Why do so many doctors not listen to patients at all?

In My Humble Opinion
41

No, I don’t resent that others make more than I do, and anyone reading the part about best job in the world and seeing patients for reduced rates would know that. What I do resent is that you made it personal. I wrote about doctors’ salaries, you wrote about me.

I resent that doctors make so much more than others who are more conscientious and then have the nerve to complain. I wish I knew all the poor middle class physicians you seem to. I know at least 10 doctors in town, and none of them live modestly. Does a median salary of $200,000 ( compared to a median salary of $26,000 across the US) not seem out of line to anyone else? A different health care system that included more reasonable salaries for physicians would allow for more time with patients and better patient care.

As for doctor’s salaries not being a big part of the problem, this article might interest you.
From the article: "They determined that higher spending on physician services in the U.S. is largely not influenced by patient volume, practice expenses, or medical school costs.

Rather, they found, Medicare and private insurers pay U.S. physicians more for their services than public and private insurers pay for the same services in other countries; in some cases American doctors are paid double for the same services."

Of corse doctors use heuristics, but those kind of cognitive shortcuts are much more likely to lead to false conclusions when the person doesn’t have time to do a complete evaluation. The other thing you mention, figuring out a diagnosis while gathering information, is also more likely to be accurate when one takes more time.

As for your question about debt, I actually got my PhD without any student loans. I lived on my stipend and attended state universities. However, post PhD I decided I wanted to do clinical work with medically-ill patients, so I went back to graduate school and racked up 40,000 in debt.

42

and your medical training/expertise is…?

43

This was making it personal.

44

I didn’t say He (or she) had a fancy car or house, only that those things are bought by doctors, and the assertion that all that salary goes for medical school debt is ridiculous. He said I (using my name) resents that other people make more than I do. iMHO, much more personal.

45

Sorry Brynda, but you are the one who made it about yourself in comparison to broad brushed and frankly mythic “doctors pretending to spend all their money on medical school debt while driving expensive cars and buying 3,000+ square foot homes” who make you ill. You stated that you “put in your time” so arguments about medical school don’t sway you. It is very hard not to read resentment in your posts about “entitled” doctors who are overpaid by the metric that they make more than you do, along with your disbelief about how many primary care docs are struggling … nope they are just “pretending”, it’s “fake poor-mouthing” and it makes you ill.

Very few in medical school get a stipend like you got (okay my MD-PhD friends did under the Medical Scientist Training Program). You got off easy even by the psych PhD standard. But you have no hesitation in stating that anyone who says those docs feel some economic pressure servicing an average of a $200K debt on a primary care docs income is, well, lying.

But again, we agree that the economics of volume based reimbursement incentivizes seeing more volume. I’d like to focus this discussion on what we can agree on: I think that you’d agree that income motivates behavior for most people. Most physicians want to do good but no doubt they also want to do well while doing it. A system that pays those who spend the most time with each patient the least is not going to encourage the most time spent. But neither can one reward those who are just being lazy. We need to have some metrics of quality and at least partially reward accordingly rather than on volume alone. The tricky part is defining those metrics wisely, in ways that motivate actual quality rather than gaming the system and merely mindlessly completing checklists, and that do not destroy the ability of small groups to compete with the large corporate medicine behemoths.

Is that something you can concur with?

Now we will have to disagree that listening and being perceived as having been listen to requires an inordinate amount of time. Our large group collect patient satisfaction data along with many other quality measures. The patient satisfaction scores have little correlation with patient volume measures. Some of the docs with the highest volumes have patients who comment on how they always feel they have all the time they need and get all their questions answered; some with low volume have poor measures (which is likely why they have poor volume, I guess). Listening is a skill and just being there longer does not mean the skill is any better developed.

46

Well, considering that you’re comparing people who have a minimum of 7 years of post-grad training to a group that includes high school drop-outs, I’d expect there to be a pretty damn huge salary gap. If you compare doctors to college graduates, the income gap narrows a fair bit. If you compare them only to professionals with post-grad degrees, the gap narrows even more. Lawyers, for example, have a median salary of $112K. Dentists have a median salary of just under $150K. AFAIK, neither of those professions requires you to spend 3-5 years in a job where they’ve had to make rules that you can only work 80 hours a week after you graduate and before you can practice on your own. And we won’t even get into the compensation of corporate bigwigs, who make doctors seem positively impoverished. (My uncle is the CEO of a tech corporation and his base salary is $750K. Add in his stocks and other perks, and his total compensation is upwards of $2mil.)

