Doctor to Doctor (Original Version)

By
Dr. Kaiser Simab Zirak

It is a frank presentation from a doctor for doctors. I am a Dermatologist in full time

Private Practice in Pakistan. I want to present two golden principles, eight practice secret
and one sincere advice. They reflect my philosophy of thinking and my keen observation
of patients in my very short Dermatology private practice. Although these were observed
in practice of Dermatology most of these practice secrets are generic and thus applicable
to all specialties. Also although these were observed in Pakistani patients they are
applicable worldwide. There is an extract from this article called Doctor to Doctor (UK
version). I have presented in this article what I feel is mostly applicable to UK audience.

Golden Principle number one: Your fight is against the disease. Rest is irrelevant.

Your prime objective as a doctor should be to make patient disease free. This should be
done at all costs. All of the rest including our ego is secondary. Whether patient can pay
or not, is demanding, irritating or arrogant or has certain traits that you can't bear in a
person should not stop you form making him disease free. If we follow this principle it
would make doctor-patient relationship very strong and rewarding for doctor and we as
doctors will get real satisfaction form our jobs.

Golden Principle number two: Ideal recipe for success is that there is no single
recipe of success at all.

Doctors are a part of service industry. I really call my patients customers because like a
customer paying and buying a cup of coffee or a loaf of bread patients pay and buy my
services.

All member of service industry including doctors have a model to handle its customers.
For example in a sandwich shop the owner would have laid down some principle by
which they would treat their customers entering the shop to buy sandwiches. He might
have instructed his employees to greeting every one with smile, always keep the coffee
fresh and hot and to thank customers after handing them the change and the sandwich.
Big companies will have manuals listing principles that employees should follow while
dealing with customers .Like wise Doctor practice firms have a model to deal with
patients.

By laying down certain general guidelines we think that we have recipe for success
regarding customer/patient satisfaction. But we are wrong because we don’t account for
individual variation. Not all five fingers are same. No matter how high standards we
adopt for customers (patients) satisfaction some customers (patients) would be
dissatisfied with us on some days.
In this commercial age the choice of an individual is unimportant. Industry pays attention
to what majority thinks is important. Surveys are part of this. For example if a survey
show that 85%of people don’t like a particular chicken sandwich the shop owner would
properly stop making it even though there would be many that like it very much and
would buy it for their lunch day in and day out.

Coming to Doctors, we have a model in our minds by which we would handle

patients .While majority may be happy with the way we treat them there might be a
minority, that is as important as the majority, that might be unhappy with the way we
treat them. So the real recipe of success is that we should treat every patient as an
individual and we should try to know the expectations and wishes of the patient sitting in
front of us and do accordingly. By adopting certain guidelines of practice we might
satisfy the majority but NOT all. There is no single recipe of success satisfying ALL
patients This is mainly because every patient is an individual having certain expectations
and demands and the ideal way of satisfying ALL patients is to judge those and do
accordingly. Make general guideline but be flexible move up or down according to
patient expectations. Hence making a judgment of patient’s expectations early on in the
patient encounter is of paramount importance

I give you a personal example . One patient came to me for lesion on his forearm. After
examining him I told him that it is keloid and the treatment of it is quite prolonged and is
not successful in all patients. He asked me just one question ”If I leave it like this will it
become dangerous?” to which I said that if he would leave it untreated it would not go
away on its own but it is not a cancer or other dangerous thing and it will not become one
if left untreated. The patient said that disease is on his forearm which he can easily cover
by his full sleeve shirt and he doesn’t want any treatment for it to which I agreed happily.
So the patient just needed reassurance that it is not a dangerous thing or cancer and he
was happy with the appearance of it.

So the point I want to make is that we as doctors think that patients always want to get rid
of their disease but few patients would be happy to live with their disease and they might
have other concerns with it .A direct questions about this should be asked early on in the
encounter. Questions like “What are your real concerns about your disease?” and “What
do you expect form us today?” should be asked early on in patient encounter. Only by
knowing personal expectations of each patient we can satisfy ALL patients.

Practice Secret One: Appearance matters- Dress according to your patient

population.

