When you have pain, or when you have medical concerns, you need to trust your doctor. If you do not, I suggest you find a doctor you do trust. That trusting relationship should provide security, hope, and cost savings.
As a Spine Specialist, I know that a majority of the patients with pains will improve over time. As I have blogged before, if you take most people with spine pain, and put them in a black box for three months, the > 90% will be better when you let them out of the box. Many medical providers will take credit for this black box effect. In other words, waiting, will likely show improvement. As the Spine Specialist, I must first make sure you are safe to go into that black box. In other words, a Spine Specialist must assess whether a patient can and should give it time before getting more aggressive (surgical) treatments. Once the decision to wait is made, the patient must trust that the doctor has made the right call. If there is no trust, dissatisfaction and increased costs invariably happen. Let’s look at some scenarios:
IDEAL SCENARIO #1
John Smith is a 42 year old healthy male, who developed excruciating back and leg pain. There is shooting pain down the legs, numbness is a specific pattern, and significant weakness of a muscle to the leg with inability to walk. John Smith knew of the Doctor from his friends, and felt confident in the Doctor’s ability. The Doctor determines the weakness is actual inability to move the leg muscles, and not just weakness secondary to pain, or fear of pain. Because of this finding, the Doctor orders testing including an MRI at a covered Hospital. The staff, understanding the urgency of the situation, arranges the study immediately. The MRI identifies a significant disk herniation to the lumbar spine. The Doctor recommends a limited disk removal procedure that can be done almost as an outpatient. Urgent disk removal surgery is scheduled, and John Smith has a rapid recovery with restoration of the strength. John Smith trusted his Doctor, and followed the recommendation to early surgery.
IDEAL SCENARIO #2
James Brown is a 50 year old healthy male, who develops excruciating back and buttock. There is spasms to the back. He has difficulty walking secondary to the pain. John Brown is healthy, and nothing in his history suggests any significant trauma, or risk for cancer or infection. John Brown’s physical exam indicates the pain is causing the difficulty with walking, but there is no evidence of nerve impairment. His Doctor decides to wait to see if he would get better by prescribing some medications, and gentle stretches. John Brown trusted his Doctor, who explained that he will likely improve, but expect a few set backs while he slowly increases activities. Because of encouragement by his Doctor, John Brown accepted that there will be some occasional flare ups initially, but in the long run, he would be better. With each week of followup, John Brown is improving. Within several weeks, John Brown had manageable pain, and was able to return to work, and gradually return to all activities. Because John Brown trusted his Doctor’s diagnostic abilities, he avoided excessive testing, and trusted that he would be able to improve despite some flareups. John Brown’s costs of treatments were confined to inexpensive medications, and monitoring by his Doctor.
In both these scenario’s, trust in the doctor allowed focus on improving the pain, instead of further testing for possibilities and opinions. Costs were minimized. Confidence in the Doctor’s opinions and treatments gave peace of mind. Without question, that decrease in anxiety helps to reduce pain, as well as fosters an environment that is conducive to healing. Confidence is an important factor in improvement.
NOT SO IDEAL SCENARIO #3
Joe Smith is a healthy 40 year old with excruciating back and leg pain. He has the same numbness and weakness as cousin John Smith in Scenario #1. He finally gets to see the available Physician’s Assistant for the available doctor, after waiting for a long time in the office. Because of the weakness, the doctor himself, examines Joe. The doctor orders an MRI, but the MRI is not authorized, as the doctor would like the MRI to be done at a specific facility. With some delay, an MRI is obtained, showing the large disk herniation. The doctor suggests a removal of the disk, but also a lumbar Fusion Surgery. Joe had recently seen the articles about the skyrocketing rates of lumbar fusion surgery, so he and his family are hesitant. Joe demands a second opinion. Unfortunately, it takes time to get a second opinion. Meanwhile, secondary to the pain, Joe develops a dependency on narcotics, and the weakness to his leg is getting worse. As time continues to pass, Joe’s work place puts him on leave, and financial stresses are additional to his medical stress. The second opinion doctor appears to be cautious about his recommendations, but in the end said he could have either a removal of the disk surgery, or the removal of the disk surgery and also the fusion at the same time. Joe did not ask what would the second opinion doctor do for himself, or his own family. Because of the pain, and weakness, Joe does get the removal of disk and fusion surgery. His leg is getting better, but he is still dealing with the healing pain from the fusion. His work has still put him on leave. The bills from the larger fusion surgery are more than anticipated He is better, but he is not happy.
