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Some Questions, Know-How That Can Save Your Life
The Advocate
By Herb Denenberg, The Bulletin
I’m going to give you some simple questions to ask your doctor that may save your life. And I’ll give you some simple things to look for in your doctor/patient relationship that may save your life.
Let me give you an example so you’ll read the whole column, and not sign off thinking I’m hyping the column too much.
Take the question of how you feel about the doctor and how the doctor feels about you. If you sense that the doctor doesn’t like you, does that mean you should drop him in a hurry? Research shows that patients usually sense a doctor’s negativity. However, unfortunately and often disastrously, they don’t understand why that is important. They simply explain away the negativity, and think perhaps it’s due to their own complaining, perhaps their own taxing of the doctor’s patience, or their own personality.
What the patient should realize is that the doctor’s negative feeling might be a killer in a real and literal sense. Here’s how one authority explains what happens when there is a negative feeling on the part of the doctor toward the patient:
“Physicians who dislike their patients regularly cut them off during the recitation of symptoms and fix on a convenient diagnosis and treatment. The doctor becomes increasingly convinced of the truth of this misjudgment, developing a psychological commitment to it. [This is in the context of a doctor who makes an initial wrong diagnosis.] He becomes wedded to his distorted conclusion. His strong negative feelings about the patient make it harder for him to abandon that conclusion and reframe the clinical picture differently.” In other words, but for that negativity, the doctor would have a much better chance of getting the right diagnosis after an earlier misdiagnosis. What’s more, the negativity will also decrease the chance of getting the diagnosis right in the first place.
What should you do about it? The expert quoted above says patients should “politely but freely broach the issue with the doctor and say something like this: “I sense that we may not be communicating well.” The conversation that follows may succeed in saving the relationship, assuming the patient is intent on continuing. The same expert writes that he asked other physicians what they would recommend if the patient encounters a doctor with a negative attitude toward him. Every doctor who was asked what a patient should do if his doctor seems to have negative feeling about him “flatly said he or she would find another doctor.”
Good communication is the heart of medicine. That means the patient should like his doctor and vice versa. If that good communication is impaired by negativity on either side, it’s time to find another doctor.
The expert I’m quoting is Dr. Jerome Groopman, the author of a classic book, How Doctors Think. He is a distinguished professor at the Harvard Medical School, and his book is loaded with insights on how understanding how doctors think can help you avoid the mistakes they so commonly make.
This is not to knock doctors, but only to acknowledge that one of the things human beings are best at is making mistakes. Even the most brilliant doctor can’t bat 100 percent just as the greatest hitters can’t get a hit every time at bat. But let me clear up an important matter of terminology. Sometimes there’s an important distinction between medical mistakes and other kinds of errors. I just used the word “mistake” in its broadest sense. Dr. Groopman says medical mistakes involve such things as prescribing the wrong dose of a drug or looking at an X-ray backward. On the other hand, errors involve such things as a misdiagnosis, something that is of a different order and involves mistakes in the doctor’s thinking. Dr. Groopman cites a 1995 report that found a 15 percent rate of misdiagnosis. This is in line with research involving autopsies, which found a 10 to 15 percent of diagnoses that are wrong.
You need some background if you are to avoid doctor’s misdiagnoses. Dr. Groopman points out that the majority are due to flaws in physician thinking and not technical mistakes. In one study of misdiagnoses that caused serious harm to patients, some 80 percent involved a cascade of errors in thinking. Another study found only 4 percent of doctor’s errors are caused by technical misunderstandings; 96 percent are caused by errors in thinking.
There’s another few pieces of background you better understand, as only suggested: The heart of medicine is not MRIs, CAT scans and other high-tech tests. It is communication between doctor and patient. One of the greatest doctors of history, William Osler, most associated with the Johns Hopkins School of Business, said (as one doctor paraphrased it), “If you listen to the patient, he is telling you the diagnosis.” That is congruent with the almost universal agreement that the diagnosis usually emerges from the medical history taken by the doctor and the doctor-patient conversation. The doctor has to listen. But that’s half the battle. The other half is making the patient comfortable in talking to the doctor. As Dr. Groopman says, “language is still the bedrock of clinical practice.”
Dr. Groopman says Osler was acutely sensitive to the power and importance of words, and that’s probably one of the main reasons he was such a master diagnostician and doctor. Perhaps that tells you something about what is wrong with modern medicine. The doctors are less sensitive to the power of words and the importance of communications, and rely more and more on testing, increasingly the high-tech variety such as the MRIs and CAT scans. In addition, the time pressures on physicians make it more and more difficult for them to properly communicate with patients. It’s faster and easier to order an MRI than to talk to the patient and to actually think about the patient’s condition.
