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Things to discuss with your doctor
Some of us are fortunate enough to have built up a relationship with a physician over many years, so there's some genuine rapport and trust to bank on. But it can be a difficult exchange to navigate. Often you don't feel great to begin with. The doctor seems hurried and speaks in jargon. You're intimidated and reluctant to talk about personal issues. Besides, even in the best of circumstances, it's hard to know what's important to mention.
Several members of the Health Letter's editorial board were asked to suggest topics and issues that patients should (but usually don't) discuss with their doctors. Here are 11 of their suggestions for things you should tell your doctor:
1. What you want to do or used to do but can't do any longer.
Either out of stoicism, denial, accommodation, or some combination of all three, people often come to accept a certain level of disability, especially if it's the result of a condition that has come on slowly or involves something private like sex. Lab tests or a physical examination aren't going to reveal the compromises you've made along the way. If you don't tell your doctor about them, you may be missing out on treatments that would ease the problem, or even solve it.
2. What you're afraid of.
Particularly after the diagnosis of a serious disease, many people dwell on the worst. Even without a diagnosis, some people carry around pretty wild fears about medical conditions. Your doctor can't become your psychotherapist. But a thoughtful, attentive doctor (not all of them are, of course) might reassure you by giving you some facts or a calmer, more objective perspective on your situation.
3. Where you've traveled.
Inexpensive airfare has made travel even to formerly remote places in Africa and Asia so common these days that we tend to take it for granted. But especially if you have those notoriously vague "flu-like" symptoms, it's essential to tell your doctor about any recent trips. You may have caught something that can be treated — and could be disastrous if it isn't.
4. If a family member has recently been diagnosed with a serious disease.
Family history is critical information for any doctor. As genetic and other forms of testing advance, people are getting diagnosed with new conditions or "preconditions" more often. Last year's family history may be out of date. Keeping it current will help your doctors make all sorts of decisions, not the least of which is whether you should be tested for a condition.
5. Over-the-counter pills and supplements you take.
Patients often forget to tell doctors about nonprescription medications they're taking regularly, and they'll deliberately keep them in the dark about herbal medicines because they think a mainstream doctor will be critical, ignorant, or — worst of all — both. But over-the-counter medications and supplements can have dangerous interactions with conventional medications.
6. The medications you take that have been prescribed by other doctors.
To put it mildly, American health care is not very well coordinated. Especially if you're seeing several specialists, you can't assume that they have conferred (indeed, they probably haven't). Medical records are often Balkanized, with information collected at one office or institution never reaching another. The form you fill out in the waiting room usually asks you about the medications you're taking, but the doctor might not have had time to look at it carefully. So to be on the safe side, you should tell a doctor about medications that other doctors have prescribed for you. Bring a list or even the pill bottles themselves.
7. The medications you're supposed to take but don't.
More than a few pills never leave the bottle. Sometimes side effects are to blame. Other times people never really intend to take the medicine. If you discuss the situation with your doctor, maybe the prescription can be changed. If you just don't like taking pills, perhaps there's a perfectly good non pharmacological approach to your problem. Either way, you won't find out unless you come clean about not taking your medications.
8. If you smoke or drink heavily.
Most smokers know they shouldn't, so they're sometimes ashamed to tell a doctor about it. If you're asked about smoking, don't lie — and if you aren't asked, bring it up yourself. The same goes for heavy drinking, although denial is obviously a problem.
9. If you've been depressed or under stress.
The stigma is fading fast, but many people still don't like to admit they're depressed. Stress isn't considered shameful, but it's hard to pin down. And both get channeled into fatigue, insomnia, or irritability, so the root cause may get buried under the symptoms. Broaching the subject with a doctor is a good way to start sorting through these issues. Particularly for depression, it may lead to treatment — antidepressants, talk therapy, or some combination — that makes you feel a whole lot better.
10. If you're having incontinence problems.
Urinary or fecal incontinence is a prime example of a condition that people learn to live with because they're embarrassed by it or see it as an unavoidable consequence of old age. There are no guarantees, but these days they're often manageable conditions — but only if you tell your doctor first.
11. If you're experiencing sexual dysfunction.
Everywhere you turn these days, it seems like there's an ad for Viagra, Levitra or Cialis, the erectile dysfunction drugs. Haven't we talked about sexual dysfunction enough? It's different, though, when it's you and your problem. Many people clam up when a doctor really could help them with sexual dysfunction.
