The doctor is often more to be feared than the disease.
—French Proverb1
So here you are, rushing into your doctor’s appointment, maybe filled with anxiety, your mind swirling with fears of illness, painful treatments, and a lifetime of prescriptions. You are not sure what to say or what to do, and you are stressed because you have to get back to work before lunch is over. Ironically, the lack of a healthy lunch and the increased stress are both bad for your health!
But this time it is going to be different. This time I am going to be with you. Well, not literally of course, but through these pages. And when we are done with our little virtual tour, you are going to know how to be there for yourself more than you have ever been before. So, take a breath and step inside the doctor’s office with me.
Most patients find going to a physician’s office very stressful but obviously necessary. Rule number one is to be on time even though your physician may not be (we will deal with doctor tardiness later). Calling to say you are stuck in traffic is courteous. Getting stuck more than once . . . not so courteous. Neither should you show up two hours early, thinking that you will get squeezed in and out more quickly. Office staff hate that. (Remember all the time they waste on insurance company issues? They also do not want to spend more time playing musical doctor appointments with the schedule.) Be clean and do not smell. I am not being humorous here. Doctors and medical practitioners are people, too. And they do not like spending a lot of time with people who smell! If you are a smoker, pop a breath mint; if you are a construction worker, put on some deodorant. This may sound trite or superficial, but the fact is, if you smell, you are much more likely to get a less-than-thorough examination, at least from me. Years ago, I cared for a retired New York City police sergeant. He did not like people and had decided to live in a dilapidated house, in the woods, which did not have hot water. But worse than that, he lived with thirty or forty cats. Jim was a good soul and could intelligently discuss his 401K and all of his investments. But there was no way I was going to go anywhere near him. I couldn’t get past my nose. Often he was sent home to find someone with a shower he could use before I would examine him. I also have a few chain smokers in my practice whose breath and overall odor were unbearable. I have had to send them off to the showers as well. I told one patient that he smelled so terrible he would have to go home and change. I didn’t promise you that these tips would be pleasant, but I do promise you that if you follow them you will increase your chances of better care. By the way, I am not implying that you smell, so please don’t take this personally.
Upon arrival, be smiling and cheerful even if you feel terrible. Treat everyone with kindness and respect. I know you are the client, you are the patient, you are paying their bills, and you should not have to do any of this. But all that really matters right now is that you don’t end up on the “life is too short list,” so that you can increase your chances of living a longer life! The fact is, no one likes a grumpy person and oftentimes doctors’ offices’ staff aren’t taking into account the fact that you are acting out because you feel terrible or afraid. They just see one more problem patient and start watching the clock, waiting to go home. What is worse, if you act really rude you may wind up at the end of the patient list instead of at your allotted time slot. Yeah, they could do that to you. Don’t give them a reason. It is not fair, it is not just. But it is the reality of it. One of my secretaries has a sign on her desk that states: “I can only please one person a day and today isn’t your day. Tomorrow doesn’t look to promising either.”
Upon arrival, this is the opportunity to inform the front office of any demographic (insurance, address, name) changes. Choose an office worker whom you know or one you can identify by name (name tag). If you are waiting a long time, quietly ask some fellow patients around you when their appointments were. And if your wait extends even further or you are running late for another appointment, kindly explain your situation to the receptionist. Rarely, your chart may have been placed out of order or misplaced. However, your long wait is probably because of the doctor. Above all, don’t take your anger out on the staff. It is the doctor who is usually keeping you waiting, not the staff. And the staff’s job is to protect the doctors so they can do their job. That is what the staff are being paid for. Let’s be honest, the doctor always wants to look good.
Finally, you are allowed into the inner office. You take a breath and, on your walk through the door, you reflect on your journey here: You fought lunch hour traffic, wolfed something down that only barely resembled food or skipped lunch altogether, you sped and rolled through a stop sign, risking a ticket and traffic school. And you did all of that so you could be kept waiting. The nerve! You are sick, you are angry, and that pretty woman with the blond hair sure didn’t have to wait long! Just keep breathing, and put all that aside. There is an old medical adage that says that you shouldn’t show your frustration to your neurosurgeon just before you are wheeled into the operating room for brain surgery. Similarly, try to refrain from complaining to your doctor about waiting too long. It is either part of his or her personality, or it is a symptom of the overburdened system. Either way, complaining won’t help you and could, possibly, lead to inattentiveness that could hurt you. If it is really a problem that the appointments are always late, make an issue of it after your appointment. And if it does not resolve itself or you find the doctor treating you with less than excellent care, maybe it is time to find a new doctor.
Right now you have to concentrate on your reason for being there. Doctors can be intimidating. We like to think we are in control most of the time (even though we really are not), but when it comes to medicine—one of the most important issues in our life—most people become almost totally dependent on someone else. I say almost because, unlike years ago, you are now going to take an active role in your health care. With this book as a guide, you will now Google your symptoms, research the doctor or hospital, and have an idea of what is wrong and what testing should be done.
But first you have to overcome your anxiety about the doctor and your medical problem. Having fear of suffering from a serious disease intimidates you and keeps you from properly communicating with your doctor. Your doctor, on the other hand, is probably thinking with a clear head but is very busy. Physicians have lots of pressure on them and must hone their skills of communication to obtain their fullest concentration, at least in a perfect medical world. The reality is that many physicians do not hone their communication skills and are not thinking about how your fear is preventing you from expressing your symptoms and needs clearly. That is where you come in. That is why you have to take control. If this were a dance, this is where you would take the lead.
In my first book, From Anecdote to Antidote, I tried to demystify the current doctor-patient relationship. Patients would place their physicians on a pedestal of awe. Now I certainly like being idolized and it does well for my ego. However, physicians are regular people who take out the garbage, go shopping, and certainly make mistakes, just as all of us do. There has to be an easing of the trepidation I see in my patients’ eyes as I consult with them for the first time. Putting me on a pedestal influences a patient’s behavior while we discuss such important things as their medical history, weight, allergies, past medical procedures, and so forth. I cannot tell you how many second opinions I have given, often in complete reversal of a previous doctor’s diagnosis, that could have been easily avoided if the patients had simply been more honest and less intimidated by their doctors during their initial consultation.
I can understand the sense of intimidation. Sometimes people feel uncomfortable or insecure around someone who may have had a more extensive education than they have. And, as in any human situation, there is the issue of “power.” Think of it: you are entrusting your health and well-being into the hands of someone who (in most cases) went to school for an additional eight years after college and regularly cut into corpses as practice for tending to your health care needs. On top of which, you are sitting there in his or her office, on his or her turf, in a paper dress, with your backside hanging out. You will hear this from me time and again, the old way of looking at your physician has to be replaced by the viewpoint of the new, empowered patient. Talking up to your doctor puts you at a disadvantage where you really should be talking to your physician as an equal. Yes, he or she went to medical school and deserves to be respected for his or her knowledge. But that is where it ends. You are part of the new “treating team.” You have to be empowered to look up everything and question, question, question your doctor. We make mistakes all of the time. My earlier book also dealt with doctors talking in “doctorese,” which I will discuss later. Another issue that threatens the lives of patients is fear. Fear of having a particular disease can oftentimes prevent patients from even seeing their doctors. There have been innumerable times, after examining a woman and finding a breast lump, I would ask if a patient knew there was a lump there. Most often the answer is yes, saying “I figured if you didn’t find the lump then nothing was wrong.”
The most important thing right now is being heard. You want to be able to communicate to your physician and have him or her listen to your complaints. Eye contact is very important. However, there should be some concern in your voice, which will get your doctor’s attention. Paying him or her a compliment doesn’t hurt either. There goes my ego.