NOT SO IDEAL SCENARIO #4
Scott Brown is a 52 year old male with excruciating back and buttock pain. Like his cousin James Brown in Scenario #2, there is nothing in his history that would suggest a fracture, an infection or a tumor. Scott Brown has difficulty obtaining a Spine doctor’s appointment, so he sees his family doctor. The family doctor orders x-rays, which are normal, and would like to order a lumbar MRI, as the family doctor does not want to miss any findings. Scott’s insurance denies the MRI as he did not have adequate treatments defined as medications, and physical therapy for 6 weeks. Scott initiates physical therapy. While at therapy, the ultrasound and massage felt good, but whenever he tries to exercise or stretch, there is more pain and spasm. The therapy aide recommended he avoid any activity that causes pain, and come in for more therapy. By 6 weeks, he is starting to feel better, but he is still fearful of doing any activities as it may cause a recurrence of the pain. He see the Spine Specialist, who seemed more interested in seeing if he would be a candidate for surgery. Because he has had PT for 6 weeks, and has been on medications, he now qualifies for a MRI of the spine. The MRI shows several small disk herniations to the lower back, but Scott is now feeling better. Scott is not sure if he needs to see the doctor, but the appointment is made so he goes. The visit is only for a few minutes and the doctor says he has a few small disk herniations, but he does not need surgery now, but may in the future. Scott forgets to ask about certain activities, and he is still not sure if he should exercise, or return to weight lifting. The bills start coming in. The $50 co payment for each therapy visit added up. He did not expect such a large bill for the MRI, and the physician’s fee’s for the providers are still pending. Six months later, while applying for a disability insurance, the two small disks that no longer cause any pain, are causing his policy to be much costlier than he originally hoped. He is better, but he is not happy.
As you can see, in the Not so Ideal Scenario’s, both people do get better, but at increased costs, with future ramifications, and with some associated disappointments and unhappiness. There are real world examples that I do see on a frequent basis. Of course, if you can choose, you would want the scenario where you trust your doctor.
To achieve that Ideal Scenario, doctors must gain your trust. In my opinion, these factors can help in gaining that trust.
1. Price Transparency. Unfortunately, only people who pay for all their own healthcare costs know the true costs. However, the doctor, along with staff, should be able to give ball park estimates on the cost of certain procedures.
2. Timely appointments. When people are in pain, the ability to see the doctor and discuss the concerns is most important.
3. Adequate time with the doctor. While physician extenders are helpful, when seeing a specialist, most patients feel most comfortable spending time with the doctor. In addition, adequate time is necessary to discuss the most important concerns.
4. Appropriate contracting by the Doctor’s office. If the Doctor underbids their fee, there is a compelling economic motivation to see too many patients. If the Doctor does not have the ability to negotiate adequate compensation from a specific insurance plan, it means (s)he will not have the ability to spend more time with you, and (s)he will likely hire physician extenders to process more of the patients.
5. Full disclosure about Business Relationships with Therapy, Surgery Center, Imaging, etc. Patients expect their doctors to be financially successful. After all, who wants to see someone who can barely make a living as a specialist. Patients, however, do not want to know, after the fact, that you had a financial relationship with any of these entities. Doctors are required to disclose these relationships. Signs are usually posted to that effect. Still, it is better when a doctor comes out, straightforward and lets you know, and also gives you a choice.
6. The Physician Version of the Golden Rule: Assuming the doctor loves his family, the doctor should make the same recommendations to you as he would to himself and his family. Patients should discuss this philosophy with the Doctor.
7. Appropriate and ongoing staff training. Without question, a happy work environment spills over to the customer. If a doctor develops a friendly, fair work environment, that spills over to a better patient experience. A well run office also means better care and service to the patient. That leads to more trust.
8. Willingness to not make the appointment for the wrong patient. Some offices do not do a good enough job in matching the patient with the doctor. Doctors are still human. Not every human will get along with every other human. If the staff understands the patient’s needs cannot be met by the doctor, the staff should feel comfortable suggesting an alternative office for that patient.
9. Understanding that trust is a two way event. Doctors must also have some expectations of the patient. Only when mutual expectations are met, can there be trust.
10. Pleasant demeanor. To gain trust, a doctor should be pleasant, not only with his patient but to his own staff. A genuine smile helps build trust, even in difficult situations.
- Grocott MPW, Plumb JOM, Edwards M, Fecher-Jones I, Levett DZH. Re-designing the pathway to surgery: better care and added value. Perioper Med (Lond). 2017;6:9. PubMed PMID: 28649376