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Fire My Doctor? Not So Fast

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Last week, a friend told me that her mother had been fired as a patient by her primary care physician in a letter she received in the mail. “Our philosophies of care are too different,” was the explanation.

Last week, I fired my oncologist by email. “I have transferred my care to ___ ___.” I gave no explanation, although the note was polite and appreciative.

My friend and I spent some time talking about how this “doctor firing” upset us. Both of us (she as her mom’s caregiver, me as an active patient) initially felt solely responsible when we saw signs that the relationship was not working out. We worried that we hadn’t figured out how to communicate with the physician and staff, that we weren’t listening carefully enough, that we expected too much.

We both wrestled with accepting that, in fact, this relationship needed to end. She accepted it after the fact, recalling years of feeling that the doctor and her staff were unresponsive and uninterested in working with the complex demands of the long-distance caregiving that she and her mom had patched together. I agonized before the fact: maybe my doctor was non-responsive because he thought I was second-guessing him or because I should have called instead of e-mailed.  Maybe he sees my queries as a waste of time: he really doesn’t think there is any intervention that might have an impact on my current disease.

My friend and I looked back on our experiences and agreed that, short of firing one’s doctor by just never showing up again (not recommended), formally ending that relationship carries significant emotional freight, whether we originate the change or our physician does.

Part of this is due to the sheer hassle of finding a new physician. Depending on where we live  and what kind of clinician we are looking for, it can be a daunting challenge to find any replacement, much less one with whom we feel we can work well. Active illness or the need for constant monitoring means that we may face a big gap in care if we haven’t prepared for the change.  This was the case with my friend’s mother, since it is not easy to find a clinician a) about whom useful qualitative information is available; b) who is taking new patients; c) takes our insurance; and d) seems compatible on the basis of available information or a single visit.

What also adds to our discomfort is the asymmetry of expertise between us and our clinicians. We patients can talk all we want about establishing partnerships with our doctors and how they possess medical knowledge but we possess unique knowledge about our own bodies, etc., but when the rubber hits the road, it’s their training and expertise that positions them as the sole gatekeepers who can provide access to the tools of health care that might ease our suffering and save our lives. It can be hard to walk away from those promises, even if staying with a clinician we dislike means we must hide our opinions and preferences or subject ourselves to disrespectful treatment by him or her and staff.

Is this just another one of those problems of the privileged? Perhaps. Many people simply don’t have a choice of the clinician who cares for them: they seek help from the nearest or the cheapest doctor. They see the clinician they are assigned to at the clinic or by their health plan.

But I also know the remarkable difference my relationship with my clinician makes in my own willingness to take on all the tasks of caring for myself. If I feel she has really listened to what is going on with me and what it is going to take for me to do what she recommends…if we together make a plan about next steps…if I trust her expertise and experience, I am much more likely to try to do my part. On the other hand, if I feel like she sees me as just the next problematic body part to appear on a fast-moving assembly line, if she is talking at me, not with me, if she interrupts, corrects me or ignores me, all bets are off. I’ll take her recommendations under advisement but do what I think is best.

Again and again, evidence points to our relationship with our clinicians as key to our effective participation in our health care. People are given facile advice by advocates, the media and the government to fire their doctor if they are dissatisfied with their care or communication style. I absolutely believe that we should try to find clinicians to care for us who are compatible with our personal preferences. But I also know that change is hard for all of us, especially when we don’t feel well, and that that the effort required to find the right clinician to replace the wrong one and the anxiety that such a move generates often outweighs the impulse and intent to make this change.

Patient-physician incompatibility is a barrier to our participation in our health and health care that has no direct policy solutions. Sure, the greater availability of clinicians – primary care providers in particular – would help. So, of course, would more qualitative and quantitative information about individual physicians (including robust patient ratings). But the bulk of the change will probably have to originate with us.  And it is likely that we will only take this task on when we learn how much more effectively we are able to care for ourselves when our efforts are in harmony with clinicians we like and trust and whom we feel are working with us to live as long and as well as we can.

More Blog Posts by Jessie Gruman

author bio

Jessie C. Gruman, PhD, was founder and president of the Center for Advancing Health from 1992 until her death in July 2014. Her experiences as a patient — having been diagnosed with five life-threatening illnesses — informed her perspective as an author, advocate and lead contributor to the Prepared Patient Blog. Her book, AfterShock, helps patients and caregivers navigate their way through the health care system following a serious or life-threatening diagnosis. The free app, AfterShock: Facing a Serious Diagnosis, offers a pocket guide based on the book. | More about Jessie Gruman


Tags for this article:
Health Care Access   Communicate with your Doctors   Inside Healthcare  


Comments on this post
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Cathie M Currie, PhD says
June 5, 2013 at 8:32 PM

Jessie,
Your comments are entirely on the mark, as always. Our modern healthcare system has commoditized physicians, as though their care is a standardized and substitutable scientific-technological product. The assumption: doesn't matter which one we get out of the carton. But nothing could be further from the truth. As a medical educator, when I talked with physicians who had lost their involvement in helping patients -- I always sensed they deeply wanted to find connections, but no longer knew how. Healthcare workers call it burnout. I call it isolation.

