Sunday, June 17, 2012

How to Ask Your Doctor Intelligent Health Care Questions



Going to the doctor can be confusing.  Doctors make recommendations based on what they know, and patients are conditioned to trust their doctors.  While I think it's wonderful that patients trust their doctors, there are times when patients want more input into their health care, and if this is the case, then let me make some suggestions as to what might be important questions to ask.  There is nothing specific to psychiatry about my recommendations, so feel free to have these types of discussions with any doctor or prescriber.


If you go to the doctor for a routine visit and it is suggested that you have routine health maintenance tests or treatments and you are fine with that, then there is not much to ask.  If you have a concern about the necessity of a test or procedure, try to figure out what your concern is so you can verbalize it.  One example might be: Will routine vaccinations cause my child to become autistic?
  • Why do I need this test?
  • What is the risk of this procedure? 
  • If a medication or supplement is being offered to decrease the risk of a specific illness later, then it's reasonable to ask if studies show that this treatment is known to be effective.  This may sound silly, but sometimes we just don't know things: so people took statins to lower their cholesterol, but it was a while before it was clear that they also lowered the risk of heart disease. And now the thinking is that Vitamin D and Calcium supplements may not lower the risk of osteoporosis in post-menopausal women (they may have other benefits however) but they do increase the risk of kidney stones. 
More importantly, if you choose not to follow your doctor's recommendations, ask:
  • What are the risks of not taking this medicine/supplement/having this vaccine?
My favorite personal example-- when one of my children turned three, I took him to a pediatric dentist to start routine care.  The dentist told me it was standard procedure to x-ray a child's mouth at this age.  I wondered why-- if there are no obvious problems, their baby teeth are going to fall out anyway.  I asked and was told that they like to make sure the adult teeth are there.  Hmmm, how many people don't have adult teeth?  I didn't ask that, what I did ask was, "If you do an x-ray and find that there are no adult teeth, what can you do about this?"  The answer was, "Nothing, we just like to know."  So I'm no dentist, but my take on this was that the x-ray exposes my little person to radiation, costs money,  and if a problem is discovered, there is nothing to do to address it.  I verbalized this and the dentist was okay with not getting an x-ray.   


If you go to the doctor with a specific problem, things are a little different.  
  • If the doctor orders a diagnostic test, you may or may not want to ask what he is looking for or trying to "rule out."  The answer may be something scary that is very unlikely and perhaps you may not want to know to worry about something that's not likely to be the problem.  
  • Is it an option to treat a presumed illness without having a diagnostic test first?  If the treatment is something easy or benign or cheap or a lifestyle change, maybe it would make sense to try that before having an expensive or painful procedure.  If the test is being done to rule out a treatable form of a serious illness, then usually doctors do not like to delay a test.
  • If the doctor recommends a specific treatment, it's reasonable to ask "How long it will take to work and when do you want to hear from me if things are not better?"  This is important, if you're supposed to be better in 3 days, you don't want to come back in 6 weeks saying you're still sick or hurting or very much worse.  And if the treatment is going to take 6 weeks to work, he doesn't want to hear that you're not better in 3 days.
  • If you don't want the treatment your doctor recommends (or you're not sure), it's reasonable to ask: Are there other treatment options available?  What is the expected course of this illness/injury/problem if I don't have this/any treatment?  Sometimes the doctor won't know because different people have different courses with an illness and this can be especially true in psychiatry.
 Sometimes people go to the doctor because they are worried they have a specific illness and are then disappointed when the doctor does not order a test to look for that illness.  Sometimes the concern is 
  • It's reasonable to say "I am worried that I have X, how can you be sure that I don't?"
  • You might then ask, "Would it make sense to order X test?"  
  • You might also ask, "If I continue to have these symptoms, are there diagnostic tests or treatment options that might be reasonable to try?"  And then ask for a time frame.
The truth is that doctors often don't have the answers to these questions, but sometimes it's helpful to hear their rationale for a decision or to let them know your concerns.  They certainly don't have crystal balls when it comes to issues of preventative care and risk, and often recommendations are made based on presumptions -- for example, people with sunburns get skin cancer, sunscreen prevents sunburn, sunscreen will prevent cancer-- before we can be absolutely certain that such logic will bear out.  And whether or not sunscreen prevents cancer, it might be nice to not be in blistering pain tonight regardless of long-term risk.

17 comments:

Emily said...

Once again, Dinah, you blow me out of the water with your assumptions about your readers - namely that we are dumb morons who are incapable of basic thought or communication. I wish that you could reread this post and think how you would feel if someone made that assumption of you. Do you think that your ability to question your son's dentist is only because you are a psychiatrist, and therefore everyone else couldn't have the same basic thought process and ask similar questions? I am blown away. Again.

Anonymous said...

