Goldilocks Medical Care: Not Too Little, Not Too Much….

In my last two blog posts, I discussed the harms of a new epidemic: too much medical care. We also don’t want the opposite, of enough care care. In fact, much of the driving force leading to overdiagnosis and overtreatment is this fear of rationing.

So what can you do to ensure that you obtain just the right amount of care?

It isn’t easy—if it were, if there an algorithm that would give us the answer, then we wouldn’t have the Goldilocks problem (“Is it too little? Too much?”).

Here are 5 suggestions that may help:

First and foremost, work in partnership with your doctor. The most critical key to getting good medial care is a trusting relationship between you and your doctor. This is not to say never question your doctor; but rather, develop a relationship of mutual respect such that you are the expert when it comes to your body, and the doctor is the expert when it comes to medicine.

Second, make sure your doctor listens. Study after study shows that the patient history will reveal the diagnosis in 80% of the cases, without the need for any tests or further interventions. If your doctor orders tests instead of listening to your story, that leads to unnecessary testing—and potential misdiagnoses. Prevent this by telling a good story, and making sure it’s heard.

Third, ask about your diagnosis. Understanding what you have is key to figuring out what should follow. Before you get any tests done, ask your doctor what he thinks you might have. This gives you some idea of what tests may be necessary, and also focuses your doctor to remember the important tests and have a justification for tests ordered.

Fourth, ask about every test done. Every single test has risks, so make sure you understand why each test is done. Ask about the risks. Ask about how it would change management: what happens if it’s negative? What happens if it’s positive? And, importantly—what happens if nothing is done at all? This helps you gauge how emergent (and also how necessary) a particular test is at this point in time.

Fifth, do your own research. This is particularly true when it comes to treatments. Look on the Internet and ask your friends and family. Be aware that not all information is equally credible, but at least this helps you formulate questions to ask your doctor. It might also help to look up your doctor and see if she has conflicts of interest that you may not be aware of: information about drug company affiliations, for example, can be found online. Write down questions, and ask them.

None of these suggestions are foolproof. These five steps can help begin the process for you and your doctor to work together to identify the right tests and treatments for you. If you have other thoughts or ideas that work, please write your comments below.

Choosing Hospitals Wisely (Is There Such a Thing?)

Here’s a thought experiment presented a recent conference on healthcare consumer (ah hem, patient) advocacy. Let’s say that you’re told you need surgery of your knee. It’s an elective surgery to repair a torn knee ligament, the ACL. Your insurance covers part, but not all, of the cost. How do you choose which hospital to go to?

At the moment, there is very little information for you to make such a decision. Many people will choose the hospital they normally go to or that their doctor is affiliated with. For the purposes of this thought experiment, let’s say that the following information is available to you:

·      Type of hospital (large academic hospital versus small community hospital versus orthopedic specialty hospital)

·      Number of ACL surgeries per year

·      Rate of infection and complications

·      Length of stay

·      Patient satisfaction

·      Total cost to system

·      Total out-of-pocket cost to you

What factors would be most important to you in making your decision?

Healthcare choices are highly personal, and it’s not surprising that participants at the conference came up with widely different answers. Many said that they would rely on recommendations. Citing that user-originated online ratings of hospitals are not yet widespread, they stated that they would ask for feedback from family and friends.

“These are the people I trust, so I trust their judgment and experiences,” several group said. “If I ask a stranger, their values may be different from mine.”



Some looked at the potential negative consequences. “Hospital-acquired infections and complications are bad, and I want to avoid those at all cost,” a participant said. It’s not clear, though, whether data will be granular enough to provide specifics that are helpful in the comparison. What if hospital-acquired infections for the hospital overall are high, but complications for that procedure are low? Are there certain complications that are worse than others—maybe you’d put up with pneumonia, but not if your wrong knee were operated on?

Others tend to value the potential positives. Some like the idea of going to academic centers, which are seen as “better” than community sites; some others like orthopedic specialty hospitals because of their brand-name appeal. A higher number of procedures connotes confidence, as does greater patient satisfaction.

Interestingly, cost was much lower in the decision algorithm. Nobody cited cost to the system as a factor. This was not surprising, but what was surprising was that cost to individual was also not a major factor. As one participant put it, “I don’t want a discount surgeon.” There still seems to be the belief that the more expensive is better, or at least that no expenses should be spared when it comes to health—at least for those middle-class conference participants.

