Here's what doctors are being to told to say and not say
July 13, 2023 2:47 PM Subscribe
Since 2020, three of the most powerful medical organizations in the United States have published new language guidelines designed to change how physicians communicate with patients.
They org's are:
1a) The Association of American Medical Colleges (AAMC), which oversees and lobbies for medical education. It represents 175 medical schools, 400 or so teaching hospitals, and administers virtually all medical entrance/qualifying examinations, including the MCAT. 1b) The American Medical Association (AMA) is the largest professional association/lobbying group for physicians in the United States. About 25% of physicians are members
For your review: their joint publication Advancing Health Equity: A Guide to Language, Narrative and Concepts
2) The The Centers for Disease Control And Prevention (CDC) is the federal government's public health organization. For your review: Its 6-part Health Equity Guiding Principles for Inclusive Communication
Physicians agree with the idea behind of the guidelines--ie, identifying the causes of disparate health outcomes across demographic and socioeconomic lines so as to eliminate them. For many reasons, however, few take the specific, use-this-word-not-that advice very seriously.
As a profession we are thinking about this stuff. I've posted these twoseminal documents as an invitation for you to think about them as well.
For your review: their joint publication Advancing Health Equity: A Guide to Language, Narrative and Concepts
2) The The Centers for Disease Control And Prevention (CDC) is the federal government's public health organization. For your review: Its 6-part Health Equity Guiding Principles for Inclusive Communication
Physicians agree with the idea behind of the guidelines--ie, identifying the causes of disparate health outcomes across demographic and socioeconomic lines so as to eliminate them. For many reasons, however, few take the specific, use-this-word-not-that advice very seriously.
As a profession we are thinking about this stuff. I've posted these twoseminal documents as an invitation for you to think about them as well.
the profession often sees the doctor-patient relationship as adversarial.
You think so? I haven't noticed that as much as the doctor-patient-insurance company relationship being adversarial, with doctor and patient on the same side.
posted by ctmf at 3:43 PM on July 13, 2023 [33 favorites]
You think so? I haven't noticed that as much as the doctor-patient-insurance company relationship being adversarial, with doctor and patient on the same side.
posted by ctmf at 3:43 PM on July 13, 2023 [33 favorites]
with doctor and patient on the same side.
Are you perhaps an able-bodied, middle class or above white male? Your experience is likely to be better than many other people's.
My experience has typically been not quite adversarial, but rather disrespectful and dismissive. I'm white, but female, overweight, and poor so I'm using the insurance of people who don't matter (I think that's Medicaid's actual slogan). I've noticed that the people who immediately advise me to see a doctor when I mention any physical problems usually have more rather than fewer points of privilege. They seem confused when I'm not immediately enthusiastic.
posted by Flock of Cynthiabirds at 3:53 PM on July 13, 2023 [72 favorites]
Are you perhaps an able-bodied, middle class or above white male? Your experience is likely to be better than many other people's.
My experience has typically been not quite adversarial, but rather disrespectful and dismissive. I'm white, but female, overweight, and poor so I'm using the insurance of people who don't matter (I think that's Medicaid's actual slogan). I've noticed that the people who immediately advise me to see a doctor when I mention any physical problems usually have more rather than fewer points of privilege. They seem confused when I'm not immediately enthusiastic.
posted by Flock of Cynthiabirds at 3:53 PM on July 13, 2023 [72 favorites]
I keep having to try to rephrase this, because I don't really want to come off as anti-doctor. But the "Advancing Health Equity" piece is 40+ pages not counting footnotes. Are doctors actually reading this? Is there some shorter version? Bullet points or something? Every doctor I know balks at reading, like, a two-paragraph email. How are they digesting this information?
posted by mittens at 4:00 PM on July 13, 2023 [16 favorites]
posted by mittens at 4:00 PM on July 13, 2023 [16 favorites]
An organization that has 25% of Doctors as members means 75% aren't members of that organization (and that doesn't even include Nurse Practitioners).
posted by Jarcat at 4:28 PM on July 13, 2023 [7 favorites]
posted by Jarcat at 4:28 PM on July 13, 2023 [7 favorites]
My experience has typically been not quite adversarial, but rather disrespectful and dismissive.
The problem is that patients expect patience, empathy, and respect, but never have patience, empathy, or respect for doctors who fail to meet their expectations. In 22 years I've never heard a patient say, "hey I understand, Doc. You're a person too, maybe you had a fight wife with your wife this morning, or maybe you're at the end of a 36-hour shift. Either way, I'll give you the benefit of the doubt this time, and hope next time things go better"
Never happens, Is it really too much to expect that patients give the very things they expect to get?
posted by BadgerDoctor at 5:08 PM on July 13, 2023 [18 favorites]
The problem is that patients expect patience, empathy, and respect, but never have patience, empathy, or respect for doctors who fail to meet their expectations. In 22 years I've never heard a patient say, "hey I understand, Doc. You're a person too, maybe you had a fight wife with your wife this morning, or maybe you're at the end of a 36-hour shift. Either way, I'll give you the benefit of the doubt this time, and hope next time things go better"
Never happens, Is it really too much to expect that patients give the very things they expect to get?
posted by BadgerDoctor at 5:08 PM on July 13, 2023 [18 favorites]
maybe you had a fight wife with your wife this morning
are u on your period?
have u tried losing weight?
š„ŗšš
posted by phunniemee at 5:24 PM on July 13, 2023 [74 favorites]
are u on your period?
have u tried losing weight?
š„ŗšš
posted by phunniemee at 5:24 PM on July 13, 2023 [74 favorites]
Wow, BadgerDoctor. You have almost no info about what my experiences have been with doctors, yet you leap to the assumption that I and others somehow deserve substandard medical care because we haven't been nice or understanding enough of human foibles. That's a huge assumption to make on little info.
What you're describing (fight with wife, etc.) should be rare. But in my experience, being dismissed and disrespected is the norm, not unusual at all. I have the attitude I do because of how I was treated, not the other way around. I didn't start out with a poor perception of the medical profession and especially doctors, and giving respect and leeway didn't result in my being provided with good care.
YES, a professional of any kind, and especially someone who literally has people's lives in their hands, is required to put aside their personal problems and do their job. Would you be understanding if a pilot crashed the plane you were a passenger in, because she was having a bad day?? If you use your personal problems or bad moods to excuse poor medical care, you can hurt or kill someone. You can influence people not to seek medical care next time because they've been treated so poorly.
I would expect a supposedly intelligent professional, which is what our society represents doctors to be, to be curious enough to want to know what was influencing people to have a negative perception of their profession. Instead, you punish an honest statement of lived experience by leaping to the assumption that the person speaking just wasn't quite *nice enough* to the people who treated her like crap.
Your comment embodies the poor attitude of many doctors. Thanks for helping me prove my point.
posted by Flock of Cynthiabirds at 5:32 PM on July 13, 2023 [85 favorites]
What you're describing (fight with wife, etc.) should be rare. But in my experience, being dismissed and disrespected is the norm, not unusual at all. I have the attitude I do because of how I was treated, not the other way around. I didn't start out with a poor perception of the medical profession and especially doctors, and giving respect and leeway didn't result in my being provided with good care.
YES, a professional of any kind, and especially someone who literally has people's lives in their hands, is required to put aside their personal problems and do their job. Would you be understanding if a pilot crashed the plane you were a passenger in, because she was having a bad day?? If you use your personal problems or bad moods to excuse poor medical care, you can hurt or kill someone. You can influence people not to seek medical care next time because they've been treated so poorly.
I would expect a supposedly intelligent professional, which is what our society represents doctors to be, to be curious enough to want to know what was influencing people to have a negative perception of their profession. Instead, you punish an honest statement of lived experience by leaping to the assumption that the person speaking just wasn't quite *nice enough* to the people who treated her like crap.
Your comment embodies the poor attitude of many doctors. Thanks for helping me prove my point.
posted by Flock of Cynthiabirds at 5:32 PM on July 13, 2023 [85 favorites]
patience, empathy, and respect is part of THE JOB. if one is not willing to - or uses their personal life as an excuse to - fail to do their job, then they are in the wrong profession. i mean, fer chrissakes, there's a reason they call 'em "patients". when people are scared, in pain, sick, and facing unknown expenses, they may well act out.
this is not to say there isn't terrible levels of burnout, overwork, and rudeness that medical professionals must contend with. but anyone who works in ANY service industry has to contend with the same. to say that patients NEVER reciprocate is untrue.
as for giving "the benefit of the doubt this time" - one often has to wait MONTHS to be seen for 15 minutes. it may be their only chance when dealing with work, kids, etc. - so to encounter someone who is dismissive, rude, preoccupied and yes, at times, antagonistic, could well be asking someone to just go die.
posted by lapolla at 5:35 PM on July 13, 2023 [49 favorites]
this is not to say there isn't terrible levels of burnout, overwork, and rudeness that medical professionals must contend with. but anyone who works in ANY service industry has to contend with the same. to say that patients NEVER reciprocate is untrue.
as for giving "the benefit of the doubt this time" - one often has to wait MONTHS to be seen for 15 minutes. it may be their only chance when dealing with work, kids, etc. - so to encounter someone who is dismissive, rude, preoccupied and yes, at times, antagonistic, could well be asking someone to just go die.
posted by lapolla at 5:35 PM on July 13, 2023 [49 favorites]
An organization that has 25% of Doctors as members means 75% aren't members of that organization (and that doesn't even include Nurse Practitioners).
Thankfully, the organizations didn't put this behind a members-only paywall and the AMA is pretty well-known even among its nonmembers. Other medical organizations like AANP have been doing the work as well.
Thanks for linking these, BadgerDoctor.
posted by kimberussell at 5:36 PM on July 13, 2023 [5 favorites]
Thankfully, the organizations didn't put this behind a members-only paywall and the AMA is pretty well-known even among its nonmembers. Other medical organizations like AANP have been doing the work as well.
Thanks for linking these, BadgerDoctor.
posted by kimberussell at 5:36 PM on July 13, 2023 [5 favorites]
Physicians agree with the idea behind of the guidelines--ie, identifying the causes of disparate health outcomes across demographic and socioeconomic lines so as to eliminate them.I'm sure language/narrative plays some role in the current amount of social injustice in this country. But at a much higher level:
The AMA's opposition to single-payer health care
There is discussion of the equity docs at the end of that article too.
posted by meowzilla at 5:38 PM on July 13, 2023 [20 favorites]
No, doctors are absolutely not reading this whole document. I'd guess that the primary audiences are probably administrators at medical schools and big managed-health companies, and they'll package up some takeaways for coursework and continued ed content in more of a "slideshow" format, and maybe use it to inform hospital policy updates.
I am always careful to mention to my doctors that I have many relatives who are doctors. This combined with my slender physique (if you've never been around docs talking to each other about patients, you'd be stunned how fatphobic many doctors are - well, if you happen to be fat, maybe not so stunned. You will never meet a lonelier doctor than an obese doctor, the ultimate medical-profession pariah) usually seems to convince them that we are peers and I'm someone they can treat with respect. So if you feel like your doctor is talking down to you and you think you might be able to convincingly fake a doctor relative, I really recommend giving it a shot! Just casually mention your sister the cardiologist, where she went to medical school (make it a reasonably good not-local-to-you school but not, like, implausibly good - grab a ranked list of med schools and choose something in the like, 50th to 100th range) and HER opinion on taking a preventative baby aspirin every day like it's no big deal or whatever, and watch how you level up in their esteem. This isn't surprising really - everything about how we recruit and train doctors basically carves credentialism into their very souls.
BadgerDoctor, we pay doctors the big bucks to be the bigger person in these interactions. That's why people expect them to put their personal struggles aside. I mean, we expect a clerk at the supermarket to treat us politely even if they had a fight with their partner this morning. Why not expect even better of someone who's actually, you know, making enough to live on?
posted by potrzebie at 5:39 PM on July 13, 2023 [41 favorites]
I am always careful to mention to my doctors that I have many relatives who are doctors. This combined with my slender physique (if you've never been around docs talking to each other about patients, you'd be stunned how fatphobic many doctors are - well, if you happen to be fat, maybe not so stunned. You will never meet a lonelier doctor than an obese doctor, the ultimate medical-profession pariah) usually seems to convince them that we are peers and I'm someone they can treat with respect. So if you feel like your doctor is talking down to you and you think you might be able to convincingly fake a doctor relative, I really recommend giving it a shot! Just casually mention your sister the cardiologist, where she went to medical school (make it a reasonably good not-local-to-you school but not, like, implausibly good - grab a ranked list of med schools and choose something in the like, 50th to 100th range) and HER opinion on taking a preventative baby aspirin every day like it's no big deal or whatever, and watch how you level up in their esteem. This isn't surprising really - everything about how we recruit and train doctors basically carves credentialism into their very souls.
BadgerDoctor, we pay doctors the big bucks to be the bigger person in these interactions. That's why people expect them to put their personal struggles aside. I mean, we expect a clerk at the supermarket to treat us politely even if they had a fight with their partner this morning. Why not expect even better of someone who's actually, you know, making enough to live on?
posted by potrzebie at 5:39 PM on July 13, 2023 [41 favorites]
Also, 36 hour shifts are utterly unacceptable for a number of reasons, and the fact that doctors see them as acceptable is an indictment of the profession.
posted by NoxAeternum at 5:48 PM on July 13, 2023 [48 favorites]
posted by NoxAeternum at 5:48 PM on July 13, 2023 [48 favorites]
"hey I understand, Doc. You're a person too, maybe you had a fight wife with your wife this morning, or maybe you're at the end of a 36-hour shift. Either way, I'll give you the benefit of the doubt this time, and hope next time things go better"
The next time is eight months away.
The next time is AFTER my cancer didnāt get caught early because the doctor didnāt listen to me when I insisted something was wrong and asked for tests.
The next time is after I no longer have health insurance.
The next time is after the medication prescribed has given me organ damage.
I donāt have any benefit of the doubt to give because my LITERAL life is in the hands of the doctor and I damn well need the doctor to listen regardless of what kind of day theyāre having.
And I say this as someone who actually has a good relationship with my doctor and does extend verbal sympathy when she seems to be having a rough day. But itās because she is entering that conversation with me having built up the trust and relationship that I know regardless of the kind of day sheās having I donāt need to extend the benefit of the doubt because she is still going to actually listen to me.
posted by Bottlecap at 5:50 PM on July 13, 2023 [83 favorites]
The next time is eight months away.
The next time is AFTER my cancer didnāt get caught early because the doctor didnāt listen to me when I insisted something was wrong and asked for tests.
The next time is after I no longer have health insurance.
The next time is after the medication prescribed has given me organ damage.
I donāt have any benefit of the doubt to give because my LITERAL life is in the hands of the doctor and I damn well need the doctor to listen regardless of what kind of day theyāre having.
