By Stephen Wilkins, MPH

First Posted at Mind the Gap on 1/21/2014

Steve Wilkins, MPH, host of "Mind the Gap"

Steve Wilkins, MPH, host of “Mind the Gap”

In a recent email exchange, the physician I was corresponding with wrote “many people [that] go to see doctors are not engaged in their health.”  My normal reply would have been “what do you mean not engaged…they people wouldn’t be in the doctor’s office if they weren’t engaged.”  Instead, I thought about what is that would suggest to a physician that the person on their exam room table was unengaged.

Then I remembered – it probably is the passive sick role we patients assume when entering the doctor’s exam room.

As people we all assume multiple roles throughout our lives. We are husbands, wives, friends, parents, bosses, and employees. And at some point or another, we are all a patient sitting on a paper-covered exam room table in some doctor’s office.

Each of the roles we assume come with a corresponding set of “rules” that help define how we are supposed to behave. Wives are always right…and husband wrong. Children are supposed to obey their parents and not talk back. Don’t argue with a police office when pulled over for a traffic ticket. And when called into the doctor’s office exam room we automatically assume a passive “sick role” opposite the clinician’s role as expert.

What Does This “Passive Sick Role Behavior” Look Like?

From the physician’s perspective, passive sick role behavior looks like we don’t care very much about our health…at least not enough to:

  • Do as we are told with respect to our health
  • Ask the doctor relevant questions
  • Ask the doctor for information
  • Challenge the doctor on diagnosis or treatments
  • Demand that we engage in shared decision making

 

A couple of key concepts typify passive sick role patient thinking and behavior as we sit in the waiting area and exam room:

Minimization of our problems and concerns

  • That person looks a lot sicker than me
  • That frail old woman deserves a lot of time and care
  • I don’t need to bring up all my problems or concerns at this visit

Respectfulness and understanding of the demands placed upon our busy doctor

  • I’ll whittle down my list of questions to one or two – surely the doctor will be too busy to answer my questions
  • I’ll just wait until I get home and look up what I want to know on the internet
  • I guess if I were as busy as my doctor I would limit patients to one question just like I have read about
  • Poor guy/gal…he/she is way too busy for me

Memories of previous experiences visiting doctors going back to childhood

  • Doctors never remember who I am – as long as he/she covers the basics I will not make a fuss
  • Doctor wants to be the boss so I will sit her and just listen
  • The last time I asked a question the doctor laughed at me
  • I read somewhere where doctors can “fire” patients if they don’t like them
  • My friends say not to act like you know more than your doctor…they don’t like it

So Why Do We (Patients and Doctors) Behave This Way?

That’s simple. Just as we were socialized into our role as a child, sibling and parent, we learned very early on how we were supposed to behave in the doctor’s office. I guess we can all blame our mothers.  After all they were the ones that took us to the pediatrician…and we never saw them question or challenged the doctor.

Don’t blame physicians either. They were taught to behave the way they do in medical school.In other words people come to a physician with a bio-medical problem (think acute) and you are supposed to diagnose and fix the problem. That’s it. You are not supposed to fix people’s lives, heal their marriages or hold their hands. The disease-oriented, physician-directed communication style still employed by the majority of physicians is an artifact of the “doctor as expert role” they were taught in medical school.

These Roles And Social Conventions Are Major Barriers To Fixing What’s Wrong With Health Care

Thirty years of evidence documents the following trends:

  • Patients ask very few important questions of their doctors out of fear (looking stupid, not wanting to appear difficult, because they are limited to the number of questions they can ask.
  • Patients often are very selective in terms of the information they are willing to share with their doctors
  • Patients give doctors the benefit of the doubt where it comes to poor communications and service.
  • Patients are afraid to challenge doctors for fear of being fired or branded as “difficult.”
  • Patients often disagree with their doctor’s diagnosis or treatment plan but will not raise the issue directly with the doctor out of fear.
  • Doctors assume that patients know more than they do about their health and patients feel doctors are too busy to ask for information.

Put another way, the roles and social conventions discussed here are a  major barrier to:

  • Patient engagement
  • Patient-centered care and communication
  • Reducing medical errors and improving safety
  • Improving patient adherence
  • Better patient health outcomes
  • Reducing preventable ER and Hospital Use
  • Improving patient experiences

What Is The Solution?

  1. Acknowledge the problem
  2. Look to high performing physicians that have “figured it out.”
  3. Get your physicians to talk about their own communication skills
  4. Conduct an assessment of your physicians’ patient-centered communication skills
  5. Offer training (in person/online) to help your physicians develop new patient-centered communication skills
  6. Teach patients how to behave and talk with physicians in today’s Brave New World

 

That’s my opinion. What’s Your?