It’s Time We Talk: A Doctor is a Doctor is a Doctor, Right?

I am a foreign born, foreign trained doctor, serving many patients from an ethnic minority, whose native language I never mastered.

So, perhaps I am in a position to reflect a little on the modern notion that healthcare is a standardized service, which can be equally well provided by anyone, from anywhere, with any kind of medical degree and postgraduate training.

1) Doctors are People

No matter what outsiders may want to think, medicine is a pretty personal business and the personalities of patients and doctors matter, possibly more in the long term relationships of Primary Care than in orthopedics or brain surgery. Before physicians came to be viewed as interchangeable provider-employees of large corporations, small groups of like-minded physicians used to form medical groups with shared values and treatment styles. The physicians personified the spirit of their voluntary associations. Some group practices I dealt with in those days were busy, informal and low-tech, while others exuded personal restraint, procedural precision and technical sophistication. Patients gravitated toward practices and doctors they resonated with.

In many of today’s medical practices, the doctors’ names aren’t on the front door, office letterhead or company advertisements; they’re often not even in the phone book. A group of employed doctors these days can consist of multiple personality types with disparate treatment philosophies and clinical styles. I once worked with a doctor who would give patients with upper respiratory infections half a dozen prescriptions while I would say “go home and get some rest; it’ll go away”. Not knowing what the two of us were like, patients could end up choosing the doctor whose style didn’t meet their needs.

I have worked with colleagues who view every laboratory abnormality as an ominous threat and pursue each one to the ultimate degree, making even the healthiest patients uncertain about their chances of survival. Some of the same doctors also insisted on seeing even patients with mundane medical conditions on a tight schedule in order to monitor them for unforeseen medical disasters. In today’s generic clinics, patients may not know if their new or covering doctor is a reassuring pragmatist or a consummate worrywart. Worse yet, they may be shuffled back and forth between doctors with opposite styles.

2) Training Differs

In Primary Care, we have MD’s and DO’s, Family Physicians, Internists and “Med-Peds” physicians. Each training is inherently different, further complicated by differences between schools, regions and countries.

Internists, trained to treat diseases of adults, are sometimes asked to treat children in the government-sponsored type of clinic I have spent most of my career in. They are also oftentimes faced with treating conditions in ophthalmology, otorhinolaryngology, gynecology and orthopedics – areas where they may have little experience. Their residency training may have been entirely urban and hospital based, but in today’s American job market, the demand and opportunities tend to be in more rural areas, particularly for visa applicant physicians from third world countries, where academic hospital medicine may be fairly similar to US healthcare, but where small town and rural medicine can be very different.

3) Culture Matters

As an immigrant physician with English as my second language, I had to work at speaking comfortably with rural American patients, many of whom were of French-Canadian origin. It must be a bigger challenge for physicians from further away than Sweden. Language is only the beginning. How different cultures view life events and medical conditions can vary greatly. I am told that the Japanese don’t have a word for hot flashes and that in Tibet, most people aren’t familiar with the notion of depression.

People in this country often talk about how doctors need to be sensitive to minority patients’ culture. Less is said about minority physicians’ familiarity with the American majority of patients; whether we are from Sweden, Japan, Tibet or India, we each have a learning curve for understanding those we are here to serve as personal physicians.

I remember one internal medicine physician from a Muslim country who found out that his American employer expected him to perform routine gynecological exams including Pap smears on his female patients. Not only had he never been trained to do any of it, he also had to wrestle with overcoming what his his entire upbringing had told him was improper.

4) What is a Good Doctor?

The industrial view of healthcare imagines that it consists of standardized processes that are easily measured: What is the average blood sugar, or glycohemoglobin, of Dr Andersson’s and Dr Singh’s patients? Their pneumonia immunization rate? How many of their heart failure patients are on a beta blocker? How many seniors have had a fall risk assessment? How many obese patients have an obesity action plan documented in their medical record?

