Physiatry Practice Management Resources

The Kirksville, Mo., obstetrician-gynecologist was treating an emergency physician who was pregnant and seemed set on a home delivery. Dr. Tettambel recommended an early glucose screening for gestational diabetes, but the patient and her husband, an internist, disagreed, saying she wasn't at risk.

Eventually, Dr. Tettambel convinced the doctor-patient and doctor-husband to do the test. The results came back borderline high.

As a result, the pregnant doctor wanted a litany of other tests. In the end, the patient-doctor and the treating doctor couldn't agree, so they severed their relationship.

"She went from denial to wanting to do all these extra tests," said Dr. Tettambel. "Some women physicians tend to really worry."

Many physicians and behavioral experts agree that doctors can be difficult patients.

Some physicians take shortcuts on their own care by substituting a colleague's curbside consult for a regular exam. When they do go to a doctor's office, some seek greater control of their treatment than the average patient, making it tough on physicians who treat them. Others want preferential treatment.

"Are there physicians who are pains in the ass to be patients? The answer is yes," said Wayne Sotile, PhD, co-director of Sotile Psychological Associates in Winston-Salem, N.C.

One of the trickiest issues in treating a physician is getting the doctor to see a doctor. "Doctors tend to take care of other people first and themselves last," said Steven Farber, MD, a cardiologist in Conroe, Texas.

Many consider their lives too busy to make a doctor's appointment. "It's sort of like trying to work on a BMW going 80 mph," Dr. Sotile said.

Occasionally, the engine breaks down.

Some of the doctors counseled by Dr. Sotile had heart attacks because they put off regular checkups for years. Another physician kept ignoring abdominal pain and ended up in the hospital with an intestinal blockage.

"His wife said he had abdominal pains for over a month and kept treating it himself with antacids," Dr. Sotile said.

This "I'm-too-busy and my-practice-comes-first" mind-set often leads physicians to seek advice or treatment from their colleagues in hospital hallways and physician lounges.

"They'll say, 'I hurt my ankle, what do you think?' They don't want to hear, 'Well, see me in my office,' " said Mark Aschliman, MD, an orthopedic surgeon in Milwaukee. "We have access in ways that other people don't, and that's actually very detrimental. By not following routine, they often get shortchanged."

A few minutes in the lounge is no substitute for a complete exam in the privacy of a doctor's office.

"I've learned over the years not to corner my colleagues. Part of it was having other people doing it to me," Dr. Farber said. "You don't want to take shortcuts to care."

Dr. Aschliman treats a colleague about once a month on average, typically for ankle sprains, injured knees, back and neck pain, and the occasional fracture.

In many ways, he can't help but treat physician-patients a little differently.

"If I know them, I call them by their first name. I'm a bit more formal with my patients," Dr. Aschliman said. "I understand that their [medical] vocabulary is better. I will probably go out of my way a little more because they're a colleague."

That could mean extra time in the exam room and some leniency on scheduling. But it doesn't mean every visit is a happy one.

Dr. Aschliman said psychiatrists are some of his most challenging patients.

"They tend to want to talk about things more," he said. "They just ask a lot more questions that are the same question but worded differently. In orthopedics, what you see is what you get. Sometimes, I pull out what little hair I have."

Dr. Tettambel said when medical students or residents come to see her, as patients or as family of patients, they practically scrub up and offer to work beside her.

"Medical students come in with textbooks and they want to help deliver the baby," she said. "I'm saying, 'Wait a minute, you're going to be a father. Be a support to the mom, not to the doctor.' "

Physician-patients do garner professional courtesy from most treating doctors. This may mean not having to make an appointment, getting free drug samples during an office visit and perhaps having an extra test or two.

But there are limits.

"Doctors expect free care and professional courtesy. [Free care] is something you cannot do. Once that situation starts, other expectations occur," said Dr. Farber, who wrote about doctors treating doctors in Behind the White Coat.

A few doctors expect to be treated a cut above. One physician patient asked a doctor to sign a "clean" physical for his life insurance, without doing an exam. Another asked that the medication he took not be included in his medical record.

"They want to be like 'frequent fliers' and hope to get that lucky upgrade. They want all the status of business class," said Dr. Tettambel.

Bruce Bonanno, MD, an emergency physician in Holmdel, N.J., said: "A lot of times they treat me fine as a colleague, but they treat the nurses terribly. That's the time when they act like they're special."

