Everybody has a story. Everybody has a story to tell about doctors who don't listen, doctors who are insulting, doctors who are insensitive, even doctors who are dishonest. To mention that you're researching the topic is to be besieged with tales of medical aggravation, from the mild to the horrific. There's the family who claim that a doctor repeatedly revived their painfully dying father at great financial and emotional expense, despite their, and his, desire that he be allowed to depart quietly--apparently so that the doctor could give a paper on the case at the next meeting of his medical society. There's the young professional woman whose doctor refused to give her any literature on her ailment "because you're not a doctor, and you wouldn't understand it anyway." There's the dignified older woman who was left, unclothed, in a drafty examining room for 45 minutes waiting for the doctor, who finally graced her with five minutes of his time and departed before she could ask him any questions about the troubling aspects of menopause. There's the young mother who was sent home from the hospital, over her objections, less than 24 hours after giving birth--only to start hemorrhaging and have to return the next day. There's the foreign-born doctor, a man who barely spoke English, who giggled all through the delicate procedure of removing from the lung of a young boy a piece of plastic he'd accidentally inhaled.
The problem seems to have worsened in the last decade or so, even as medical technology has made it more possible than ever for doctors to help their patients. Indeed, some of the seeming insensitivity may be due to the fact that new tests, new machines, and new procedures tempt physicians to order up a battery of exams instead of simply talking to the patient to see where it hurts.
My informal survey showed specialists, particularly surgeons, to be the biggest offenders in the insensitivity sweepstakes--for which the surveyed had a variety of explanations, ranging from the surgeons' lack of time to establish a relationship with the patient to "Jerks just seem to gravitate naturally toward surgery." (Those surveyed were happy to supply details but not names for publication; those who were under medical care were afraid that care would be withheld from them if they discussed the shortcomings of even doctors who were not presently caring for them.)
Some cases of insensitivity are simply the result of professional arrogance--of the old, paternalistic "MD stands for Medical Deity" attitude. Some are the result of individuals having gone into the wrong field, for the wrong reasons. And others are the result of pressures from insurance companies, review boards, the government, and--yes--obnoxious patients.
The problem of medical jerkiness has been identified by the medical establishment, and steps are being taken to deal with it. How successful they can be remains to be seen.
"This whole issue really began a decade or more ago," says AMA spokesman Harry S. Jonas, MD. "The public began to be a little more aware of it, and there was a lot written at that time about doctors more interested in X rays and lab reports and CAT scans than patients, and spending more time on them than with their patients. It's like anything else--you're not going to have a perfect fit between the client and the provider. But there has been an effort to concentrate more on communication skills and compassion."
To Jonas, former dean of the medical school at the University of Missouri, this is a "multipronged issue" that starts with the selection process for medical school. "Medical students have traditionally been selected from a very top-notch academic group of people--many of whom aren't interested in patient care, but in things like biochemical research.
"Right now I'm part of a task force that's looking at the interview process and how we can improve on that selection process. We're looking at how to predict the bad apples. We pulled all the lists of individuals who'd had their licenses lifted in the U.S., and interestingly enough we found a high percentage had their licenses removed for alcohol or substance abuse. As we go back into past records, we find very few things that served as predictors" of who would be a poor physician. Jonas recalls that the man who graduated first in his own medical-school class developed alcohol problems, committed fraud, and killed two of his own children--hardly a foreseeable series of events. "Outrageous things--whether you're dealing with doctors, lawyers, or journalists--can happen anywhere. Trying to find predictors didn't work out."
However, he observes, the composition of medical-school classes has changed significantly in recent years; medicine is no longer the exclusive bailiwick of young white males who marched in lockstep through college premed courses and into medical school at age 22. "We're seeing a much different type of medical student today. They're older, there are many more women--almost 40 percent, especially in ob-gyn. Will more women mean more compassionate care? Will the older student, who maybe majored in sociology, mean more compassionate care? Some people might argue that compassion is something you can't teach--I think you can. But we don't know yet if the new emphasis will have an effect."
One of the ways they're trying to teach compassion in medical schools is through the use of "standardized patients," surrogates who take the place of real patients for medical students trying to learn how to interact. "The medical students are put in with these actors and actresses and expected to establish a rapport with them. Some [of the 'patients'] are very hostile, some are verbose--they go all across the spectrum. The standardized patient actually serves as an evaluator and grades the student." Probably 75 medical schools out of 126, he estimates, now use this approach; some videotape the encounters so the students can judge how well they're doing and see where to improve.
"We're attuned to the problem. I don't know if we have an easy answer--behavior is a soft science that isn't as easy to address as a retrovirus. But things have certainly changed a lot from the demigod position. In the old days the doctor said, 'You need to have this,' and nobody ever questioned it. Now the patient questions everything, knows the right questions to ask, and gets a second or third opinion. It's been a real evolution."
Everybody has a story. Julia Schopick's is rendered slightly ironic by her being the daughter of a doctor and a public-relations consultant who specializes in promoting medical practices. After a lifetime of mostly good encounters with physicians, she was not prepared for the experiences attending the discovery of her husband's brain tumor.
He was diagnosed with the tumor after he suffered a seizure in September 1990. "We came in to the emergency room at West Suburban Hospital [in Oak Park] in the middle of the night," recalls Schopick. "We were badly dressed, we were discombobulated, and I didn't know my insurance number. We were treated like beggars." Until much later, when an attending physician happened to recognize her husband.
At 3:30 AM, after waiting for four hours and being largely ignored by the ER staff, Schopick tried to find out whether her husband would be admitted or sent home. "I'd been waiting, and waiting, and waiting. It was very scary--I'd just seen a seizure, and my husband was just lying there. I finally approached the head ER physician and asked him what they'd found out. He looked at me angrily and said, 'The neurologist will tell you when he wants to!' I was shocked, and I told him I didn't appreciate his attitude. This time he literally spat out his reply: 'I will repeat myself. The neurologist will tell you if and when he wants to!' I got very upset, but you really are a prisoner in a situation like that, you know what I'm saying? What could I do, pick up my husband and go home?"
