Crumbling Boundaries Between Patients and Doctors

Physicians manage multiple conflicting domains: diagnosing and treating disease, complying with payer rules, and using what's been called cumbersome EHR technology, to name a few. While that may not be anything new for agile, multi-tasking physicians, it leaves little time to connect with patients. And connecting with patients has taken on new urgency as physicians are now judged on their ability to make patients happy, via satisfaction surveys like the Consumer Assessment of Healthcare Providers and Systems (CAHPS). But as any experienced physician knows, relaxing the professional boundaries that are so necessary to establishing an effective provider-patient relationship can be problematic.

Barbara Malat, a retired, certified physician assistant (PA), who practiced family medicine for 22 years, most recently in Rochester, Minn., says it is becoming harder to maintain patient boundaries for many reasons. Due to a prevalence of direct-to-consumer pharmaceutical ads on TV and homeopathic cures touted on social media and the web, many patients are becoming anxious, fearful, and demanding. "I actually had one young woman call me and say, 'I'm really anxious when I go to parties and I don't know anyone. I think I have social phobia. I saw that commercial on TV and I'm sure that is the medication that I need,'" says Malat.

If you find yourself experiencing similar pressures and wonder how you should respond to increasing patient demands for specific treatments that they may not need, in order to maintain their good will, here's what other physicians and consultants are saying.

Strained Relationships

Many patients nowadays seem to have an expectation of instant access to medical care. However, they are busy, too, and many cannot take an afternoon off to see the doctor for fear they will be laid off or receive a short paycheck. Unfortunately, this can place undue pressure on physicians to succumb to patient demands. Malat, who was also past president of the Association of Family Practice Physician Assistants, says she has experienced this scenario many times.

"Not uncommonly, patients would come in and say, 'I'm here and I need to be treated because I have to get back to work tomorrow.' … There were a series of those kinds of things, because someone didn't have good benefits or their employer said, 'You have to be back [in] two days or this is it for you,'" Malat says.

That lack of time may also push patients to ask the physician for a prescription over the phone for a malady they have self-diagnosed, like a suspected sinus infection. Malat says when she had established trust and a good working relationship with her patients, they were often more open to listening to her diagnosis and suggested treatment plan, even if that meant trying a course of over-the-counter medication first.

One conflict of interest that physicians are often exposed to is when coworkers or staff ask them to diagnose or treat a problem on the fly, at work. The greatest problem for Malat, she says, was that conceding to patient demands didn't allow for a medical work-up or adequate documentation in the medical record. Her approach was to ask herself, "Would I do this for one of my own patients?" If the answer was no, she would ask the staff member to make an appointment to see her in the office.

Another catalyst for tense interactions is the disconnect between physician-patient perceptions.

Meryl D. Luallin, CEO of California-based Sullivan Luallin Group, a consulting firm that specializes in helping physicians improve patient satisfaction measures, says that quite often physicians do not view themselves in the same light as their patients do. While their goal is to help patients and provide the best patient care possible, she says, they can often be too focused on clinical measures, forgetting to make that all-important personal connection. "… It's hard for them to shift into the chat mode," Luallin notes. 

Unfortunately, if physicians can't make that personal connection that patients so desire, they will often find themselves the recipients of low patient-satisfaction scores. That is why larger practices are engaging firms to conduct "shadow coaching," hiring a consultant to follow a physician through her day and observe her interactions with patients. It is most often the little things that mean the most to patients, says Luallin, and that can make the difference between an average patient satisfaction rating and one that is outstanding. She frequently reminds physicians to ask patients about their lives. Simple questions like "How was your weekend?" or "How's work going?" can show patients that you care about them as individuals.

Keeping Patients Satisfied

Physicians may feel pressured to make patients happy because they fear they will be dinged by payers or their practice if they do not perform well on patient satisfaction surveys, or find themselves the recipient of a scathing online review. One example is Medicare's use of the CAHPS survey, where results are published on Medicare's Physician Compare website. But pleasing patients can sometimes get in the way of good medicine, and slow down the delivery of care.

Given the almost universal access to the Internet, many patients now visit their doctor armed with print-outs from "Dr. Google," self-diagnosing their own illness and requesting the new antibiotic they saw advertised on TV. Unfortunately, it takes time to explain to them that they don't need an antibiotic for a viral illness, for instance.