Yes, a lot of the doctors I know have big fancy houses and drive flashy cars–and a lot of them either have next to no savings or are in debt to maintain that lifestyle. Just because someone is living a certain lifestyle, that doesn’t mean they can actually* afford* that lifestyle. Doctors can have just as bad financial judgment as anyone else; my husband once worked with one who asked to have a $200 personal check held till payday, I shit you not.

But leaving all that aside, I’m not sure that very many people would be all that interested in eating the utter shit sandwich that is med school and residency if there wasn’t a financial payoff at the end. I mean, imagine someone came to you and proposed this career path to you: You’ll spend the 4 years after college when most of your friends are establishing careers and moving up in the world living in the student ghetto on stipends, and for the first 4 months of that time you and everything you own will reek of formalin. You won’t be allowed to get a job to defray expenses, even during your summer break. You’ll pay a couple hundred grand for the privilege of spending your 4 years like this, or more accurately, you’ll be a couple hundred grand in debt at the end of those 4 years. At that time, you’ll move to somewhere you don’t ultimately get to pick to take a job where you work 80-hour weeks for about $40k/year. You’ll be there 3-5 years, at which point you can get another job. The new job will require you to be on call 2-3 nights a week and a couple weekends a month. When you’re on call, you can’t be more than 30 minutes from your job site at any time in case they need you to come in. You’ll get called approximately 2-3 times an hour between 8am and midnight, and about every hour and a half from midnight to 8. When a call comes in, you’ll need to answer it pretty much immediately, no matter if you’re sleeping, taking a shower, attempting to have sex with your spouse, or just picked up your fork to eat Thanksgiving dinner. This new job will pay you $80K, out of which you’ll have to pay off that $200K you went into debt the first four years.

Would you take that deal? I mean, c’mon, it’s $80K. That’s more than 3 times the national median. Or would you think that deal sucked and tell this person to take a long hike off a short pier? And if you’d turn down that deal, what amount of money would make it seem equitable to you? Whatever number it would take to make you take that deal, you have to expect that doctors will expect to make at least that much money.

47

Perhaps the answer is to make training not suck so much. But how do we do that?

Problem is, we’re now mired in a system that no one really likes until they’re done with it, but we can’t figure out how to get out of it. It would make sense to pay Interns and Residents a better wage so they can pay down their debt faster. Maybe pay should be a bit more equitable throughout the careerspan of an MD, and we should lower the salary of the Attendings to pay more to the Baby Docs. But we really owe the Attendings, because we formerly paid/treated them like crap. We recognize that if we slash their salaries to pay the Baby Docs more, we’ll have no Attendings to supervise them!

And I think this is where we’re back to APNs…different training system, similar end product. APNs take on debt to get where they’re going, sure, but they’re not so horribly restricted in salary and burdened with quite such terrible work loads on their path. They don’t make as much in the end game, but they don’t have the debt load, either. They don’t have to become APN’s all at once, and there are several degrees and even two licenses they can earn on their way, and work which pays alright they can work as they need/want to. A person can become a CNA in less than a year, and work for a little better than minimum wage. He can become an RN in another year or two, and work for considerably better than minimum wage. He can continue schooling (online, even!) and earn his BSN while working as an RN without doing any more clinical hours for school. Then he can go on for his MSN and perhaps a PhD, and again, many nurses do this while working as RNs and getting paid a decent wage. Voila, you’ve got yourself a shiny new Advanced Practice Nurse who isn’t hundreds of thousands of dollars in debt already.

I think that’s pretty close to the kind of path I’d create for doctor training, if we had a blank slate to do it on. Lots of patient contact throughout your training, but you’re getting paid for it at a livable wage, and the cost of the education isn’t totally crippling. It builds on and rewards you for what you do know how to do, instead of breaking you down and making your poor for what you don’t.

48

WhyNot, I don’t have to agree with every point this article makes to realize that you’d find it of some interest.

