Partnering with your doctor

kw: book reviews, nonfiction, medicine, polemics, self help

Item: More than one-third of cases of female infertility are caused by low thyroid. Guess how many women who visit a "baby doctor" get a thyroid hormone test early in the process? You can count them on the thumbs of one hand.

Item: In an emergency room, if you've brought your youngster in because your doctor's office is closed, and you want to have the tyke checked for bronchitis, they'll usually do a chest x-ray. In fact, they'll often be rather bullying about not providing any services at all without that x-ray.

On the other hand: Item: Some doctors have to be persuaded to order a test that is genuinely needed. This can go hand-in-hand with the first item, in principle: the most useful test is deferred in favor of a string of less-effective, but more costly, tests.

These items come from the experience of me and my family. Here is what to do in each case. Infertile? Demand a blood test for thyroid hormone levels. Got a sick kid? Prepare by getting a stethoscope and asking your family doctor what to listen for to distinguish bronchitis from pneumonia. If you must go to the ER, be prepared to say, "Use your stethoscope, or let me use it. Otherwise we're outta here." Don't allow that x-ray. Finally, if the doctor is setting you up for a battery of tests, ask, "Which single test will do the most to rule in or rule out a life-threatening condition?" If the doctor can't or won't answer, get another doctor, pronto!

I may rant at length some other time, but I really want to introduce Rosemary Gibson and Janardan Prasad Singh, who have written The Treatment Trap: How the Overuse of Medical Care is Wrecking Your Health and What You Can Do to Prevent it.

This is a very scary book. Rather than use lots of statistics, the authors present a selection of cases. These cases really get a fellow's attention: unneeded brain surgery that results in debilitation then, three years later, death; unnecessary amputation; chemotherapy for someone who doesn't have cancer. These aren't cases of mistaken identity or getting a patient mixed up in the shuffle. They are cases of doctors going to extremes "just in case".

While I have had some bad experiences, as hinted at above, I've also had some good ones. I had the good fortune to go to an oncologist who is the one the other doctors in the area would go to themselves if they had cancer. He is a sensible man. In particular, when I asked him what follow-up was needed after the chemo, he gave me a copy of a medical journal article. This article presented the results of a study done with a few hundred cancer patients, all of whom had been treated for colon cancer. One group received a standard follow-up, yearly checkups with the oncologist and the surgeon for five years and CT scans plus colonoscopy after years 1, 3, and 5. The other group got twice as many CT scans and colonoscopies and a quarterly checkup, plus quite a battery of blood tests, looking for all kinds of obscure enzymes. The article concluded that there was no difference in outcome. My oncologist said, "All that extra testing turned out to just be an early death detector for some, and a confirmation of wellness for the rest."

The biggest problem the authors unearth (and it isn't hard) is the Green Monster: financial incentive to do more to get paid more. Doctors are paid per procedure, so they have an incentive to do more procedures. Some doctors can be ethical in this environment, perhaps even most can. But to see how ethical your doctor is, count the decorations in the waiting room and the anatomy posters in the exam room, and figure out what percent of them were "gifts" from drug companies. Are the pens at the desk carrying a drug company logo? I have yet to find a doctor's office that is free of such trinkets, but in some offices, it is a deluge! In for a penny, in for a pound I say, so I assume the doctor's judgment is shaded and take precautions.

I can think of one doctor whose office is nearly free of such stuff. There is art on the waiting-room walls, not ads, and the only drug-company-supplied item is a single anatomy chart in the exam room. The doctor actually has several other anatomy charts that must have been purchased, because they don't have any advertising on them!

I think everyone must have a story or two of going to the doctor and getting more than you bargained for. Some of it is defensive medicine, intended to pre-empt problems that could lead to a lawsuit. Not all. Are you, or do you know, a woman over fifty? Ask her (or ask yourself) if a doctor has recommended a hysterectomy, "just in case." Even if an aging uterus grows a few fibroids, a D&C can remove them at much less cost and pain. Has anyone recommended back surgery for your sore sacroiliac? There's a case for the traction/massage table at the chiropractor's. Lost less invasive and usually lots more effective (but the chiropractor couldn't do anything useful with my sore neck).

The book's four parts end in a self-help section, including a chapter "Twenty smart ways to protect yourself." The chapter needs two or three more items that relate to handling emergency situations. You don't always have the leisure to get a second opinion, or contact Cochrane (see below), or dig around in the medical journals (online or at a University library). However, the points given are very helpful, and include a number of online resources, listed at the end of this post.

The chapter with the most useful message, however, is titled "Do it with me, not to me." It is worth the trouble to find a doctor who is willing to explain, one who is not irritated by questions, one who will collaborate with you in your treatment rather than demand that you passively accept "medical care" without knowing why. A doctor who can intelligently answer the question, "How do you know this will help me" is worth rubies.

We can't do everything for ourselves. We trust farmers and grocers to provide wholesome food; we trust the auto mechanic (who is also paid by the procedure) to do just what our car needs and no more; we trust the appliance repair service to get a broken dishwasher working again; and we can't do our own surgery, so the time is likely to come that you and you and you (and perhaps I, again) will need to trust a medical team with our life and future health. The more we know, and importantly, the more that they know we know, the better things are likely to go.

Resources:

Cochrane Consumer Network – "a global network of consumers who are experts in their field." (that is, an experienced patient is often the best doctor)
Health News Review – reviews of news stories by independent experts.
Foundation for Informed Medical Decision Making – provides information and resources to help patients make better medical decisions.
FBI – whom to contact if excessive tests or procedures were charged to Medicare or Medicaid.