Dr. Joshua Kosowsky & Dr. Leana Wen: "When Doctors Don't Listen"
http://thedianerehmshow.org/shows/2013-01-24/dr-joshua-kosowsky-dr-leana-wen-when-doctors-dont-listen
The United States spends $2.5 trillion on health care, accounting for more than 16 percent of our gross domestic product. But more spending has not translated into better results: the U.S. consistently ranks below other countries on delivering quality health care. A major culprit in rising costs is medical testing, which totals $250 billion extra every year. In a new book, two Harvard doctors say physicians rely too much on algorithms and formulas to make a diagnosis, leading them to order unnecessary tests. How to get the right diagnosis and better care from your doctor.
Guests
Dr. Joshua Kosowsky
vice chair, Brigham & Women's Hospital Emergency Department; assistant professor, Harvard Medical School
Dr. Leana Wen
emergency physician, Brigham & Women's and Massachusetts General Hospitals; clinical fellow at Harvard Medical School
Read An Excerpt
Excerpt from "When Doctors Don't Listen: How to Avoid Misdiagnoses and Unnecessary Tests" by Leana Wen and Joshua Kosowsky. Copyright 2013 by Leana Wen and Joshua Kosowsky. Reprinted here by permission of Thomas Dunne Books. All rights reserved.
Comments
Please familiarize yourself with our Code of Conduct and Terms of Use before posting your comments.
Please ask the panel to address several potential issues:
a.How can an untrained neophyte patient hope to properly advocate for one's own health either for good outcomes or cost effective spending on tests and treatments?
b.Most physicians have invested many years and great expense in education and hands on experience. Some develop a near "God complex" and feel such superiority that they downplay the intelligence and self worth of patients, and even the potential usefulness of technology and expertise in other areas. (a surgeon recently said he eschewed databases, electronic medical data, and the use of software in ANY way in medecine......"No records system can hope to provide the detail and complexity of what I need".) How can proper care come from a know-it-all?
c.How can medicine shift away from fee for service billing to true health CARE outcomes while allowing providers to receive appropriate compensation during the transition?
d. How can the profit motive in medicine be normalized to serving real care per the Hippocratic ethic, not "all the traffic will bear", especially regarding insurers?
(Insurers bring little to the table in patient care.)
Be careful going to the doctor because they are often financial predators. Take an advocate with you as an adviser and witness. Submit a written account of your complaint and history . (Beware if it is refused.) Most doctors conduct staff meetings to instruct their employees in maximizing profit. It's almost like having a McDonald's Menu of Medicine on the office wall. Your complaint or condition is forced into crude categories for operational convenience. (Environmental, dietary and occupational causes of illness are particularly avoided. Every ailment must be suggested to be caused by patient fault.)
Once inducted into a disease category and labelled it is difficult to extricate oneself. Subsequent practitioners hesitate in contradicting earlier ones. (professional courtesy?) With your new label you become a profit center of reimbursement and frequent charges, even kickbacks from referral. Remember: Our medical system is probably sicker than you are when you seek treatment, and it is getting sicker by the day.
I'd like to hear addressed the idea that surgeons push surgery. I have a friend who has had many unnecessary surgeries, because the Dr. told her she needed to. Never got second opinions, never once questioned diagnoses. Five years later, she's still ill & covered w/scars. I doubt she needed even one of the operations.
What does it take to give the patient the confidence to question their Doctor? And why do so many doctors get defensive when questioned.
Also, I confess I don't always tell my own doctor the whole truth, due to fears of what is written in my file & reported to my insurer. For example, I'd NEVER tell my doctor I needed mental health help, if we had public insurance I wouldn't feel afraid to tell my doctor anything. How much does that impede my health care?
Dentists seem to be the worst for sales pitches in recent years. Refusing expensive optional treatments causes a lot of friction between me & my dentist.
Jom: Your observation about "pushing" specialties (by surgeons and others) is accurate. Remember that physicians hire consultants who teach strategies to maximize income.
