Tuesday, 21 May 2019

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Piece of My Mind

 “Oh I’d like to give him piece of my mind”.  I may think (but not say) this on days when the patient:

  • Declares he didn’t fill that prescription or didn’t go for X-rays 
  • Didn’t see the consultant neurologist
  • Can’t remember any instructions form the last visit
  • Does not know what his meds are or what doses he takes

Whether this is your fault, or patient self-neglect, disease denial, noncompliance or a lost prescription or instructions, you may be tempted to offer patients “a piece of my mind”.

However, “a piece of my mind” needn’t be sternly delivered. An appropriately worded instruction is far superior to condescension, or negative instructions.  The latter are surefire ways to widen the communication gap between you and your patient. 

Beyond the diagnosis, coding, and treatment plan, the doctor and patient gather periodically to share information.  They update you with their tale of an ER visit or response to your last joint injection.  In return, you deliver pieces of the doctor’s mind – perspective, corrections, advice, interpretations, or in my case, long-winded allegories designed to entertain and instruct. 

What you share has to be educational, encouraging, and a pathway for improvement, adherence and normalcy for the patient.  You know so much, and they have too much to learn, but limited time and few opportunities make it difficult to share information and fill that gap - especially in a way that will “stick” and be meaningful to the patient.  

I recently came across a discussion and podcast by Michael Hyatt that focused on how to get your boss to be a better leader/boss, or at least do what you think he/she needs to do. His step-by-step instruction does translate to getting your patient to be a better patient.

I often make clear that the patient is the “boss” and they have hired me to give the best possible care and advice.  Hyatt offers 8 suggestions how to approach the reclamation of your boss. In the table below I counter with suggestions for what this means to your patient.

 How to Influence Bosses

 How to Reshape Patient Behavior

1. Check the weather

1.  Understand who you are dealing with, their current state and circumstance and if they are in a listening/learning mood.

2. Be humble

2. Humble (“let me suggest…”) is more palatable than Authoritarian (“what you need to learn is….)

3. Praise first

3. It’s very easy to spot the patients mistakes or failures. Better to praise the good before focusing on the bad.

4. Ask for Permission

4.  They may not want to hear that “tough love” lecture. But if you ask permission to deliver it – its impact and recall will be greater than if they have tuned you out

5 Know what’s at stake, put in context

5. Why is this change, alternative approach, new drug necessary? What are the consequences of change vs. not changing?

6. Assume the best

6.  Assume they are on your side and will enact your advice. Let them know that a partnership is needed (patient + doctor) to achieve the outcomes they want most.

7. Believe that it matters

7. You know what’s at stake and you believe that change or treatment matters.  You need to make sure they have the same belief – that it matters.

8. Take the time and risk – they’ll appreciate it.

8. It’s easy to believe that such discussions are difficult and are best avoided, as the patient will ultimately catch on (or not).  But the stakes are too high. Not taking the time or avoiding the risk of a blowout conversation, will cost you and the patient dearly in time, damage, and limit treatment success.


You must do your part, and the patient must do theirs.  You know what you’re doing; you’ve been a physician for how long? Seen how many patients?  But, it’s all new to the patient.  Rheumatoid, gout and lupus don’t come with a manual. You need to help and teach them how to be great patients.


The author has no conflicts of interest to disclose related to this subject
Dr. Cush is the Director of Clinical Rheumatology at the Baylor Research Institute and a Professor of Medicine and Rheumatology at Baylor University Medical Center in Dallas, TX. He a Professor of Clinical Medicine at the University of Texas Southwestern Medical School.
Dr. Cush is the Executive Editor of RheumNow.com and also Co-Edits the online textbook RheumaKnowledgy.com. 
Dr. Cush's research and interests include novel drug development, rheumatoid arthritis, spondyloarthritis, drug safety, pregnancy and Still's disease/autoinflammatory syndromes. He has published over 140 articles and 2 books in rheumatology.
He can be followed on twitter: @RheumNow.

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