I started thinking about the communications deficiencies of doctors while interviewing medical experts over many years while on television. I noticed it was rare to find a doctor who could communicate in simple, clear and understandable English. And I noticed that in the instructions doctors often distribute, there are almost always ambiguities that can leave unanswered questions at best and can lead to mistakes at worst. What’s more, I often found serious ambiguities and mistakes in books from leading medical centers, such as the Harvard Medical School.
With that background it should be easier to understand the questions recommended by Dr. Groopman to avoid doctors’ misdiagnoses and the approaches he recommends for doctors to avoid these errors. You can watch for good medical techniques to judge your doctors, and perhaps help them toward such techniques.
Play It Again
Sometimes a misdiagnosis arises because of miscommunication. So when a doctor doesn’t get the right diagnosis or is in doubt it is useful to return to the patient’s language and communication to make sure he’s got it right and to pick up new clues. The question might be, “Tell me the story again as if I’d never heard it — what you felt, how it happened, when it happened.” If the doctor doesn’t do that, Dr. Groopman suggests you offer to retell the story.
Tell The Doctor What You Think
Dr. Groopman says to help the doctor think in broader terms, it helps to communicate your concerns. For example, if you have been told you have acid reflux, but fear it might be cancer, don’t hesitate to tell that to your doctor. Alerted to such concerns, the doctor may be prompted to ask more questions, do more thinking, and perhaps come up with a new and correct diagnosis.
Should Tests Be Repeated?
There can be different results and interpretations from the same X-rays and other test results. So at times the patient may wonder whether new tests would make sense under the circumstances.
What Else Could It Be?
This question might force a new look at your case and perhaps an escape from errors of thinking that produced the wrong diagnosis. Such a question may help the doctor think of a new test or new procedure that might point to another diagnosis.
Is There Anything That Doesn’t Fit?
This is another question, like the one immediately above, that forces the doctor to think along different lines and impart a broader perspective.
Is It Possible That I Have More Than One Problem?
You might have acid reflux but you may also have angina. This question forces the doctor to cast a broader net, and perhaps discover an error in his thinking.
How Sure Are You Of Your Diagnosis?
This is a question I’d recommend in addition to Dr. Groopman’s. It makes sense, as often the doctor is less certain of his conclusion than the impression he tries to give. Even Dr. Groopman notes that some surgeons, when stumped, propose surgery to find out what is going on. You should know when such exploratory or diagnostic surgery is proposed. Sometimes such surgery makes sense, but sometimes it makes more sense to spend more time searching for the problem. In that circumstance, you better know what the surgeon is thinking and how certain … or uncertain he is about his conclusions. This question might also help what accomplish one essential recommended by Dr. Groopman — the doctor factoring into his analysis the possibility that he may be wrong.
When To Question The ‘Nothing Wrong With You’ Diagnosis
When you feel something is wrong with you, make sure there is a real foundation for the conclusion that there is nothing wrong with you. Dr. Groopman writes, “The statement ‘Nothing is wrong with you’ is dangerous on two accounts. First, it denies the fallibility of all physicians. Second, it splits the mind from the body. Because sometimes what is wrong is psychological, not physical. This conclusion, of course, should be reached only after a serious and prolonged search for a physical cause for the patient’s complaint.”
Conclusion And Summary
Dr. Groopman writes, “For three decades practicing as a physician, I looked to traditional sources to assist me in my thinking about my patients: textbooks and medical journals; mentors and colleagues with deeper or more varied clinical experience; students and residents who posed challenging questions. But after writing this book, I realized that I can have another vital partner who helps improve my thinking, a partner who may, with a few pertinent and focused questions protect me from the cascade of cognitive pitfalls that cause the misguided care. That partner is present in the moment when flesh-and-blood decision-making occurs. That partner is my patient or her family member or friends who seeks to know what is in my mind, how I am thinking. And by opening my mind I can more clearly recognize its reach and its limits, its understanding of my patient’s physical problems and emotional needs. There is no better way to care for those who need my caring.”
Herb Denenberg is a former Pennsylvania Insurance Commissioner, Pennsylvania Public Utility Commissioner, and professor at the Wharton School. He is a longtime Philadelphia journalist and consumer advocate. He is also a member of the Institute of Medicine of the National Academy of the Sciences. His column appears daily in The Bulletin. You can reach him at advocate@thebulletin.us.
