Making a Contribution

When I was in college a good friend of mine, who had been raised in Bolivia, when talking about career plans of college students, would ask, "What contribution do you plan to make?"  To George, one worked to "make a contribution" to society.  I've always thought this was an admirable point of view.

It's amazing to me how many people in our society could work but don't.  The bottom line is that the many are being supported by the few.  In my opinion, everybody who can work should work.  Everyone needs to make a contribution.

This is not only the right thing to do.  It's also good for a person's physical and emotional health, to be making a contribution every day.

Not working is destructive to the spirit.  Every day I see people who have gradually slid into a helpless outlook.  In many cases, their health problems are more the excuse than the reason.

I am not by any means referring to those in our society who cannot work.  Of course there are people who are legitimately disabled, or who are caring for children, or who are retired after a lifetime of contributing.

It's interesting to notice how someone who is employed in a fulfilling job will fight tooth-and-nail in the face of an illness or injury to get back to work as soon as possible.  In contrast, the patient who is not working, or who is working in a boring job, will magnify his symptoms, exaggerate his disability, and generally delay his recovery in order not to have to return to work.

Why do some people have boring jobs and others have fulfilling jobs?  Could it be that, when they were in high school and their parents told them to study so they could get into a good college, and they chose to go party with their friends, or play computer games, or send text messages, could this be when their choice of a life of drudgery was made?

When I was 35, I was unhappy, in a boring job.  I decided to go back to school.  I got a night job so I could take pre-med courses, then applied to medical school, spent 4 years in med school and 3 years in residency.  Then at the age of 45 I began working in Hagerstown, Maryland as a family practice physician.  And I'm still here.

There was a time in my life when I was so depressed that I found it difficult to go to work each day.  Often I would call in sick, not realizing that my real sickness was depression.  I felt alienated from society, cut off from all that was good in the world.

So I know how impossible it can seem to pull oneself out of the bottomless pits of inertia, inactivity, and despair that constitute the lives of so many people in our society.

Making a contribution is the opportunity that constitutes living in a free and affluent country such as the US of A.  It's also an obligation.   But, most importantly, it's a privilege.

Let's all make a contribution.  Starting with studying hard in school, choosing a fulfilling career, getting and staying healthy, getting a job, and sticking to it even when times are hard.

Laziness

Patients have a fear of being cared for by an incompetent doctor.

But competence is not usually the issue.

In my opinion, when a patient doesn't get the best possible care, it's more often due to laziness.

Here is a sample scenario.  This is fictional, but not far from reality:

Mr. X, an 18-year-old young man, goes to see his internist, Dr. A, on Friday afternoon about a painful lump in his groin.  The doctor examines him, and finds an abscess.

Dr A knows that the abscess needs to be incised and drained.  This is a procedure which could be done right there in his office.  But Dr. A has a golf game in an hour, so calls a local surgeon.

The surgeon, Dr. B, says this is not a surgery case.  "Since it's in the groin it's a urology case, you need to call the urologist".  So Dr A calls a urologist, Dr. C, but Dr C is in his car headed for the theater, and says to send the patient to the ER.

The patient goes to the ER as instructed, waits 6 hours to be seen.  The ER doctor, Dr. D, listens to his story, examines him, and calls the urologist on call.  This is a different urologist, Dr. F.  Dr F tells the ER doctor to call a surgeon.  "This is a surgery case, not a urology case".

So the ER doc calls a surgeon, Dr G, who is currently out to dinner, and instructs the ER doc to call the hospitalist doctor to admit the patient, and he'll see the patient the next morning.

The ER doctor calls the hospitalist, Dr H, who says that this 18-year-old patient is actually a pediatrics case, so the ER doctor needs to call a pediatrician to admit the patient.

The ER doctor calls the pediatrician on call, Dr I, who is asleep.  Dr I is upset that he's being called about a patient who is not even his patient.  But he sucks it up and comes in to the ER to admit the patient.

