disease. There are surgeons who will. The news is filled with stories of doctors who did surgery when it wasn’t necessary and something bad happened to the patient. Don’t be a victim. Surgery is already a big enough deal when you need it, don’t make it an issue when you don’t.
  8. Do not order tests when it’s not indicated
    1. Patients will often come to a physician’s office certain they have some terrible disease for which they demand a treatment or a diagnostic study. In my world, this happens very frequently to the patient who finds a lump in their neck they are certain is cancer. They want a CT scan to evaluate it. Their history and physical exam would indicate that their “cancer” is only a normal lymph node that had remained unnoticed for years until the right touch while shaving or rubbing the neck at the right time found it. The problem is that it seems everyone knows someone who had a lump that a doctor told them was no big deal and it turned out to be cancer. Recall that the title of this article is what “Good Physicians Do” so you have to presume that your (good) doctor, when telling you that you don’t need to expose yourself to the cost and/or the radiation of an imaging technique, is using the best prudent information available to make that decision.
  9. Charge for completing extra paperwork
    1. This is a controversial one for sure. When you need to take time off work for surgery or to take care of someone who needs surgery you may need to file paperwork (FMLA forms) with your employer. These are usually not short forms and take time from a doctor’s schedule to fill out. This is one classic example of time taken away from a doctor’s schedule to meet requirements of your employer. If your doctor charges for it, it’s because their time is money. I know if a patient is being charged a fee for it I’m going to be much more diligent about taking care of that paperwork than I would if it’s just one more stack of things I need to sign off on before I can spend time with my family at the end of a long work day. Doctors spend ridiculous amounts of time already doing work that isn’t reimbursed. I would bet none of my patients know how many hours I’ve spent in the last year on the phone arguing with their insurance about allowing them to get a surgery, an MRI, or a drug approved to better take care of a patient. Those are things that doctors rarely charge for but that take a tremendous amount of time. In fact, there are 3 surgeries that I do where the paperwork takes longer than the procedure. That’s new. When I started practicing medicine in 2004, paperwork never took longer than even the shortest surgery.
  10. Charge for missed appointments
    1. A good doctor is usually on time—or not far from it. For reasons discussed above, it’s impossible to always be on time and most of the time when they’re late it’s because a patient had greater needs than were initially indicated when the appointment was made. However, just as a good doctor should be on time out of respect for the patient’s time, patients need to understand that if they no-show for an appointment, it’s not a trivial burden to the practice. When I first started in medicine, I found out that if I have 2 patients who miss an appointment in a day, I’ve lost more than two full-time employees’ salaries for that day. However, there’s more to it than that. Not only did I miss out on seeing those 2 patients, I’ve lost the chance to see 2 other patients who could’ve been scheduled in their place. A good physician knows their business. They know that encouraging a patient to show up for an appointment is not only good business sense, it’s a good way to ensure timely care is being delivered to as many patients as is reasonably possible.

 

So there’s my list. It may not help a patient feel better when they’re upset, but I hope it helps improve understanding at a time when trips to the doctor’s office have become more and more cumbersome on both sides of the equation.

 

–Richard D. Thrasher III, MD

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