What on earth do I mean by that? What is perception? All I know is that perception is reality. How many times have we heard that? And how often do we think of that when we’re in the medical environment? Probably not as often as we should…..

I was having lunch with a good friend and his wife (whom I’ve gotten to know fairly well in the past 2 years). She told me about her encounter with a new doctor recently for a sinus infection. She was adamant when she simply stated "I know enough about what’s going on in my body that by the time I go to the doctor, I just want them to give me the drugs I need." My internal reaction to that was very disconcerting. I understood what she was saying but my doctor-instinct was horrified - I know I’m telling alot about myself

I wanted to explain to her that sometimes she might not know exactly what was wrong with her because "after all, you’re not medical" but i restrained my tongue for once, knowing that what she believed was, in fact, reality to her - and therefore, she probably did know what she needed.

I recalled a very sad case where a mother did not want to take her twin daughters home from the ER because they did not seem "better" to her after their asthma treatment. The ER doctor (not me, thank goodness) told her that the girls were not wheezing so they "must" be better. So, reluctantly mom took them home. The outcome was not good - one of the girls ended up dying. I tell this not to be morbid but to emphasize to patients that they really do know their bodies better than anyone (and to remind the physicians to listen to the patients and pay attention). I learned such a valuable lesson that night, nearly 28 years ago - and I think that’s what held my tongue in abeyance with my friend’s wife.

The point is that doctors and patients have different perspectives and therefore the perception of each is most likely 180 degrees apart. Each of us has to ask for clarification or offer it if we want to be understood by the other - and if we’re not understood, we’re in deep trouble.

Doctors - throw away your judgments and open up your ears AND your minds.

Patients - stick up for yourself and make sure your doctor hears you and where you’re coming from. And then make sure you understand what he’s saying.

Perception really is reality

Til next time…..

Terrie

This is very long but well worth the read (to me anyway). Although it’s about the mental health professionals, it could certainly be applied to any physician. Know anyone who fits this bill?

This article received a Thinking Blogger Award!

 This is my proposal for the DSM inclusion of a new section that outlines and categorizes the features of Mental Health Professional Personality Disorders or MHPPDs.

This proposal begins with a general definition of Mental Health Professional Personality Disorder that applies to each of the 4 specific MHPPDs. An MHPPD is an enduring pattern of inability to empathize with or understand the inner experience and behavior of certain patient populations that deviate markedly from the MHP’s own expectations, individual culture, life experience, values, and personal lifestyle preferences. MHPPD is pervasive, inflexible, prejudicial and has an onset upon reading educational psychiatric literature, engaging in disparaging prejudicial discussion with “more experienced” colleagues, may be triggered by reading a chart with which includes a previous undesirable diagnosis for a patient, is stable over time, and leads to further distress or impairment in the condition of the MHP’s patient. The Mental Health Professional Personality Disorders included in this proposal are listed below.

Mental Health Professional Paranoid Personality Disorder is a pattern of distrust and suspiciousness such that patients’ motives are interpreted as malevolent or manipulative.

Mental Health Professional Antisocial Personality Disorder is a pattern of disregard for and violation of the rights of patients.

Mental Health Professional Narcissistic Personality Disorder is a pattern of grandiosity, need for the compliance of one’s patients, and a lack of empathy for the experience or suffering of those patients.

Mental Health Professional Coercive Personality Disorder is a pattern of dominant and aggressive authoritarian behavior related to an excessive need to be in control of patient treatment decisions.

Mental Health Professional Personality Disorder Not Otherwise Specified is a category provided for two situations: 1) the MHP’s personality pattern meets the general criteria for an MHPPD and the traits of several different MHPPDs are present, but the criteria for any specific MHPPD are not met; or 2) the MHP’s personality pattern meets the general criteria for an MHPPD that is not included in the Classification (e.g., mental health professional passive-aggressive personality disorder). It should be noted that MHPs frequently present with co-occurring personality disorders.

More on Satire - But, Oh So True!

Great article on how to talk to your doctor about embarrassing medical problems - Dr. Vicki Rackner has the same sense of teaching patients how to take charge of their own health and care as I do - of course, she’s much younger and seemingly more energetic so Bravo to her for championing the cause! Check her out.

The realization hit Natalie like a ton of bricks. Her mother, Joann, had literally died of embarrassment! Joann had noticed blood in her stool almost a year before she was diagnosed with colon cancer. At first she told herself it must have been those beets she ate. Then she thought it was most likely her hemorrhoids, although she had not had a flair-up of hemorrhoids since Natalie’s birth 52 years earlier.

