An ophthalmologist anxious about the health crisis. A psychiatrist well-versed in drug metabolism and contraindications. An otologist with a chicken bone lodged in his esophagus. A surgeon who offers advice during his own medialization laryngoplasty.
Explore This IssueJuly 2020
Otolaryngologists encounter interesting cases all the time. In some cases, the patient happens to be a physician, which can make the encounter more or less challenging, according to veteran otolaryngologists. While the paradigm often changes when the patient is a physician, it doesn’t always have to be for the worse.
“Every patient is different. The best interactions I have with patients who are physicians is when they’re humble enough to check their white coats at the door, let me know their background, and then just be the patient,” said Sujana S. Chandrasekhar, MD, clinical professor at Zucker School of Medicine at Hofstra/Northwell, clinical associate professor at Icahn School of Medicine at Mount Sinai, and a partner with ENT and Allergy Associates LLC in New York City and New Jersey. “Some physicians are sure they have ‘X,’ and you have to say, ‘Let’s start with a history and exam. What are your symptoms?’
“Most physician-patients figure it out, and a weight is lifted. You can see it—they exhale and realize they can just be a patient.”
According to a study of family medicine physicians (Domeyer-Klenske A, Rosenbaum M. When doctor becomes patient: challenges and strategies in caring for physician-patients. Fam Med. 2012;44:471-477), common challenges treating physician-patients include:
- Maintaining boundaries;
- Avoiding assumptions about patient knowledge/behaviors; and
- Managing access to informal consultations, test results, and opinions from other colleagues.
“Some of my favorite patients have been physicians or healthcare workers … [but] there’s always more pressure for the physician-patient to have a good outcome,” said C. Blake Simpson, MD, professor in the department of otolaryngology at the University of Alabama at Birmingham, and director of the UAB Voice Center. “One of the pitfalls to avoid is making exceptions. When you start deviating from your normal practice patterns, that’s when you can get into trouble.”
Every patient is different. The best interactions I have with patients who are physicians is when they’re humble enough to check their white coats at the door, let me know their background, and then just be the patient. —Sujana S. Chandrasekhar, MD
Positives Outweigh the Negatives
While some physician-patients can be demanding or difficult, the majority are grateful for and appreciative of the care provided, according to Samir S. Khariwala, MD, MS, associate professor and chief of the division of head and neck surgery in the department of otolaryngology, head and neck surgery at the University of Minnesota in Minneapolis. He said it often enhances the relationship because the conversations can be more technical.
“One of the most difficult parts of my job is to impart what’s going to happen during the course of their treatment to a patient—what it will look and feel like, and the symptoms they might have,” he said. “I feel I have a head start when the patient is a physician. I can describe something about a procedure, like a surgical incision or surgical drain, and they’re ahead of my non-physician patients in comprehension.
“We also share this common knowledge of how to treat patients, so I think they have a better understanding of what I’m trying to accomplish. In terms of things like informed consent, explaining all the risks, etc., they know I’m not trying to scare them.”
Dr. Chandrasekhar said she encounters “a lot less nonsense” in terms of physician-patients expecting special treatment now when compared to 15 or 20 years ago, including being more respectful of her front desk staff. “Overall, physicians are more down-to-earth today,” she said, “and more open to sharing emotional concerns as well as physical ones.
“I recently cared for an ophthalmologist who seemed hesitant in the beginning,” said Dr. Chandrasekhar. “As we were talking, he opened up, and we talked about the anxiety he was feeling. We discussed the fact that one of his relatives suggested a medication that he didn’t want to take. It was really interesting. I understood immediately what his concerns were, and we talked about how we could best manage the situation.
“As I got to know him, I found he was a very nice person. At the end of treatment, he said, ‘You really know your stuff.’ I now have a colleague I can get a cup of coffee with and can refer my patients to.”
According to Dr. Simpson, an initial consultation with a physician-patient can be both different and enjoyable. “It tends to be very focused,” he said. “They usually know the important details, but occasionally they forget and leave things out of the history. When it comes to counseling, it’s terrific. You can use medical lingo, and they understand everything you’re saying with no filtering. You can discuss research studies and your own clinical experience. I think they appreciate that.”
Dr. Simpson, who spent two decades in San Antonio before starting at UAB in the winter of 2019, said he’s noticed throughout his career that physician-patients, more than lay patients, tend to ask him what course he would choose if he were the one receiving treatment.
“Doctors in procedural specialties—surgery, cardiology, gastroenterology—realize that there are risks involved in any procedure you suggest, and they tend to accept those risks better,” he said. “They also tend to pick the procedural route more often than not if the risks are low. I think they’re used to fixing things.