And I say this as someone who actually has a good relationship with my doctor and does extend verbal sympathy when she seems to be having a rough day. But itās because she is entering that conversation with me having built up the trust and relationship that I know regardless of the kind of day sheās having I donāt need to extend the benefit of the doubt because she is still going to actually listen to me.
posted by Bottlecap at 5:50 PM on July 13, 2023 [83 favorites]
Cool more stuff not to do for this soon to be NP
posted by BlunderingArtist at 6:04 PM on July 13, 2023 [4 favorites]
posted by BlunderingArtist at 6:04 PM on July 13, 2023 [4 favorites]
Totally agree on the way that the US health system et. al. has made every interaction with a doctor critical because at best you might have once a year preventative visit covered. Not to mention the 8 month wait for a new patient appointment.
The health systems, doctors, and schedulers know itās a problem. I work with doctors, NPs, pharma, etc. all time time trying to help them create better ways to help people. They really do care about helping people, I believe it, Iāve seen it. A few weeks ago I sat in a room with 14 hospital CEOs talking about changing their orgās entire mandate to be improving the health of people instead of the purely corporate bent it had before. Deciding to focus their entire line of services on advocacy at the highest levels in Washington. However, the unsaid thing is always that in a capitalist system the individual will never win.
On the point of the health disparities, something Iāve been hearing a lot about in the medical world the past 5 years, I just saw it in action in my life. My online check-in before my annual physical this year had a number of questions around SDH (social determinants of health) like ādo you worry about having a place to sleep, do you need help tonight? Do you ever not have enough foodā etc. Itās a pretty fancy health system and I purposely buy the one policy sold to self employed people that includes it in the network. So itās great, but also not sure how far reaching it will be with the demographic they serve.
posted by Bunglegirl at 6:06 PM on July 13, 2023 [7 favorites]
The health systems, doctors, and schedulers know itās a problem. I work with doctors, NPs, pharma, etc. all time time trying to help them create better ways to help people. They really do care about helping people, I believe it, Iāve seen it. A few weeks ago I sat in a room with 14 hospital CEOs talking about changing their orgās entire mandate to be improving the health of people instead of the purely corporate bent it had before. Deciding to focus their entire line of services on advocacy at the highest levels in Washington. However, the unsaid thing is always that in a capitalist system the individual will never win.
On the point of the health disparities, something Iāve been hearing a lot about in the medical world the past 5 years, I just saw it in action in my life. My online check-in before my annual physical this year had a number of questions around SDH (social determinants of health) like ādo you worry about having a place to sleep, do you need help tonight? Do you ever not have enough foodā etc. Itās a pretty fancy health system and I purposely buy the one policy sold to self employed people that includes it in the network. So itās great, but also not sure how far reaching it will be with the demographic they serve.
posted by Bunglegirl at 6:06 PM on July 13, 2023 [7 favorites]
The problem is that patients expect patience, empathy, and respect, but never have patience, empathy, or respect for doctors who fail to meet their expectations. the profit-centered nature of the US medical establishment means doctors have more patients than they can reasonably see in anything more than a cursory manner, which causes burnout and/or the dehumanization of patients into basically just clusters of numbers fed into a risk-assessment algorithm. It isn't totally removed from things like the gamification of workers at Amazon warehouses. Do more, care less.
posted by grumpybear69 at 6:41 PM on July 13, 2023 [35 favorites]
posted by grumpybear69 at 6:41 PM on July 13, 2023 [35 favorites]
In my med school interviews, I was asked what I thought about "entitlement" in medicine. It was a softball, a clear invitation to show how keen I was by slagging off on the Kids These Days and their insistence on call shift maximums and work-life balance and so on.
I talked about entitled physicians who are surprised when their advice isn't unquestioningly followed and an entitled medical profession that doesn't get why it has lost the trust of many of the people it ā genuinely, passionately ā wants to help and believes it can help.
(I did not end up going to that school.)
I live on both sides of the profession, as a doctor and as a patient. I believe Western medicine is one of humanity's greatest accomplishments. It has alleviated and prevented more human suffering than anything else in history. When a patient rejects my recommendations or expresses skepticism about the way my specialty works, I feel indignant and frustrated on behalf of a practice and institution I truly believe in. Is this the entitlement I recognized in more senior physicians years ago?
I've also been on the other side of the curtain, having my symptoms waved away, waiting months for appointments and months more for tests and months more for results and finally obtaining them by being a pest to various administrative staff, being diagnosed with somatic syndromes that nobody understands well or seems particularly interested in learning more about. I can only imagine what the encounter feels like for someone more marginalized than I am (which is not very marginalized at all). Medicine has worked miracles, but they've not been evenly distributed, and we all know disquiet is driven by inequality.
Sober incremental progress is a tall order when the stakes are so high, but we have to figure out a way to accomplish it, holding these contradictions together, celebrating what we've built but doing the renovations to ensure it doesn't fall apart. I'm trying to do the work, to become more conscious of my biases, to stay humble. But in the grand scheme of things, the way this change is going to happen is not through re-educating us old farts, it's through the next generations of medical trainees. An MCAT that assesses their social and emotional awareness. Asking them better interview questions than what I got. If the AAMC is working on it, that's a lot more meaningful than whatever the AMA has to say.
posted by saturday_morning at 6:46 PM on July 13, 2023 [31 favorites]
I talked about entitled physicians who are surprised when their advice isn't unquestioningly followed and an entitled medical profession that doesn't get why it has lost the trust of many of the people it ā genuinely, passionately ā wants to help and believes it can help.
(I did not end up going to that school.)
I live on both sides of the profession, as a doctor and as a patient. I believe Western medicine is one of humanity's greatest accomplishments. It has alleviated and prevented more human suffering than anything else in history. When a patient rejects my recommendations or expresses skepticism about the way my specialty works, I feel indignant and frustrated on behalf of a practice and institution I truly believe in. Is this the entitlement I recognized in more senior physicians years ago?
I've also been on the other side of the curtain, having my symptoms waved away, waiting months for appointments and months more for tests and months more for results and finally obtaining them by being a pest to various administrative staff, being diagnosed with somatic syndromes that nobody understands well or seems particularly interested in learning more about. I can only imagine what the encounter feels like for someone more marginalized than I am (which is not very marginalized at all). Medicine has worked miracles, but they've not been evenly distributed, and we all know disquiet is driven by inequality.
Sober incremental progress is a tall order when the stakes are so high, but we have to figure out a way to accomplish it, holding these contradictions together, celebrating what we've built but doing the renovations to ensure it doesn't fall apart. I'm trying to do the work, to become more conscious of my biases, to stay humble. But in the grand scheme of things, the way this change is going to happen is not through re-educating us old farts, it's through the next generations of medical trainees. An MCAT that assesses their social and emotional awareness. Asking them better interview questions than what I got. If the AAMC is working on it, that's a lot more meaningful than whatever the AMA has to say.
posted by saturday_morning at 6:46 PM on July 13, 2023 [31 favorites]
profit-centered nature of the US medical establishment means doctors have more patients than they can reasonably see in anything more than a cursory manner
Take it from a Canadian ā it's not just profit-centred care that suffers in this way. Public systems have different financial pressures, but those pressures have the same results.
posted by saturday_morning at 6:55 PM on July 13, 2023 [17 favorites]
Take it from a Canadian ā it's not just profit-centred care that suffers in this way. Public systems have different financial pressures, but those pressures have the same results.
posted by saturday_morning at 6:55 PM on July 13, 2023 [17 favorites]
Never happens, Is it really too much to expect that patients give the very things they expect to get?
So, Iām a domestic violence victim advocate. My clients are always traumatized when they come to me. They are often on drugs, drunk, and/or are in psychosis when I see them. They usually come from a family background of physical, mental and sexual abuse, and substance abuse. An awful lot of them have no idea how to act in society - theyāre sometimes one step above a feral animal. I have many times spent 2 hours with a client, listening to them cry and rant, helping them fill out a ton of paperwork, explaining where and how to get food, to get clothes, to get food stamps, to get a forensic medical exam, to get medical attention, to file their petition for a restraining order, etc., and then they leave and never once even say thank you. Iāve been yelled at by victimās parents, had victimās kids destroy things, been obviously lied to, and had them not show up for their court hearing and not even call, so that Iām left sitting there wasting time. And through it all, in my own life, Iāve been dealing with my adult child who has severe schizophrenia, with complete disrespect from my executive director, with coworkers who never took Covid seriously, with a mother in law with dementia, a favorite relative whoās drinking himself to death, and all the general stresses of living blue in a severely red town. The clients who have mental illness are severely triggering to me, because it hurls me right back into what Iāve dealt with helping my mentally ill child. But I have never been rude to a client, nor dismissed their concerns (even when theyāre clearly the ones who were wrong in the situation). Because I understand that every person who walks in our door has been through something (even the abusers, who we see in a separate program), and I may very well be the only person in their entire life who has ever actually listened to them. My partner works in health care, and deals with people who are abusive towards him every day, but theyāre at the hospital because they have a problem, and itās his job to help them fix it, not to judge them or take anything personally.
As a victim advocate, we spend hours and even days every year taking training about being ātrauma informedā, which means understanding that your clients are dealing with a lot (just like sick people), and we need to be understanding of that. It sounds like maybe doctors need some of that training too.
posted by MexicanYenta at 7:05 PM on July 13, 2023 [95 favorites]
So, Iām a domestic violence victim advocate. My clients are always traumatized when they come to me. They are often on drugs, drunk, and/or are in psychosis when I see them. They usually come from a family background of physical, mental and sexual abuse, and substance abuse. An awful lot of them have no idea how to act in society - theyāre sometimes one step above a feral animal. I have many times spent 2 hours with a client, listening to them cry and rant, helping them fill out a ton of paperwork, explaining where and how to get food, to get clothes, to get food stamps, to get a forensic medical exam, to get medical attention, to file their petition for a restraining order, etc., and then they leave and never once even say thank you. Iāve been yelled at by victimās parents, had victimās kids destroy things, been obviously lied to, and had them not show up for their court hearing and not even call, so that Iām left sitting there wasting time. And through it all, in my own life, Iāve been dealing with my adult child who has severe schizophrenia, with complete disrespect from my executive director, with coworkers who never took Covid seriously, with a mother in law with dementia, a favorite relative whoās drinking himself to death, and all the general stresses of living blue in a severely red town. The clients who have mental illness are severely triggering to me, because it hurls me right back into what Iāve dealt with helping my mentally ill child. But I have never been rude to a client, nor dismissed their concerns (even when theyāre clearly the ones who were wrong in the situation). Because I understand that every person who walks in our door has been through something (even the abusers, who we see in a separate program), and I may very well be the only person in their entire life who has ever actually listened to them. My partner works in health care, and deals with people who are abusive towards him every day, but theyāre at the hospital because they have a problem, and itās his job to help them fix it, not to judge them or take anything personally.
As a victim advocate, we spend hours and even days every year taking training about being ātrauma informedā, which means understanding that your clients are dealing with a lot (just like sick people), and we need to be understanding of that. It sounds like maybe doctors need some of that training too.
posted by MexicanYenta at 7:05 PM on July 13, 2023 [95 favorites]
Oh, and I once had to go to the emergency room because Iād had a miscarriage, and the doctor on duty was very young and clearly exhausted, and forgot what he was saying in the middle of a sentence. And yes, I expressed sympathy and concern, and asked if I could get him some coffee or something.
posted by MexicanYenta at 7:09 PM on July 13, 2023 [25 favorites]
posted by MexicanYenta at 7:09 PM on July 13, 2023 [25 favorites]
Mod note: A few deleted. Please see the Guidelines for best practices when participating in a thread. We encourage participation that is respectful and considerate, does not aim to argue with other users, and please remember to speak for yourself, not others.
posted by travelingthyme (staff) at 7:11 PM on July 13, 2023 [5 favorites]
posted by travelingthyme (staff) at 7:11 PM on July 13, 2023 [5 favorites]
One thing I'm seeing a more of is signs posted at clinics and hospitals about zero tolerance for abusive language and the need to treat staff respectfully. I keep wondering is nobody else bothered by those signs being the default, like with a sort of chilling effect (are people allowed to complain or is that disrespectful?), and so for all this talk about being more client centered, what will actually change in praxis?
posted by polymodus at 7:22 PM on July 13, 2023 [7 favorites]
posted by polymodus at 7:22 PM on July 13, 2023 [7 favorites]
I have had a bad year. 6 surgeries so far with 2-4 still to come. And most of my doctors have been surgeons. And they have, except for the plastic/reconstruction guy been very empathetic and good. Some of the random attendings that came by, especially that one guy who always came by at 6 in the morning when I was in the hospital, he was pretty lame...
But, I am an old, cis-het white male, so I may get more understanding than others do. But my symptoms and treatment were pretty obvious, (get in there, cut out the flesh that is infected and killing him, put him in the ICU on a ventilator and hope for the best!). And it worked.
I've spent over a year in pain/discomfort/grossness, and getting surgeon 3 involved has meant it's going to be months now until my shit can be fixed, which I am very unhappy about, but I have been very pleased with the way I have been handled by my doctors. Except for the logistics. Takes so long to get an appointment for what doctor A ordered, and doctor C wants stuff ordered as well, and, well, etc.
And thank god for my nurses, who had to do all the nasty heavy lifting. Well, except for the one who turned on me and got mean, and the CNA who rinsed out my colostomy bag with my drinking water in the cup on my tray... yikes.
I agree that women get the short end of the stick in patient/doctor relations. Which sucks. And there is a long history of women's symptoms being "hysterical". But isn't this training a better thing than continuing down the same historical path that has gotten us here?
And yes, there are Associations that are questionable.
Anyway. More empathetic doctors that are being taught to actually listen seems like a good thing.
posted by Windopaene at 7:39 PM on July 13, 2023 [4 favorites]
But, I am an old, cis-het white male, so I may get more understanding than others do. But my symptoms and treatment were pretty obvious, (get in there, cut out the flesh that is infected and killing him, put him in the ICU on a ventilator and hope for the best!). And it worked.
I've spent over a year in pain/discomfort/grossness, and getting surgeon 3 involved has meant it's going to be months now until my shit can be fixed, which I am very unhappy about, but I have been very pleased with the way I have been handled by my doctors. Except for the logistics. Takes so long to get an appointment for what doctor A ordered, and doctor C wants stuff ordered as well, and, well, etc.
And thank god for my nurses, who had to do all the nasty heavy lifting. Well, except for the one who turned on me and got mean, and the CNA who rinsed out my colostomy bag with my drinking water in the cup on my tray... yikes.
I agree that women get the short end of the stick in patient/doctor relations. Which sucks. And there is a long history of women's symptoms being "hysterical". But isn't this training a better thing than continuing down the same historical path that has gotten us here?