Let me give you an example so you’ll read the whole column, and not sign off thinking I’m hyping the column too much.
Take the question of how you feel about the doctor and how the doctor feels about you. If you sense that the doctor doesn’t like you, does that mean you should drop him in a hurry? Research shows that patients usually sense a doctor’s negativity. However, unfortunately and often disastrously, they don’t understand why that is important. They simply explain away the negativity, and think perhaps it’s due to their own complaining, perhaps their own taxing of the doctor’s patience, or their own personality.
What the patient should realize is that the doctor’s negative feeling might be a killer in a real and literal sense. Here’s how one authority explains what happens when there is a negative feeling on the part of the doctor toward the patient:
“Physicians who dislike their patients regularly cut them off during the recitation of symptoms and fix on a convenient diagnosis and treatment. The doctor becomes increasingly convinced of the truth of this misjudgment, developing a psychological commitment to it. [This is in the context of a doctor who makes an initial wrong diagnosis.] He becomes wedded to his distorted conclusion. His strong negative feelings about the patient make it harder for him to abandon that conclusion and reframe the clinical picture differently.” In other words, but for that negativity, the doctor would have a much better chance of getting the right diagnosis after an earlier misdiagnosis. What’s more, the negativity will also decrease the chance of getting the diagnosis right in the first place.
What should you do about it? The expert quoted above says patients should “politely but freely broach the issue with the doctor and say something like this: “I sense that we may not be communicating well.” The conversation that follows may succeed in saving the relationship, assuming the patient is intent on continuing. The same expert writes that he asked other physicians what they would recommend if the patient encounters a doctor with a negative attitude toward him. Every doctor who was asked what a patient should do if his doctor seems to have negative feeling about him “flatly said he or she would find another doctor.”
Good communication is the heart of medicine. That means the patient should like his doctor and vice versa. If that good communication is impaired by negativity on either side, it’s time to find another doctor.
The expert I’m quoting is Dr. Jerome Groopman, the author of a classic book, How Doctors Think. He is a distinguished professor at the Harvard Medical School, and his book is loaded with insights on how understanding how doctors think can help you avoid the mistakes they so commonly make.
This is not to knock doctors, but only to acknowledge that one of the things human beings are best at is making mistakes. Even the most brilliant doctor can’t bat 100 percent just as the greatest hitters can’t get a hit every time at bat. But let me clear up an important matter of terminology. Sometimes there’s an important distinction between medical mistakes and other kinds of errors. I just used the word “mistake” in its broadest sense. Dr. Groopman says medical mistakes involve such things as prescribing the wrong dose of a drug or looking at an X-ray backward. On the other hand, errors involve such things as a misdiagnosis, something that is of a different order and involves mistakes in the doctor’s thinking. Dr. Groopman cites a 1995 report that found a 15 percent rate of misdiagnosis. This is in line with research involving autopsies, which found a 10 to 15 percent of diagnoses that are wrong.
You need some background if you are to avoid doctor’s misdiagnoses. Dr. Groopman points out that the majority are due to flaws in physician thinking and not technical mistakes. In one study of misdiagnoses that caused serious harm to patients, some 80 percent involved a cascade of errors in thinking. Another study found only 4 percent of doctor’s errors are caused by technical misunderstandings; 96 percent are caused by errors in thinking.
There’s another few pieces of background you better understand, as only suggested: The heart of medicine is not MRIs, CAT scans and other high-tech tests. It is communication between doctor and patient. One of the greatest doctors of history, William Osler, most associated with the Johns Hopkins School of Business, said (as one doctor paraphrased it), “If you listen to the patient, he is telling you the diagnosis.” That is congruent with the almost universal agreement that the diagnosis usually emerges from the medical history taken by the doctor and the doctor-patient conversation. The doctor has to listen. But that’s half the battle. The other half is making the patient comfortable in talking to the doctor. As Dr. Groopman says, “language is still the bedrock of clinical practice.”
Dr. Groopman says Osler was acutely sensitive to the power and importance of words, and that’s probably one of the main reasons he was such a master diagnostician and doctor. Perhaps that tells you something about what is wrong with modern medicine. The doctors are less sensitive to the power of words and the importance of communications, and rely more and more on testing, increasingly the high-tech variety such as the MRIs and CAT scans. In addition, the time pressures on physicians make it more and more difficult for them to properly communicate with patients. It’s faster and easier to order an MRI than to talk to the patient and to actually think about the patient’s condition.
