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Most doctor visits do not fail in the room. They fail after you walk out, holding a plan and no clear idea of when something has gone wrong enough to call back. In this episode, retired surgeon and patient advocate Alan P. Feren explains why “call me if it gets worse” is not real guidance, and what clear instructions actually look like. He argues that sharing responsibility with patients only works when both sides share clarity, because a threshold no one defined is one no patient can act on. You will hear why patients delay care when they are unsure what counts as worse, why feasibility, whether a plan is actually doable for that person, matters as much as the plan itself, and the three things every clinician should name before a patient leaves. This episode is based on his article “Shared responsibility in patient care needs boundaries,” published on KevinMD. Press play to hear how to turn a vague plan into one a patient can follow.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Alan Feren, retired surgeon, health care consultant, patient advocate. Today’s KevinMD article is “Shared responsibility in patient care needs boundaries.” Alan, welcome back to the show.

Alan P. Feren: Thanks, Kevin. Appreciate the opportunity to come back and chat with you.

Kevin Pho: All right. So what made you write this particular article on KevinMD?

Alan P. Feren: Well, I realized that typically patient encounters don’t fail in the moment. They fail really afterwards. That’s when patients are given a treatment plan that may or may not be usable. They’re asked to make decisions. Basically, they’re performing a clinical function, but they can’t do this without defined thresholds.

So for example, a typical exit encounter might be, “Call me if you get worse.” And they don’t know what getting worse is, because the boundary, the threshold, really hasn’t been defined, and without that definition it’s nearly impossible for them to know when to escalate, when not to escalate, how to escalate. Do I use the portal? Do I just call you? Do I call the office? What am I supposed to do?

Kevin Pho: And as a primary care physician, I’m certainly guilty of that scenario sometimes. Sometimes you would leave the patient with, “Make an appointment if it doesn’t get better.” Like you said, “Call me if it gets worse or doesn’t get better.” And there aren’t a lot of guide rails guiding patients after that.

Now, is that different from, in shared decision-making, we obviously emphasize patient empowerment, and sometimes as physicians, we give patients perhaps a menu of treatment or diagnostic options and simply ask the patient to choose what they want. Is what you’re describing a little bit different from that scenario?

Alan P. Feren: It is, in several different ways, Kevin. First of all, you can give patients a menu of opportunities to choose, but the specific question that needs to be asked is, is this usable? Is it doable? I use the terms in my writing feasibility and treatment burden. I’ve mentioned this before, I think, in conversations with you, where we need to understand the patient in terms of, can they take a medication that’s twice a day or three times a day? Is there a problem with getting the medication in advance? Is there a transportation problem? Is there a childcare problem? Are they able to return or see a specialist that you’ve referred them to?

So all these things really need to be taken into consideration. I think the key word that I would use is usability, and I think confirming that before the patient leaves, “Not only do you understand my treatment plan, but is it usable for you?”

Kevin Pho: Now, should we incorporate some of these questions when it comes to offering patients menus of options or directions as to the next steps? Are these the type of questions we should be asking more often to better tailor our treatment options to them?

Alan P. Feren: Absolutely. I think you raise a very important point. I think as clinicians, before the patient leaves, we need to make sure that the patients understand what’s the expected course. And tell me again, based upon our conversation, what are the concerning changes that we’ve discussed? And tell me what are the thresholds that you need to be aware of? For example, suppose you’re not getting better, what does persistence mean?

And then be very clear about the responsibilities that you each have. I want to reassess you when, and then you define when that is. And clarify the channels in terms of, if there is a problem, who do you contact? And this is typically in this day and age, not only a primary care issue, but because patients are being seen by multiple specialists and subspecialists, who’s the captain of the ship? So patients don’t know who to call and when to call them. So clarification of not only the channel, but also exactly where.

And then again, I really push hard on this feasibility question. So it’s really a teach back, just so you know this is what you’re going to watch for, and I think that’s going to save a lot of time, a lot of confusion on the patient’s side.

Kevin Pho: Now, do you have a scenario or a story where some of these feasibility questions aren’t addressed and a patient, because of their misinterpretation and unclear directions, it actually led to a poorer outcome? What would be a hypothetical scenario and what would that look like?

Alan P. Feren: Well, I can give you a classic scenario with my parents who, unfortunately, are now deceased. But frequently with both of them, when they went in to see their doctor, and I think this is generational, doing whatever the doctor says but not asking questions, they would come back from their appointments and they would tell me what the doctor said. And then I would ask a specific question about, for example, if it was hypertension and the blood pressure was elevated still, and I asked them, “Did you ask the doctor whether or not you should increase the dose?” And the response typically was, “Well, he didn’t say.” And the question is, “Did you ask?” And of course not.