People get comfortable with the appearance of doctor. This is largely due to their own
perception of what is good dressing and appearance. A person that always wears
traditionally (shalwar kameez) becomes comfortable when seeing a doctor in shalwar
kameez. Similarly a religious person having a beard will become happy when he sees a
bearded doctor. One teacher of mine said to me once that a person who comes from
village when enters doctor’s room and sees a suited booted person will think how that
doctor can understand me. Thus the appearance of doctor has an impact on doctor-patient
relationship. It immediately raises barriers without saying a word! So wear according to
your patient population. If you practice in rural area where most patients wear traditional
dresses (shalwar kameez) wearing similarly would help a lot in gaining confidence of
patients.

Practice Secret Two: Know what patients want and give them want they want.

There are certain things that patients like and dislike in private practice. Knowing them is
important. Here are few things from my personal experience.

1) Patients don’t like short prescription. Prescribing a single drug might not be good.
Prescribe with at least two items.
2) They like to have some per oral meds as well with topical ones. They believe that
topical medicines control the disease superficially and oral medicines are necessary to
completely eradicate a problem.
3) The patients don’t like long follow up period. This is the GP effect in Pakistan. When
a patient goes to GP he gives medicine for one day and patient has to come for follow up
next day. When I ask patients to come for follow up in 2-3 weeks they are mesmerized.
4) They don’t want to hear that there is no treatment for their illness- they won’t believe
it.
5) They want soap for every condition

Practice Secret Three: Price tag is important

Generally many rich or poor alike think that costly medicines are good and thus are more
effective. It is very difficult to change the mindset of people. On the other hand not all
especially the poor can afford the costly medicines but still they believe that the costly
medicines are more effective than cheap ones. In this sense prescribing very cheap
medicine is not a good move. It will be demoralizing for patient. A good practice is to
give medicines of moderate cost.

Another issue is that brand drugs differ in prices greatly even when they have same
generic drug. Currently at least in Pakistan there is no awareness whatsoever in public
about generic vs trade drugs. People don’t understand that two drugs with different brand
names could be practically the same drug. Currently I am preparing myself for a public
awareness seminar on acne .In that I will tell the general public about basics of acne.
There is a drug that I use very often in acne namely Iso-A Gel (isotretinoin).I shall speak
briefly about Iso-A gel also. One of the features of this is that it is very cheap as
compared to the brand leader--- less than half the price. But I can’t dare to say this in
public. People will think why I don’t prescribe the expensive drug. They will not
understand that the two are practically same with similar active drug but with huge price
difference.

Practice Secret Four: Proof of Authenticity- Always beware of this.

Patients want to check whether the doctor is good or not. They will inquire about the
doctor’s skills and knowledge form a nearby Pharmacy, grocery store or even from
patients exiting the doctor’s clinic. It is important that you have good rapport with your
neighbouring pharmacy or other shops because your patients will inquire from them a lot
about you.

Practice Secret Five: Demanding Patients and the good way to deal with them

Every doctor no matter what his specialty is will encounter demanding patients. These are
really pain in the neck for every one. We really wish they don’t come to us for follow up
or come when we are off so they see other doctor. The real reason behind not liking these
demanding patients is that they demand what is against the nature or principles of doctor.

When patient asks us to do a thing that is severely against our principle We really don’t
want to do it. It really becomes an “ego” issue. The solution is to let patient know that
you don’t like this. But you are doing this to help him or making a favour. You don’t
refuse a patient but do him a favour and show him that. For example let’s assume that
you are a General Practitioner (GP) and you have DPD form Cardiff University. You
consider yourself very good at Dermatology and would treat the majority of Dermatology
patients yourself. You would refer to Dermatologist in small minority of cases when you
deem it is absolutely necessary. Given this one patient comes to you and asks for
Dermatology referral for a condition that you don’t normally refer because you can very
effectively treat it. But patient insists on dermatology referral. You are getting upset by
this but patient is demanding a referral and he wouldn’t go until you do so. What you do?

If I analyzed this there are two facts. First you can easily treat the patients yourself and
you don’t think there is need for referral. Second, Patient is persistent with his request for
referral so you know you will have to refer him. These two facts fight in your brain and it
becomes and ego issue but in the end you know that if patient is persistent you have to
refer him. So you refer him but this causes unpleasant feelings in your self because your
ego is hurt. It is unpleasant when you are forced to do a thing against your will. This is
exactly like you might spare some money for a homeless approaching you on street and
be happy but would be extremely uncomfortable when he points a gun at you and takes
your wallet.

