Doctor and Patient

GUEST: Dr. Pauline Chen
AIR DATE: 12/19/2013
VTR: 10/04/2012

I’m Richard Heffner, your host on The Open Mind. And this is our second program with Dr. Pauline Chen, the brilliant liver transplant surgeon whose compelling Alfred A. Knopf volume, Final Exam: A Surgeon’s Reflections on Mortality occupied us last week … and whose regular New York Times online column, “Doctor and Patient” provides so very much grist for our mill today.

Indeed, I’d like to start today by asking Dr. Chen a question that Ammaarah Khan, my indomitable Rutgers Aresty researcher feels throws the whole doctor-patient relationship into its very sharpest perspective…namely just “How Much Can Patients Learn in a 15 Minute Doctor Visit?”, the title of my guest’s August 16th, 2012 New York Times online column.

But, last time, last show and you should go to our archive and look at it, Dr. Chen was ending on a most interesting note and first I want to ask you, Dr. Chen, to pick up there.

CHEN: Sure. I was talking about one of the things that I most like doing. I speak fairly regularly to medical students and residents, trainees … doctors in training. And one of the groups of people that I most enjoy interacting with are surgeons at the end of their training, young surgeons in training.

Because I was in that position a little over a decade ago and I like talking to them because I remember how I felt about end-of-life care issues at that time.

I felt very uncomfortable, I had no facility with the words … I, I really pretty much distanced myself. And what I find so wonderful and so optimistic is that when you talk to these young surgeons now, many of them have an incredible facility with issues in end of life care. With talking about, with asking about it, with, with advocating for their patients with it.

That I just … it makes me very hopeful. And I, and I love that because I really think that it is … to me it is just such wonderful proof that the efforts of reformers in end of life care, the efforts of educators, the efforts of, of all of us … of patient advocates … that it’s making a difference. Because it certainly … I certainly wasn’t like when I was at that point in my career.

HEFFNER: Oh, I’ll bet you were. I’ll bet you were.

CHEN: (Laughter)

HEFFNER: But now, let’s go back … not for 15 minutes, but to the fifteen minute interview between doctor and patient. What can you get out of it?

CHEN: It’s very … that’s, that is so interesting to me because … well first of all I think it’s unfortunate that we’re often limited to 15 minutes and when you talk to, to practicing doctors, especially the doctors who are in private practice in the community who are maybe the only doctor for several counties in parts of the country. And those doctors make up the greatest number of doctors in the United States at this moment.

They often have even less than fifteen minutes. But no significant … there have not been … there has not been a lot of research on how to best … let me put it this way … it’s a little … that many professional organizations and much of our research on different preventive health issues … on different health issues tells us that we need to tell patients X, Y and Z … and I think that no field in medicine feels that as much as, for instance, pediatrics. They have all sorts of preventive things that they tell parents at each stage of a child’s life. In fact there is even a huge book that the American Academy of Pediatrics produces for pediatricians … guidelines of what to say.

Now I’m not a practicing pediatrician … but it’s very difficult with 15 minutes and you have so many things to tell people, all of which have been shown to be important in some way.

So there’s starting to be some very interesting research on what is the best way to tell certain things to patients … that is there a way that we can do it … that it doesn’t come out as a long laundry list of “do this, do this, do this, do this” for the patients of which … you know, I think it’s difficult for anybody to remember maybe one or two things.

So, a group of researchers has looked at the whole notion of diet and obesity in children. And what they looked at was how do you help mothers of babies feed their children in such a way that it’s healthy and not, not … it won’t promote obesity.

And the researchers tried three ways of doing it. One of the ways was to basically give them the list … the official, sanctioned list and tell them well, “do this, do this, do this and do that”.

But one of the three ways that they tried … they divided parents up into three groups when they did this.

One of the three ways that they tried was to talk to the parents about how they ate. Sort of an indirect way …

HEFFNER: The parents ate.

CHEN: The parents … not sort of about the babies, but of the parents. And what was interesting, what they found was that the message stuck far better … that the children … that the, that the weight and the habits at the end of the study period was much better than the way that it’s usually done, which is basically telling a parent to do this, this and that.