Of course, you're probably not going to have time to talk about all of these topics in one appointment. So you need to make the most of it by thinking ahead. Writing down some details
- like your travel dates and destinations,
- the over-the-counter medications you're taking,
- and family history of disease can be a major time saver.
Many people find it helpful to identify the three or four most important issues they want to discuss with a doctor.
Make a list of your priorities, or have someone do it with you.
Afraid to Speak Up at the Doctor’s Office
By Pauline Chen, MD : NY Times : May 31, 2012
A friend of mine, a brilliant and accomplished academic in her 70s who once specialized in history and literature, recently phoned to ask for medical advice after being discharged from the hospital for what sounded like a mini-stroke. Ever eager to learn something new, she pressed me on “the latest research” and asked what doctors around the country were doing for her condition.
We discussed a few research studies, diagnostic tests and treatment options, but when I suggested she speak with her primary care doctor and perhaps a neurologist, her end of the line went silent. I wondered if my cellphone had dropped the connection or, for a single harrowing second, if my friend was having another strokelike event.
When she finally spoke again, her once-confident voice sounded nearly childlike. “I don’t really feel comfortable bringing it up,” she said. While her doctor was generally warm and caring, “he seems too busy and uninterested in what I feel or want to say.”
“I don’t want him to think I’m questioning his judgment,” she added. “I don’t want to upset him or make him angry at me!”
For over a generation now, efforts to make health care more patient-friendly have focused on getting patients and doctors to work together to make decisions about care and treatment. Numerous research papers, conferences and advocacy organizations have been devoted to this topic of “shared decision-making,” and even politicians have clambered aboard the train, devoting several provisions in the Affordable Care Act to “preference-sensitive care.”
But one thing has been missing in nearly all of these earnest efforts to encourage doctors to share the decision-making process. That is, ironically, the patient’s perspective.
Now a study published in the most recent issue of Health Affairs has begun to uncover some of that perspective, and the news is not good. In our enthusiasm for all things patient-centered, we seem to have, as the saying goes, taken the thought of including patient preferences for the deed.
The researchers conducted several focus groups with 48 patients from five primary care physicians in the San Francisco Bay area. First, they showed the patient participants a short video on several equally effective but very different treatment approaches for a heart ailment. Then, they asked them questions about what they did with their own doctors when faced with a choice among several treatment options that might be equally effective but could differ in lifestyle effects, cost or range of complications. Finally, the researchers asked the participants if they were comfortable asking doctors about different treatments, discussing their values and preferences or disagreeing with their doctors’ recommendations.
The participants responded that they felt limited, almost trapped into certain ways of speaking with their doctors. They said they wanted to collaborate in decisions about their care but felt they couldn’t because doctors often acted authoritarian, rather than authoritative. A large number worried about upsetting or angering their doctors and believed that they were best served by acting as “supplicants” toward the doctor “who knows best.” Many also believed that they could depend only on themselves for getting more information about treatments or diseases. Some even said they feared retribution by doctors who could ultimately affect their care and how they did.
The findings fly in the face of previous optimistic assumptions about shared decision-making that were based mostly on studies that examined physicians’ intent, but not patient perceptions. “Many physicians say they are already doing shared decision-making,” said Dominick L. Frosch, lead author of the new study and an associate investigator in the Department of Health Services Research at the Palo Alto Medical Foundation Research Institute in California. “But patients still aren’t perceiving the relationship as a partnership.”
Interestingly, most participants in this study were over 50, lived in affluent areas and had either attended or completed graduate school. “It’s hard to think that people from more disadvantaged backgrounds would find it any easier to question doctors,” Dr. Frosch said.
While understanding health care issues and making themselves heard in discussions were not difficult in general for the participants in the study, the skills and confidence they had in other settings appeared to have little relevance once they were in their doctors’ offices. They could not speak as easily as they normally did. “People experience a different sense of self in the doctor-patient interaction,” Dr. Frosch observed. “The clinical context creates a reluctance to be more assertive.”
Dr. Frosch and his colleagues are working on a larger study examining the extent to which patients feel constrained. And they have plans to study whether there are better ways to encourage patient engagement.
Systemic changes to increase shared decision-making must be addressed as well. Care organizations and doctors’ practices must be restructured to allow more in-depth conversations; clinicians need to be reimbursed for the time required for more meaningful conversations; and health care systems must adopt rigorous quality standards that measure and value real patient engagement in decisions.
