What, in your opinion, makes a good healthcare provider?

I think you might like this radio story about hospice nurses and how they handle dying people and the families. I listened earlier today, and was awed at the personal skills and calm empathy. It’s like watching Olympic athletes. That sounds hyperbolic, but really, the nurses are amazing. Link

A good listener.

Caring, kind, humane, caring less for money.

FYI, there used to be a comedy mocking the doctors’ attitude in my country. Basically it was about a woman (let’s call her Miss. A) who one day got a stomachache and was introduced by a man (let’s call him Mr. B) to his “innovative” hospital. She was greeted by a “robot doctor”. Here is their conversation:
Miss. A (talking to the robot): Doctor, I’ve got a stomachache. Can you tell me what is wrong… Doctor, why don’t you talk?
Mr. B: this “doctor” is very special. He won’t talk until you insert this coin (showing the coin to Miss. A). You can buy the coin from me for <some very large amount of money>.
Miss. A: OK, here you are, the money.
<Inserting the coin into the robot>
Robot: good day. How do you feel?
Miss. A: oh doctor, I’m having this annoying stomachache! Please tell me what to do!
Robot: there are many causes of stomachache. It can be because you eat something unhealthy. It can be because you have a disease. It can be because… <stop working>
Miss. A: Oh no! What is wrong?
Mr. B: Well, you need more coins for him. Buy from me :)
<Inserting the coin>
Robot: good day. How do you feel?
Miss A: Oh doctor, I’m having a stomachache!
Robot: there are many causes of stomachache. It can be because you eat something unhealthy. It can be because you have a disease. It can be because you are imagining it. To know the right cause, you have to… <stop working>
<Repeating the same process>
Robot: good day. How do you feel?
Miss. A: If I were well why the hell did I have to meet you?
Robot: there are many causes of stomachache. It can be because you eat something unhealthy. It can be because you have a disease. It can be because you are imagining it. To know the right cause, you have to perform the right analysis. First, you have to do an X-Ray scan. Then you have to do a test on your blood, then… <stop working>
<Repeating the same process>
Robot: good day. How do you feel?
Miss. A: cut the poetry now! I’m having a stomachache and I want you to cure me fast!
Robot: there are many causes of stomachache. It can be because you eat something unhealthy. It can be because you have a disease. It can be because you are imagining it. To know the right cause, you have to perform the right analysis. First, you have to do an X-Ray scan. Then you have to do a test on your blood, then you have to do a test on your urine, then you have to scan your brain for detection of any sign of paranoia…
Miss. A: OK, so I have done everything now! What is wrong with me?
Robot: you have a stomachache.
Miss. A: What the hell? I came here just for that diagnosis? OK, so I’ll listen to you because you’re my doctor. So what am I to do now!
Robot: Go to the drugstore and buy some aspirin.
Miss. A got too furious and chased Mr. B and the robot.

I think it kind of paints for you the picture of a bad healthcare provider.

The best doctors I have ever had all told me that their goal was to work themselves out of a job, meaning that they wanted to educate me so I wouldn’t have to show up in their offices so often. Every one of them were alternative doctors. When I find a doctor like that I know I’ve hit gold.

Communication is the key in my view. I get texts from my health centre reminding me of appointments. Little things like that make a big difference in how the provider is seen and how many appointments are kept.

Nursing care:

To my Dad post-op: “Ooh your feet must be so cold. Let’s get something on them right away.” Good care.

Nurse’s aide (said in my hearing): “I don’t want to go in that room. That man is crazy – and his wife is even worse.”

And then to him when he is was screaming because of his neuropathy: “Well, we have to clean you, you stink.”

And medically, when I asked the surgeon what would happen if we didn’t operate on his broken hip:

“Well, he’ll die. Is that what you want?”

He died anyway.

As a provider and a patient, the first thing is to listen and respect that most people do know their own bodies. The case history is truly the most important diagnostic tool, as it is the starting point from which we choose which course to take and additional tests to order. I’ll often ask, “What did you think was causing it when it first started? Do you still suspect that is the root of the problem?” I also ask what their family members have observed, and include them in the history if they’re at the visit, sometimes they’ll remember additional symptoms that a patient may have mentioned in the moment, that they don’t recall because the most acute symptom had them overwhelmed. I try not to ask leading questions, but to let people describe their issues in their own words. When they’re struggling to find the words, I’ll say, “Some people say it’s like a, or b or c, or d…” just to help them feel comforted that they’re not alone (because the often say that I’ll think they’re crazy because of how they describe it, but most of the time it’s a description I’ve heard numerous time), or because one of the suggestions is a close match to what they’re trying to express.