And that study was interesting because it opened up the question of … you know “How can we best convey this incredible information that we have about health to our patients within the constraints of fifteen minutes?”

You know, ideally, you would have much more time. But we don’t. And so how can we best do it?

HEFFNER: Let me ask, because I’m certain it must be occurring to our viewers … why 15 minutes? Are we talking about the pressure of fewer doctors than we should have in many parts of the country? Are we talking about insurance limitations? What looms largest?

CHEN: Yeah. I think it’s all of those. I think it’s all of those. And, unfortunately, I think in, in certain areas of medicine the pressure to, to maintain a practice and to cover all costs and to see patients, to see a certain number of patients, to make things work … it pushes that time period that’s allowed … that’s, you know, that’s set by payers to … I mean many doctors feel even more squeezed than the usual sort of 15 minutes for a return patient versus 45 minutes for a new patient.

It’s, it’s difficult. There are many, many forces, sort of forcing doctors to do that. And unfortunately, I think, in the future … I mean we are facing a significant primary care doctor shortage … primary care provider shortage, but especially doctor shortage in the next few years.

We’re facing shortages in other specialties as well. In general surgery there will be a shortage. And so, I, I think, you know, fortunately there are some very smart experts out there, researchers out there who are looking at new ways of providing care … or reorganizing the way that we practice so that we can maximize what time we have.

You know one of those ways, one of the most promising … many people feel is promising … is something called the patient centered medical home. Which basically takes the … there are many … it’s sort of more of a team approach … I think is a good way of putting it … to taking care of a patient so that every person on the team, whether it’s the doctor, the nurse, the medical assistant … every person is working at the best of their training …the best of their capability.

So, for instance, a patient who is a long-term diabetic may come in and first get their vital signs taken, their labs drawn by the medical assistant and then will go to the nurse who will talk to them about their diabetic care, about their insulin, about diet, about sort of preventative … about their medications, sort of hammer that out. And then they’ll see the doctor who will examine them and talk to them about things that … will take care of things that are under his or her rubric of, you know, area of expertise.

And so what it does is, instead of having the doctor do all of that, it sort of maximizes the time and it, it creates a, a team … a very nice team approach. And I think there are very interesting … there’s very interesting work going on now in the country, looking at establishing these medical homes and whether or not they are … how they affect patient care, how they affect patient outcomes … so that is one of the things that’s being looked at.

But I think that, you know, one of the issues that we’re going to have to deal with in the future is not only just how much time each patient has, but how are we going to deal with the large influx of patients and the shortage of, of doctors in certain fields.

HEFFNER: There is a pronounced shortage.

CHEN: Yes. Yes.

HEFFNER: How do you remedy that?

CHEN: You know it’s, it’s, it’s, it’s very difficult also because the training that’s required for doctors is … you can’t remedy it right away.

In many areas now they are looking at sort of increasing the definition of “provider” so having more physicians’ assistants be a bigger part of the team, more nurses, more advanced practice nurses, more doctors … and I think that will definitely be helpful. But I don’t think we have the answer completely clear. I mean I think it’s a huge worry for many, many physicians, for many of the professional societies at this point.

HEFFNER: Let me, let me move to some of these many, many other pieces that you’ve written. And I’m, I’m just, I’m just looking at the recent ones from this year.

You say, this is the title of one of your Times pieces “When doctors don’t tell the truth”. What are you talking about there?

CHEN: Ahh, that’s very interesting and I, I wonder if I can connect that to an article that appeared even more recently on sharing doctor’s notes with patients.

HEFFNER: The illegible ones?

CHEN: (Laughter) It’s, it was very … that was based, that study was based on a survey of physicians and how truthful they always were with their patients.

And it was very interesting because not all of the physicians … I mean the physicians were very honest in this survey and they said they weren’t always …

HEFFNER: You mean talking to each other?

CHEN: Talking … no talking to patients …

HEFFNER: Oh, to the surveyer …

CHEN: Yes, they were honest in the, in the questionnaire, but they weren’t always open with patients. And some of that extends back to our previous show that, you know, it is very … when you have a patient that you care about, that you’ve seen for decades and suddenly that patient has a, a terminal diagnosis and you need to talk to that patient about … to say “Well, you have a terminal diagnosis, we need, I need to know what … how you want me to proceed. What you want to do with your time?”