“We urgently need support of shared decision-making that is more than just rhetoric,” Dr. Frosch said. “It may take a little longer to talk through decisions and disagreements; but if we empower patients to make informed choices, we will all do much better in the long run.”
By Pauline Chen, MD : NY Times : May 31, 2012
A friend of mine, a brilliant and accomplished academic in her 70s who once specialized in history and literature, recently phoned to ask for medical advice after being discharged from the hospital for what sounded like a mini-stroke. Ever eager to learn something new, she pressed me on “the latest research” and asked what doctors around the country were doing for her condition.
We discussed a few research studies, diagnostic tests and treatment options, but when I suggested she speak with her primary care doctor and perhaps a neurologist, her end of the line went silent. I wondered if my cellphone had dropped the connection or, for a single harrowing second, if my friend was having another strokelike event.
When she finally spoke again, her once-confident voice sounded nearly childlike. “I don’t really feel comfortable bringing it up,” she said. While her doctor was generally warm and caring, “he seems too busy and uninterested in what I feel or want to say.”
“I don’t want him to think I’m questioning his judgment,” she added. “I don’t want to upset him or make him angry at me!”
For over a generation now, efforts to make health care more patient-friendly have focused on getting patients and doctors to work together to make decisions about care and treatment. Numerous research papers, conferences and advocacy organizations have been devoted to this topic of “shared decision-making,” and even politicians have clambered aboard the train, devoting several provisions in the Affordable Care Act to “preference-sensitive care.”
But one thing has been missing in nearly all of these earnest efforts to encourage doctors to share the decision-making process. That is, ironically, the patient’s perspective.
Now a study published in the most recent issue of Health Affairs has begun to uncover some of that perspective, and the news is not good. In our enthusiasm for all things patient-centered, we seem to have, as the saying goes, taken the thought of including patient preferences for the deed.
The researchers conducted several focus groups with 48 patients from five primary care physicians in the San Francisco Bay area. First, they showed the patient participants a short video on several equally effective but very different treatment approaches for a heart ailment. Then, they asked them questions about what they did with their own doctors when faced with a choice among several treatment options that might be equally effective but could differ in lifestyle effects, cost or range of complications. Finally, the researchers asked the participants if they were comfortable asking doctors about different treatments, discussing their values and preferences or disagreeing with their doctors’ recommendations.
The participants responded that they felt limited, almost trapped into certain ways of speaking with their doctors. They said they wanted to collaborate in decisions about their care but felt they couldn’t because doctors often acted authoritarian, rather than authoritative. A large number worried about upsetting or angering their doctors and believed that they were best served by acting as “supplicants” toward the doctor “who knows best.” Many also believed that they could depend only on themselves for getting more information about treatments or diseases. Some even said they feared retribution by doctors who could ultimately affect their care and how they did.
The findings fly in the face of previous optimistic assumptions about shared decision-making that were based mostly on studies that examined physicians’ intent, but not patient perceptions. “Many physicians say they are already doing shared decision-making,” said Dominick L. Frosch, lead author of the new study and an associate investigator in the Department of Health Services Research at the Palo Alto Medical Foundation Research Institute in California. “But patients still aren’t perceiving the relationship as a partnership.”
Interestingly, most participants in this study were over 50, lived in affluent areas and had either attended or completed graduate school. “It’s hard to think that people from more disadvantaged backgrounds would find it any easier to question doctors,” Dr. Frosch said.
While understanding health care issues and making themselves heard in discussions were not difficult in general for the participants in the study, the skills and confidence they had in other settings appeared to have little relevance once they were in their doctors’ offices. They could not speak as easily as they normally did. “People experience a different sense of self in the doctor-patient interaction,” Dr. Frosch observed. “The clinical context creates a reluctance to be more assertive.”
Dr. Frosch and his colleagues are working on a larger study examining the extent to which patients feel constrained. And they have plans to study whether there are better ways to encourage patient engagement.
Systemic changes to increase shared decision-making must be addressed as well. Care organizations and doctors’ practices must be restructured to allow more in-depth conversations; clinicians need to be reimbursed for the time required for more meaningful conversations; and health care systems must adopt rigorous quality standards that measure and value real patient engagement in decisions.
“We urgently need support of shared decision-making that is more than just rhetoric,” Dr. Frosch said. “It may take a little longer to talk through decisions and disagreements; but if we empower patients to make informed choices, we will all do much better in the long run.”