Meanwhile, about 10 hours have passed from the time the patient presented to the first doctor with the abscess.  When Dr I arrives to see the patient, Mr. X not only has an abscess (much worse than it had been when he originally presented to the office of Dr A), but now he also has shaking chills.  This means that the infection has spread to his blood stream.  The patient's blood pressure is now dangerously low, meaning that he's in septic shock.

The ER doctor runs to the bedside, gives the patient antibiotics and fluids, and the blood pressure rises.  But now the pediatrician says he can't admit the patient.  "This patient belongs in the intensive care unit".

So the ER doctor calls the ICU doctor, Dr J, who refuses to admit the patient, saying, "This patient isn't sick enough for the ICU.  After all, his blood pressure is normal now."

Finally, the ER doctor is able to convince the pediatrician to admit the patient.

The next morning, the surgeon, Dr G, comes in and sees the patient.  He is alarmed by the deteriorated condition, yells at the nurses (as if it weren't his fault in the first place for not coming to see the patient the previous night), takes the patient to the OR, and incises and drains the abscess.

The patient makes a full recovery.

What does the patient think of all this?  He thinks that the surgeon is his hero.  He thinks that the surgeon is the only doctor who took care of him who knows what he's doing.

In reality, there were only 2 good doctors involved in the care of this patient:  the ER doctor and the pediatrician.

(Incidentally, the pediatrician doesn't get paid by the patient's insurance company, because the insurance company says he's not the patient's doctor.)

Baseline Expressions

A Baseline Expression is the expression a person has on his face when he has no expression on his face.

You can tell a lot about a person by his Baseline Expression.

Here are some examples:

• Some people look like they've been abused all their lives, and are just waiting for the next bad thing to come their way.
• Some people look like they're hostile toward everything and everybody.
• Some people look happy, with a positive outlook.
• Some people look cynical, like nothing's going to disappoint them because they're not expecting anything anyway.
• Some people look sad.
• Some people look perpetually amused, like they've just heard a good joke and would love to share it.
• Some people look excited, like they're looking forward to what they're about to do.
• Some people look kind and benevolent, like you could trust them with your feelings.

What is your baseline expression?

A corollary to the Baseline Expression is the expression people wear when they encounter strangers, such as when you're walking in the mall and someone meets your eyes.  I call this the Stranger Expression.  Some examples:

• Hostility
• Distrust
• Fear
• Arrogance
• Friendliness
• Compassion

What is your stranger expression?

Good Health is an Obligation

I frequently hear excuses for why patients have been neglecting their health.

• I've been under a lot of stress lately.
• I've been on vacation.
• I've been taking care of a sick uncle.

But the fact is, taking care of your health is a social obligation.  Like putting on your clothes before you leave the house, or brushing your teeth, or paying your taxes, or not killing anybody.

Can you imagine:

• Your boss comes to work naked, saying, "I've been under a lot of stress lately".
• A corrections officer at the prison leaves the gates open, saying, "I've been on vacation".
• A customer at Wal Mart walks out without paying for something, saying, "I've been taking care of my sick uncle".

There is no excuse for not taking care of ourselves.

Making Your Bed

Let's say you wake up in the morning and see that your bed's unmade.  You make the bed.  You get it just right, all the corners lined up, the pillows fluffed, the bedspread without wrinkles.  You stand back and admire your handiwork.  It makes you feel good.

By making the bed, you have accomplished 3 things that make life worth living:

1. You straightened up something that was in disarray.  You put something in its place.  When everything is in its place the way it should be, it gives one a sense of security.
2. You completed a job which needed to be done.  This gives one a sense of accomplishment.
3. You performed a creative act.  People who notice the nicely made bed might ask, "Who made that bed?" And you could say with pride, "I did it."

But by making the bed, you've done much more than those 3 things:

Later on, when you get home from work and see the beautifully made bed, it will make you feel good.  It will raise your energy level.

Other people who see the nicely made bed will also have their moods lifted.  So by making the bed you have made a contribution to the lives of all the people who will see the bed that day.

And both you and those other people who will see the beautifully made bed, by virtue of having your energies raised, will have a rosier outlook, will accomplish more, will contribute more to the lives of others.

When you take this approach to every single task in your day, to every single task in your life, you really begin to reap rewards.

