When doctors disagree: What should you tell patients?

A recent research article in the Journal of General Internal Medicine, and the gap between its findings and the real world, helps point up the usefulness and limitations of research. The article, by Susan H. McDaniel, PhD, and coauthors, set out to determine how often doctors speak about their colleagues in supportive or critical ways.

Their method is one widely used in the field: simulated patients, actors, were prepared with lifelike stories about their feigned cases of advanced lung cancer complete with manufactured charts describing what previous doctors had done. The conversations they had with physicians (some oncologists, others family medicine practitioners) were recorded, transcribed, and analyzed; each statement by a physician about the care provided by other doctors was categorized as supportive, critical, or neutral.

The results were not altogether surprising, but I’ll let their abstract’s summary speak for itself (I edited it slightly):

Twelve of 42 comments (29%) were supportive, 28 (67%) as critical, and 2 (4%) as neutral. Supportive comments attributed positive qualities to another physician or their care. Critical comments included one specialty criticizing another and general lack of trust in physicians.

As far as I can figure out, however, the article did not discuss what doctors should do in a very common circumstance: when their patients did receive treatment from another physician that they, the doctors, feel was incorrect. Last week, for example, I saw a patient who had been treated by some oncologists (they weren’t from Hopkins, which doesn’t mean this story couldn’t have applied to them). They had given her treatment without discussing with her the risks or benefits. She came to me bewildered and frustrated.

So what should I have done in that case? Made polite noises? Reflected the patient’s feelings? I did those as well. At some point, though, the patient’s intuitions should be verified and the truth called out: no, it is not okay to leave the patient’s wishes and preferences out of the equation, and all the more so when they are vulnerable, as cancer can make anyone.

Sure, tactfulness is key, and collegial relations with other providers can be maintained in such a circumstance, but identification of systematic missteps in care (such as leaving the patient out of a treatment discussion) is no vice. In fact, such honest talk is in the very service of professionalism.

How do you talk about your other doctors with your primary care provider?

Zackary Berger is an internal medicine physician.  He blogs at his self-titled site, Zackary Sholem Berger, and is the author of Talking to Your Doctor: A Patient’s Guide to Communication in the Exam Room and Beyond.

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  • DoubtfulGuest

    I have experience with this issue from the patient side. I’ve read that this is a major liability concern for doctors. They don’t want to put themselves or a colleague in the line of fire. I do understand the fear that they could ruin another doctor’s career with just one poorly worded comment. I was harmed pretty badly by one doctor who refused to question another’s opinion that I was malingering. This was not an evidence-based conclusion. It had a snowball effect on my care and I’m still trying to recover psychologically and medically. Disclaimer, here: I’ve tried to get all the facts about this situation, but no one will talk to me. This is my impression based on limited information.

    I’ve had other doctors disagree with their colleagues by way of criticizing me. Once for over-treatment (in their opinion), but more often for over testing. I often heard “YOU’VE had a lot done. Why did YOU have so much done? Why did they do XYZ test for YOU?” Well, I had a few different problems that were all diagnosed in a short time, after decades of feeling poorly…and — defensive medicine was a factor, of course. That part is out of my control, since it’s against my beliefs to sue doctors.

    On the other hand, my current doctors seem well practiced at questioning others’ opinions. They’re very tactful. The key is to always put patients’ welfare first. They don’t get personal about previous doctors’ decisions. They focus only on the patient’s needs. For example: “I think that more could be done to find out if you have Disease X, or not.” “Hmm, they didn’t tell you about Y? Well, that seems like a reasonable question, so here’s the information”. In the first situation I mentioned, I was completely focused on getting well. It should have been easy for the doctor to say: “This referral did not work out. Let’s think about some other possibilities” without ever saying anything negative about the other physician.

    • Zackary Sholem Berger

      I like the phrases your current doctors are using. I also like “this referral did not work out.”

  • DoubtfulGuest

    Yes, that seems like a reasonable way for your doctor to handle it. I hope your next referral works out much better.

    I wonder about this study Dr. Berger cited in his post. Their findings seem counter to almost everything else I’ve heard or read about doctors disagreeing with one another. I take it you’re in the legal profession? I’d appreciate any insight you could offer us about doctors’ liability concerns and lawyers’ roles in this issue.

    In my experience, some doctors are so caught up in presenting a united front and preventing patient “dissatisfaction” with care, that the patient’s welfare gets lost in the shuffle. I try to base my opinions about my care on facts. I haven’t been allowed to get those, so my ability to see things accurately is limited — on purpose, I expect. There is no benign deception, in my opinion. I’m not sure how a doctor or his lawyer could reasonably decide what I can and can’t handle after the doctor spent < 3 hours with me, total. Anyone could use another person's supposed emotional state to justify withholding information. "Oh, what a tangled web we weave…" – Sir Walter Scott (I think?)

  • Kay Dee

    I am fortunate enough to have a primary care physician who will be open with me. I’ve had concerns about a specialist that I’m seeing, and when I described those frustrations to her, she concurred with my suspicion that the care was inadequate, and took it over herself. I have multiple specialists (too many, as far as I’m concerned), multiple meds (too many, as far as anyone should be concerned), and it’s taken me years to find a doctor who is willing to help me get off the “let’s run another test” hamster wheel.I am more grateful than she can imagine.

  • http://warmsocks.wordpress.com/ WarmSocks

    “How do you talk about your other doctors with your primary care provider?”

    I am hesitant to be critical of other doctors when talking with my family physician. When I asked for a referral to a different rheum, he wrote one, then asked why, but I simply said, “It doesn’t seem like a good fit,” because, “I like the doctor okay, but he assigned me to a PA instead and I don’t like the PA. He tried to put me on painkillers instead of a DMARD which does not meet the standard of care, he told me that there would never be any reason for a patient to call between appointments (even given a bad reaction to a new prescription), he told me that he doesn’t like this country and would be looking for employment in Germany when he went there on vacation the next month, he criticized my family size, he shares all sorts of information about himself and his private life that I, frankly, don’t care about.”

    The new rheum to whom I was referred is much better. Twice I’m been chastised for not calling between appointments because they want to know if symptoms get worse. What a difference! The only things I’ve really discussed about this specialist with my PCP was when he looked askance at my lengthening meds list: “If she’s trying to see how many pills I’ll take before I refuse to take any more, we’ve reached that limit.”

    When I went back to my PCP and asked for a referral to a different surgeon instead of his first choice, he said he would be happy to do that but wanted to know why. The surgeon yelled at me, which was completely inappropriate. “Wait and see” is a legitimate approach to medical issues. Most things resolve on their own without the need for surgery and for the surgeon to yell at me for waiting, thus creating scar tissue and making his job more difficult was waaaaaaayyy out of line. My PCP listened, agreed that the surgeon was in the wrong, and said he would be willing to write a referral elsewhere. He also said that such behavior is uncharacteristic of that particular surgeon and that perhaps he was having an off-day. In all it was a good discussion.

    In general, I don’t say anything about specialists unless there has been a problem.

  • DoubtfulGuest

    I’m a patient, not a consumer, but your comment is very well stated. Their ethical codes clearly state that we’re to be given information we need to make our own decisions about our care.

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