Waiting turned out to be a leitmotiv of Schopick's experience as the spouse of a severely ill patient. Doctors always seemed to run late; their staffs never called to warn the patient there would be a delay, even when it was of more than an hour. On one occasion her husband went to see a neuro-ophthalmologist at a major teaching hospital downtown. After waiting for several hours he simply got up and left. "Ten minutes after he got home--and that's a trip of about an hour on public transportation--the office staff finally missed him. They called and demanded, 'Where is he?'" recalls Schopick, who told them her husband had waited as long as he could stand to. "He shouldn't do that!" said the staffer. "You shouldn't keep people waiting so long," rejoined Schopick. To his credit, the doctor called and apologized, but when he suggested making another appointment, he was politely informed that they had found another specialist. It's a long drive to Sycamore, but the neuro-ophthalmologist there saw her husband promptly and his staff was polite.
The first experience with chemotherapy was hideous. Arriving on time at 9 AM, they waited for hours for treatment. Her husband was given his antinausea drug too soon, and it had worn off by the time he had his chemo. He threw up for hours. They finally made it home at 7 PM, six hours after they were told they'd be done. But when Schopick looked into home-health-care chemo and asked the oncologist about it, the response was a resounding "No, I can't allow it." "I was afraid to confront her, I admit," says Schopick. "But I asked her why. And she said, 'Because I'm a perfectionist.' After the way my husband suffered [in her office] that's a ridiculous statement." They found another oncologist.
The self-employed Schopick found that her own business suffered from days spent hanging around waiting rooms. She often rose before daylight to attend to the details of her work. When, suffering delays as usual, she asked doctors' staffs if she could use a telephone, she was invariably directed to a pay phone in the hall, "usually without even a shelf to put a writing pad on." Wanting to talk to one specialist and trying to juggle her work schedule with the doctor's, she explained her situation to his receptionist, saying, "I need to know about what time the doctor might call so I can touch bases with him. What can you advise?" The response: "I advise you to be there when the doctor calls."
Stung by these experiences, Schopick wrote a column for the American Medical News, touching on what she and her husband had endured and offering some advice for physicians. "Lesson #1: Listen to your patients. . . . Lesson #2: Respect the time of your patients and their families. . . . Lesson #3: Phone etiquette is important. . . . Lesson #4: Don't be condescending."
"The truly frightening thing about this is the response I got," she says. "I got a big response, but it did not come from doctors. It came from lay people who saw the article. A lot of people contacted me to tell me about their own experiences. This is a big problem. And it's like most of the doctors don't know or don't care."
Elliott Kroger, MD, is an internist who has taught a course in doctor sensitivity at Rush Medical College. He's the kind of sensitive doctor who listens to his patients, who takes into consideration their life-styles and needs, treating one sore throat aggressively and letting another one take its course, depending on the individual. He thinks the problem of medical insensitivity may be exaggerated--and he thinks there are reasons why doctors might seem insensitive, reasons that might not occur to the average layperson.
Told of Julia Schopick's ER odyssey, he responds, "That demonstrates the difficulty of penetrating the system, of getting through the maze of the emergency room--or, for that matter, of getting through any large bureaucracy. Normally people understand and can deal with that kind of situation. But when the health and well-being of a loved one are at stake, it's a lot different than when you're getting a passport, where you put up with it.
"That's one part of the problem. Another part is the brusque, rushed physician who for one reason or another is not attentive. There are some doctors who are always like that, and some who are sometimes like that."
Kroger agrees that there are doctors "who just never should have gone into medicine in the first place. But I think there are some physicians who are equally frustrated by a system that doesn't seem to work. There are other pressures--like the peer-review organization that, appropriately, examines what you do, but sometimes imposes limitations which are unfair. The PRO plays a large role in determining the standards of care and what is considered appropriate care. They sometimes overlook individual variability."
Physician-review organizations are federally mandated, federally funded local organizations run by doctors. There are 43 of them in the 50 states and territories, reviewing physicians' treatment of medicare patients, making sure they do things economically and "appropriately." The guidelines are set up by medical specialists and bureaucrats in concert; physicians judged to have acted improperly are contacted and set straight.
"The PRO in Illinois--as do all PROs--also oversees the validity of the length of stay in the hospital. They can come back and tell you that your patient has been in the hospital one or two days too long. Sometimes it can seem that the doctor is rushing the patient out of the hospital. The doctor wants to be the advocate of the patient, but he has to be the advocate of the PRO. The doctor is serving two masters. The patient may get a letter from the PRO saying 'Your doctor kept you in the hospital too long,' which doesn't do much for the patient-doctor relationship. Or the patient may feel that he or she has been rushed out of the hospital. Anger occurs, and it doesn't get directed at the PRO--it gets directed at the doctor."
In a perverse way, improving technology can also harm the doctor-patient relationship. "Technology has advanced tremendously, and the expectations of the public have been commensurately increased. But there are many instances where those expectations can't be met. People read about things like liver transplants, and then they're disappointed when their loved one can't be helped in the face of a seemingly bottomless pit of technology."
In teaching medical students how to interact with patients, Kroger says, he told them to make sure they introduced themselves, and taught them how to position themselves in the room and how to listen--make eye contact, instead of writing or just asking a series of questions. "It doesn't take much to convince the patient that you're a caring physician. It takes a few minutes of listening to pick up cues. Obviously, time is sometimes an issue. Most doctors I know put in long days--12- or 14-hour days are not unusual, six-day weeks are not unusual. Time is at a premium, but any problem deserves the time it takes."
Considering the popular perception of the brusque, uncaring doctor, Kroger asks, "Is it that he truly is brusque and uncaring, or is it that he's in such a unique position? Primary-care medicine is the interface for the entire medical community. It takes the brunt of the frustration. It takes the heat for many aspects of the system--insurance, the high cost of pharmaceuticals, the high cost of hospitalization. We're on the forefront of the battle lines.
"What's the worst thing about being sick? It's the loss of control, of being unable to manage your own well-being, or the risk of losing that control. It's a frightening, horrifying situation; the stress that a person encounters in that situation requires such an effort to mollify that some doctors aren't able to meet those needs. Physicians will do what they're most able to do. I think most doctors will approach their patients and their problems with a sense of priorities.
"Physicians feel a great deal of pressure--from patients, PROs, hospitals, medical liability. We have just as much trouble with medicare and Blue Cross as the public does. We have just as much trouble with third-party insurance and laboratories."
Kroger agrees that the public today is much more sophisticated about medical matters than it was in years gone by. "They're much more informed. They read, they watch TV, they listen to the radio. The media has done a tremendous job of bringing information to the public--although the media also sometimes distorts things. The paternalistic physician is no longer the norm; it's no longer expected. But while patients are better educated, they're not as well educated as they think they are. While they can discuss issues and options with their doctor, the doctor certainly is more knowledgeable and better able to present options.
