Q: I am very frustrated about my parents. They are both in their eighties and still very independent. They are able to live alone and only this year we started helping with groceries, driving and the checkbook. Although they are blessed with good health they constantly complain about their doctor. Apparently he is not spending enough time with them. He brushes them off and even dismisses some of their complaints. My mom says that he is never with them longer than a few minutes.
I have met my parents' physician. He is an experienced practitioner and appears to be a caring individual. He is very busy, but other doctors are as well. The complaints from my parents have gotten to the point where they want to look for another doctor. I would prefer for them to stay with this one. Whatever arguments I have used have fallen on deaf ears. Is there anything you would suggest that would make my parents appreciate their doctor as I do?
A: This situation is not uncommon and we should try to analyze it and maybe come up with a solution. First, let me take a step back. As a physician myself I need to explain something very important.
We practice in a very outdated system of reimbursement. The main insurer of Americans over 65 is Medicare. Enacted in 1965, Medicare was a true innovation when it first started. What happened is that the times have changed. Imagine a company that is almost 50 years old and has done very little upgrading. Though it might be very successful at its inception, after 10 years, some of its technology, design and ideas will be outdated. The same thing happened with Medicare.
Medicare still pays relatively well for emergent and procedure-driven care. It does not pay well for chronic care and it does not pay at all for long-term care in the nursing home. Moreover, the more procedures, tests and surgeries doctors do the more money they get paid.
Medicare historically does not pay at all for longer discussions with patients, for phone calls or for what we call care coordination. This is when one doctor, just like an orchestra conductor, talks to all the other doctors involved in the patient's care to try to come to a unified plan for a given problem.
We also have a culture in this country that is intoxicated with the pursuit of youth. Aging and being frail is something we do not treat as a "part of the journey." Patients often expect simple solutions to their complaints, preferably not requiring any ownership of the problem presented.
Another fact is that the population is living longer. The average life expectancy in 1967 was 67 years for a man. Now it is 76 and for a woman it is now 81. Since we live longer, we have more illnesses and frailty in the last decades of our life. The old, stagnant insurance payment system has not been prepared for that at all.
We are currently at the crossroads of the healthcare debate. Many very smart people are actively trying to change this system as we speak. In the meantime let's try to help Rebecca's parents like their doctor again.
The first thing that needs to be discussed is what exactly the point of contention is. This may not be easy, but the question to ask would be: "For your doctor's visit to be truly great, what would it need to look like? What advice are you looking for?"
It may surprise some of you, but many people actually cannot answer these questions. For some, it may turn out that what they want, a doctor cannot grant. I had one of my patients once tell me that her ultimate goal was not to be lonely. She did not realize that the only person who could have made this happen was her.
The next step is to write all of the questions and problems down and discuss them with the family first. It may help to have a family members accompany parents to the doctor's office. There may be a need for more than one visit -- maybe even few of them over a short timespan -- to get to all of the issues.
In rare circumstances, problems with a doctor may be about personality and a difference of opinion. The doctor might have inadvertently criticized a lifestyle choice or demanded from Rebecca's parents something they were not willing to engage in. Sometimes, an experiment with the medication or a treatment plan may not produce desired results. Patients and families may get discouraged and loose the trust they gave to their physician. This is hard to rebuild even for the best of doctors.
Rebecca is on the right track with her initial comments about her parents' doctor. She needs to honestly talk with both of them and the doctor about this situation. Almost all physicians would welcome this conversation.