It’s also interesting how a patient will tell me different information than they tell the Medical Assistant and/or the Doctor. We have 2 or 3 people going over the history, which I know seems cumbersome to the patient, but it also helps us ensure that we don’t miss something. Recently, I asked a patient if they experienced and dizzy spells or imbalance with their symptoms, and they said they had when it first started a few years ago. They didn’t mention it to the MA, and I asked her because I had the sense that the patient was downplaying it because it wasn’t a primary complaint, but I felt it could be relevant to the etiology. Unfortunately, we’re usually too busy to match our notes, so I have to hope that my attention to detail and charting everything the patient reports is picked up by the others who see the patient.

One of the biggest challenges is to customize your “bedside manner” to the person you just met. Some people are very passive and want the professional to do their job and tell them what to do in an authoritative manner. Some people are pretty well informed and and want options and descriptions about everything that’s happening before, during and after you do it. Some patients need the process sugar-coated with humor, others need straight talk, and you have to figure that out within the time you meet and introduce yourself, and ask them why they are in your office. Some people are very needy, overly anxious, and even true hypochondriacs—they’re the biggest challenge, because they have been looking for someone to tell them what they want to hear. Depending what type of practice you find yourself in, some patients are in your office reluctantly or against their will. Some people have such a stigma against having their hearing checked that the family tricks them into coming in! Accepting that sometimes the only help you can offer a patient is information and education because they don’t want to be helped beyond that is hard to do, because you chose healthcare to help others, but not everyone wants to be helped.

Now we’re entering an era in healthcare where patients will be rating us like car salesman, and our reimbursement will be based on those ratings, and only the top ranking counts, all other scores are neutral or negative. But we all know that you can’t please everyone, and in healthcare we can’t always give good news or fantastic outcomes. Health care is already a field where we have high standards because that’s the type of people we are, going ‘above and beyond’ is already standard practice. I think this system is unfair, and it will harm our ability to focus on doing what’s best and what’s right, because it forces us to do what will make the patients and their families perceive that we did the right things, and we made them happy every single time. They’ll judge us by how warmly they were greeted at the front desk, how well-organized the waiting room was, how quickly the phone was answered, and if they got a live person rather than a recording, etc. It is not just about the care that we providers give.

My current complaint about the specialist I see for my chronic condition is that the first two visits, when I was there for diagnosis. My labs confirm that something is wrong, but are not high enough or specific enough for differential diagnosis. I was listened to and respected, in terms of the treatment course and medication I wanted to try first, based on my research; but since then it has been a passive, maintenance mindset. My labs are stable, but my symptoms seem to be slowly progressing, and I want to know what’s wrong. I want someone who is motivated to find the etiology and to be more proactive in slowing the progress of the disease beyond writing a script – recommending that I see other specialists for evaluation that might offer additional insight into the global causes and effects of the condition, and also to rehabilitation services for physical management of living with these illnesses.

Perhaps my specialist thinks that should be done by the Primary Care Provider, but most of us think of our PCP as the person we see for basic health management and minor conditions. Most PCPs don’t have the time to really be the hub for coordinated care, which was the intent of the HMO model back in the ‘80s. In my own practice, we do recommend that a patient consult a different speciality for further assessment of systems that may also be contributing to their symptoms, and we recommend that they discuss that further with their PCP to confirm and to get referrals if needed. I don’t know why my specialist hasn’t done so with me.

Someone who believes me and who understands me. I like to feel like they are my partner, not just the medical boss, especially with chronic conditions. With chronic conditions I want to be trusted to have lab results released to me without having to beg and call for them, and I certainly don’t want to have to come in for an appointment every time for results when I get the tests done every three months for the last ten years. Diabetics get to test their blood at home, I know how to read my thyroid results don’t make me beg for them.

Tell me about my options even if my insurance doesn’t cover it.

Tell me if you are a referring me to a doctor you recommend, or just one that is in my network. Years ago another jelly asked doctors how they choose a doctor when referring patients and all the answers were they look up who is in network. The OP and I were in a state of shock and dissappointment. In all other parts of business and among friends, we refer people when we know their work and want to recommend the person. We had no idea doctors refer and sometimes have no clue who that doctor is and no history with them.

