How to Transform a Doctor’s Appointment into A Shared Opportunity for Learning and Collaboration

Great care requires collaborative dialogue between patients & doctors

Great care requires collaborative dialogue between patients & doctors

Patients’ often express varying levels of dissatisfaction following appointments with their physicians. One of the most frequent complaints centers on a lack of clear, empathic communication whereby the patient and physician exchange information that not only serves to reinforce their interpersonal relationship and trust, but also facilitates collaborative decision-making.

Before this problem can be addressed, physicians must first be aware of the deficit. According to an article in the Ochsner Journal, “Tongue et al reported that 75% of the orthopedic surgeons surveyed believed that they communicated satisfactorily with their patients, but on 21% of patients reported satisfactory communications with their doctors.”[i] Similarly, “A study released by the nonprofit Cancer Support Community found that more than half of patients with cancer feel unprepared to discuss treatment options with their medical team…”[ii] In fact, we know from research that “…Only 36 percent of patients facing important medical decisions indicated that they were extremely well informed about the decision confronting them.”[iii]

Yet, rather than assign culpability to the doctor for this informational deficit, the patient often excuses it by saying such things as I know my doctor is very busy and doesn’t have time to answer all of my questions or I didn’t remember an important question until after I left the examining room. While other patients are simply too intimidated to speak up out of fear of repercussions.

Poor communication clearly comes at a high price to the patient: “…Unsatisfactory communication by healthcare providers (including too little information, too much information, and/or abrupt or blunt sharing of information) is named the second highest reason for suffering by cancer patients.”[iv]  Physicians, too, pay a price when they fail to satisfy their patients: “Satisfied patients are less likely to lodge formal complaints or initiate malpractice complaints [and] are advantageous for doctors in terms of greater job satisfaction, less work-related stress, and reduced burnout.”[v]

A failure to receive informed consent may carry the greatest cost – both in terms of patient angst and the possibility of litigation! Informed consent, by definition, means the patient must understand all of the standard treatment options for their disease, as well as how these options differ in their potential efficacy, side-effects (short-term and long-term), costs, and other factors. Only then is the patient in a position to assess relative risk versus relative reward.

There are steps patients can proactively take to transform encounters with their physicians from ones of frustration into opportunities for learning and collaboration. Before your first or next appointment, consider the following:

  1. Consider having a family caregiver on-board who will attend the appointment and act as your scribe and advocate – ensuring that the information exchanged during that encounter is faithfully recorded, and your needs respected and addressed.
  2. Identify trustworthy sources of information that will help you understand more about your disease so that your time with your doctor is not spent on the basics, but on very pertinent questions about your disease and treatment options. For cancer patients, such sources include: Major NCI Cancer Centers,, and the American Cancer Society to name but a few.
  3. With your caregiver’s assistance, spend an hour developing a list of questions in advance of your appointment. Consider how the answers to these questions might impact your decisions about treatment. Be clear about what you want to know, as well as what you do not want to hear from your physician. Since there may not be time to answer them all, list them in priority order.
  4. Think about how your personal values will come into play when considering treatment options. Write them down, and be in a position to share them with your physician. Personal values vary dramatically, e.g., some cancer patients want to have every possible treatment exhausted before ceasing active treatment, whereas others may put a higher priority on quality of life during the last stages of their cancer.
  5. If your doctor’s office is agreeable, consider providing your questions to your physician’s nurse a few days in advance of the appointment with a note indicating that these are topics you hope to have covered by your doctor.
  6. When your physician provides answers to your question, ask for clarification if necessary – particularly if there is medical jargon that you do not understand.
  7. When agreeing to a treatment, reiterate your understanding of all issues related to the treatment before consenting to it.