And yes, there are Associations that are questionable.
Anyway. More empathetic doctors that are being taught to actually listen seems like a good thing.
posted by Windopaene at 7:39 PM on July 13, 2023 [4 favorites]
Those signs, polymodus -- as a datapoint, when I was on in-clinic hemodialysis, I personally saw patients hit and scream at the nurses and technicians, and it took multiple events of this happening before the clinic intervened. I mean... it's kind of an emotionally charged place where people are very, VERY sick and often in pain. Pain dramatically changes people's behavior. More than once I saw someone going through active psychosis during a session.
So we had a signed code of conduct. This was handled very differently from the standard complaint or grievance process, which was pretty much the fill-this-form, meet-with-the director, make-this-change sort of thing.
posted by mochapickle at 7:40 PM on July 13, 2023 [4 favorites]
So we had a signed code of conduct. This was handled very differently from the standard complaint or grievance process, which was pretty much the fill-this-form, meet-with-the director, make-this-change sort of thing.
posted by mochapickle at 7:40 PM on July 13, 2023 [4 favorites]
One thing I'm seeing more of is signs posted at clinics and hospitals about zero tolerance for abusive language and the need to treat staff respectfully. I keep wondering is nobody else bothered by those signs being the default, like with a sort of chilling effect (are people allowed to complain or is that disrespectful?)
I work in direct patient care, hospital based, in the imaging department. In my experience, these signs started going up in the later part of the worst of the Covid years, as we staff members were experiencing more active hostility from (a few) patients. I've had patients yell right in my face because I politely asked them to please pull their mask up over their nose. I've heard similar stories from coworkers. The intent of the signs wasn't to prevent people from complaining, but to give staff support when dealing with truly abusive language and behavior. It's rare in my department, but it did get worse during the Covid restrictions.
posted by dorey_oh at 7:43 PM on July 13, 2023 [46 favorites]
I work in direct patient care, hospital based, in the imaging department. In my experience, these signs started going up in the later part of the worst of the Covid years, as we staff members were experiencing more active hostility from (a few) patients. I've had patients yell right in my face because I politely asked them to please pull their mask up over their nose. I've heard similar stories from coworkers. The intent of the signs wasn't to prevent people from complaining, but to give staff support when dealing with truly abusive language and behavior. It's rare in my department, but it did get worse during the Covid restrictions.
posted by dorey_oh at 7:43 PM on July 13, 2023 [46 favorites]
Patients are, almost by definition, suffering in some way. Even if it's just for an annual physical, they're suffering the anxiety of wondering if this will be the visit that puts them on the road to medical bankruptcy. Or the visit that ultimately ends with some unexpected terminal diagnosis. For the doctor, it's just another day at the office.
Among attorneys (particularly in criminal law, family law, etc), there's a saying: "Remember that when you meet your client for the first time, it is quite possibly on the worst day of their life. And it might be about to get worse." A lot of doctors would do well to remember that, too.
posted by jedicus at 7:46 PM on July 13, 2023 [36 favorites]
Among attorneys (particularly in criminal law, family law, etc), there's a saying: "Remember that when you meet your client for the first time, it is quite possibly on the worst day of their life. And it might be about to get worse." A lot of doctors would do well to remember that, too.
posted by jedicus at 7:46 PM on July 13, 2023 [36 favorites]
I think anyone who works in a customer-facing role has had to deal with those anti-mask/vaxx fuckers. "People are ALLOWED TO HAVE THEIR OWN OPINIONS!!!" What assholes. And I'm not sure how we change that. I can't imaging getting what may be live saving imaging, and then being angry and confrontational about being asked to wear my mask properly. Jesus...
Keep helping people dorey_oh, stay safe, etc.
posted by Windopaene at 7:50 PM on July 13, 2023 [6 favorites]
Keep helping people dorey_oh, stay safe, etc.
posted by Windopaene at 7:50 PM on July 13, 2023 [6 favorites]
Compliance describes purely passive behavior in which patients follow instructions. Non-compliance places blame for treatment failure solely on patients. Adherence is the preferred term, and can be defined as āa process, in which the appropriate treatment is decided after a proper discussion with the patient. It also implies that the patient is under no compulsion to accept a particular treatment, and is not to be held solely responsible for the occurrence of non-adherence.ā Non-adherence may come from many sources, including frustration and legitimate mistrust of health care, structural barriers that limit availability and accessibility of medications (including cost, insurance barriers and pharmacy deserts), time and resource constraints (including work hours, family
responsibilities), and lack of effective communication about severity of disease or symptoms.
From the pdf Advancing Health Equity, I quite like the suggestion of changing terms from non-compliance to non-adherence. Non-compliance always sounded a bit like scolding a naughty child for not takings their medications. Rephrasing to non-adherence is a wider umbrella, including those that may have trouble getting their meds, or not have a full understanding of how and when to take them, etc.
posted by dorey_oh at 7:50 PM on July 13, 2023 [25 favorites]
responsibilities), and lack of effective communication about severity of disease or symptoms.
From the pdf Advancing Health Equity, I quite like the suggestion of changing terms from non-compliance to non-adherence. Non-compliance always sounded a bit like scolding a naughty child for not takings their medications. Rephrasing to non-adherence is a wider umbrella, including those that may have trouble getting their meds, or not have a full understanding of how and when to take them, etc.
posted by dorey_oh at 7:50 PM on July 13, 2023 [25 favorites]
Thanks, Windopaene. Yeah, the hostility certainly wasn't in hospitals only, so much worse I think in lots of other public-facing jobs. It seemed more complicated to deal with, at some level. You can ban a person from the local corner mart, or even a grocery store, for aggressive behavior. Can you ban a person from the hospital? One department only? Most of the time I could deal with it ok, settle things down. Only once did I have a patient (middle aged white woman) who was so verbally aggressive and in my face that, after doing her scan, I emailed my manager about the incident and said that I personally was not willing to care for her again. I didn't hear anything directly back from the manager, but about a week later we had a sign up at reception that stated that aggressive language would not be tolerated. I expect the signs were already in the works, but it did make me feel like I would have support if I refused to scan a non-emergent patient.
On that level, things are better now. Where I am, at least, patients aren't required to wear masks. It's recommended but not required in my department. I'm required to wear one, which is fine with me, and I keep up on vaccinations, so it doesn't really bother me that most patients don't mask up anymore. We still have the signs up, though.
posted by dorey_oh at 8:02 PM on July 13, 2023 [4 favorites]
On that level, things are better now. Where I am, at least, patients aren't required to wear masks. It's recommended but not required in my department. I'm required to wear one, which is fine with me, and I keep up on vaccinations, so it doesn't really bother me that most patients don't mask up anymore. We still have the signs up, though.
posted by dorey_oh at 8:02 PM on July 13, 2023 [4 favorites]
Yeah costs are insnae...
My hospitalization was like 488K thousand dollars. And I get that, but still...
Glad I had decent health insurance with some yearly OOP limits.
I've been trying to get a simple colostomy supply. Some wax/aspic rings that are helpful in preventing leakage. And the company will not do that, without doc authorization, (because insurance bullshit), so I just bought them on amazon, (though they haven't arrived).
Our medical shit is just so fucked up, because, CAPITALISM!!! Ugh
Hugh to all the Mefites that are having to deal with this shit.
posted by Windopaene at 8:36 PM on July 13, 2023 [4 favorites]
My hospitalization was like 488K thousand dollars. And I get that, but still...
Glad I had decent health insurance with some yearly OOP limits.
I've been trying to get a simple colostomy supply. Some wax/aspic rings that are helpful in preventing leakage. And the company will not do that, without doc authorization, (because insurance bullshit), so I just bought them on amazon, (though they haven't arrived).
Our medical shit is just so fucked up, because, CAPITALISM!!! Ugh
Hugh to all the Mefites that are having to deal with this shit.
posted by Windopaene at 8:36 PM on July 13, 2023 [4 favorites]
But isn't this training a better thing than continuing down the same historical path that has gotten us here?
The point of my initial comment is that this training is addressing symptoms of a larger problem, one that isn't being addressed. Is it better than what we have currently have? Yes. But it's still just kicking the can down the road.
When doctors are unable to say "You are sick because [you smoked two packs a day/you did not exercise/you are overweight]" then the problem is not the doctor. The problem is 'you should have bought the protection plan'. The problem is ... you are in denial.
Nobody is saying that, so you can put the strawman down. What people are pointing out is that too often, doctors engage with patients in an adversarial manner, especially when the patient is not white/male/cisgender/of means/skinny - and this results in poor outcomes for the patient. That is a problem with the medical profession, and it needs to be fixed.
Also, smoking - the gains we've made there as a society have been through public health campaigns that have both lessened the number of people who smoke as well as the exposure of the public to smoke in general. Obesity is a public health problem in large part because we have created a society that limits natural exercise while making empty calories cheap and easily available. Trying to pathologize that on the individual level does nothing to address the issue.
posted by NoxAeternum at 8:38 PM on July 13, 2023 [27 favorites]
The point of my initial comment is that this training is addressing symptoms of a larger problem, one that isn't being addressed. Is it better than what we have currently have? Yes. But it's still just kicking the can down the road.
When doctors are unable to say "You are sick because [you smoked two packs a day/you did not exercise/you are overweight]" then the problem is not the doctor. The problem is 'you should have bought the protection plan'. The problem is ... you are in denial.
Nobody is saying that, so you can put the strawman down. What people are pointing out is that too often, doctors engage with patients in an adversarial manner, especially when the patient is not white/male/cisgender/of means/skinny - and this results in poor outcomes for the patient. That is a problem with the medical profession, and it needs to be fixed.
Also, smoking - the gains we've made there as a society have been through public health campaigns that have both lessened the number of people who smoke as well as the exposure of the public to smoke in general. Obesity is a public health problem in large part because we have created a society that limits natural exercise while making empty calories cheap and easily available. Trying to pathologize that on the individual level does nothing to address the issue.
posted by NoxAeternum at 8:38 PM on July 13, 2023 [27 favorites]
Patients are, almost by definition, suffering in some way
"Patient" in Japanese: ę£č kanja . . . quite similar to åæč ninja now that I think about it . . . č is 'sya' (from the Chinese zhÄ) and means "one-who-..".
åæ is 'endure' and ę£ is 'suffer' . . .
posted by Heywood Mogroot III at 8:40 PM on July 13, 2023 [3 favorites]
"Patient" in Japanese: ę£č kanja . . . quite similar to åæč ninja now that I think about it . . . č is 'sya' (from the Chinese zhÄ) and means "one-who-..".
åæ is 'endure' and ę£ is 'suffer' . . .
posted by Heywood Mogroot III at 8:40 PM on July 13, 2023 [3 favorites]
hey thank you, dorey_oh and MexicanYenta (and your partner). keep up the good works. you make a difference - for the better - every day.
posted by lapolla at 8:49 PM on July 13, 2023 [13 favorites]
posted by lapolla at 8:49 PM on July 13, 2023 [13 favorites]
I don't know - I come from the public health end, and I work adjacent to (US) federal policy on health care, especially federsl health care IT.
You'll start to see more SDOH questions- they (onc) just published a draft rule making changes in the way certain information is collected - and they're the ones regulating the health IT vendors (epic, cerner, the other computer systems providers use for documentation and electronic referrals, prescribing, billing, etc).
I know public health wants those SDOH data desperately because that could help us demonstrate funding need, argue for more food stamps, housing, and I hope UBI! They'll also let us clearly connect poor health outcomes we see today to the lack of resources and discrimination that are the 'upstream' drivers of health.
What really matters on a group/social level is all the shit outside of the provider's office, but we've refused to prioritize public health over our profit-driven health care system.
So health care sees the writing on the wall that the feds are willing to throw money their way if the collect that (sdoh) data, and then use it to get extra payments from CMS if their populations are more disadvantaged. (Onc incentivuzes certain software functionality, then CMS pays providers and hospitals for meeeting certain measures often requiring that functionality - for example, this is why your providers have pushed so hard for you to sign up for online access to their systems (ie mychart, others) - that's a cms measure with extra monwy going to providers/hospitals if they can get a certain percentage of patients to use it).
The feds are trying to do the same thing with rural health care, black maternal mortality and morbidity, community access hospitals.
But you know what the feds can't or won't do?
They can't price cap, negotiate and set prices (or services or drugs) across the board (including for private insurance) the way germany does, and they have a limited and steadily shrinking ability to impact medicaid and Medicare pricing (thank you Medicare advantage, you over-billing and deep-pocketed assholes).
Why? There's obvious levers that the feds could use to improve care for all of us. It can't be blamed on providers, though their biases do *plenty* of harm (black maternal mortality, under-treating pain in black people, women, and I don't know the research in the last one, but I'd bet low-income patients. They ignore symptoms and (medical) problems because they're inconvenient, complex, and there often aren't easy answers even once you've got a diagnosis, if there's even a test. Anyway, I'm not letting providers off the hook, but I think the drivers for extraction and poor quality (ie late stage capitalism extraction of work for diminishing pay) are uphill.
The CEOs, CIOs, COOs, etc, and their deputies, chairs, and the accounting machinery that ensures health care as a sector is wildly profitable may (and do!) really care as individuals. They want to make patients healthier, but what drives their day-to-day decision making is about loss avoidance (lawsuits, insurance, not extracting every possible cent from payors) and return on investment (increasing billing, better rates from private insurance, mergers and acquisitions to decrease competition, doing their best to stay out of the news for understaffing, patient harms, lawsuits, etc.).
Look at VC investment in health care - it's terrifying. We've seen what that funding model does to other industries - they see lots of places to 'trim fat' (with violent nausea of using that analogy for care of our parents, children, friends, unhoused neighbors, uber drivers, and students).
That same 'return on investment' logic is there now, but mitigated to a small degree by people who care, and may remember a time when health care was less extractive. Ownership by equity means stripping value and maximizing return on their short-term investment, which doesn't consider patient health, maintainance, provider burnout, adequate staffing, and other things required to keep the hospital functional.
I don't have anything new - unionize (everyone, including doctors, residents, specialists, and omg nurses, aids, etc) and somehow vote in single-payer health care. We are all in the same (sinking) boat and need to act like it.
We know single-payer health care isn't perfect (hi Canada and NHS!) but it costs 1/4th what our predatory private system costs! And we have worse outcomes! https://www.latimes.com/science/story/2020-01-07/u-s-health-system-costs-four-times-more-than-canadas-single-payer-system Inequality is terrible for everyone, including those at the top (Spirit Level is a fascinating read showing that at a country level).
Point of this novel of a comment is that docs are under the same pressures as the rest of us, so support unions and vote your faces off.
The work being done in the SDOH area isn't including plans beyond data collection - like how to give money to patients -directly- to improve low SES (socioeconomic status). There aren't solutions to help people more negatively impacted by SDOH (lgbtqi+, black, fem, etc), we're just collecting data.