The truth was that Joann was embarrassed to talk with her doctor about private topics such as her bowel habits. She didn’t raise the concern with her doctor until she had bloating, cramping and abdominal pain. This led to the diagnosis of colon cancer that ultimately took her life. Natalie’s brother-in-law, who was a nurse, wondered whether Joann would still be alive if she had told her doctor about the blood in her stool when she first noticed it.

Let’s face it; certain topics are embarrassing to talk about with your doctor. I call them the 5 P’s:

• Peeing
• Pooping
• Paying
• Procreating
• Psychic moaning

Although at first blush the challenge of talking with your doctor about embarrassing medical topics seems simple enough, for some people, it can cause significant suffering.

Hillary, for example, had what’s now called a shy bladder. She had not used a public restroom in over 20 years. She was too embarrassed to talk with her doctor about this; instead, she remained a prisoner to her bladder.

Ed was laid off from work and could no longer afford his asthma medications. Instead of talking with his doctor about it, he decided to do without He wound up in the emergency room with an asthma attack that could have been avoided with regular medication.

Tom had some sexual side effects from his blood pressure medicine. Instead of talking with his doctor and getting a different medicine, he just stopped taking it. The doctors wonder if this might have contributed to his heart attack.

Jerry noticed his loss of appetite and sleeping problems as his caregiver responsibilities for his aging father mounted. He wondered if he might be depressed, but dismissed the thought because real men don’t get depressed.

Imagine how each of these stories might have been different if these individuals who suffered in silence could have talked with their doctors.

Here are 6 tips that can help you talk with your doctor about embarrassing medical topics:

1. Own the embarrassment.

Say to your doctor, “This is a taboo topic in our family, so it’s hard for me to ask. Is it normal to have a funny smell coming from your belly button?"

2. Find the words.

Your doctor speaks a specialized language acquired through years of training. Sometimes patients are embarrassed because they don’t know the “right words" or have a hard time describing the problem.

Remember that your job is to communicate. You don’t need to know the fancy words to do that. If a patient said to me, “Dad had an operation on the dingle-ball thing at the back of his throat", I would know just what he meant. And, the patient would seem relieved when I said, “Oh, you mean the uvula."

The best way to make sure you and your doctor understand each other is to use anatomically correct words. Get a basic anatomy atlas. Use anatomically correct words with your children.

3. Practice saying the words.

Sometimes embarrassing words can be hard to get out of your mouth. Gertrude, a 90-year-old patient said to me, “You youngsters don’t understand how much things have changed. When I got breast cancer in the 1962, the words ‘breast’ and ‘cancer’ were not uttered in polite company." Some words are still embarrassing to say. Practice saying these words out loud when you’re alone! That will make it easier to say them at the doctor’s office

4. Find the right person to ask.

You may have an easy rapport with the nurse or physician’s assistant at your doctor’s office. You can bring up the sensitive topic with them. Say, “Trish, could you please give the doctor a heads up. I want to know why I should say no to those steroids my buddies at the gym are offering me. I would love to look like they do."

5. Find the right way to ask.

Maybe it’s easier for you to drop a note or a cartoon to your doctor rather than ask in person. Find the style that works best for you.

6. Remember that your doctor is there to help you, not to judge you.

Your doctor has heard it all before. I promise! Your doctor will not think less of you for asking an embarrassing medical question; in fact, your doctor with think more of you for overcoming your fear and helping you take charge of your health.

Dr. Vicki is a board-certified surgeon who left the operating room to help families take the most direct path from illness to optimal health. Her book, “The Personal Health Journal", can save your life today by helping you understand your health story. Empower yourself with the tips and tools that will help you direct your story and partner with your doctor more effectively at: http://www.drvicki.org/drvicki-store-health-journal.html 

Excellent article from the University of Chicago’s Medical Center 

Talking to Your Doctor about Asthma

Good communication between people with asthma and their health care providers is essential for making the most of health care, and for ensuring that quality of life is the best it can be. Communication isn’t always easy, though, and both sides have to work to make sure that understanding is reached. Being "the patient" can sometimes feel intimidating and confusing. Many of us have had the experience of leaving a doctor’s office never having asked a question we went in meaning to ask.

Here are some things to think about to make your interactions with your health care provider the best that they can be.

Prepare for each visit. Write out any questions you have, or anything particular you have to report. That way, even if you get flustered during the visit, you can refer to your list and make sure not to forget anything important.

Take along any records that you keep at home. Many people with asthma keep symptom diaries, and/or logs of daily peak flow measurements and medication use. It can be tremendously helpful to your care provider to be able to go over these, to track how you’ve been doing from day to day.