And the people around you benefit from your meticulous approach to life.

So make your bed.  And make the world a better place.

Get Your Numbers Right for Optimal Health

To achieve and maintain optimal health, get your numbers right:

1. LDL (bad cholesterol) under 130.
2. HDL (good cholesterol) over 40 (man), 50 (woman).
3. TG (triglycerides) under 150.
4. Blood sugar under 100 (fasting), 140 (post-prandial).
5. Weight under ideal body weight plus 10%.
6. Abdominal Circumference under 40" (man), 35" (woman)
7. Average Blood Pressure under 140/90

For more on these, follow these links:

• http://drbeckwith.com/Cholesterol.php
• http://drbeckwith.com/sugars.php
• http://drbeckwith.com/BPs.php
• http://drbeckwith.com/IBWcalc.php

Family Practice Dull?

Lots of medical students choose specialties other than internal medicine and family practice, thinking that being a generalist is dull. Here are some diagnoses from my past 2 weeks of patients to contradict this idea:

Chronic Paroxysmal Hemicrania

Osteosarcoma

Bipolar 2

Sacral Fracture

Cocaine Use

Dyslexia

Rectal Prolapse

Erythrasma

3rd Degree Burn

Anosmia

These are all diagnoses which I made myself, rather than problems which the patients had already been diagnosed with by specialists.

Of course, interspersed among all the unusual diagnoses are plenty of sore throats and poison ivies. But I tell you what, when I get the simple cases, I'm happy. It's a relief to have something easy to deal with.

When the Doctor is Rude

Sometimes I'm rude to my patients.

I admit it.

I'm constantly working to be nicer, but I'm not a finished work.

Here are some examples of things I've done lately that were rude:

The patient interrupts me when I'm talking, so I say, "Let me finish..." That's rude.

I ask the patient a question, and the patient's answer is not exactly what I asked. So I say, "That's not what I asked." That's rude.

I don't want to be one of those doctors who only have patients who are nice enough to not get upset when the doctor is rude. Patients shouldn't have to put up with rudeness from their doctor.

Of course, all of us are working constantly to be better people.

The reason I'm posting this is to let those patients of mine who read my blog and to whom I may have been rude know that I realize it and am working on it.

False Accusations

A young man tells his girl friend he wants to split up. She gets mad, calls the police, and tells them that he threatened suicide. Six uniformed men show up and forcibly drag him to the ER, where he is held for 24 hours against his will. The whole time, he insists that he is not suicidal, and his ex-girl friend is just being vindictive. Unfortunately, even if the police and the ER personnel believe him, there's nothing they can do. It's the law.

Someone calls my office anonymously and says that a patient of mine is selling his Percocets on the street. What do I do? Most likely I will discharge the patient from my practice, even though I have no proof, and even though the person might be lying. Because there are plenty of other doctors out there, and I don't want to be prescribing opioids to a drug abuser.

In many cases the caller is being honest and has good intentions. But a certain percentage of such calls are doubtless malicious. Sometimes it's just that someone is pissed off at the patient for some reason, but sometimes it's because there's a child custody case pending and they want to make the patient lose custody of the children.

It's a damn shame that some malicious person can make trouble for a good person, but I know of no good way to handle the situation that is completely fair.

Great job!

I sometimes wonder what it is that brings people in to see me over and over again, when each visit consists of me hounding them to optimize their health.

I try to be as pleasant as possible about it, but surely my patients dread these visits, where I'm telling them they need to lose weight, stop smoking, take their medicines, etc. Not only that, but each visit costs the patient money.

Finally today I just realized what it is that keeps them people coming back: It's their commitment to their health.

A patient may not succeed in losing weight or quitting smoking, but simply returning to the doctor and being reminded of these things demonstrates an admirable commitment to good health.

And for people who have the most difficulty doing what the doctor recommends, it's even more admirable. Because for them, it's harder. Yet they keep coming back.

Great job!

Finding ways to say YES

Being a human being, is a privilege and a joy.

But so much of our lives seems to be about drama.