But your observation of "friction" from rebuffed sales pitches is even more intriguing. I suggest we can better understand these behaviors if we compare the dentists' offices to new car showrooms. It makes one wonder if dental staff may work on commission or if the "hurt" reaction when the customers don't bite is trained and feigned. One must remember that reimbursements for dentistry are much less common than for other medicine. Because half of us can't afford dentistry we have too many practitioners for the participating population. If we included dental care in our national health plan they'd have an easier time making ends meet. No wonder our overall outcomes are so poor when we abandon the preventive procedures of dentistry, Oral health has proven directly related to heart health. Not to criticize people who have lost their teeth, but wearing dentures is about as much of an inconvenience as having one artificial or missing limb. Those of us with missing and blemished teeth (Mine are not that attractive so I know.) are often rejected out of hand for opportunities and many are relegated to an underclass. Bad teeth and poverty are synonymous for the most part. The conservative epithets to the disadvantaged (should have planned better, and take personal responsibility) are particularly discredited and revealed as sadism when you consider how discrimination and unfairness result in sick mouths. A better pair of dentures now costs about $5,000... about half the cost of a funeral. Dentistry itself is a terrific demonstration of how poorly the private market works in general.
A bit more than 2 years, I went to my doc many times complaining of exhaustion. She said I was anemic because of fybroids and of course I was tired, I had adopted 3 special needs kids. After 6 months of going back and forth, a trip to the ER for collapsing, and then having unnecessary surgery, it turns out I had acute myeloid leukemia.But not after fungal pneumonia was diagnosed as an upper respiratory tract infection. When I finally got a doc to listen to me, my ob/gyn, he ran a series of blood tests and the cancer was discovered, literally just in the nick of time. I wasn't expected to survive the fungal pneumonia and/or the cancer but I did, thanks to one doc that actually listened to me.
Hi Diane,
Please extend this story to your guests, I am available for them if they have questions, i suffered from a birth defect and interactions with doctors is very important to me.
Last year I had a major surgery. It took me 10 years after first diagnosis to finally get to need it, kept avoiding it by informing myself about my status having sporadic x-rays to keep track. Until it finally was undermining my lifestyle, I took the endeavor of searching for a surgeon that I WANT! after interviewing 9 (NINE) doctors, one seem to fit my criteria:
a. Good bedside manners
b. Comprehensive in his questions, that he actually asked something related to me
c. Face to face time
d. Did not spend all the time with assistant, and his assistant was a reflection of him and his philosophy
e. Not rush me out
d. I liked the hospital
f. Recup time after surgery
g. Type of procedure
h. Is he/she the top on what he does
My only downside is that he does not participate with ANY insurances, so I have to pay out of pocket and than file my insurance. How convenient isnt?
Have a nice day
Diane:
I am a medical anthropologist. As the U.S. becomes a minority-majority country, the sad issue is not just asking the RIGHT questions but rather understanding what the answers mean and what to do with the information given to them by the patients. We get stuck with pills and bills rather than goodwill.
Kate
Kathy- For your kids' sake I'm glad you made it!
You are probably affluent and well-educated with some status in the community. You are articulate and confident. What does it say when doctors won't listen to "the cream of the crop"?
The people I advocate for have it so much worse. No wonder they tend to avoid doctors until they are dying.
Our ER physicians pay is now substantially based on "bonuses", determined by how quickly they free up the ER rooms. With the business model driving more and more of health care, this is probably the only hope an individual has to get any quality health care in the future.