It is the same ritual every three months. Michael comes in to see me quarterly for his multiple medical ailments. As I walk into his exam room, he presents me with a neatly typewritten note. On the top of the page are listed his medications and doses. Next are written any visits with other physicians, reasons for these visits, and the physicians’ recommendations. Then he lists the reasons for this day’s visit (check his blood pressure, any new symptoms or complaints, etc.) and a list of needed prescription refills. Since Michael works for the city, the last typed request is for a note proving that he was actually at the doctor’s office that day. In our complex, hectic medical world, this is perfection.
We then discuss everything on his list in a quick and orderly fashion. There is still time to talk about his job, our families, and world happenings. That is how streamlined an “office visit template” can—and should—be. And that is what I want you to do when you see your doctor.
I always encourage my patients to write lists similar to this template and then bring it with them! One important point, never wait until your doctor is leaving the room on his or her way to the next patient to ask an important question. Your doctor’s mindset is already finished with you and his or her thoughts are on the patient in the next room. That list that you so thoughtfully filled out and brought in should have covered that important question right up front. If you carry a PDA, BlackBerry, or whatever the latest planner/phone gadget is, you can keep it on there. I know I am starting to sound like a broken record, but being an active participant in one’s health care is essential for survival. Furthermore, if you anticipate that there will be serious or deep discussions regarding a serious illness, bring an advocate. Once a patient hears the words “you have cancer,” that patient will not hear another word for a while. Therefore, bringing a prepared advocate is important. Someone will have to be asking the right questions and writing down the answers. That surrogate will be calmer and perhaps he or she should bring a tape recorder as well as pencil and paper.
Just as important as being heard by your doctor is being proactive in the maintenance of your own health, which will also add strength to your voice. We are just as responsible as our physicians for our own health care, and so we must know as much as we can and must stay as informed as we can about the issues that relate to our health. You and only you are the best barometer of the goings-on in your own body. You know best when you feel normal and when you do not. But a doctor is almost always the best source of help if, and when, something does go wrong. And though our skills are many (if I do say so myself), we are not mind readers. We cannot just look at you and tell what you are thinking, what is bothering you, and what exactly is wrong. So you should never be afraid to ask your doctor a so-called stupid question, make a so-called dumb suggestion, or offer an observation that seems obvious. Do not hesitate to share any information that you have discovered, hunches you may have, or information you have heard about relevant health issues with your doctor. We, as physicians, certainly do not know everything.
As difficult as it is to suffer with a malady, or even the fear of one, it is more difficult to suffer in fear of the unknown. It is an unfortunate fact of life that disease happens. Fortunately, many diseases are curable if found early. If you take a positive approach to disease and are open with your doctor, you have a much higher chance of being one of the fortunate to be cured. You may or may not open the door—and your doctor’s eyes—to a new avenue of treatment, but you will demonstrate your own level of commitment to your own health (something doctors appreciate and welcome), and that will go a long way to livening up those dry, clinical conversations.
After you go over your list of complaints, expect to be put through the regular routine examination, having your vital signs checked (temperature, blood pressure, pulse, respiration rate, and weight). Make sure the technician or nurse actually measures all of these values, instead of just asking “How much do you weigh?” More than likely, there will be a significant difference between what you think you weigh and what the scale actually says.
I once testified against an orthopedic surgeon who missed a serious wound infection in a patient. One of the complaints was that he never took the patient’s temperature in all of the patient’s post-op office visits. How could he know if the patient had a fever if he did not measure for one? His defense was that his staff never kept a thermometer in the office because they never needed one. He was serious.
In training, we internists used to chuckle because all surgeons believed their patients never got infected. It is ironic because you have to sign a consent form for any surgery and near the top of the list of informed complications you will find the word infection. One of the common causes of medical malpractice is the lack of recognition that a serious underlying infection is present.2
Weight is one of the most important vital signs. Fluctuations can be a valuable diagnostic tool. Weight loss without being on a diet can suggest endocrine disorders (such as an overactive thyroid gland or diabetes), cancers, and more commonly, anxiety and stress. Unexplained weight gain could also suggest endocrine disorders, such as underactive thyroid, water retention, congestive heart failure, organ failure (kidney, liver), poor peripheral circulation, massive tumor growth (rare), and most commonly (and, interestingly, the hardest one to accept for some people) unknowingly eating and drinking more calories than one should. I always find it amusing when, after an extensive negative workup for weight gain, so many patients will deny that it was their fault. Your doctor should do as thorough a history as possible. More than 90 percent of diagnoses are made just by the story you tell and the facts drawn out of you by asking the right questions. Physicians are taught to use open-ended questions versus closed-ended questions. A closed-ended question, such as “You never had that happen in a car?”, is usually intimidating and often causes people to agree with the doctor, versus a more opened question, such as “Did it ever happen in a car?”, which allows people to offer their own response. “No, it never happened in a car” is easier for a patient to respond to because it does not challenge what the doctor is saying. I want you to always challenge your doctor and to always be prepared to question, yes, question and question again.
We are taught to do physical examinations by the organ system. Lungs belong to the respiratory system and therefore the respiratory system is examined apart from the gastrointestinal system. Similarly, the neurological examination is done separately from anything relating to cardiology. So the question you must ask is: Were all of the parts of your body that are involved in your complaint examined? If you had a sore throat, were your throat, ears, nose, thyroid, as well as the glands under your neck examined? If there were swollen glands, were the ones behind your ears, under your armpits, and in your groin examined? Presently, you may not know what body parts are involved in your particular complaints. That is understandable. You did not go to medical school. But that does not stop you from doing a little research online before going in. And it certainly does not stop you from asking your doctor: “What organs and functions are involved in (fill in your complaint)?” Then, you need to ask the doctor to check all those areas.
After the examination, your physician will usually (though not always) have your diagnosis and will suggest some testing to confirm or rule out possible diseases or disorders. It may be a simple urine test (no, you do not have to go home and study for a urine test), a complete blood count, or a scan of some kind. Once all the tests are in, the doctor (hopefully) will sit down, review his or her thinking, and go over all the testing results. If all you get are results mailed to you, you have a right to ask the doctor to give his or her overall analysis. You must have all results explained to you, whether they are normal or abnormal. If there was an x-ray, look at the report. Radiologists always cover themselves. Sometimes they will describe an abnormality, which is more likely normal, but they aren’t 100 percent certain. They may add, “I would suggest a further study” if there is suspicion. Similarly, certain blood values may suggest another disease is going on rather than the original one suggested by your doctor.
You are not a physician. So I am not suggesting that you try to diagnose yourself here. However, all studies show that the leading cause of medical malpractice resulting from negligence stems from a wrong initial diagnosis and the failure of the physician to change his or her mind, despite new facts that are contradictory.3 That means that, once again, the ball is really in your court. Make sure everything is explained to you. Use your logic, your common sense, and even your intuition to determine if what the doctor is telling you makes sense. If it does not, you have a right to a second opinion. Make sure to retain copies of all pertinent testing. You may need this if you talk to another doctor. As I have repeatedly said, doctors make mistakes. Your doctor may have been so busy that he or she subconsciously overlooked an abnormal blood result. The other day, Lisa, a long-standing and close patient, said “Doctor Klein, you said that my tests were normal, but there are two tests that the laboratory noted as abnormal!” Sure enough, my eyes must have glossed over her laboratory slip and failed to register that there were two abnormal liver tests. How unusual, but it proves the point that we, as physicians, make mistakes and sometimes we are not even aware that we do. Fortunately, it turned out to be a laboratory error, but I thanked Lisa and told her she had to continually question all of her doctors, including me. So it is worth repeating that the other lesson I want you to learn (in addition to my drilling in the point again and again about not being afraid to question your doctor) is that you learn from this experience and obtain copies of all tests and results for your own review.
