Streams

When Doctors Don’t Listen

Tuesday, January 29, 2013

Dr. Leana Wen examines the doctor-patient relationship and argues that diagnosis, once the cornerstone of medicine, is becoming a lost art, with grave consequences. When Doctors Don’t Listen: How to Avoid Misdiagnoses and Unnecessary Tests, written with Joshua Kosowsky, uses real-life stories of bad diagnoses to show how active patient participation can prevent these mistakes. They offer follow-up questions patients can incorporate into every visit to the doctor’s to get the best medical care.

Guests:

Dr. Leana Wen

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Comments [25]

j276

Shaun's comments are spot-on. There is a reason for guidelines and algorithms - at least in human medicine they are based on lots of data. Pattern seeking is not a substitute. For every anecdote relating unnecessary additional testing, you can trot out another in which physicians are sued for not ordering tests on low% differentials, or catching things too late. Patients are not charitable or understanding in such instances.

Christine: Every chest pain is indeed not a heart attack. I presume you are fine with avoiding recommended diagnostics to rule out problems, and if by chance your doc is wrong, will agree not to sue? Great! If only more people were like you it might work.

I am glad you heard from a practicing physician that said flat out that this approach is unrealistic - especially from and ER perpective. As it stands patients are also seen as potential future litigants, and treating on your best guess/pattern recognition and scrapping diagnostics will bite you no matter how well informed the patient is ahead of time - later on the patient or their family will want some money if they can bully the hospital into providing it. Precisely what the doc said on her call-in.

Evidence based medicine already rationally addresses many of these concerns. Communication is critical but not enough in a broken system. What is needed is a retrospectascope - and that will never exist.

Feb. 01 2013 10:09 PM
Sainted_Mother from Red Hook, Brooklyn

I am of 2 minds (did not listen to show, but WAY familiar with the MIC (medical industrial complex)).

(a) patients don't educate selves, ask for stuff they don't need (antibiotics for viral illnesses, always BAD!!!), and don't follow advice given (doc friend refrains from slapping patients: _of_course_ if you insist on doing X, you'll most likely get Y ... JUST STOP IT!).

(b) reducing or eliminating alcohol, cigarette, and salt consumption (not to mention losing weight (self included) would go a VERY long way to solving a LOT of healthcare risk. We don't do it, because it is hard to do.

(c) natural is not always better, better is sometimes weird, and as for the causes of dis-ease ... think horses not zebras. Yes, some of us have the odd-ball issue, but most likely, any one of us _does_not_ but if we believe we do have a zebra by the tail ... by all means BUG yer doc "I did research: blah blah blah matches my symptoms, here's a printout, please listen or refer me to someone who will."

I feel BLESSED to have a doc that listens to me. I was patient #3 in his first database. He's helped me thru a variety of things, has good / bad reviews on Yelp, etc., but he knows I don't call him for no reason, I keep my records mostly up to date, and aside from losing weight, I do what he asks. He has docs in his practice that allow him to be a 1-stop shop (cardio, gastro-entero, gyn, internal med, and a podiatrist). I have watched him change / grow over the last 18 years. I give him time, too.

Jan. 31 2013 06:30 PM
Mary from Westchester

I lived in three countries in Europe for 12 years and the best medical care I received was in both France and Switzerland. Doctors talk with their patents and make sure they understand your particular situation. Your job, your stress, do you have a partner who helps you. Also you can' t advertise drugs on TV. Like go to your doctor and ask for medicine / drugs ... They look at you like your so sort of freak.
Yeah they just rip off the insurance companies here the American medical system is not good and it does not rank well against other countries. Of course advertising drugs can create hypochondria.
Like it's more than lack of communication it is the system your Doctor/ Guest is rather naive.