I hate feeling ripped off. The system is basically set up for patients to feel that way if they have high deductibles, so I am not sure what you can do about it. It truly makes me sick, and probably has shortened my life. The only doctor I don’t feel that way is the one who gave me a price sheet up front.

Voicemail! In TN I had more than one doctor who had receptionists take messages and it was extremely frustrating. It is difficult to give a lot of detail to someone writing a note, and the receptionist is unreliable to convey what is wrong. If I leave a message it can be played for the NP or doctor if necessary.

If you are telling me no, don’t send someone else to do it unless they know why. If I call for a medication and the nurse calls me back and says, “the doctor won’t prescribe it.” Well, why not? If I called and asked for a script, it was because I felt it was a reasonable request or she has prescribed it before.

I really like being able to email my doctors. I almost never do it, but I like having the option.

The employees in the office need to understand customer service. I swear I get better service buying a dress in Bloomingdale’s sometimes, and this is my flipping health we are talking about! If I complain about your staff tell me, “thank you for letting me know.” Then either continue buy assuring me you will address it with the staff or explain to me without making excuses why it might have been right for the staff to do what they did so I can see the reasoning behind it. I have left more than one doctor because of their staff.

Know that people with chronic illness without a specific isolated cause have been through a lot of crap. They are less likely to trust you and easily frustrated. They are difficult patients because they have spent years going through many treatments and reading up on their condition. They know more than you about their body, even if you know more about the disease, sometimes you know less about the disease because medicine knows very little about some conditions or the current thinking is incorrect.

Take medication allergies and negative side effects seriously. Along with that, look up meds you prescribe. Read the inserts. Now with the medication software programs you are less likely to prescribe something dangerous, but just know my mother, my father, and I have been prescribed drugs that were downright dangerous! My mom and dad each were prescribed two drugs that should never be prescribed together. Black box warning dangerous. I was prescribed a wrong dosage that was very high and dangerous.

Depending on your specialty, don’t forget that your patients are sick. They are concerned about their health and their condition. A well visit is very different from a something is wrong visit.

Follow up to see if a new treatment is working out. I only know one doctor who does this. Sometimes through his nurse, sometimes himself. This is above expectations performance.

Most important, don’t stop thinking out of the box. Use your medical background and patient information to try reasonable treatments. I know the CYA aspect limits you. You have to do your best to stay within the standard of practice, bit there is some reasonable leeway. Stay curious, don’t fall into the doctor trap of memorizing and that’s it. Listen to your agents, look for patterns.

@Seaofclouds What are you going to specialize in?

Thanks for all the great answers everyone. I appreciate them. Sorry I didn’t get back sooner. I’ve been working the past few days and it’s hard to post a lot from my phone.

@jaytkay Hospice nurses are a special bread. I’ve been with a lot of patients in their final moments, but never in an exact hospice setting (though I have worked with hospice nurses preparing a patient for discharge). As morbid as this may sound, the dying process is it’s own thing of beauty. The hospice nurses I’ve worked with have an amazing ability to make sure their patients die with dignity and comfort.

@chyna From what I’ve been looking at for my upcoming studies, I’ll be doing a lot of listening. I have a class dedicated to the health assessment and taking a history and physical. It’s a lot of listening and a little bit of asking questions to get deeper answers.

@Mimishu1995 Thanks. The story gave me a laugh and I understood the point… no robots in the office with me.~

@snowberry I hope I get the opportunity to work with patients that want to be educated. I’ve met so many patients that are the exact opposite. Sometimes we (healthcare professionals) spend so much time trying to educate a patient, just for them to ignore what we say (and do the opposite). It can be very disheartening. I’ve watched so many patients make choices that we have explained over and over again were not good for them. It’s definitely a hard line. I even had one diabetic patient convince his mother to bring him candy bars (he was a very brittle diabetic). Those candy bars killed him. He ate all of them at once and went into a diabetic coma. He ended up dying a few hours later.

@flutherother That’s helpful. If I ended up working in an office, I’ll keep that in mind. It would probably be something the office staff does, but if there isn’t already something in place, I can definitely suggest something.

