Dr. Joshua Kosowsky & Dr. Leana Wen: "When Doctors Don't Listen"

MS. DIANE REHM

11:06:56
Thanks for joining us. I'm Diane Rehm. Studies show unnecessary medical tests cost the health care system an extra $250 billion each year, but more than 100,000 people still die from medical errors.

MS. DIANE REHM

11:07:16
In a new book titled "When Doctors Don't Listen," Harvard physicians, Leana Wen and Joshua Kosowsky, argue the root of the problem is bad diagnoses. They explain how the wrong diagnosis leads to cookbook medicine and unnecessary tests and they show patients how they can get better care from medical professionals.

MS. DIANE REHM

11:07:42
Doctors Wen and Kosowsky join me in the studio. I welcome your calls, 800-433-8850, or send us an email to drshow@wamu.org. Follow us on Facebook or Twitter. Good morning to both of you.

DR. LEANA WEN

11:08:02
Good morning.

DR. JOSHUA KOSOWSKY

11:08:02
Good morning.

REHM

11:08:03
Good to have you here. Dr. Wen, you had very personal reasons for writing this book, talk about those.

WEN

11:08:14
Thank you for having us on your show again, Diane, it's a pleasure to speak with you and to your listeners. When I was a medical student, my mother was diagnosed with breast cancer. But she wasn't just diagnosed with breast cancer, she went through over a year of misdiagnoses where she told her doctors about the symptoms she was having, of having a cough and feeling run down and these pains throughout her body.

WEN

11:08:39
She knew something wasn't right, but her doctors kept on saying, oh, you're young, don't worry about it. It wasn't until a year later that they told her she had metastatic cancer in her lungs, in her brain and her liver. And in that process, I learned how disempowered and how out of control patients can feel about their health.

WEN

11:09:03
And unfortunately, my mother passed away two years ago, but I know that she would have wanted me to write this book to share with patients and family members and caregivers about the lessons that we learned in the process of trying to get better health.

REHM

11:09:16
I'm so sorry for your loss. I want to ask, did you accompany your mother on those visits to the doctor? Were you asking questions as well as she asking questions?

WEN

11:09:38
I tried. So I was a medical student in St. Louis and my mother was living in Los Angeles.

REHM

11:09:44
I see.

WEN

11:09:44
But I went with her. But she didn't want me to ask a lot of questions and I suspect that a lot of patients feel this way too because you don't want to be, what patients think at least, you don't want to be the bad patient that's complaining and that's creating this trouble because patients are supposed to be the child in the relationship and the doctor is the parent. So people think.

WEN

11:10:09
So my mother was scared that if I asked questions that it would somehow make the doctor angry and that mentality is something that I'm working very hard now to change.

REHM

11:10:22
And of course, you, as a medical student, were in an even more vulnerable place as you confronted your mother's doctor. How about you, Dr. Kosowsky, did you have personal reasons for wanting to write this book?

KOSOWSKY

11:10:43
So I did -- not quite as powerful perhaps as Leana's story. I grew up in a medical family. My father was a physician and sitting around the table, I remember hearing stories of diagnosis and treatment from a very young age.

KOSOWSKY

11:11:00
One of the reasons I went to medical school like most people went to medical school and this is, I'm dating myself but this is nearly 20 years ago now, was number one to help people but number two because people are curious. Doctors are curious and patients are curious about what's wrong with them.

KOSOWSKY

11:11:17
And one of the reasons why I specifically gravitated to emergency medicine is because that's where so much diagnosis is meant to happen. People come in literally off the street with all sorts of complaints, young and old, and they don't typically walk in with a diagnosis stamped across their forehead and it's the job of the doctors there to figure out what the diagnosis is.

KOSOWSKY

11:11:36
To my chagrin, as I went through my medical training and then as I was a trainer of new medical students and saw how they were being trained, it became apparent that a lot of what we were doing was not focused so much on diagnosis, but focused on these pathways to rule out particular syndromes or diagnoses or to work up certain syndromes or diagnoses and leaving patients often as confused and as frustrated as when they walked in.

REHM

11:12:06
And do you think it is in part because patients don't ask questions?

KOSOWSKY

11:12:15
I think there's a responsibility on both the doctors' and patients' part and I've spent my career educating medical students and residents about the importance of getting to a diagnosis and it really is about getting to a diagnosis. Diagnosis is not always a destination you can reach in a defined period of time, but it's a process.