Take along all of your inhalers and other medications (including the ones that are not for asthma). This is vitally important, especially if you are taking more than one or two medicines.

Be assertive (not aggressive). Speaking up is not always easy, but it is important for your care provider to know what your concerns are. If you don’t get a response initially to your question or your worry, just ask again. If you don’t understand what you are told (doctors and other health professionals sometimes forget and lapse into medical jargon), ask for clarification. Be both persistent and polite. You should be able to keep interactions respectful and friendly while still being firm about getting the information that you need.

Similarly, if you do not feel comfortable with a proposed treatment or test, make that clear to your care provider. There may be alternatives available, and you can’t know until you bring it up!

Be truthful. A health care provider needs to know what is really going on with you in order to make good (and safe!) decisions about your care. If you have not been taking a prescribed medicine, or have not been doing your peak flow measurements, say so! (Giving incomplete or false reports in these situations can be DANGEROUS, because your health care provider is basing your treatments on the information.)

If you have not been following the recommended plan, it is also very helpful if you can explain the reasons that you haven’t. That starts the conversation. Then you can work out a plan together that comes closest to fitting all of your needs (health, safety, convenience, comfort, and cost).

Find a health care provider you can work with. Even the smartest, most accomplished doctor in the world might not be the right one for you if you can’t communicate with each other. Most health plans offer a choice of different physicians and other care providers (such as nurse practitioners). Don’t be afraid to shop around until you find someone who is right for you:

• Someone you trust
• Someone who listens to you
• Someone who respects you
• Someone who answers your questions and explains things in a way you can understand
• Someone who is willing to negotiate with you and take your concerns into account

Be a partner in your own care. You are the person who has the most power over your health. Doctors and nurses have expert knowledge and can guide you in choosing a treatment path, but you are still the one caring for yourself day in and day out. Take an active role!

BE YOUR OWN EXPERT. Learn what you can about asthma, especially about your different treatment options, and steps you can take to keep yourself healthy. Know what to do if you start having worse symptoms or if your peak-flow measurements go down (signalling the possible start of an asthma episode). Know when to call your health care provider, and when to go to the emergency room. (If possible, get written instructions to keep on hand.)

BE YOUR OWN HISTORIAN. Keep records of your asthma care. Know the names of medicines you are taking, and medicines you have tried in the past. Be able to report how well they worked for you, and whether you had any side-effects from them. If a symptom diary or peak-flow log is part of your care plan, keep it up to date and organized. Keep a list of things that have triggered asthma episodes for you.

BE YOUR OWN ADVOCATE. Health care is not one-size-fits-all. Your preferences and priorities are important in determining the asthma care most appropriate for you. Let your care providers know what is important to you. Do you just hate taking pills? Are you unable to take medicine in the middle of the day while you are at work? Is sleeping through the night your top priority? Speak up! Negotiate!

BE YOUR OWN DRILL-SERGEANT. There are difficulties with maintaining any kind of daily regimen, whether it’s exercise or diet or doing one good deed every day. Staying faithful to a medication and inhaler regimen can be even trickier, because we don’t like to be reminded of illness, especially when we’re feeling healthy. But remember that it’s sticking to your treatment plan that keeps you healthy. Be strict with yourself, and stay on your program

Expect good asthma control. Some people with asthma are so used to having their activity limited and feeling crummy all the time that they have grown to accept this as normal. It doesn’t have to be!

With careful treatment (and sticking to the treatment plan), the vast majority of people with asthma can achieve good asthma control. Good asthma control means:

• sleeping through the night without being awakened by coughing or wheezing
• being able to exercise as much as a person without asthma
• not missing school or work days due to asthma
• not having to go to the emergency room or into the hospital for asthma · using a quick-relief inhaler once a day or less
• being able to do the things you want to do without asthma getting in the way

If you do not have good asthma control, talk to your health care provider about changing your treatment plan.

Boy is this a pertinent quip from Medical News Today .

In today’s world of very educated patients, most would be insulted if the physician even mentioned anything to do with depression. And yet, the universal presence of depression in the U.S. is phenomenal. Many people do not know that that is their diagnosis though. And therefore, they think that there "must be something wrong with me" - something that enough "tests", enough "diagnostic studies" - enough something - would show. The somatic symptoms of depression are multiple. And it should be considered in most scenarios. AND most patients should not be so resistant to the screening process. This resistance is what keeps physicians from even considering it as a diagnosis.