So what is the remedy? When you have established that patients is demanding and
persistent with his request. Instead of getting upset do a patient a favour and show it to
patient that it is a great favour form you. For example in current example you could refer
him to Dermatologist and could say some thing along these lines “I don’t like referring
patients to Dermatologist when I can easily treat them. I really don’t like this at all. But I
am doing this for you as a favour”.

So instead of being forced to do a thing against your will you are making clear to patient
that you are doing him a favour. By saying that you are doing a favour you satisfy your
ego. If you don’t say anything and do it silently then you feel that you are being forced by
patient to do it and your ego is hurt in this way. Another advantage of this technique is
that by letting the patient know that you don’t like this thing but still are doing it he might
not ask it second time so a real upsetting issue is avoided.

Let me quote you a personal example. I don’t like patients that try to dodge me or be over
clever to gain their own means .I quote you one example a female patient phoned me
whom I saw her once for acne pimples and said that I gave her medicines for pimples
when her real problem was acne scars also she said she is from Gujranwala(another town
60 miles away) and can’t come in. so she asked me that I give her scar medicines over the
phone. I said that I gave her pimples medicine because she was having those at that time
and now she should come back to my clinic so I could examine her and give scar
medicines. She said there is no need for me to examine they are produced as a result of
her squeezing the acne pimples and she again requested me to name the drug for scars so
she could buy from the market. I said that there are many types of scars and I really
needed to have a look but she said just give me the name of drug. This continued for
some times no matter what I said to her she said the same that I should give her the meds
over the phone. By now I had figured out that she was trying to get the med over the
phone free of cost because if she would come in she would have to pay the fee. So
instead of requesting me to give her med free of cost to which I would have agreed first
she said that I gave her wrong medicine in first place so to put me under pressure and
now she is saying that she is living far away and want med over the phone .I became
upset by that and said there is no need to argue with me I shall not give you the medicine
over the phone. She hung up.

I was upset over this because my principle is to fight with the disease rest is irrelevant.
But this patient was trying to be over clever and I can’t stand those persons. I called her
after some days and said she should have requested me to give her drug name free of cost
and I would have been happy to do so. Then I said I shall text message her name of drug.
She was happy. I my text message I mentioned the drug name and said that she was
trying to be over clever with me which I didn’t like but I am helping her because I believe
it’s doctor’s duty to help.

So patient was over clever and I don’t like this but by vocalizing it and making it clear
that I don’t like this behavour it made it easy for me to help her. So by letting patient
know that I don’t like such behavior it somehow satisfied my ego and made it easy to
help her as our fight is against the disease not the patients. If I didn’t vocalize my view
point it had become an ego issue for me and it would have been extremely difficult for
me to help her. She phoned me again after couple of weeks and discussed an issue at
length. I was happy to her again.

I really urge you to try this technique with your demanding patients and let me know the
response by e-mail.

Practice Secret Six: If you are Newcomer to Private Practice Advice for you is
“Enjoy the present moment it will never come back again”.
Everyone has to start form somewhere. Doctors who are very successful in practice today
started form zero at the beginning of their career. I myself started from scratch few years
ago and now I am seeing many patients each day. I know it is stressful at the start of
practice when very few people know you. You may have zero or very few patients to see
each day. But it is important that you don’t despair and be patient and enduring and you
will become successful.

If you have started your practice quite recently my sincere advice to you is to enjoy the
present moment and forgot the rest. It takes time to get set in private practice and your
turn will come soon. So until then enjoy your present moment because you will not get
such free time when you are famous and busy doctor. I am telling you form my personal
experience. When I had few or no patients to see at the start of my practice few years ago
I used to spend my time by reading medical books, some times I would go out in the
sunny winter day to enjoy the sun and very often I would make a cup of tea for myself
and get out in patient waiting area which would be totally empty to chat with my staff
sipping hot tea. Now when I have many patients to attend to I really miss these activities.

We are preoccupied with either our past but mostly our future. Today we think about
tomorrow and when tomorrow comes we think about the day after tomorrow. So my
advice for you is to relax, cool down and think about today. Spend the free time that you
have got with fun activities, read an interesting book, chat with drug representatives and
with your staff, enjoy the evening breezing and many more like these. You will not get
time to do these when you are busy with your patients.