KOSOWSKY

11:12:37
And having a patient as a partner is critical to doing that. So doctors need to be open to engaging their patients. But we wrote this book because we feel like patients have a role in opening themselves up to doctors. And in some sense, maybe we'll talk about this a bit later on, giving their doctors permission to open up to them.

REHM

11:12:54
Dr. Joshua Kosowsky, he is vice chair at Brigham & Women's Emergency Medicine Department, assistant professor at the Harvard University Medical School. Dr. Leana Wen is an emergency physician, again, at Brigham & Women's and a clinical fellow at Harvard University Medical School. Do join us, 800-433-8850. I know everybody has a story to tell and we'll try to take as many of your calls as possible.

REHM

11:13:40
You call this cookbook medicine and why cookbook medicine is such a problem for patients. What do you mean, Dr. Wen?

WEN

11:13:51
I want to ask our listeners too if they've ever had this experience where they go to the doctor with a problem. Let's say you have a headache and the doctor spends some time listening to you, not very much. We know from studies that patients get interrupted in eight to ten seconds after they begin talking.

WEN

11:14:10
And then doctors begin saying, oh, do you have chest pain? Do you have shortness of breath? Have you had this before? They ask this litany of yes/no, close-ended questions rather than actually listening to the patient. And the reason this checklist happens is so that the doctor can try to put this patient into this algorithm of what's actually going on, not necessarily personalizing care to that patient but trying to fit them into something that everybody has, this cookbook, this recipe.

WEN

11:14:40
And this is our problem with it, not that inherently recipes or algorithms are wrong. In some cases they could be very helpful in treatment, for example if I were having a surgery.

WEN

11:14:52
I would want to make sure there aren't sponges left in my body. I mean, that's probably a good use for a checklist. But in the diagnosis process, the cookbook medicine depersonalizes people and leads to unnecessary tests and misdiagnoses.

REHM

11:15:06
But to what extent, Dr. Kosowsky, is time a factor? In other words, that doctor is trying to get as much information as possible as quickly as possible in that closed time factor and therefore it's not really a conversation. It's a question and answer period.

KOSOWSKY

11:15:29
So that's a really good question and it's a question that we get a lot from our colleagues and I hear people concerned even more nowadays where the time that you have with the doctor may be literally on the clock, 15 minutes and you're out the door because there's a line of patients coming through.

KOSOWSKY

11:15:48
I would say that there's no place that's more time-pressured than the emergency room when you think about it. The types of time pressures that we deal with can be remarkable and yet in my experience and in the experience of the folks that I've trained, spending a little more time up front can actually save time down the road.

REHM

11:16:05
Give me an example.

KOSOWSKY

11:16:07
Let me give you an example of that. Let's say, Leana talked about a patient who presented with a headache. So I could, with a few yes/no questions find some algorithm that would push me down a pathway to get a CAT scan or this or that blood test. Well those tests are going to take some time. I then have to go back to the patient, presumably to explain what those results are.

KOSOWSKY

11:16:27
Oftentimes, you find something that you might not have even been looking for. You find if you do enough studies, you'll find some incidental finding on the CAT scan that now needs to be followed up. Before you know it you're spending more and more time.

KOSOWSKY

11:16:41
On the other hand, if you spend just a little bit of time, it doesn't necessarily take hours and hours to just let a patient tell their story. Studies have shown that between 80 and 90 percent of diagnoses can be made just based on a story.

KOSOWSKY

11:16:53
Now I will grant you that if you happen to encounter, you run into a patient who is long-winded and wants to tell you their story...

REHM

11:17:00
Their life story...

KOSOWSKY

11:17:02
...and their history of their dog and their cat you could be there for a while. One of the reasons we wrote this book is to explain to patients how they can take their story which may be long and complicated and have lots of plot twists to it, and really narrow it down into a piece of work that they can present to their doctor in a limited amount of time without getting interrupted.

REHM

11:17:26
You opened the story. You opened the book with a story about a patient named Denise from New Hampshire. What happened to her Dr. Wen?

WEN

11:17:36
Our book is full of stories of patients that we saw and we talk about these stories to illustrate that really this could happen to anyone. Denise was a lady who came in with just some abdominal pain, some nausea, and some diarrhea. She wasn't feeling very well, but she wanted to make sure she was okay and that's the reason people go to see their doctor, to make sure that they're okay, to know what they have.

WEN

11:18:02
She ended up getting a CAT scan done of course because the doctor didn't really spend that much time listening to her story. And the CAT scan shows a finding that was a little concerning and so the doctor says, oh, we need to send you to another hospital to figure out what's going on.