Finally, many would not even make the choice at all. They would go based on the recommendation of their doctor. According to multiple participants, asking their doctor about the possibility of a hospital different from their recommendation was difficulty. “How do I even go about addressing it?” they asked asked.

This exercise underscores an important realization: in the movement to empower patients, we must keep in mind that healthcare is not transparent, and not a true market. There is a difference between shopping for a TV and shopping for a surgeon. This is not to say that more information isn’t better; it is important for us as patients to get more information so as to make a better decision. But we must also be cognizant of the type of information that is available. Even in this information age, little is currently available to make a decision of what doctor or which hospital to choose. Ultimately, it will take time to develop trust in a source enough to rely upon it to supplant word of mouth and personal experience.

Guest Post: 3 Common Hospice Myths Worth Clarifying

This week, I am honored to host a guest post by Paula Spencer Scott, the Senior Editor at Caring.com, the leading online destination for caregivers seeking information and support as they care for aging parents, spouses, and other loved ones. Paula is a 2011 MetLife Foundation Journalists in Aging fellow and writes extensively about health, caregiving, and hospices.


Hospice care is an underused resource that can make a loved one's waning days more comfortable and less stressful. Unfortunately, misconceptions about hospice abound. As a result, many families avoid it or wind up having less-than-ideal experiences.
Frank conversations about hospice care are useful, whether you're wary about choosing hospice in the first place or you've decided to put a hospice plan in place.

The following three myths come up again and again, hospice providers say. If they strike a chord with you, use them as starting points to clarify what to expect from the experience.

Myth: Hospice is only for the tail end of life. 
When to start hospice? Usually, "earlier than you think," palliative care experts say. Sometimes families, or even doctors, are reluctant to bring up the subject for fear they'll be thought of as "giving up." As a result, their loved ones spend only a few days in hospice care, although it's designed to provide a peaceful end-of-life transition for weeks or months.

The general rule of thumb for admittance to hospice is that a patient is diagnosed with a condition that generally will result in six months or less of life. But nobody has a crystal ball -- and nobody gets kicked out of hospice because they're still alive six months and a day later. Many patients check in and out of hospice programs.

Ask your care provider: What comfort care options your loved one has at the same time you're discussing treatment options, especially if he or she wishes to have a noninvasive death experience at home. It's also possible to pursue both comfort care and curative care at the same time, so ask about that.

Myth: Hospice can't know what my loved one needs as well as his or her doctor. 
Hospice focuses on providing comfort and support, rather than curing an illness. It's a form of specialty care, although the patient's doctor can remain in the loop about care management. Regular medical treatment is not usually front and center, however, because the focus is shifting to allowing the person to live with as much privacy and dignity, and as little pain, as possible.

Hospice services differ by individual need and preferences but may include basic care management (such as chores, meals, personal care), counseling, physical or occupational therapy, caregiver respite, spiritual care, and bereavement support. There's some evidence that people at the end of life live slightly longer when enrolled in hospice than they would if not, possibly because there's less stress from futile invasive therapies.

Ask your care provider: What kind of services he or she recommends, how your loved one's primary doctor plans to interface with the case, how communication will flow between hospice and the medical practice, or whether a hospice doctor will now manage care.

Myth: The medication will "dope up" my loved one. 
Pain medication given as part of palliative care is meant to ease suffering -- not to hasten your love one's decline and demise. Dosages are carefully calibrated to manage pain, which makes it easier for your loved one to talk, rest, or spend time with family and friends. Uncontrolled pain is a common reason for poor quality of life at the end of life.

What's more, pain management is only one part of the full picture of comfort care. Your loved one can receive talk therapy, spiritual counseling, and physical support (even things as basic as help avoiding painful bedsores) that help him or her feel better than he or she might otherwise.

Ask your care provider: What the pain medication is for, how to use it, how to know when it's necessary, and what signs of pain and discomfort to watch for.

For more information about caregiving and hospice, visit Caring.com. Thanks to Paula for joining us at The Doctor is Listening!

6 Tips For Getting Your Doctor to Listen to You

Have you ever gone to the doctor and felt like he wasn't listening to you? Have you tried to tell your story, only to have him interrupt with a checklist of questions: do you have chest pain, shortness of breath, fevers, cough, and so forth? Have you ever felt ignored, and left thinking that your doctor never understood why came to him in the first place?

