Why Your Doctor Needs Your Help
Your doctor needs your help urgently.
Almost anyone who has ever been a patient waiting in a physician=s office has direct reason to know that doctors need help. Why is it a common experience routinely to have to wait for an hour or more to see your doctor? The reason is because they can=t get it all done in the time allowed. They can=t get what they think is important done, and often they can=t get even what you think is important done. Why not?
There are two basic reasons. One of them has to do with you. Often you are not prepared to make the most use of strategically important time with your physician. Many patients either have a list of 4-7 things they want to talk about (it is pretty routine to have at least 4 problems once you hit the age of 55 years), and doctors just don=t have enough moments in a 15-minute visit to address so many issues. This is why it is absolutely critical that you be prepared, have a specific agenda, and know your own priorities for that 15-minute interaction. This, of course, is what this article is about. In subsequent articles I will help you plan a very specific agenda for your physician for that 15-minute visit.
The other reason is that doctors generally are blindly trying to follow the advice of various experts in determining how much attention to give each problem. Doctors have an endless set of authorities to whom they defer to help make most of their basic decisions: how many pieces of data to ask you about, how much of a physical examination to do on you, how many tests to order, how many and which prescriptions to write for you, and how soon and how many times to see you again after this visit. The problem is that they have to do this for each of the problems you mention to them. Thus, even if they cut out all the chit-chat (that makes your personal to you), they run out of time half way through the second problem. If they chit-chat, then they barely get the first problem taken care of. It is up to you to determine the appropriate level of chit-chat. It is always a trade-off between getting specific agenda items handled properly and being able to share bits of yourself with this fellow human being. Sometimes absolutely the right thing to do is to just drop all task-related agenda items and talk about your concernsBanxiety, depression, sleeplessness, social embarrassment, difficulty with the kids or your spouse. But this is a decision for you to make, not for your doctor.
In order to grasp the absolute need for you to take control of the agenda in the doctor=s office, you need to understand the nature of the pressure he=s under. Let me try to explain it this way.
You expect your doctor to be able to take care of your chronic health problemsBlike asthma, high blood pressure, diabetes, heart disease, etc. Right? If he doesn=t, who else would? And you also expect her to advise and implement preventive health measures that might be beneficial to you. Right? And, finally, you probably have some specific concern, something not right, that prompted you to schedule this particular visitBwhat physicians call your >chief complaint.= Here=s the dilemma, as presented in a few important studies over recent years.
In a study reported in the Annals of Family Medicine in 2005, investigators attempted to determine how much time it would take an average physician to care for 10 of the most common chronic diseases he sees daily in his office if he followed various expert guidelines published which define quality care for these diseases. The striking answer produced by this study was that it would take 10.6 hours per day just to take care of this handful of common chronic diseases. This answer was reached merely by adding up all the number of expert-recommended visits, assuming a standard 15-minute visit, for these 10 problems in varying degrees of control from stable to actively progressing or deteriorating.
To take an example that I have experience with, consider the management of a patient with diabetes. In 1998 the American Diabetes Association, the recognized expert in its field, published a AStandards of Care@ for the management of patients with diabetes. Their guideline recommended over 30 different, complex pieces of historical information be obtained for all patients at the first visit, that a full physical and neurological exam be done, then about a dozen laboratory test results to review or order, and then extensive patient education both about the disease and about the medications given. A reasonable estimate of the time to do this adequately would be 2 hours. Some specialists (endocrinologists) in private practice may actually have 2 hours of time to spend with a new diabetic patient, but no one I know in primary care, where 90% of all diabetes care goes on, has ever had this amount of time.
In order to try to put a practical face on these recommendations, I convened several focus groups of family physicians in south central Pennsylvania (a rural area where primary care physicians do most of this work). When describing their own experiences, these physicians reported that they were lucky if they were able to spend a half-hour with a new diabetic patient; they reported the frequent experience of making this diagnosis incidentally in adults in the middle of evaluation for another problem and trying to cover the basics in only 10 minutes.
Diabetes is probably the most complicated disease that primary care physicians manage, and good care requires regular systematic coverage of over a dozen issues. These physicians, at least as confided in my focus groups, would love to have an authoritative guideline that was short, simple, and focused on the critical aspects of care. That=s not what they get from the experts. Instead they get a completely untested, impractical, overly elaborate set of recommendations that simply have no place in the real world. (In fact, even at the time of this writing there has never been any study that showed either that even specialists used these guidelines or that anyone was able to achieve better outcomes by using them.)
In this column in future articles, I will tell you exactly what you need to know to take superb care of your diabetes. It=s very doable, and it=s very important. Few diseases do as much damage as diabetes does, if it is not managed well.
Returning to my point of how little time your doctor has, I want you to be aware of a similar study by some of the same authors in the American Journal of Public Health in 2003. There they analyzed how much time it would take general physicians to comply with standard preventive medicine guidelines. In an effort to make the task more manageable, they decided to look at only the top half of more than 169 different potential preventive interventions Bthe ones that had the best scientific evidence to support their benefit. They performed a time-motion study in physician offices recording the actual amount of time spent doing the recommended interventions. The surprising result here is that they determined that it would take 7.4 hours per day just to carry out the top 50% of all recommended interventions.