Providing a voice to an often silent disease, Epocrates, Inc. surveyed 500 clinicians to identify trends in depression diagnosis, prevalence and treatment. People dealing with stress, whether in the workplace or at home, should take note; nearly all clinicians identified stress as the leading contributor to depression.

The majority of clinicians reported seeing an increase in depression in the past five years, and believe this increase may be driven by greater disease awareness, and ultimately more patients seeking help. However, clinicians reported that many more patients may be experiencing symptoms that are going undiagnosed. More than half of survey respondents felt that physicians are hesitant to diagnose depression, primarily due to resistance from patients and lack of societal acceptance. Clinicians also reported uncertainty about diagnosing depression, as patients may present symptoms differently based on gender and ethnicity, or may be a product of another medical illness.

"In today’s digital age, the increasing pressure to get it done yesterday can lead to more stress and potentially depression. Early recognition and intervention are important to prevent the loss of jobs, damage to relationships or suicidal thoughts," said John Luo, MD, Assistant Clinical Professor of Psychiatry at UCLA Semel Institute for Neuroscience and Human Behavior.

The vast majority of clinicians reported recommending prescription therapies for their patients experiencing depression. Beyond pharmacotherapy and psychotherapy, 60 percent of respondents believe lifestyle changes such as diet, exercise and meditation may also be helpful in treating depression, depending on the patient’s individual situation.

Additional key survey findings include:

– Gender makes a difference when diagnosing depression

– Thirty percent of clinicians reported being less likely to discuss depression with men.

– Clinicians reported it is often more difficult to treat men because they are less "open" than women, and symptoms such as anger or addiction may not be immediately linked to depression.

– Clinicians may be more likely to experience depression

– More than 50 percent of clinicians reported experiencing depression at some point in their lives, which compared to the National Institutes of Health data, could make them more than twice as likely to experience depression as the general public.

– Additionally, 12 percent of clinicians reported missing work because they felt depressed. Clinicians are not alone-a national study revealed that depression is the leading cause of missed work days, and lost productivity due to depression is estimated at $83 billion a year.

For more about depression, including a podcast with UCLA psychiatrist Dr. Luo, clinicians’ comments and comprehensive survey results, please visit http://insights.epocrates.com/depression. Comprehensive dosing and drug interaction information for anti-depressants can also be found at http://www.epocrates.com.

 Another clip from Medical News Today about the number of pills and Daily Adherence to medication. Although it focuses on certain conditions, the issue is applicable to everyone and every condition. Compliance (adherence to instructions) is such a big factor in health success that we all (doctors and patients alike) must pay attention to what will improve a person’s ability to follow the advice/instructions:

New Study Suggests Number Of Pills Not A Factor When It Comes To Daily Adherence To Medication

There is no correlation between the daily number of pills a patient is prescribed to take and how well a patient will adhere to a dosing regimen, suggests a new study presented recently at the 19th Annual Meeting of the Academy of Managed Care Pharmacy (AMCP) held in San Diego (April 11-14). The large-scale study looked at patients taking a variety of high blood pressure medicines, specifically calcium channel blockers (CCBs), and provides more supportive evidence that adherence to prescribed medication is influenced by a multitude of factors. The study specifically examined dosing regimen to see if there was a relationship between that factor and adherence in patients with a co-payment of at least $20.

More on Do You Take Your Medicines As Prescribed?

Great article on how to talk to your doctor about embarrassing medical problems - Dr. Vicki Rackner has the same sense of teaching patients how to take charge of their own health and care as I do - of course, she’s much younger and seemingly more energetic so Bravo to her for championing the cause! Check her out.

The realization hit Natalie like a ton of bricks. Her mother, Joann, had literally died of embarrassment! Joann had noticed blood in her stool almost a year before she was diagnosed with colon cancer. At first she told herself it must have been those beets she ate. Then she thought it was most likely her hemorrhoids, although she had not had a flair-up of hemorrhoids since Natalie’s birth 52 years earlier.

The truth was that Joann was embarrassed to talk with her doctor about private topics such as her bowel habits. She didn’t raise the concern with her doctor until she had bloating, cramping and abdominal pain. This led to the diagnosis of colon cancer that ultimately took her life. Natalie’s brother-in-law, who was a nurse, wondered whether Joann would still be alive if she had told her doctor about the blood in her stool when she first noticed it.

Let’s face it; certain topics are embarrassing to talk about with your doctor. I call them the 5 P’s:

• Peeing
• Pooping
• Paying
• Procreating
• Psychic moaning

Although at first blush the challenge of talking with your doctor about embarrassing medical topics seems simple enough, for some people, it can cause significant suffering.