The New Year is the time to make changes in your health. If you feel dissatisfied or frustrated by your care, now is the time to figure out how to get better care.

Studies show that 80% of diagnoses can be made based on your history alone. Yet, doctors these days spend less and less time listening. “Cookbook medicine” is prevalent, with doctors resorting to checklists of yes/no questions rather than really listening to what’s going on with you. You have to make sure that your concerns are addressed—and even before that, to make sure your story is heard. Here are 6 tips for getting your doctor to listen to you:

Tip #1: Answer the doctor’s pressing questions first. Many doctors are so accustomed to relying on a checklist of questions that they have to get these answers before they move on. Help them out and answer these questions. If the doctor want you to describe the location of your chest pain, describe it (“it’s in the middle of my chest, right here”). If she want to know what you took to make it better, tell them (“I took an aspirin. It didn’t help”).

Tip #2: Attach a narrative response at the end of these close-ended questions. If your doctor persists on asking close-ended questions, add a narrative response at the end that may not so easily fit into a yes/no answer (“it’s in the middle of my chest, right here, and it started after I really pushed myself in swimming tonight”). Pretend that you are being asked “how” or “why” instead of “yes/no”, and add your own response. Look to make sure your doctor registers this answer—does he ask you more questions to follow-up on what you said, for example?

Tip #3: Ask your own questions. If you don’t understand why a particular question is relevant to your situation, ask about it. You may be surprised to find that the doctor herself isn’t sure and is only asking the question out of habit. On the other hand, you may find out that issues you wouldn’t have thought were related might actually be very important to discuss.

Tip #4: Interrupt when interrupted. If your doctor cuts you off when you try to explain your full answer, free to interrupt. Pretend you’re having a conversation, even when it feels like you’re being interrogated. For example, if you’re asked “when did headache start,” rather than responding “10am,” go ahead and tell your story of how the pain started: “I woke up this morning and I was fine, then I started walking to work and the pain came on suddenly like a lightening bolt striking me.” This is not a new tactic; lawyers will often coach clients in advance to answer yes/no questions with a narrative so that answers can’t be taken out of context. Interrupting is a way to ensure that your entire answer is heard, not just the part that the doctor thinks he wants to hear.

Tip #5: Focus on your concerns. If you get the sense that your concerns are being brushed over, interject, “Excuse me, doctor, I have tried to answer all your questions, but I am still not certain my concerns have been addressed. Can you please help me understand why it is that I have been feeling fatigued and short of breath for the last two weeks?” and so on. You can take charge of the conversation at that point. It’s your body and your duty to advocate for yourself if you don’t feel like your story has been understood and your concerns have been addressed.

Tip #6: Make sure you are courteous and respectful to your doctor. Your doctor is a professional, and is probably trying her best to help you. Your story has to be heard and your concerns addressed, but make sure you present your points in a respectful manner. This will ensure that a solid doctor-patient relationship is present, and is critical to the partnership you need to establish. 

You may be dissatisfied and frustrated by your medical care, but you can take control of your health care and transform your health today. I discuss more in my book, When Doctors Don't Listen: How to Avoid Misdiagnoses and Unnecessary Tests. Try these tips on your next doctor’s visit, and build your partnership for better care.

10 Things to Bring With You to Every Doctor's Visit

Most patients I see are surprised to find out that there’s something they should have brought to their doctor’s visit. Granted, I’m an emergency physician, and many of my patients come to me in emergency situations that they can’t plan for. However, most people have some heads-up for going to their doctor. Certainly if you’re going to your annual check-up or a routine appointment, you should bring these items with you. Keep this checklist readily accessible; even if you’re going to the hospital for an emergency appointment, aim to take the following 10 items with you:

#1. A medical card. It would be ideal for every doctor to have a full list of your medical history, but our country is not even close to having a nationally accessible medical record system. To make sure your doctor has your information available, carry a card with you. You can find many cards that easily downloadable on the Internet where you list your medical problems, surgeries, doctor’s names, insurance, and allergies. Especially if you are seeing a coverage doctor or visiting the E.R., he or she may not have your medical record. This makes sure that your doctor can see your most critical medical information.