I just wanted to add, that I actually found this helpful. I work as a nurse, and probably challenge my doctor more than most patients. I found this to be a good article outlining different strategies that can be used for self advocacy.

I disagree with the previous poster. From my personal and professional experience, I know people often struggle to articulate questions and self advocate in discussions with doctors.

RoseAG said...

I think your dentist missed a good answer. The future of your childs' adult teeth is likely to impact their need for orthodontics. I was missing two adult teeth, other kids have more teeth than they'll need.

Orthodontists have wiggled themselves down to treat younger ages than they did when I was a girl, some things are supposed to be done while the jaw is in various growth spurts.

Even if 3 is a little young for a trip to the orthodontist, but it's not too young for Mom/Dad to be budgeting for future trips to the Orthodontist.

Not every family will want to go through the expense and hassle of straight teeth for their children, but since the dentist is devoted to teeth he probably prefers to assume everybody wants those services.

rob lindeman said...

I disagree with Emily too, respectfully, of course.

Unfortunately for most of us, we are so thoroughly marinated in the culture of overtreatment that we would not dare ask such questions.

Except we should ask.

Bravo, Great Post!

Anonymous said...

My kid was missing four adult teeth. There can be consequences, beyond cosmetic, and these can be dealt with through building teeth up with artificial materials, or implants, depending on various factors. My kid had his teeth fixed in the least expensive way, with no fancy orthodontics once it became clear that
it was best for the integrity of his other teeth to have the work done. Your dentist probably didn't want to waste the time to argue with you.

Liz said...

dinah--

i found this post helpful as well. thanks.

liz

rob lindeman said...

Sorry to stick my nose in the dentistry debate...

If you think overtreatment is bad in medicine, it is positively over the top in dentistry.

Regard with extreme skepticism anything your dentist recommends. Then go look for the evidence backing the recommendation. And good luck finding it.

Carolyn Cummings said...

Thank you for this article. So often I find that I am easily intimidated when I actually show up for a visit and don't spit out my actual concerns and questions, or even remember them until I am in the car going home. The last time I thought there might be something seriously wrong with me, I actually typed up an entire assessment of my symptoms, when they started, what I thought they might be, etc, and took that in with me. I found it really helpful to be able to reference it for myself and it helped me stay on track and ask my Dr. the things I really wanted to ask.

I took courses to become an ESL teacher for adults at one point in my life, and I learned a phrase in one of those classes that sticks with me when I do presentations today:

"Always overestimate your students' competence, but underestimate their knowledge."

I appreciated your post and did not feel that you assumed us to be morons or anything like that, rather that you were aware that not everyone has an understanding of the perspective of the medical profession. In a day and age of specialized career fields, it'd be quite easy for an intelligent, competent human being to be highly in tune with information from their own field of work and not have knowledge about the medical profession. I would like the same sort of post to be written by a mechanic about how to work with mechanics.

Jane said...

I didn't feel demeaned by the post. I think it's a good topic. It's hard to ask questions sometimes with doctors or PAs or NPs. I've asked questions that I thought were intelligent, but the doctor/NP/PA whatever it was, would get defensive and act like I was trying to pick a fight. And I've wondered, in hindsight, if maybe they had some insecurity issues. But it's important to ask the questions anyhow.

That and we all know that docs are busy people, and I think a lot of people don't want to take up too much time with questions. Even if they are good ones, like the ones you listed.

I briefly saw a GP who would prescribe medicine w/out even telling me he was prescribing it. He would walk out and then send in someone else with the prescription, no explanation about the meds, after my appointment with him. Even his PAs were like that. Which I thought was weird, because PAs and NPs tend to be more socially adept and take a little longer with patients in explaining things.

I didn't stay with him long. And I've never had a doctor or PA before or since that would routinely prescribe something without telling me, and then send in someone else (who knows nothing about medicine), so that I would be unable to ask questions or request a different drug.

merope3 said...

Try asking ANY of these questions when you are confined in a psychiatric hospital. ;)

(I agree though, a good useful post. It is always good to ask questions.)

Dinah said...

I certainly did not intend for this post to sound like I thought anyone was a moron.

It was provoked by a visit one of my very intelligent family members had to a doctor recently. My husband, with his multiple Ivy League degrees, does not question physicians, and I've listened to many very intelligent patients over the years struggle with issues pertaining to medical care.

Doctors are trained to know the latest recommendations, not to question them, and lately I find that the things I assumed were givens in medical care are being questioned: yearly mammograms, yearly pap smears, yearly measures of prostate specific antigen, even yearly physicals. I've heard of patients being pushed to take hormone replacement back before....

I have one doctor who gets so in my face about calcium supplements, despite my assertion that I eat a healthy diet which includes milk/yogert/cheese/ice cream-- she asked me "So you eat ice cream every day??"-- no I don't, but I'm certainly not undernourished. Finally, I decided it's easier to eat a Tums twice a year so I can say with impunity that I sometimes take Tums for calcium supplementation and that shuts down the conversation.

