Inside a Doctor's Diagnosis
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Inside a Doctor's Diagnosis

Sure, doctors are highly trained -- but they're still only human. And sometimes they're wrong about what's wrong with you.

Getting the Most Out of Your Doctor

Is it possible to get good medical care from a doctor visit that lasts just 15.7 minutes? That's the average amount of time patients spend with their physicians per visit, according to a recent study from the Texas A&M Health Science Center -- and it includes both the physical examination and any time you spend talking about your problems and treatment. If your visit is average, you and your doctor will discuss about six separate concerns, spending some five minutes on the major topic and allotting a little more than a minute to each of the others.

This doesn't leave much opportunity to have a thoughtful discussion about your health, especially if you have several worries. Adding to the challenge: A doctor typically interrupts a patient after an average of 18 seconds, according to a landmark study from the '80s.

Then you face another challenge: getting your physician to give you enough time to explain what's going on before he or she arrives at a diagnosis and treatment plan. While doctors are encouraged to include patients in medical decisions -- a practice known as "informed decision making" -- not many have embraced the concept, according to a 1999 study in the Journal of the American Medical Association. They argue that there isn't enough time and question whether patients really want to be so involved.

Many physicians don't even tell patients why they are ordering a laboratory test or prescribing a medication. A 2006 UCLA study in the Archives of Internal Medicine reported that often doctors don't discuss the purpose or potential side effects of medication or even the names of drugs they prescribe. This is a significant problem because understanding the risks and benefits of a treatment makes patients likelier to consent and adhere to it.

And it's not only patients who lose when there's a communication breakdown. Doctors who score poorly on patient-physician communication tests are likelier to be the recipients of complaints to regulatory authorities, a recent Canadian study published in the Journal of the American Medical Association found. They may even be sued more often: "The most frequent instigator of malpractice claims is the patient who feels insulted or ignored," says Richard Frankel, PhD, a professor of medicine at Indiana University School of Medicine and an expert in doctor-patient communication. "Many patients could sue because of a bad outcome but don't because they have a good relationship with their doctor."

Contributing to the communication shortfall is the pressure many doctors are under, in this era of tight finances and managed care, to see more and more people -- an average of 20 per primary-care physician every day, according to a 2002 study in the New England Journal of Medicine. This places working fast at a premium. Even doctors who want to draw out information from patients that can clue them in on less-obvious symptoms and help them make a correct diagnosis may simply not have time.

As a result, doctors often rely on various mental shortcuts called "heuristics." These techniques tell them that certain combinations of symptoms generally point toward a specific diagnosis: A patient with X, Y, and Z almost always has Q wrong with her. Heuristics work much of the time but they can also be cognitive traps that can make your doctor miss what might be a more unusual but correct diagnosis, at least initially. One sobering look at the ultimate bottom line? An analysis of autopsies published in the Journal of the American Medical Association found that doctors make major diagnostic errors 8 to 24 percent of the time.

What to do? From the get-go you need to be an active, engaged participant in your own healthcare. If you're lucky enough to have a doctor who does hear what you say and tries to keep you informed (see "3 Signs Your Doctor Is a Good Listener"), your part is to describe your health problems clearly, pay attention to the choices you're offered, and follow through on the treatment your physician develops with you, reporting back how it's working. If your doctor tries to steamroller you into passive-patient mode, push back by interrupting, asking for clarification, and showing that you want to be involved. Remember, the informed decision-making school of medical care is on your side, and doctors who don't practice it are out of step.

When you are being treated for an ailment, you also need to watch that your doctor is not falling into those cognitive traps, especially if the first attempt at treatment doesn't seem to be working. To be fair, not every doctor can be expected to get every diagnosis right the first time. But if after a week or two your symptoms don't resolve, fail to respond or worsen, speak up.

The following information will help you understand how your physician looks at you from the first moment you meet and which techniques he or she may be using to diagnose your problem. Use this guide to identify each technique and to respond, if you need to, in ways that help your doctor see you and your case in a fresh light.

 

The "Doorway Diagnosis"

Even before you say hello, your doctor is already assessing the way you sit or stand, the tilt of your head, your complexion, and other aspects of your appearance to assess whether you look healthy or sick. For instance, an unusual pallor may suggest anemia or extreme pain, while bloodshot eyes could mean a fever or a virus, explains Jerome Groopman, MD, a professor of medicine at Harvard Medical School and author of How Doctors Think. Just by looking at a patient who appears unwell, the typical doctor comes up with two to three possible diagnoses within minutes, says Dr. Groopman. He or she may also already be forming an opinion about how easy or difficult a patient you are likely to be. Of course, the doctor could also be wrong, especially if you don't look as ill as you feel; maybe you're always cheerful and energetic or just came from the office and are wearing makeup.

YOUR JOB: To make sure your doctor doesn't get the wrong first impression of your situation.

WHAT TO DO: "Don't hide how you feel," advises Dr. Groopman. "If someone is pale and anemic I don't want her coming in with rouge on her cheeks. We need patients to help us think, both in terms of giving us information and keeping us from making errors." "Let your doctor know what you are most concerned about at the start of the visit," advises Dr. Frankel. "That will almost always ensure that your doctor will listen more carefully." Describe your symptoms concisely but thoroughly. It's not enough to say "I feel lousy" or "my shoulder hurts." Instead say "I started feeling nauseous five days ago and I get a pain in my stomach about 15 minutes after I eat." Or, "I have a dull ache in my shoulder, but when I swim -- which I do five days a week -- I feel a sharp pain."