Practice Secret Seven: Most effective referral is from Patients you treat successfully

When it comes to acquiring services of service industry including doctors people in

Pakistan relay heavily upon personal references. For example in one need a plumber in
countries like UK or USA he/she would most properly look up in yellow pages to find
one. But in Pakistan person would ask his relatives if they know a good plumber. He
would get the plumber that his cousin or auntie got to fix their problems and according to
them he did a good job. Same applies to doctors when persons need a doctor they would
ask their friends/relatives if they know a good doctor and go to him.

The most strong factor for a patient choosing to come to you is referral form some one in
his friends/relatives. It is even stronger than your name being published in holy Quran or
holy bible!

If a person needs a doctor and God mentions your name in Holy Bible but his auntie
recommends a different name. Whom will the patient go to? I can bet my bottom dollar
that a person in Pakistan will go with Auntie’s recommendations!

I am mentioning this from my personal experiences. I experience this day in and day out
in my practice. Very recently a man came with a female patient to me I recognized him
and asked hasn’t he came few days ago with his wife he said “Yes. She got better and
now I am bringing my sister to you”
In this context it is important for us, the doctor, to give effective treatments. And in order
to do that It is important for us to do our best to make accurate diagnosis. Most important
step is to make an accurate diagnosis. After diagnosis is made anyone even a GP can start
a treatment.

So when a patient comes to you do your best that you give him effective treatment
because if he gets better he will send five of his friends/relative to you.

Practice Secret Eight: Do a telephonic follow up.

When I see patients for first time I ask them to come for follow up after 2 weeks. But I
noticed that not many patients turn up for follow up. There could be many reasons for
that.

• Money Factor-If they come for follow up they have to pay fee so they don’t
come
• Get cured- Patients get cured and there is no need for follow up.
• They get better- One reason could be that patients get better but not
completely cured and they consider it acceptable. In Pakistan we call this
Kafi Farik Hai (There is a lot of difference)
• They don’t get better and go to other doctor!

In our practice the rate of follow up is quite low and the reasons could be any of above. I
suppose this is applicable to other practices in Pakistan. In my view the major reason in
our practice is that patients get acceptably better (Kafi Farik hai) and decide not to come
again as they will have to pay the fee.

Given that there is low rate of follow up in our practice the real concern for me is to
know whether patients are getting better, getting acceptably better or not getting better at
all and going some where else. The good mean of answering this burning question is
telephonic follow up. When patients come into my clinic I get their telephone numbers
and follow up by calling them.

It is very good practice and apart form answering the real concern mentioned above it has
lot of advantages .First, it make a very good impression of you when patients gets your
call .They will tell others “doctor called me to inquire about my health.” It is a real
practice booster in this sense. Secondly, It increases your knowledge about diseases. For
example in Dermatology books tell us to apply certain creams for a certain diseases but
often it doesn’t mention how quick the response would be apparent. It is a practical think
that we learn from patients. After you have learnt it form one experience you can tell
other patients that by applying creams the conditions will get better in such time period.
Also you can learn from your patients that didn’t get better from your treatment. When a
patient with similar condition will come to you next time you will prescribe a differently
and may be this time patient will get better. So it teaches you in this sense and it is really
very helpful.

Given the benefits mentioned above I strongly urge you to do telephonic follow up with
your patients in your practice.

One Sincere Advice: Keep your knowledge up to date by reading daily.

We are taught a lot about diseases in Medical College. When we come in practice we
apply practically what we have learned from text books. It is my personal experience that
we forget the finer points about ailments especially those that don’t present frequently. I
once looked up an ailment that is infrequent in our practice and I thought that I have not
read about it in the same book. When I starting reading text appeared new to me but I
recognized by seeing the photo that I have read the same topic from same book in the
past. So it appeared to me that I am reading the topic the first time but the fact was I had
read it before but completely forgotten about it because the case doesn’t present in my
practice frequently. It is obvious that repeated readings are necessary to imprint a subject
in our minds.

So it is my sincere advice that you should make it a habit to select daily a topic from what
you saw in your practice during that day and read about it form the book when you come
back home in the evening.

Regarding books I recommend text books or large books reading from concise books is
not that efficient. In dermatology I recommend “Clinical Dermatology” by Thomas
Habif. One plus point of this is that It got lots of photos so you don’t need to buy an atlas
along with a book.

That’s it folks.

Waiting for your comments and feed backs.

Author is UK trained Dermatologist currently in full time private practice in Lahore and
Sialkot, Pakistan. For feed back/comments/suggestions e-mail the author at:
kzirak@yahoo.com. Website: www.zirakskin.com