Our private health care system disincentivizes impacting upstream determants of health - CMS is trying surprisingly hard to expand what counts as 'treatment' to find a cost-neutral or cost-saving way to provide housing and healthy food. Uber and Lyft have large and growing plans to work with hospitals and insurers to bill for transportation to medical appointments (not sure if they're involved with the CMS pilots though). I find it sickly fascinating that now that it will make money for someone, health care is willing to pay for patient transportation and meds delivery. Cms is willing to pay for it because they've known it was a problem but can't 'make' heath care do anything - everything the feds do in this policy space is voluntary.
Anyway - everyone in the US will see more SDOH questions in future intake forms, but outside of data analysis and use for internal agency funding allocation and grant applications, for people who can get that agregate data, there aren't clear levers to do anything with it.
The costs of housing, food, transport, and UBI mean even if we can clearly illustrate insane death rates (omg black birth mortality rates, it's shameful that we and our politicians aren't losing their minds about that), the cost savings to our -private health care system- won't be sufficient to get money directly ro the people who need it.
There will be pilots (there have been, for years!), and they'll probably show minor improvements in certain populations, at least some of the time, which is why I think health care is going so hard for SDOH. They're hoping for heartwarming stories and 'sucesses' to loudly trumpet and keep attention off steady-to-worsening health of their service populations).
posted by esoteric things at 9:02 PM on July 13, 2023 [12 favorites]
You'll start to see more SDOH questions- they (onc) just published a draft rule making changes in the way certain information is collected - and they're the ones regulating the health IT vendors (epic, cerner, the other computer systems providers use for documentation and electronic referrals, prescribing, billing, etc).
I know public health wants those SDOH data desperately because that could help us demonstrate funding need, argue for more food stamps, housing, and I hope UBI! They'll also let us clearly connect poor health outcomes we see today to the lack of resources and discrimination that are the 'upstream' drivers of health.
What really matters on a group/social level is all the shit outside of the provider's office, but we've refused to prioritize public health over our profit-driven health care system.
So health care sees the writing on the wall that the feds are willing to throw money their way if the collect that (sdoh) data, and then use it to get extra payments from CMS if their populations are more disadvantaged. (Onc incentivuzes certain software functionality, then CMS pays providers and hospitals for meeeting certain measures often requiring that functionality - for example, this is why your providers have pushed so hard for you to sign up for online access to their systems (ie mychart, others) - that's a cms measure with extra monwy going to providers/hospitals if they can get a certain percentage of patients to use it).
The feds are trying to do the same thing with rural health care, black maternal mortality and morbidity, community access hospitals.
But you know what the feds can't or won't do?
They can't price cap, negotiate and set prices (or services or drugs) across the board (including for private insurance) the way germany does, and they have a limited and steadily shrinking ability to impact medicaid and Medicare pricing (thank you Medicare advantage, you over-billing and deep-pocketed assholes).
Why? There's obvious levers that the feds could use to improve care for all of us. It can't be blamed on providers, though their biases do *plenty* of harm (black maternal mortality, under-treating pain in black people, women, and I don't know the research in the last one, but I'd bet low-income patients. They ignore symptoms and (medical) problems because they're inconvenient, complex, and there often aren't easy answers even once you've got a diagnosis, if there's even a test. Anyway, I'm not letting providers off the hook, but I think the drivers for extraction and poor quality (ie late stage capitalism extraction of work for diminishing pay) are uphill.
The CEOs, CIOs, COOs, etc, and their deputies, chairs, and the accounting machinery that ensures health care as a sector is wildly profitable may (and do!) really care as individuals. They want to make patients healthier, but what drives their day-to-day decision making is about loss avoidance (lawsuits, insurance, not extracting every possible cent from payors) and return on investment (increasing billing, better rates from private insurance, mergers and acquisitions to decrease competition, doing their best to stay out of the news for understaffing, patient harms, lawsuits, etc.).
Look at VC investment in health care - it's terrifying. We've seen what that funding model does to other industries - they see lots of places to 'trim fat' (with violent nausea of using that analogy for care of our parents, children, friends, unhoused neighbors, uber drivers, and students).
That same 'return on investment' logic is there now, but mitigated to a small degree by people who care, and may remember a time when health care was less extractive. Ownership by equity means stripping value and maximizing return on their short-term investment, which doesn't consider patient health, maintainance, provider burnout, adequate staffing, and other things required to keep the hospital functional.
I don't have anything new - unionize (everyone, including doctors, residents, specialists, and omg nurses, aids, etc) and somehow vote in single-payer health care. We are all in the same (sinking) boat and need to act like it.
We know single-payer health care isn't perfect (hi Canada and NHS!) but it costs 1/4th what our predatory private system costs! And we have worse outcomes! https://www.latimes.com/science/story/2020-01-07/u-s-health-system-costs-four-times-more-than-canadas-single-payer-system Inequality is terrible for everyone, including those at the top (Spirit Level is a fascinating read showing that at a country level).
Point of this novel of a comment is that docs are under the same pressures as the rest of us, so support unions and vote your faces off.
The work being done in the SDOH area isn't including plans beyond data collection - like how to give money to patients -directly- to improve low SES (socioeconomic status). There aren't solutions to help people more negatively impacted by SDOH (lgbtqi+, black, fem, etc), we're just collecting data.
Our private health care system disincentivizes impacting upstream determants of health - CMS is trying surprisingly hard to expand what counts as 'treatment' to find a cost-neutral or cost-saving way to provide housing and healthy food. Uber and Lyft have large and growing plans to work with hospitals and insurers to bill for transportation to medical appointments (not sure if they're involved with the CMS pilots though). I find it sickly fascinating that now that it will make money for someone, health care is willing to pay for patient transportation and meds delivery. Cms is willing to pay for it because they've known it was a problem but can't 'make' heath care do anything - everything the feds do in this policy space is voluntary.
Anyway - everyone in the US will see more SDOH questions in future intake forms, but outside of data analysis and use for internal agency funding allocation and grant applications, for people who can get that agregate data, there aren't clear levers to do anything with it.
The costs of housing, food, transport, and UBI mean even if we can clearly illustrate insane death rates (omg black birth mortality rates, it's shameful that we and our politicians aren't losing their minds about that), the cost savings to our -private health care system- won't be sufficient to get money directly ro the people who need it.
There will be pilots (there have been, for years!), and they'll probably show minor improvements in certain populations, at least some of the time, which is why I think health care is going so hard for SDOH. They're hoping for heartwarming stories and 'sucesses' to loudly trumpet and keep attention off steady-to-worsening health of their service populations).
posted by esoteric things at 9:02 PM on July 13, 2023 [12 favorites]
(In case some people may not know the "SDOH" acronym: "social determinants of health," which can be things like poverty, food access, exposure to pollutants/environmental racism, all the different ways your neighborhood does or doesn't support your health, etc, etc, etc...)
posted by Jeanne at 9:10 PM on July 13, 2023 [10 favorites]
posted by Jeanne at 9:10 PM on July 13, 2023 [10 favorites]
The last time I had a doctor tell me my problem was that I was overweight, he (older white dude) wasn't bothering to pay attention to the markers in my bloodwork that had changed significantly since my visit two years before. Probably since the year before too, but since someone in his office had failed to enter that result into their online system, I couldn't check against that value. Meanwhile since that last result in the system, the too-high value had gone from slightly above "healthy normal" to not quite 250% of healthy normal while my weight remained roughly the same.
I fired him and got a new doctor in his specialty for the care I needed. I'm glad I have the privilege/luck/medical insurance to do that. (I did not say anything nasty or unpleasant to his face, just cancelled my next appointment and moved on.) I do think part of the problem was that for several years I'd been a very easy patient, just see me for 15 minutes every year, do blood work, and update prescriptions as needed, and now I was presenting with an actual problem. Fortunately my new doctor works in a teaching hospital and views "we don't know what's going on" as a challenge instead of a personal insult.
As a chronic illness patient with multiple complicated diagnoses, I've been in and out of specialist offices multiple times every year since I got out of high school. The pressures on (US) doctors are real and I recognize that those pressures are making health care worse, but also there is a lot of attitude about how it's the patient's fault when we live in a country where it's hard to (earn enough money to) take good care of ourselves, to eat well-cooked/healthy food, to exercise, to get enough sleep, to avoid chronic stress. Low pay, bad jobs, the fact that unhealthy processed food is easier to get and eat than healthy food, etc.: that's all systemic and part of late stage capitalism. Individual choices cannot solve systemic problems.
Similarly, the problems with the medical profession are systemic (high debt, poor working conditions, etc., aka late stage capitalism) and individual doctors can't really solve them either. I wish I had a solution better than voting and calling my elected officials and occasionally throwing some money at groups trying to solve the problem, but that's all I've got.
posted by gentlyepigrams at 9:17 PM on July 13, 2023 [15 favorites]
I fired him and got a new doctor in his specialty for the care I needed. I'm glad I have the privilege/luck/medical insurance to do that. (I did not say anything nasty or unpleasant to his face, just cancelled my next appointment and moved on.) I do think part of the problem was that for several years I'd been a very easy patient, just see me for 15 minutes every year, do blood work, and update prescriptions as needed, and now I was presenting with an actual problem. Fortunately my new doctor works in a teaching hospital and views "we don't know what's going on" as a challenge instead of a personal insult.
As a chronic illness patient with multiple complicated diagnoses, I've been in and out of specialist offices multiple times every year since I got out of high school. The pressures on (US) doctors are real and I recognize that those pressures are making health care worse, but also there is a lot of attitude about how it's the patient's fault when we live in a country where it's hard to (earn enough money to) take good care of ourselves, to eat well-cooked/healthy food, to exercise, to get enough sleep, to avoid chronic stress. Low pay, bad jobs, the fact that unhealthy processed food is easier to get and eat than healthy food, etc.: that's all systemic and part of late stage capitalism. Individual choices cannot solve systemic problems.
Similarly, the problems with the medical profession are systemic (high debt, poor working conditions, etc., aka late stage capitalism) and individual doctors can't really solve them either. I wish I had a solution better than voting and calling my elected officials and occasionally throwing some money at groups trying to solve the problem, but that's all I've got.
posted by gentlyepigrams at 9:17 PM on July 13, 2023 [15 favorites]
IndelibleUnderpants, if you are interested, this excellent ProPublica article lays out the causes and effects surrounding JaMarcus Crews, a kidney patient for whom SDoH and systemic biases in healthcare led to a catastrophic end. It's long but I promise it's worth your time.
Crews and I had VERY different outcomes, largely based on our life circumstances. We were both second-generation dialysis patients. But I'm a white lady in Colorado. I had a solidly middle-class upbringing, a resume filled with white collar jobs, and very good insurance. My kidney failure was due to a brutal hereditary illness, not brutal diabetes. And I'm not exaggerating when I say I was practically given a gilded invitation to join the transplant list, at both the urging of my doctors and with the full encouragement of DaVita itself.
I received a transplant 11 weeks before Crews died waiting for one.
Reading this story, I'm not sure what Crews could have done differently, even in hindsight. He did everything he could, and he deserved so much better.
This issue isn't just about the words we use -- it's about how the words we use are tied to longstanding inequities in the way healthcare is delivered. Crews' story is an example of this result.
posted by mochapickle at 10:15 PM on July 13, 2023 [33 favorites]
Crews and I had VERY different outcomes, largely based on our life circumstances. We were both second-generation dialysis patients. But I'm a white lady in Colorado. I had a solidly middle-class upbringing, a resume filled with white collar jobs, and very good insurance. My kidney failure was due to a brutal hereditary illness, not brutal diabetes. And I'm not exaggerating when I say I was practically given a gilded invitation to join the transplant list, at both the urging of my doctors and with the full encouragement of DaVita itself.
I received a transplant 11 weeks before Crews died waiting for one.
Reading this story, I'm not sure what Crews could have done differently, even in hindsight. He did everything he could, and he deserved so much better.
This issue isn't just about the words we use -- it's about how the words we use are tied to longstanding inequities in the way healthcare is delivered. Crews' story is an example of this result.
posted by mochapickle at 10:15 PM on July 13, 2023 [33 favorites]
Often, the reason is lifestyle (co-comorbidities) but a medical practitioner cannot use (obvious) words to prevent them having a later conversation regarding an outcome.
Phew. Spoken like someone who has never ever been in front of a doctor while even modestly overweight.
posted by praemunire at 10:58 PM on July 13, 2023 [25 favorites]
Phew. Spoken like someone who has never ever been in front of a doctor while even modestly overweight.
posted by praemunire at 10:58 PM on July 13, 2023 [25 favorites]
The intent of the signs wasn't to prevent people from complaining, but to give staff support when dealing with truly abusive language and behavior.
Well let's unpack that. If the intent is to support staff, then why is the answer to make a sign that tells patients and clients there is "zero tolerance for language and must respect staff"? Support for one group should not come at the expense of creating implicit bias against another group. This shouldn't be run like a bureaucratic high school principal would manage problem students. These are medical institutions based on science and empiricism. And as per the intention of the papers above trying to move to a more progressive approach.
Another way to took at this is that such signage is an "individual solution to a structural problem". There's a thread from yesterday about that problematic concept.
And for reference, there actually are academic studies written by medical researchers who explain why such signage is anti-health. I remember one author that found the signs don't in fact help staff feel more safe, based on surveys. Another warned that such signage tends to silence clients, which becomes counterproductive, and that this goes against medical ethics. One can easily google the research, which I imagine is in line with the more progressive approaches that the whitepapers in the OP propose. The Ontario Medical Association president has discussed this issue on his blog/book (https://shawnwhatley.com/zero-tolerance/), and he critically points out:
Well let's unpack that. If the intent is to support staff, then why is the answer to make a sign that tells patients and clients there is "zero tolerance for language and must respect staff"? Support for one group should not come at the expense of creating implicit bias against another group. This shouldn't be run like a bureaucratic high school principal would manage problem students. These are medical institutions based on science and empiricism. And as per the intention of the papers above trying to move to a more progressive approach.
Another way to took at this is that such signage is an "individual solution to a structural problem". There's a thread from yesterday about that problematic concept.
And for reference, there actually are academic studies written by medical researchers who explain why such signage is anti-health. I remember one author that found the signs don't in fact help staff feel more safe, based on surveys. Another warned that such signage tends to silence clients, which becomes counterproductive, and that this goes against medical ethics. One can easily google the research, which I imagine is in line with the more progressive approaches that the whitepapers in the OP propose. The Ontario Medical Association president has discussed this issue on his blog/book (https://shawnwhatley.com/zero-tolerance/), and he critically points out:
Should professionals, trained at managing the emotions of all kinds of emergency situations, need to have giant posters telling patients what they will not tolerate? Is there a chance that zero tolerance promotes callous and pitiless treatment of patients?And see the broad-minded admonishment of this policy position (https://web.mhanet.com/media-library/hospital-signage-outlining-behavioral-expectations-in-a-health-care-environment/):
In schools, zero tolerance fosters the opposite approach that behavioural concerns require. ...
