Help doctors to best care for their patients

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.  He is the author of The Undefeated Mind: On the Science of Constructing an Indestructible Self.

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    Alex, thank you so much for this beautifully written post. I think what is so pertinent and important to remember is that the doctor and the patient work together as a team. To be a good team, there has to be mutual respect, interest and an emphasis on challenging each other. I really appreciate when you say most doctors truly do want to do a good job and that they respect patients who want more information.

    Even as a medical student, I find that sometimes it can be very frustrating when a patient comes in with an expectation of what they want even when this option can seem silly or unnecessarily aggressive. I remember vividly a patient with severe knee pain, but with negative Xrays and MRIs who was demanding surgery instead of rehab. Nothing we said could convince her that this would not fix her problem. In that very instant of her deciding for surgery, we weren’t a team anymore, but competitors, like on a soccer field, trying to get the ball around each other and score.

  • W

    It goes both ways…at my annual physical three days ago, my primary care doctor scheduled me for an abdominal ultrasound without explaining why. I’m sorry to hear that some patients demand unnecessary tests, but by the same token, if a doctor is going to have a test scheduled (and it was not presented as my choice) I really think the objective should be communicated. I know you’re busy, but I can’t be a “partner” if I don’t know what the problem may be.

    The radiology tech explained during the procedure that a radiologist would have to examine the images, report to my doctor, and it would be up to my doctor to communicate any findings to me at his prerogative. So I sit here and wait for a letter to come or the phone to ring. Not fun.

    BTW: Yes, I wish I’d pressed for an explanation during my physical exam. But it caught me off guard and the doctor left so quickly that, as obvious as it might seem, there really was little opportunity for a dialogue.

  • W

    Received a letter from the doctor yesterday. To quote in full: “There was no etiology found for the left side abdominal bruit. We will discuss this at the time of your return visit.”

    Return visit will be in spring 2011.

    Thank [insert diety of your choice] for web medical dictionaries, as I had no idea what a bruit was…

  • ACS

    Wow! This article is so offensive to a patient. Instead of complaining that patients are not submissive enough, it would be best if you guys could actually do some research on pathology, pharmacology, etc so you can know how to do your job. As a patient it’s very frustrating to go to a doctor who doesn’t have a clue what’s wrong with you, and dismisses your symptoms as if you’re nuts. Patients would be more trusting and nice if they would not have to wait 45 minuts to see the “doctor” for 5 minutes and not be able to figure out what’s wrong with them.
    I’ve been having pain in my hands for 4 years and no diagnosis until this year when my knees and feet started to hurt. Even then in the begining I was told that the knee pain is due to a loose muscle (which I could even tell is not the case) and the doc didn’t even bother to look at my feet. Evenually when the inflamation in my hands became pretty bad I was told that I have RA. The doc told me to start on oral steroids for 2 weeks and after that “we’ll have to figure out how to get you off.” Yeah, I supposed to have a lot of confidence in this guy? Or shoudl I go from doctor to doctor until maybe I can find one that knows what he/she is talking about?
    I suggest you read the following book written by one of your felow doctors.
    “How Doctors Think” By Jerome Groopman Houghton Mifflin

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