Hillary, for example, had what’s now called a shy bladder. She had not used a public restroom in over 20 years. She was too embarrassed to talk with her doctor about this; instead, she remained a prisoner to her bladder.

Ed was laid off from work and could no longer afford his asthma medications. Instead of talking with his doctor about it, he decided to do without He wound up in the emergency room with an asthma attack that could have been avoided with regular medication.

Tom had some sexual side effects from his blood pressure medicine. Instead of talking with his doctor and getting a different medicine, he just stopped taking it. The doctors wonder if this might have contributed to his heart attack.

Jerry noticed his loss of appetite and sleeping problems as his caregiver responsibilities for his aging father mounted. He wondered if he might be depressed, but dismissed the thought because real men don’t get depressed.

Imagine how each of these stories might have been different if these individuals who suffered in silence could have talked with their doctors.

Here are 6 tips that can help you talk with your doctor about embarrassing medical topics:

1. Own the embarrassment.

Say to your doctor, “This is a taboo topic in our family, so it’s hard for me to ask. Is it normal to have a funny smell coming from your belly button?"

2. Find the words.

Your doctor speaks a specialized language acquired through years of training. Sometimes patients are embarrassed because they don’t know the “right words" or have a hard time describing the problem.

Remember that your job is to communicate. You don’t need to know the fancy words to do that. If a patient said to me, “Dad had an operation on the dingle-ball thing at the back of his throat", I would know just what he meant. And, the patient would seem relieved when I said, “Oh, you mean the uvula."

The best way to make sure you and your doctor understand each other is to use anatomically correct words. Get a basic anatomy atlas. Use anatomically correct words with your children.

3. Practice saying the words.

Sometimes embarrassing words can be hard to get out of your mouth. Gertrude, a 90-year-old patient said to me, “You youngsters don’t understand how much things have changed. When I got breast cancer in the 1962, the words ‘breast’ and ‘cancer’ were not uttered in polite company." Some words are still embarrassing to say. Practice saying these words out loud when you’re alone! That will make it easier to say them at the doctor’s office

4. Find the right person to ask.

You may have an easy rapport with the nurse or physician’s assistant at your doctor’s office. You can bring up the sensitive topic with them. Say, “Trish, could you please give the doctor a heads up. I want to know why I should say no to those steroids my buddies at the gym are offering me. I would love to look like they do."

5. Find the right way to ask.

Maybe it’s easier for you to drop a note or a cartoon to your doctor rather than ask in person. Find the style that works best for you.

6. Remember that your doctor is there to help you, not to judge you.

Your doctor has heard it all before. I promise! Your doctor will not think less of you for asking an embarrassing medical question; in fact, your doctor with think more of you for overcoming your fear and helping you take charge of your health.

Dr. Vicki is a board-certified surgeon who left the operating room to help families take the most direct path from illness to optimal health. Her book, “The Personal Health Journal", can save your life today by helping you understand your health story. Empower yourself with the tips and tools that will help you direct your story and partner with your doctor more effectively at: http://www.drvicki.org/drvicki-store-health-journal.html 

Kristen Gerencher is a reporter for MarketWatch in San Francisco.

Here’s an interesting article that hinges around communication differences between men and women and the diagnosis of  complex pain conditions.

More Difficult For Doctors To Diagnose Complex Sources Of Pain In Women Than In Men

It is more difficult for doctors to diagnose complex sources of pain in women than in men and the reasons for this are rooted in language use. This finding, which is of major importance for both doctors and patients, is revealed by a now completed project by the FWF Austrian Science Fund. The results of this research into how the two genders typically describe pain are to be presented at the 2nd International Congress of Gender Medicine on 2nd and 3rd June in Vienna.

For quite some time, we have all known that men are from Mars and women from Venus, but scientific research has now proven that, when it comes to describing complex pain, men and women are worlds apart. This finding comes from studies that investigated patients suffering from complex headaches. While female patients give doctors brief and vague illustrations of their complaints, men describe their pain in an extremely concrete manner. This means that male patients are at an advantage when it comes to treatment as an accurate analysis of pain is essential for both diagnosis and therapy. 