WEN

11:18:20
And she gets sent to another hospital where they said, oh, no, this study. We need to do another study just to repeat it, just to make sure that we find out exactly what was the cause of this first problem. And so she goes through test after test only to find out at the end of the day there was nothing wrong in the first place.

WEN

11:18:37
But the reason we mention this is so many patients go through so many things for no particular reason.

REHM

11:18:43
Dr. Leana Wen and Dr. Joshua Kosowsky, short break and we'll be right back.

REHM

11:20:05
And just before the break, we were talking about a patient named Denise, one of many that Dr. Leana Wen and Dr. Joshua Kosowsky talked with when they were putting together their new book, "When Doctors Don't Listen: How to Avoid Misdiagnoses and Unnecessary Tests." What went wrong with Denise, Dr. Kosowsky?

KOSOWSKY

11:20:39
So it's a little bit hard to know for sure. But if you put yourself in the position of that first doctor, walking in a busy emergency room and a patient presents with abdominal pain and no doubt it seemed severe at the time as abdominal pain often is. And whether this particular doctor was working off an explicit algorithm, an actual checklist or equation or he was plugging in variables based on answers to yes/no questions or whether it was something more implicit.

KOSOWSKY

11:21:10
He was essentially foisting this patient down a pathway where he was committing her to a CAT scan to essentially rule out a number of things that must have been in his mind. Perhaps he was worried about appendicitis or he was worried about some other serious infection. But instead of using the history to explain what was going on, ordered a test and expected that to be the answer.

KOSOWSKY

11:21:40
Now one of the risks of ordering tests, in addition to things like radiation or exposure to contrast, which can cause allergic reactions, not to mention the cost. One of the risks of tests, which we have already alluded to, is that you may find something. And that thing that you find may not be what you're looking for, it may not even be real. And so in this particular case, the doctor found something or perhaps it was the radiologist who called him and pointed it out to him.

KOSOWSKY

11:22:08
There was something that didn't look quite right in the area of the pancreas. Now, again, if you took this patient's history and heard about the diarrhea and the cramps and the symptoms that she had had, you wouldn't at all think about the pancreas. But now that you're faced with an abnormality on a CAT scan, wow, you know, gee, you can't just write that off. So now, this requires additional testing.

KOSOWSKY

11:22:31
Well, this is a small community hospital. They don't have any pancreas specialist. Let's send them to the medical center where they can maybe do an MRI.

REHM

11:22:39
Did you ask questions?

KOSOWSKY

11:22:44
So I try not to ask questions, as I it turns out. And, in fact, I do an exercise with my medical students, which I call no questions asks, where I ask my students to go into a patient's room and take as complete a history as they possibly can and not to ask any questions. And, well, you're looking surprised.

REHM

11:23:04
Yes.

KOSOWSKY

11:23:04
I allow them to ask why questions and I allow them to ask how questions and questions that come up in a course of normal conversation, like, "Is your husband here with you?" or "what do you do for work?" That's okay. But no pointed questions, certainly no yes/no questions about the diagnosis that brought the patient there. I have to tell you, the look on my students is like the look you're giving me when I say you can do this.

KOSOWSKY

11:23:31
They say it absolutely can't be done because we need to fill out all this informational checklist to figure out what's going on. But after trying this two or three times, it's remarkable what kinds of histories that patients are able to provide to these doctors because the doctors stopped interrupting them with lots of questions. They don't lead them in directions that don't make sense.

KOSOWSKY

11:23:51
They don't pepper them with a long laundry list of yes/no questions that have marginal relevance. And they walk away actually understanding the story. Now, remember, these are medical students, so they may not be in a position to actually make a diagnosis, but at least they're heading in the right path.

REHM

11:24:05
Interesting. Dr. Wen?

WEN

11:24:08
So patients have a big role to play in making sure that doctors are telling the story as well. We emphasize in our book the eight pillars to better diagnosis. And the first pillar and the most important one is to tell a good story. And so what Josh was just talking about with doctors who ask yes/no questions, we show in the book how you can interrupt the process and to change the yes or no question into a how or why.

WEN

11:24:36
And to also say that if you know that you only have these 10 seconds to get across your story, because we know that's the average time to interruption, then you should really practice that story in advance. Write it down, practice it, use the other elements that you normally would use in a good story. For example, chronology. Start with a beginning and end with the end, and to use context such as instead of saying my chest pain was a 6 out of 10, say it was so severe that I couldn't get out of bed this morning.