"You read that everybody hates Congress, but loves their own congressman. I think the same is true with doctors. I can tell you that why a patient prefers a doctor has little to do with how one doctor might view another doctor."
For all the faults of some medicos, says Kroger, "I still think that most doctors are primarily concerned with alleviating pain and suffering. Anyone who goes into medicine just to make money is going to be disappointed--and I really don't think there are very many doctors like that."
Everybody has a story. Judi Strauss is 48, a professor of human-resource management at Illinois Benedictine College with her own financial-planning business. "I'm a relatively sophisticated consumer who looks for the best, for doctors who will listen to me. As I got older, I was especially concerned about finding someone who would listen to me as I approached menopause. The listening is important--I'm a kvetch. And six weeks after I remarried, I had to have an emergency hysterectomy when my IUD punctured my uterus and formed an abscess. It was very traumatic, so I have that experience to think about."
Strauss's internist recommended a colleague, a female ob-gyn. "I purposely chose a woman, but she paid attention to my head and not my feelings. I'd ask her questions about menopause, and she'd throw me articles to read. She sent me to a crummy mammogram place, and I never got the results."
The crowning blow came when Strauss went for a pap smear. "I was in [the examining room] for 12 minutes. I needed to talk to her--I had questions about estrogen-replacement therapy and menopause. And she almost threw me out. The bill was $105, and as I was walking out she came through and said, 'You won't hear [about the pap-smear result] if it's normal.'"
Furious, Strauss called other obs in the same area to check their rates; the average was $85. She registered her discontent with the Chicago Medical Society's fee-complaint section. "I teach customer service, and I deliver customer service in my business. If you want H & R Block's style, it's cheaper. If you want time, it costs money. I understand that. But you shouldn't have to pay for time you're not getting.
"There should be some sort of social or personal consciousness in any field. But in the field of medicine, it really should be the first requirement."
Paulette Trumm, MD, started out in ob-gyn, switching to psychiatry when back surgery made it impossible for her to take all the standing and leaning of deliveries. An intern when she had her operation, she recalls, "It was my perception that prior to the laminectomy the neurosurgeon had an excellent bedside manner. But after the surgery he lost interest. Only residents took care of me--and I had more experience than they did."
Before her surgery, she says, "I observed my fellow ob-gyns wouldn't talk to women--only to husbands. What I find so disturbing is that so many doctors don't seem to have time to talk to nondoctors at all."
Trumm, who was a teacher before she went to medical school, thinks there's still quite a bit of sexism in the medical world. "Some male physicians wouldn't talk to me in medical school. I was appalled that several of my medical-school classmates came right out and said that women didn't belong in medicine--in 1980. We're all socialized to somehow value women's opinions less. Women are valued less generally; we're not taught to be assertive or to take care of ourselves. We need to be assertive and to ask questions. When you have a physician who can't give you the time of day, you need a new physician.
"In psychiatry the thing most on the forefront is listening skills, but I actually believe that listening is the most important skill for any physician. If you haven't made the right diagnosis, you can't give the right treatment. If you don't listen and get information from your patients, you're more likely to make an incorrect diagnosis."
Part of the problem, Trumm believes, is "a wide variability in how [listening] skills are taught. It's an age-old debate: medical schools tend to select very scientifically minded people. Those with a social-sciences or humanities background are at a distinct disadvantage in selection and course work." Still, she thinks that today's students are more likely to be listeners than students were a decade ago.
In practical terms, she points out, doctors are often expected to accomplish "24 hours of work in 12 hours. So they're going to be rushed. If you're overworked, it's very difficult to sit down and listen. If you're overscheduled, the doctor can't sit down and listen." And for some doctors, Trumm notes, taking more time with patients equals making less money, and that's not acceptable to them.
"I believe surgeons are generally the worst offenders. People who go into surgery are usually more interested in technical details. Surgeons are often not people oriented. And surgeons are often very antiwomen. The best are family doctors, internists, and pediatricians--pediatricians are the most patient. I think people do self-select for specialties. If you have a great deal of trouble dealing with sick people, you might want to become a radiologist or a pathologist, where you're generally not interfacing with the public.
"I want a physician who will talk to me. I want him to educate me. On the other hand, I think I'd prefer the surgeon with the best track record--he could probably be a real asshole personally, as long as his patients got well."
Are doctors ever justified in withholding vital information, such as knowledge of a fatal disease? "That's rarely indicated. I don't think you should ever dash all hope, but people should know what the situation is." Trumm cites the case of her brother-in-law, who had a malignant melanoma and whose physician instructed his wife not to tell him. "She lied to him for eight months. She finally told him the truth--and that let him say good-bye.
"It's much more fun to be the doctor than the patient. All of a sudden when you're sick you're very dependent on someone else to give everything--food, Tylenol, water, permission to get out of bed or go to the bathroom. I do believe patients get better faster when they're a part of the decision-making process."
Everybody has a story. Erin Rose Prunty is a businesswoman, the owner of a cleaning service and a partner in a store in Oak Park. Nine years ago, when she was in college, her mother died of cancer. "She had very little money and was trying to save what she had. So she negotiated with her doctor to have her insurance payment accepted as complete payment, instead of just 80 percent of it. My mother was overjoyed." The doctor treated her for three years, says Prunty, accepting the insurance payment as payment in full. "And when she died, he back-billed me for $14,000."
Prunty, grieving, assumed the bill was a mistake and ignored it. A second bill threatened legal action if the money wasn't paid immediately. "There wasn't $14,000 in her estate to give to anyone," says Prunty. Prunty wrote back, telling the doctor that she was a law student, that she had been in the room listening to the conversation when he agreed to accept the insurance payment as in full, and that she was prepared to take him to court. He dropped the matter. Prunty, who says she knows of other patients of this physician who got the same treatment, says that once when her dying mother asked for pain medication he screamed "It's not an emergency!" She also says she was there when he told her mother's roommate, who was recovering from a mastectomy, "You'll be lucky if your husband takes you back after losing one of those."
(The doctor, truculent in an interview, says the billing "was a choice the hospital made. . . . I don't remember discussing it with her." Of the other charges, he says flatly "That's a lie. I never said that to any patient in my life.")
Prunty is more assertive than the average patient, and she takes a very hard line on waiting. "If the doctor makes you wait, you deserve an explanation. I run two businesses, I do volunteer work, I'm overextended--then to sit and wait somewhere without anyone telling you why is too much. I tell my doctors, 'My time is as valuable as yours. I want a call if you're going to be more than 15 minutes late.'