So I subconsciously proved my point. Doctors are human and we all make mistakes. I say this not to let myself and my fellow colleagues off the hook, but to protect you, the patient, from the mistakes that can be made when you believe that your doctor is infallible—or, worse, when your doctor believes that he or she is! The fact is that doctors come to this partnership carrying their own baggage (sometimes an entire monogrammed set of Samsonite), and it is ultimately up to you, the patient, to determine if they are qualified and competent to help you. Are they knowledgeable or caring enough? Will they stay on top of your case? Do they create a safe environment where you feel comfortable sharing your deepest thoughts and concerns? Will they protect you, as the captain of the medical ship, from the often rough seas of the hospital environment?
In this complex mix of patients’ needs and fears, as well as those of physicians, there has to be a way for both to unite positively. And that, finally, is the true aim of this chapter: to begin a dialogue that will help you and your doctor create a powerful partnership for achieving optimal health. Your physician must be able to hear you, understand you, and use all of your cues to come up with a fitting and effective diagnosis and a treatment plan. But you, the patient, are not along for a free ride. As it is the physician’s role to cure, it is the modern patient’s role to be an active participant. You are empowered to protect yourself and always be on the alert for mistakes. But you must be on a quest to know all there is to know about your illness and your options. You are not a passenger, but the copilot, along with your doctor, on this flight toward total well-being. It is not always a smooth ride. There will likely be some choppy weather and turbulence, and you may even get off the flight course at times. But as long as you and your doctor continue to navigate together, you will make the necessary course corrections to keep on track toward your destination, and hopefully, and happily guide you to that safe landing of true and lasting health.
The National Data Bank and State Professional Licensing Bureau can usually tell you how many malpractice cases your prospective physician has been involved in, although most cases of office malpractice are never made known and therefore do not become part of the statistics. The feeling among most analysts is that many malpractice cases either begin or are limited to your physician’s office (this is estimated at 36 percent).4 That is, the PCP develops a diagnosis and treatment plan, which, if wrong, may lead to the patient winding up in the hospital for a procedure or operation (and the inherent complications) for the wrong reason. Or the patient may undergo some form of malpractice but never know that a mistake was made.
As an example of the latter, a patient may receive the wrong treatment and worsen or may receive a medication that he or she is allergic to, but the doctor has forgotten about the allergy. It is easy to blame the “worsening” on the disease (“Your infection really got worse and there was nothing I could have done. Thank goodness I came up with a better medicine!”). You may have been given antibiotics that would hide a serious underlying infection, making it difficult to diagnose and properly treat. But you survived, even though it took weeks or months to get over the “virus.”
A Soft Belly and a Hard Head
Recently, my head nurse’s 20-year-old daughter developed some lower abdominal pain, which necessitated a local emergency room visit. The girl had fever, abdominal pain, and some tenderness in the lowest point of her abdomen, on the right side. Her abdominal examination showed a soft abdomen (usually not a sign of a serious illness, unless she had taken a narcotic). The on-call surgeon rightly ordered a blood count, blood screen, and a CT scan of the abdomen. The CT scan showed a normal gall bladder, normal organs, and no acute process. The tip of the appendix was not viewable, but there were no signs of any rupture of any organ, including the appendix. The patient’s white blood count was low normal at 3,000. But during the twelve hours of her illness, a lymph node enlarged on her neck. That prompted the physician to do a mononucleosis test. When this test also returned normal, the surgeon told the family that surgery was necessary as it probably was a diseased appendix that could not be visualized because of some technical problem. In other words, exploratory surgery. You know, get under the hood, kick a few tires around, and see if it springs a leak.
Don’t get me wrong. Sometimes, after every option has been exhausted and the patient is still suffering, exploratory surgery is a legitimate next step. But let’s look at this a little closer. Was every option explored first? Was this examination truly thorough or was there some other agenda here besides giving the patient the best care possible? All hidden motives aside, there was more to the story that was not being accounted for. For one thing, the patient was in the middle of her menstrual cycle. This significant fact was not sought out by any of the treating physicians. Furthermore, information that was withheld from the family, who now had to make a decision regarding surgery, was that the CT scan showed fluid in the cul-de-sac, an area surrounding the ovaries.
The surgeon should have told the family about this, as it is very suggestive of a ruptured ovarian follicle, common to women, especially during the middle of their menstrual cycle (we call that middle schmertz). The fact that this was withheld from the review process (it was clearly written on the x-ray slip) suggests that the surgeon either did not read that portion or ignored it because it differed from what he had already concluded in his mind. No explanation was given for a normal or low white count, which is usually counter to an acute infectious process, such as appendicitis (low white counts can occur in seriously infected very young children and very old people). The patient was 20 and did not exhibit signs of an overwhelming infection. The final pathology report of the appendix was that it was normal. The swollen lymph gland turned out to be a concomitant mononucleosis infection. And the physicians did not even inform the family that quite often the mono test will be negative for up to two to three weeks. The final diagnosis: The patient actually ruptured an ovarian follicle, the evidence of which was right there on the x-ray.
There were plenty of signs that indicated it was not appendicitis, and plenty of signs that is was, indeed, something else. But once the doctor had made up his mind, a cognitive blind spot occurred that made it difficult for him to see anything else. Either that or he just did not care enough to take the time to make an accurate diagnosis. I am giving him the benefit of the doubt on this one. But when your health or that of a loved one is on the line, you cannot be so generous. You must be the final say. You must become informed, review all the reasoning offered by the physician, go over every lab or x-ray value (normal or not), and get a second opinion, if needed, before making the final decision. The doctors have a lot of other things on their minds—other patients, other problems. You must, therefore, have only one thing on your mind—getting the best diagnosis and treatment you possibly can.
Just in case you are not yet convinced of your need to take charge of your medical evaluation when you make an office visit and are not sufficiently fired up so that you never forget it, let me cite a few more examples.
Give Me a Double Vision with a Twist of Lyme
I recently reviewed a medical malpractice case of a young man who developed double vision and was sent to a leading neuro-ophthalmologist for care and treatment. Although the patient had a febrile illness two months previously (in the middle of the summer in Lyme-infested Westchester County), neither the PCP nor the specialist thought to test for this curable disease. They actually did not look for any cause of this acute nerve palsy. The patient went on from one neurological complication to another, ultimately developing Lyme arthritis.
Old World Loyalty Has to Go
My wife’s grandmother, Ruth, developed fevers and swelling around her recently replaced artificial knee following a fall. Her local small town orthopedist guessed, correctly, that she suffered with a knee infection and immediately started her on intravenous antibiotics. The treatment lasted six weeks, which was appropriate. What was not appropriate? You know the answer. It was the fact that the doctor never did any culturing; he believed the infecting organism was due to a particular bacteria and that is what he treated her for. When her fever returned after the six weeks of treatment, his treatment was to repeat the same antibiotic again and again.
