Have you ever wondered if your doctor is giving you the “right” advice?
You are smart to consider this. In many cases, doctors don’t provide the best recommendations.
This is an uncomfortable truth about health care that people tend to learn the hard way. The story usually goes like this: You get sick or otherwise put your health care to the test. You suffer through sub-optimal health care and learn first-hand about the pervasive flaws. And so you slowly become a savvier wrangler of the health care system, which is sometimes called being an engaged and empowered patient.
The Benefits of Anticipating Health Care’s Flaws
As a doctor who has studied health care quality, it pains me to see people routinely going through this rocky path to better understanding health care. If you anticipate the flaws ahead of time, you can:
- Be equipped to get better health care for yourself and your loved ones. As in, you’ll get more health care that’s likely to help you reach your health goals. And you will minimize health care that’s likely to be useless, risky or a drain on your time or wallet.
- Help make the health care system better for everyone. As you and enough other people become able to identify and insist on better health care, you’ll help speed up sorely needed improvements in how the system delivers care to patients.
It’s not surprising that most people are unaware of the flaws of health care. Many people I know tend to kind of ignore their health until something feels wrong (“What is that nagging pain?”) or definitely is wrong (“Yikes, I just pooped blood!”).
Despite all their years of education ... doctors often don’t provide you with optimal medical recommendations the first time around.
Plus, it can feel a little depressing to think about all the pitfalls and problems in the health care system. We want to feel like our doctors and hospitals are equipped and ready to take great care of us.
I don’t want you to stress too much about what might go wrong when you go see the doctor, or get hospitalized. But it’s just smart to learn more beforehand. And it might even help you prevent some health disasters.
What a Better Medical Recommendation Looks Like
When you see a doctor to get advice about your health, the physician usually ends up providing you with a recommendation on how to manage your health concern. But here’s an uncomfortable truth: Despite all their years of education and their best intentions, doctors often don’t provide you with optimal medical recommendations the first time around.
By “optimal medical recommendation,” I mean a medical recommendation that meets at least three criteria:
1. It should be grounded in the most recent medical knowledge, which is generally reflected in the relevant expert guidelines, as well as in peer-reviewed clinical resources such as UptoDate.com.
This doesn’t mean that doctors should follow guidelines blindly and practice “cookbook medicine.” It does, however, mean that for you to get better health care, your doctor should be aware of recent recommendations for how a given condition should be evaluated and managed. And when doctors decide that your circumstances merit a different approach, they should be prepared to explain their reasoning. (“Because I like to do it this way with my patients” is not an adequate explanation.)
2. These recommendations should be adapted to your preferences and values when it comes to medical care. In most cases, especially when it comes to people who are middle-aged or older, “one size fits most” medicine isn’t optimal. That’s because often there are a number of reasonable ways to manage a certain health problem. Historically it has been the doctor who chooses among those ways, based on his or her preferences and values.
So for instance, for mild-to-moderate major depressive disorder, although guidelines say that either psychotherapy or medication can be used as initial treatment, most doctors tend to start by prescribing medication. But this is a little backward. If you’re a patient, it’s your body and health at issue. So if there are two reasonable ways to proceed with the medical care, it should be your preferences and values that drive the medical recommendations.
3. An optimal medical recommendation should be made after informing a patient of the options for treatment and involving the patient in the medical decision-making process. So if your health problem is mild-to-moderate major depressive disorder, the doctor shouldn’t just ask herself, “Hmm, does this patient tend to prefer pills or non-drug treatments?” (That’s the considering-your-preferences-and values part.) The doctor should also tell you about these two approaches, and then you’d decide together which to start with. This is called shared decision-making.
Not How Doctors Were Trained
Now, you probably know that many medical recommendations do not meet the above three criteria. Why is this? The short answer is that many doctors were not trained to practice in this way.
Plus, there are many other factors that influence doctors. For one thing, going through this ideal process can take more time than just telling a patient what to do, and doctors are usually forced to be in a rush. Pharmaceutical companies have historically spent a lot of time and money influencing doctors to prescribe their products, too. Lastly, being human, doctors tend to fall into habits and do whatever takes less mental and emotional energy.
The fact is that medicine is usually practiced according to the doctor’s preferences, rather than according to what the best evidence and best practices recommend.
Case in point: a recently published study found that half of the ophthalmologists performing cataract surgery are ordering unnecessary pre-operative testing. (Such pre-operative testing, which includes blood tests and EKGs, has been deemed unnecessary for most patients since 2002.) As best the researchers could tell, the main factor driving pre-operative testing was the doctors’ preferences, not the health factors of the patients.
4 Things You Can Do
Now that you know the truth, let’s talk about what you can and should do:
1. Choose carefully. Select doctors who seem willing and able to involve you in the medical decision-making process,and are open to checking guidelines. Doctors have their own personalities and practice styles; you’ll probably get better care if you find someone who sees his or her role as supporting you in your health care decision-making, rather than being the authoritative decisionmaker for you.
If you can, look for doctors who seem open to discussing options with you. A doctor who gets defensive when you ask about guidelines or alternatives is probably not a good choice.
2. Do your homework when it comes to your health conditions and treatment options. There is really no substitute. Even if your doctor is progressive and used to shared decision-making, you’ll participate better in the process if you’ve done a little preparation beforehand. Prepared patients and families generally get better health care.
To learn more about your health conditions and your options for evaluation and management, go to reputable websites. I find that the Mayo Clinic website is generally quite good. You can also get useful information and support by accessing online communities of people with the same health problem. SmartPatients.com and PatientsLikeMe.com are two well-established sites.
The goal, of course, is not to doctor yourself. The goal is to arrive at your doctor’s office with good questions and ideas.
3. Ask about alternatives. When the doctor makes a medical recommendation, be sure to ask what other alternatives are available. You may want to specifically ask about non-drug options for treating a problem. These often exist and are even often now recommended as first-line treatment. But busy doctors may not think to suggest them unless you ask them.
For instance, although incontinence can be treated with medication, guidelines now recommend that people try exercises and bladder training first. (I applaud this change, since many medications for over-active bladder are anti-cholinergic and hence increase one’s risk of developing memory problems.)
It’s also important to ask the doctor to clarify the likely benefits and risks of the treatment options. As a recent series in The New York Times explains (see here and here), the likelihood of benefit is often smaller than people realize and sometimes is outweighed by the risk of harm from the treatment.
4. Consider a second opinion. Especially if you’re considering a treatment of significance, such as a major surgery, it can be good to get a second opinion. Maintaining your own copies of your medical information in a personal health record can facilitate this.
Is All This Really Worth Doing?
You may be now wondering if all this is worth the effort. After all, you’re busy.
I’d say it is worth doing. Taking care of your health — or helping your parents with their health — is like investing energy in maintaining or even renovating your home. You don’t have to be super involved in monitoring the people involved in the process and things very well might turn out OK. But then again, they might not. The people working on your home, after all, have less at stake than you do. For them, it’s one of many jobs. For you, it’s your home and your money.
The body is like your home, except you have much more at stake.
For better health care, plan to do your homework, prepare to ask questions and remember that the medical care should be based on your preferences, not the doctor’s preferences.
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