"I have a friend from the Middle East with a bad back problem. He goes to a doctor three times a week for it, and he can't get anyone to explain the problem in a way that he can understand, or even to write it down so someone else can read it to him. I told him, 'You're a consumer. They want your dollars; they owe you explanations.' I'm in a service business, and I make sure my customers are happy. If I acted like some of these doctors, I wouldn't get away with it. I wouldn't be in business.
"There are very few people who go to the doctor because they feel well, and if [physicians] could just take that into consideration when they're thinking about their doctor-patient relationships, we'd all be a lot better off."
Pediatrician Jim Pollack was a construction worker before he got his MD, and that may have made him more down-to-earth than some of his colleagues. "My dad raised me to believe that the garbageman was the equal of the physician. Generally when you get insensitive, holier-than-thou types, it's something that people bring with them to medicine. Just like any other profession, you get people who go into it for different reasons. I think one dangerous reason to go into this one is because of ego. There are a lot of doctors who derive a great deal of their ego reinforcement from being physicians. I think they look at it as, 'I'm a physician, I'm better than you are.' I'm not sure the profession necessarily changes people or gives them that attitude, but I think the times, the way everything is changing in medicine, and the way the public looks at medicine are going to change some attitudes--probably for the worse."
Pollack thinks most of the problems are with specialists rather than primary-care physicians. Not because the specialists are more insensitive, but because they don't have the relationship. I do think the type of person who would go into primary care is more congenial. And I have stopped referring to certain people because they're jerks."
Society's view of medicine and its providers has changed drastically, he suggests. "One of the things you look forward to when you're in medical school is being your own person--having control over the situation, how many patients you want to see, how hard you want to work. But that's all starting to change because of economics. People are now looking at medical care as a right, not a service. If your car breaks down, you have to pay to fix it. There's no free care. But people are starting to look at medical care as a right. As soon as that happens, you're taking away from the physician his ability to feel that he's going to be able to do what he wants to do."
Pollack, whose office is in Downer's Grove, says that he and many other doctors see national health care as a decided threat for that reason. "When you're threatened, you're apt to become more insensitive. 'You want me to practice medicine your way?--then I'm going to look at this as a nine-to-five job.' And I think anybody in the same position would feel the same way.
"A lot of people think they'd like national health care, but it's really the exact opposite of what they want. One of the big things that's driving the cost [of care up] is that people demand state-of-the-art medicine. We've got an aging population, we've got a lot of expensive diseases, like AIDS. There's not a kid that comes into my office with a history of headaches who doesn't have a CAT scan at a cost of hundreds of dollars. If I don't do it and I miss a tumor, I'm gonna get sued--and I think about that every day. With national health care that won't happen. If you're a government worker you can't be sued, and there will be big pressures to save money. One of the ways you save money is to postpone treatment. In England you can wait six months to a year for a hernia operation. You'll see that here--and you'll see a big increase in churlishness [among doctors]."
While Pollack says that certain specialties are overpaid, he points out that pediatricians are relatively underpaid. "We get paid by the head, basically. If we see 30 children, we get paid for 30; if we see 50, we get paid for 50. There are no big-ticket items. I gross $900 for six or seven hours, seeing 30 people. In a surgical subspecialty, you can take out something and make twice that much in an hour.
"How would the CEO of General Motors react to someone saying, 'We're going to set your fees and cut your salary in half?' That's what they want to do to doctors."
Pollack, a friendly man who gets lots of points for caring from his clients, also reports problems with patients that can wear a doctor down. "I try to be the nicest person in the world, but after I've been on call for 48 hours, dealing with fever and diarrhea, I may lose it when I get a call at 1 AM for a diaper rash. A lot of people have a White Hen philosophy about medicine: you're supposed to be open 24 hours a day. People's schedules are different now. I get calls all the time at 11 at night, from people who say, 'I just got home from work.' People abuse doctors. A lot of people think physicians are supposed to be nice all the time. And as hard as we try, it's just not going to happen."
Everybody has a story. When I became pregnant, I chose my ob with great care, getting referrals, interviewing him over the telephone. But I never met his associate until I was several months along. The associate--call him Dr. God--was a younger man, of the sensitivity-training generation. I explained to him that I wanted as natural a childbirth as possible, with as little intervention as I could get away with; but that if I did have to have a cesarean section, I wanted the "bikini cut" rather than the once-standard vertical cut.
"Why?" asked Dr. God.
"Because I've heard it heals much faster," I responded.
"Who told you that?" he asked.
"Other women who have had both kinds of C-sections."
"Women!" he exploded. "Women think they know everything about having babies, but they don't know anything! I'm sick of hearing what women think! Don't tell me what women think!"
Shaken, I left and called my internist, who in turn called my ob. He called me back and declared himself puzzled by the whole thing, but said he would speak to his associate. I didn't have to deal with Dr. God again--fortunately, my baby didn't decide to arrive on his shift--until the morning we were to leave the hospital, when he kept us hanging for 40 minutes while he saw every other patient on the ward and then had a cup of coffee. "We've told him three times that you're waiting to go home," said one frustrated nurse, "and he just says, 'I know.'"
I wasn't particularly surprised.
Karen Lindemann, RN, has been a nurse for 24 years, working in oncology for 12 of them. She is now a home-health-care nurse, and she agrees that doctors are often insensitive to the needs of patients. "A lot of times they walk into the room, say 'You've got cancer--we're going to give you chemotherapy and radiation treatment,' and walk out of the room. There's no time for the patient to ask questions. Or they go on and on about the treatment, and never give the patient time to let it sink in. The patient only hears 'You have cancer.'
"Training to listen is not part of medical school. Many times doctors have to give bad news, and they really haven't learned how to give bad news without feeling bad themselves. It's a defense mechanism. But most of the time the nurse is the person who has to sit and explain--explain about chemotherapy, explain about monitoring blood counts."
Some doctors, she says, are sensitive to the patient's need to go home; others don't believe that minor medical procedures can be properly performed outside of a hospital setting. Many doctors don't seem to be able to listen to their patients, she says, or to explain things in terms they can understand. And sometimes "patients feel that doctors pass them from one doctor to another--they call in umpteen million specialists and don't explain why. The patient has five doctors seeing them, and everyone's telling them different things. The patient gets confused and depressed. I probably spend 70 percent of my time explaining things to patients--in home care I'm teaching patients how to manage their problems--and 30 percent explaining things to doctors. Communications is definitely at least half of the nurse's job.