I started thinking about the communications deficiencies of doctors while interviewing medical experts over many years while on television. I noticed it was rare to find a doctor who could communicate in simple, clear and understandable English. And I noticed that in the instructions doctors often distribute, there are almost always ambiguities that can leave unanswered questions at best and can lead to mistakes at worst. What’s more, I often found serious ambiguities and mistakes in books from leading medical centers, such as the Harvard Medical School.
With that background it should be easier to understand the questions recommended by Dr. Groopman to avoid doctors’ misdiagnoses and the approaches he recommends for doctors to avoid these errors. You can watch for good medical techniques to judge your doctors, and perhaps help them toward such techniques.
Play It Again
Sometimes a misdiagnosis arises because of miscommunication. So when a doctor doesn’t get the right diagnosis or is in doubt it is useful to return to the patient’s language and communication to make sure he’s got it right and to pick up new clues. The question might be, “Tell me the story again as if I’d never heard it — what you felt, how it happened, when it happened.” If the doctor doesn’t do that, Dr. Groopman suggests you offer to retell the story.
Tell The Doctor What You Think
Dr. Groopman says to help the doctor think in broader terms, it helps to communicate your concerns. For example, if you have been told you have acid reflux, but fear it might be cancer, don’t hesitate to tell that to your doctor. Alerted to such concerns, the doctor may be prompted to ask more questions, do more thinking, and perhaps come up with a new and correct diagnosis.
Should Tests Be Repeated?
There can be different results and interpretations from the same X-rays and other test results. So at times the patient may wonder whether new tests would make sense under the circumstances.
What Else Could It Be?
This question might force a new look at your case and perhaps an escape from errors of thinking that produced the wrong diagnosis. Such a question may help the doctor think of a new test or new procedure that might point to another diagnosis.
Is There Anything That Doesn’t Fit?
This is another question, like the one immediately above, that forces the doctor to think along different lines and impart a broader perspective.
Is It Possible That I Have More Than One Problem?
You might have acid reflux but you may also have angina. This question forces the doctor to cast a broader net, and perhaps discover an error in his thinking.
How Sure Are You Of Your Diagnosis?
This is a question I’d recommend in addition to Dr. Groopman’s. It makes sense, as often the doctor is less certain of his conclusion than the impression he tries to give. Even Dr. Groopman notes that some surgeons, when stumped, propose surgery to find out what is going on. You should know when such exploratory or diagnostic surgery is proposed. Sometimes such surgery makes sense, but sometimes it makes more sense to spend more time searching for the problem. In that circumstance, you better know what the surgeon is thinking and how certain … or uncertain he is about his conclusions. This question might also help what accomplish one essential recommended by Dr. Groopman — the doctor factoring into his analysis the possibility that he may be wrong.
When To Question The ‘Nothing Wrong With You’ Diagnosis
When you feel something is wrong with you, make sure there is a real foundation for the conclusion that there is nothing wrong with you. Dr. Groopman writes, “The statement ‘Nothing is wrong with you’ is dangerous on two accounts. First, it denies the fallibility of all physicians. Second, it splits the mind from the body. Because sometimes what is wrong is psychological, not physical. This conclusion, of course, should be reached only after a serious and prolonged search for a physical cause for the patient’s complaint.”
Conclusion And Summary
Dr. Groopman writes, “For three decades practicing as a physician, I looked to traditional sources to assist me in my thinking about my patients: textbooks and medical journals; mentors and colleagues with deeper or more varied clinical experience; students and residents who posed challenging questions. But after writing this book, I realized that I can have another vital partner who helps improve my thinking, a partner who may, with a few pertinent and focused questions protect me from the cascade of cognitive pitfalls that cause the misguided care. That partner is present in the moment when flesh-and-blood decision-making occurs. That partner is my patient or her family member or friends who seeks to know what is in my mind, how I am thinking. And by opening my mind I can more clearly recognize its reach and its limits, its understanding of my patient’s physical problems and emotional needs. There is no better way to care for those who need my caring.”
Herb Denenberg is a former Pennsylvania Insurance Commissioner, Pennsylvania Public Utility Commissioner, and professor at the Wharton School. He is a longtime Philadelphia journalist and consumer advocate. He is also a member of the Institute of Medicine of the National Academy of the Sciences. His column appears daily in The Bulletin. You can reach him at advocate@thebulletin.us.
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