A recent article in Nursing Times suggests the same thing: Do Zero Tolerance Policies Deskill Nurses? Zero tolerance policies assume that dealing with aggression is not part of a healthcare professionalās job.
Hospitals increasingly look for ways to deter patients and visitors from engaging in aggressive or violent behavior toward staff. When considering posting signs or other notices referencing policies against violence, hospitals must consider whether they could be interpreted to deter patients from coming to the emergency department. The Centers for Medicare & Medicaid Services previously condemned signs it determined could discourage patients from seeking emergency care, in violation of the Emergency Medical Treatment and Labor Act. MHA recommends hospitals use positive messages that encourage a healing environment instead of focusing on aberrant behavior by patients and visitors.posted by polymodus at 11:46 PM on July 13, 2023 [11 favorites]
I am:
-Fat (and meds made me gain substantially more weight)
-Physically disabled
-A woman
-Mentally ill
-On the kind of drugs that are legal, but no one will give you if your lifeās not at risk
Iāve had doctors be wonderful and save my life, but Iāve also had them:
-body-shame me so much that I didnāt see a PCP for 8 years
-steal the meds I need to live when there was no way for me to get more
-send me home with Advil after my tubes were removed. (They did the same to a friend after her C-SECTION.)
-And these are just the parts it takes only a line or two to explain. There are so many awful stories.
I am very lucky I was stubborn enough to Bartleby the Scrivener my suicidality for 20 years, until the doctors told me we were out of options and I found the most effective treatment Iāve ever had on my own on a 23andMe test and Google Scholar. Turns out I have a vitamin-processing issues that leaves the neurotransmitter-making process with low levels of key ingredients.
Iāve spent enough time dealing with doctors to know that most are trying, but if we donāt completely overhaul not just our health system, but our medical education system (weeding out everyone who canāt work crazy hours on no sleep means thereās a certain attitude towards perceived weakness and leads doctors to think non-adherence is the sole fault of the patient.) This isnāt just any system, this is the system that holds life and functionality in its hands, and we as a society need to fix it or more people will die. Because everything that happened to me, happened to a cis white woman giving off educated, upper-middle class signals. I canāt imagine how doctors treat everyone else.
posted by vim876 at 3:42 AM on July 14, 2023 [17 favorites]
-Fat (and meds made me gain substantially more weight)
-Physically disabled
-A woman
-Mentally ill
-On the kind of drugs that are legal, but no one will give you if your lifeās not at risk
Iāve had doctors be wonderful and save my life, but Iāve also had them:
-body-shame me so much that I didnāt see a PCP for 8 years
-steal the meds I need to live when there was no way for me to get more
-send me home with Advil after my tubes were removed. (They did the same to a friend after her C-SECTION.)
-And these are just the parts it takes only a line or two to explain. There are so many awful stories.
I am very lucky I was stubborn enough to Bartleby the Scrivener my suicidality for 20 years, until the doctors told me we were out of options and I found the most effective treatment Iāve ever had on my own on a 23andMe test and Google Scholar. Turns out I have a vitamin-processing issues that leaves the neurotransmitter-making process with low levels of key ingredients.
Iāve spent enough time dealing with doctors to know that most are trying, but if we donāt completely overhaul not just our health system, but our medical education system (weeding out everyone who canāt work crazy hours on no sleep means thereās a certain attitude towards perceived weakness and leads doctors to think non-adherence is the sole fault of the patient.) This isnāt just any system, this is the system that holds life and functionality in its hands, and we as a society need to fix it or more people will die. Because everything that happened to me, happened to a cis white woman giving off educated, upper-middle class signals. I canāt imagine how doctors treat everyone else.
posted by vim876 at 3:42 AM on July 14, 2023 [17 favorites]
In 22 years I've never heard a patient say, "hey I understand, Doc. You're a person too, maybe you had a fight wife with your wife this morning, or maybe you're at the end of a 36-hour shift. Either way, I'll give you the benefit of the doubt this time, and hope next time things go better"
This is something for FRIENDS to say if you snapped at them when you're out having a beer or something.
Patients are customers, not friends.
posted by EmpressCallipygos at 4:32 AM on July 14, 2023 [14 favorites]
This is something for FRIENDS to say if you snapped at them when you're out having a beer or something.
Patients are customers, not friends.
posted by EmpressCallipygos at 4:32 AM on July 14, 2023 [14 favorites]
Getting back to the original publications linked in BadgerDoctor's post....
I don't know, man. In about 2 weeks, the brand-new first-year medical students are going to step on campus, all bright-eyed and bushy-tailed. (Those early weeks are so precious. Seriously, they are like adorable little bunny rabbits, just before they get hounded half-to-death for the next 7-10 years of their life. I've written before about being a woman physician of color in healthcare spaces, and the Milgram experiment that is medical education.)
Anyway I'm giving a talk in week 2 about "patient-centered communication" and clinical documentation, so I was eager to find some fresh examples in these documents. But while I strongly agree with the principles that generated the report (social determinants of health and historical/structural racism as the primary drivers of chronic disease in general and health inequities in particular), the examples they give are just ... bad.
Like, on p.20 of the AMA/AAMC publication, they write that instead of "Low-income people have the highest level of coronary artery disease in the United States," a textbook/lecture/grant/article should say "People underpaid and forced into poverty as a result of banking policies, real estate developers gentrifying neighborhoods, and corporations weakening the power of labor movements, among others, have the highest level of coronary artery disease in the United States."
That is possibly the most convoluted sentence I've read since I got lost in The Sound and the Fury looking for a close-parenthesis. Like what's with that "among others"? I take it they mean other, unspecified economic forces, but it can equally be read as other people who are not underpaid/forced into poverty etc etc. At least the first, "bad" example directly ties income with heart disease; it's punchy and easy to parse. And even in the "good" example, the people are totally passive, like pawns of banks and developers and corporations. Not to mention that articles and grants have word limits! (I am working on one right now with a character limit, including spaces!)
I like what they are trying to do, and the stuff at the end about changing the dominant narratives of race and individualism is solid, but I'm gonna look elsewhere for my examples. Lord knows I see enough weird-ass language in referring physicians' notes.
posted by basalganglia at 4:35 AM on July 14, 2023 [10 favorites]
I don't know, man. In about 2 weeks, the brand-new first-year medical students are going to step on campus, all bright-eyed and bushy-tailed. (Those early weeks are so precious. Seriously, they are like adorable little bunny rabbits, just before they get hounded half-to-death for the next 7-10 years of their life. I've written before about being a woman physician of color in healthcare spaces, and the Milgram experiment that is medical education.)
Anyway I'm giving a talk in week 2 about "patient-centered communication" and clinical documentation, so I was eager to find some fresh examples in these documents. But while I strongly agree with the principles that generated the report (social determinants of health and historical/structural racism as the primary drivers of chronic disease in general and health inequities in particular), the examples they give are just ... bad.
Like, on p.20 of the AMA/AAMC publication, they write that instead of "Low-income people have the highest level of coronary artery disease in the United States," a textbook/lecture/grant/article should say "People underpaid and forced into poverty as a result of banking policies, real estate developers gentrifying neighborhoods, and corporations weakening the power of labor movements, among others, have the highest level of coronary artery disease in the United States."
That is possibly the most convoluted sentence I've read since I got lost in The Sound and the Fury looking for a close-parenthesis. Like what's with that "among others"? I take it they mean other, unspecified economic forces, but it can equally be read as other people who are not underpaid/forced into poverty etc etc. At least the first, "bad" example directly ties income with heart disease; it's punchy and easy to parse. And even in the "good" example, the people are totally passive, like pawns of banks and developers and corporations. Not to mention that articles and grants have word limits! (I am working on one right now with a character limit, including spaces!)
I like what they are trying to do, and the stuff at the end about changing the dominant narratives of race and individualism is solid, but I'm gonna look elsewhere for my examples. Lord knows I see enough weird-ass language in referring physicians' notes.
posted by basalganglia at 4:35 AM on July 14, 2023 [10 favorites]
Patients are customers
... is what the bean-counters at my institution say. (Actually, they point out that the insurance company is the customer.) Divorce healthcare from capitalist metaphors; patients are patients.
Vulnerability in clinical encounters isn't always clear-cut, especially when, like me, you are a petite woman of color trying to examine a 6'2" white Veteran who liberally uses the n-word and the g-word (that one had to be explained to me by a colleague). That said, 99% of the time the patient is having a worse day than the doctor; a fight with your spouse doesn't exactly compare to "It's malignant."
posted by basalganglia at 4:49 AM on July 14, 2023 [19 favorites]
... is what the bean-counters at my institution say. (Actually, they point out that the insurance company is the customer.) Divorce healthcare from capitalist metaphors; patients are patients.
Vulnerability in clinical encounters isn't always clear-cut, especially when, like me, you are a petite woman of color trying to examine a 6'2" white Veteran who liberally uses the n-word and the g-word (that one had to be explained to me by a colleague). That said, 99% of the time the patient is having a worse day than the doctor; a fight with your spouse doesn't exactly compare to "It's malignant."
posted by basalganglia at 4:49 AM on July 14, 2023 [19 favorites]
I want to preface this by saying I am a normal American and hate doctors and wish only the most floridly horrific things for them and their chiseling kind. HOWEVER, there is a contradiction between these two ideas:
- Health care should be free at point of service.
- The doctor should under all circumstances treat you like a high end paying American customer, to the point where they shouldn't put up "do not yell at me" signs on the walls because that is infringing on the customer rights of patients who want to yell at the doctor.
Fortunately this is all academic because there is no way in hell that your elected representative is going to give up a house, a boat, a vacation, and their reelection money to help some broke stranger who's mad on the Internet. That's why the American insurance system still exists.
There's always crystals.
posted by kingdead at 5:11 AM on July 14, 2023 [3 favorites]
- Health care should be free at point of service.
- The doctor should under all circumstances treat you like a high end paying American customer, to the point where they shouldn't put up "do not yell at me" signs on the walls because that is infringing on the customer rights of patients who want to yell at the doctor.
Fortunately this is all academic because there is no way in hell that your elected representative is going to give up a house, a boat, a vacation, and their reelection money to help some broke stranger who's mad on the Internet. That's why the American insurance system still exists.
There's always crystals.
posted by kingdead at 5:11 AM on July 14, 2023 [3 favorites]
One thing I'm seeing more of is signs posted at clinics and hospitals about zero tolerance for abusive language and the need to treat staff respectfully. I keep wondering is nobody else bothered by those signs being the default, like with a sort of chilling effect (are people allowed to complain or is that disrespectful?)
They're there because patients will verbally abuse staff who are not doctors. They will cuss at us, threaten us, and cause us to call security. And here's the kicker: the patients don't care about the signs. It's not like they work.
You want to yell at your doctor? Go ham. But christ on a cracker, we do not make their money as receptionists. We have so very little control over, well, anything. So don't harass us.
Morale for the predominantly female admin staff I work with is low. Low because there are no repercussions for patients who threaten us, who have followed some of us after work to our cars. Sometimes if the doctor has had enough of their behaviour--all charted--they will "fire" the patient. (No small thing currently in Ontario's healthcare system where family doctors are at all time low.) But this is rare. Mostly they get a talking to.
posted by Kitteh at 5:37 AM on July 14, 2023 [16 favorites]
They're there because patients will verbally abuse staff who are not doctors. They will cuss at us, threaten us, and cause us to call security. And here's the kicker: the patients don't care about the signs. It's not like they work.
You want to yell at your doctor? Go ham. But christ on a cracker, we do not make their money as receptionists. We have so very little control over, well, anything. So don't harass us.
Morale for the predominantly female admin staff I work with is low. Low because there are no repercussions for patients who threaten us, who have followed some of us after work to our cars. Sometimes if the doctor has had enough of their behaviour--all charted--they will "fire" the patient. (No small thing currently in Ontario's healthcare system where family doctors are at all time low.) But this is rare. Mostly they get a talking to.
posted by Kitteh at 5:37 AM on July 14, 2023 [16 favorites]
I don't know if anyone has mentioned this yet, but private equity firms are buying up physicians groups at a rapid rate.
posted by DJZouke at 5:37 AM on July 14, 2023 [8 favorites]
posted by DJZouke at 5:37 AM on July 14, 2023 [8 favorites]
- The doctor should under all circumstances treat you like a high end paying American customer, to the point where they shouldn't put up "do not yell at me" signs on the walls because that is infringing on the customer rights of patients who want to yell at the doctor.
The thing about this is, I think it's necessary to consider in a broader context what effect these kinds of signs have on all kinds of people, including people who are definitely not going to yell at the health care workers.
If you're used to being disbelieved, condescended to, dismissed, you might think, "How much am I going to be able to push back against what I'm being told before my pushback gets me dismissed as angry and abusive?" - and that might be especially true if racism (for example) leads other people to unfairly characterize you as being scary or angry or intimidating.
These kinds of signs have the potential to set up an adversarial relationship between patients and health care workers, especially when patients are already in a position of being vulnerable, worried, in pain.
I'm thinking of times like when I went to the emergency room for a broken finger, and they sent me up for an orthopedic consult (it turned out to be a benign bone tumor for which I eventually needed surgery), and when I went to the desk to check in the receptionist said (quite harshly) "We know you're here, sit down." And so I waited for maybe an hour or so, and I went back up to the desk, and they said "Oh, why didn't you check in when you got here?"
It's just so easy to make people feel disempowered. And I know I am more anxious than average, and not everybody is carrying around a feeling of "I am going to break a Rule, and there will be Horrible Consequences," but pre-emptive signage tends to make people like me more anxious and afraid to advocate for themselves, while not dissuading people who are going to yell either because they're rude entitled assholes or because they're frustrated and in pain and at the end of their rope.
posted by Jeanne at 7:29 AM on July 14, 2023 [21 favorites]
The thing about this is, I think it's necessary to consider in a broader context what effect these kinds of signs have on all kinds of people, including people who are definitely not going to yell at the health care workers.
If you're used to being disbelieved, condescended to, dismissed, you might think, "How much am I going to be able to push back against what I'm being told before my pushback gets me dismissed as angry and abusive?" - and that might be especially true if racism (for example) leads other people to unfairly characterize you as being scary or angry or intimidating.
These kinds of signs have the potential to set up an adversarial relationship between patients and health care workers, especially when patients are already in a position of being vulnerable, worried, in pain.