"I definitely think there should be a course in medical school where they should be evaluated on their ability to explain. Let them have a barium enema--and see how many they order without explaining them. Let them have a variety of painful processes so they don't say, 'This won't hurt much.'"
What makes a good doctor? "First, listening skills, communication skills. And then knowledge, because that knowledge doesn't do any good if you can't communicate it." She cites the case of a doctor walking in on a patient and saying, "You need surgery, and you're having it tomorrow." The patient became hysterical and refused. "The doctor didn't take the time to find out why the patient said no. He just wrote on the records, 'Patient refuses to have surgery; no need to follow up'--and washed his hands of it. That doctor didn't do his job."
Lindemann doesn't hold out much hope for the future. "The sad thing is, I don't think things are getting better. I think they're getting worse."
J. Gregory Carroll, who has a PhD in behavioral sciences, heads up the health communications and training area for the Miles laboratory in Connecticut, which five years ago began offering workshops on physician-patient communications for doctors now in practice. Its most promising program seems to be a half-day workshop that presents doctors with information on, according to the workshop brochure, "procedures for inquiry, instruction, and empathy." Also offered are communications methods that work, demonstrated through videotapes and mini-group exercises, as well as a chance for doctors to discuss some of their toughest cases with their peers. Workshop participants receive reduced malpractice-insurance premiums and four hours of credit toward their continuing-medical-education requirement.
"Doctors with the ability to get good diagnostic information get good diagnoses," says Carroll. "Secondly, there's a correlation between the quality of the communication and the patient's satisfaction with the medical visit. There's also a link between good communication and physician satisfaction."
The Miles laboratory has an ulterior motive for offering the workshops: patients who aren't getting the information they need from their doctors may not take their medicine or even get their prescriptions filled. "We've got a good research base to show that patient compliance to a regimen depends in large part on patient-physician communication," says Carroll. "We've found there to be almost no correlation between the severity of the disease and whether they follow [doctor's orders]--it all depends on the patient's own beliefs about his condition. Improving adherence [to a regimen] is a big part of what we're trying to do." There's a good reason for malpractice-insurance companies to offer discounts on insurance to participants: "There's a strong link--not overlooked by the insurance companies--between the quality of communication overall and the likelihood of a malpractice claim."
Good communication, he says, emphasizes four basic factors: "Engage--use techniques or procedures that help engage the patient in dialogue, and also in a professional relationship with the physician. The physician should ask the patient to tell a story about what's going on and allow the patient to express multiple complaints. Empathy--with problems or perceptions, the importance of feeling seen, heard, and accepted. Education--patient education [about the disease or condition, and what should be done about it]. And finally enlistment--the process of enlisting the patient in his or her own care.
"For example, simplifying instructions for the patient is very important. Writing things down is important, indicating a rough timetable of what will happen when. That's a strong motivator to continue the course of therapy, particularly if it's likely to be lengthy."
The physician should explain possible side effects, says Carroll, so that disturbing conditions like queasiness or dizziness don't take the patient by surprise. What about suggestibility? Will patients turn up with side effects if they're told about them? "We don't worry about suggestibility," says Carroll. "It's a real phenomenon, like the placebo effect, and if you tell patients everything you will statistically see more side effects. But even though that is true, it is still important to identify all possible side effects."
Carroll says Miles has had a good reaction to its workshops, first offered in 1989; 4,200 physicians--of all age groups, specialties, and types of practice--have now gone through the program. "It's gratifying to see the scope of the response," he says. "It's pretty clear that we're meeting a real need."
Everybody has a story. Bridget O'Malley (not her real name) is in chemotherapy for cancer. She also runs a business that puts her in contact with a number of doctors--the reason for her anonymity.
"Physicians sorely need to learn two things," she says. "How to treat their patients, and how to treat their staffs. It's very rare that I find a physician who knows how to treat his staff like human beings, instead of interchangeable things that can be replaced."
In December O'Malley found herself suffering from severe back pain and went to see an osteopath. He did blood tests, which were ominous; an ultrasound revealed tumors in her liver. "I decided I should be in a teaching hospital, so I got a referral to an oncologist at Northwestern. He was abusive, abrasive, arrogant--he never gave me a diagnosis I could accept. I wanted to know if it made sense to have chemotherapy, or if I should just go home, get my affairs in order, and get ready to die. He just wouldn't play straight with me: all he would tell me was 'You have small-cell cancer.' Well, I don't know small-cell cancer from big-cell cancer or middle-sized-cell cancer. He wouldn't give me any answers about my chances. And meanwhile I was getting sicker and sicker, in more and more pain."
O'Malley began chemotherapy ("Very expensive, very effective"), and saw the doctor exactly once during her week in the hospital. "No one ever gave me explanations of what I was taking, why I was taking it, what it would do. It cost me $936 a day for a room that was filthy, with no working shower. I was left in my own excreta for hours--I was even taken to tests in that condition! I was on morphine, but even with morphine you remember that. It was like I was put there to die."
To her doctor's apparent surprise, O'Malley lived. She worked to get out of the hospital as quickly as she could, then found a new doctor and a new hospital.
"My new doctor sat with me for an hour, explaining things, answering my questions. He told me I was treatable. It's like you're on his team, and he's glad to do all he can for you. He makes you a part of the decision-making process. For instance, one of the side effects I'm suffering from is a loss of hearing. He says, 'They're your ears--what do you want to do?' I appreciate being treated as an intelligent person and having a say in what is going to happen to me. It makes the whole process easier to take.
"I know now why people sue their doctors. It's not just because the doctor makes a mistake. It's because they've been insulted."
Kathy Greco is a professional patient. She works at the University of Illinois, testing doctor wannabes on their communication skills. Her program, she says, is "aimed at addressing the most common patient complaints: language barriers, insensitivity, talking down to patients--if they talk to them at all! It all boils down to respect, and the patient's right to be treated like a human being."
Greco's boss, Anita Ward, the Clinical Performance Center's coordinator, has a background in theater. She started out as a patient herself. "Healthy people are taught the usual chief complaints of illnesses. Sometimes it gets very realistic in the exam," says Ward. "One time I played an abuse case. One of the students became so wrapped up in it that he even came back in with telephone numbers for me to call for assistance and offered to speak to my husband. And a couple of others had a real 'big deal' attitude. Sometimes you just cringe." Remediation is available for insensitive dolts.