Selective Vision

The term for this is "confirmation bias" and it means the doctor subconsciously picks and chooses symptoms that confirm the diagnosis he or she suspects. Or early on he or she may lock on to certain symptoms that point to a given health problem and fail to adjust his or her thinking as he or she gathers facts that contradict it -- or fail to seek those facts.

For example, you make an appointment to discuss the chest discomfort you've been experiencing because you're afraid you could be having a heart attack. Your doctor suspects heartburn, a diagnosis your symptoms support, but doesn't order tests for heart disease. "Doctors often look for confirmatory evidence so they don't have to keep looking further," admits Mehmet Oz, MD, director of the Cardiovascular Institute at New York Presbyterian Hospital/Columbia University Medical Center and coauthor of You: The Smart Patient.

YOUR JOB: To get your doctor to consider other possibilities.

WHAT TO DO: Pay attention to how your doctor processes the symptoms you're describing. "If your doctor interrupts you to get more-specific information and then encourages you to keep going, that's fine," says Dr. Groopman. But if you are interrupted and the doctor says, "I think you have X," your response should be: "But I want to make sure I tell you everything that is going on."

"If you don't," Dr. Groopman explains, "that deprives the doctor of the full breadth of information he or she needs to come to a good working diagnosis. It could be the fourth symptom on your mind that will be the key clue."

If you aren't satisfied with the doctor's diagnosis, say something like, "Please help me understand. These symptoms are bothersome and I am concerned that something serious might be going on with my heart, so could we just go over things again?" advises Ronald Epstein, MD, associate dean for educational evaluation and research at the University of Rochester School of Medicine and Dentistry, in New York.

The goal is to prompt your physician to explain her reasoning in a way that addresses your fears: "It sounds as though your chest pain is sharp, but heart pain is dull. You don't have shortness of breath, which is common with heart problems." If you're still not convinced, ask for further steps to be made to clarify the situation. A 2005 study at the University of Arkansas for Medical Sciences found that many women who eventually suffered heart attacks had been initially diagnosed with stress.

The "Everyone Has It" Trap

Your doctor's diagnosis may be influenced by what is going on in the community, a bias called "availability" because it means the tendency to choose the likeliest, top-of-mind explanation. Say you have a fever, ache all over, and have an upset stomach. It's flu season and your doctor's waiting room is filled with flu cases. It stands to reason that you have the flu, too. But maybe you don't. The main reason doctors fall into this trap: "premature closure," the failure to consider other alternatives after an initial diagnosis is made, according to research in the Archives of Internal Medicine.

YOUR JOB: To make your case stand out if you think something else might be wrong.

WHAT TO DO: Dr. Epstein says you should say something like: "I know you think it's the flu but I have had the flu before and this feels different. Could something else be wrong?" An Archives of Internal Medicine study suggests that one way a doctor can minimize cognitive errors is to assume a diagnosis is incorrect and ask herself, "If this were anything but the flu, what would it be?" Try asking your doctor, "If the flu weren't going around, what other conditions would you consider?" says Dr. Epstein.

Laws of Averages

One diagnostic tool physicians use more and more is evidence based medicine, which was developed to help them boil down research on different illnesses and treatments and apply it to individual cases. The doctor uses algorithms, comparing your symptoms with charts compiled by medical organizations, to arrive at a diagnosis and the treatments that work best. Most of the time this helps physicians make the correct diagnosis. "They are useful, evidence-based reference points," says Dr. Groopman. Problem is, they may not fit your case, especially if the treatment plan you've been following isn't making you better.

YOUR JOB: To get your doctor to look further.

WHAT TO DO: Say, "I don't seem to be getting better. Is there something else we should look at, or do I need to wait longer for the treatment to work?" You can't always tell immediately whether your approach is right. "Ask your doctor how long it should take for your symptoms to improve," says Dr. Epstein.

Another reason to look further: New research can change the algorithm. In an ongoing study, doctors came to fully understand coronary microvascular syndrome (CMS). This spasm of small blood vessels, which is more common in women, causes the symptoms of heart disease, even though arteries look clear on the standard tests. Using the old algorithms, a woman with CMS might be sent home with "stress" when, in fact, she is at high risk of heart attack.

Stopping Too Soon

Once physicians think they've found the cause of an illness, they may stop seeking others, a practice called "satisfaction of search." Often this is completely reasonable. "A doctor can't consider every possibility," says Kate Lorig, RN, DrPH, director of the Stanford Patient Education Research Center at Stanford University School of Medicine. "Doing so could unnecessarily cost several hundred thousand dollars in diagnostic tests, many of which are dangerous." But by calling off a search too soon he may miss something key.

YOUR JOB: To ask whether all possibilities have been considered.

WHAT TO DO: Say, "Is it possible I could have more than one problem?" "Could this be something else?" The recent discovery that early ovarian cancer has symptoms (bloating, frequent or urgent urination, pelvic or abdominal pain) that resemble other more benign conditions, such as irritable bowel syndrome and incontinence, is a reminder to all women to keep pushing if your symptoms are recurring, painful, or unusual.

While it's your doctor's responsibility to rule out other alternatives, reflective questions asked by patients can sometimes trigger a new perspective on the problem. "Sometimes I wake up in the middle of the night and think about a patient and say, 'Wait a second. Something doesn't fit,'" says Dr. Epstein. "Making a diagnosis is like solving a Sherlock Holmes mystery. If there is one little detail that doesn't work, it can change the whole picture."

And that leads to one final point: When you're meeting with your doctor, discuss your most-important health issues first. Many patients disclose their most bothersome problem just as they are about to leave the examination room. The psychology of this is understandable, especially if the situation is scary or embarrassing. But even the best doctor can't do her best unless patients are forthright.

 

Originally published in Ladies' Home Journal, December 2007.

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