I'm thinking of times like when I went to the emergency room for a broken finger, and they sent me up for an orthopedic consult (it turned out to be a benign bone tumor for which I eventually needed surgery), and when I went to the desk to check in the receptionist said (quite harshly) "We know you're here, sit down." And so I waited for maybe an hour or so, and I went back up to the desk, and they said "Oh, why didn't you check in when you got here?"
It's just so easy to make people feel disempowered. And I know I am more anxious than average, and not everybody is carrying around a feeling of "I am going to break a Rule, and there will be Horrible Consequences," but pre-emptive signage tends to make people like me more anxious and afraid to advocate for themselves, while not dissuading people who are going to yell either because they're rude entitled assholes or because they're frustrated and in pain and at the end of their rope.
posted by Jeanne at 7:29 AM on July 14, 2023 [21 favorites]
When a patient attacks a nurse with a knife, the first question the nurse gets asked is "What could you have done differently? You should have deescalated." When a patient is attacking another patient, of the nurse does not grab them in exactly the right way based on a class they took a year ago, the nurse gets fired. Notice I said when and not if. I'm glad people are rethinking the signs, they don't seem a great way to protect nurses from being punched in the face because we took too long to bring a cup of water. If you want hospital workers to handle any and all aggression then you are going to have to do more than a four hour class once a year because it is bad out there.
posted by SyraCarol at 7:47 AM on July 14, 2023 [14 favorites]
posted by SyraCarol at 7:47 AM on July 14, 2023 [14 favorites]
I'm disabled, with a lifelong illness, and thus someone for whom interactions with physicians have been part of my life from birth. I'm also otherwise privileged on most axes.
And from my twenty years here on MeFi, especially, as well as some significant conversations elsewhere, it's clear that my experiences with doctors is not even remotely representative of the experiences of others who do not share my privileges. Many people receive very poor health care simply because of who they are.
In the past, I would often talk about how it's important to be an active partner in your health care, but I stopped doing so when I realized that many people are preemptively denied this role and treated like badly behaved children just for needing health care in the first place, even more so if they dare to be assertive.
This vast disparity is inexcusable. It reflects deeply embedded systemic failures in one of the most important aspects of modern life, and is especially egregious given the very nature of health care and the Hippocratic Oath.
posted by Ivan Fyodorovich at 8:04 AM on July 14, 2023 [7 favorites]
And from my twenty years here on MeFi, especially, as well as some significant conversations elsewhere, it's clear that my experiences with doctors is not even remotely representative of the experiences of others who do not share my privileges. Many people receive very poor health care simply because of who they are.
In the past, I would often talk about how it's important to be an active partner in your health care, but I stopped doing so when I realized that many people are preemptively denied this role and treated like badly behaved children just for needing health care in the first place, even more so if they dare to be assertive.
This vast disparity is inexcusable. It reflects deeply embedded systemic failures in one of the most important aspects of modern life, and is especially egregious given the very nature of health care and the Hippocratic Oath.
posted by Ivan Fyodorovich at 8:04 AM on July 14, 2023 [7 favorites]
they shouldn't put up "do not yell at me" signs on the walls because that is infringing on the customer rights of patients who want to yell at the doctor.
As someone who's jumped around the lower-to-middle income scale a bit, seeing that sign tells me instinctively that I am in a place to treat poor people, where the staff feels confident treating the patients like unruly high school students. You don't see those signs in the private wing of Cedars-Sinai. It inspires wariness, not confidence. (Like a metal detector at the door--I recently went to two ERs in two different neighborhoods in rapid succession, and guess which one had the detector [and searched bags] and which didn't?) And I can't imagine that people who want to lose their temper and yell at medical staff (warranted or not, and I cannot say it is never warranted, especially when hospitals are staffed in such a way that if you aren't a squeaky wheel, you could straight-up die for lack of a little grease) would be deterred by a freaking sign.
posted by praemunire at 8:50 AM on July 14, 2023 [6 favorites]
As someone who's jumped around the lower-to-middle income scale a bit, seeing that sign tells me instinctively that I am in a place to treat poor people, where the staff feels confident treating the patients like unruly high school students. You don't see those signs in the private wing of Cedars-Sinai. It inspires wariness, not confidence. (Like a metal detector at the door--I recently went to two ERs in two different neighborhoods in rapid succession, and guess which one had the detector [and searched bags] and which didn't?) And I can't imagine that people who want to lose their temper and yell at medical staff (warranted or not, and I cannot say it is never warranted, especially when hospitals are staffed in such a way that if you aren't a squeaky wheel, you could straight-up die for lack of a little grease) would be deterred by a freaking sign.
posted by praemunire at 8:50 AM on July 14, 2023 [6 favorites]
That is possibly the most convoluted sentence I've read since I got lost in The Sound and the Fury looking for a close-parenthesis.
Yes. I think it is indeed very important to remove slurs and overtly stigmatizing or inappropriately framing language from medical texts, but replacing them all with awkward circumlocutions three times as long is just going to make everything harder to read and to write. Replacing "homeless" with "unhoused" (or, in one of my former professions, "slave" or "slaveowner" with "enslaved person" and "enslaver") works reasonably well because you're not adding six words or, God forbid, two appositive phrases, but you've got to make the cognitive burden worth it.
posted by praemunire at 8:54 AM on July 14, 2023 [2 favorites]
Yes. I think it is indeed very important to remove slurs and overtly stigmatizing or inappropriately framing language from medical texts, but replacing them all with awkward circumlocutions three times as long is just going to make everything harder to read and to write. Replacing "homeless" with "unhoused" (or, in one of my former professions, "slave" or "slaveowner" with "enslaved person" and "enslaver") works reasonably well because you're not adding six words or, God forbid, two appositive phrases, but you've got to make the cognitive burden worth it.
posted by praemunire at 8:54 AM on July 14, 2023 [2 favorites]
As someone who's jumped around the lower-to-middle income scale a bit, seeing that sign tells me instinctively that I am in a place to treat poor people, where the staff feels confident treating the patients like unruly high school students
These signs are in my doctor's office, which is a very middle-of-the road practice with patients primarily middle to upper middle class. They specifically call out that bodily fluids count as assault - i.e., don't spit on your health care provider.
posted by PussKillian at 9:02 AM on July 14, 2023 [5 favorites]
These signs are in my doctor's office, which is a very middle-of-the road practice with patients primarily middle to upper middle class. They specifically call out that bodily fluids count as assault - i.e., don't spit on your health care provider.
posted by PussKillian at 9:02 AM on July 14, 2023 [5 favorites]
The problem is that patients expect patience, empathy, and respect, but never have patience, empathy, or respect for doctors who fail to meet their expectations. In 22 years I've never heard a patient say, "hey I understand, Doc. You're a person too, maybe you had a fight wife with your wife this morning, or maybe you're at the end of a 36-hour shift. Either way, I'll give you the benefit of the doubt this time, and hope next time things go better"
I literally did this a couple of months ago. It did not turn out well.
I had waited nine months for an appointment with an Ear, Nose, and Throat doctor whom I will call Dr. S. His office is in a two-story building in a mini-medical district in the suburbs. When I arrive, I go to the address on the second floor, where I am checked in and wait with the rest of the crowd in the waiting room. It's standing room only. I wait for about a half hour before one of the receptionists call my name. I'm told to go down to an office on the first floor. There, I finally get to sit down, which is a good thing, because I wait for another 90 minutes. The bathrooms in this medical building are absolutely filthy. I've seen nightclub bathrooms that were cleaner.
Finally, I get called back to an exam room, where I wait for another fifteen minutes. Finally, a woman comes in. She is wearing street clothes--no smock, no nametag, nothing--and does not identify herself. She starts asking questions about my health, and I answer. Then I say, "You're not a doctor, are you?"
No, she is a Nurse Practitioner. I don't object. She's clearly had a very busy day. She decides I have a severe sinus infection and asks if I am allergic to penicillin. I say yes. She rattles off a series of instructions: I am to take 3 weeks of the antibiotic she is prescribing, and come back to see her in a month. She also wants me to see an allergist before our next visit, and bring in the results of an allergy test. She says it's important that I not take any medication for two week before the allergy test.
Well, that's impossible, I say. If you want to see me again in four weeks, and I have a three week course of antibiotics to complete, I simply won't have time to comply with the two-week no-medication rule. Besides, it took me nine months to get this appointment. What makes you think I can make an appointment to see an allergist in a month?
That's ridiculous, she says. We have an allergist on the first floor. All you have to do is go downstairs and make an appointment.
"Are they in the basement?" I ask.
"No, they're downstairs! We don't have a basement," she scoffs.
"Ma'am, we're on the first floor," I say.
She lets out a big sigh and says, "I don't know where I am."
"Look, you're clearly overworked and tired," I say. "This is not your fault. There are people making a lot of money by exploiting you. It's OK. I will try to get an allergist appointment and come back in a month Can I see Dr. S. on my second appointment?"
The NP assures me I can. Then I go to the pharmacy, where I wait another hour to get my prescription filled. The pharmacist comes out with a concerned look on his face and says, "Your medical records say you are allergic to penicillin. But your doctor prescribed an antibiotic that is derived from penicillin. There's about a 1 in 1000 chance this medicine will kill you. Do you want me to call your doctor?"
By this time, the doctor's office is closed. I've lost most of a work day, and I don't know if or when the doctor will ever answer the pharmaicst's call. "I talked about it to my doctor (which was not true, I had not talked to an actual doctor) and she said it was OK." So the pharmacist reluctantly filled my script for ten days, with one, ten-day refill. Twenty days is close enough to three weeks, so I figure I'm good.
The antibiotic makes me sick and I get a rash. But I keep taking it. After ten days, I ask for a refill. The pharmacy refuses. At this point, my sinuses are feeling a little better, and I don't have time to deal with any more bullshit. I'll just talk to Dr. S about it when I go back.
Twenty days later, I return to Dr. S.'s office. We do the second-floor, first-floor shuffle again. This time I only have to wait an hour. A different woman enters the exam room. She's wearing a smock, but no name tag. I tell her story of everything that has transpired. She seems baffled. "Let me get your records."
A few minutes later, she returns to the exam room with a printout. When she looks at the second page, her eyes bug out of her head. "You took that antibiotic?"
Well, yeah, because you told me to, and I trusted you. "By the way, are you a doctor?"
"No," she says. "I'll get the nurse you talked to."
So I wait another half hour until the first NP returns. She says "I can't believe you took that antibiotic. The pharmacy should have refused to fill the prescription."
I can't believe what I'm hearing. "I need to see Dr. S. right away," I say.
Dr. S. is not here today, she says.
"Is there a doctor, any doctor, anywhere in the building whom I can talk to?"
No, there is not. But she can make me an appointment to see Dr. S. at some point in the future.
"I already paid you people $150 for this visit. Will that appointment cost another $150? And you promised me the last time I was here that I could see Dr. S. today. How do I know he will be here the next time?"
She promises to refund me my money for this visit, and we go to see the office manager to cancel my credit card transaction. "No, we can't do that because of the 5-minute rule," the office manager says.
I laugh in their faces. "You people can't find your ass with both hands," I say loudly in front of a packed room full of people waiting for their own personal medical mistake. Then I walk out.
posted by vibrotronica at 9:47 AM on July 14, 2023 [21 favorites]
I literally did this a couple of months ago. It did not turn out well.
I had waited nine months for an appointment with an Ear, Nose, and Throat doctor whom I will call Dr. S. His office is in a two-story building in a mini-medical district in the suburbs. When I arrive, I go to the address on the second floor, where I am checked in and wait with the rest of the crowd in the waiting room. It's standing room only. I wait for about a half hour before one of the receptionists call my name. I'm told to go down to an office on the first floor. There, I finally get to sit down, which is a good thing, because I wait for another 90 minutes. The bathrooms in this medical building are absolutely filthy. I've seen nightclub bathrooms that were cleaner.
Finally, I get called back to an exam room, where I wait for another fifteen minutes. Finally, a woman comes in. She is wearing street clothes--no smock, no nametag, nothing--and does not identify herself. She starts asking questions about my health, and I answer. Then I say, "You're not a doctor, are you?"
No, she is a Nurse Practitioner. I don't object. She's clearly had a very busy day. She decides I have a severe sinus infection and asks if I am allergic to penicillin. I say yes. She rattles off a series of instructions: I am to take 3 weeks of the antibiotic she is prescribing, and come back to see her in a month. She also wants me to see an allergist before our next visit, and bring in the results of an allergy test. She says it's important that I not take any medication for two week before the allergy test.
Well, that's impossible, I say. If you want to see me again in four weeks, and I have a three week course of antibiotics to complete, I simply won't have time to comply with the two-week no-medication rule. Besides, it took me nine months to get this appointment. What makes you think I can make an appointment to see an allergist in a month?
That's ridiculous, she says. We have an allergist on the first floor. All you have to do is go downstairs and make an appointment.
"Are they in the basement?" I ask.
"No, they're downstairs! We don't have a basement," she scoffs.
"Ma'am, we're on the first floor," I say.
She lets out a big sigh and says, "I don't know where I am."
"Look, you're clearly overworked and tired," I say. "This is not your fault. There are people making a lot of money by exploiting you. It's OK. I will try to get an allergist appointment and come back in a month Can I see Dr. S. on my second appointment?"
The NP assures me I can. Then I go to the pharmacy, where I wait another hour to get my prescription filled. The pharmacist comes out with a concerned look on his face and says, "Your medical records say you are allergic to penicillin. But your doctor prescribed an antibiotic that is derived from penicillin. There's about a 1 in 1000 chance this medicine will kill you. Do you want me to call your doctor?"
By this time, the doctor's office is closed. I've lost most of a work day, and I don't know if or when the doctor will ever answer the pharmaicst's call. "I talked about it to my doctor (which was not true, I had not talked to an actual doctor) and she said it was OK." So the pharmacist reluctantly filled my script for ten days, with one, ten-day refill. Twenty days is close enough to three weeks, so I figure I'm good.
The antibiotic makes me sick and I get a rash. But I keep taking it. After ten days, I ask for a refill. The pharmacy refuses. At this point, my sinuses are feeling a little better, and I don't have time to deal with any more bullshit. I'll just talk to Dr. S about it when I go back.
Twenty days later, I return to Dr. S.'s office. We do the second-floor, first-floor shuffle again. This time I only have to wait an hour. A different woman enters the exam room. She's wearing a smock, but no name tag. I tell her story of everything that has transpired. She seems baffled. "Let me get your records."
A few minutes later, she returns to the exam room with a printout. When she looks at the second page, her eyes bug out of her head. "You took that antibiotic?"
Well, yeah, because you told me to, and I trusted you. "By the way, are you a doctor?"
"No," she says. "I'll get the nurse you talked to."
So I wait another half hour until the first NP returns. She says "I can't believe you took that antibiotic. The pharmacy should have refused to fill the prescription."
I can't believe what I'm hearing. "I need to see Dr. S. right away," I say.
Dr. S. is not here today, she says.