@janbb Unfortunately, I understand those examples all too well. I wish there was a way to get staff to understand that hallways aren’t as sound proof as they seem to think they are. I hate hearing staff say things like “he’s crazy”. I always make it a point to correct them and say “no, he has _____ or ______”.

@hearkat Thanks for the tips about the H&P. One of the first classes I’m taking this summer is about assessment skills and taking a history & physical. I am really excited about it. I’ve been reading every patients H&P at work and trying to pick up ideas from the doctors I work with.

@JLeslie Thanks. In regards to getting your lab results. Are you okay with your doctor mailing (snail mail) them to you once they are received and reviewed? That’s what my current doctor does. I’m sure this is different for everyone. So I’ll have to figure out a good time to ask patients what they prefer and try as best as I can to accommodate them. As for specializing, right now I am going to be studying to become an Adult Gerontology Acute Care Nurse Practitioner. Link from another school’s program that explains what it is a bit. Once I finish the program, I’m not sure where I’ll work yet, but I’ve already had 2 offers from doctor’s I currently work with.

@Seaofclouds Snail mail is not good enough for my thyroid. Not for anyone’s thyroid. I sometimes go for a blood test because I am becoming symptomatic, so it is not a regularly scheduled blood test. Thyroid medicine takes 6 weeks to plateau. I don’t run in for a blood test every time I feel a little off. I wait 2–3 weeks to make sure I am not confusing it with something else. So, by then I feel like shit for over two weeks. Often, a doctor does not call me back for a week. The test takes one day for the results. That really pisses me off. For the life of me I cannot understand why it takes them so long to do something with test results. I worked in a psych hospital in the outpatient chemical dependency wing and every day labs came back and they were reviewed that day and something was done that day. Snail mail might mean a week and then additional days until it finally is in my mailbox. So, ok, two weeks or more feeling like shit, another week until I get my result, and oh, all too often they call in my medicine change without talking to me and they screw that up. They almost never have my current dose recorded correctly. Waste of my time, their time, and the pharmacy. So now I am over a month with my hair falling out and my eyes sticking and sleep problems. Finally start my meds and at least three weeks until I start to feel more normal again. I should mention that each thyroid pt has a range that they feel best, which is narrower than the “normal” range on labwork. Some doctors see nornal and think normal, but with thyroid that is not really good enough.

For other blood tests snail mail can be ok. Especially if they are routine and the pt is not sick. Sick patients and well patients are very very different in my mind, but I think many doctors treat them all as patients. I have high cholesterol, but if I don’t get the results for two weeks I don’t care. I don’t feel like crap and at any time I can always eat better. My CBC I care, because if I am exhausted I need to know if I am anemic or is it my thyroid or what?

Why not release the results immediately?

My endo, she was an nurse practitioner actually, in TN had a website for her office and she could release the results there even though it is illegal in TN for patients to get labs directly from the lab. I could log into her website and see my labs, update my info, make an appointment, and send an email. It was great.

Also, noting in a chart or somewhere which patients seem to be able to manage their own care would be a good idea. Or, allowing a nurse to discuss labs even if the doctor has not seen them yet.

@JLeslie I only meant mail for normal results. I get all my results within a week from testing from my doctor via snail mail. Abnormal results are called as soon as they are reviewed by myddoctor, which is usually within 48 hours. I’ve never had a doctor just mail abnormals without talking first. Sorry for the confusion. I’m well aware of Thyroid issues, my son was born with congenital hypothyroidism. As for making a note for nurses to just give out the results without the doctor reviewing them, that’s against many states nurse practice acts, so it may not be legal for the nurses and could get them in trouble with the board of nursing in their state.

@Seaofclouds Not good enough for my thyroid issue, because my doctor and most doctors think TSH of 1.2 is just fine and I am totally screwed up less than 2. My heart rate is 80, my blood pressure is so low I feel spacy at times, my hair is falling out, I can’t sleep through the night. It took 4 years until my nurse practioner “remembered” my good range. She was great in helping me figure out where I felt good, great from the get go, but in terms of remembering when lab results came in, not so much. Now, I am again at the mercy of waiting for results because I moved. Thank God I am more stable now than years ago. She saved me from so much frustration by letting me test whenever I felt bad, and when I felt great. I couldnjust call anytime and make an appointment with the phlebotimist. That only went on for a year, we found the pattern. She was the only medical professional who believed me that I take my medicine perfectly, and I do, and she observed the pattern also, it is obvious it is not from taking the medicine poorly, the pattern is too perfect.

