August 15, 2006
The Consumer
Patient Power: Making Sure Your Doctor Really Hears You
By DEBORAH FRANKLIN
It’s one thing to feel like a master of the universe when wearing a
buttoned-down power suit. But how can you negotiate anything — how can you
even
contemplate “Getting to Yes,” as one motivational best seller puts it —
when
standing barefoot in a paper gown under the fluorescent lights at a hospital or
a
medical clinic?

Research shows that although most people claim to want as much information
about their medical conditions and treatments as they can get, even the most
confident are struck dumb — or at least awkward, anxious and often
ineffective
— when talking to doctors.

The power gap often shuts patients down.

“My doctor’s great in most ways,” said Katherine Rosenberg-Wohl, a
Harvard-trained lawyer turned playwright who has stood up to more than her
share of
glowering judges and corporate stiffs.

“If we need to talk about something important, he waits until after the
exam, after I have my clothes on, and has me come into his office,” she said.
“
But even that doesn’t help much.

“He’s still the guy with the white lab coat behind the giant desk. He’s
moved on to being David Letterman, and I still feel like the schlub in the
paper
dress.”

In the last few years, medical schools have started trying to bridge this
gap by teaching students clinical communication skills — Bedside Manner 101.

As part of earning a medical license, for example, third- or fourth-year
students are now required to face actors playing the roles of patients with
myriad diseases and dispositions.

The students are then tested on how well they interview the patient, conduct
the physical exam and convey the findings to the patient and to colleagues.
Empathetic skills are considered a big plus.

The training doesn’t stop after graduation. In March 2005, the Communication
Skills Laboratory at Memorial Sloan-Kettering Cancer Center began offering a
series of three-hour interactive workshops intended to give hospital
oncology residents practice in “Breaking Bad News,” “Discussing
Prognosis” and “
Responding to Patient Anger,” among other touchy topics.

Still, with all the emphasis on doctor-patient communication, the patient
side has largely been neglected.

Sure, there are plenty of patient “empowerment” Web sites and books, like
“
You: The Smart Patient: An Insider’s Handbook for Getting the Best
Treatment,”
published this year. Written by two physicians — Michael F. Roizen and
Mehmet C. Oz — the book is a well-written guide, packed with pep talks and
tips
to help patients cut through medical jargon, find a good surgeon or hospital,
get a second opinion and navigate health insurance problems.

But like others in its genre, the book tends to skimp on the rules of
etiquette and body language that can transform a hostile or misunderstood
exchange
into a smooth connection. It offers a checklist of 34 questions you should
ask your doctor before surgery, but it doesn’t provide guidance on how or
when
to raise those questions — or even how to get through the list — without
alienating the guy who’s about to carve you up.

Under the time pressure that is part of any medical visit, how exactly do
you respectfully disagree with your doctor and still get the help you need?

Virginia Teas Gill, a medical sociologist at Illinois State University, said
the number of encounters that require a negotiation between the doctor and
the patient seemed to be on the rise.

This is not just because of the time and financial squeezes imposed on every
visit by health insurance companies but also because new therapies and
sensitive scans and tests are permitting diagnosis and treatment for many
diseases
much earlier than ever before. Lumpectomy or mastectomy? Injectable insulin
or a pump? Statins or simply more exercise and less food?

In many cases, Dr. Gill said, when and whether to treat has become as
legitimately debatable as what treatment to use.

Some patients show up to a scheduled appointment with a fistful of
questions, “and that’s fine, that’s very good,” Dr. Gill said.

“But,” she continued, “to get them answered, write the questions down
beforehand, and say at the outset of the office visit: ‘I’ve got some
questions.
When would be the best time for me to ask them?’ ”

That alerts the doctor — who has to keep an eye on the time — to what the
patient’s agenda is, so that the two can prioritize what to cover and decide
whether they’ll need a follow-up meeting, Dr. Gill said.

Richard Frankel, a medical sociologist at Indiana University who helped
develop a training program that Kaiser Permanente is now using to teach its
doctors to be better listeners, suggests that medical encounters often go wrong
because doctors assume that the first symptom or concern a patient raises is
the only one — or at least that it’s the most important.

Instead, Dr. Frankel said, studies show that the most important symptom or
worry — a suspicious mole or lump, for example, or the feeling that life
isn’
t worth living — is often the third or fourth item on a patient’s list,
blurted out at the very end of an appointment. This may be because the patient
is
afraid, the problem is hard to admit or the patient didn’t understand how
medical exams were typically structured.

Dr. Frankel advises patients to put all the items on the table at the start
of a visit. If the doctor interrupts to focus on the first problem, say
something like: “You know that’s one concern, but maybe not my most
important.
Could I give the full list before we go on so we can prioritize?”

Rather than be offended, most doctors are likely to listen more attentively,
he said.

“Patients always have the right to question or refuse treatment or tests,”
Dr. Frankel added. “Anyone worried about offending the doctor might find it
easier to begin such a discussion with something like: ‘Could you please
review the benefits of this treatment for me again so that I can write them
down?
Good. Now, could we talk about risks, too? O.K, so tell me again why you
think the benefits outweigh the risks in my case?’ ”

Patients can improve the quality of their care — and their lives — by also
being straightforward with a doctor, but as specific as possible.

“Instead of asking, ‘Is it important that I start the chemotherapy next
week?’ don’t be afraid to tell the doctor: ‘My cousin’s wedding is next
week,
and I’d like to go. Would it be O.K. to start the chemo after that?’ ”
suggested Carma Bylund, a behavioral scientist in the psychiatry department at
Sloan-Kettering who helped create the hospital’s communication skills program
for students.

Bringing a trusted friend or family member to the exam can also help make
sure that delicate questions are asked and answered.

Preliminary research suggests that the Internet is already transforming many
medical encounters, Dr. Bylund said. Some patients now come armed with
sheaves of journal articles and printouts, and demands for specific treatment.

However, she cautioned, just because patients now have access to much of the
same information that doctors do doesn’t mean they have the expertise or
experience to weigh that information.

Doctors don’t like confrontation any more than patients do; they may give in
to a patient’s request if it is made in an assertive manner. In a study
under review for publication, Dr. Bylund found that patients who persistently
asked for a specific treatment or test, based on Internet research, were more
likely to get it than patients who came in with a vague list of symptoms, or
who were more deferential to the doctor.

But be careful, she warned. Anyone who treats a doctor as a dispensary
instead of a trusted medical guide loses the advantages of the physician’s
experience.

Negotiating to win, in this case, may get you what you want, but not what
you need.





[Non-text portions of this message have been removed]