Someone gets their feelings hurt, lashes out, hurts someone else's feelings, then before you know it we're making ourselves even more miserable. We cut ourselves off from others. Enemies are made. Then we don't feel safe, because now the universe isn't benevolent any more.

And the joy of being human is lost.

This is the Hindu idea of Karma. Negativity begets negativity.

The answer is to break the downward spiral by not reacting to the negativity of others with more negativity.

Sometimes we create negativity needlessly. Such as when we say no, when we could just as easily say yes.

As a health care provider, I say no many times each day. Some of these no's are appropriate. Others are not. It's those inappropriate no's which are a measure of my personal limitations. Finding a way to say yes to people who come to one in need is a great way to work on one's humanity.

After all, being in a position where people come to you for help is a privilege in itself.

Why are Europeans thin?

I just returned from my first-ever trip to France. Spent a week in Lyon. Had a great time.

During the entire week I spent in France, I probably saw about 5 overweight people. Can you believe it?

I often advise my overweight patients to avoid bread and sweets, but the French eat bread and sweets often.

I'm convinced that the reason they're thin over there is that they don't eat as much at every meal as we do.

If you go to a French cafe, the people are sitting around talking, drinking tea or beer or wine, and snacking on a croissant or something. They're not eating sweet rolls, and they're not eating huge meals.

Yesterday I went to Olive Garden and ordered linguini with meat balls, and a salad. I got a bowl of salad with about 4 servings of salad in it, from which I served myself a bowl of salad, followed by a second and a third. There was still salad left in the big bowl when my linguini came. I realized right then that I was already full, but since I'd ordered it I ate about half the linguini.

So essentially, in one meal, I ate about 2 complete meals--and still left half the linguini uneaten.

In Europe I would have been served a single small salad and about half the linguini that I was served at Olive Garden.

So now I have this theory that we in the U.S. are fat because we eat too much. Go figure.

Getting Younger

It seems to me that getting healthier is the same thing as getting younger.

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If a patient is 25# overweight, has pre-diabetes and hypertension, then loses 25#, no longer needs BP meds, and gets a 2-hour glucose tolerance test and discovers that the pre-diabetes has resolved, isn't it reasonable to say that s/he has gotten younger? I think so!

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After all, if your health improves, then you'll live longer.

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So let's all get younger (instead of older)!

Universal Healthcare is Inexpensive

I think President Obama has it right when he says we need to revise our nation's healthcare system to reduce costs.

According to the World Health Organization, France has the highest-quality healthcare in the world. Yet they spend less per capita on healthcare than we do here in the U.S. Here is a list of selected countries' healthcare costs as a percent of GDP as of 2006:

U.S. 15%
France 11%
Germany 11%
Canada 10%
U.K 8%
Japan 8%

Yet these countries have universal healthcare, and we don't!

So it is possible for every single person in our country to have health insurance, and actually spend less money on healthcare than we do now.

The reasons for this are complex, but among other things are explained by 2 facts:

1. Emergency Room care is expensive. A patient can go to the ER and spend $1500 easily, whereas comparable service in my office would be about $130. Patients who have no health insurance go to the ER.

2. People without health insurance delay going to the doctor until they are very ill. From then on, you're playing catch-up--trying to get their diabetes controlled, dealing with the heart disease resulting from untreated hypertension, dealing with kidney failure, etc. These are expensive diseases to treat. If these people had health insurance, they'd find a primary care physician and be diagnosed much earlier. They might even avoid these medical conditions in the first place, by appropriate preventive medicine measures.

So three cheers for Barak Obama and his efforts to reform our healthcare system.

I'm Everybody's Friend

My new motto is "I'm everybody's friend".

The idea is to have every patient who comes to see me have a positive experience.

Some co-workers have told me that this is an unrealistic expectation, because patients sometimes need to hear things they don't want to hear, and sometimes patients wants things they shouldn't have.

But I think there's a tactful way of saying no.

The bottom line is: The patient is the boss of his or her own health care.

What got me thinking about this is, I noticed that I always go out of my way with little children to make them have a positive experience--blowing up balloons, etc. So why don't I do the same thing with adults? Not blow up balloons, but make them have a positive experience.