I also think that you are correct. The medical education system of attempting to create individuals who understand the breadth of the basic sciences and can apply them to daily clinical problem solving has become an crazy monster as new students still must learn every arcane muscle attachment and brain nucleus, the Kreb’s cycle (Hell Kreb’s epicycles from my POV), along with sciences that had not even existed a few decades back. One professor at the start of medical school introduced the process by warning us, only part as a joke: “You will forget half of what you learn during medical school. Half of what you learn will be found to be wrong by the time you are in practice. Make sure they are the same half.” What he didn’t say is that 90% of it will never be useful to you in actual practice. Then the sleep deprived and stressed hours of the clinical training years also contribute to learning poor listening skills - a resident may be able to make good enough clinical decisions when functioning on a severe sleep debt and under stress, but making the process as quick as possible is required in order to survive. Not the habits that foster good listening skills.

I doubt however the physician training system will change all that much, at least not all that quickly, whatever the merits of making wholesale changes. Instead I see it going as you and that article describe. Various so-called “mid-level providers” will be tasked to do more and more. As the range of what they can do increasingly expands more of the very top students will look at the choice between the M.D. path, as clearly laid out by CrazyCatLady, and that “mid-level provider” path, and make a rational decision to forgo that level of debt.

Yeah, what you said.

49

Thanks for the link!

I cannot fathom how much y’all have to learn in school, just simply because there is so much more to learn. Research is great, and expanding fields of knowledge are awesome, but there’s just no way for one person to know the entire field of medicine anymore. Wayback when the med school model started, perhaps it was possible. Before we knew even so much as CPR or what the appendix was for, a sweet country doc could know most of what there was to know about pregnancy and childbirth, childhood diseases, farm implement accidents and common illnesses in adulthood. When there was nothing to be done and tincture of opium was what you had for palliative care, things were simpler, if mortality higher. When all your tools fit into a little black bag, you could learn how to use them all in an afternoon.

Now I rather feel like I (a year old home RN) am filling the role of the country doc of old, and actual doctors are doing something else entirely. Something that can’t be trained for like they were trained for.

But now we’ve strayed very far from the path of the OP, haven’t we? Perhaps I’d better shut up now and practice that listening thing. :wink:

50

I’m not so sure we have strayed actually. While the op may have really just wanted to vent about how lousy doctors are (s)he did ask a question and this discussion does seriously address that question.

I do want to add how much your comment reminds me a something a good friend of mine who is a neonatologist has observed - Up until the middle of the last century doctors had very little to offer in way of effective interventions for illnesses. They did spend a fair amount of time at the bedside however and they were well respected. Now doctors do a lot more. They have the ability to intervene pretty effectively a fair amount of the time. But they spend less time actually at the bedside and are respected much less.

51

The US healthcare system is broken. I believe part of that is due to physician salaries. Studies like the one I cited above support that, but physicians themselves fight that notion. I get it. It is hard to think about making less than you expected or think you deserve. However, I don’t see how the healthcare system is going to be fixed without adjusting physician salaries.

The argument that doctors can’t live on less due to debt just doesn’t convince me. The argument that no one will want to be a doctor if they are paid less is belied by the fact that doctors are paid less in other countries, and people still want to be doctors. How Much Do Doctors in Other Countries Make? - The New York Times

The argument that their lives are so hard that they deserve high pay-- well, physicians have created that trap for themselves. If you want that kind of pay, you have to see tons of patients, which is where this thread started. Imagine for a moment you saw only 2 or 3 patients per hour. What would that be like? Ignore the income implications at first. Then think outside of the box. Does the system have to be the way it is?

52

I do agree with the above. When I worked in hospitals, I often would observe physicians who I knew I could help with their patient interactions, if they would have been open to it. It is a skill. I also know that the best listener can’t listen without at least a minimum of time.

53

Ayup. And on that note, I have to go drive 45 minutes in traffic to pack a Stage IV pressure ulcer with undermining bigger than my fist. It will take about an hour, and I’ll shudder and scream inside every time I accidentally touch bone, while maintaining a gentle calm demeanor the whole time. When I’m done, the patient will thank me with tears in her eyes, tell me how it feels so much better, and make it all worth it.

But I’m still paid less than you make on your lunch hour. :wink:

54

I make it a point to avoid old male doctors whenever possible. The young females tend to be less jaded due to age, and more empathetic due to sex. I know it’s a stereotype, but it works for me. I will never ever go back to a male gynecologist, after having a horrible experience with a paternalistic asshole. But the young female doctor at Planned Parenthood was great.