So that’s not an unusual situation. So patients really need to understand what the expectations are. What can I expect over the next few days if we’re starting a new medication or over the next coming weeks?

I, as a surgeon, for me, it was very important for patients to have very explicit postoperative instructions, so I would tell them in my educational materials what to expect day by day so that they knew what was normal to experience, how long the pain would persist, how much drainage I could rely on, and when to call me if there was a problem. So I think that having very clear expectations and setting these escalation thresholds is really the key to having clarity.

What I would say is that we have a shared responsibility, but without shared clarity, there’s not really a partnership, and what we end up having is just plain ambiguity.

Kevin Pho: So it sounds like the decreasing time, well, especially for me in primary care, that doctors in general have with patients may be a direct cause of this lack of clarity. Because when we’re measured by throughput, when we’re measured by quantity of patients seen, it sounds like a lot of this clarity that you’re proposing often is the first thing that gets lost.

Alan P. Feren: I think that we can do a better job, Kevin, by being very clear on setting what matters, which are the thresholds, what is concerning to us, and what to do next, and when the treatment plan should change. Those three questions really set a course that is not going to take more time for you and add clarity to the patient and improve the entire encounter so that it doesn’t fail when they leave your exam room.

Kevin Pho: Now, is there a role for technology not to replace, but to supplement what you’re saying, perhaps with more comprehensive discharge instructions, including some of the things that you talked about, or even an AI solution that patients can certainly turn to if they don’t get that information from their clinician? Is there a technological solution that can help with this?

Alan P. Feren: I’m not sure that I can specifically cite a technology solution. What I can say is that technology is something that is an add-on and not in place of. So I think that if you yourself can develop a set of standard instructions for common things that you see, that can be very helpful. It was something that I actually did in practice and had a diagram, because the head and neck can be very complicated for patients to understand. And just write down, “Here, this is the diagnosis. These are the thresholds.” And you can go ahead and give them links if you, of course, have the time or have your staff, to valid sources. You want to make sure they’re not going to Dr. Google. I think that there is currently a lot of good information that’s available on AI, but it needs guardrails.

Kevin Pho: In your article, you alluded that sometimes patients even hesitate to make that follow-up call or appointment even when their symptoms persist. Why do you think that is?

Alan P. Feren: It’s, again, because they don’t understand what worsening or persistence is. They will delay care. What we’ve done in not defining these thresholds is shifted the clinical decision-making to patients. And they’re not capable of making those decisions without your guidance as a clinician.

Kevin Pho: And sometimes when patients don’t make that follow-up appointment, there’s even the misinterpretation from the clinician standpoint that it’s assumed that everything’s getting better, right?

Alan P. Feren: Absolutely. It’s the no news is good news situation.

Kevin Pho: So going forward, just give us some next steps, some concrete pieces of advice that physicians should do just to reduce that amount of misinterpretation. I think that we talked about a lot of things, but what would you say would be the top three that people in my position, say in primary care, should include when it comes to those discharge instructions?

Alan P. Feren: Yeah. I think for clinicians it’s important to name the expected course of events, and then name what would concern you most in terms of the follow-up, and let them know what the persistent thresholds are. So that goes directly to your question about someone who is not getting better but not getting worse and doesn’t know what to do. And then finally, I think the most important thing is name what the escalation thresholds are. What are the things that would be most important, and what would require them to contact you?

And on the patient side, I would say it’s really the exact reverse. In other words, what can they expect over the next few days? I would ask, “Kevin, tell me, based upon what you’ve seen today, what should I expect to happen?” Ask what specific changes would be concerning for you as a physician. And then most importantly, “If I have any of those changes, what is going to be the change in the treatment plan?”

Kevin Pho: We’re talking to Alan Feren. He’s a retired surgeon, health care consultant, and patient advocate. Today’s KevinMD article is “Shared responsibility in patient care needs boundaries.” Alan, as always, we’ll end with some of your take-home messages that you want to leave with the KevinMD audience.

Alan P. Feren: There’s a big difference between assigning responsibility and sharing responsibility. It’s really our job as clinicians, physicians, to make sure that the shared responsibility is done with shared clarity, because without it, it’s ambiguity. And I think patients can’t act on a threshold that was never defined. And so clear thresholds, they don’t eliminate uncertainty, but they certainly give uncertainty boundaries. And with those boundaries, I think our patients are going to do better, follow our treatment plans, and end up with the best clinical outcomes they can based upon the care that they’re given.

Kevin Pho: Alan, as always, thank you so much for sharing your perspective and insight. Thanks again for coming back on the show.

Alan P. Feren: Thanks, Kevin. Nice to be with you again.