#2. Changes to your medical record. If you have had recent test results since you last saw your doctor, bring these with you. Even if it was your doctor that you’re going to see who sent you to get the test, bringing the results will make sure that they are discussed during the visit.

#3. Your medications. Very often, patients come in and say that they can’t remember what they’re taking. “I think I stopped taking the pink tiny pill, but I’m still taking the white one and the blue one,” is not as helpful as actually seeing the actual bottles with the labels on them. Take all your medications, put them in a bag, and bring them with you. Tell your doctor if you’ve stopped taking any of your medications, and be honest if you haven’t been taking them as much as you were supposed to. Otherwise, your doctor may assume they’re not working, and prescribe you even more!

#4. A list of alternative therapies. The majority of our patients use some type of alternative therapy. It is better for your doctor to know about it. Most doctors are not experts in herbal therapies, but it’s useful for them to know what’s your taking in case there are some interactions with your other medications. Keep a list of fish oil, vitamins, and supplements that you’re using, and a record of any visits to chiropractors, naturopaths, or other practitioners.

#5. A journal of your symptoms. If you have a chronic condition, or if you have a new symptom you’re concerned about, you should be keeping a journal that documents your symptoms and how it is throughout the days and weeks. Your doctor may also ask you to keep track of your response to treatments you’re doing at home. Sometimes, there are objective measures that you need to write down, such as your blood sugar. Bringing the journal with you to your appointment can help remind you of your story, and allows for your doctor better understand what’s going on and how your symptoms affect your daily life.

#6. A list of your questions. You should always come prepared with a list of questions to ask your doctor. Brainstorm the list well before your appointment, and have a concise list of questions, starting with the most urgent that you must get answered. Don’t leave your doctor’s office without asking them.

#7. A notebook and pen. This may seem obvious, but your doctor may not always have writing equipment readily accessible, and it’s important to have a notebook and pen to take notes. Write down things that don’t make sense, and ask for clarification. If there are words mentioned that you’ve never heard of, ask your doctor to spell them. At the end of the visit, ask for a verbal summary. Make sure you write down and understand your plan.

#8. A family member or a friend. Having someone with you will give you support and company during the appointment. As importantly, they can help remind you of your questions and concerns, and is another measure to help ensure your doctor answers all the questions that you have.

#9. A smartphone. Everyone seems to have some kind of smartphone device: an iphone, a blackberry, an ipad. There will downtime when you’re waiting. Use this time to look up what your doctor has told you. The smartphone also keeps you busy if your wait is particularly long!

#10. Some snacks. Often, there are limited food options are the doctor’s office, and you may be waiting for some time. Unless you’re told not to eat, or have a complaint that you’re not sure how it will go, having something on hand can help make you feel better.

I hope this list is useful for you as you prepare for your next doctor’s visit. Please give me feedback: what’s on the list that you find helpful? What’s not on the list that should be? And what would you would like to hear about next?

Some Advice on Partnering With Your Doctor

My last post was about Lisa Nash, a breast cancer patient who found out six months after her tumor removal surgery that she had metal placed in her breast without her knowledge or consent. Lisa is an extremely articulate woman who, in addition to being a software specialist and the mother of two daughters, has training in counseling and patient advocacy. If Lisa had difficulties getting her doctor to listen, what hope is there for the rest of us?

The bad news is that we may not be able to eliminate every negative experience. The good news it that there are some practical things you can do at your next doctor's visit to advocate for better care. Here are five:

1) Ask questions. Always start by asking for your diagnosis. What is it that you have? If your doctor can't tell you a diagnosis, what is it that you're treating?

2) Know what questions to ask. Do your research. There are many websites for your condition or your symptoms. Not every website is going to present accurate information, but looking through them will help you build your knowledge base and help you formulate questions.

3) Don't be afraid to challenge your doctor. If there is something you don't understand, ask about it. If there is something you don't agree with, speak up. Be respectful, but also remember that it is your body, and your doctor is there to help you.

4) Know the plan and ask about alternatives. The benefits and risks should be clearly explained to you, along with alternatives to the treatment plan. Informed consent means that you need to understand exactly what is happening. The doctor is busy, but this is your body and your health at stake.

5) Insist on being a partner in your care, every step of the way. You doctor will have more medical expertise than you, but you are the expert about your body.

I will continue to write articles about your stories and offer advice for you. Some more tips are on our website. As always, I welcome your feedback and comments on this blog post.