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U.S. News & World Report
Jan 31, 2000
by Josh Fischman
Get better care by being a little pushy with your doctorI really don't have time to explain all this," Dennis Moore's physician said as he hurried away, and for the second time in a week Moore saw red, his anger rising. The first red Moore had seen was his own blood, after going to the bathroom. Now he needed some answers. "Why am I bleeding? Do I have cancer? Will I be alive in a year?" He had gone to the doctor for an exam but couldn't get anyone to tell him the results.
Moore, a 53-year-old who had commanded a river gunboat in Vietnam, isn't easy to ignore or to frighten, but his doctor had managed to do both. Though the incident was over a decade ago, the raw feelings still sound in his voice: "You're confused. You don't know where to go next. I was so mad that I just pulled my pants up and stomped out," the Cape Cod, Mass., resident remembers. Then he stomped into another doctor's office to repeat the tests. The bleeding came from ulcers in his colon plus a noncancerous tumor and led to six stomach surgeries.
Today, stories like Moore's are more common than ever. More than half of the country's households changed doctors during the past two years, chiefly because they weren't happy about the communication with their physicians, according to a survey taken last summer by VHA, one of the nation's largest networks of community hospitals. Just last month, a study of over 1,000 conversations between doctors and patients published in the Journal of the American Medical Association showed that in 9 out of 10 cases patients didn't get good explanations of proposed treatments or tests. This slapdash approach has a huge effect on health: Several studies have shown that people with high blood pressure, diabetes, ulcers, and arthritis are more likely to follow their treatment plans and get better when they understand their care--and have a voice in planning it.
Raising that voice isn't easy. "Patients feel very vulnerable," says social scientist Sherrie Kaplan, who researches health-care communication at Tufts University Medical School in Boston. "You're sick, you're scared, and half the time you're naked!" And doctors--not only those in managed-care networks--send all sorts of signals that they are very pressed for time; the average length of an appointment is just 15 minutes.
The solution is to manage your doctor instead of letting doctors manage you. It takes some advance research, preparing a few questions, being forthright about what you want from the relationship, and getting to know how a doctor's office works--nurses and office managers can be gold mines of information. But, says Wendy Levinson, an internist at the University of Chicago Hospitals and co-author of last month's study on doctor-patient conversations, the extra effort can make the difference between sickness and health.
What's bugging you? It all starts with a list. Before you even go to see a doctor, write down all the things that are troubling you and all the questions you'd like answered. Because time with a physician is so short, you must prioritize. "You enter an office where everything is kind of speeded up," says Nancy Dickey, who has a family practice in College Station, Texas, and until recently was president of the American Medical Association. "You're hustled through the system, and you don't really know the doctor that well. But this is, after all, your health care and you need to plan it." Identify what's really bothering you. Dickey says that if someone came into her office with a four-page list of items her jaw might drop and she would probably say, "Pick three."
Many doctors suggest hitting the library--or, increasingly, the Internet--for information about your symptoms. Bring the material with you, read it, and show it to the doctor. "That way, instead of sitting in the waiting room reading old copies of U.S.News & World Report, you can be preparing," says Kaplan.
Finally, bring a pad and pencil. Patients tend to remember no more than half of what's said in the office. Consulting your written list, and sticking placeholders into the conversation if something new comes up ("Can I come back to that later?") can be a big help.
Just ask. Now you're ready for your 15 minutes of fame. Being organized and focused increases the chances the doctor will listen to you and hear what's important. Levinson bemoans meandering conversations that take an abrupt turn when she gets up to leave and her patient says, "Oh yeah, and I've got these sharp pains in my chest." Immediately, she and the patient are back to Square 1.
It's the active, assertive, focused patients who have better health outcomes, Kaplan and her colleague and husband, physician Sheldon Greenfield, have found in studies of diabetes and arthritis patients. One reason is they are more likely to stick with a treatment plan. After all, they had a hand in designing it. For instance, more than 2 billion prescriptions are dispensed each year in the United States. But two thirds of the people buying those drugs fail to take the full course, according to the American Heart Association. That's often because they are blindsided by side effects or have not fully discussed them in advance. Many men with high blood pressure, for example, don't take their antihypertension drugs after hearing that impotence is a possible side effect, says cardiologist Ira Ockene of the University of Massachusetts Medical School in Worcester. Instead of admitting that the word impotence sets all their internal alarm bells clanging, and exploring other drugs and other doses, the men simply toss the prescription.
What if being active and assertive in front of an intimidating person garbed in a white coat simply isn't your style? "Bring a family member. Bring a friend," says Chris Allen, the nursing director in Dickey's office. Often a companion will be able to ask the questions or describe the symptoms that fluster you.
Follow-up is just as important. Ask your doctor how you can get in touch if you have further questions after you leave the office. Some doctors set aside scheduled phone time for follow-up calls. A few are comfortable with E-mail, but surveys show most doctors still don't like dealing with patients through cyberspace.
Nurses, physician's assistants, and other health professionals in the office can also be a good source of answers. "I spend a lot of time on the phone with patients answering medication questions, or a mother will call up asking about immunizations for her kids," says Allen. "We usually know the right answer. And if we're not sure about anything, we ask the doctor." She also gives out medication calendars with doses and schedules printed on them.
Use 'em or lose 'em? These tips don't work with every doctor. Many, Ockene says, have a " 'Me Tarzan, you Jane' attitude toward patients. And that's not good." It's especially harmful these days, when patients often need an advocate to help them get the treatment they need from their insurance plans. "They ask you to jump through so many hoops, and eventually you just want to say 'I'm paying for these services! Give them to me already!' " says Mary Schriever. The Cypress, Calif., mother recently spent a year and a half fighting with her doctor and insurance company to get her emotionally disturbed son referred to a specialist. "It's important to get a doctor who'll be aggressive on your behalf, who'll be on your team," says Jamie Court of Consumers for Quality Care, a patient advocacy group based in Los Angeles. With limits on physicians that you can see in managed-care plans, he acknowledges, you may be stuck with Tarzan and have to make the best of it, but it's worth shopping around even within the plan.
The real test of whether a doctor is on your team comes in the examining room, of course. Michael Goldstein, associate director of the Bayer Institute for Health Care Communication in West Haven, Conn., suggests patients ask doctors if they agree or disagree with statements such as "The doctor is the one who decided what we talk about" and "Patients should have equal power and status with doctors." Most patients would look for "disagree" and "agree," respectively; if you don't like the answers you get, search elsewhere. Ask the doctor to explain your medical chart; you're entitled to see it. Kaplan says the best test is often a gut reaction: "You know it's bad for you because it feels bad."
Or you could use Dennis Moore's solution. He acknowledges that it isn't available to everybody, but it gets him expert advice, responses to phone calls, and quick symptom evaluations. "I'm dating a nurse."
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