55

This study shows a strong relationship between time spent and patient satisfaction, BTW.

http://psycnet.apa.org/psycinfo/1998-10713-001

56

I saw a Doc about this time last year with weight loss and fatigue being the primary symptoms that got me there and he told me my weight loss was at a good rate. People who’ve always been heavy don’t start losing weight without trying unless there is something wrong. Saved up and went to another Doc. I was diagnosed with stage 3 b lung cancer.

57

People who want to help people will still want to be doctors. Money grubbing jerk-offs will not. And we’ll all be better off.

My grandfather was a doctor. He never cared about money. He’d often take produce rather than money. If a farmer had extra peaches, he was fine with being paid in peaches. But that’s because he actually cared about helping people not getting the biggest house in the fanciest neighborhood.

58

I want to help people, but there are a lot of ways to help people. If there hadn’t been the promise of a decent financial reward at the end I might have picked a way that didn’t involve seven post-college years of soul-crushing training and a huge pile of debt.

(And it should be said–three years ago I took a significant pay cut to leave a job where I felt like my superiors cared a lot more about money than good patient care. Best move I ever made.)

One thing a lot of people don’t understand is that doctors have very little say in the amount of money that they charge for a visit. When you accept payment from third-party payors (Medicare, Medicaid, private insurance, etc.) you say in those contracts how much you charge, and in theory they pay you some percentage of that. (In reality you set your fee based on what the insurers will pay.) And the thing is, you really do have to charge that to people without insurance or the payors come along and say, “Why should we pay $50 for a visit from one of our members when you saw that other patient for a bag of peaches?” You can institute a sliding scale based on income, but it’s complicated and there’s a minimum that you can go down to.

Also, when your grandfather was practicing his patient base probably included some of the richest and the poorest people in town and everybody in between. These days the rich and the poor are so concentrated and segregated that they don’t go to the same doctors’ offices. About 40% of the patients in my clinic (which is a community health center and teaching clinic in a very poor part of the country) have no insurance and pay based on our sliding scale, and most are at the bottom of that. If you can be sure that 95% of your patients are going to pay, you can afford to see the other 5% for produce. But if your average patient is flat broke and you’re willing to take produce from them, you’re going to be up to your ass in produce and before long you’ll be closing your doors.

59

I’ve had both good doctors and really terrible ones, sometimes both at once. The problem is exacerbated if you’re trying to get treatment for pain or psychiatric issues. There’s a very real chance that something that doesn’t help will not just do nothing, but actually make things much worse. And also a very real chance that if you find something that does help, it’ll turn out to be a very heavy medication – either with serious known side effects, scheduled, or both – that doctors don’t like giving out willy-nilly.

One of the really terrible ones literally stopped letting me finish sentences after I said that I’d been in the ER for panic attacks, and told her exactly what sedative they gave me and what the dosage was. A therapist told me later that the doctor probably saw this as a huge red flag. Apparently most people really do go in saying things like ‘they gave me these little pills, they were round but not too round, and they were kind of orangey but not really’. (I told her that was the dumbest thing I’d heard that week, possibly that month, and that I was not going to be snorking down any pills unless I knew exactly what was in them and how much.) Given that her first words to me were, “So, you’re in here for a diabetes screening?” I don’t think she read my intake form or my chart, where my primary complaint (hint: not even remotely like the symptoms of diabetes) was laid out pretty plainly, in short sentences.

On the other hand, the ER resident who had given me the medication in the first place asked me intelligent questions, listened to my answers, and gave me both (a small amount of) the unscheduled antidepressant I’d requested to try and benzodiazepines that I didn’t ask for. I made it quite clear to everyone that I had no money and that they would be dealing with the state’s insurance-for-the-destitute because I couldn’t possibly pay for any of this. The resident apologized profusely that she couldn’t convince the dispensary to give me the unsolicited 90-ct bottle of Xanax for free.

I’ve run into mostly average doctors outside of high-stress emergency care situations, although there was one dermatologist that I loved as a teenager, because he once managed to throw my mother out of the room so that he could get answers to his questions without her chiming in. The Planned Parenthood people are also typically very helpful, though their list of questions is shorter and more to the point, since they only do a few very specific things there.