And doctors present things as "it's the standard" -- so I do think most people who hear this feel like they would be bad parents to say no to the standard xrays (not because they are dumb, but because they are human). Doctors don't present such things as Here are the Pros/ Here are the Cons, What do you want?

And if the issues of communication aren't hard enough in deciding if preventative care and routine screening are optimal, certainly people get very vulnerable when they are ill. Even as a doctor, I sometimes resort to asking "What would you do if my child was your child?" Or what would you recommend if I was your sister?

Please, everyone, rest assured that my children had ample, expensive orthodontia, and all the radiation that goes with such processes. The need was not subtle.

It's hard to strike a tone that pleases all of the people all of the time, but my intentions were good.

jesse said...

Your tone was fine for me, Dinah, and I think it was a good post. Medicine is today much more collaborative than it was years back when doctors' pronouncements were essentially treated as ex cathedra.

Sarebear said...

I can see that sometimes is the case w/dentistry, Rob; 4-5 years ago I broke a tooth, and he wanted to do below the gum cleaning of every quadrant, besides fixing thetooth. We had to apply for a medical credit card to pay for it, and didn't qualify for enough; he wrote $800 off for us, but still I wonder if I shoulda just got the tooth fixed . . . we only just paid it off last week. Interest rate was ridiculous.

On the flip side, when I was thirteen in New York the ortho started my braces and never had a clear estimate of how long it'd take. He never even tried to figure out or said anything about my jaws possibly being misaligned . . . we moved to UT whe I was fifteen, and even before the x-rays, the ortho said it was likely my jaws were misalighned, congenital problem . . . he was incredulous the otherguy woulda just said braces . . . anyway, 1 months-2 years of braces, and then I had surgery to break both my jaws and move em around (I was a 9out of 10 on how hard it was the surgeon said).

I was so pissed off at the dude in NY, who may have just not known what he was doing. I don't know. The guy in UT didn't stretch us out for 4, years of braces; even when we left NY, the ortho there didn't have a date I'd be done, and I'd had the braces for a couple years (not very effective, since the UT guy moved thing quite a bit in almost two years)

Sometimes you don't know there'squestions you need to ask that you're missing, though, and that can be hard to accept later down the line when you wished you'd known to ask something.

With my knee surgeries, I got to good degree on how far I could bend them after each surgery; the first, left one, however, was much more stubborn. The physical therapist didn't think bending the leg completey back while under anesthesia for the right leg was necessary; my surgeon wanted to do it, however. I WISH I'd asked more, and even objected. Because I'm left with, on top of the other pain the surgeries left me with, the whole backof the calf will just burst into agony if I step on it wrong, or just random, and I can't steel myself for it . . . this did not happen at all in the four months between the first surgery on the left leg, and the second replacement, my right knee. And a couple other problems I think the bending it all the way back caused . . . .

I was kinda overwhelmed with all the medical stuff at the time, though, but still I wish I'dve askd about it more . . .

Dinah said...

I think sometimes there just aren't answers and yes, I would love it if someone could tell me how to ask intelligent questions of my car mechanic. I always feel like I am at their total mercy and I have no idea what is flying-- it's not even in a language I can understand.

Sarebear, if it makes you feel any better, my mother took me to numerous orthodontists for opinions, she refused to let any one break my jaw, and I ended up being treated at the state's dental school, where 8 orthodontists stuck their heads together to figure out how to fix my bite. Then I had to wait until there was an available student, by this time, ages had gone by and everyone else seemed to be getting their braces off. I was told I'd need braces for 4 years, and at every appointment, I'd ask "how long"...one day after two years and expecting the usual "two more years" I was told, "next visit" and I was very happy to be de-braced at 16, and not 18. There were multiple opinions of how to treat the problem, I don't know who was right and who wasn't, or if there were multiple ways to approach the same issue.

My point was just that this stuff is hard, you may never know if asking the right questions would get a different result, or if another doctor could have done a better job. When in doubt, get a second opinion (with surgery, dentistry, and the car) and you still may not be sure of the right thing to do.

rob lindeman said...

And I would augment Dinah's advice as follows:

When in doubt, do nothing. Experience proves that you will be right more often than not.

Maggie said...

According to oralanswers.com, if you don't count wisdom teeth, which are pretty common not to ever get, 5% of people are congenitally missing one or more adult teeth.

My dentist said at one point that they had to break my jaw to fix my teeth. My parents weren't into that idea. Later, the same dentist (I think it was the same dentist -- maybe just the same office?) asked if I'd ever had braces and said that my teeth were perfectly straight. No broken jaws involved.

Dinah, I'd imagine that there are plenty of automotive blogs that would do exactly that.

Anonymous said...

I generally ask my doctor intelligent questions. I rarely get an intelligent response.