Can the Dr.'s please address the proper way to confront/question a physician's treatment plan particularly if the doctor becomes defensive? My daughter has had two recent experiences with doctors who don't want to listen/respond to patient questions regarding the treatment plan. I taught my children that they should be their own patient advocates and make sure that all of their questions and concerns are addressed before they blindly accept the doctor's decision. In one case, my daughter told the physician (not her regular doctor) that she was experiencing severe nausea and vomiting. She explained that she had been camping with her fiance and that they had eaten some undercooked chicken. The fiance was experiencing the same symptoms and both began to experience symptoms on the same day. Her doctor insisted on sending her to a nearby ER for testing to "rule out" appendicitis. When questioned he told her that "he was not treating the fiance and did not know what he had" and that she should submit to the tests or "he would not continue to treat her". It was late on a Friday afternoon so she went ahead and had the tests. The resulting ER bill was $16,000 and it was determined that she was not suffering from appendicitis and, indeed, had a gastrointestinal problem.
I am a nurse practitioner recently laid off from a medical school. I applied for a job at a federally qualified health clinic to see maternity pts. I would have 34 pts scheduled every! day, to makes sure 28 - 30 r seen. This is not possible and have time to review labs, call pts etc. This ia a big problem
I would like to encourage listeners to be proactive with their health. A few years ago, I began experiencing stroke-like symptoms in the middle of the night. I was rushed to the hospital by ambulance, and after a series of tests, the only thing the ER doctors could find was a UTI. My symptoms subsided, and I was released but told to visit my primary care physician, which I did the following day. She told me nothing was wrong, that UTI's could do strange things to the body. I wasn't satisfied and asked to be referred to a neurologist. She tried to talk me out of it, saying it was a waste of my time and money. I was insistent, though, and was referred. The neurologist told me that I was too young (26) to experience that type of symptom from a UTI, and after a couple of lumbar punctures, she discovered that I had viral meningitis. I never would have known if I hadn't been determined to find an answer.
I hear constantly from medical people that I have to be my own advocate, I have to ask the right questions, I have to follow up on tests, etc. But I don't have a medical degree! I don't know what I don't know, so how can I possibly ask all the questions I need to ask?
Mostly, why am I spending all this money to visit a doctor or dentist when they seem expect me to pretty much figure out what problem I have or which symptoms are important before I walk in the door?
katereed- Do you mean to suggest that America is not monocultural (as many conservatives argue)? Wow! If we are multicultural allopathic capitalist medicine has been pursuing a nonproductive course for some time. No wonder we are now in the "horse latitudes", cooking over a currency fire and eating our shoes. Thanks for chiming in Dr. of Anthropology. Live long and prosper. (i think our authors need to consult Anthropology because diversity improves medicine.)
The elephant in the room: defensive medicine
Physicians, in many cases, have to follow algorithms, order tests and provide potentially irrelevant documentation during patient encounters solely to protect themselves against malpractice litigation.
Further physicians must comply to insurance provider standards for a given diagnosis to be reimbursed for the care provided. If approved algorithms and documentation are not followed, the physician and health care facility will not be compensated.
Please comment on these realities with respect to your premise.
I'd like for all front line doctors and dentists to be thoroughly trained for screening for TMJ disorder. Signs and symptoms include headache and neck pain, ringing in the ears, dizziness and a myriad of other indicators. I spent a year undergoing invasive and irrelevant tests trying to get to the bottom of extreme and excurciating headaches before I deducted on my own that i was suffering from nocturnal clenching headaches. This was my warning sign that a more serious TMJ dysfunction was a possibility. It took me another ten years to find a Dr skilled in treating my condition. So many like me are suffering unnecessarily. Physicians are largely ignorant of this condition. Please please interview tmj professionals in regards to this disorder. thank you.
Suzanne: Even when you've figured out your malady they don't listen. If you persist you're a problem patient and mentally unstable. Inquisitional financial extraction trumps treatment. Good luck, buddy. Stay well.
theo- Capitalism and the profit motive are the elephant dung on doctors' shoes. We need universal care without private profit. Anything else is predatory.
Having worked in ICU settings for 20+ years in a major hospital, I've learned that I'm probably better off avoiding doctors wherever possible.
Why should a patient have to create a new persona, have a already self-diagnose before they go on for a six minute Md visit ?
It is amazing and ridulous
?