{Terrie’s note - I do not necessarily agree with the statement that women give brief and vague illustrations of their complaints - or if they do, perhaps it’s for multiple, complex reasons - perhaps it’s perceptions of how the doctor is dealing with them or many other things…this statement is not well qualified to me and it gives women a bad "name" again}

LACK OF COMMUNICATION

A team headed by Prof. Florian Menz of the Department of Linguistics at the University of Vienna established that these different approaches to describing pain are caused by language barriers. Prof. Menz believes that "Women are rather vague and less detailed when portraying their pain, often focusing on the day-to-day situations in which the pain occurs. However, this does not constitute a description of pain in medical terms, as doctors develop a largely symptom-oriented language over the course of their careers. Men, on the other hand, describe their pain in very concrete terms focusing on their symptoms, which is very compatible with medical diagnostics and makes it easier for doctor and patient to understand one another."

{Terrie’s note - so maybe doctors need to be aware of this and change their approach to women?}

By investigating other patients suffering from chronic pain, the study showed that doctor-patient communication is also inadequate on other levels and leads to misunderstandings. While doctors are again primarily concerned with analysing pain when they speak to patients, the patients themselves ¬ who have lived with their pain for a number of years ¬ are more focused on treatment options for example. In such a scenario, doctor-patient discussions often fall short of patient expectations, as they are keen to be involved in the decision-making process.

 This is about heart disease from About.com but the info is still pertinent

Getting What You Need From the Health Care System

There’s nothing more frustrating, or more dangerous, than having to solve your own medical problems. No matter how many hours you spend searching the Internet, listening to the accumulated wisdom of your Great Aunt Hilda, or engaging in games of Twenty Questions with taciturn medical personnel, you can never be sure you’ve got the right answer. 

It’s not supposed to be like that. When you’re sick and need help, you’re supposed to be able to rely on a doctor - a doctor who is knowledgeable, who really cares what happens to you, and who will leave no stone unturned in seeing that you get exactly what you need.  Unfortunately, having such a "model" doctor is becoming rare. Patients are on their own much more often, and to a much greater extent, than they used to be - and it’s getting worse all the time.  

If you’ve read Part 1 of this series, you’re acquainted with our contention that patients are feeling abandoned by the health care system because they really have been abandoned; and that (because widespread covert rationing is systematically destroying the doctor-patient relationship,) the abandonment of patients is happening by design rather than by chance. But even if you don’t buy DrRich’s explanation of the problem, the problem still remains. When you’re sick and find yourself engaged in a hostile health care system, you need somebody in your corner who knows what she’s doing, and who cares about you.  And that somebody is supposed to be your doctor.

Choosing the right doctor for yourself, and nurturing a good relationship with him, is probably the most critical step you can take in becoming an effective patient. With the right doctor at your side, the path to good health care becomes clear and wide. Without that doctor, you’re lost and alone in the enchanted forest.  Accordingly, this article discusses two aspects of dealing with your doctor: Choosing the Right Doctor, and The Care and Feeding of your Doctor-Patient Relationship.

Rule # 1. We ought to begin with the first rule of choosing a doctor, to wit: You hired him; you can fire him.

Choosing a doctor is different than, say, choosing a car. When you buy a new car, you can shop around to your heart’s content, but once you plunk down your money and bring that baby home, you’re pretty much stuck with it. If it’s not everything you hoped it would be, you can’t just get rid of it - why, it lost 50% of its original value the minute you drove it off the lot. Besides, it’s not life and death, it’s just a car. So if your new car turns out to be a disappointment, you’ll usually shrug your shoulders and resolve to live with it for a few years, at least until you can justify buying another one. 

It’s different with doctors. For one thing, it’s harder to shop around before you make your move. For another, starting with a new doctor doesn’t require an up-front investment of tens of thousands of dollars. Early on, all you’ve invested is some time and inconvenience. And finally, choosing the right doctor potentially is a matter of life and death.

Many patients have the same attitude when they’re dissatisfied with their doctors that they would have if they were dissatisfied with a car - "Oh, well, guess I’ll just have to live with it." This is the wrong attitude, since, indeed, in this case you may not live with it. Doctors are serious business.  Choosing a doctor is an important decision, but it’s not an irreversible one. It’s not uncommon for discerning patients to run through two or three doctors before finding the right match. And there’s nothing wrong with doing it that way. So if you’ve tried a new doctor and you’re not satisfied with him, get another one. Remember: You hired him; you can fire him.

The most important factor in choosing a doctor: Communication.  If you can’t communicate well with your doctor, you’re in trouble. This is the person, after all, who will need to understand your wishes and values regarding your health care. She is the one who will need to explain to you, so that you can understand it, the nature of your medical problems - the causes, the testing that may be needed, the potential treatments, the pros and cons of the various therapeutic options, and why she’s recommending one option over the others. She’s also the one who has to convince your insurance carrier that the course of action you and she have decided upon is the right one, that it’s medically necessary, and that they - the insurance carrier - ought to pay for it. Communication has always been important in medicine. Now it’s vital.