Physicians can also take meaningful steps to optimize the learning and collaboration that occurs during patient appointments, by considering:

  1. How you provide information is as important as the informational content.
  2. The warmth and empathy with which you welcome your patients into the therapeutic relationship will be a tremendous determinant of their comfort and satisfaction with each encounter.
  3. Patients may not want certain types of specific information, such as the statistical probability of survival after five years, but virtually every patient wants you to be honest and forthright in answering their questions.
  4. Because you have obvious constraints on your time, there may be tremendous value in having your nurse, nurse educator or social worker available for further consultation with the patient.
  5. A patient’s decision regarding treatment (or refusal of treatment) may be incongruent with your personal values and thus frustrating. What is important, however, is your agreement that the patient made it from an informed perspective after weighing the pros and cons, and considering their personal values.
  6. You will be the beneficiary of excellent communication, and may wish to seek out resources to further hone your skills in this regard.

The operative word for both patient and physician is collaboration. From that collaboration, trusting and valued relationships can be built that enrich the lives of patients and providers.


[i] The Ochsner Journal  2010 Sring 10(1):38-43

[ii] Cure Today.

[iii] – Veroff et al. Health Affairs. February 2013..


[iv]  – Bevan & Pecchioni, Patient Education and Counseling, 71


[v] Oschner Journal. Pg. 2

Important Information for Newly Diagnosed Cancer Patients and Their Loved Ones…I Hope You Will Listen

INTERVIEW on KBOO FM in Portland (Health Watch with David Naimon 8/3/15)

INTERVIEW on KBOO FM in Portland (Health Watch with David Naimon 8/3/15)

Radio host, David Naimon, (of KBOO FM/Portland) does an excellent job of asking guest, John Leifer, pivotally important questions regarding issues facing recently diagnosed cancer patients and their loved ones.

Among the many topics covered in this 30 minute interview are:

  • How to evaluate and select a physician
  • How to know whether you are receiving the appropriate treatment for your condition
  • When to obtain a second opinion
  • The importance of understanding the goals of your treatment
  • Differentiating between cure, control, and comfort in cancer treatment
  • Unexplained geographic variations in care, and what they can mean to your treatment
  • Financial issues associated with treatment and how to manage the challenges
  • Identifying if your physician has a financial conflict of interest associated with your treatment…and what this can be mean to your care
  • The role of nutrition and exercise during the journey through cancer
  • The role of complementary medicine in cancer treatment
  • How to obtain more information about your disease and its treatment

The interview came about due to the publication of Leifer’s new book, After You Hear It’s Cancer: A Guide to Navigating the Difficult Journey Ahead, written collaboratively with his wife, Lori, a radiation oncologist in practice for 25+ years.

John has spent 30 years immersed in the health care industry as a health care executive, consultant, academician, and author.

In addition to their formal training, John and Lori also bring the perspective of patient and caregiver (Dr. Leifer is a cancer survivor)

Here’s a link to the podcast:


Here is a link to the book’s web-site:

In the Aftermath of Dr. Farid Fata — Straightforward Advice for Cancer Patients (and others)

Dr. Fata is an egregious example of profits over patients' well-being.

Dr. Fata is an egregious example of profits over patients’ well-being.

Dr. Farid Fata, a Michigan hematologist oncologist, is simply the latest in a long list of physicians who have betrayed the trust of their patients, bilked the federal government of millions of dollars, and caused unnecessary pain and suffering for thousands upon thousands of patients. On July 10, Fata was sentenced to 45 years in prison based upon nearly two dozen counts of health care fraud, as well as a plethora of other charges.

Rarely are we more vulnerable than when facing a devastating illness like cancer. It’s a time when we often overwhelmed with anxiety, yet have to make decisions that may impact the balance of their lives; it is a time when we would like to believe, without reservation, that our physicians have our best interests at heart. Fortunately, the majority of the time, they do. But what of the exceptions? How do we protect ourselves against the unscrupulous doctors that abuse their cultural authority and the trust bestowed upon them?

There are clear steps you can take to safeguard their health when selecting a medical specialist and undergoing treatment. First, you need to take a very hard, data-driven look at your doctor. There are some basic questions you should be asking, including:

  • Is the physician Board-certified? Though Board-certification is no guarantee of either competency or ethical behavior, it does improve the likelihood of receiving appropriate medical care.
  • How long has the physician been practicing in his or her given specialty area?
  • Have there been complaints filed about the physician with your State Medical Board or can you identify legal action taken against the physician?
  • Does your primary care physician have an opinion regarding the competency of the specialist, and upon what is this opinion based?