In her "focused" examination, which comes early in the medical students' training, Greco rates each person on eight points. "First, the doctor should greet the patient warmly, using the name the patient prefers--a first name or Mr. or Mrs. 'Hi, I'm Dr. So-and-so. What would you like me to call you?' And shake hands. Second, the doctor should be talking to the patient on the same level, not talking down or treating him like a child. Third, the doctor should be listening carefully to the patient's complaint--after all, it's the reason he's there--without interruption. So many patients say, 'He's not listening!' Fourth, he should be using layman's language in his questioning and explanations, not using a lot of medical mumbo jumbo or jargon that is not understandable to that individual. Fifth--and this sounds redundant, but it really isn't--is treating you like a person and not just a medical case, showing respect. Sixth is encouraging questions and answering those questions without evasion, enlisting the patient's help in outlining the follow-up process. They shouldn't just impose procedures: 'You're going to have a chest X ray and an EKG.' Instead, it should be, 'I think you need a chest X ray and an EKG--is that OK with you?' The last point is: Would you choose this person to be your doctor?"
Ratings are on a scale of one to five, with one the highest. The exam is also videotaped, so the student can evaluate her or his own performance and see where things need to be corrected.
Greco's been doing this for two years and says she has seen an improvement in the students' attitudes. She says some of the biggest problems are with foreign students, whose command of English may be tentative and whose treatment of women may be execrable. "In a lot of these cultures women are not valued, and their attitudes toward us may be very, very bad. But if they're going to practice medicine in the United States, they're going to have to shed that.
"We don't see ourselves as others see us. We think we're being nice--then we see the videotape, and it can be a rude awakening. Sometimes doctors have an exalted attitude--they think they're just a little lower than the angels, and you're down on the ground, groveling and petitioning. I've had [to evaluate] doctors where I thought, 'Well, boy, it will be a cold day in hell before I come to you again!'"
Greco says the worst commonplace situation is the result of doctors not considering what nakedness can mean. "They leave you lying on the table exposed, with a TV camera on you. They're so eager to get to your complaint that they forget you're undressed. They don't remember that older women especially are not used to exposing themselves unnecessarily. For me, the worst thing is when they're not careful about draping me. Sometimes, they wink at me, like 'We're just playacting.' But we're not playacting. It's like doing a simulator in drivers' ed.
"Every so often you get someone who just doesn't care, who thinks they don't have to be courteous to patients. They may not get flunked out for it, but I think they're kidding themselves."
Greco, who says she always tries to find things to praise, also has the delicate task of telling students they need deodorant. "I have a very acute sense of smell, and I have a hard time when a doctor has bad breath. Doctors don't like to get close to people who stink--well, they shouldn't stink either. Foreign standards are different, and foreign students sometimes look immaculate and smell terrible, or have terrible halitosis."
Everybody has a story. In 1986, Pat Orzechowski had an accident on her back porch. It seemed like a small enough thing--a deck chair collapsed under her--but her back hurt. She called her doctor, who diagnosed a fractured coccyx, though he never took X rays. The doctor told her the coccyx needed to be removed.
"I trusted this guy," says Orzechowski. "He'd operated on me once before, when he removed a tumor from my back. Well, I'd been admitted to the hospital for my surgery, when the anesthesiologist came in, and he took a look at my back. 'Who butchered you?' he asked. I told him about the tumor, and that it had been as big as your thumb. "If it was that small, why did he cut you all the way across your back?' he asked.
"The next thing I knew, the hospital administrator came in--at night--and asked me questions. It turned out that the procedure--removing the coccyx--was no longer approved. The next day an orthopedic surgeon looked at my back. It turned out that I did have a fractured coccyx, but it had healed. The cause of my pain was a herniated disc.
"My doctor actually asked me, did I want to transfer to another hospital where they'd still let him remove my coccyx? I told him no."
A chiropractor who knew the doctor told Orzechowski, "Oh, yeah, he probably had to make a car payment." Orzechowski claims, "He was scheduling people for surgeries they didn't need. He was operating just to make money."
Was her earlier tumor surgery necessary? "That's something I'll never know. I still have the herniated disc, I'm still not healed, I still go to therapy twice a week. The doctor I have now says if we'd known in time, we could have treated it and maybe corrected it. But where the tumor was taken out is where the disc herniated. There's too much scar tissue to operate. I should have sued the asshole. I don't know why I didn't.
"Now I get three opinions before I do anything. I spend at least four months of the year in bed. I'm considered disabled because of this problem. I'm not dependable, because I don't know from day to day if I'll be there. It's pretty much wrecked my life."
Leonard Cerullo, MD, is a neurosurgeon with strong feelings about his profession. He's friendly, open, and, according to all reports, the kind of doctor who makes his patients feel cared about. How do the nice doctors like him stay that way? "The nice ones were born that way," he replies. "Why people who are not nice are in medicine is the question--why they're allowed to go into it, why they're encouraged by their teachers.
"Once you're admitted to medical school, it's almost impossible--regardless of personality, personal habits, or almost any other fault--to fail out. A major commitment has been made, in terms of investment, in terms of class size. And once the student or the faculty discover the fact that he is unfit, it's too late. So they continue on, and they look for other things than the altruistic things that we would hope for. They replace those altruistic things with egotistical things--power, money, medical politics. But they have to make a living, so they continue to see patients."
There are also those who go in with the best of motives and then lose their faith, as it were. "People who are true humanists and true scientists, and then later lose track of what it's about. What could cause such an effect? Overwork and underpay can do it. We're not used to thinking of doctors as underpaid, but in poor areas it's possible to take care of a whole lot of patients and find out that medicare is paying 50 cents on the dollar, public aid is paying 10 cents on the dollar--and the patient doesn't care. The patient wants 100 cents on the dollar. They don't care if they call at inappropriate times or with inappropriate concerns. They want the doctor's full attention all the time.
"There's a group of people who have been burned, or at least threatened, by the personal-injury atmosphere. It's disastrous. Many physicians have been reexamining their own lives under this constant threat: "What am I doing, risking my livelihood like this?' If someone who calls me at three in the morning, waking me up from a sound sleep, asks me a question, and I give the wrong answer--I'm risking everything. Twelve people sitting on a jury who don't know anything about the situation may ruin me."
But most burn-outs, says Cerullo, keep on working as doctors. "They can't do anything else, so they continue to practice--but with incredible insensitivity, arrogance, even incompetence."