Jan. 31 2013 01:54 AM
Dr. Leana Wen from Boston, MA

Thanks for the excellent comments and for listening, everyone! I’m going to address a few things:
1) I have no disclosures, definitely none to insurance companies or pharmaceutical companies.
2) It’s not about extra tests being good or bad. Our goal is not to save money (though costs are high and this is a problem); it’s to get the best care possible. Many examples in our book are about patients not getting ENOUGH tests, because they got the wrong tests.
3) This would actually save money to get the right diagnosis quicker—so insurance companies should pay for time with patients!
4) Checklists can be helpful as I explain, but not so much for diagnosis.
5) So many of you talk about the importance of the story—bravo! Pay attention to context. Tell your whole story to get your doctor to pay attention and be a partner in your care.
6) Is it offensive to ask patients to do the work? Well, it is the duty of the doctor to do better. It’s also the duty of our system to get better. But what happens if you have a less than ideal healthcare situation? Instead of saying, there’s nothing we can do, it’s the fault of someone else, why not take matters into your own hands?
Thank you all for commenting. Please let me know what you think of our book! www.whendoctorsdontlisten.com.

Jan. 29 2013 05:15 PM
anonyme

Find out about alternative ways of understanding and taking care of yourselves - try not to let things go far enough to get acute - there is so much going on that's available and even free that's energy based.

THANK YOU DR WEN!!!

I am the daughter and niece of doctors who called their patients at home and who made house calls. I have so little faith in our current system - I have the so-called best in the world taking care of me because I'm connected but I think this is bullying, not to mention possibly deadly treatment I'm getting. You need your spirit to survive!

EXPLORE YOUR OPTIONS!!!!!!!

Our medicine looks at our bodies and our ecosystem in such a splintered, disconnected way compared to more "indigenous" or traditional medicines.

Jan. 29 2013 02:01 PM
Truth & Beauty from Brooklyn

I know of two instances in which the tests that doctors did were for entirely different reasons, but their accidental findings saved the lives of the patients.

One was a distant relative of mine who had a complete physical recommended by her plastic surgeon prior to a face lift. Her chest x-ray revealed a spot on her lung and she had surgery for cancer and scrapped the face lift.

The second was the sister of someone I know who had a shoulder injury. When it was x-rayed, the technician got a bit of lung in the shot and found a spot, which she then had removed.

Sometimes doctors do know what they're doing when the recommend extra tests.

Jan. 29 2013 01:59 PM
sandra from nyc

What about House Calls? Any chance to bring these back even to a small degree?
Last month I had horrible back pain and severe numbness in my right arm.
It really scared me and almost went to The Hospital. Then I realized it was my very old mattress.
I replaced it and cured myself! A doctor needs to understand the living situation of a patient well also!

Jan. 29 2013 01:54 PM
Amy from Manhattan

Do they really say to *treat* the most likely diagnosis? I would think that the 1st thing to test for is the most likely diagnosis, & that that should mean the most likely diagnosis given the specific patient's history & symptoms. Treating (except to relieve symptoms) before you have a known diagnosis makes no sense.

Jan. 29 2013 01:53 PM
Kassie from Brooklyn

Is there no place left for "hands on" examination of a patient? I remember the doctor tapping on my chest, feeling organs in the abdomen to see if they were enlarged, and now it seems patients just get sent for MRI's or X-rays. Am I just old fashioned?

Jan. 29 2013 01:48 PM
margaret

I am a physical therapist and it is very concerning to me that many doctors look at tests as the reason to operate - while it is so much more complicated than that. Many doctors have no idea what good physical therapy is - and that is very alarming.

Jan. 29 2013 01:46 PM
David from Fredericksburg, VA

@ Serena from UWS

If she's speaking for insurers, it sure is odd what she's saying. Insurance don't like paying for doctors to listen - get them in & out. Paying attention to patients costs too much.

Jan. 29 2013 01:43 PM
Kate from Washington Heights

You should know about a great organization called PULSE at http://www.pulseofny.org/

Their whole mission is to increase communication between doctors and patients.

Jan. 29 2013 01:42 PM
Amy from Manhattan

Saying that every patient w/the same symptom gets the same treatment sounds as if nobody does a differential diagnosis anymore--is that what Dr. Wen is saying?