Next, you need to understand your purported diagnosis and recommended treatment plan. Your physician should provide and interpret all of the results from your diagnostic imaging studies, laboratory analyses, and other tests.  He or she should then explain, in terms you can understand, the best course of treatment to achieve a specific goal. In cancer care, there are three, potential goals: cure, control, or make one more comfortable.

Before agreeing to the recommended treatment, there are two, critical steps that will help ensure your safety. First, try to determine if the recommended treatment is considered a “standard pathway” or a generally agreed upon method for treating your disease. The National Comprehensive Cancer Network ( publishes guidelines for the treatment of most forms of cancer – including versions that are designed specifically for patients to review. If your physician’s recommendations deviate from these standards, you need to ask why.

Second, don’t hesitate to get a second opinion. If your physician balks or is not supportive of such action, find a new doctor. When seeking a second opinion, search out a specialist who has no affiliation with your current doctor. If there is a National Cancer Institute Center in your city, this may be a good place to start.

Doctors are every bit as mortal as you and I (trust me, I’m married to one…albeit a very good one). Fortunately, most physicians believe that it is a sacred responsibility to provide the best possible care.

We all know the saying about “a few bad apples.” When you find yourself faced with a serious illness, such as cancer, your job is to find the good ones!

John Leifer’s Recent Radio Conversation with a Physician About the Myths of Modern Medicine

On The AirDr. James Mirabile was kind enough to have me as a guest on his hour-long radio program on 3/14/15.  We discussed some of the key themes found in The Myths of Modern Medicine: The Alarming Truth About American Health Care. 

I would invite you to spend a few minutes listen to the podcast…and then I would, as always, welcome your thoughts & comments!

Here is the link:

PS: You can order The Myths of Modern Medicine on


shutterstock_162343382(The following post is an excerpt from The Myths of Modern Medicine: The Alarming Truth About American Health Care by John Leifer and available at


Imagine navigating the Amazon without a guide. Though the health care system isn’t rife with venomous snakes and flesh-eating fish, there are a great many hazards that can make the experience tortuous, expensive, and even deadly. Your tour guide, the one who keeps you out of harm’s way, is your primary care physician (PCP). He or she has drawn the map for your journey, enlisted others to help you surmount obstacles, and carefully tracked your progress. When you need someone with specialized knowledge, your PCP should know the best resources to call upon for help. When an unexpected complication arises, he knows how to course-correct.

It’s doubtful that you will find the Indiana Jones of primary care. What you will find, with a dedicated search, is a highly competent and compassionate physician who is dedicated to your family’s health. You can improve your odds of finding the right PCP through a well-organized search process that includes some or all of the following elements:

Your search starts here:

