Disagreeing With Your Doctor

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Few people feel comfortable confronting their doctors when they disagree with a diagnostic or therapeutic plan. It’s more common for patients to wait until it all goes bad. They then enter the unhappy world of medical litigation. Malpractice suits are common (75% of us get sued) but not usually successful.

The Doctor-Patient bond should be an exchange relationship like that with a Buick dealer…what’s the quality, what’s the price and what’s the service going to be. If it isn’t good…you’re gone! Consumers, for example, when buying a car check Edwards, the IIHS, Consumer Guide or the NHTSA to get their facts and then judge the vendor.

In contrast, medical doctors are offered what’s called a communal relationship with their patients. It’s free of judgment. “Hey, they’re doctors…right? They gotta be good.” The relationship is held to be like that with the clergy. The benefits are seen as too valuable to challenge, much less lose. This provides doctors with what is called “the halo effect”. All this interferes your likelihood of voicing disagreements. We research our next vacation more carefully than our next surgery. It’s consumercide.

The first step if you disagree with your provider
So, if there is discontent, consumers must first make sure who’s right before getting into a contretemps. Check the facts. Not on Google or WebMD. Nor does watching TV commercials or a news segment serve as valid information. Newspaper articles are often just press releases disguised as news. Commercial ventures exist that promise to turn an ad into an article. Healthnewsreview from Gary Schwitzer has a website devoted to dissecting good from bad health journalism.

 

Opinions You Can Defend
How to have an opinion that you can defend? Industrial strength resources. Make sure you’re right. Use physician literature. Free articles on PLoS and, within a year of publication, open access articles appear in JAMA and the Archives series . Or purchase a year’s subscription to the Journal of Family Practice. This journal is aimed at doctors who deal with the most common ailments and their contents are often basic but sufficiently rigorous enough to use as an end-source. This journal offers webcasts, videos and audio, an ad-free medical encyclopedia and more. Listen to clinical conversations. Do reliable searches. How much for this one stop shopping site? $80/year. That ain’t much.

Almost every medical journal, even those to which you don’t subscribe, offer weekly or monthly tables of contents. You can also request free email updates that are automatically sent to you on topics of interest. Create an archive relevant to your problems. There are many other reliable places to check your facts.

These are the ways to make sure that your facts are right before you defend them in this exchange or transactional relationship. Using your doctor’s literature also elevates your role and empowers your opinions. This literature is not hard to decipher if you skip the statistics and go right to the conclusions…I call it bottom reading.

It’s also wise to make sure your expectations are in line with reality. A quick fix, a full fix, or a permanent medicated or surgical fix may not be realistic or safe. It’s not the questions that hurt patients; it’s the answers.

OK. You’ve checked the facts. You have your expectations in line.

It looks like you have a disagreement on your hands.

 

What’s wrong with your doctor? Why can’t you agree with him?
1. He’s not that smart. Half of the doctor population is not as smart as the other half.

2. He’s smart but has fallen behind in the tsunami of data that flood his desk and desk-top.

In above scenarios 1 and 2, all you can do is present the facts that your doctor may not be aware of and allow him to comment on them in a constructive way or to offer to research them and get back to you.

3. He’s biased. We all are. But doctor biases get you in trouble. Biases based on habit, profit, geography, race, religion and culture (the doctor’s and yours) language, education and publication biases name just a few. These biases can be overcome by knowing that they exist and taking them into account when talking through your disagreements.

4. He hasn’t taken your priorities into account. The facts are right. They’re just not right for you!

Risk Tolerance
Some people are risk averse; others risk tolerant. That means some people will take a very slight risk right now, to prevent the risk of something that may or may not happen at some point in the future. Others don’t want to take a risk now for a ‘maybe-or-maybe not event’ decades away. That’s the issue of screening in a nutshell. For example, your doctor wants you to have a colonoscopy. You should know that a sigmoidoscopy or fecal occult blood test is a reasonable and safer alternatives that may be a better fit for your risk tolerance profile. Some people chose to do nothing at all. And that’s fine too if you have taken the effort to assess your chance of getting colon cancer. When the literature says that 5% of people screened for colon cancer prevention have polyps, it also means 95% didn’t. And when it comes to getting colon cancer 96% of people at standard risk won’t get it. I’ve had four colonoscopies (positive family history of colon cancer makes it more important).

Trade offs
Some people are willing to make trade offs for the length of their lives at the expense of the quality of their lives. Others aren’t. For example, your doctor wants you to get have a surgery preceded by radiotherapy and followed by chemotherapy for a tragic cancer diagnosis. You’ve got18 months…13 will be lived with a poor quality of life.

Instead, might you prefer 10 months of life with 8 of them a higher quality of life? Do you prefer or prioritize a life enjoyed rather than endured? Did your doctor ask? Probably not. That would be the source of disagreement that also requires a discussion.

Pre diseases.
What is a normal BP, Sugar, Cholesterol or PSA? Wait, don’t answer. The values change frequently. What wasn’t a disease yesterday is a disease today. And if it’s not a disease it’s called a pre-disease that also requires therapy. Example. Doctor wishes to treat you for a BP of 140/90. Just a couple of years ago and still for many doctors today, this BP needs monitoring..not therapy. That’s why again, physician based literature is the best place to find out where the debates and controversies live so that you can have a role when issues are not settled.

So how do you disagree?
Please don’t ask a question unless you first know the possible answers. The range of answers or alternatives is provided by your industrial strength resources. By researching the questions beforehand, you can judge the quality of the resulting answer. And you can also judge the quality of the physician who answered it.

1. Check your facts and present them.

2. Thanks but no thanks doc. How about some alternatives? How about watching and waiting?

3. Inform your doctor that although you understand what he prefers, they don’t fit with your own goals objectives and priorities.

4. You are thinking it over and would like a second opinion.

5. You are thinking it over and would like to discuss it with a specialist

And if the doctor says, “NO”?
Saying “no” is your job…not your doctor’s.

If the doctor won’t listen; won’t take your research or priorities into account; won’t refer you for a second or specialist’s opinion….then take off the Halo and take off to find a new doctor. Get used to asking the tough questions. When you are healthy, your disagreements can be healthy too. But when you are unhealthy, it’s less likely you will have the tools to participate in your care, much less disagree with it. You didn’t take the opportunity of becoming a patient that your doctor has come to regard as ‘special’.

It’s OK to stroke a doctor’s fragile ego. “Hey doc, I think you’re great but….”

“Hey doc I’m not one to disagree with you but….”

“Hey doc I usually let you call the shots but…….”

Then lower the boom and see if it raises his hackles…If so, the best view of his office is through your car’s rear view mirror.

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