So that's what I've been doing this week, and for the most part I've succeeded.

We'll see whether I can keep it going.

The start of a typical day

8:00 Ms. B arrives early for her 8:15 appt.
8:14 Mr. A arrives 14 mins late for his 8:00 appt, is shown into a room.
8:15 Ms. B complains to receptionist that Mr. A got to go in first. Receptionist explains that Mr. A's appt was before Ms. B's appt.
8:15 On way to room to see Mr. A, Dr is told that Mr. X is on phone with chest pain.
8:20 Ms. B is shown into a room.
8:25 On finishing phone call with Mr. X regarding his CP, Dr goes to Mr. A's exam room. Mr. A has list of 5 problems he wants addressed.
8:30 Mr. C arrives on time for his 8:30 appt.
8:40 After addressing first 3 items on list, Dr tells Mr. A that he'll need to do the other 2 on his next visit. Mr. A is displeased, says that if his disability form isn't completed today he'll lose his job. Dr says he should have brought that item up first, now regrettably there's no time to address it. Mr. A goes up front to complain to office manager.
8:45 Dr goes into room to see Ms. B, now 45 minutes behind. Ms. B is visibly angry. Dr apologizes for keeping her waiting. Ms. B says she doesn't know why she's there, was told she had to come in. Doesn't see why she should have to come to the doctor when she feels fine. Dr explains that all patients with diabetes need to see the doctor every 3 months. Ms. B asks why. Dr explains. Dr reviews pt's labs, notices that cholesterol is high despite dietary changes, suggests a medication. Pt says she doesn't like to take medicines. Dr explains that a high cholesterol causes heart attacks, suggests pt cut back on meat, dairy products and eggs. Pt says she hardly eats any of those. Dr says, "Then medication is the only other option". Pt reiterates she doesn't like to take medicines. Dr refills patient's prescriptions. Pt is displeased that the doctor doesn't put 3 refills on each 90-day Rx. Asks why. Dr explains that if he put 3 refills on the Rx's, pt would not return for a year, and needs to be seen every 3 months. Ms B accepts the prescriptions and walks out in disgust.
9:15 Dr goes into room to see Mr. C, still 45 minutes behind. Apologizes for keeping him waiting. Mr. C says, "Hey, don't worry about it, Doc, I know you're busy." Dr smiles and shakes Mr. C's hand, grateful for the nice patients.

You can't please everybody

The patient tells me about a problem. I type what he says into his chart, asking appropriate questions. While I'm typing, he's thinking, "Hm, well, he's not saying anything, what am I supposed to do? Well, I guess I'll tell him about another problem." So he tells me about another problem. I'm still typing up the previous problem, but I don't want to tell him to wait because people don't like that. So I keep typing up the previous problem, and simultaneously try to remember what he's saying about the second problem. I make appropriate sounds of acknowledging what he's saying. Then the patient thinks, "Well, he's not saying anything, so I guess I'll tell him about another problem." But I'm still typing up the first problem. So now I'm trying to hold the fact of 3 problems in my head. Then I just have to say, "Hold on there, dude, you're 3 problems ahead of me, give me a second to catch up, okay?" But this makes the patient upset, and he thinks I don't care about him, that I'm not a nice doctor, etc.

Here's another scenario: The patient tells me all her symptoms. I'm now typing into the computer, thinking about her symptoms, trying to figure out how to approach the problem, trying to figure out what the causes of her symptoms might be, what tests to order, etc. Since I'm not saying anything, she thinks, "Hm, he's not saying anything sympathetic, I wonder if he cares? I wonder if he really understands how serious this problem is." So she starts to tell me how terrible the problem is, how it's destroying her life. Then she tells me all the terrible stressors in her life, and how in addition to all those stressors this medical problem is just making things worse. I'm now listening to a terrible tale of woe, and getting more and more distressed all the time. This is getting really painful, and meanwhile I'm unable to think about her medical problem because I'm so sympathetic to her suffering. So I say, "Okay, give me a minute to think about what to do about this," but that just makes her irritated and impatient. She's thinking, "He doesn't care about me."

