Monday, June 21, 2010

Physicians, heal thyselves

kw: book reviews, nonfiction, medicine, polemics

The first general rule for finding a doctor or lawyer is to pick one who is between 35 and 60 years old. Professionals who are 35 or older have probably already made their worst mistakes, but by the age of 60, many have lost their "fire" and are more likely to be marking time until they can afford to retire (by their own lights).

The second rule is to find a doctor in a social situation and ask, "If you had [whatever], which doctor would you want to treat you?" or "If your child had [whatever], which pediatrician would you choose?" About ten years ago, with very fortuitous timing, a local group published a guide to physicians, which included, for a number of specialties, "Which doctor I would go to". The oncologist suggested by my surgeon is locally considered the best, so this helped me make the decision to have him treat me, rather than going to Fox Chase, a greater distance away. No complaints; I like him a lot, as a physician, not just as a friend.

But getting to the point where he could treat me was another matter. As I have mentioned in the past, I had to be my own doctor to get the cancer treatment I needed. My family physician at the time was not very proactive, and was taking a very slow, measured approach to finding out why I had abdominal pain. One day, after an inconclusive consultation, I asked his office scheduling clerk, "If the Doctor were to send me to a gastroenterologist, whom would he choose?" She told me, and I made my own appointment, then called that clerk to process a referral to him. It saved my life. The GE said I was days from death when he diagnosed my cancer, so I told (not asked) my doctor to get me a surgeon pronto, and went to the emergency room. They put me in the hospice! But they also gave me six days of IV feeding in two days to strengthen me for surgery. On a ward in which every program board had the notice "Comfort", mine read, "Comfort and Feed 3x". Now my GE, whom I still see for periodic colonoscopies, calls me a Trophy.

So my current doctor just turned 60. He is much more proactive, and wants me to get blood pressure medication. I'm amenable, but I decided to try a folk remedy first, and allowed our son to bring home a kitten. Three days after the kitten arrived, I checked my blood pressure. The long-term average for the past few months had been 148/90. The average of the past three measurements (post-kitten) is 132/80. While it doesn't bring me into the 120/75 range my doctor would prefer, it may mean I can use one of the less aggressive medications, with, of course, fewer side effects.

The cancer tale is one of four in which my wife and I have had to intervene in the medical process to get appropriate care. That makes Dr. Richard S. Klein a man after my own heart. It is just the kind of advice he offers in Surviving Your Doctors: Why the Medical System is Dangerous to Your Health and How to Get Through it Alive. The root of his concern is this: At least 100,000 people die every year in the U.S. from medical mistakes. Dr. Klein says this rampant malpractice constitutes a pandemic that is, numerically, equivalent to a jumbo jet crashing nearly every day. A web-based service called HealthGrades contains the claim that the number is actually closer to 200,000 yearly deaths by malpractice. Contrast either figure with 40,000 yearly deaths in auto accidents. Malpractice is the third or fourth leading cause of death.

How are we to avoid becoming a statistic in this race with untimely death? For starters, read this book. It has joined my reference library. Every chapter has, in addition to narrative and stories, particular advice in a certain area. A few themes show up repeatedly:
  • Prepare for any doctor visit by writing down everything you are taking, including vitamin supplements and over-the-counter pills; and write all your questions about what's currently bothering you (medically).
  • Get very, very good at finding medical information using the Internet, using sources such as MedlinePlus and the NIH and NIMH web sites, plus, which has a great drug interactions checker.
  • Whenever a nurse shows up with a pill or hypodermic, first ask, "Who is this for?" In a hospital setting, it is surprising how many times Mr. Jones gets an injection or pill intended for Mr. Johnson, or even Mr. Smith. Secondly ask to see the doctor's order, and thirdly ask what this medication is intended to accomplish.
  • Always ask what to expect after a medication or procedure, including side effects and expected course of recovery. Very few doctors will bring this up on their own.
  • If your doctor won't communicate with you, get another doctor. Any doctor who feels threatened by a patient's knowledge or questions should get out of medicine.
Dr. Klein is an internist, so while he has made his book as comprehensive as possible, he admits he can't cover everything. He recommends, as mentioned, researching anything new by yourself, using both internet resources and asking your doctor more questions, and then even more questions. Your doctor went to school and residency for ten years after finishing high school; drag some of that knowledge out of him or her.

He refers to HealthGrades frequently, so I spent some time at their web site (see link above). Some results are free, such as reports on nursing homes, but in general it costs $13 to get a full report on your doctor, and $18 to get a report on a hospital, for which you first have to pick up to 20 conditions out of a menu of 57, so if you wanted every condition covered, it would cost you $54. However, if I were again faced with choosing a hospital in which to spend a week after having my insides re-plumbed, I'd definitely spend the $36 to get reports on the two in my area that are available to me, and maybe another $18 to get a report on Thos. Jefferson Hospital in Philly for comparison.

Along with the theme of that daily jumbo jet crash (and statements such as "While you read this chapter, five people will die of malpractice"), Dr. Klein has a full chapter on reforming the medical system, in addition to recommendations that appear throughout the book. For example, there is a very strong inclination for doctors to deny ever having made a mistake, probably because their malpractice lawyer has advised them to minimize liability by never admitting wrong. They need to be convinced that correcting a mistake quickly is less costly than going through a malpractice trial (even if they win, as they do 70% of the time). But first a doctor has to admit that a mistake has occurred. A national medical climate that encourages the acknowledgment of mistakes and encourages learning from them is needed. But so is a climate that stops the rampant covering-up for those few physicians who are responsible for the great majority of actual malpractice that occurs. It is a kind of 80-20 rule, or more likely, 90-10: 90% of the malpractice is committed by 10% of the physicians, who need to be "encouraged" to find another line of work.

Since that is very unlikely, taking the proactive steps Dr. Klein recommends will make it more likely that you, the educated client (not patient) of your doctor, a collaborator with your doctor rather than a passive receiver of medical "services", will not just survive, but thrive.

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