On Being a Patient: Some Useful Tips
How can we reconcile patient's traditional respect for their doctors as authority figures with current medical etiquette which assumes that patients are consumers and "knowledgeable health care partners"? The doctor-patient relationship can never be reduced to an equal opportunity manifesto. Even in this Information Age, when any 12-year old can look up lymphocytic choriomeningitis on the Internet, being a patient still is the equivalent of always playing on your doctor's home court, i.e. relying on his or her years of training and experience. This does not prevent you from challenging your physician when the occasion arises, or even firing him, always the ultimate patient right.
What brings up this subject are increasingly frequent reports I receive from friends, relatives, and former patients: "Dr. G. doesn't listen to my complaints or examine me; all he does is take my blood pressure and sends me off for tests." "Dr. K. doesn't talk to me; she simply rattles off a lot of diagnoses, and sends me for an MRI." True, it takes two to tango. Patients don't always tell the whole story, and often distort or mislead their physician, as in: "No, doc, I'm down to half a pack a day," or, "I'm taking my pills just as it says on the bottle."
While most physicians are caring and competent, an increasing number of my fellow professionals claim to be overwhelmed by paper work unrelated to patient care, such as administration, billing, Government regulations, and the latest practice guidelines. There is always office staffing to minimize these problems, and, thanks to group practice, the ability to enjoy reasonable time off. Your doctor's primary responsibility is simply to take care of you. He or she earns your respect and loyalty by caring and competence, not personality, and not because there's an MD after his or her name. The trick is to have a sense of what really constitutes medical professionalism, without necessarily trying to call the shots. Are there simple guidelines short of looking up every possible condition or complaint on Google or asking friends married or related to a physician?
Here are some obvious questions you might ask yourself and your doctor, not necessarily in order of importance:
- Is it difficult to get an appointment or reach my doctor (think emergency)? Is there a convoluted automated call system, making direct communication difficult? Does my doctor return calls? How difficult is it to get a prescription re-filled?
- At the conclusion of the office visit, does my doctor take time to explain his tentative diagnosis and answer my questions? Is my physician really interested in what I have to say; does he or she Talk and Listen, or rather seem anxious to end the visit?
- When I have a physical complaint, does my doctor examine me? For example, when I have back pain, does he/she examine my back? If I have abdominal pain, does he examine my abdomen (and not through my clothes, but lying flat on the exam table with my abdomen exposed.) When I have new or unexplained abdominal pain does he do a rectal or pelvic examination?
- Does my physician encourage specialty consultation in the event of serious illness or when there is a question of a difficult diagnosis, or is he reluctant to defer to outside opinion?
For decades common clinical knowledge held that the average office visit ended generally one of two ways: the patient received either a prescription, or an order for a test-or both. Not much has changed over the years except that orders for tests now seem to outnumber all other office visit dénouements. Here are some compelling facts and warnings to keep in mind:
- When I have a new complaint does my doctor tend to rattle off a list of diagnoses, and then order a long series of tests to exclude some far-out possibility? Beware the Rule Out Doctor. Patients often willingly collaborate in this clinical farce. Because we live in an age of entitlement, many patients feel the more tests ordered, the better, and why not "check out everything and go for broke, after all it's paid for already." Nothing could be further from the truth. Unnecessary or redundant medical testing is a principal reason our healthcare system is lurching into bankruptcy. To paraphrase a famous presidential speech: Ask not what you can do for the laboratory or the radiology department, but rather what they can do for you.
If an invasive or dangerous study, such as endoscopy or cardiac catheterization is ordered, the question is: Will the results of this test change my treatment? No test or procedure should be performed as a fishing expedition or for mere curiosity, but only for the purpose of changing the management of a patient.
- If you have undergone a diagnostic test, imaging study or had a consultation, have you been notified of the results? A common medical error is failure of a physician or hospital in reporting results to patients. In a 1998 study, only 55% of referring physicians received feedback from the consultant, and in a survey of practicing primary care physicians, 72% did not notify patients of normal results. Only 55% of physicians always notified their patients of abnormal results! Such missteps may lead to disastrous, even fatal delays in diagnosis or treatment. You are entitled to know promptly, normal or abnormal results of all imaging, endoscopic, or other clinical studies. If your doctor told you he would call only in case of an abnormal result, insist that you be called in any case. How else can you be assured that your test results were forwarded in the first place, or that your doctor remembered to ask?
On a personal note, I once had a 39-year old woman with advanced cervical cancer whose report, from a University Hospital, of an abnormal pap smear done seven years previously, had never been sent to her. Six months after I saw her she was dead. In 1999 The Institute of Medicine reported in To Err is Human: Building a Safer Health System, 44,000 to 98,000 Americans die each year as a result of medical errors. For an excellent discussion on the subject, see this article.
- Beware of Medical Celebrities, especially doctors whose appearance on TV news or popular shows seems to suggest self-promotion. Always check the credentials of such physicians. Also, does a physician advertise his services, either on TV/radio or via billboards or direct mailing? Be a healthy skeptic when you encounter crass commercialism in the professions.
A recent case received wide notoriety in the press. A 42-year old Irish woman, Kay Cregan, a wife and mother of two, chose a high-profile New York specialist for a face lift. The surgery performed in his offices on Central Park South resulted in her death when she was taken off life support last March 17. From the time of her death her family had a simple question: How did a farmer's wife from Limerick meet her end 3,000 miles from home? In her knapsack they found a folded copy of The Sunday Independent of Ireland containing a glowing account of a face-lift performed by Dr. Michael Sachs, "a leading facial and cosmetic surgeon." What Mrs. Cregan did not know was that according to the National Practitioner Data Bank Dr. Sachs had since 1995 reportedly made more than 33 malpractice settlements. In 2000 The Daily News of New York included Dr. Sachs on a list of the most sued doctors in New York State. Moreover, there had been evidence of falsification of his hospital affiliations on his web site. McCalls and Harpers Bazaar featured him in makeover stories as early as the 1980's and early ‘90's, and in 1991 and 1993 he appeared on Oprah.
- A final note: Medical quackery is widely and increasingly prevalent in this health-conscious society. It is found virtually anywhere you turn in the media or on the Internet, be it in the form of false advertising claims, illegal marketing, misleading diet promotion, or involving a number of issues including, but not limited to "alternative medicine," chiropractic, homeopathy, etc. Quackwatch, Inc., which was a member of Consumer Federation of America from 1973 through 2003, "is a nonprofit corporation whose purpose is to combat health-related frauds, myths, fads, and fallacies," an outstanding site.
Martin F. Sturman, MD, FACP
Copyright 2005, Mathemedics, Inc.
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