Can we still manage the relationship with patients?

Eighteen years ago, I started my out-patients’ experience as specialist dermatologist. I worked from the very first day with National Health Insurance System. It was a chance to build a huge experience (more than 120,000 visits since then). Over time, relationships with patients have changed, influenced by many factors. To preserve good relationships we have to reflect and to use different approaches. In 2001, my stamp and my signature were enough for a consultation. The cell phone era was at the beginning. Over the years, the process has become more and more complicated. Today, if the computer, internet, different types of applications, software, other devices (printer, card reader, etc.) are not working, my knowledge becomes absolutely necessary, but not sufficient for a consultation. So, the doctor is now, totally dependent on IT issues. Besides instant information, cell phones induce a lack of intimacy. Everyone could reach you everywhere, every moment. You are almost “forced” to give advice on whatsapp, e-mail, messenger and people expect you to answer on-site, otherwise you are not “reachable”. Time is the first pressure that we are feeling. Patients want and expect a consultation as soon as possible even you have appointments for the next few weeks. I try my best not to push later than 10 days, if it is a new ordinary consultation. Sometimes, it is possible for me to see the patient on-site (a child, an emergency, pregnant women, etc.). In the literature, time for appointment could vary from 7 working days in Brazil [1], to median 41 days in Canada (Ontario) [2] or median 45 days in US (Pennsylvania) [3] to a certain dramatic situation waiting list of 57 weeks in a unit in UK [4]. The number of consultations tends to increase. It is not only a perception, but a reality, revealed also by a French study (21% increase from 2000 to 2010) [5]. Time is also a burden for the doctor, because the real time for consultation has dramatically reduced in favor of bureaucratic issues. Official papers seem to be more important than people. It is a constant effort to remain emphatic and to really listen to patient’s history. The stories that we are ignoring for lacking time could give us important clues for diagnosis, approach, could enforce the relationship and give trust, could relief the worries. “You are the 5th dermatologist I am seeing”- a young woman told me the other day. I looked at her: she was around 20, some pimples on her jaw (not too many) and some tiny scars on her forehead covered by a lot of makeup. Not quite a good start for a relationship. Her expectations were not fulfilled by visiting the other doctors. Maybe the expectations were not realistic, maybe she was fed up trying different things. “How can I propose something new or miraculous when she tried probably “everything”? - I asked myself. I spent at least half an hour discussing about acne, therapeutic options and adjusting the expectations to our limits. It was more a counseling session than a dermatologic consultation. Today, patients are coming in our office very informed. They “know” the diagnosis and sometimes even the treatment they want or need. After “Dr. Google” you can be a second opinion. Dermatology is underestimated even by other physicians that feel competent enough to prescribe medication inducing iatrogenesis [6]. So, what to expect from patients? It is a good thing to have an informed patient. It will save you a lot of time and energy in expanded explanations. But, there is also a lot of incorrect or 1 Dali Medical, Bucharest, Romania 118 misunderstood information, prejudices from other’s experience shared on forums, incorrect auto-diagnosis or even incorrect auto-medication. It is our duty to listen and to correct, as much as we can. Patients have to be taught how to choose important information from the constant “soup of news feed”. The flux of information is huge, also for doctors as for patients. Thousands of opinions, articles, and new approaches invade our space daily. A good selection criteria for useful, relevant data is absolutely necessary. A “happy” patient seems to be the one with a certain diagnosis, with clear treatment plan, including explaining side effects and with a contact number in case of recurrence [7]. The access of any information being so instant, patients expect a rapid response of the treatment. The result has to be now and definitive. The pressure of quick response is not very subtle, the doctor feeling it as a burden. It takes time to explain and to understand the progression of chronic illnesses. Sometimes, the expectations are to get well with any treatment, eventually without any changes of their life style, even when doctor explains that some habits could aggravate or maintain the lesions. Taking responsibility for some adjustments is an important part to discuss with patient, as part of therapeutic approach. Paternal, omniscient doctor’s image is no longer in actuality and patient is an important part of the relationship. Instead of an “infantile” patient, coming for any transitory rash or any mosquito bite, it is better to “grow” him/her as a self-confident “partner”. The new and healthy bond has to transform patient from the passive, sometimes passive-aggressive role, into an assumed, informed, pro-active one. Cooperation is the key of healthy relation. Patient has the right to ask for explanations, to discuss therapeutic options, to refuse treatments. Patients have opinions that have to be respected and sometimes corrected if they are distorted. On the way to get therapeutic alliance and long-term cooperation, the doctor-patient relationship has to be personalized, giving value to it. This kind of relationship will make the difference in the end and even the direction is to involve more high tech and robots. Face-to-face relationship will not be replaced by anything and it will be highly appreciated after the “speed” condition passes. More social skills are often required, doctors not being known as the best communicators. Sometimes, doctors are not aware of patients’ perception regarding communication [8]. I have got my social skills working day by day, no special courses were made during faculty, unfortunately. “We need fewer memorizers and more thinkers and communicators in modern medicine” is the most recent conclusion of Canadian Debate Series regarding medical students’ selection [9]. Another pressure point is the constant fear of errors. With all the efforts of protocols for reducing the risk of mistakes or misconducts, unfortunately there are lots of gaps and debates. The fear of error and malpraxis leads to excess of medication and investigations, sometimes too expensive and useless. Doctors should not be scared by the abundance of products, instruments, techniques, aggressively promoted. They have to be more flexible, more intuitive and more eager to try, making personal experience and not taking results for granted. Many of these products will not pass the test of time, even they are presented as “miraculous”. Sometimes, patients’ needs are the trigger for experimenting new methods and push us to progress faster. Not only patients are in a rush, doctors too. The race for EMC points is making the doctor more informed, but we have to be careful not to become too superficial. Even a doctor is getting a diploma after a “3 days course”, it doesn’t mean that he/she will be an expert in that field, not even competent. It will take a lot of time and energy to really get the expertise, that course being only the very first step on the road. The “diplomas wall”, real or virtual is a false goal. In the end, the real skills are more important than a sublime image and it will take time to get them. Sometimes, vanity makes the teamwork harder. This will be unproductive for both doctors and patients. It is not a shame to refer the patient to an expert on a field when you feel that you have reached a limit. People are hardly trying to change our state from patient to client, that new status being debatable. Being a client means to take some responsibilities as in a contract. That is the good part. But, fortunately, remaining a doctor means more than providing services. Practicing medicine is a state of knowledge, art, experience, intuition, with magic touches sometimes. Fortunately, with all the changes during the last years, dermatologists seem to remain satisfied with their specialty. A recent Mexican study shows that 93% of dermatologists (with an average of 16 years of practice) were happy with their professional life, more than 98% choosing it once again [10]. Maintaining certain levels of professional and personal happiness, keeping informed and open-minded, avoiding burn-out, trying to fulfill patients’ expectations, doctors are not in a battle, but in strong alliance with patients.

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