Advancing technology is working against the physician's art in some ways, he observes. "The most basic rule is 'Listen to the patient'--let him tell you what's wrong with him. But we're in such a technologically advanced age--and the insurance companies give you one day to find the answer instead of the two weeks you used to have. So you give up on some of the touchy-feely aspects of medicine and go immediately to the MR scan. It's beyond the doctor's control."
Patients have to do the spadework if they want to find a compassionate doctor, says Cerullo. "We investigate the next restaurant we're going to eat at more carefully than we do the next doctor we're going to see. We take it for granted that we're healthy--until we get ill and have to scramble for a doctor. It's a downward spiral."
But most people are probably not planning on needing a neurosurgeon. "No, of course not. But we should spend more time establishing a relationship with our family doctor, seeing the family doctor as a mentor who would refer us to specialists who share his point of view, his chemistry. Ideally, he would have a list of specialists, tried and true, of the same ilk and caliber as he was, and of similar chemistry--doctors we could call on with confidence."
Unfortunately, the insurance companies, even more than human inertia, keep that ideal from becoming reality. "We--all of us--are in a situation where we don't have freedom of choice. Even the primary doctor doesn't have freedom of referral. The insurance companies decide which doctors we can go to, which doctors we can refer to. I don't know the answers. I know the problems pretty well."
How does Cerullo cope with the pressures? "I guess I have the type of personality that allows me to deal with my patients and still offer the humanism that I would want from a physician. I have to love my patients. I have to recognize that people seeing a neurosurgeon already have two strikes against them. No one sees a neurosurgeon for fun. It's always an event, and usually a devastating one."
If a patient falls apart in his office, Cerullo says, he tries to find out why. "I mobilize my resources. I've created a system that has tremendous resources--nurses, social workers, religious, partners--who can deflect some of the responsibility, some of the onus from myself. I let my patients know they're not just dealing with a person, but with a group of people."
Why does it seem that doctors are reluctant to criticize their colleagues? "Doctors are very reluctant to criticize other doctors for a number of reasons. Number one--which I hope is the best reason--is that it's not a good idea to cast aspersions before you have the full story. Two, we're too often tempted to look at the treatment that went before and say 'That was wrong, that was stupid' when we've got the benefit of what the other doctor discovered. One of my partners says, 'The last doctor is always right,' because we've got the benefit of that substrate of experiences. It's a 20-20 retrospectroscope."
There are also negative reasons doctors don't like to dump on their colleagues. "They're afraid. They're afraid to be sued. They're afraid to be involved in a lawsuit. Finally, there's an unseen network, a pressure not to be critical of the other guy, because then he's not going to send you another patient. That's the worst reason I can think of. If that doctor's bad, I don't want him to send me patients. I don't want him to have patients.
"A doctor is like a player in the Chicago Symphony. I'm sure those musicians have bad days--a violinist has a fight with his wife, and he has to come downtown and make great music. But their bad days are still good enough that most people won't know it. A doctor's bad days have to be better than most people's good days too.
"Sometimes patients can be impatient. Sometimes they can be so demanding that they overwhelm the doctor, so that good intentions can be lost in mollifying, ass covering, rationalizing, explaining. The good doctor has to rise above that. Everything has to be balanced."
"Jean Baker" is a medical technologist; she went to school for five years to be able to do complicated lab tests. Her biggest complaint is physicians who don't allow sufficient time for lab work and scream for results before the tests can be completed.
"There are basically three types of physicians," she says. "There are some docs we never see and never hear from. They breeze by us in the hall; they have no interest in who we are or what we're doing. There are some who are so nice that we'll just kill ourselves for them. They act like they remember you and smile at you in the hall; you're a fellow hospital employee, and they know who you are. Then there are those who call and harass us about everything, who are very obnoxious. And they know who you are too. They scream at the nurses, they're horrible to their patients, and they're short and sharp with us."
Baker says the worst offenders seem to be specialists in any given field who also do surgery. "The obs who do surgery are often horrible people. Urologists who do surgery can be horrible. The worst physician in this hospital is a urologist who does a lot of prostate surgery. I've found most of the ones who do straight surgery are OK. One surgeon called me at 3 AM when he needed to look at some patient results. He said, 'You walk me through this now, and I'll never call you again.' And he never did."
"The biggest thing I've gotten out of working in the laboratory is that it enables me to choose doctors based on real knowledge of what they're like. I won't go to doctors who can't control themselves when they're talking on the phone. Whether or not you can control yourself does impact on how you care for that patient. I want a doctor who can be succinct and clear, who doesn't scream at the staff, because I'm afraid if they lose control they won't be thinking clearly--and that's when you make mistakes. I pick and I choose. I know who's good."
Everybody has a story. Debra Jensen worries about her cholesterol. It's high, a condition that runs in her family, and she tries to regulate it with diet. During a checkup before Jensen went on a trip to Europe, her HMO doctor promised to give her a call if her levels were up. "A year later I went in to see her again, and she said, 'Oh, by the way, last time your cholesterol was 280'--which is pretty high. I told the doctor I had expressly asked her to call if it was above normal, and she said, 'Oh, it doesn't really matter. Diet doesn't matter. It's all heredity, and you can't influence it one way or another.'
"I told her I wanted to know anyway--I certainly wouldn't have eaten all that wonderful rich food on the trip if I'd known what my levels were--and that she had promised to call me. She went into a tirade, all about how she put herself through medical school, and now she couldn't afford a condo in Lake Point Towers, and the system sucked. She obviously had joined the medical profession to make a lot of money, and when it didn't work out that way she was miserable. I think a lot of doctors just went to medical school to get rich.
"Needless to say, I never went back to her. I wrote a letter to PruCare and complained about her, but I never got a response. I hope the people who read this article will start to demand more from the medical profession--and I hope the members of the medical profession who read it will think about changing their ways to be more sensitive to the people they treat. If you went into medicine to make a million dollars in the first year, you're doing it for the wrong reason."
"Marie van Bett" is not in medicine to make money, and she has some theories about why there are jerks in her profession. "Most doctors aren't jerks of course, but as in most fields, the jerks get attention, and people tell stories about them. They ask you why you're in medical school when you start out, and everyone says, 'I want to serve people, I want to serve people.' And I think most people mean it when they start. But things happen in training that bring out the negative things in personalities. People are abused in residencies and medical school, and, like child abuse, this form of abuse perpetuates itself. I've seen people go from being wide- and starry-eyed--'I want to serve people'--and get abused for it. And then turn around and do the same thing to others. Often the doctors who have been most abused become the most abusive."