Trying to gently encourage an elderly patient to get another opinion is extremely difficult, if not impossible. Ruth lived in this small community for years and was loyal to her physicians. As far as she was concerned, they could do no wrong (if only she had read the previous anecdotes). The family knew things were amiss, but nobody could convince Grandmother. After four months of the same see-saw regimen with no hope in sight, Ruth finally gave in. She was transferred to an orthopedic hospital where all antibiotics were stopped for two weeks. Cultures were then obtained, which revealed the real culprit, which was obviously quite different from that assumed by her community physician. The infection was finally eradicated and Ruth can walk and dance once more. Stubborn loyalty to a physician, who was stubborn himself (as well as unknowledgeable) for not getting his head out of the sand, led to an unnecessary four months of suffering.
Just a Stroke of Bad Luck?
I testified at a malpractice case that involved a middle-age patient who had undergone a prostate biopsy. Three days later he was in his internist’s office for his blood pressure check and he informed his physician that he had some chills and a low grade fever. The physician examined the patient’s urine with a dip stick test (a stick of chemicals that change colors if there are abnormalities). Sure enough, the indicator for microscopic blood lit up (there is almost always microscopic bleeding after a prostate biopsy), but without a positive indication of white blood cells (the cells that arrive, like the cavalry, to fight infection) and without sending the urine for a culture to prove if there was an infection.
The physician gave the patient an oral antibiotic. Sure enough, the patient felt better; however, when the antibiotic ran out, the fever returned. The physician reordered the antibiotic, not once, but twice more. Each time no urine was taken and no culture was obtained. The physician had made up his mind once, without any proof, that the patient had a urine infection and never took his head out of the sand. The patient really had endocarditis, an infection of the heart valve, which occurred at the time of the original biopsy. The bacteria invaded the patient’s valve and stayed there, chewing and chewing away. Only when the oral antibiotic was given did the bacteria take a temporary break. Oral antibiotics are sufficient to cure ordinary urinary infections but do not attain high enough blood levels to cure a heart valve infection. And after two months of this ill-advised treatment based on a lazy diagnosis, the patient was found on the floor of his home, having suffered a major irreversible stroke (a piece of the infection from his diseased valve broke off and clogged a cerebral artery).
An improper diagnosis in a physician’s office led to an improper treatment. And the physician never gave a thought to the possibility that there might have been something else wrong.
The Patient Brush-Off
Another case involved a woman who had a simple cyst removed from her finger at her dermatologist’s office. She was properly advised of the possible complications (bleeding, infection, recurrence) and home she went. Two days later, she presented to her dermatologist’s office with swelling and pain. The physician’s assistant, who covered the office when the physician was out or too busy, injected her finger with cortisone (for whatever reason). Over the next two weeks, the finger swelled more and the redness worsened. The dermatologist tried reassuring the woman that it was just some local reaction to surgery. An emergency room physician (where she went after the third week) started her on oral antibiotics and suggested she see her PCP. Two days later, she had an appointment, was told she possibly had a deep infection, and was sent for an orthopedic appointment (rather than having tests done for the deeper infection).
Four days later she was seen by the orthopedist, who did an x-ray, which he read as negative for osteomyelitis (the deeper infection). He continued the oral antibiotics, which hadn’t worked over the past six or seven days. The patient was now four to five weeks into her infection, and a proper diagnosis and treatment had not yet been arrived at. She went another two weeks before the proper test, an MRI, was done which found the osteomyelitis. The longer the delay there is in the treatment of a disease, the poorer the outcome. This is especially true in the field of infectious diseases. The infection could have spread to this woman’s heart or to her brain. The worst that happened—pain, suffering, and deformity—were bad enough. It is interesting that the dermatologist had her sign a piece of paper warning about some of the consequences of the surgery (infection being one of them), but he never thought of that himself in her diagnosis. Perhaps one of the best suggestions one can give a doctor is to read his own paperwork!
What We’ve Got Here Is a Failure
to Communicate
A common form of medical malpractice that occurs in physicians’ offices is failure to communicate. Frequently, test results arrive and the office or the physician does not communicate them to the patient in a timely manner.5 One case I testified at involved a nurse who felt ill and, after her examination by her physician, she asked for a Lyme test. The test proved positive, but the physician never acknowledged the results. In fact, the woman was seen two or three times by her physician over the next few months, complaining of joint pains and ultimately, joint swelling. She subsequently went to a rheumatologist who ordered another Lyme test. This new test was positive for the old Lyme disease and, after checking with the laboratory (he was in the same multispecialty group as the woman’s internist), he found the old acutely positive Lyme test of five months earlier. Unfortunately, for the patient, she was to suffer for a few more years before all of her symptoms would dissipate.
As I mentioned earlier with my own patient Lisa, this is a common circumstance. Doctors are busy. Yes, we are usually attentive, however we review thirty or forty sets of test results a day (laboratory, x-ray, electrocardiograms, MRI), and can easily overlook an abnormal result. Adding to this dilemma of worsening good care is the assumption by patients that their tests were normal because their physician did not call to tell them different. It is never a good idea to assume a test is normal just because your doctor did not call. What if the laboratory lost the specimen and, therefore, the doctor never received the results? What if the clerk filed the results away without the doctor reviewing them? What if, as in my case, the doctor saw the results but because of inattentiveness, the results did not “register”? Patients must be empowered to be their own advocates. Did you ask the doctor for the results? Did you get a copy and see the results for yourself?
In this case of Lyme disease (it is Lyme and not Lymes), the symptoms, as in many other diseases, can initially disappear as the body’s first line of defense stalls the bacterial invasion. Weeks to months later, the secondary and tertiary complications set in and that is when trouble will rear its ugly head.
Doctors’ Dirty Little Secrets
A recent in-depth interview with 53 family physicians revealed that 47 percent of the doctors (nearly half) had a case where a patient died due to physician error.6 Only four of these cases led to a malpractice suit. That is, approximately 10 percent were sued. An editorial article in the New York Times summarized a study reported in the Archives of Internal Medicine. In it, 2,600 doctors in the United States and Canada confirmed that they were less likely to admit a serious mistake if they thought they could get away with it. Ninety-eight percent of the doctors endorsed the need to disclose any serious error to the patient, but only half of the doctors would actually use the word “error.” It was found that many of the doctors would only admit to a mistake if the mistake became overtly obvious (a sponge left in after surgery, requiring another operation). If the error was too subtle for most patients to recognize, most of the doctors would not admit an error had been made. The researchers suggested that placing limits on malpractice claims would not have any impact on what doctors admitted.7
A colleague of mine admitted to destroying a cardiogram that he misread when finding out that the patient went to the hospital that same night and died of a heart attack. The cardiogram had been grossly abnormal and the physician did not really study it well. Had he seen the abnormal changes, the patient would not have died. The tainted evidence was easily destroyed without a trace of culpability. Usually most office malpractice errors will not have a bad outcome, and most cases will never be known to the patients. If the error causes the patient to be admitted to the hospital, then the outcomes seriously worsen.8
One case of such doctor denial that I sat through was that of Mrs. Mercer. She had gone upstate New York to visit friends in a town called Hyde Park, about a two-hour car ride north of New York City. Two weeks later, she sought medical advice when she developed a flulike illness (fever, malaise, and chills). When she was examined, she pointed out a rash behind her right knee. Her physician told her it was a virus and that she should take aspirin and fluids. Three days later, she called complaining of no improvement. Her physician was off but, for some unknown reason, she did not speak to either of his partners. Two days later, she was feeling weak and had a mild fever. She now had many large blotches of redness (a rash) over her body and was seen again by her physician. She again told him of her trip to upstate New York (where Lyme disease is prevalent). “No, this is not the classic rash of Lyme disease but I don’t know what it is,” the doctor said. He made an appointment with a dermatologist for two days later. The visit was too late. She awoke the next day with Bell’s palsy (the drooping of one side of her face). After the dermatologist diagnosed correctly that she did have Lyme disease, she was sent to a well-known neurologist. This prominent physician proceeded to put her on oral antibiotics instead of intravenous antibiotics, which is the recommended treatment for neurological complications (if the doctor had just used Google, he would have discovered that! Forget the fact that, as a neurologist, he should have known!). This is another reason why you, the patient, should use that ubiquitous search tool Google. (Of course, not everything you find will be true or accurate, but the corroboration of multiple sources of information will certainly make you a more informed patient.) Remember Sy Simms’s motto.