Some of my favorite patients have been physicians or healthcare workers … [but] there’s always more pressure for the physician-patient to have a good outcome. —C. Blake Simpson, MD
“The other specialties, like internal medicine, pathology, and psychiatry—as you might expect—tend to be more conservative. They come to me armed with data or research studies, and they may ultimately arrive at the same decision as the procedural doctors, but as a general rule they want to talk it out more. I enjoy that—they make you think.”
Dr. Khariwala said he’s impressed by physicians’ resilience and work ethic in the face of difficult health issues. “The ones I’ve treated have been resolute in their desire to get back to work,” he said, remembering a physician-patient who had a second primary in the head and neck area. “He was in his 60s, was treated years ago, and had a new tumor develop. On our first visit, he told me he wanted to get back to work. He underwent a big surgery, had free tissue reconstruction, and got back to seeing patients within a few months.”
What if the physician-patient shares your specialty? According to Dr. Simpson, otolaryngologists can be great patients. “It hasn’t always been rosy, but they understand the field better than anybody and can relate to the particulars of our practice,” he said.
One of Dr. Simpson’s colleagues was diagnosed with thyroid cancer. During his surgery at a well-respected institution, his vocal cord was paralyzed. They agreed he would need medialization laryngoplasty.
“He was awake during the surgery, of course,” he explained. “He wanted to see the image of his larynx on the OR monitors. He was joking around, saying he didn’t think the implant was big enough, [telling me] to carve another one to his specifications. The whole time he was critiquing the procedure, but no one else realized he was joking with me. I thought it was a scream, and, fortunately, he did very well. But I’ve never had input in the middle of a surgery until that patient.”
Do You Know Who I Am?
Influential patients commonly request special medical treatment, a phenomenon known as “VIP syndrome” (Allen-Dicker J, Auerbach A, Herzig SJ. Perceived safety and value of inpatient “very important person” services. J Hosp Med. 2017;12:177-179. doi:10.12788/jhm.2701). These patients, who may be wealthy, famous, or leaders in a field, often pressure the healthcare team to bend the rules (Guzman JA, Sasidhar M, Stoller JK. Caring for VIPs: nine principles. Cleve Clin J Med. 2011;78:90-94).
According to Drs. Chandrasekhar and Simpson, these kinds of exceptions can include:
- Requesting off-hours or off-location appointments;
- Delaying post-surgical follow-up appointments;
- Requesting variances from standard care (for example, requesting physical therapy when inappropriate); and
- Asking for additional medications that aren’t warranted (although both have noted that they have never had a problem with medication exceptions for physician-patients).
“I think it’s really important, whether we are the patient or the physician, to understand that bending the rules can cause imperfect outcomes,” Dr. Chandrasekhar said. “You have to be kind and gentle, and when they ask for an exception, you have to say no.”
Lay patients can become anxious about symptoms and treatment when they rely on “Dr. Google” for researching information. While physician-patients aren’t likely to do their research through search engines, they can also develop anxiety when they research treatments on their own.
“I have found myself in all-out negotiations with a physician-patient,” Dr. Chandrasekhar said. “I have had to dig in my heels. One patient, a psychiatrist who really understands drug metabolism more than most people, had really in-depth questions. I listened to her and explained the best I could, but I eventually had to tell her to stop. Her ‘academic’ discussion was distracting from the care she needed.”
Dr. Simpson agreed, explaining that open lines of communication are important. He often gives physician-patients 24/7 access via phone or text but said he has never had a problem with someone abusing direct access.
Questioning a medical opinion is less common but not unheard of. “A physician-patient once argued with my interpretation of the videostroboscopy exam findings,” Dr. Simpson recalled. “I was 20 years into my practice, and he said I didn’t know what I was talking about. He was being combative and aggressive—I didn’t see that coming. I was respectful to him, but ultimately referred him to someone else.”
No patient likes to hear the word “cancer,” Dr. Khariwala said, and physician-patients are no exception. “It’s more sobering for them,” he said. “They know the potential outcomes can be very bad. The challenge is to not let their knowledge and experience, and what they’ve seen this disease do, impact their outlook and attitude,” he said. “You have to make sure they know that many patients do very well. I emphasize the upside, the cure rates, the likelihood of success.”
One of Dr. Khariwala’s physician-patients with a small tongue cancer was disappointed when a lymph node test was positive upon completion of the surgery, resulting in the need for adjuvant radiation.
“She thought she would get the surgery and be done,” he said. “She started worrying about end of life. It was very hard for her because her initial impression was that it was an early tongue cancer, which it was, but it kept morphing into more and more treatments. It became overwhelming at some point. I’m delighted to report she’s doing well now, but it wasn’t easy.”
Richard Quinn is a freelance writer in New Jersey.