REHM

11:25:06
That's really, really good, because even in talking with friends sometimes you'll say, well, how are you feeling, and it'll be something vague instead of something specific that comes through that gives you a hint of what's going on in their lives. Here's an email from Gary in Ohio. And this is clearly to the heart of what you all are talking about. He says: As a retired physician, I was disturbed by your lead that physicians follow too many decision trees and algorithms. Please have your guests discuss the litigative risks of not following such standards. There are the very decision trees and algorithms we are held to in the court room as standards of care. That's worrying doctors a lot. Dr Wen?

WEN

11:26:24
Fear of malpractice. We hear this all the time when we discuss our book. And the reasons for listening to a story and not relying on tests, we hear this from patients, we hear this from doctors saying, well, we don't want our patients to sue us because we didn't do this test. However, I have two comments to that. The first is, we know the most common reason why doctors are sued is because of lack of communication.

WEN

11:26:50
You know, we strongly believe that our approach, which is a partnership approach, we're not saying, don't order tests. We're saying, get the right diagnosis and let your patient help you in that process. If you actually treat the patient right and make sure that you -- that your patient is involved every step of the way in deciding tests with you, you as a physician are not going to get sued.

WEN

11:27:13
My second point about this, and what he mentioned, what Gary mentioned earlier with the email on decision trees. In the book, when doctors don't listen, we interviewed some key leaders who came up with many of these key decision rules. And they all emphasized that you should not treat them as rules, but rather as tools to help you think. And yet, physicians have gotten so far away from incorporating these rules, so-called rules, into their thinking process, but yet it's actually, event the pioneers of these rules, the people who wrote them and did the research to come up with them, they would argue that you have to look at the whole patient and only use the rules as a guide.

KOSOWSKY

11:27:56
I'd like to say something about the medical malpractice environment. I have some experience with this and I've spoken to malpractice attorneys about just this point. At the end of the day, the person who is going to judge you is going to be a layperson. It's gonna be a jury of your peers, are going to be sitting there, trying to figure out, does this make sense, what you did or not? Now, certainly there'll be experts, hired guns on both sides trying to point out why you did or did not uphold a specific standard of care.

KOSOWSKY

11:28:24
But at the end of the day, you have to explain to 12 people who are laypeople that what you did as physician made sense and it was in the best interest of the patient. What we're talking about makes sense and it is in the best interest of the patient. It's collaborative. It's engaging. And in most cases, it won't even rise to the level of an action because patients will understand exactly what was going on every step of the way.

KOSOWSKY

11:28:48
If you talk to malpractice attorneys, they will tell you that as much as it's about getting compensated, it's about proving to that doctor that I was right or my sister was right and you were wrong and you weren't paying attention.

REHM

11:29:00
It seems to me then that you're writing this book not just to encourage doctors to listen more but to educate patients as to how to give more, to be more specific. You talked about writing down what you want to say. I would argue that you've always got to have somebody else in that room. Every doctor's appointment that I go to with my husband and vice versa. I mean, there's always somebody else there who listens with a fresh pair of ears and may hear things the patient doesn't hear at all.

KOSOWSKY

11:29:56
That's -- that is so completely true. And the culture around that has certainly changed. In our emergency department, for example, we have done a complete 180 from a paradigm that was very much provider-centered. We want access to our patients, family members are ancillary, they can come in when we have time for them to a model where the patient and their advocate, whether it'd be a family member, a close friend, that person is central to the experience of the patient.

KOSOWSKY

11:30:28
And from our experience, not only is it a better experience for the patient, but it helps the doctors get to a better diagnoses and a better plan that really incorporates the patient's best wishes.

REHM

11:30:40
There's another story in the book I'd like you to talk about and that's the story of Jerry, the auto mechanic.

WEN

11:30:51
We begin the book with Jerry, who is in his 40s and is an auto mechanic. He was moving some boxes over the weekend and then woke up in the morning with this pull in his chest, which didn't feel quite right. But actually it felt similar to the pull that he was having in his arms maybe after moving too. But he'd always heard that if you have something somewhere between your belly and your neck, that you have to worry about this being chest pain.

WEN

11:31:17
And so, he goes to the ER. And in the ER, everyone says, oh, you have chest pain. And so...

REHM

11:31:22
Heart attack.

WEN

11:31:23
Heart attack.

REHM

11:31:24
Yeah.

WEN

11:31:24
We have to make sure it's not a heart attack.

REHM

11:31:26
Right.