The common denominators in these 2 scnarios are my silence while I'm thinking or typing, and the presence of the computer in the room. When I'm thinking, the patient thinks I'm not doing anything. When I'm typing into the computer, the patient thinks I'm ignoring him.

Unfortunately, there's no good solution to this problem. I have to think. While I'm thinking, I can't talk. To think effectively, I have to not listen either. But I know from experience that when the patient speaks I have to listen, or I might miss something really important. So for me to think effectively about the patient's problem, there has to be silence.

Also, I have to type into the computer. The computer is the patient's chart. It's also where I go to look up recent test results, to read what consultants have reported, to see what I did on the patient's last visit, to see what medicines the patient is taking, etc.

Some patients understand that when I'm paying attention to the computer I'm paying attention to them, since I'm looking at their chart and thinking about their case.

Some patients understand that when I'm not talking I'm thinking, and they're not uncomfortable with silence.

Fortunately, I'm more committed to the health of my patients than I am to making them happy. If that weren't the case, I'd listen sympathetically, make a lot of eye contact, not type into the computer at all. Patients would love me, but I wouldn't be solving their medical problems. I wouldn't be a very good doctor.

But I want to make everyone happy. It hurts me when patients are unhappy with me. So I'm a good doctor who helps a lot of people, but daily has to deal with the disapproval of the people he's trying to help.

Actually, I'm not unique. This is the dilemma that all doctors go through, for one reason or another. It's not always the computer that's the problem, or the doctor's silence. There are lots of things that patients can be displeased with which have nothing to do with the doctor's competence. And a sensitive doctor will be taken aback by the patient's displeasure and to a certain extent be less able to do the job he needs to do to help the patient as a result.

On the other hand, should a patient never express displeasure with the doctor? That's no solution either. Sometimes, I learn some of the most important things about the patient's problem when the patient gets upset with me. And patients should always feel free to communicate with their doctor. This is also the time when I can learn how to be a better doctor and a better person.

So I try to let people know I care about them, and at the same time ask them politely to slow down, or give me a second to think about their problem, and just hope that I'm not offending them. And when they're offended anyway, I try to just realize that that's what being a doctor involves, and you can't please everybody.

Only patients who want to be healthy need apply

What are your medical goals? Do you want to get healthier than you are? If so, how much are you willing to do? Are you willing to:

• See the doctor regularly
• Lose weight
• Stop smoking
• Take medication
• Exercise
• Be on time to doctor visits
• Keep all appointments with doctors
• Eat a healthy diet

I have many patients who are not willing to do some or all of the above.

I believe that patients are the bosses of their own medical care. A patient who doesn't want to do certain things is okay with me. But I don't necessarily have to be that person's doctor, either.

The problem is that health care involves a lot of work. If the patient is not willing to do anything, then the doctor has to do more. This puts a strain on the doctor's resources. In effect, the patient is saying, "I don't want to do anything, Doctor, so you need to do more."

It may seem that the doctor should be willing to do more, since he's being paid for his time. But it doesn't work like that. Here are some examples:

• The patient doesn't want to go to the doctor more often than once a year. She brings with her a long list of complaints. The doctor now has an unpleasant choice to make: either tell the patient she needs to return for another appointment to address some of her issues, or take more time with the patient and keep his other patients waiting.

• Under Medicare's new Pay for Performance program, doctors incur financial penalties from Medicare for not keeping their patients healthy. A diabetic who isn't willing to stop eating sweets, for example, will cost the doctor money.

• The patient who only wants the doctor to write prescriptions for a sore throat, and doesn't want to take care of himself, still has to listen to the doctor's suggestions to lose weight, get blood tests, stop smoking, etc, and has to say no to each of the doctor's suggestions. This is unpleasant for the patient, so the patient gets irritated with the doctor. The doctor's feelings are hurt because the patient doesn't seem to like him. The doctor doesn't have the option of not making those suggestions, since if he did not make them he wouldn't be a good doctor. The patient thinks the doctor is unpleasant, the doctor thinks the patient is unpleasant, and the whole interaction is unsatisfying for both parties.

