A rule not to live by

Tara Parker-Pope of the New York Times summarizes six rules doctors need to know, based on a blog post by Dr. Rob at Musings of a Distractible Mind. One is a rule that doctors follow far too often:

Rule 5: They pay for a plan.

What do people pay for when they come to the medical office? They pay for opinion, yes. They pay for knowledge as well. But what they really pay for is a plan of action….They want to know what is going to be done to help. I try and give a plan, either verbal or written, to each patient that walks out of the exam room. What medications are given and why? What medications are to be stopped? What tests are ordered and what will the results mean? When is the next appointment? What should they call for if they have problems? The better I can answer these questions, the more confidently the patient will walk out of the exam room. The days of paternalistic medicine are over – no handing a prescription and just saying “take it.” Patients should know why they are putting things in their body.

I asked SimulConsult CEO Michael Segal, MD, PhD for his thoughts on this one:

This is why many doctors give treatment plans that are worthless or worse – patients expect something more than advice that the problem will get better by itself.  Much use of band-aids (with potential latex allergies), antibiotics (with potential bacterial resistance) and cold medicines (with side effects such as secondary infections) is attributable to doctors following Parker-Pope’s rule when they should be providing reassurance.  In addition, this focus on intervention is built into reimbursement schedules, making it so doctors are paid little for diagnosis and paid well for intervention.

Then this morning I saw this piece this morning from MedPage Today (For Unexplained Infertility, Continued Trying Is as Good as Treatment)

ABERDEEN, Scotland, Aug. 8 — Commonly used treatments for unexplained infertility may be ineffective in raising the odds of pregnancy, researchers found.

The live birth rate was similar whether couples continued to try for pregnancy naturally, used oral clomiphene (Serophene, Clomid), or had unstimulated intrauterine insemination (17% versus 14% and 23%), reported Siladitya Bhattacharya, M.D., of the University of Aberdeen, and colleagues online in the BMJ.

However, women in the randomized trial were least satisfied with the just-keep-trying approach — dubbed expectant management by the researchers — despite a significant difference in outcomes.

August 11, 2008

4 thoughts on “A rule not to live by”

  1. This is a misunderstanding. “Plan” does not imply prescription. It simply answers the question: “So What?” at the end of the visit. Patients need to understand why they came and what, if anything, will be done as a consequence. “See you next year” is a perfectly fine plan. “Just keep trying” may be appropriate as well. The problem is that many patients leave doctor visits without any idea of what is going on. It is THEIR care, not the doctor’s.

  2. As a practicing physician who teaches other docs how to operate a high quality profitable office, this is a sore spot for me.

    I maintain that if you want to see a really poorly run small business, look at most doctors’ offices. If you bought a new Porsche would they just shrug their shoulders and say “see ya” when you drive of the lot?

    Most doctors need to work ten times harder to educate their patients on when they should come in for their preventative and disease management visits. It’s good medicine and good business.

    David Zahaluk, MD
    Founder, MIP Practice Performance

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