As a resident in pediatrics, van Bett is about halfway up the teaching-hospital food chain that runs from medical students ("scut puppies") at the bottom, through interns, residents, senior residents, and attending physicians at the top, and she works long, hard hours for very little pay. "The people who are paid the most and have the most prestige do the least work," she observes. "An intern typically works 80 to 100 hours a week, and makes about $22,000 a year. Can you tell me why it's necessary to work a 36-hour day? I've seen [young doctors] suffering from such a level of fatigue that it's amazing there is good medical care given."
Van Bett describes a typical 36-hour shift: She arrives at the pediatrics ward by 6 or 6:30 AM and sees her patients before her morning rounds. There are a lot of rounds, with different physicians. She does her ward work--examining patients, writing notes ("we do tons of documentation")--goes to lectures, and admits patients, a process that usually takes an hour and involves a physical examination, getting a medical history, and writing up orders. She's constantly interrupted in the course of the day by patient needs. When she's on call, she stays overnight, doing admissions, putting in IVs, drawing blood, "keeping people alive overnight." She then repeats the previous day's activities. "If it's a good program, people try to get you out early. If it's a bad program, you stay until everyone else goes home. In all that time I may not get to lie down, I may not get to eat, I may not get to pee. Many times I've wished I had an IV in my arm and a Foley [catheter] in my leg to get me through. And there's always a tremendous pressure to get things done in the shortest amount of time possible." The 36-hour shift usually ends at 5 or 6 PM, though when things are especially busy it can go as late as 11. And the doctor is expected to be back at work first thing the next morning. In most programs, she says, there's one 36-hour shift every four days--sometimes more, sometimes less.
Van Bett characterizes the medical training system as virtual slavery: "I've never heard of any other profession where people are legally allowed to work other people like that. And I'm surprised at how few mistakes are made. We get through because all our attention is on the patients. We have accidents on the way home--falling asleep at the wheel, falling asleep at a red light. We make jokes about it, but it happens all the time. People make mistakes with drugs--little things, a matter of a decimal point, that can make a big difference. Errors would happen anyway, because that's human, but there's little room for error in our profession. It's a potential time bomb.
"All of this fosters a lot of resentment. Angry people who have terrible fatigue are not going to be wearing happy faces at 2 AM when they're called to see sweet Mrs. Jones who has a bellyache."
There's another pressure, the reason for her anonymity. "If I shoot my big mouth off honestly, my career could be in jeopardy--because they want people who conform, conform, conform. And we have to conform with some very sexist attitudes. Women residents have to be very careful of how they dress. When I was interviewing [for her resident position], I was told, 'Oh, you can't possibly compete. You have a child.' Another asked me about my day-care arrangements--and they would never ask a man that. Women have to work a lot harder and be a lot better [than male students] to make it in medicine. The presence of more women really should improve the field of medicine; it's been proven in several studies that women are better listeners than men. On the other hand, when you get a jerky female, you get a real jerk."
Some of the arrogance, she says, may stem from the fact that medical students tend to be life's winners. "A lot of the people who become doctors have never failed in their lives. They've been the pampered sons and daughters, they've always been the best in their class--and they get to medical school and find everybody's the best in their class. The first time a lot of us ever fail an exam is in medical school, and we can't even deal with the concept. It's emotionally horrible."
Van Bett, who had another career before entering medical school, thinks the trend toward older students like her is a good one. "After all, how does a 25-year-old man understand some of the life-and-death situations people go through? Most of them haven't lost anyone, and until you've had a tragedy in your own life you can't possibly understand what it's like. One of the reasons some doctors are accused of insensitivity is that they like to flash their knowledge--they'll tell people the worst possible thing that could happen to them right away, before they've had a chance to absorb the diagnosis. You have to let the patient tell you how much they need to know."
But some patients want the doctor to be in charge, she says. "There are different kinds of patient-doctor relationships, and I have to think about what the patient wants from me: An authority figure, where I say, 'This is what we're going to do'? Or an alliance? To my mind, an alliance, where we are equals and discuss the options, is better--and it makes for much better compliance. Patients want doctors to be infallible. They still have this 1950s, Ben Casey version of what the doctor knows. They get upset if they see us looking things up, but if the infallible doctor makes a mistake--oho! A lawsuit!"
To avoid making mistakes, van Bett tries to make sure her patients understand what they've been told. "I give them instructions, and then I say, 'Tell me back what I said.' I give them my card with my number on it, and I say, 'Call me if you have questions.' It gives them so much comfort and confidence. You need to be accessible--it's part of the price you're paying for the privilege of being a doctor."
But van Bett thinks the medical profession needs to come down harder on incompetent doctors. "I have lodged complaints with my authorities about things I've seen done, even though there's a risk when you open your mouth. My father was a doctor who would testify in malpractice suits when a wrong had been done. I think we really need to police our own and stop hiding things.
"We have to remember that it's a privilege to practice medicine. I am not here for the money--I'm not making any money. And you couldn't pay me enough to put up with the emotional turmoil and some of the things I see. There's not enough money in the world to pay me to take a dead infant in to its mother and watch her stroke it and hug it and say good-bye. People think we're unfeeling--and sometimes we're feeling so much! A patient of mine might die, and I'd go back to work--and then I'd go home and cry and cry. I may be too empathetic. You have to shut the feelings away. If you let yourself feel the suffering, you go crazy."
What's more important: having the best scientist and most technically competent doctor possible, or having a doctor with a great bedside manner and lots of warm fuzzies? "They're both important," says Julia Schopick. "And you can have both. My dad was a doctor, and he considered himself a detective. He got his clues by listening to his patients. He used to ask, 'How can you be a good doctor if you don't listen?'
"More people are upset by shoddy treatment, by arrogant behavior, than by malpractice. You know, there was a survey done that found that people who sue would usually not have sued if they'd been treated well. My father was a doctor. Did he make mistakes? Yes. He was human. Was he ever sued? No. It's very hard to sue your friend, the family doctor, who comes and sits with you at four in the morning. People sue for malpractice because they don't think they're cared about. The patient who waits for hours and hours over and over, the patient who can't get questions answered, the patient who is treated with arrogance and insensitivity--when that patient's doctor screws up he says, 'OK, I'm suing.'"
"I guess I've been lucky," says Elliott Kroger. "I don't see much problem with insensitive doctors. In fact, from many quarters I've seen a great deal of increased awareness of the situation. But if it's a patient perception, then it's real."
Art accompanying story in printed newspaper (not available in this archive): illustration/Tony Griff.