Is your doctor really listening to what you are saying? Does he show he understands your concerns by responding meaningfully to them? When he explains medical issues to you, does he make them understandable? Does he have more than one way of explaining a difficult concept? Is he patient with you, waiting for you to grasp what he’s saying, or does he try to embarrass you into saying you understand, with shakes of his head or rolling of his eyes? Do you like him, and more importantly, does he seem to like you? (This may become very important when it’s time for him to go to bat for you.) 

The inability to communicate effectively with your doctor is sufficient reason to move on to someone else. Without communication, you’ve got nothing.

The second most important factor: Does your doctor know what she’s doing?

Sometimes its hard to know for sure how knowledgeable your doctor is. But at a minimum you should check to see if your doctor is board-certified in her specialty.  At least two sources can help. The Directory of Physicians in the United States and the Official American Board of Medical Specialties Directory of Board Certified Medical Specialists list doctors who are board-certified. These books are available in most public libraries, and your doctor should appear in them.

Does your doctor seem smart to you? When you ask a question about one of you health problems, are the answers quick, logical, and cogent? Do the answers jibe with what you know to be true? Are her answers given confidently, or is she dissembling? Keep in mind that it’s often fine for a doctor to answer, "I don’t know," as long as she promises to find out the answer, and then follows through on that promise.

For specialists you will be seeing only once or twice, or who you are going to for some complex or esoteric medical procedure, their experience, knowledge and ability are often much more important than how well they communicate. If I’m having a heart valve surgery, I care much less about how warm and fuzzy the surgeon makes me feel during the pre-op interview, and much more about how many similar procedures she’s performed, and what have been her surgical results.

The third most important factor:  Is your doctor respected by his peers?

Doctors watch each other perform in the trenches, and in general, are pretty good at sizing each other up. If you can get a recommendation on a doctor from another doctor you know you can trust, that’s likely to be a good starting point.  If you know some doctors, ask them what they think. Would they send their own patients to your doctor? Or, better yet, do they send their own family members to him? Do they use him as their own doctor?  And, if your doctor is invited to participate in the training of medical students or medical residents at the local university, that’s a reasonably good sign that he’s held in high regard by his peers.

Other factors to consider. 

• Where is your prospective doctor located? Is her office convenient to you?
• Which hospitals does she have admitting privileges to? Are these hospitals convenient to you, and do the specialists there (since the specialists in those hospitals are the ones she will be referring you to) have a good reputation?
• What are her practice arrangements? Who covers for her when she is away?
• Is her age, gender or race important to you?
• What is her office staff like? Are they reasonably competent, friendly, and helpful, or is their main job to keep you out?
• What are her office hours and office policies?
• What insurance plans does she participate in? This may be especially important if you are likely to be changing jobs (and thus changing insurance carriers.)

Where to look.

Start with your family and friends - people whose opinions you trust. Find out who their doctors are, and whether they are happy with them. Find out why they like them.  Also, talk to medical specialists, and especially to nurses and (if you know any), physicians’ assistants.  See which doctors they respect and admire, and why.

Another place you might consider looking is www.bestdoctors.com.  This is a listing of American physicians chosen through a survey of other American physicians.  For a doctor to make the list, a large number of physicians have to assert that they would want that doctor to take care of them or their family members if they were sick. Best Doctors is a business, however, and currently requires a $35 subscription fee.  A problem with Best Doctors is that it is sometimes weighted toward academic physicians, and there are potential drawbacks to academics - doctors often sing the praises of academics not because they are especially good doctors, but because they have published a lot, or are in positions of power. Some of the most famous university doctors are not especially good clinicians. The bottom line is that while you may find Best Doctors useful, it should by no means become your chief searching tool.  The large majority of excellent doctors in the U.S. are not listed there at all. If you strictly limit your search in this way you may be cheating yourself.

Once you have made your list of doctors, check for them in the Directory of Physicians in the United States or the Official American Board of Medical Specialties Directory of Board Certified Medical Specialists in your public library to make sure they are board certified.  Finally, call the office of one or two of the doctors still remaining on your list. See what you have to do to get an appointment.  See whether the office personnel seem friendly and efficient, or whether they’re obstreperous and obstructive.  Remember that you may need to deal with these people fairly often, and that before you ever get in to see the doctor, you’ve got to get past them. And remember that the doctor’s front office is a reflection of his own personality.  If his receptionists and nurses are difficult to deal with, you’ve got to assume that the doctor likes it that way. 