But perhaps the biggest issue physicians face when treating physician-patients is that of control -- chiefly who has it.

"They are harder to treat, in a nutshell, because they're not willing to let go and be the patient," said John-Henry Pfifferling, PhD, director of the Center for Professional Well-Being in Durham, N.C.

Competitiveness nurtured in medical school and practiced in the working world makes it harder for physician-patients to trust their colleagues, Dr. Pfifferling said. They may question what the doctor tells them about drug side effects.

So staying in control seems the logical way to prevent problems. "There's a lack of confidence, to some degree, of everybody but yourself," Dr. Pfifferling said.

Dr. Farber struggled for control with a doctor-patient who came to see him for chest pains. The doctor-patient questioned the cost of the tests and wanted to pay a cheaper rate. He also didn't want to take time for stress tests.

Finally, he agreed with Dr. Farber, but only after the pain intensified. "Doctors have a little bit more difficulty giving up control than the average patient," Dr. Farber said.

Some never fully relinquish control, leaving treating doctors to forge a relationship much different than the one they have with other patients.

"A lot of times when you treat a doctor, you're a consultant," said Tyler Cymet, DO, an internist in Baltimore. "Even though they're coming to you for care, they want you to give them the information and then decide [themselves] what to do."

That medical expertise can make treatment tougher.

"Anybody who has textbooks of knowledge is going to be more difficult than someone who has scoured the Internet for information," Dr. Cymet said. "[Doctors] live in the medical world, so they have seen more medical problems and they want them addressed to their satisfaction."

Of course, not all doctors are bad patients, physicians said. Medical knowledge can make doctors excellent patients.

Some treating doctors don't mind a physician-patient looking over their shoulders at blood work and test results.

"Dealing with a doctor gives you the ability to communicate the information that goes to the heart of the problem. It can be an aid to communication that the patient knows the language," said Marc Siegel, MD, an internist at New York University Medical Center in New York City. "It's one thing to tell a patient, 'I'm doing that scan just to make sure,' but the doctor knows what you're trying to make sure of. Most of the time, they defer to your judgment or they wouldn't come to you."

One diabetic doctor seen by Dr. Siegel stopped taking his medication because he was in denial. Dr. Siegel talked about the medical implications, and his persistent information exchange prompted the doctor-patient to go back on medication.

"That's where a doctor being a patient is an asset, because it can make total sense to them," said Dr. Siegel, who also is an associate professor of medicine at New York University Medical School.

Regardless of the challenges and control issues, physicians said they welcome doctors into the exam room.

"It's actually an honor. It means the word on you as a doctor is pretty good," Dr. Siegel said.

Dr. Farber agreed, saying, "The positives, I think, outweigh the negatives."

Taking care of a physician who works with you or is a close friend poses another dilemma.

A physician friend asked Dr. Cymet to be his doctor, but Dr. Cymet declined. He said it would have been too difficult to separate their friendship from doctoring. If they were out in a social setting, Dr. Cymet might have worried about what his buddy ate or drank.

"I had to say, 'I don't feel comfortable. I'd rather be your friend than your doctor,' " Dr. Cymet said.

One of Dr. Tettambel's partners asked the Missouri ob-gyn to see her through pregnancy. Dr. Tettambel had mixed emotions.

"I was flattered, but then I thought, 'Oh, boy.' Part of me, as a physician, said she needed to slow down. Part of me [as a partner] was, 'Oh damn, I got extra call,' " Dr. Tettambel said.

Sometimes, a physician has to treat a partner.

One day in 1989, Dr. Farber found his partner in cardiac arrest on the bathroom floor at their office.

Dr. Farber tried to revive the physician and continued to work frantically on him at the hospital. But his partner died that day.

"I didn't want to give up because I didn't want to let him go," he said. "It took two other doctors I was working with to say, 'Steve, that's enough.' "

Written by Damon Adams, AMNews Staff

ADDITIONAL INFORMATION: How to be a good medical patient

• Avoid curbside consults.
• Give control to the treating physician.
• Remain objective.
• Define and clarify financial arrangements with the treating physician.
• Show courtesy to nurses and other staff.
• Don't demand free care.

Sources: Steven Farber, MD; Marc Siegel, MD, John-Henry Pfifferling, PhD