Thursday, February 14, 2013

A patient wants to know when to speak up

Matthew writes:

My only experience with the medical profession is strictly as a patient. I'm wondering what is an appropriate balance between being an educated patient (willing to ask questions, make observations, etc.) versus being one of those supposedly "self-educated" know-it-all patients that I'm sure are one of the banes of a doctor's existence.

We've all heard the stories of the patient whose doctor didn't listen to their concerns until it was too late, but on the other hand, I don't deny that my doctor knows worlds more about my body than I do, or ever will.
I want to trust my doctor, but without having to blindly accept whatever he tells me. Yet I've dealt with members of the medical community who see anything BUT blind acceptance as a personal affront.

As such, is there ever a time to research symptoms online before making an appointment? Is there ever a time to disagree with a diagnosis? Is there ever a time to request or ask about alternate treatments? And if so, how can this be done in a way that is respectful to my physician?

You ask some excellent questions.

I’m not sure I have all the answers. I hope some of my physician colleagues will comment. 

There is a fine and very fuzzy line between asking good questions and being a pain in the ass. And that line is drawn in different places by different doctors. It ranges from zero tolerance for questions (See Dr. Sung on “Monday Mornings,” who, when asked a question about a procedure he recommended, said, “Not do—dead.”) to the most open-minded, usually a primary care doc or psychiatrist. There are issues of time, urgency, the physician’s perception of the patient’s level of understanding, the complexity of the disease or operation and many more.

I had no problem with patients who researched their symptoms online. However, I would hate it when a patient brought a portfolio with 100 pages of downloaded material for me to comment on. There is a lot of garbage on the Internet.

I think you should always ask what your options are. Informed consent discussions should include the risks, benefits and alternatives for any procedure. The doctor should also tell you what the risks and benefits of the alternatives are too.

Go with your gut. If what the doctor says to do does not sound right, say you will think it over. Don’t be afraid to get a second opinion. Run away quickly from any doctor who discourages second opinions. I always encouraged second opinions for patients who were reluctant to have surgery I recommended. I felt that if I was proposing the right thing, the second opinion doctor would support me.

One of the worst things a patient can do is be too acquiescent to the physician. I used to tell patients “Don’t worry about hurting your doctor’s feelings. This is your life we are talking about. The doctor will get over it. If she doesn’t, you don’t want her as a doctor anyway.”


  1. First, I'm not a physician. I'm speaking as an "informed patient". When I go to a doctor for an initial examination because I'm hurt or ill, I listen and ask questions about the tests the doctor wants performed to aid his or her diagnosis. Then, in the interval between initial exam and follow-up for test review and treatment plan, I do research to learn as much as I can about the likey diagnosis and treatment options so I can discuss them intelligently with my doctor. I expect my doctor to be willing to have such a discussion and provide reasons for the recommended treatment. If the recommendation follows what appears to be the most outcome-based treatments I found during my research, I nearly always go along with my doctor's treatment plan.
    Sometimes, the doctor's reaction to my questions has led to my changing doctors in midstream. When I had a meniscectomy on my right knee, the first doctor reacted with surprise and indignation when I asked him a simple anatomical question about where my meniscus was torn. Needless to say, another doctor more open to informed discussion performed my surgery.
    My position is simple: just as we should treat doctors with respect for their experience, training, and wisdom and follow their treatment plans as directed, doctors should treat us with patience and respect as knowing what hurts, how bad it hurts, and wanting to know why it hurts and how it's best fixed. Anything less on either part leads to diminished success in treating the ailment.

    1. Very well put. The next commenter has it right. Those who lack confidence tend to see questions as challenges or threats.

  2. I agree that these are excellent questions. I like to tell my patients that I want a partner and not a passenger. As such, I encourage questions and my goal is that they could explain our visit to someone who wasn't there. In my experience, doctors who discourage questions may be doing so due to a lack of confidence. As a patient, I would see that as a red flag. Also, I completely agree about the second opinion. I think for most doctors, as long as the questions aren't confrontational, they would be welcome. One thing that may hamper the relationship though is the "oh, by the way" question just as the visit is wrapping up which might really require another half-hour. That either makes you feel short-changed or makes the rest of the day for the clinic run late. If you have multiple concerns, make sure that is known when scheduling.

  3. Good comments. I agree with you. Your point about that "Columbo" style oh by the way question is well-taken.

  4. The best doctors I've known have suggested I call them by their first name (One said, "Why not? I call you by yours, and besides, I don't need to be reminded I'm a doctor, I already know that!") and never freak out when I ask a question or say, "Didn't I read a study about [something relevant]?" (Even before the WWW; I was lucky enough to work somewhere where I had access to medical journals.)

    On the other hand I always think of the one time I was in an ER and the doctor dismissed my complaints as "just a UTI". When I said, "but I'm already taking a broad spectrum antibiotic", instead of saying, "Well, it's possible this one is resistant to that one" or something like that, he started screaming at me, "You are not the doctor! *I* am the doctor! Have you gone to medical school? Unless you have gone to medical school you do not know anything about medicine!" He kept at it until I started crying (he appeared to be waiting for that).

    About a month later he wound up berating a college student who went there after being raped for "asking for it." The next time I was in the ER, about a month after that, he was no longer working there.

    Thank God. Although I'm horrified to think about where he is today.

  5. I too have experienced specialists who have told me to "stop mucking around" when I was unable to get up onto the table for an examination, another told me "just be quiet I can't understand you, you're husband can speak for you", yes, this was because my speech was slurring and I was drooling - another who after I rang a medical support organisation advised me to fill out a form with symptoms (as I am forgetful as when in pain that is not treatable due to allergies to codeine etc) and when I saw the specialist was told "So why are you here, you've self diagnosed." And they allow ten minutes for each person and charge a fortune. My local doctor will see me for over an hour and barely charges, has known me for over 20 years, and knows I am unwell. Some specialists need to pull their heads in, they are not God, we don't expect them to be, we expect them to work with us, help us, guide us, listen to us and not dismiss us or put us down as I've had happen time and time again. This does nothing for one's confidence let alone their health!

  6. Anon, thanks for commenting. It looks like you've managed to find a number of obnoxious doctors. I agree with your last two sentences.

  7. Matthew's thoughts exactly echo mine. Thank you for your thoughtful response. I hope that, like Michael, if I am concerned with getting the right balance between asking questions and accepting advice, then I am probably in the right "skeptical place".

  8. “When one extremely hostile relative bombarded me every time I walked in, I developed a tendency not to go in the room. If you have three pages full of questions, show them to the nurse. Say ‘How many of these should I wait to ask the doctor about? How many can you help me with?’”
    —General surgeon who blogs under the name Skeptical Scalpel”
    Read more:

    1. I admire your internet searching skills. It's not inconsistent with this post.