We know the patient saw her physician in a timely manner, and we know that the patient came down with oftentimes reversible paralysis of half of her face. But you must also know that the physician will, to his last breath, deny any culpability. He will hire the fanciest lawyer and pay thousands of dollars in fees to argue that it was not his fault. His reasoning will be that the rash was not classic—many people travel upstate and do not come back with Lyme disease. Forget the fact that New York, and most of the surrounding states, are well known for Lyme disease. Forget the fact that the area north of New York City is the epicenter for this disease in the northeast. A lesson I teach my medical students is that anyone who has the summer flu with fever has Lyme disease until proven otherwise. And Lyme can present as any type of rash, not just as the classic bull’s-eye that one reads about. Any practicing physician in that area worth his or her license should know and consider that. I like to remind my colleagues about my alma mater, the University of Rome. Near the ancient campus compound, there is a large and impressive building to the immediate right. It bears the name The Institute for Syphilis and Dermatology. Interesting combination, no? What could the link possibly be between dermatology and history’s most famous venereal disease? The pairing cracks open the door to any number of jokes, but the fact that it is carved above the entrance to a departmental building at one of the oldest institutions of higher learning in the Western world leaves many scratching their heads.
Before the antibiotic era, when syphilis was rampant, the rashes caused by this disease were plentiful and diverse beyond the initial skin ulcerations in the genital area. Therefore, the presentation of any rash or skin lesion always contained syphilis as part of the differential diagnosis: it was so prevalent that it deserved equal billing with dermatology. To get to the point, both syphilis and Lyme are caused by a similar bacteria, a spirochete, which can show itself by many different types of rashes.
But more important, why did the doctor have to deny that he obviously made a mistake (especially when it is so obvious)? Is it the unwillingness to believe that he is capable of making a mistake or not wanting to have an “insurance” record of mistakes? Either way, it is a flaw in the system that consistently leads to errors and omissions, which leads to a lack of understanding, and, ultimately, the wisdom that could prevent the problems in the future. This, of course, means more people get sicker and even die—unnecessarily.
The fact is, Mrs. Mercer got sick and developed complications on his watch. He did not cause the disease, but he failed to recognize it. He made a mistake in diagnosis. That happens all the time and doctors must have the courage to admit it instead of fearing that they won’t be covered by malpractice insurance. Furthermore, insurance companies should allow doctors to admit errors. As it now stands, if a doctor admits an error, his malpractice insurer can drop the case and not be responsible for any damages. It states this on the malpractice contracts we sign.9 Many malpractice educational programs, participation in which is encouraged by these malpractice insurance companies, are now suggesting that perhaps we could tell patients if we make a mistake. But the insurance companies still make you sign the waiver that you cannot. The insurer would have difficulty defending a case when the doctor admitted responsibility. Even the greatest of lawyers have difficulty defending against a confession. Nobody should deny compensation to an injured patient if the injury was caused by malpractice. But that is the way our present system works. Do not admit to wrong doing. There may be some lawyer who can prove it was not your fault that you cut off the wrong foot. If we are not allowed to admit guilt, the system will remain broken and will eventually collapse under the weight of its own burden.
Most cases I see are just like that. The doctor sees the patient, makes the wrong diagnosis, the patient develops a complication from the mistaken diagnosis, the patient goes to court, and the insurance carrier denies his or her part. Earlier, I mentioned the case of a woman who developed osteomyelitis after her dermatologist operated on her finger. The patient originally had a cyst. The dermatologist performed three procedures on the cyst and the patient went on to develop a deep-seated bone infection. In court, the physician denied he did anything to cause the infection. I sat there in disbelief. It is bad enough that a patient is harmed by a mistake. But to watch the person you trusted with your health sit there and downright lie
. . . it is a form of violation that ranks up there. Ultimately, the doctor’s defense attorney sufficiently twisted things out of context, confused the jury with bells and whistles, and the patient lost her case because the doctor had a better, perhaps higher-paid, lawyer.
Doctors not only lie to you, the patient, they lie to other physicians, thinking that they can get away with it. A patient of mine was having a benign growth removed from her ovary and underwent gynecological surgery at a nearby hospital (at which I do not attend and therefore did not know the gynecologist). One week later, the patient’s mom called me in hysteria that her daughter had been in the intensive care unit of the hospital, near death, for the past five days. I got the doctor’s name and called him. “Oh,” he said, “the surgery went fine but two days later she had a diverticula (out pouching of the large intestine) perforate and she developed acute peritonitis, which we didn’t pick up for a day or so. So they had to go in a second time to remove the diseased intestine.” Now that is the kind of stuff that is outlandish. What are the odds of somebody having a ruptured intestine a day or so after surgery? Seems that something was being hidden and you can guess along with me that perhaps the gynecologist did something wrong. So I called the pathology department at that hospital and explained that I was her physician. He kindly sent me the pathology report on the “diseased” intestine, which had a laceration through it and not a ruptured diverticula. Thankfully the hospital has to examine and save the surgical specimen. The gynecologist perforated the intestine while doing his surgery and tried to absolve himself from blame. It will be interesting if he stated the ruptured diverticula as the cause in his medical records. This would be contrary to the pathology report, and would have made for a nice medical malpractice case.
The majority of office medical injuries, however, do not directly lead to death and maiming, because there are very few life-threatening invasive procedures done in private offices. Bad outcomes of “missed” diagnoses in offices usually end up in the hospital. Here, statistics show, for every six medical injuries occurring, one patient will die.10
However, the overall incidence of medical malpractice in offices is much higher than estimated.11 Unlike hospital records, private office records are more easily altered. Laboratory and x-ray records can be easily destroyed. Hospital records are usually unalterable and malpractice more easily traceable. I testified at a case two years ago where a state agency was asked to look into the unexpected death of an inpatient. The state copied the records for review, unbeknownst to the treating physician. Usually, if a patient, lawyer, or the patient’s family requests copies of hospital records, the treating physician is notified as a courtesy. In this instance, no one was notified when the state agency copied the records. When the case went to court, the doctor’s hospital records were different from the original records. This was picked up by the state’s lawyer, who noted the “doctored” physician’s progress notes, obviously rewritten to hide any misconduct. It usually is quite difficult to change hospital records, and although the doctor almost got away with it, justice prevailed and he lost his medical license.
Most physicians mean well and are not evil. The negative climate of malpractice, as it is seen today, can cause physicians to lie or cheat. The hope is that we can change everyone’s outlook and be able to acknowledge that we, physicians, are not perfect and admit our errors. Obviously, the goal is not to have a country full of error-admitting physicians. The aim is to lower the error rate. Not only will this change in attitude strengthen the bond between patient and physician, but it will also help prevent future errors and accidents. The bottom line is that you, the patient, deserve an explicit acknowledgment of error, information about why it happened and, at the very least, an apology.
