According to a recent study conducted by the Kaiser Family Foundation of women ages 18-35, doctor visits aren’t always positive. More than 46% of women said that their health care provider did some of these things: dismissed their concerns, assumed something about them without asking, and blamed them for their health problems.

Moving up the ages, menopause “received little attention in clinical visits.” Only 35% of women ages 40-64 said their health care provider ever talked to them about what to expect in menopause, ranging from 42% of women who have gone through menopause, 39% of those currently going through menopause, and 19% of premenopausal women.

Now add to the list something I read in Dr. Jerome Groopman’s book, from 2008, How Doctors Think. On average, a physician will interrupt a patient describing her symptoms within eighteen seconds. In that short time, many doctors decide on the likely diagnosis and best treatment. Often, decisions made this way are correct, but at crucial moments they can also be wrong — with catastrophic consequences.

Groopman describes why doctors err including his concern about how technology has invaded medical diagnosis. “Over the past few years,” he writes, “in order to establish a more organized structure, medical students and residents are being taught to follow preset algorithms and practice guidelines in the form of decision trees.” This is sometimes referred to as evidence-based medicine. Insurance companies love it, giving them easier ways to deny tests and expensive uncommon treatments.

“The trunk is a patient’s major symptom or lab result, contained within a box. Arrows branch from the first box to other boxes. Ultimately, following the branches to the end (via yes and no answers) should lead to the correct diagnosis and therapy. But what about when a doctor needs to think outside those boxes? Thinking independently and creatively are discouraged.”

            Dr. Groopman was the first physician to describe and admit to making errors that I’ve ever read. He outlines three ways this can happen: First is making snap judgments. The short time patients have with doctors, especially now, can cut off deeper listening and thinking. The second is a common cognitive error called availability. This refers to assuming that an easily remembered prior experience – often a recent patient – falsely explains the new situation and diagnosis. And the third mistake is termed attribution. This refers to the tendency to mentally invoke a stereotype and “attribute” symptoms to it. Often the stereotype is a negative one: complainer, hypochondriac, or someone unable to cope with naturally declining abilities. This last is linked to illnesses that go undiagnosed because the doctor sees an elderly person and assumes “this old fart is just cranky about getting up there in years.”

In the service of patients, which Dr. Groopman clearly is, he offers several suggestions for both doctors and patients. For doctors he offers:

  • Listen to your patients, the diagnosis is in the history
  • Ask the patient what they are most worried about and address it
  • Ask yourself what doesn’t fit with the decision tree
  • And – this one I loved – don’t take gifts from drug companies!

For patients he has three major recommendations or “Asks”:

  • Ask – “What else could it be?” This question breaks up a diagnosis that has been formulated too quickly or the most familiar to the doctor.
  • Ask – “Could two things be going on to explain my symptoms?” As Groopman writes: “Physicians sometimes stop searching once they find an initial problem, even if the patient does not fully recover.”
  • Ask – “Is there anything in my history, physical examination, laboratory findings, or other tests that seems not to fit with your working diagnosis?”

These questions might help your doctor think outside the box and give you, the patient, some sense of being a part of a team rather than a bystander. It is also a way for a patient to encourage more effective listening and communicating as part of a doctor’s practice.

And if your doctor takes offense? Time to find another one or explain that you’re looking for a partnership not a dictatorship. Well, maybe don’t use that word but you get the idea. This is your body, your life, and you are paying for this service.

“You’re the customer – get your money’s worth” a good friend and a fine doctor used to advise me and all of his patients.

No hidden meaning here – I just liked the picture. Well, it is the year of the rabbit.


Photo credits: Doc on the cover – sasun-baghdaryan, women – linked in sales solutions, tree – raychan, pills – myriam-zilles, We hear you – jon-tyson, the adorable bunny – erik-jan-leusink.