Getting the Best Medical Care: a Newsletter from Patrick Malone

In This Issue

Why "What Else Can It Be?" Is So Important to Ask

What Else You Need to Ask the Uncertain Doctor

Why Good Doctors Are Vulnerable to Misdiagnosis

Quick Links

Our firm's website

Read an excerpt from Patrick Malone's book:
The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst

The Life You Save cover

Learn More

Read our Patient Safety Blog, which has news and practical advice from the frontlines of medicine for how to become a smarter, healthier patient.

When the Doctor Isn't Sure: What You Can Do

Dear Patrick,

We have all taken a sick child (or a parent, or a spouse, or ourselves) to a doctor's office or emergency room looking for answers to worrisome symptoms. But what if, when the time comes, there are no answers?

This newsletter is about life-saving questions we can ask to start a dialog, a conversation, to make sure the doctor hasn't overlooked something that could cause a terrible injury.

Consider this common scenario: You've waited for a long time, in both the waiting room, and in the cramped examination room. The doctor comes in, asks a few questions, does a brief exam, and then ... the doctor shrugs and says, "It's probably ... nothing."

But the doctor isn't really sure, and so you, the worried parent/spouse/patient looking for clear answers, are left even more worried.

If this hasn't happened to you, it will at some point. I want to am you with key questions you should ask and things you should do to protect your loved one's health.

This continues our conversation about health care conversations which we started in the last issue of this newsletter. These are conversations that can truly save a life: yours or a loved one's.

As before: Feel free to "unsubscribe" on the button at the bottom of this email. But if you find it helpful, pass it along to people you care about.

The Most Vital Question You Can Ask Your Doctor

When it's clear the doctor doesn't know what's wrong with the patient, one simple question is very important to ask:

"Doctor, what else could it be?"

This question is not for every visit. But it's a great, important, even lifesaving question when:

The doctor obviously hasn't fit all the pieces of the puzzle together, such as when the patient has developed symptoms that don't fit neatly into one diagnostic box;

The doctor is unsure about what's wrong but tries to reassure you that it probably is nothing to worry about; or

The doctor has seen the patient multiple times, and the patient's body isn't responding to his or her treatment plan.

This simple question -- what else can it be? -- can seem rude and impertinent to put to someone in a white coat. But there's a deeper problem that makes many of us hesitate to ask. Especially when the diagnosis offered is benign, it's a lot easier to embrace a vague pronouncement like "probably nothing" than to entertain the idea that something bad may be lurking undiscovered within our patient, something that might rear up and cause permanent harm or even death. Who but a hypochondriac would challenge the diagnosis of "probably nothing"?

It's the job of the health-care professional to take the patient seriously. A doctor who looks first for a benign source for the patient's symptoms rather than for those things that can kill the patient does no service to the patient. We don't take our children to doctors to feed our natural instinct for denial. We go to doctors to make sure that something really bad isn't happening, and if it is, to find the right treatment to make it better.

The question, What else could it be?, is intended to prod the physician into a thinking exercise she learns in medical school: the differential diagnosis. Here's how it works. The physician takes the patient's significant findings and makes a list of all the diseases that could fit. The list is supposed to be prioritized to put dangerous treatable conditions first. Often, though, the doctor makes a probabilistic diagnosis as a shortcut: If it's very likely this is just, say, a common cold, the doctor doesn't bother with the tests that can determine if it's a more serious bacterial infection that needs antibiotics.

Read on for more good questions to ask the uncertain doctor.

Talking to Your Primary Care Doctor: What You Need to Ask

Here is what else you should ask when the doctor isn't sure about what's wrong:

"Is there any chance that my child (my spouse, etc.) has a condition that can be treated now but if not caught soon, could be a disaster? If so, how do we get to the bottom of that?"
"Are there any symptoms or test results that just don't fit your diagnosis? If so, what else could be going on?"
"You say the patient has two separate, unrelated things wrong. Is it possible there's just one thing wrong that explains all the symptoms?" Or,
"You say you've found one thing wrong. But that doesn't explain all the symptoms. So is it possible there is more than one thing going on?"

Final thought: Get a written action plan from the doctor when you leave the visit. If things are uncertain, it's very important for you to know exactly what to look out for and what changes in symptoms should bring you back to the doctor's office.