Changes in medical education and encouraging disclosure would help. Furthermore, computerized systems to detect errors are needed that would otherwise remain unnoticed and help lead to eradication of these errors. There has to be a national registry where all of these errors and mistakes are computerized and analyzed. Physicians and hospitals would report errors without fear of being punished. Nor would the reporting physicians’ or hospitals’ names be made known to the public. The errors should be publicized so that the consumers can also know what to look for. The results would be for teaching and learning how to avoid the same pitfalls, thereby cutting down on the amount of errors.
I have a patient who is a surgeon and his operating infection rate was quadruple all other surgeons at his hospital for the same procedures. This was a fact that was not known by the public at large nor by most of his referring physicians. The hospital had not approached him or tried to evaluate his technique. This makes no sense. When he informed me recently of this high rate of infection, which had been going on for years, I sent him for skin cultures. Sure enough, the surgeon had many unusual bacteria growing on his skin. The problem was identified and the cure was in showering twice daily with hexachlorophene soap. His infection rate is now the same as his peers.
Of a list of surgical adverse reactions, infection is one of the highest acceptable complications. This will be dealt with in Chapter 13. However, if theoretically the average surgical risk were 5 percent for a gallbladder removal (a number I just made up) and a particular surgeon has an infection rate of 30 percent, that is not acceptable. That is malpractice. Even today some juries in malpractice cases are not allowed to know what the surgeon’s infection rate is, compared to acceptable standards, or his or her prior malpractice history. Surgical infections are usually not caused by multiple rare bacterial colonizations on the skin (such as the general surgeon I mentioned). First and foremost, in 99 percent of clean surgeries, the infection is put into the surgical site at the time of surgery. Once the wound is closed, you can sprinkle bacteria over the wound and they would not be able to get into this sealed environment. A gunshot wound to the abdomen is dirty surgery as compared to a clean, elective gallbladder removal. At the time of surgery, the introduced bacteria arise from the failure of properly sterilizing the environment. There is a break in sterile technique, and it is usually the patient’s own bacteria, which was not properly cleansed, that is introduced into the wound. That is, the patient’s skin was not cleansed properly. To further complicate things, if a patient has an infection on some other part of his or her body, there will be a good chance that the same bacteria will wind up in the wound. Other than not cleansing the patient adequately, bacteria can come from many other sources, such as the surgeon, surgical assistant, infected instruments, and so forth. I would take it with a grain of salt if a surgeon tells you that the bacteria got into the wound two days later because you scratched yourself or because the wound got wet. Remember, as residents in training we used to kid about how surgeons never ever believe that they are the cause of a surgical wound infection. Even though they make you sign a piece of paper stating it isn’t so, that could be one of the complications. They or someone in the operating room are usually the cause.
I had not spoken with my friend Hal in years and he called recently to wish me a happy New Year. Then he proceeded to tell me about his terrible back surgery and its many complications. He told me that he had lumbar surgery for a herniated disc. Two weeks later, he was back in the hospital with a terrible wound infection, causing him ultimately to come down with meningitis. The infection had spread into his spinal cord, because it was in the nearby disc space. His surgeon told him later that it, the infection, probably was because he had a shower two weeks after surgery. How disingenuous of the surgeon. It is true, no one wants to admit responsibility and get sued. But the surgeon knows, just as I know, that the infection is almost always put in the wound at the time of the original surgery.
The American Society of Anesthesiology did an in-depth analysis of the most common types of errors performed by sending questionnaires to their members. By statistically studying surveys of thousands of anesthesiologists, a set of guidelines was developed. The result: the nationwide error rate for this group was decreased by 50 percent.12 In other words, bringing awareness to this problem and holding people accountable help to eradicate the problem. And that saves lives.
I further propose that patients should have access to a physicians “report card” (not from information supplied to the National Registry). The report would consist of the amount of malpractice claims and losses and the physician’s infection or complication rates. Poor grades would require extra training. In the meantime, you can take steps to create a report card of your own. While you may not be able to obtain all the necessary information to create a complete picture of your doctor’s grade level, with a few phone calls, some Googling, and a bit of sleuthing you can begin to get a much more accurate sense of who you are dealing with. And as more patients take this kind of control, more doctors will stop taking their positions for granted and take their practice to the next level.
Remember, statistics show that 5 percent of our practicing physicians are responsible for 50 percent of malpractice payments.13 Until now nothing has been done to this 5 percent. Should they be identified and legally forced to be retrained? Should they have to practice under the guidance of another physician? Nothing has been done to improve their abilities. These physicians are still practicing, without any sanctions by their respective state licensing authorities. I am presently preparing to testify against a physician who had lost her license five years ago, for a period of three years. Her offense was treating dozens of patients for a disease they did not have, not diagnosing them with the proper disease, and using all sorts of witchcraft and bogus injections that would not work on any infection. She told all of these adult patients that they were suffering with chronic mononucleosis. Now that is a diagnosis that can be proved by doing the appropriate testing. All of the tests that this physician performed were negative for chronic mononucleosis (that is they failed to prove the existence of this infection). She gave these patients injections of gamma globulin and vitamin B12, as well as a host of other medications. She treated them all for years and years, carrying this diagnosis, when in actuality they suffered from serious, life-threatening diseases (one patient had leukemia). Yes, the physician deserved to lose her license, but she came back. You cannot teach a leopard to lose its spots, and similarly this physician went on to practice the same medicine as before. She started treating patients again for chronic mononucleosis, despite the lack of laboratory confirmation. Unfortunately, there was one woman who complained of back pain, which progressed and progressed. Of course this physician told her that it was because of the chronic mononucleosis. To get to the point, at the end of eight months of suffering, the patient wound up in an emergency room, where an x-ray, yes an x-ray, was finally taken which showed that the patient had bone cancer that had spread from her lungs. The family of this now deceased woman is suing the physician, who never should have been allowed back into medicine or, at the very least, should have been closely monitored by the state authorities. I have to reiterate, mistakes can be and are made by any physician.
Unlike years ago when the local doctor was godlike, today we as patients must question everyone and everything. We know that millions of errors occur yearly. We must do whatever we can to make sure we are not the victims of one. As more patients begin taking an active role in their health care, asking questions, pointing out problems when they suspect medical malpractice, and raising their voices to their political representatives, the momentum this will create will lead to real change.
As a final note on the subject of system changes, to better aid caring for patients, physicians should initiate online record keeping. This would allow records to be available, online, in real time. These records would be set up to prevent deletion, although new information could be subsequently added, and the records could be viewed by health care workers anywhere in the world (obviously, with proper permission). Patients’ electrocardiograms, laboratory data, x-rays, and other information would be available for review in real time if a patient were ill at a different location. Think of the benefits of such a system. Two patients within the past two months had symptoms suggestive of heart disease. Each had separately had a stress test at their previous cardiologist’s offices, which I had been unaware of. Remember, just like Michael, who informs me if he went to another physician and if a test had been done, he would produce a copy of the test and the results; you must do the same. The cardiologists failed to send me the results and the patients never told me, their primary care physician, that tests had been done. Getting copies of these tests is important for the PCP so he or she can review them as well. In these two cases, the patients were told that their tests were normal, but they were not. They were both walking around with cardiac time bombs, thinking themselves healthy, when the truth lay in reviewing of the tests. Both went on to cardiac catheterization and both are now healthy. I will discuss this in detail in Chapter 7. Until online record keeping exists, one thing you can do is at least keep copies of all pertinent test results and diagnoses. Perhaps it could be kept on a small thumbnail drive that you could travel with, in case of medical emergencies. Or perhaps it could be put on a personal, password-protected Web page. The point is, there are options. Despite the flaws in the system, there are many things you can do to prevent becoming a victim of it. If you get nothing else from this, my hope is that you accept that premise and begin to operate from it in your future interactions with the medical industry.