That’s a very difficult conservation to do and so … you know … it’s far easier to finesse it or to by-pass it or to not really address it, to not be completely truthful.

And what that … what was interesting about that survey was the even though some of those conversations, those missed conversations may be quote/unquote “self-protective” for the physician or may be a well-intentioned move on the part of the doctor not to … so that the patient doesn’t lose hope.

Ultimately, I mean I think we all know … that what we need to have are very open conversations with one another about these most important topics in our life.

And, and one of the things that the researchers suggested from that study which I think is really important is that … and I think this is very important for patients … for viewers who are patients … is sometimes it helps when the patient says to the doctor, too … “Doctor, I …” when they have the discussion about what to do if there comes a time that a topic that’s very difficult, you know, comes up … how do we approach this?

Sometimes it’s very helpful for the doctors if the patients say, “Doctor, I want you to be totally honest”. It’s a difficult topic to touch on altogether.

HEFFNER: Do you think … are you convinced that most patients really want the truth? Do you think that there’s a possibility that this … what I call “the tribal dance” …

CHEN: Yes.

HEFFNER: … is a function of fear, want, desire … whatever on the part of patients as well as physicians?

CHEN: Absolutely. Absolutely. Because I do think that as a society we have difficulty addressing those topics. But I think that is precisely why we need to at least talk about how we’re going to talk about it together openly. Before it happens because I think it will make it easier when that time comes.

There will be patients … there are patients … there are people who don’t want to talk about it.

HEFFNER: Yeah.

CHEN: But I think that most people, if they had a certain amount of time left on this earth, or if they had a terminal diagnosis … for many people it would be helpful to know that.

So I think, I think at least having the discussion and this is what the researchers said … having the discussion about how you’re going to approach difficult things …

HEFFNER: How are we going to approach a topic you don’t want to approach?

CHEN: Yeah. Exactly.

HEFFNER: Or neither of us wants to approach.

CHEN: Exactly. Exactly. And you know, I think having that kind of transparency, that openness in a relationship is good because it may turn out that you don’t agree on that. And I think that’s a really important thing for doctors and patients to know about … for each other.

It’s, it’s … it’s, it’s a very interesting idea … the whole notion of the transparency in the patient/doctor relationship.

It’s very interesting to me because I think that, you know, those kind of conversations are open, but I don’t think and I may be saying something kind of controversial here … but I don’t think we, as a profession, as a, a society have gone far enough.

And there was a … and a study that I thought was very exciting … that came out in the Annals of Internal Medicine about sharing doctor’s notes with patients or allowing patients access to their notes.

Now, since 1996 when Congress passed HIPPA the law, patients have actually had the legal right to access their notes and even amend their notes.

But few have because it’s difficult, it’s really difficult to get a copy of your records. I have had … it’s very, very difficult. And … but there is a group of researchers in Boston who just completed a study, just published the results of a study where they had little over 100 doctors in three centers … and over 13,000 patients.

And they gave those patients access … easy access on a secure website to their doctor’s signed notes.

HEFFNER: They didn’t look.

CHEN: Well, actually a large percentage did look.

HEFFNER: Really?

CHEN: And what’s fascinating is … this, this I find, I find it absolutely fascinating. So the doctors who participated in the study and this I can totally relate to … were nervous about it. They were worried that, you know, small abnormalities in their results would sort of make patients worry. They were worried for their patients. They were afraid that their routine sort of … their shorthand … so,for instance a doctor may say a patient is “s.o.b.”, which means “short, short of breath”. Or is anorexic, which means the patient’s lost their appetite. They might think the patient … they were afraid that the patient would take offense.

And then they were afraid that it would cause all sorts of work on a day that it’s … I mean their workload is already … it’s huge currently. So they were afraid that patients would read their notes, email and ask all sorts of questions and sort of … it would be crazy.

So that was the doctor’s point of view. The patients … no, they were interested in being able to see what the doctor wrote about them.