  • Decide whether it is important for your physician to adhere to a certain demographic profile:
    • Does it matter whether your physician is male or female?
    • Do you want your physician to fall within a certain age range?
    • Do you have any feelings relative to the ethnicity of your physician?
  • As we’ve discussed, physicians undergo varying levels and types of education and training. It is important to identify what level of training and credentials are important to you:
    • Are you seeking a physician who has trained at a traditional medical school, or are you equally comfortable with someone who has undergone osteopathic training? There are subtle philosophical differences between the traditions that still exist today. You may find one more appealing than the other.
    • How important is it that your physician be American trained? An increasing number of primary care physicians are foreign medical graduates. Their training may be impeccable, but it is a factor worthy of your consideration.
    • Will you be more comfortable with a family practice physician (who integrates care for patients of both genders and every age, and advocates for the patient in a complex health care system[i]) or with an internal medicine physician (who provides long-term, comprehensive care, managing both common and complex illness of adolescents, adults, and the elderly[ii])? If you select a family practice physician, what range of services are you comfortable receiving from this physician before being referred to a specialist (e.g., would you allow your FP to perform a colonoscopy or would you expect to be referred to a gastroenterologist? What about delivering your baby?)
    • Do you value certain training institutions more than others, be it for medical school, osteopathic school, or residency? Would you, for instance, have higher confidence in an internist who trained at the Mayo Clinic?
    • Is your physician board-certified or board-eligible by either the American Academy of Family Practice (AAFP) or the American Board of Internal Medicine?
  • How will you determine whether your physician possesses the requisite experience, knowledge, and wisdom to manage your care optimally?
    • How many years has your physician been in practice?
    • How long has he or she been in their current practice?
    • What does your physician do to stay current on medical advancements? Can you discern whether they are a “life-long learner?”
    • Can you obtain informed opinions from other physicians about your PCP?
    • Have you been introduced to any of your PCP’s partners—particularly the primary physician providing coverage when your physician is off or unavailable?
    • What have you heard from friends and family about this physician? They may have limited ability to discern his or her clinical skills, but they may provide wonderful insight into the physician’s bedside manner.
  • Your physician’s sphere of influence:
    • Are you comfortable with the hospital(s) with which your PCP is aligned? Since chances are you won’t see him or her if hospitalized (hospitalists increasingly act as the primary care provider within the confines of the hospital), you should give this issue serious consideration.
    • Is your physician independent or employed by the hospital? If they are employed, all the more reason to be comfortable with that facility or system, since it may pressure your physician to use the resources of that system.
    • Your PCP may have a relatively tight-knit group of referral sources who are also tied to one or more hospitals. Are you familiar with some of the key specialists upon whom your PCP relies, and are you comfortable with these groups based upon your limited knowledge about them?
  • Is the physician’s philosophy of care congruent with your beliefs and values?
    • Under what circumstances would your physician consider it essential to see you the same day?
    • Does the physician welcome you as a collaborator in your care or does he or she prefer that you defer to their judgment?
    • Is the physician relaxed and thorough when addressing your questions or concerns?
    • How does the physician manage your fear or anxiety? Is it with compassion or is he or she dismissive?
    • How will your physician actively coordinate your care when multiple specialists may be involved?
    • Does your physician have a particular bias toward medications in general or specific categories of drugs?
    • How much importance does your physician place on wellness and prevention versus intervention? How do they demonstrate their commitment to wellness?
    • How much importance does your physician place on well-being or emotional health? How do they demonstrate their commitment to this element of our lives?
    • Does your physician practice within a medical home?
    • Does your physician’s staff include advance practice nurses and nurse educators who can play an important role in your health?
    • What is your physician’s perspective on end-of-life care?
  • How confident are you that your physician will recommend treatment regimens based on the latest medical science?
    • Does he practice evidence-based medicine?
    • Does he utilize an electronic medical record?
    • Are there standard protocols of care integrated into the record that your doctor relies upon?
  • Can you discern any other important information about your physician from trustworthy third-party data sources?

You can glean some of this information by scheduling an appointment to meet your potential new PCP and conduct an “interview.”

With perseverance complemented with a little luck, you will end up with the guide you need. Remember, though, even the best of guides are human. Your job is not to place blind trust in any single individual within the health care system, but to use your discernment to know when to be deferential and when to seek more information. A good primary care physician will not be offended or threatened by your questions, but rather respect your stewardship of your own health.

If you are worried about asking your doctors tough questions, get over it. As Charles Inlander advises, “The bottom line is that you have to walk in with an arsenal of questions to be able to pick a primary care doctor or specialist.”[iii] When we began, I indicated that selecting the right PCP is a formidable task. If you’ve done the homework, you are in agreement that the effort is well worth the time.

Otis Brawley, MD, offered similar advice when I asked him how a consumer could find the “right” physician—be it a PCP or specialist: “I think that people should interview doctors. If someone has a chronic disease, this may be the most important interview of their life. Think of it as a hiring decision.”[iv]

[i] American Academy of Family Physicians, last modified 2013,

[ii] Intermountain Health Care, last modified 2013,

[iii] Ibid.

[iv] Otis Brawley, MD (Chief Medical and Scientific Officer, American Cancer Society) in discussion with the author, August 16, 2013.