So I've decided to not see patients who are not willing to take care of themselves.

Helping people get and stay healthy is a wonderful experience. I thoroughly enjoy helping people all day long. There's no better job in the world. But there are so many patients out there who would like to be healthier, who are willing to do whatever it takes, that I don't need to waste my time on patients who aren't. It's as simple as that.

Moving from Helpee to Helper

One way to see whether you're getting healthier is to ask yourself: "Am I a helper or a helpee?"

If you are healthy, you can help others in your life. If you are extremely unhealthy, you will be spending all of your time seeking help from others.

Some patients I see are healthy enough to help others, but are for some reason committed to being helpless. Some patients I see are very unhealthy, but still manage to focus on helping others.

So it's partly one's attitude.

Patients who want to be healthier might want to examine their lives to see whether they are primarily a helper or a helpee. No matter where you are on the continuum, you will benefit from moving closer to the helper end of the spectrum.

Poor Customer Service

I had a bad customer service experience at my car dealership this weekend. When I arrived (for my 5000-mile maintenance appt) there were people standing around waiting expectantly for one of the attendants to notice them. There was no organized way of figuring out who was next in line, so all of us customers were eyeing each other with suspicion. The attendants didn't seem to care about us. Finally, one approached me with a list of appts. I told him my name, but I wasn't listed. Apparently my appt had been forgotten. I waited around for 10 more minutes, then left in disgust.

This is not much different from the experience some of my patients have at my office. They arrive on time, only to find that the doctor is 45 minutes behind schedule. Talking to other people in the waiting room, they discover that 2 other patients have appts at the same time they do. Sometimes they get fed up and leave in disgust. When they do wait it out, they sometimes find me to be distracted, in a hurry, or paying more attention to my computer than to them. Or I help them with 2 problems but tell them I don't have time for a third.

My experience at the car dealership has caused me to be more sympathetic to disgruntled patients, and to resolve to make my patients' experience at their doctor's office rewarding rather than frustrating.

This is something that I feel is well within my capabilities. Some doctors would not agree. They would say that, with the state of modern managed care, a doctor cannot survive financially without seeing at least 4 patients per hour. This means 3 problems will never be addressed in one visit. Also, since patients will come in with emergencies, there's no way you can avoid keeping patients waiting sometimes.

However, even when a patient has to wait, I can be gracious enough to apologize for the delay when I walk in the room, and listen sympathetically to every problem. Most patients are willing to tolerate occasional delays, if after their wait they are greeted by a sympathetic doctor who really is interested in them and wants to help them.

Since I started working on my manner with patients, I have been pleasantly surprised to find that, when you make an effort to make the other person's experience more rewarding, you make your own experience more rewarding as well.

You may wonder, "Well gee, after 10 years in practice, why didn't he learn this years ago? Why don't they teach doctors to be sympathetic to patients' complaints right from the beginning?"

It's true that there is very little if any training in bedside manner. This is one problem. Medical schools and residency programs really should start training future doctors in how to make patients' experiences with health care providers more positive.

However, there really is a huge problem staying financially viable when you are a primary care doctor these days. You simply cannot take adequate time with each patient and still stay in business. So your doctor is sitting there trying to be sympathetic to your problem, while at the same time he's thinking about the 3 patients who are already in rooms impatiently awaiting his arrival. He cannot book 2 patients per hour and spend 30 minutes with each patient, because then he wouldn't be able to pay his office staff, pay his rent, etc.

Finally, the doctor's first allegiance HAS to be to the patient's health. There are many doctors out there whose first allegiance is to the patient having a positive experience, who are loved by their patients, but who don't keep their patients healthy. A doctor who is always nagging you to lose weight, to stop smoking, etc is a better doctor than one who always tells you what you want to hear.

It's taken me 10 years of practice to find a way to have all 3: financial viability, optimal health care, and happy patients. I don't achieve this goal with every patient encounter--far from it--but I think I've figured out how to achieve it now. Each day my skills improve. And with each satisfied patient, my job becomes more enjoyable and rewarding.