Alan Rosenstein, a San Francisco-based internal medicine physician, has practiced medicine for more than 20 years and says time has become much more limited over the course of his career, especially for employed physicians. Because of tight schedules, physicians will sometimes just give patients what they want, hoping to eliminate excessive time spent trying to explain their reasoning to patients.

"You are going to spend all of that time talking to patients …" says Rosenstein. "It's the right thing to do, but do you want to do it? [Patients] are probably not going to get hurt if you give them the antibiotics and they'll probably feel happier when they leave."

Traditional medical training has typically focused on knowledge and technical competence, often giving short shrift to personal communication skills, says Rosenstein. Medical students frequently had to cultivate those skills on their own. Now, medical schools are beginning to acknowledge that students need more than just a sound background in math and science and are recruiting students with a liberal arts background, like humanities, he says.

However, while communicating well with patients is vital to good care, giving patients the time they need is just as important and key to building patient trust. Here are a five suggestions from experts to help physicians make a lasting connection with their patients.

1. Give the gift of time

Leann DiDomenico McAllister is administrative director for Performance Pediatrics, LLC, a pediatric micro-practice based in Plymouth, Mass. One of the greatest benefits stemming from this type of practice model for McAllister and her spouse, pediatrician Terence McAllister, is the ability to set longer appointment times, because their patient panel is smaller. Time allows the physician to establish trust with patients and also to provide education that will contribute to better health, she says.

"We use our long appointment times to listen to the parent's concerns, clearly state our recommendation, and agree to disagree. Taking the time to listen and educate might not quickly change minds, but we have many parents who, over time, have come to trust us to vaccinate their children."

2. Make respectful compromises

It is that sense of trust and respect between physician and patient that can often mediate disagreements or convince doubtful patients to try physician-recommended treatments in place of "quick fixes" like a course of potentially unnecessary antibiotics. When good rapport is established, Luallin notes, patients will be more likely to accept physician recommendations.

"If you have an ongoing relationship with a patient, and the patient knows you care about them personally, then as a physician you can say, 'You know, Mrs. Smith, if you were my sister this is exactly what I would prescribe for you.' And she would believe you," she says.

3. Share personal beliefs

Because she practiced in a rural community outside Rochester, Minn., with a population of about 2,500 people, Malat says she knew just about all of her patients - and if she didn't, she knew someone who did. It was part of the charm of a small-town practice. But that intimacy could sometimes stress patient-provider boundaries. Elderly patients often asked what church Malat attended. She generally tried to side-step the issue, telling them "Well I live in Rochester."

She used it to her advantage, however, when the situation was urgent and the patient clearly distressed, as part of exploring a patient's support system. In this case, she would ask if they had religious beliefs. "That was a nice direction to go because many people would not want you to refer them to a psychologist. But if you could refer to their priest or minister or a support system within the church [patients would be more open to that]," she says.

4. Rely on staff

Certain patients can be too clingy and may interpret polite interactions with their physician as permission to develop a closer relationship. Malat says that is when a well-trained staff can step in and intercede between the physician and patient. Quite often, if the patient is denied access to the physician, the problem will resolve itself.

5.  Reach patients where they live

Malat, who specialized in adolescent medicine, found that sometimes it was easier to communicate with younger patients using secure emails. The relative anonymity allowed patients to ask her embarrassing questions that they might otherwise not. It also allowed them to connect whenever they wanted - sometimes at 1:00 or 2:00 in the morning. Her patients were generally respectful of the provider's time, she says, and rarely abused the privilege of increased access. The key, she says, is making sure patients have a clear of idea of the provider's expectations, and offering increased access only to appropriate patients.

In the end, patients are much more willing to respect physician boundaries and heed the advice they give if together they have built a foundation of trust. "The best result may not be giving the patient everything they came in there expecting," says Rosenstein. "There's a certain art in managing that [expectation]. It's almost like a difficult conversation - it's the right thing to do, but can you do it in the time allotted?"

Erica Spreyis associate editor at Physicians Practice. She can be reached at erica.sprey@ubm.com.