What was interesting was at the end of the study, the patients were overwhelmingly enthusiastic. They loved it. They also … this was interesting … almost … I think it was like almost 80% of them said that they actually took their medications better and were better able to follow the doctor’s advice because they had the note there.

And most of them said that they loved the experience so much that from now on they were going to base their decisions on what doctor they were going to see, what hospital they were going to, based on whether or not they could access their notes. And the most …

HEFFNER: Trouble in River City.

CHEN: Right. And the most surprising part of all … at least for me … for, for all of us, I think, for all physicians was that the physicians loved it as well. The end of the study, none of the physicians asked that the open access stop.

HEFFNER: Let me ask you a question now … this may get me into trouble …

CHEN: (Laughter)

HEFFNER: … enlightenment … the enlightened physician who wants open access, who can talk about death with his or her patients. What’s the sexual differentiation? Do you find that male doctors or female doctors are more likely to be enlightened … to use that phrase as you think … as you must know I mean it.

CHEN: That’s a very interesting question. Because I’m occasionally asked what’s it like to be a female surgeon or what’s it like to be a woman practicing in a field that was for many … for a long time … predominantly male … but is now quite … there are a lot of women in it now.

It’s interesting because there have actually been interesting studies on it as well … showing that what actually may matter more is not whether your doctor is a male or female, but what you are as well … whether you’re male or female.

HEFFNER: The patient.

CHEN: The concordance … yes … the concordance between doctors and patients.

HEFFNER: Ah, I see …

CHEN: And, you know, I, I think actually that that kind of research and their similar research in terms of race and culture.

I think that … those kinds of studies that show that patients feel more listened to … her doctors feel more comfortable when there’s better concordance. I think that speaks for a more diverse work/doctor population … the more doctors of different backgrounds practicing.

You know I, I did a recent piece on pain in cancer patients …

HEFFNER: MmmHmm.

CHEN: … and how many cancer patients were still in pain even though they were being seen by … even though 20 years ago there was a famous landmark study that showed that, you know, 30%, 40% of cancer patients were still in pain after seeing their doctor.

Well, the more recent study showed that it was like 30%. And one of the things that the principal investigator of that study said is that what can be … what might be happening is that … you know people express pain differently.

They express their symptoms differently, depending on where they’re from, who they are … so, you know, a gentleman who comes from a background where being strong is really valued may not talk about being in pain. May not talk about the problem that he’s having with his shoulder … you know whether it’s cancer or not … may not talk about all his symptoms in the same way that I might, let’s say. Or that, you know, a physician from a different background would.

And so what that requires is, you know, what would be ideal would be as diverse a physician population as a patient population, but it might also … it also requires that, that doctors … and this is both the great challenge and the great fun of medicine … of practicing medicine … is that we focus on the art of it … like we really … and it’s hard … but we really open ourselves and ask open-ended questions. We ask that patient not, “Does it hurt? Do you have any pain?” because he may say “No”.

But we ask, “So, what are your days like?” and he may tell us, “Well, you know I still garden, but I don’t get around quite as much as I used to.” And then we ask why. And he might say “Well, my shoulder doesn’t quite work like it used to”. So it requires a lot of work on the part of doctors, but it’s, it’s the art.

HEFFNER: And if I return to my question in the less than one minute that we have … is it more likely to be the male doctor or the female doctor who is aware of those limitations?

CHEN: (Laughter) I think it could be either.

HEFFNER: I knew that you were going to say that. Could be, but I really mean it … and I’m not going to get the answer in this program … we’ve done two thus far and you’ve got to promise me that you’re going to come back to the Open Mind again and again …

CHEN: I would be honored.

HEFFNER: Dr. Chen … that’s …those are the best words I’ve heard in a long time. Thank you for joining me today.

CHEN: Thank you.

HEFFNER: And thanks, too, to you in the audience. I hope you join us again next time. Meanwhile, as an old friend used to say, “Good night and good luck.”

And do visit the Open Mind Website at thirteen.org/openmind to reprise this program online right now or to draw upon our Archive of 1,500 or so other Open Mind and related programs. That’s thirteen.org/openmind.