Why Doctors Are Vulnerable to Misdiagnosis

Research says that as many as 15 percent of all medical diagnoses are wrong. Any misdiagnosis causes wrong treatment. But tragedy lurks in one distressingly common type of misdiagnosis: the assumption that the patient has a benign, self-limited condition, when in reality the clock is ticking on a treatable serious disease that could kill if left untreated.

Pediatricians are vulnerable to misdiagnosis, not because they're bad doctors, but because they see so many healthy children with benign illnesses, that on occasion when a child appears with a really serious condition, they mistake it for just another ordinary illness.

The same is true for any frontline, primary care doctor: whether they are an internist, a family practice doctor, an emergency room doctor, or even an ob-gyn in general practice, they see an awful lot of really plain vanilla mild ailments that will go away whether treated or not.

It's natural to want to fit a new patient's symptoms into a familiar box. It's when the patient doesn't fit the box comfortably, and the doctor sort of understands that -- as shown by unease or lack of certainty -- that we need to gear up our questions.

Past issues of this newsletter:

We're now in our second year of this newsletter. This is issue No. 16.

Issue No. 15 is also about conversations. This one is about talking to your surgeon: the "informed consent" discussion that so many of us misunderstand. It's not about signing a form to get surgery. It's about having an intelligent, adult discussion to build a bond of trust with a surgeon -- and to make the right decision about what to do.

No. 13 and 14 focused on doing your own health care research on the Internet. No. 13 opened the discussion of "separating fact from hype" in health care advice with a piece on HealthNewsReview, plus articles on the five most overrated prescription medicines and the Miranda warning you see on a lot of so-called natural health products. Read No. 13 here.

No. 14 featured a short list of reliable web sites for health care information. We also did a short expose of a very popular website that one writer memorably called "a hypochondriac time suck." As a bonus, one more click will give you an excellent food pyramid for a healthy diet. Read No. 14 here.

Here's a rundown of our newsletters in 2010:

Our first newsletter focused on the problem of conflicts of interest in medicine -- what you need to know in general, and how to find out if your doctor has a conflict that might affect the quality of your care. Click here to see that newsletter again.

Newsletter No. 2 expanded the discussion into the related topic of why experience counts -- especially when choosing a surgeon. We focused on the story of minimally invasive prostate surgery with the device called the da Vinci robot. We explained how the lessons apply to any kind of surgery or medical procedure. To see newsletter No. 2 again, click here.

Newsletter No. 3 talked about why "more is not always better" in modern medicine. We focused on cancer screening, especially for breast and prostate cancer, and why you can feel not so guilty if you're a little less aggressive about getting the test. (But if you have any symptoms, you shouldn't wait!) Click here to read it again.

Newsletter No. 4 talked about choosing a hospital, and why the best known rating systems such as U.S. News & World Report may not be all they're cracked up to be. I give some tips about other ways to make sure your hospital is up to par. Click here to read it again.

Newsletter No. 5 talked numbers -- how it's important for all consumers of health care who want to make informed choices to learn a little bit about how statistics are used -- and misused -- in health care. I introduced readers how to read medical statistics in a straightforward way. To read it again, click here.

Newsletter No. 6: Back pain and heart disease: how less can be more. The simpler approaches can work just as well as or better than more complex kinds of surgery. Here's the link to see it again.

Newsletter No. 7: Preventive care: what every adult American needs. Here's the link.

Newsletter No. 8: Colonoscopy: two questions you must ask to make sure you get a competent screening exam. These questions can be a real life-saver when you know how often colonoscopies miss life-threatening lesions. Read more here.

No. 9: Why getting and reading your own medical records can save your life -- and how to do it. The link is here.

No. 10: The joys of being a health care skeptic -- or, Why statisticians are our friends. And more on why most published research eventually turns out to be wrong. The link is here.

No. 11: Part one of preventing injury in the hospital, discussing why 24/7 bedside coverage is essential, and focusing specifically on bedsores and falls. Read it here.

No. 12: Part two of preventing injury in the hospital: infections, blood clots and wrong medicine/wrong dose problems. Here is the link.

To your continued health!

Sincerely,

signature block

Patrick Malone
Patrick Malone & Associates