WEN

11:31:26
We have to make sure it's not something else. And so he got shuttled to the x-ray room, to the lab, he gets blood drawn, he gets an EKG. He gets told he has to stay overnight. He runs on a treadmill in the morning. He gets more blood drawn. At the ends the of all this, a doctor comes in and says, congratulations, you don't have a heart attack. And he says, well, but what do I have?

WEN

11:31:46
And he says, oh, well, you have chest pain. But Jerry doesn't understand because he came in to the doctor with chest pain. How did he get a diagnosis of chest pain? What does that mean? And how is he supposed to get better? Is he supposed to be worried about this? Should he follow up? He has no idea. And we use this to illustrate how frustrated and dissatisfied so many people are with their care nowadays because there's just no...

REHM

11:32:09
So what could Jerry have done to improve his own care?

WEN

11:32:16
Well, we encouraged Jerry to use the eight pillars for better diagnosis. And we actually illustrate this in the book too. Had Jerry used the eight pillars, what would have looked like. So...

REHM

11:32:26
Give me the first pillar.

WEN

11:32:28
The first pillar is to tell a good story. And so, had Jerry followed that pillar, for example, he might have said when the first nurse heard his story and said, oh, you have chest pain, you need to come with me right now. He could have said, well, that's not exactly it. I felt this pull in my chest that happened after moving boxes. Again, this is something that Jerry and all of our patients need to practice well in advance.

WEN

11:32:52
Just as if you were talking to your boss and you have an elevator pitch ready, you need to practice this well in advance so that you don't sidetracked.

REHM

11:33:01
Second pitch.

WEN

11:33:02
The second thing, also extremely important, is to assert yourself in the doctor's thought process. All doctors are thinking something as they're seeing you, even before any tests are done. A lot of patients think, oh, well, let's get the tests first and then see what's going on. But rather, it should be the opposite.

REHM

11:33:21
Third pillar.

KOSOWSKY

11:33:22
The third is to participate in your own physical exam. So typically, when you go to a doctor for a full physical exam, there may be parts of the exam you don't even understand why they're being tested. Other times, it's very clear, you've got a rash and the doctor is looking at that area. But you may need to point out that you've got a rash somewhere else that your doctor is not looking at. So you need to participate.

REHM

11:33:45
And you're listening to "The Diane Rehm Show." We've got so many callers. I'm going open the phones and add their comments to our conversation. Let's go first to Julie in Tulsa, OK. Good morning, you're on the air.

JULIE

11:34:09
Good morning, Diane. I just wanted to, this really touched me because I took my dad to the doctor. He was diagnosed with rheumatoid arthritis. They didn't want to give him anything for pain because they were afraid he might become addicted, which was strange. He was 85 and had never taken anything. But anyway, he just kept feeling worst and so I would take him from this doctor to that doctor and we'd get these different diagnoses.

JULIE

11:34:37
And finally, he ended up in the hospital. They decided he had meningitis. Three spinal taps later, they determined it wasn't meningitis and the medicine they had had him on had just made him worst. Well, anyway, he ended up passing away. But a month before he did, they'd said, well, he's got lewy bodies dementia. But the thing is, is that after he died my uncle said, you know, the doctors killed him.

JULIE

11:35:07
And I feel like I assisted in that because I was the one that took him from doctor to doctor. And when they would say, you're just enabling him, make him do this, make him do that, and it's a terrible thing to live with.

REHM

11:35:23
It's a terrible thing to live with. But, Julie, somehow I cannot believe that you should bear so much guilt. I'm so sorry about your dad. What do you think, Dr. Wen?

WEN

11:35:42
Well, Julie, first of all, I really feel for you. And I feel with you, too, because I know it's hard as it is to not harbor the skilled. I harbor so much guilt about my mother's illness and death as well, because I do feel like there are, and looking back, there are all these things that maybe I could have done. There are these, at these doctor's appointments, things that I could have said or should have said.

WEN

11:36:06
But at the same time, you're father must have been so appreciative that you were there for him, that you were there with him every step of the way. And I think that is extremely important. I do think, though, that what you said also underscores the importance of a diagnosis because everything that you're saying when you brought your doctor, when you brought your dad to all these appointments that it really is about getting the diagnosis rather than just ruling out meningitis or ruling our this or that.

WEN

11:36:34
That it's actually about trying to find out what it is that he has. Why is he feeling this way?

REHM

11:36:40
You know, I talk to other individuals, friends of mine, whose parents have had such a difficult time getting a diagnosis. Why is that, Dr. Kosowsky?