"Is there a doctor, any doctor, anywhere in the building whom I can talk to?"
No, there is not. But she can make me an appointment to see Dr. S. at some point in the future.
"I already paid you people $150 for this visit. Will that appointment cost another $150? And you promised me the last time I was here that I could see Dr. S. today. How do I know he will be here the next time?"
She promises to refund me my money for this visit, and we go to see the office manager to cancel my credit card transaction. "No, we can't do that because of the 5-minute rule," the office manager says.
I laugh in their faces. "You people can't find your ass with both hands," I say loudly in front of a packed room full of people waiting for their own personal medical mistake. Then I walk out.
posted by vibrotronica at 9:47 AM on July 14, 2023 [21 favorites]
I'm glad people are rethinking the signs, they don't seem a great way to protect nurses from being punched in the face because we took too long to bring a cup of water.
This one made me flinch because on one of my last ER visits accompanying my very in pain husband, I had to ask repeatedly for even a cup so I could get water for him. While staff chatted and laughed and brushed me off.
I know these are different situations. But I read so many small moments here in these comments and think of the times I was anxious and scared and treated as a nuisance. And I stayed polite! Had enough spoons to do so, luckily. Very intrigued by the idea of retiring to a country with kinder overall care.
posted by tiny frying pan at 10:04 AM on July 14, 2023 [4 favorites]
This one made me flinch because on one of my last ER visits accompanying my very in pain husband, I had to ask repeatedly for even a cup so I could get water for him. While staff chatted and laughed and brushed me off.
I know these are different situations. But I read so many small moments here in these comments and think of the times I was anxious and scared and treated as a nuisance. And I stayed polite! Had enough spoons to do so, luckily. Very intrigued by the idea of retiring to a country with kinder overall care.
posted by tiny frying pan at 10:04 AM on July 14, 2023 [4 favorites]
In 22 years I've never heard a patient say, "hey I understand, Doc. You're a person too, maybe you had a fight wife with your wife this morning, or maybe you're at the end of a 36-hour shift. Either way, I'll give you the benefit of the doubt this time, and hope next time things go better"
This is something for FRIENDS to say if you snapped at them when you're out having a beer or something.
Patients are customers, not friends.
I...have been sitting here trying to imagine any medical situation I've ever been in where responding like this to an aggressive or dismissive or unhelpful doctor would have gone over well. Come on. I would not dare. It would be taken as impertinence.
If you'd need to say it in the first place, you already know you're not speaking to a doctor who it would be safe to speak to like that.
posted by BlueNorther at 12:30 PM on July 14, 2023 [13 favorites]
This is something for FRIENDS to say if you snapped at them when you're out having a beer or something.
Patients are customers, not friends.
I...have been sitting here trying to imagine any medical situation I've ever been in where responding like this to an aggressive or dismissive or unhelpful doctor would have gone over well. Come on. I would not dare. It would be taken as impertinence.
If you'd need to say it in the first place, you already know you're not speaking to a doctor who it would be safe to speak to like that.
posted by BlueNorther at 12:30 PM on July 14, 2023 [13 favorites]
Is it really too much to expect that patients give the very things they expect to get?
it isn't true that they don't, on average, but that's beside the point. it is not smart, realistic, or reasonable to expect someone who is sick or injured and effectively helpless to be in control of their affect and personal presentation in the way that someone who is at work and actively working is expected to be. this is not a special fact about medicine, this is just how workplaces do. a doctor who is forced to work when sick or injured deserves to be afforded the same latitude as a patient, although it is their employers who owe it to them, not patients. otherwise, if they wish to be treated with particular kindness and sensitivity, they are invited to come to someone else's place of business and present themselves as clients or customers, where they will be catered to in due course so long as they pay for it, even if they are personally unpleasant. that is how work works.
doctors are notoriously oversensitive to "disrespect," probably because what they often get in place of respect is feigned awe and subservience from patients who have real reason to fear that if they aren't humble, they will suffer for it. unfortunately nobody is as good an actor as they think they are, so it degrades the frightened patient without pleasing the resentful doctor. a waste of time all around.
posted by queenofbithynia at 2:02 PM on July 14, 2023 [14 favorites]
it isn't true that they don't, on average, but that's beside the point. it is not smart, realistic, or reasonable to expect someone who is sick or injured and effectively helpless to be in control of their affect and personal presentation in the way that someone who is at work and actively working is expected to be. this is not a special fact about medicine, this is just how workplaces do. a doctor who is forced to work when sick or injured deserves to be afforded the same latitude as a patient, although it is their employers who owe it to them, not patients. otherwise, if they wish to be treated with particular kindness and sensitivity, they are invited to come to someone else's place of business and present themselves as clients or customers, where they will be catered to in due course so long as they pay for it, even if they are personally unpleasant. that is how work works.
doctors are notoriously oversensitive to "disrespect," probably because what they often get in place of respect is feigned awe and subservience from patients who have real reason to fear that if they aren't humble, they will suffer for it. unfortunately nobody is as good an actor as they think they are, so it degrades the frightened patient without pleasing the resentful doctor. a waste of time all around.
posted by queenofbithynia at 2:02 PM on July 14, 2023 [14 favorites]
There's a whole lot of "The American Healthcare system and Capitalism have created this horrible situation so OF COURSE we should get to be rude to underpaid reception workers" in this thread.
Also, Nurse Practitioners receive as much training and education as Medical Doctors, at least in primary care. So yeah, good job to the person insulting the woman who is a Nurse Practitioner and telling her that she's inferior to her male coworker.
posted by Jarcat at 2:02 PM on July 14, 2023 [2 favorites]
Also, Nurse Practitioners receive as much training and education as Medical Doctors, at least in primary care. So yeah, good job to the person insulting the woman who is a Nurse Practitioner and telling her that she's inferior to her male coworker.
posted by Jarcat at 2:02 PM on July 14, 2023 [2 favorites]
Also there are over a million doctors in the US alone, it's frankly stupid and insulting to compare your own anecdotal experience to such a large number of people and it erases the hard work of so many women and people of color when people act like 'arrogant cis white person' is the default setting for all doctors.
/rant over, removing this from activity. If anyone wants to yell at me please note that I don't have a sign saying you can't.
posted by Jarcat at 2:10 PM on July 14, 2023 [1 favorite]
/rant over, removing this from activity. If anyone wants to yell at me please note that I don't have a sign saying you can't.
posted by Jarcat at 2:10 PM on July 14, 2023 [1 favorite]
The pharmacist comes out with a concerned look on his face and says, "Your medical records say you are allergic to penicillin. But your doctor prescribed an antibiotic that is derived from penicillin. There's about a 1 in 1000 chance this medicine will kill you. Do you want me to call your doctor?"
By this time, the doctor's office is closed. I've lost most of a work day, and I don't know if or when the doctor will ever answer the pharmaicst's call. "I talked about it to my doctor (which was not true, I had not talked to an actual doctor)
this story does not make the office employees look like the most unreasonable or badly behaved parties in the story. and I am as difficult a patient as they come, otherwise I would not feel justified in saying so.
I have never spoken to a pharmacist with such regard for human life - or, let us say, for my human life in particular, which I am sure is my fault. but this is what their degrees and their salaries are for. you want to take medication after a warning it might kill you, go ahead, I support your right to do that. but then why care about seeing a real medical doctor? you didn't care what the real pharmacist with his real doctor of pharmacy degree said.
posted by queenofbithynia at 2:38 PM on July 14, 2023 [12 favorites]
By this time, the doctor's office is closed. I've lost most of a work day, and I don't know if or when the doctor will ever answer the pharmaicst's call. "I talked about it to my doctor (which was not true, I had not talked to an actual doctor)
this story does not make the office employees look like the most unreasonable or badly behaved parties in the story. and I am as difficult a patient as they come, otherwise I would not feel justified in saying so.
I have never spoken to a pharmacist with such regard for human life - or, let us say, for my human life in particular, which I am sure is my fault. but this is what their degrees and their salaries are for. you want to take medication after a warning it might kill you, go ahead, I support your right to do that. but then why care about seeing a real medical doctor? you didn't care what the real pharmacist with his real doctor of pharmacy degree said.
posted by queenofbithynia at 2:38 PM on July 14, 2023 [12 favorites]
Nurse Practitioners receive as much training and education as Medical Doctors,
absolutely terrifyingly objectively untrue. sometimes they are nicer, sometimes they are smarter, sometimes they have particular experience in very specific things that a given doctor does not. but they do not have an equivalent medical education. the competent ones are trustworthy precisely because they are fully aware of this, make no secret of it, and haven't got a chip on their shoulder about it. jesus christ in a crowded waiting room.
nps are often better than physicians for uncomplicated things that a patient already understands perfectly. which is not the same as having "as much" training. often they can be convinced to try things that a doctor could not be convinced to try. they are good PCPs for people who like to disregard standard warnings, in both good ways and bad.
posted by queenofbithynia at 2:49 PM on July 14, 2023 [15 favorites]
absolutely terrifyingly objectively untrue. sometimes they are nicer, sometimes they are smarter, sometimes they have particular experience in very specific things that a given doctor does not. but they do not have an equivalent medical education. the competent ones are trustworthy precisely because they are fully aware of this, make no secret of it, and haven't got a chip on their shoulder about it. jesus christ in a crowded waiting room.
nps are often better than physicians for uncomplicated things that a patient already understands perfectly. which is not the same as having "as much" training. often they can be convinced to try things that a doctor could not be convinced to try. they are good PCPs for people who like to disregard standard warnings, in both good ways and bad.
posted by queenofbithynia at 2:49 PM on July 14, 2023 [15 favorites]
A friend of mine, who is AFAB and presents as petite and femme, literally just received their MD. They have an encyclopedic knowledge of their own bodyāI mean, they go Hermione Granger over the slightest new snippet of information about how people's physiologies worked.
It took them nearly a year to find a doctor who was willing to treat the fairly-serious nerve issue they were having like it was, in fact, a serious issue. They saw multiple doctors, and were forced to make multiple late-night emergency room visits. They were able to describe their symptoms in precise, exacting detail. They kept documentation of incidents that arose with them. They had a good idea, almost from the beginning, about potential root issues, and were looking for a doctor to help them investigate which were likelier causes than others.
And doctor after doctor dismissed them. Not dismissed like "you didn't do your research right," or like "I don't need your hypotheses." Dismissed them as in every last fucking one of them insisted to their face that their nerve issues were psychosomatic, or they were just routine bodies-doing-body-things, or that if they gave it a week, everything would go back to normal. Never mind that they were saying this half a year after everything hadn't, in fact, gone back to normal.
The punchline to this is the punchline to so many of the stories I've heard from women and AFAB friends of mine: eventually, they got a diagnosis, and they got it by specifically hunting out a woman doctor, who recognized the issue as serious within minutes and put them in physical therapy stat.
Unrelatedly, I've worked with the AMA and AAMC in several capacitiesānot as a medical professional, but as a software guy who works for and with medical professionals. They are famously... not exactly on the ball. Working with their specifications, and working to meet their standards, is routinely one of the more frustrating parts of my job.
I can't imagine that what they do is easy, and I'm sure that they mean well, but I'm not sure that advising people replace terms like "underprivileged communities" with "communities that are underserved by/with limited access to (specific service/resource)" is addressing the real issue here. In fact, any medical professional who cares enough to use a phrase like "underprivileged community" is probably already in the upper echelon of medical professional awarenesses. (And that's presuming that most medical professionals are reading a dense 54-page DEI initiative PDF, which... is not my experience of how most medical professionals operate.)
posted by Tom Hanks Cannot Be Trusted at 3:24 PM on July 14, 2023 [3 favorites]
It took them nearly a year to find a doctor who was willing to treat the fairly-serious nerve issue they were having like it was, in fact, a serious issue. They saw multiple doctors, and were forced to make multiple late-night emergency room visits. They were able to describe their symptoms in precise, exacting detail. They kept documentation of incidents that arose with them. They had a good idea, almost from the beginning, about potential root issues, and were looking for a doctor to help them investigate which were likelier causes than others.
And doctor after doctor dismissed them. Not dismissed like "you didn't do your research right," or like "I don't need your hypotheses." Dismissed them as in every last fucking one of them insisted to their face that their nerve issues were psychosomatic, or they were just routine bodies-doing-body-things, or that if they gave it a week, everything would go back to normal. Never mind that they were saying this half a year after everything hadn't, in fact, gone back to normal.
The punchline to this is the punchline to so many of the stories I've heard from women and AFAB friends of mine: eventually, they got a diagnosis, and they got it by specifically hunting out a woman doctor, who recognized the issue as serious within minutes and put them in physical therapy stat.
Unrelatedly, I've worked with the AMA and AAMC in several capacitiesānot as a medical professional, but as a software guy who works for and with medical professionals. They are famously... not exactly on the ball. Working with their specifications, and working to meet their standards, is routinely one of the more frustrating parts of my job.
I can't imagine that what they do is easy, and I'm sure that they mean well, but I'm not sure that advising people replace terms like "underprivileged communities" with "communities that are underserved by/with limited access to (specific service/resource)" is addressing the real issue here. In fact, any medical professional who cares enough to use a phrase like "underprivileged community" is probably already in the upper echelon of medical professional awarenesses. (And that's presuming that most medical professionals are reading a dense 54-page DEI initiative PDF, which... is not my experience of how most medical professionals operate.)
posted by Tom Hanks Cannot Be Trusted at 3:24 PM on July 14, 2023 [3 favorites]
Take it from a Canadian ā it's not just profit-centred care that suffers in this way. Public systems have different financial pressures, but those pressures have the same results.
I don't know what part of Canada you are from and there is provincial variance given that health care is a provincial issue in Canada but most doctors are in private practices. They are paid for by public health insurance and quite regulated but the majority are in private practices which they either run themselves or a businesses that employ them. The differences between American and Canadian healthcare are in the regulation and funding rather than the lack of capitalist imperative.
posted by srboisvert at 3:26 PM on July 14, 2023 [2 favorites]
I don't know what part of Canada you are from and there is provincial variance given that health care is a provincial issue in Canada but most doctors are in private practices. They are paid for by public health insurance and quite regulated but the majority are in private practices which they either run themselves or a businesses that employ them. The differences between American and Canadian healthcare are in the regulation and funding rather than the lack of capitalist imperative.
posted by srboisvert at 3:26 PM on July 14, 2023 [2 favorites]
nps are often better than physicians for uncomplicated things that a patient already understands perfectly. which is not the same as having "as much" training. often they can be convinced to try things that a doctor could not be convinced to try. they are good PCPs for people who like to disregard standard warnings, in both good ways and bad.