When I start feeling badly I can’t be sure which direction I am going hyper or hypo because both have hair loss, dry skin, dry eyes, feeling out of sorts. When it gets bad enough then the heart rate, blood pressure, and change in appetite gets exaggerated enough I don’t need the test. I prefer not to have to wait that long when I can get a blood test for $15—$50, and it is only necessary maybe once a year at this point if I want to test outside of my normal schedule.

I don’t want nurses to do anything illegal.

I had one doctor who tested me and I was leaving the country ten days later. After 5 days of hearing nothing I called for results when no one called me back after 2 more days I called back. The next day when no one called back I asked the receptionist if she would do me the favor of personaly telling the nurse I am going to be leaving the country I need my results, and I have called twice before. The receptionist said, “I have left those messages I did my job.” I told her I was not accusing her of not doing her job. She hung up on me as she said that she won’t be spoken to like that. I was not yelling at her, although there was probably some frustration in my voice, but not with her. At that point I am furious! I called the office manager, because the gatekeepers would never let me talk to a doctor, right? I told the office manage and she told me my doctor had been on vacation. Fuck them! There are 3 doctors in that office. They didn’t call me back to tell me my doctor was out, they didn’t do anything they just fell silent expecting me to be ok with zero response to my calls for my results. I have already been patient for over a week. I do my very best toshove them time, days, to respond. I am going to leave the country and nobody cares that I feel horrible. Nobody cares, nobody can put themselves in my place. Ten minutes after talking to the office manager I got my results. I didn’t scream at her, or threaten, or anything bitchy, she just had a brain in her head. However, when I saw the doctor at my next appointment, I told her the story and she said, “yeah you kind of have a reputation now.” Last time I went to see her.

Typo: I don’t know how apple decided toshove is a word? Should be to give.

Another example, I asked a doctor to test my iron, actually do a CBC, when I saw her. The test came back almost perfect, just minimally outside of normal. She saw no reason to call me. The nurse after I freaked out on her, and I did freak out on her admittedly, when she called back she tried to reassure me the numbers are ok even if they are not “nornal.” That isn’t the point. I take tons and tons of iron to stay normal. When I can reduce my iron intake I do and then sometimes I have to increase it again. If I was dropping down to low nornal levels, or even below nornal, I need to increase my iron intake again. My doctors don’t keep track of it closely enough, I guess they are incapable. I don’t mean that as a criticism. My only point is the doctor is not going to tell me to take more iron until the next test, which will likely be very low. That test sent to me in the mail would have been fine, but that doctor doesn’t call if they don’t see a problem, and they don’t mail results.

Oh, and some doctors will not leave a message with test results on vmail. That is just completely frustrating. They can leave a message without stating the pt’s name. I have played phone tag for hours with some nurses.

@JLeslie It sounds like you just have a lot of communication issues with your providers. I’ve never encountered any of the issues you’ve mentioned. I understand your concerns and what you are saying. I’ll keep it in mind when I become a provider.

@Seaofclouds I don’t think those providers think there is anything wrong with how they conduct business. It happens too often, and too many people complain about the same things. I do have a communication problem with some providers, some of it is my fault I am sure, because I expect them to be the same ol’ mess I constantly deal with. I’m sure some of it comes out in my attitude, but I really do my best to be fabulous my first visit. If they surprise me and seem concerned and wanting to work with me and interested in my story then I begin to trust them. My preference is trust. I am stuck paying really high first time visit fees to see if I am going to like the doctor. It’s so unfair. I have tried to call ahead to see if the doctor will give test results over the phone once a patient is established, and I have been told the wrong thing. I wish I could pay a small fee to meet a doctor, he doesn’t even examine me, just rapport curiosity to see if we can work well together.

I wish I could find a GP, NP, or internist who would coordinate my care, who knew me well and who could be a liaison for me with other doctor. I have not had that since adolescence. Although, I don’t really like going to GP’s and similar because contagious people go to those offices. There are concierge doctors, and I have seriously considered trying one. I don’t mind paying a higher fee if I actually get the service I am paying for.

I’m sure you will be wonderful at your job. It’s very exciting. I think being a Nurse Practioner is a great thing. I think you can help a lot of people. Just asking this question shows you care about the experience the patient has.