• Rosalind Kaplan, M.D.

What Do Doctors Want?

I've been reading the many Doximity, Medscape and Kevin, M.D. posts that I receive in my email daily.

I read about 'burnout' and depression, about anger at the Maintenance of Certification process, the debate about payment models. I read about the daily struggles with insurance companies (prior authorizations and pre-certifications, and about daily struggles with EMR's (physician overload from logging data and excessive 'clicks' and difficulty maintaining human contact with patients when the computer gets between the doctor and the patient.) Today I read a particularly sad story about a hospitalized patient and his family receiving bad news via a telemedicine monitor. While the hospital stated that the doctor made rounds twice a day, in person in the morning and by telemedicine in the evening, and that there was staff present with the family when the news was delivered, the patient and family did not understand the use of this technology in the same way, and felt dehumanized and frightened. I felt sad for both sides- I wonder how many patients the doctor rounded on twice daily?

Still, I have to say that I don't think I could justify giving bad news over a TV monitor, and if I was the patient, I would probably feel the same way.

I also read some positive posts. Most of them are about good interactions with patients or families, the interactions that touch both sides of the doctor-patient duo. And occasionally a post about good teamwork, or caring colleagues. These are the interactions that carry us as physicians- that make all the hard work and sacrifice of time and sleep and family time worthwhile.

There has definitely been a trend to the negative sort of articles over the past few years, and I'm sure it makes people- patients, administrators, those in other professions- ask 'well, what is it that physicians want? What do they need to be happy? Or at least not miserable? It seems like so many things are wrong that there is no way to satisfy the doctors.'

I don't think this is true at all. I think overall, we want some pretty simple things.

The first is to feel appreciated. I was very, very lucky when I was in primary care practice to have a group of patients who showed me their appreciation all the time. It was one of the things that sustained me for 30 years of practice. Unfortunately, in the last few years of practice, it became the only sustaining factor, and that wasn't enough. But it did keep me there longer than I otherwise could have done it. I will also say that now, in Urgent Care, patients are very appreciative on the whole- they are there with acute illness or injury, and we are there for them 12 hours a day, seven days a week. They really appreciate this.

I also am able to understand when patients are not 'appreciative'. Usually it is because they are under a huge amount of stress. Doctors don't want to be abused by angry patients. It has happened to me- fortunately it is rare- but it happens. What I say about this is that, if a patient is acutely suffering, they get a pass when they are angry or irritable. When it's not okay is when patients are rude to the doctor because of things we can't control, like bills coming from the hospital system or problems with their insurance companies. What I, as a doctor, would like is a buffer between me and these types of complaints. I didn't have that at my last practice. I do now, and it has taken a lot of stress off of me!

And it's not okay for a patient to ever be physically violent or consistently, over time, verbally abusive towards their care providers. We should be protected from this by our employers. Again, in the past, I have experienced times when employers have not protected me- and that is not okay.

Appreciation from our institutions is a whole other thing. Unfortunately, in many institutions, appreciation comes only when we exceed financial expectations or receive accolades in the media, which advances the institution's goal to attract more 'covered lives'. Physicians are too often measured by their RVU's and their 'metrics'- have we collected some kind of data in a high enough percentage of patients for insurance companies to pay more? Have we gotten good enough 'patient satisfaction scores'? If our 'report cards' are good, we might get a few words of appreciation. We rarely receive appreciation from administration for giving truly excellent care to patients, for going the extra yard for students or residents, or for having exemplary ethics. The extra hours we put in when the system makes an IT change or institutes a new patient care initiative often go unnoticed. The mentoring we provide to junior faculty, NP's and PA's is assumed, and not rewarded in any form, just like the hours we spend in committee meetings and 'faculty development'. It would take very little for institutions to just acknowledge everything we do. It would be a start. Financial incentives for such feats as data collection, in my personal opinion, is not helpful- all it did was reinforce that I would be rewarded for doing things that have not been shown to improve patient care and which actually took away time from the things that were truly important.

Appreciation from our institutions dovetails with the next thing I think physicians want. Respect.

I'm not talking about reverence or blind allegiance. For me, it is not a problem to be questioned. I like it when my patients are well-informed and educated. Recently, I took care of a scientist at Urgent Care. He asked me some great questions, like what were the signs associated with bacterial versus viral infection, and what potential harms were associated with the treatments he was being offered. I don't expect everyone to ask erudite scientific questions, though. Even if I am asked why I think one thing, when the google page the patient read said something else, I will always answer a respectfully worded question. It's fine for patients to ask for second opinions, too. As long as the exchange over a difference of opinion is respectful, I'm good with it!

What doesn't work is an administrator admonishing me for 'spending too much time with a patient',

instead of asking 'what happened with this patient that required a 45 minute visit?' If I need to spend extra time with a patient, I would like to be afforded the assumption that there was a good reason. That's part of respecting me as a professional. If a colleague takes issue with something I did, again, there should be the assumption that I had a reason, and I am happy to tell them what it was. But colleagues who talk behind each other's backs and administrators who bash doctors for wasting time or money without knowing the facts are not being at all respectful.

I also found 'report cards' comparing me to other providers to be disrespectful. There are people who may disagree with me about this. But I felt like the 'report cards' I got when I was in academics, which compared my data collection to that of other providers, devalued me. Competing with my colleagues to be the best at logging in my vaccines or colonoscopies seemed absurd, especially when that work should have been done by clerks, and for some docs, it was.

I think the third thing doctors want is a quality life-long learning experience. I have been very happy in my current position because I am constantly learning new things. I love learning things, and implementing what I've learned. There is routine formal weekly and monthly education, at which I both teach and learn. In my previous position, there was weekly Grand Rounds, and there were many, many opportunities to attend other meetings and conferences. This was an aspect of academic medicine that I loved. Except for one thing. I rarely got to Grand Rounds because our patient sessions always ran over! There was no protected learning time for us. Protected learning time is crucial, and is one of the things that I think would improve doctor satisfaction.

That brings me to Maintenance of Certification. Doctors are pretty universally dissatisfied with the way our board certification mush be maintained currently. The ABIM forces learning modules and tests with irrelevant material on us and charges exorbitant fees for us to take them. The system is no longer consistent with the way physicians learn in this digital age, and takes more time out of our already crazy schedules. Finally, internists have taken charge of this situation and the class action lawsuit against the ABIM is forcing a hard look at the process. It's sad that it's taking litigation for this absurd situation to be examined seriously, when doctors and advocacy groups have been asking for reform for years. I think the majority of doctors agree that we want, and need, a big change in this process.

Finally, I think physicians want, and need, human connection. We want to work collaboratively with colleagues and other healthcare professionals to provide good care for our patients. We want to give our patients an experience of both good technical care and also good healing. We want to be healers and to teach students and trainees to be healers. To be healers, we have to be well. To be well, we need to care for ourselves and care for each other. Institutions or practices that pit physicians against each other, or faculty against trainees, or doctors against other staff or even administration against providers, are eroding our humanity and our sense of well-being. We need to be here for each other as well as our patients. There needs to be kindness.

Being in a situation where I feel heard and respected by my colleagues and by the staff I work with is essential to my sanity. Anything less is unacceptable.

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