 The remaining step is to pick one of the "finalists" on your list, and make yourself an appointment.  If after meeting with the doctor you decide this isn’t going to work out, remember Rule # 1.

If you’ve read Part 1 of this series, you know that the traditional doctor-patient relationship is in deep trouble.  The problem, of course, is that the health care system simply can’t afford the traditional doctor-patient relationship anymore. There’s no way that HMOs, hospitals, insurance carriers, or federal regulators can allow doctors to continue directing the spending of health care dollars as if the only important consideration is the welfare their patients. In thousands of ways doctors are being coerced into giving the needs of each of these other parties a higher priority than the needs of their patients. So in becoming an effective patient, you’ve got to take the weakened state of the doctor-patient relationship into account.

The effective patient’s strategy 

Simply assuming that your doctor is always going to be acting in your best interests - no matter how good a doctor he is, or how ethical - is a big mistake.  The effective patient understands this, but she understands something else, too. She understands that her doctor (if she’s chosen her doctor wisely) deeply wants to honor the traditional doctor-patient relationship, since honoring that relationship is his first duty as a professional. She understands that, despite all the coercive pressure to the contrary, her doctor will occasionally go up against an HMO for the benefit of a patient. He needs to do this as a matter of professional pride - just to be able to live with himself. (The HMOs understand this, too. Letting the doctors win one now and then - only, of course, after putting up a stiff resistance - costs them some money, but in the long run keeps the doctors mollified. It keeps the doctors working, and it keeps them quiet. It’s just one of the costs of doing business.) The effective patient also understands that, as much as he may want to, her doctor cannot go to the wall for every patient, or for every issue that comes up for a given patient. The process would be too grindingly difficult, and fatal to his career. She knows that her doctor must choose his battles carefully.

The effective patient understands all this, and nurtures her relationship with her doctor accordingly. She tailors the relationship in such a way that, when the chips are down, she is likely to be one of those her doctor will go to the wall for.  To be such an effective patient, consider following these three general strategies:

Strategy 1 - Be empathetic.  Show that you understand the constraints under which your doctor is laboring, and adjust your expectations accordingly. Don’t be too demanding, especially regarding the small stuff. Show that you respect your doctor’s skills, and that having his skills working for you is worth a few minor inconveniences. After all, you make clear, you know how hard it is to be a good doctor these days, and you’re thankful he’s there for you despite everything. 

Strategy 2 - Align your interests with those of your doctor. Remember: you and your doctor are in this together. He feels your pain, and you feel his. You both want the same things. You both want the patient (you) to get good health care; and you both want the doctor’s practice - and professional integrity - to thrive. So while you fully expect to get the care you need from your doctor, you will help him to deliver that care as efficiently and as cheaply as posible.

You will not bother him needlessly, or thoughtlessly. You will make the most efficient use of your time with him. You will learn how his office operates, and cooperate with his office staff in minimizing interruptions and special requests. (For instance, inquire as to the best time to call the office with questions, or to speak with the doctor.) The main idea is: you are interested in making the doctor’s job as easy for him as possible, while still having your own vital needs served. 

Strategy 3 - Become engaged in your own good health. Nothing makes doctors crazier than patients who completely neglect their own health, then expect their doctors to pull out all the stops for them when they get into medical difficulties. The fact is, your doctor simply cannot afford to vigorously advocate for every problem for every patient. This being the case, which patient is your doctor more likely to fight for when they get sick - the obese smoker who has made no visible effort to take care of himself, or the diabetic who has carefully tried to follow her difficult diet and drug regimens?  

Maybe it isn’t fair, but it’s nonetheless true. If a doctor is considering stepping out of line and jeopardizing his own security to fight for his patient’s best outcome, you can be sure he’s more likely to reserve that action for a patient who’s fighting right at his side for the very same thing. 

You greatly increase the likelihood that your doctor will go to the wall for you if you are fully engaged in maintaining your own good health. You need to stop smoking, lose weight, exercise, take an interest in disease prevention, and during your visits to your doctor, demonstrate how involved you are with your own health care. Make yourself into the kind of patient that doctors find it rewarding and fulfilling to fight for.

Summary

By understanding how and why the doctor-patient relationship is under fierce attack, you can "manage" your own doctor-patient relationship to make yourself a more effective patient. 
Any doctor worth her salt will respond favorably to patients who seem to understand the duress she faces each day in the practice of medicine, who try to help her keep her head above water while she provides health care, and who take an active role in maintaining their own health. Patients like that are worth their weight in gold, and doctors try hard to provide them with the best health care they can possibly manage.