Ron Harman King believes it leads to a dysfunctional relationship that undermines quality of care A recent study published in JAMA1 has jolted me into considering a crazy, radical idea. The article's title is, and I quote, "Prevalence of and Factors Associated With Patient Nondisclosure of Medically Relevant Information to Clinicians." Whew, can't wait to see the TV mini-series. Thankfully, a MedPage Today news writer summarized both the findings and the title under a much clearer headline: "Why Do Patients Withhold Information?"2 In the JAMA study, two online surveys found that a shocking majority of healthcare consumers consciously withhold at least one type of medically relevant information from their providers. One survey recorded 61% of respondents admitting a failure to fully disclose, while the other pegged the rate at a mind-boggling 81%. Eighty-one percent! To state the inverse, only one of every five patients potentially comes clean with his or her caregiver. Even more chilling were the common reasons respondents gave for keeping secrets, in descending order: Patients didn't want to be judged or lectured. They didn't want to hear how harmful their behavior is. They feared embarrassment. They didn't want the clinician to think they're difficult patients. And they didn't want to take up more of the clinician's time. Which provoked my crazy, radical idea. Maybe it's time to take a long-standing healthcare tradition, wrap it up into a 40-gallon contractor-grade trash bag, and cart it out to the dumpster in the alley. That is, perhaps it's time patients stop addressing physicians as "Dr. So-and-So." Where do I get such a kooky notion? From the five most common reasons respondents gave for withholding. Three of those five explanations – possibly four – suggest an extraordinarily pernicious level of deference patients render to doctors. Fear of embarrassment, of appearing difficult, and of wasting the clinician's time. To me, these are symptoms of a dysfunctional relationship that undermines quality of care. Could this dysfunction be underpinned by outdated mores? Certainly, it is entirely possible that habitual use of the formal title "Dr." either consciously or subconsciously makes patients just too darn bashful to engage in more productive dialogue. It may feel to many like having the audacity to ask the queen of England what brand deodorant she prefers. Anecdotally, many of us have witnessed such non-communicative deference in older patients. Over the years, aged relatives of mine, as well as elderly neighbors and friends and my own parents, have repeatedly failed to volunteer relevant information or ask pertinent questions during physician encounters. When pressed for an explanation, their answers were typically something like, "Who am I to question or doubt a doctor?" Yet I recently had an illustrative experience with a quite young person. Several weeks ago, I attended a scientific meeting as the conference's only non-physician speaker. At the hotel reception desk, an employee of the millennial generation initially addressed me Mr. King – until he glanced down to his computer screen and saw my conference affiliation. "Whoops," he said, "I mean DOCTOR King." At that moment, his demeanor and tone of voice shifted from routine politeness to near obsequiousness. I was left with the impression that had I requested it, the hotel employee might well have sent a complimentary bottle of Dom Perignon champagne to my room. This was Las Vegas, after all, where status begets big perks. If a shift in title provokes such instant behavioral change more widely, what might happen if doctors and patients worked together on a first-name basis? Mind you, I see no panacea here. Yes, this issue is too complex for a single, simple fix. For example, when MedPage Today interviewed several leading physicians for reaction to the JAMA study, they speculated on multiple possible factors, including: a hesitation to share information that may appear in electronic medical records for others to see; the threat consumer-oriented medical websites may pose to physician-patient relationships; and reluctance to reveal actual alcohol consumption or other poor health habits. Add to that the understandable fear of the elderly of losing their driver's licenses and independent living, plus just plain old human denial – "Doc, it's really nothing, just a little cough." Okay, so individual providers can do little to counter the juggernauts of electronic health records, medical websites, or basic human behavior. However, little things can make big differences. To be honest, I struggle to find much downside to dropping the formal title of "Dr." True, sometimes it's wise to keep a professional distance in the same way that physicians shouldn't always share email addresses and cell phone numbers with patients. On the other hand, if the JAMA study is accurate, we have a giant problem on our hands, folks. As Dr. Robert Wachter of the University of California, San Francisco told MedPage Today, "(I)n the real world there's a power differential, and patients are often intimidated and feel like there may be some psychological risk to being fully open and honest with their clinicians." I want to know what you think. Leave your comments here, and don't hold back. If we've learned anything from this research, it's that timidity isn't always the best policy. Source