The ER nurse who cleaned my scrapes after I had a bike crash where I was knocked out cold short-circuited a very nervous and concerned five doctor conference about my abnormally heart rate. Her great trick? She talked to me. She came over and asked me if I was runner and if I normally had a very low heart rate. They don't have the same education as doctors for sure but they do often have valuable and practical front-line experience and insight that a lot of inexperienced junior doctors stuck doing ER work with just one experienced on call doctor for over-stretched supervision just don't seem to have. She also shaved my legs and arms near my scrapes before putting bandages on me which made me want to adopt her as god-mom. I remember her but I cannot recall a single one of the doctors who examined me mostly because they barely even spoke to me.
posted by srboisvert at 3:44 PM on July 14, 2023 [3 favorites]
The ER nurse who cleaned my scrapes after I had a bike crash where I was knocked out cold short-circuited a very nervous and concerned five doctor conference about my abnormally heart rate. Her great trick? She talked to me. She came over and asked me if I was runner and if I normally had a very low heart rate. They don't have the same education as doctors for sure but they do often have valuable and practical front-line experience and insight that a lot of inexperienced junior doctors stuck doing ER work with just one experienced on call doctor for over-stretched supervision just don't seem to have. She also shaved my legs and arms near my scrapes before putting bandages on me which made me want to adopt her as god-mom. I remember her but I cannot recall a single one of the doctors who examined me mostly because they barely even spoke to me.
posted by srboisvert at 3:44 PM on July 14, 2023 [3 favorites]
Mod note: One removed. Let's try to keep the discussion focused on the topic rather than other posters. Thanks.
posted by taz (staff) at 11:36 PM on July 14, 2023 [1 favorite]
posted by taz (staff) at 11:36 PM on July 14, 2023 [1 favorite]
In 22 years I've never heard a patient say, "hey I understand, Doc. You're a person too, maybe you had a fight wife with your wife this morning, or maybe you're at the end of a 36-hour shift. Either way, I'll give you the benefit of the doubt this time, and hope next time things go better"
IMO, that is most likely because it would be a wildly inappropriate thing to say. It's condescending. (cf. "Having a bad day?") It's also full of assumptions-- doc looks to me like a male so he has a wife, etc.-- AND it's going to hit much different if the doctor is a woman/underrepresented group in medicine and the patient is not.
posted by BibiRose at 11:11 AM on July 15, 2023 [7 favorites]
IMO, that is most likely because it would be a wildly inappropriate thing to say. It's condescending. (cf. "Having a bad day?") It's also full of assumptions-- doc looks to me like a male so he has a wife, etc.-- AND it's going to hit much different if the doctor is a woman/underrepresented group in medicine and the patient is not.
posted by BibiRose at 11:11 AM on July 15, 2023 [7 favorites]
My understanding of the "Don't yell" signs is that they're coming from the same train of thought as a manager sending a group email when only one employee is doing something objectionable, thus creating anxiety among employees who were already doing things well and probably being completely ignored by the person whose behavior they wanted to change. We've got clients literally threatening medical staff or using racial slurs where I work and higher-ups say that we can't possibly refuse to continue seeing those clients unless we have written guidelines about behavior, in part because we're a public clinic which means the clients have legal rights to care in ways that don't necessarily apply to private clinics. Hence the signs (and why they're more common in places that take Medicaid), rather than a more straightforward approach that would be clearer to clients and more supportive of staff, of just telling individuals who are acting inappropriately that they're not welcome back.
As for the "Say this, not this" stuff -- I think language is important as a reflection of one's respect for the client, but I think the respect for the client is more important than language policing. A huge part of the reason the euphemism treadmill exists is because people can update their language without actually changing any internal belief or social stigma. Teaching updated language has to come with teaching why the reframing is important, and focus more on updating the thinking over nitpicking words.
posted by lapis at 2:42 PM on July 16, 2023 [2 favorites]
As for the "Say this, not this" stuff -- I think language is important as a reflection of one's respect for the client, but I think the respect for the client is more important than language policing. A huge part of the reason the euphemism treadmill exists is because people can update their language without actually changing any internal belief or social stigma. Teaching updated language has to come with teaching why the reframing is important, and focus more on updating the thinking over nitpicking words.
posted by lapis at 2:42 PM on July 16, 2023 [2 favorites]
In reply to these comments:
Nurse Practitioners receive as much training and education as Medical Doctors, at least in primary care. So yeah, good job to the person insulting the woman who is a Nurse Practitioner and telling her that she's inferior to her male coworker.
why care about seeing a real medical doctor? you didn't care what the real pharmacist with his real doctor of pharmacy degree said.
First, I did trust the NP and respect her authority. The first visit I was polite, sympathetic to her on what was clearly a bad day, and afterwards I tried as hard as I could to comply with her instructions, even though those instructions were contradictory. I gave her the benefit of the doubt when her judgement was (rightly) questioned by the (male) pharmacist. In retrospect, I should have listened to the pharmacist instead of the person who admitted she didn't even know where she was.
Secondly, I didn't make an appointment and wait nine months to see a nurse practitioner. I made that appointment to see a doctor. Is it unreasonable to expect to see a doctor when you make an appointment to see a doctor? Is it unreasonable to expect there to be a doctor in the doctor's office?
Third, I continued to trust the NP right up until she and her co-worker admitted that she had made a medical mistake. Had she said, "I evaluated your medical records and determined that the antibiotic was safe for you to take," I would have accepted that and we would have moved on. Instead, she and another NP freaked out and tried to pass blame onto the pharmacist and, as you have, onto me. That's when I asked to see a doctor, because I no longer trusted her.
Fourth, I resent and object to the poster's accusation of sexism against me. My GP is a woman, and I trust her. This had nothing to do with the NP's gender, and everything to do with her demonstrated ability.
posted by vibrotronica at 8:33 AM on July 17, 2023 [1 favorite]
Nurse Practitioners receive as much training and education as Medical Doctors, at least in primary care. So yeah, good job to the person insulting the woman who is a Nurse Practitioner and telling her that she's inferior to her male coworker.
why care about seeing a real medical doctor? you didn't care what the real pharmacist with his real doctor of pharmacy degree said.
First, I did trust the NP and respect her authority. The first visit I was polite, sympathetic to her on what was clearly a bad day, and afterwards I tried as hard as I could to comply with her instructions, even though those instructions were contradictory. I gave her the benefit of the doubt when her judgement was (rightly) questioned by the (male) pharmacist. In retrospect, I should have listened to the pharmacist instead of the person who admitted she didn't even know where she was.
Secondly, I didn't make an appointment and wait nine months to see a nurse practitioner. I made that appointment to see a doctor. Is it unreasonable to expect to see a doctor when you make an appointment to see a doctor? Is it unreasonable to expect there to be a doctor in the doctor's office?
Third, I continued to trust the NP right up until she and her co-worker admitted that she had made a medical mistake. Had she said, "I evaluated your medical records and determined that the antibiotic was safe for you to take," I would have accepted that and we would have moved on. Instead, she and another NP freaked out and tried to pass blame onto the pharmacist and, as you have, onto me. That's when I asked to see a doctor, because I no longer trusted her.
Fourth, I resent and object to the poster's accusation of sexism against me. My GP is a woman, and I trust her. This had nothing to do with the NP's gender, and everything to do with her demonstrated ability.
posted by vibrotronica at 8:33 AM on July 17, 2023 [1 favorite]
FWIW Covid really brought a lot of this talk out from behind closed doors. It's mentioned in the document as a flash point at which injustices in health systems just totally fell apart at the seams. I bailed on clinical medicine during Covid. Or, correction, I bailed on clinical medicine in the USA during Covid. While the communication document emphasizes the effort that needs to be put into ensuring medicine is humanized in very clear and specific ways, what it still doesn't do is emphasize that everyone in medicine is also a human. Everyone in medicine should have the ability to say to difficult patients that the buck has stopped here and the next step in that patients care will be with someone else.
Healthy equity is good, hard work. I think it's largely reactive, though, and not yet proactive. It uses a very cobbled-together language right now, and I think that's a sign of the times. At some point in the indeterminate future, I imagine that a lot of the emphasis on recognizing the detailed niches of inequity may fall away in favor of a structural approach that is simply set at a good baseline of care and access for the largest group of people possible, with additional staffing and funding available for situations in which the people who intake and triage can recognize that situation-specific needs are going to fall outside of what that baseline can accommodate. Since leaving the US I've been working in health systems in countries that are working in directions that feel more like this. Even in the US, some regions' service areas are shifting to community-based care that performs this way as a default. And community-based care, by making sure that clinicians themselves are humanized as Humans You Know, aren't expected to be treated like shit, either.
That's not to say this kind of work product isn't great to see. This'll be on the agenda (and style guides) for the medical/public health conferences and journals from now on, so this is a real way a cumbersome set of professions come to align on ideas. I strongly suspected that I would open this comment thread to find the bickery thing up above more than any comment on the linked text (which is good!).
Your comment embodies the poor attitude of many doctors. Thanks for helping me prove my point.
So I really didn't wander beyond this moment, at all, to see if I'm wrong. Good lord. I'm reminded, again, of how far beyond my ability to be in clinical care I've been extended. I made the right decision to bail.
posted by late afternoon dreaming hotel at 5:14 AM on July 18, 2023 [1 favorite]
Healthy equity is good, hard work. I think it's largely reactive, though, and not yet proactive. It uses a very cobbled-together language right now, and I think that's a sign of the times. At some point in the indeterminate future, I imagine that a lot of the emphasis on recognizing the detailed niches of inequity may fall away in favor of a structural approach that is simply set at a good baseline of care and access for the largest group of people possible, with additional staffing and funding available for situations in which the people who intake and triage can recognize that situation-specific needs are going to fall outside of what that baseline can accommodate. Since leaving the US I've been working in health systems in countries that are working in directions that feel more like this. Even in the US, some regions' service areas are shifting to community-based care that performs this way as a default. And community-based care, by making sure that clinicians themselves are humanized as Humans You Know, aren't expected to be treated like shit, either.
That's not to say this kind of work product isn't great to see. This'll be on the agenda (and style guides) for the medical/public health conferences and journals from now on, so this is a real way a cumbersome set of professions come to align on ideas. I strongly suspected that I would open this comment thread to find the bickery thing up above more than any comment on the linked text (which is good!).
Your comment embodies the poor attitude of many doctors. Thanks for helping me prove my point.
So I really didn't wander beyond this moment, at all, to see if I'm wrong. Good lord. I'm reminded, again, of how far beyond my ability to be in clinical care I've been extended. I made the right decision to bail.
posted by late afternoon dreaming hotel at 5:14 AM on July 18, 2023 [1 favorite]
Aside from a lot of this discussion, I'm part of a group that trains med students and doctors on how to have human, empathetic conversations with patients. I'm usually called in as the Transgender Special Episode day, which is fine, I get paid for it and it's Union work (steelworkers!).
These med students are desperate for a list of what to say and what they can't say. They want to memorize it by rote and make sure they use it when they're running down the latest acrynom heuristic for that patient scenario. We talk a lot about pronouns and not assuming that a man has a wife and a woman has a husband, and maybe not assuming a typical PIV-generated pregnancy, etc. It results in awkward scenarios like they're trying to figure out if I can get pregnant or not but are too scared to ask about anatomy so they say things like "so are you uhh the one uhhmmmmmmmm who would be donating sperm to a pregnancy?" and I get to be like uhhh that's...uh... one way to put it?
Anyways the thing I have them do now is fuck up and recover, rather than have the perfect list of words and terminology and say and don't say. The terms will change! Society will change under them while they're being doctors! Now I get them to misgender me, and I get to be like "I checked with the admin and they said they'd amended my file with the right name and pronouns. I know this would happen! This always happens with you people. I can't get good care here, you don't even know what gender I am!!" and they have to recover the interview. Because that's what's going to happen. They're tired, they're full of information and (hopefully) some knowledge, and they wil have seen dozens of people that day, and they'll fuck up. So I make them practice the skills of fucking up and getting back some trust.
The whole effort of the program is to install some basic empathy into the absolute functional technical nightmare that is med school and practicing medicine. In Toronto, showing these skills is part of your exams, which I also participate in and help evaluate. It's very interesting work.
posted by robot-hugs at 7:28 AM on July 19, 2023 [10 favorites]
These med students are desperate for a list of what to say and what they can't say. They want to memorize it by rote and make sure they use it when they're running down the latest acrynom heuristic for that patient scenario. We talk a lot about pronouns and not assuming that a man has a wife and a woman has a husband, and maybe not assuming a typical PIV-generated pregnancy, etc. It results in awkward scenarios like they're trying to figure out if I can get pregnant or not but are too scared to ask about anatomy so they say things like "so are you uhh the one uhhmmmmmmmm who would be donating sperm to a pregnancy?" and I get to be like uhhh that's...uh... one way to put it?
Anyways the thing I have them do now is fuck up and recover, rather than have the perfect list of words and terminology and say and don't say. The terms will change! Society will change under them while they're being doctors! Now I get them to misgender me, and I get to be like "I checked with the admin and they said they'd amended my file with the right name and pronouns. I know this would happen! This always happens with you people. I can't get good care here, you don't even know what gender I am!!" and they have to recover the interview. Because that's what's going to happen. They're tired, they're full of information and (hopefully) some knowledge, and they wil have seen dozens of people that day, and they'll fuck up. So I make them practice the skills of fucking up and getting back some trust.
The whole effort of the program is to install some basic empathy into the absolute functional technical nightmare that is med school and practicing medicine. In Toronto, showing these skills is part of your exams, which I also participate in and help evaluate. It's very interesting work.
posted by robot-hugs at 7:28 AM on July 19, 2023 [10 favorites]
Personally as a patient Iām not a huge fan of sitting in a tiny waiting room with one exit with a highly belligerent person with no escort who is trying to start a physical fight with someone. Honestly there should some way to get that personal medical care, but treating them with ātoleranceā isnāt gonna do it. I highly doubt they are going to comply with medical guidance if theyāre ready to throw a punch over filling out a short medical history.
Honestly same problem with any belligerent element of society. Iām not going to call the cops or rat them out, and I feel badly. But weāre not doing anything for that person, even if we feel so bad that we allow them to freely abuse others.
I feel the least bad for the doctor because they have the most power in the situation. Despite the fact that I have generally tolerable interactions with doctors.
posted by stoneandstar at 3:33 PM on July 27, 2023
Honestly same problem with any belligerent element of society. Iām not going to call the cops or rat them out, and I feel badly. But weāre not doing anything for that person, even if we feel so bad that we allow them to freely abuse others.
I feel the least bad for the doctor because they have the most power in the situation. Despite the fact that I have generally tolerable interactions with doctors.
posted by stoneandstar at 3:33 PM on July 27, 2023
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The problem is that the profession often sees the doctor-patient relationship as adversarial.
Fix that, and the rest will follow.
posted by NoxAeternum at 3:06 PM on July 13, 2023 [29 favorites]