Most motor vehicle accidents occur within a few miles of one’s home or physician. That’s one argument for not going to your doctor. But let me give you a few more facts that will better prepare you for that medical experience that might be around the corner.
Importance of Updating Your Address
Alice was a baggage handler for a major airline and sought relief from a flulike illness in June 1999. Her physician smartly drew a blood specimen for Lyme disease. The following week, the test was reported as positive but for some reason did not arrive on the proper physician’s desk for another two weeks. The nurse placed phone calls, but the line was disconnected and they could not get in touch with the patient. It turns out Alice had moved months before and had never given her new forwarding telephone number or mailing address.
The physician, in her examination before trial (EBT), claimed that a letter was sent to Alice but was returned because of a lack of a forwarding address. The only proof of this was a copy of the letter and not its envelope. As is usually the case, acute Lyme disease is self-limiting and Alice seemingly got over her illness naturally. She therefore did not bother calling for any blood test results. Four or five months later, however, Alice started experiencing severe arthritic complaints with major swelling and disability of her left knee. When she went back to her physician, she discovered she had had Lyme all that time, which had gone untreated.
She was now experiencing the complications of secondary Lyme disease, Lyme arthritis. The physician prescribed oral antibiotics for one month. During this period, Alice’s condition worsened. She lost weight as well as strength. Her mental cognitive functions diminished and, needless to say, her arthritis worsened. At the end of the month, Alice went on disability because she could not lift bags anymore. She was sent to an infectious disease expert and finally started on the proper course of intravenous antibiotics. Acute Lyme is successfully treated with oral antibiotics. However, the sequelae (complications such as arthritis) should be treated intravenously. After all of these examples, you will unlikely forget that treatment.
Alice sued her physician because of a delay in notifying her, thereby allowing her disease to worsen. There was a three-week period where the doctor should have received the blood results. That wasn’t the doctor’s fault, but certainly not within the standards expected in our community. Telephoning the patient was an attempt, but sending a registered letter would have been more in keeping with proper notification, as there usually is a forwarding address. At least a registered letter would have given proof that an attempt was made.
I testified in this case two years after the malpractice suit was instituted. Reviewing her chart two years later, I found her work number at the airline listed under the place of business section. Two years after she had stopped working, the airline number (her place of business) had not been changed. Alice could have been notified because she was first seen while she was fully employed. Furthermore, the office had kept a copy of her copay check from the original office visit when her blood was taken for Lyme as part of her record. The check had her new address on it. My testimony dealt with what would have happened to Alice if there had not been a delay in treatment (in this case there was by a delay in notification). Obviously, by treating her in a timely and proper fashion, she would have been cured. Unfortunately, Alice was treated from the start with the wrong modality: she should have received intravenous and not oral antibiotics.
But the real issue here is not the mistake the doctor’s office made after the delay in communication; the lesson here is that all of this could have been avoided by Alice. Had she called for her blood results, rather than just assuming that, since she was feeling better, the doctor would have called her if something was wrong, her years of suffering and heartache would have been avoided entirely. Don’t get me wrong, I’m not siding with the doctor. In fact, I found in favor of the plaintiff. What I am saying is that the ball really was in her court. And that is the message I want you to take away. Yes, the doctor made mistakes. So what! That will offer you little comfort when you or a loved one suffers irreversible complications from an event that you could have prevented by making a simple phone call for test results or making sure the doctor had your correct contact information.
Picking the Right Doctor
After choosing the right insurance company, choosing the right doctor is the most important step in protecting yourself from medical injury. Doctors are ranked in their medical school class. That ranking, however, may not hold true as to the quality of physician one ultimately becomes. For example, they were not graded on empathy, caring, and inquisitiveness. Neither were they graded on fact finding or solving the ultimate puzzle. Once fully matured, physicians attain a new ranking, which has nothing to do with prior grades. Nevertheless, most medical mistakes are made by a handful of less-than-excellent doctors. Statistically speaking, 5 percent of practicing physicians cause 50 percent of all malpractice hospital deaths. Again, yes, mistakes can be, and are, made by most physicians at some time in their careers.
There are many other factors that lead to bad physicians (or bad practice habits):
• Being overworked
• Being unhappy at home
• Personal and mental problems (which worsen as one ages)
• Political and peer pressure from hospitals
• Insurance companies (which compare the amounts of testing and use of specialists to similar physicians in the area, or the amount of CT scans or other test ordered)
Referrals from neighbors and patients may tell you how concerned and sincere your next physician is; however, they won’t really tell you about his or her medical abilities. Only other physicians have knowledge and insights into the quality of care practiced by other physicians. So if you want to know who is a good doctor, ask another doctor whom they would see if they were sick.
My son Brian was away at college when he called one evening to say he had been ill for the past day and got worse that afternoon, losing his appetite for those delicious homemade cookies he received. Now that is an admission of being ill! He had gone to the student health center, but it was now closed at 5 p.m. His next stop was the local emergency room. And by the time I flew to his college in Syracuse, New York, he was already under anesthesia and under the knife, having his diseased appendix removed by the on-call surgeon.
Who knew how good that surgeon was? Fortunately, Brian did just fine. But the experience taught me a strong lesson. From then on, any time a family member was going to be gone for an extended period (school, work), I called the local hospitals and spoke with the chiefs of service. I obtained names of internists and surgeons who they thought were good. I then requested that my children make “well” appointments with the internists, becoming an official patient. This way, a good physician, or his or her covering staff, would be in charge in case of an emergency. This is a proactive practice I strongly encourage you to adopt.
Physician recommendation is very important. Hospital affiliation is also up there and will be discussed later. Great physicians still make medical errors and we must still, therefore, be vigilant and active participants in our own care. The likelihood, however, is usually a lot less for a doctor with a proven track record of excellent care. Bottom line, it is a numbers game. And doing this kind of due diligence before there is a medical crisis will increase your odds of receiving better care.
How Not to Pick the Right Doctor
I recently saw a gentleman as an infectious disease consultation for swelling and cellulites of his face. Unfortunately, Pat had been in and out of the hospital for short bouts of intravenous antibiotics (two days each, separated by two days). He had no improvement in his infection. The point is not to stress the importance of continuous intravenous therapy, rather than an intravenous treatment here and there. The real problem was when I called the infectious disease specialist caring for him. It turned out he was someone I had known thirty years ago and had not seen since. “Oh, that guy is a real pain,” the specialist told me. “He Googles everything and asks too many questions.” Let me make no bones about it—that physician turned out to be a real jerk. He represented the antithesis of this book. He was not open or willing to participate in collaboration with his patient. As a result, no one made the proper diagnosis. Perhaps this lack of success, and the resulting bruise to his ego, compelled this doctor to devalue this patient’s input. After all, it was either that or admit that he was in error. Or maybe it was the fact that the patient left him for another doctor—me. Sadly, this type of arrogance even goes so far as to blame the patient for not getting better. “I never had a patient that didn’t get better with what you have,” the doctor might say, in an effort to alleviate all responsibility from himself. “You must have done something,” he will add. “Did you wet it? Did you dry it?”
Question, Question, Question!