One group of oncologists had prepared a teaching case with a fictitious patient, a physician, who decided to forgo chemotherapy to treat her breast cancer. Their discussion was jocular, trying to decide how many months to give her to live. I thought about my role as an educator, and thought about my training as a psychologist.

I turned the case materials face down and said, quietly, "What's going on?" No one said anything, they stared at the case papers in front of them. "Do you want your patients to give up?" I asked. I was walking on thin ice, but I continued. "I don't think so. I don't think you want to give up on your patients. But maybe you feel like you have."

One muttered, "Look what we do to them. We put them in pain. We cut them up. We put drugs in them that make them wretch . . . and then the ones we know the most die." "Yes," I said, "In some ways, it's like my field of psychology. When I've done the best I can, it often isn't enough."

Misery blanketed the room. "What do you do?" one of the oncologists whispered. "My best, and it isn't always good enough. But I have to try." They all nodded. But nothing was better.

I asked them if they understood anticipatory nausea -- if their patients became nauseous before chemotherapy treatments or after. Before, they said. I taught them about anticipatory response, and predosing with anti-emetics so that the response does not get started. Their mood brightened, they had a new immediate benefit for their patients. They changed the case: their ill physician now said "Give me whatever you've got that'll give me my best chance!" They wanted the connect, they just had lost their way. They gave me a warm goodbye when they left our faculty session, in a very different spirit than before.

After that incident, I asked medical students what they did to reconnect to themselves, to their humanness, after difficult, upsetting cases. The students always looked baffled. So I would tell them that reconnecting was as important a part of self care as sleep and food. I said I had to remind myself that my human need to succeed got in my way in some clinical situations. I had to do the best that I could, but that couldn't guarantee a good outcome. Then, to make sure I was staying in feeling, I would touch my arm or forehead -- a symbolic and sensory reconnection.

I do not know of any other way to reduce clinician burnout -- which severs the connections between physician and patient, disastrously.

Jesse, I don't know if your oncologist was burned out, but someone who isn't able to connect to you?! :-) That's the reason my guess is burnout. The good news: it is treatable. The bad news: they do not know how to treat it. My way, reconnecting, is counter to their training in modern medicine.

maggie hover says
June 6, 2013 at 2:04 PM

I had a similar experience years ago. In that situation, the entire team did treatment posts on two patients who died. No one had asked either patient why she wanted to die, in one situation, or why he wanted to live, in the other.
I particularly like the way in which your articles, Jessie, explore all the tendrils of a situation, as in noting that choice of physician is a dilemma of the privileged. And the dialogue with respondents makes me sorry I retired. maggie

Jen says
June 6, 2013 at 7:39 PM

Thank you for this timely article, Jessie. My family has been discussing firing my husband's oncologist who gives us little real guidance and pressures us to make quick decisions. I had to really ask myself if these were things that mattered enough to look elsewhere for care. The answer isn't obvious. You clearly name the concerns with trying to find other care and also the benefits of finding a physician with whom we are more compatible, which will certainly help this important conversation my family is having at the moment.

Annabel says
January 18, 2014 at 11:05 PM

The surgeon who removed my ovaries, not explaining before hand that you can't tell if so done has cancer before doing a biopsy. He didnt look me in the eye before the op. luckily I didn't have cancer but when I came round I knew aged 44 I was on the menopause. His comment the following day was "I only agreed to to stay and work late last night, because I thought it would be quick"! I will never forget his cruel tongue. Guess what I was ill through nothing I had done and I never asked him to work on either. Surgeons need to be taught that arrogance is not clever when speaking to a patient. I was always polite!

Gary says
January 19, 2014 at 12:22 PM

I just recently came from my doctor who says he can no longer see me as a patient because if now involved in a nursing medical mal practice suit . He is my family doctor and it is almost impossible to find another family doctor . I'm 61 and have to see many other doctors for things such as; pressure ulcers that can get infected easily . I'm a paraplegic that needs constant care . I use a vac machine for the ulcers . With spinal cord injury and type two diabetic care I feel that he is throwing me to the wolves . I am suing a well known nursing home care sevice for a wound gone bad that made me have a leg amputation . Although my family doctor had nothing to do with the burn because the nursing care provider was treating it . IS THIS ETHICAL or dangerous to my health ?