Electronic medical records r for billing not to follow a problem
Electronic medical records r for billing not to follow a problem
I agree with fheo. We need to address defensive medicine. Unneccessary testing, done to avoid malpractice scrutiny, is always a problem. Even more of a problem, in my experience, is the inability of health care providers to use many more physician-extender practitioners (nurses, nurse-assistants, nursing aides, etc.) to deal with patient questions and concerns, and to offer lower-level non-acute care, without fear of being accused of malpractice because the doctor did not see the patient.
Republicans tried, threatened, cajoled, agrued, etc., for broad national malpractice reforms in the Affordable Care Act. But because it was passed as a one-party directive, and because the trial lawyers are some of the most persuasive paymasters of the Democrats, almost no malpractice reforms were included. The President threw in some federal money for 'malpractice reduction study projects.' Nothing else.
Please discuss pansycandyass syndrome, too many people going for unneeded professional treatment for the most minor ailments. Things that would just go away if they waited a week. My opinion is with just like anything else, remove the knowledge and burden of the costs involved and people use a resource irresponsibly and therefore ruin proper treatment for those that really need it.
Hello, I am a retired alternative health care provider, and always sat down with the patient for a case history and asked the questions of the patients. I was taught in school, that "if you really listen to the patient, by the end of the case history, you will be fairly sure of what their problem is". This willingness to listen to my patients was something that many patients commented on, telling me that their "regular" doctors did not listen as much. I encouraged them to ask questions and continue to engage in dialogue with their doctors. If the doctor will not be on your team in this way, perhaps it is better to find another doctor.
susan barry- Any para-professioal like yourself should not have to stay late every night and come in weekends to do paperwork. It undermines your abilities.
This 'Stretch-out" reaches across the American workplace and is unreimbursed productivity extracted by force from we who labor. This is why union organization is so important. Our older experienced practitioners and artisans are generally being squeezed out because they provide a nagging institutional memory to when job duties and scheduling were more equitable, to when things were more efficacious in general. Younger people burn themselves out now doing sloppy and pointless work to please an ever more pressurized management. This is particularly evident in the claims aspect of insurance work where I've been researching. Most chaotic and increasingly unfair is the disability insurance field which involves medical evaluation. Many senior nurses try case evaluation in this industry for awhile to great frustration. Claims reps cut off the poorer with a valid claim and continue the more affluent who lack a basis for benefits, and this is due to the legal threat. Congress needs to conduct hearings on this profit center.
So i the patient, if I follow all the eight steps ,can make my doctor a better doc
So, if my script, my' good story' does not engage him/her
enough it is somehow put back on me to get a good diagnosis
How many doctor's visits can you afford to go to before giving up? How much work can someone miss? I complained for two years of abdominal pain, shoulder, back and sent for one x-ray after another, ultrasounds, MRI, until finally after two years of complaint my blood platelets tested abnormally low and Hepatitis C was diagnosed. No one in my city knows very much about this disease, have to go to another city, but by the time a simple blood test for hepatitis was ordered I am now in stage 4 liver cirrhosis, went into a hepatic encephalopathy pass out, wrecking my car. I can hardly get a straight answer from any doctor until sent to hepatologist at a center in another city. Even now, off work for the last couple months waiting to see if I will qualify for a transplant. Unbelievable costs, I am considering bankruptcy at this point to try and hang on to my home at least.
If discovered two years ago I wouldn't be at this late stage of the disease, and who questions these doctors with their threats of not prescribing or treating you? Who COULD pay without some insurance assistance?
susan barry 2- Yep, it's always the patient's fault. That is a our prevaling medical model (and script) in media and education. Surprised? (Dr. Oz is the master of blame propaganda.)
Diane is correct that most doctors are just as perplexed as their frightened and frustrated patients. That's the recipe for a structural problem. I think our economic system is at the root of it all. The USA is the craziest Libertine Capitalist nation in history on Earth. We need to exempt medicine from this crapshoot. Otherwise it's genocide.