Then there was the doctor who admitted his patient into the hospital suffering from anemia and having chest pains. Acutely anemic patients can exhibit cardiac symptoms (especially if elderly), as the lowered hemoglobin (red blood cells) carries less oxygen than is needed. People with underlying heart disease already have a “strain” on their oxygen supply because of blockage of the flow of blood to the coronary arteries (which feed the heart muscle). Rather than doing a rectal examination to see whether the anemia was due to gastrointestinal bleeding (which is a major cause of acute anemia) and which is standard protocol, the physician ordered stool cards to be sent to the laboratory. This test takes a few days whereas the rectal test will give immediate results. After three days, the cardiologist deemed that there was no acute cardiac disease or event and scheduled the patient for an outpatient stress test. He recommended discharge.Just prior to the patient going home, the laboratory called the admitting physician and informed him that the stool cards were positive (that there was blood present in the stool). This should have been a warning to the doctor but he decided to ignore this important piece of information and discharged the patient, instructing him to see a gastroenterologist later that week. The patient should have been kept in the hospital for an immediate evaluation, which is the normal standard of care. Two days later, the patient was readmitted as an emergency, suffering from a massive gastrointestinal bleed and peritonitis, caused by a penetrating gastric ulcer (which ate its way through the stomach wall). The patient was in shock and required multiple surgeries because of the complications of this unnecessary disaster. Gastric ulcers are known to cause chest pain, and this was the original symptom the patient presented at the emergency room.
Many of us are still fearful of doctors and what they say to us. Sometimes they say something that sounds ominous, something we do not understand, and we leave their office preoccupied with their last statement. Did he mean that I have cancer? Did she say I was getting worse? We then spend the weekend ruminating over that last phrase. We don’t sleep, we go to work thinking it may be our last day. Why didn’t I ask him what he meant? On and on the mental suffering goes.
Well that was yesterday’s tradition! From today forth, you will not leave a doctor’s office until you fully understand everything that has been said. I would rather your physician get frazzled a little than have you spend one sleepless night, worried about something that could be totally innocuous. I know I have said this before, but you need to ask as many questions as possible. Not only will it help you understand what it is you may or may not have, it also puts your physician on notice that he or she really has to think out loud about the diagnosis. Mention diseases that you are concerned about. It is possible that the physician did not think about them. Perhaps he or she had and these diseases are not even near what you have. Fine. At least you can relax, knowing that these are eliminated. Just remember that the most common cause of medical malpractice is the wrong diagnosis. One only arrives at the right diagnosis if one thinks about it. If your doctor isn’t thinking for him- or herself, ask questions until he or she starts.
Study after study shows that you are not alone when it comes to asking questions or telling the doctor that you did not understand what he said. Patients are either embarrassed (after all, the physician is wearing the white coat and is the knowledgeable one) or just not up to knowing medical terminology.14 Medical terms are confusing, and because most people do not understand or ask for clarification, they are more apt to have poorer care or more complications. Studies further show that death rates among those with limited health literacy are twice as high as those who are literate. Doctors often fail to speak laymen English and, as a consequence, many people (educated or not, rich or poor) will suffer for not speaking up. Insist that your doctor speak plainly. You want to hear: “You don’t have HIV,” rather than “Your HIV test was negative.” What does that mean to the average person? You want to hear: “Do you have pain in your chest when you take a deep breath?” rather than “Do you have pleuritic pain?” To the average person, they might as well be speaking in tongues.15
A physician once told me: “One day I had to be the bearer of bad news when I told a wife that her husband had died of a massive myocardial infarct.” Not more than five minutes later, I heard her report to the rest of the family that he had died of a “massive internal fart.” Now that may make some people laugh, but I can assure you, it was—and is—no laughing matter.
When I give complicated instructions to my patients (to me that is the equivalent of two or more changes in their prescriptions, or getting a certain test before doing something else), I ask them to repeat to me what it is that I want them to do. Furthermore, I then write out everything on a piece of paper. If your doctor does not have you write things down, then you need to remember to do it for yourself. Additionally, if you are to discuss anything of importance with your physician, make sure you have your clothes on and are in his or her consultation room. This stuff is hard enough to understand fully clothed, you do not need the additional distraction of asking questions half naked! Also, being half dressed puts you on less than an equal par with your physician. If the physician insists that you complete your questions while still undressed, insist that he or she take off his or her clothes too!
Bring paper and pen to your appointment. Even better, bring a spouse or close friend with paper and pen. The best of all is to tape the conversation. This way you can play it again and again, to your spouse or to another physician when you go for a second opinion. Before you leave from this parting consultation, ask yourself: What questions can and should I come up with, rather than the doctor asking “Do you have any questions?” And one more word about second opinions: I love them. Patients have often told me that their prior physicians have blustered or got upset if they questioned their doctor’s authority. Unfortunately, there are many immature or insecure physicians who go ballistic if you suggest getting a second opinion. Oftentimes in life bluster is a mechanism for hiding ignorance of the facts. Think about changing your doctor, because that behavior is unacceptable. I encourage second opinions because (a) it is nice if I discover I am right, and (b) it is even better to hear I am wrong before the patient suffers. There is an old medical adage that the farther away and more expensive, the better the second opinion. This refers to sending your patient to a major research and teaching center.
This is your health and your life and you must be an active participant. Question. Question. Question. Is the procedure ordered necessary? Are you allergic to the medicine? Will you be allergic to the dye used in the x-ray or scan? I will wager that if you ask your doctor if the medicine that he just prescribed for you (for your sore throat, or congestion, or whatever) was absolutely necessary the answer 50 percent of the time would be no! That is just a guess on my part, but imagine that 50 percent of the time you would probably be putting yourself at risk for a medicine that really is not necessary. Think of how many times you were given an antibiotic for the common cold. They do not work for a virus. Furthermore, according to a USA Today article, one of seven commonly used drugs are taken for off-label uses lacking any scientific support.16 If you had a head cold and suffered with prostate inflammation, cold remedies would cause you to have difficulty urinating. Many people will stay up all night because of the ingredients in cold medicines. But the real concern is that we really do not need half of what our doctors give us. It is as if patients really want something to take for their effort in going to their doctor. The doctor is only obliging. Just try asking.
Contact your state and federal legislators and ask them to fight for a physician’s report card as well as a National Registry. Ask them to fight for unalterable electronic records. And ask them to help save our lives as well as theirs. Injuries and deaths are preventable.
Prescription
• Bring a list of all of your complaints on your next doctor’s visit. Include on this list all names of the medications (prescription, over the counter, and herbal remedies) that you are taking. Another physician may have added or subtracted something that your doctor does not know about.
• Make sure your physician answers each question/problem satisfactorily.
• Look at every laboratory slip, review every positive result with your physician.
• Make sure your name is on each tube of blood removed from you and on your requisition form. (In the next few chapters, you will see that improper labeling is responsible for many injuries to patients.) I asked my nursing staff if they would be insulted or imposed upon if patients requested their double checking. They assured me that they would not mind.
• Make sure your name is on the laboratory or pathology reports when they return.
• Keep copies of every test obtained and the subsequent results.
• Make sure you have your doctor’s full attention. Do not ask an important question when he or she is finishing with you and is halfway out the room.
• If possible, get copies of your office notes.
• If you are waiting a long time for your doctor, locked up in an examination room, it is okay to open the door. Perhaps they did forget about you. However, if you stand outside the doorway, with your arms folded in an angry stance, you will get nothing but negative points with the doctor and staff.
• Ask for second opinions.
• Ask for over reads on x-rays done in your physician’s office.
• If you feel any uneasiness about answers, or if you feel that the doctor is holding back or hiding something, get another opinion.
• Ask if the medicine you are being prescribed is absolutely necessary.