KOSOWSKY

11:36:56
Well, we are in the generation now where we're taking care of our older parents or grandparents. We were just at a book event the other night and an older woman came up to us and said to us, what do you see when you look at me? And we weren't exactly sure what she was getting at. And she said, you can say it, you see an old woman. And her point was that people make assumptions that if you're old, you're chronically ill and maybe it's not as important to figure out what's wrong because it's chronic. This is a cultural challenge that we all have to deal with.

REHM

11:37:31
And the book we're talking about is titled, "When Doctors Don't Listen." Stay with us.

REHM

11:40:05
And welcome back. We'll go right back to the phones. Let's go to Potomac, Md. Darlene, you're on the air.

DARLENE

11:40:14
Hi, Diane, thank you for all you do and for your producers.

REHM

11:40:19
Thank you.

DARLENE

11:40:19
So my -- I'm talking -- from what I've heard -- conversations -- that my husband's a family physician and he's been practicing a long time. And the doctors that he is working with now are asking him to work with this electronic -- and you'll have to correct if, maybe, I'm wrong. But you have the electronic, kind of, information that you have to put in when you take a history.

DARLENE

11:40:48
And I hear him complaining that he -- there's no space there -- there's no way there that he can follow the patient and what they're saying in terms of writing the history down or recording it. And that he's kind of required to, you know, fill in these questions and he can't -- and his -- the reason he likes being a doctor is diagnosing. That is, to him, the exciting part. Is that -- is that what we're seeing, you know, as we move to electronic? And, if so, maybe some programs are better than others and should we -- if that's so should we, you know, really right now make sure that that's not going to happen?

REHM

11:41:42
Lots of questions.

DARLENE

11:41:44
OK, so I'll -- OK. There you go.

KOSOWSKY

11:41:48
So, Darlene, your husband seems to be a physician who would be very comfortable with our book, as well. He loves diagnosis. And I think most doctors do. When it comes to electronic medical records, you're right. They're not particularly good at capturing narrative. They're very good at capturing check boxes and, truth be told, a lot of that is driven by the coding and billing that is incumbent upon doctors in order to get paid in our current system.

KOSOWSKY

11:42:18
So it's unfortunate that that's the way a lot of charting has evolved. I can tell you on the receiving end when I look at a chart like that and I see just a litany of checked boxes filled out it's very difficult to figure out what's going on. And often you have to go back to the patient to find out what happened. But even worse, I think, is when you start using those boxes to then dictate not just what you're documenting, but how you're making decisions. And I think that's where it gets really scary for patients.

REHM

11:42:49
All right. And do follow up on that with Alex in St. Petersburg, Fla. Good morning.

ALEX

11:42:57
Good morning to you, Diane. And also good morning doctors. After practicing and teaching nursing for almost 40 years I've stumbled upon my little recipe of where the culprits lie in our healthcare delivery system. One, I'd like to briefly comment about algorithms. And it's very obvious to me that they algorithms exist for several reasons. One, to assist the physician in not missing an obvious diagnosis, but also it is also so clear that the algorithms exist so as to prevent the physician from missing the diagnosis and the sequelae of that behavior would be litigation.

ALEX

11:43:53
So my first bottom line is I think the main culprit in the healthcare delivery system is the attorney, the lawyer who is looming to nail the physician so quickly. And, secondly, when the physician in his or her gut feels that they have a diagnosis that is not on the algorithm and if, in fact, they order tests that are not on the algorithm in all probability the tests are not going to be paid for.

REHM

11:44:29
Dr. Wen.

WEN

11:44:30
Alex, I first want to say that what you do in nursing, practicing nursing and teaching nursing is so important, actually both Josh and I say frequently that we learned so much from our nurses because they tend to be really excellent listeners. One of the tips that we give in the book, for example, is to talk to your nurses and enlist the nurses as your advocates because very likely they know about you and your family member even better than the doctors do.

WEN

11:44:59
But to your about checklists, I agree with you wholeheartedly that they can be very useful in being a final check in making sure that we don't miss something. In making sure that everything is considered at the end of the day. Our only concern is when they're used to replace common sense, to replace the intuition that you were discussing. And that's also why the patient really needs to play such an integral role in advocating for yourself and loved one when you see these checklists being used on you in an unfair way.

REHM

11:45:33
Here's a Tweet from CSPAN who says, "I think patients become an intellectual exercise to many doctors. Their role ceases to be caring for the person rather than finding answers." Dr. Kosowsky.