Nobody talks about this, but all those quality indicators make less difference for individual patients’ longevity and for entire populations’ health than healthy lifestyles do. For individual patients’ health as it relates to healthcare, accurate diagnosis of new symptoms can amount to an all-or-nothing disparity between health and disease, even between life and death.

Some of the most basic measurements of physician quality are surprisingly irrelevant: Beta blocker therapy in heart failure patients only increases average survival 6-12 months, it takes 50,000 pneumonia vaccinations to prevent one pneumonia death, and prostate cancer screening, once a basic minimum requirement for men’s health care, is no longer even recommended.

My uncle had waxing and waning paralysis of his left arm, but his doctors never checked his carotid arteries, and soon thereafter he had a stroke. My aunt had a cough for well over a year, but because she never smoked, her doctor didn’t order a chest x-ray until it was too late and her lung cancer was inoperable. This happened in Sweden, where the average life expectancy is the 6th highest in the world, 3 years more than 32nd ranking USA. It could have happened anywhere, because doctors are people, each one different, and the real quality of their work cannot be measured, let alone regulated.

Employers and bureaucrats may think a doctor is a doctor is a doctor. My aunt, for one, doesn’t think so anymore.

1 Response to “It’s Time We Talk: A Doctor is a Doctor is a Doctor, Right?”

  1. 1 meyati December 14, 2014 at 1:08 am

    I understand what you’re saying. Personally I don’t really like American doctors or their training anymore. In Sept. the HMO gave me the choice of
    3 PCPs. I took the female Saudi female doctor that was trained in the Caribbean. The other 2 were American born and trained.
    Sure I say things that they don’t understand. I use Armour thyroid-Medicare and HMOs don’t like it. I feel horrible that a doctor is put in this position of being lectured about writing a script for me. I pay for it out of my pocket. I want to live-and it costs me about 32 cents a day.

    She told me that she’d be happy to write the Amour scripts for me. I told her that I really hoped that she was comfortable with it. The fog drifted across her face. I quickly said that I hoped that she did not feel conflicted about the Armour, and she could maintain a good relationship with the HMO, that I hoped that we would have a good doctor-patient relationship that made her comfortable. Then she smiled.

    To most foreign doctors, I’m now an elder, not someone to hustle out of the office as fast as possible. I’m not told that I confabulate, when I say that as a Navy wife, I had South Vietnamese and South Korean medical corps officers care for me. That I had Iranian, Cuban, and Peruvian doctors that joined the military to get citizenship, and I was under their care.

    When I was young they respected me, as they would want their own wives to be respected. Now that I’m old they listen to me, when I tell them that my BT has always been low. They quickly scan the EMR, and move on. American doctors want to fight about it. Was I sucking on ice-whatever?

    Native born Americans have different styles and manners based on where they lived, and who trained them. Then there are different personalities. Everybody has to make adjustments, but that doesn’t always happen.

    I had a ROKN OB-GYN. I didn’t have any problems with him doing a pelvic (That’s how they cared for IBS back then). I went in one day, and he asked if he could talk to me. He’d go into an exam room, and the women would refuse to let him exam them. He was warned that he had to fix this or go to South Korea in disgrace. If that happened, he would socially and culturally have to commit suicide to not shame his family, his profession as a physician, his navy, and his country.

    I remembered how doctors got mad at my temp, and they’d flip angrily through the chart. They’d stop- look and snarl–“Let’s get this over with” I told him about that. He was appalled that a doctor would be so disrespectful to a patient. I told him that he had to take charge or go home. That he was a good doctor.. That he go through the chart- go- Uhmm, snort, look up and stare while the woman was complaining. They’d stop complaining, and he needed to say, “Do you want to be examined now, or do you want to wait months for a new appointment. Are you sick or not?” I also reminded him to be careful and not to hold the chart upside down like some of white American officers did.

    We talked about this a year later. Many of the patients wanted to keep him as a doctor, because he wasn’t as rough as some Americans. He never had another patient walk out on him, and he shared this with other Asian naval officers.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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