Jan. 29 2013 01:39 PM
Christine from Westchester

To Shawn: No, she's saying they need to listen and not just do every test for every symptom. More specific treatment is possible: the devil is in the details. Yeah, it's mostly like a horse except for those big black and white stripes. Every chest pain isn't a heart attack.

Jan. 29 2013 01:38 PM
Serena from UWS

Please ask her for full disclosure of her relationship to insurance companies.

Jan. 29 2013 01:37 PM
Tiffany from Westchester

I've been experiencing extreme fatigue for a number of years with no clear cause. I sleep 12 or more hours a night and still feel tired all the time, which has caused serious problems for me. Doctors tend to write off this complaint, saying "we all get tired sometimes." How can I get my doctors to take me seriously?

Jan. 29 2013 01:36 PM
suzinne from Bronx

There's something inherently offensive about a doctor writing a book about how we, as patients, should learn to present ourselves to doctors! If we're paying doctors so much money, shouldn't they learn how to listen to US?

Jan. 29 2013 01:36 PM
Ken from Upper West Side

What about the recent emphasis on clinical practice guidelines to ensure that practitioners aren't all over the map in terms of their treatment?

Jan. 29 2013 01:34 PM
Shawn from Old Tappan

What she is missing is the fact that these checklists and pathways are based on previous data collected. So based on the numbers, pathways will catch more patients that Dr. Wen's suggestion. As physicians we are constantly playing the odds.

Sure, I can come up with a few anecdotal instances where people deviate from the norm. But being aware that there are people who deviate is important, not throwing out our pathways all together. The fact is that the numbers don't lie. When you take those out of the equation, you will miss more cases.

When you hear hoofbeats, you think horses, not Zebras (in the US). She is asking everyone to think about Zebras first.

Jan. 29 2013 01:33 PM
David from Fredericksburg, VA

The doctor I work for doesn't "back in the door." So of course the insurance companies are always giving us flack about billing for too much evaluation and management time.

Mind you, he's a surgeon & he's discovered several serious conditions that were missed by the primary care providers. You get what you pay for (at most).

Jan. 29 2013 01:33 PM
Mary Fran from New York CIty

I went to my doctor with a persistent cough. I tried to describe what it was like and he just prescribed medications and tests that didn't work. I was referred to a pulmonologist, an allerist and an ENT. More tests, more experiments with meds and still, no one listened to my symptoms. After a year I gave up and went on the internet and found the answer. A doctor in Chicago described my symptoms as I tried to tell my own doctors. He had a cure for it which worked. No cough now for a year.

Jan. 29 2013 01:33 PM
Christine from Westchester

Hard to believe it takes 4 years of undergraduate, 4 years of medical school, 3 + years interning to follow a cook book. The rare doctor who listens to the patient these days but even worse, once admitted you are "treated" by a battalion of providers who don't listen to you are talk to each other. As a clinician I know describes it "be quiet, lay there and we'll commit medicine on you." No wonder healthcare cost so much.

Jan. 29 2013 01:32 PM

Much of what happens on a visit to the doctor is unrelated to the patient or any desire to treat the patient. Instead, doctors go through lengthy checklists simply so they can bill the insurance company for having done so. The insurance companies pay a certain amount for a doctor getting the patient's family history; getting the patient's history; getting the history of the current problem (onset, symptoms). It's a shame, but the fact is that doctors rush through check-lists so they can make more money.

If a young doctor goes to work in an established doctor's practice, the young doctor is told they must see a certain number of patients per hour, and must bill a certain amount per month in order to continue to be employed. It's all a treadmill, about getting more and more money, and it has very little to do with patient care.

Jan. 29 2013 01:32 PM
anna

there is a very good documentary (2012) dealing with this... Escape Fire.
also, the Freelancers Union just opened a medical center in Brooklyn - Metro Tech area that is a primary care practice where each patient is assigned a medical coach to help them with preventative care/life style beyond just meeting with the doctor

Jan. 29 2013 01:31 PM
clive betters

so much "diagnosis",is simply retrofit to prescribe a drug. if you don't address that as a primary issue,then all other discussion around this matter, is simply fatuous nonsense.

Jan. 29 2013 12:50 PM

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