KOSOWSKY

11:45:54
Well, I think if that's true that's very unfortunate because the way we look at it it's impossible to go through the exercise of diagnosis without engaging the patient as a partner. If you only look at it as a list of symptoms to be thrown into a box and subject to some very fancy equation and come out at the other end with an answer that may be intellectually interesting. And I think, unfortunately, there are some doctors who have made careers out of this. But at the end of the day for any individual what you want is a doctor who is taking your story seriously and not looking for a fast food diagnosis, but is looking to engage you in the process of getting to a diagnosis.

REHM

11:46:38
Here's an email from Amanda who wants to know -- she says, "I'm wondering who in your studies doctors are least likely to listen to or take seriously. May I guess women, the young or the elderly?" Dr. Wen.

WEN

11:47:03
There are conflicting studies about this. What we know from anecdotal experience is that it tends to be the people who doctors think will wax on and on, so to speak. So the story that Josh was referring with the older woman who thinks well, all you see when you look at me is an old woman. And you're not going to take my concerns seriously because you think I have all kinds of issues that I'm just making up.

WEN

11:47:30
When we emphasize and when doctors don't listen, though, is that's it not even about what that doctor may think of you. They'll have all kinds of assumptions about you. But you really need to take control of that situation and you really need to advocate for yourself to overcome whatever prejudices they may have because doctors all have their various biases. You don't know what they are, but no matter what it is you can make your doctor into the ideal doctor that you deserve.

REHM

11:47:56
All right. And to Durham, N.C. good morning, Aniel.

ANIEL

11:48:00
Well, hi there.

REHM

11:48:01
Hi.

ANIEL

11:48:02
Thanks for taking my call, Diane.

REHM

11:48:02
Surely.

ANIEL

11:48:03
And I'm -- this is the perfect time for me to ask my question.

REHM

11:48:07
Sure.

ANIEL

11:48:08
My problem is I'm out of college several years now, but back in high school and college I played a lot of soccer. And in 11th grade, I started developing a tear in my lower abdominal muscle called the rectus abdominis. It's called a sports hernia. Now this tear didn't hurt too badly, though. And the main symptom was neurological pain in my intestines and my testicle. And when I went to a urologist about this a year after that tear probably started happening, I was very prepared and confident -- all the things that the panel are saying that you should be.

ANIEL

11:48:42
And I concentrated in my story on the pain and the inflammation in my testicle which was, for a young man, definitely the most disturbing kind of symptom that I was experiencing. And he recommended an invasive surgery to correct testicular torsion. Took a month out of my life to recover from that and it was a total waste of my time and took several years after that for anyone to finally diagnose the thing properly. And I still have neurological pain to this day.

REHM

11:49:12
I'm so sorry. Dr. Kosowsky.

KOSOWSKY

11:49:15
Well, Aniel, what you described is a little bit like the old saying that when you're a hammer all the world is a nail. The neurourologist -- anything above the belt is really not in your "differential diagnosis." And so I think that's a problem with specialists. Not to say that there aren't great specialists out there who are great listeners, but it goes back to the decision to go to a specialist in the first place or for a primary care doctor to refer you to a specialist. By doing so you are limiting the scope of diagnosis considerably. And so it's hard to sit here in retrospect and blame the urologist...

REHM

11:49:54
Sure.

KOSOWSKY

11:49:54
...For making a diagnosis that -- or not making a diagnosis that was out of his -- out of his realm. But we see this happening very commonly.

REHM

11:50:02
Here's a follow up to that. An email from Margaret who says, "I went to the ER with severe pain under my right ribs. The ER looked at me for heart issues and the ER doc was heading in the direction that it was just unexplained pain perhaps from a heart murmur. It wasn't until I asked if it could be my gall bladder that the doctor agreed to look at that. And it was gall stones. The ER doc, to his credit, came back and said I was absolutely right. If I had not spoken up the tests would not have been done to get the right diagnosis."

KOSOWSKY

11:50:57
One of the reasons why we wrote this book is that, well, actually, at the end of the day, we're optimists about doctors. We think most doctors are actually teachable. They actually are pretty good students. They went through all that training. And so you, as a patient, in this particular case, the person that sent in the email, actually educated her doctor about how to be a better doctor. And my guess is the next time a patient like her comes in with pain like that he'll think about gall bladder maybe earlier on before doing lots of tests for her heart. So our book is an example of how you can improve the health, not just for you, but for the next patient, as well.

REHM

11:51:33
Let's go to Louisville, Ky., hi, Mike.

MIKE

11:51:39
Good morning, thank you.

REHM

11:51:39
Surely.

