Part four of a series. See also parts one, two, and three.
When dealing with your doctor’s biases, you have on your side a fact I firmly believe to be true: most doctors want to do a good job and help their patients as best they can. So what exactly can you do to maximize your doctor’s ability to help you?
1. Position your symptoms and requests carefully. Don’t demand medications or tests. Ask about them. Wonder about them. It’s perfectly all right to bring up research you’ve done about your symptoms, but explicitly express your openness to the possibility that your ideas might be wrong. Not that you should aim for subservience by any means, but rather for a genuine partnership.
2. Remain reasonable even when you’re irritated. Most doctors, even when stressed, will respond to reason and reasonableness in kind.
3. If your doctor suggests your symptoms might be due to stress, acknowledge he or she may be right. Even if you disagree. First of all, your doctor may be right, even if it doesn’t feel that way to you. Secondly, if you dismiss the notion out of hand, you might make your doctor defensive and therefore more likely to cling to an idea that a moment before was only one possibility among many.
4. Ask questions that promote transparent, logical thinking. Many doctors don’t explain their thought processes clearly. Write all your questions down before your visits and ask smart questions that actually help your doctor think through your symptoms and his or her approach to working them up (“What possibilities will this test rule in or out?” “What else is on your list of possible diagnoses?”). Of course, this presumes you’re comfortable knowing the answers. I recommend you summon your courage to ask these questions, however, because they’ll encourage sharper thinking from your doctor.
5. Be explicit about how you want your doctor to work with you. Show them you’re interested in understanding the process of medical detective work. Position yourself as your doctor’s student. Nothing helps improve someone’s thought process like having to explain it to someone else.
6. Ask your doctor to explain the risks and benefits of any proposed test or treatment quantitatively. Get percentages for risks and compare them to the risks of activities you tolerate every day. For instance, your annual risk of dying in a motor vehicle accident is 0.016%. You’d be surprised how many worrisome side effects to drugs, for example, occur at an even lower frequency.
7. Get second opinions. And sometimes third opinions. And sometimes more. Do this carefully, recognizing that in doing so you risk ending up even more confused than you were with only one opinion. But don’t assume because your doctor doesn’t know what’s going on that no one else does either. There’s almost no way for you to be sure your doctor doesn’t know what’s wrong because he or she doesn’t know or because no one knows.
Sometimes you have to go through multiple doctors until you finally find the right one with the right experience to figure out your problem (if your insurance will let you, of course). Neither doctors nor patients like to acknowledge this, but serendipity sometimes plays a role in arriving at the right diagnosis. I once figured out why a patient had been nauseated for 30 years after they’d been seen by almost as many doctors. The patient said something that just happened to make me think of an obscure diagnosis I’d never seen but had read about. I looked it up, sent the patient for a test, and found the answer.
I have a small cadre of patients who suffer from symptoms more horrible than I can describe, some with known diagnoses and some without. In all cases, my ability to help them is tragically limited. Sometimes I want to ignore these patients. Sometimes I cringe when they call, not because I don’t like them or because they complain to me too much or because I don’t care about them but because I have so little real relief to offer them.
I know how much my simply being present and being willing to listen has meant to them (they tell me this all the time) and I don’t discount it. And I do my best to diagnose and treat what problems I can and sympathize with them when I can’t. But it’s hard. I must constantly be on guard not to fall under the influence of all the thought errors and biases I’ve described here.
So while I hope everyone who reads this series of posts about what happens when doctors don’t know what’s wrong finds them helpful, I have to confess that the person to whom I actually wrote it was myself.
Alex Lickerman is an internal medicine physician at the University of Chicago who blogs at Happiness in this World.
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