Thus, it will take your doctor 18 hours a day to handle the minimum expected medical standard of care. Mind you, this is without considering whatever amount of time it will take to address your >chief complaint,= typically a cold, or bladder infection, or muscle sprain.
The bottom line is that there is no way it is all going to get done. This is the fact of modern medicine. It presents a dilemma for every one. Doctors become disillusioned and frustrated by their inability ever to get it all done and by the perpetual experience of having to accept so much less accomplishment than they aspire to. Patients are continually frustrated (and occasionally sue) because a lot of very important issues never get adequately addressed. The health care system (if it can be called that) in the U.S. just tolerates this grossly inadequate status quo. According to one expert in the August 2006 New England Journal of Medicine, there is no major impetus on the current horizon to address this issue.
This is the very problem that this column will help to solve. Without a gargantuan effort by scientists, academicians, and politicians, nothing else will solve this problem for you. And, even if such an effort was commenced, it would, of course, will take years to bear fruit. The best recent example of a health care project of similar magnitude was the fate of the Clinton proposal for national health insurance, and you remember what came of that.
So you=ve got to do it. There are two basic means of insuring your own healthBwhat you do for yourself and what you do with your doctor. This column discusses both of them. What you can and should do for yourself without your doctor, however, is quite simpleBreally no more complicated than--30 minutes of exercise daily, 5 servings of fruits and vegetables daily, and avoiding obviously toxic substances like cigarettes, excessive alcohol, and illicit or excessive prescribed drugs; these need not take up a lot of our time. The major portion of this column will be devoted to very specific details of what you need to know and need to ask your physician to do for you in the context of your personal, specific health care needs and preferences.
The other exciting and reassuring result of modern medical research is the information that many chronic diseases, like diabetes for example, are much better managed, and with more favorable results when patients take over management of their own care rather than when physicians do it. This is a very important piece of new research information which we need to try to understand. There is already some supporting evidence to demonstrate that, if you take charge of your own care, as I suggest, you will achieve substantially better results. We will look later at some of this research in detail.
To give an example of how your role begins, you can start with the unmanageable list of 169 potential interventions. Fortunately, only a very few of these will apply to you. So all you have to do is to prescreen the list and, based on your age, gender, and situation, you can pick the handful that apply. I will give you some specific guidance on the ones that have the highest value to insure that you limit your list to a feasible number. Remember, you are only selecting your highest priorities, because there is only time to do so much in a visit. (It is a perfectly valid strategy to schedule a follow-up visit specifically to include more of these preventive services, but don=t try to get too many into a single visit. That=s just frustration for everyone.)
The second job for you is both easier and more difficultBdealing with any chronic health problems. It is easier because you know what health problems you have, and you just don=t have to bother with any others (and, in general, don=t let your doctor go off on tangents and screen you for diseases you=re not concerned about them; they tend to do this because of certain biases built into the healthcare system, which makes them (not you) feel better when they do this). Your job is to stay focused.). It is harder because you have to master a small amount of very specific information that will give you a handle of your own disease. For example, if you have high blood pressure, it=s worth knowing that family history is not important (i.e., don=t waste time on it). The most important part of the general history is to review the complete set of heart disease risk factors (age, gender, smoking status, high blood pressure, diabetes, lack of exercise, metabolic syndrome, cholesterol, and renal impairment, and family history of heart disease [not of hypertension]). The physical exam (except for the measurement of blood pressure) is unimportant (so don=t waste time on it; the experts love to have your doctor do time-consuming, useless, and awkward things like looking into your eyeballs with a light and listening to your heart, etc.). Treatment is simpleBall patients should start first with a mild diuretic (called a >thiazide=, like hydrochlorothiazide (HCTZ)) and second with a drug called an ACE-inhibitor (like Vasotec, Lisinopril, Accupril, Benazepril, etc.; it doesn=t matter which one; just go for the best price in your drugstoreByou have to ask your pharmacist. Your doctor will usually not know [prices change so fast, and he has just got so much else to keep up with]). The goal of treatment is to keep your blood pressure below 140 mm Hg over 90 mm Hg (< 140/90 mm Hg). Measurement at home or at your pharmacy or supermarket is generally more reliable than measurements in your doctor=s office (mainly because we all tend to get tense in the doctor=s office; if you follow the recommendations in this book, you should be able to feel a lot less tense too!). If your blood pressure is below that level, it is enough to come in for a check-up and medication refill every 3-6 months; if it is not, you should plan more frequent visits, medication adjustments, and lifestyle adjustments involving diet and exercise.
OK. On to the real work of becoming an informed patient who can really help your doctor. Let=s start with some general principles of good health in our next few columns. I hope I can illuminate a few nuances and provide the specific reassurance that there is nothing more important that you can do for your own health.