MIKE

11:51:40
I, too, would like to make two points. One is, I think, it's dangerous to use the word they instead of we. I'm speaking as a physician. I think that it's very important to include ourselves in the conversation. Secondly, as a rural physician, it's difficult for me to completely buy into the idea that posited by individuals that are in an academic environment that has the time.

MIKE

11:52:05
If I'm seeing three or four patients a day a lot of what I do is rely on algorithms and I make mistakes like everybody else. But I'm also not pressed to make diagnoses as much as to hear what the patient says. Nonetheless, I do have time constraints. I'm wondering...

REHM

11:52:21
Mike, I couldn't hear that last point. Let me ask you one question. How many patients do you see in a day?

MIKE

11:52:31
Well, I try to see about 30 to 35 to cover overhead. If I'm salaried that's a different story altogether. And I feel like I can take the time and I've been in both situations.

REHM

11:52:44
That's really an interesting point. He is not salaried. He has to move on to cover overhead, Dr. Wen.

WEN

11:52:54
Yeah, so, first of all, you're totally right, Mike, in that we are on the same side. It's not just us versus them. I'm not even sure who us versus them are because we are physicians, but we're also patients. And we really are on the same side in terms of aiming to get the diagnosis and to aim to help patients get better.

WEN

11:53:15
We do hear about the time pressures all the time. And what Josh and I were saying earlier is that we are emergency doctors. I mean we are aware of time constraints in the same way that a primary care doctor, specialist aiming to cover their overheads is. I mean we see traumas and at the same time -- in between traumas and people with heart attack and strokes we also have to see people with toe pain.

WEN

11:53:35
And, you know, it's -- there's so much that we have to see and 30 to 35 is something that -- well, 30 to 35 patients is something that we see in our practice every day, as well. The issue, though, is we still, at the end of the day, need to help our patients. In getting to the diagnosis we say is actually the most important because that's the basis upon which everything else depends.

REHM

11:53:57
And you're listening to "The Diane Rehm Show." Mike, do you want to comment further?

MIKE

11:54:04
It presents a conundrum simply because I think that in our society we're in a hurry to give a diagnosis as opposed to simply say I don't know. Let's see how this turns out. And in my day-to-day practice that's the challenge. I think that in books like this sometimes homogenizes individuals a little bit and it presumes that we're all of the same culture. And it winds up being very difficult for -- difficult for anyway to contemplate.

KOSOWSKY

11:54:32
So I agree with you, Mike. And I want to be clear that the point of our pillars about getting to a diagnosis -- as I said very early on is that it's not about getting a definitive diagnosis after 15 minutes. You know, the reality is that most of the time you can't get a definitive diagnosis. That diagnosis is a process. And you engage in that process with your patient.

WEN

11:54:53
And at the end of the 15 minutes or whatever period of time you have with that patient you need to explain to the patient where you are. And maybe we've gotten very -- we haven't gotten very far at all. We haven't really narrowed it down at all, but here's our plan going forward. Here's the things that we're concerned about and here's how we expect them to play out. Here's our working diagnosis. Here are some of the other things on the differential. It doesn't necessarily take that long and you certainly can't be expected to have a definitive diagnosis at the end of every single encounter.

REHM

11:55:18
Good luck to you, Mike. Thanks for calling. I know you're both against over testing. But, clearly, these technological breakthroughs have been very important in the advancement of medicine and diagnosis. Dr. Wen, what you're saying is don't over rely on them.

WEN

11:55:44
That's right. And, in fact, to aim our tests at specific things not just to test just to see what we get. So often we hear about tests being done to "rule out this or rule out that." And sometimes people even say -- you see the advertisements for the full body CAT scan just to see what's in your body to have the living anatomy. But why? What is the reason for this?

WEN

11:56:07
That's why we encourage our patients to take charge and to just ask their doctor every time what is this test for? What are the risks? What are the alternatives? Is this test going to change the management because, if not, why am I getting this done? The purpose of what we're doing is not just to cut cost. I mean we know that 30 percent of medical cost is waste. We think that's a problem for our society. But we think it's an even bigger problem for you, the patient, because these unnecessary tests have risks. They're not good for you overall.

REHM

11:56:38
Dr. Leana Wen and Dr. Joshua Kosowsky coauthors of a brand new book. It's titled "When Doctors Don't Listen: How to Avoid Misdiagnoses and Unnecessary Tests." I think this is as much a primer for patients as it is for physicians. Thank you both.

KOSOWSKY

11:57:07
Thank you, Diane.

WEN

11:57:09
Thank you, Diane.

REHM

11:57:09
And thanks for listening all. I'm Diane Rehm.
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