BECOMING A PROACTIVE PATIENT

One of the most important diagnostic tools a physician has available to him or her is his ability to think deductively.  That is, to think in a deductive fashion.  This is taught in several ways during a physician’s training under the guidance of professors and in a way that will reveal ‘thinking traps’ that teach the physician-to-be to recognize and/or stay away from these thinking errors that can lead to a misdiagnosis or waste precious time in arriving at the correct one.

Grand Rounds is a good example of this.  In university hospital teaching centers it is held weekly and consists of the presentation of a patient with an unusual or uncommon constellation of symptoms, and then the audience (students and professor) are invited to ask questions, discuss, and offer opinions about the case with a view towards arriving at the correct diagnosis.  It involves an attempt to reveal the likelihood that a certain disease process exists or not.  

Over the past couple of decades medicine has undergone a commercialization and corporatizing that has come to bear upon an unbiased approach in some quarters to the practice of medicine.  Actually, capitalism itself, good in most respects, is a saw that cuts both ways when it comes to seeking the truth and offering the best procedure or treatment, yet by the same token motivates some health care providers to engage in unnecessary treatments or procedures.

In his book, “How Doctors Think”, doctor Jerome Groopman gives an excellent example of this with regard to chronic back pain due to a slipped disc.  In the past a simple discectomy has been the operation done to repair a slipped disc.  But lately spinal fusions have become very popular even though the results are
not appreciably better than a simple discectomy, as revealed by a Scandinavian study that discovered that only 1 in 6 patients reported ‘excellent’ results.  It turns out that surgeons in the northeast are reimbursed $5,000 for a simple discectomy, where they otherwise are reimbursed $20,000 for a fusion procedure.  

At any rate, back to the corporate influence of health care.  Big Businesses now have their own clinics in an effort to cut their health care expenses/benefits provided to their employees.  In most cases, the financial incentive is to reduce encounters, reduce medications, reduce procedures and this is done by way of compelling the health care provider, typically a nurse practitioner or physician assistant, to follow a proscribed algorithm or protocol for every symptom presented.  If ’A’ is present, then do test ’B’.  If  ’C’ is absent, then proceed to ’D’, etc.  Currently, there is a debate among clinicians as to whether this algorithm approach to the practice of medicine is beneficial or not.  Basically, it lulls the provider into robotic ‘lazy’ thinking and discourages him from thinking out the box -- of all possibilities.

So how can patients protect themselves from this phenomenon of ‘lazy thinking’ or misguided financial intentions, which by the way can affect any physician, much more lesser trained and experienced health care providers who work under the auspices of a corporation interested in profiting for shareholders.

Probably the most effective empowering tool for a patient is to ask questions.  Especially, if the physician or provider seems rushed.  And especially even more so if a physician breaks in as you answer a question, so that you feel he is not letting you tell him everything about your symptoms.  If this rushed ‘breaking in’ occurs you are probably dealing with a provider who is biased in his thinking and suffering from a cognitive bias called 'anchoring’, which is a shortcut in thinking where a person doesn’t consider multiple possibilities but quickly and firmly latches on to a single one, sure that he has thrown his anchor down just where he needs to be.  Or he may be engaging in another form of cognitive bias called ‘availability’ in which one has a tendency to judge the likelihood of an event by the ease with which relevant examples come to his mind.

Some patients are intimidated or feel ill-informed to ask what they think might be pertinent questions (“Doctor, I have a dumb question”).  There’s really no need to be.  Research on the internet, either in anticipation of, or after the visit, is certainly a good way to glean knowledge to ask questions.  Asking questions does not impugn a physician’s judgment, and if a physician feels it does then you may want to consider running in the opposite direction.  

Questions like:  What’s the worst thing this can be?  What are three other things this could be? What body parts are near where I am having my symptom? These are questions that will prompt a hurried physician to consider lifting his anchor from the most available harbor, as well as perhaps stop him in his tracks and revert to a less flippant form of behavior.

It may seem presumptuous to expect patients to help a doctor think better.  But what patients say to a physician, and how they say it, sculpts his thinking.  That includes not only their answers but also their questions.