If you’ve ever owned a car and never built one, you know the sense of powerless frustration when something goes wrong with it. Unless you have the good fortune of having a best friend who is a mechanic, you never know whom you can trust to fix your car.
That sputtering and clanking, the clutch’s failure to engage, the air conditioner that keeps conking out – who knows what’s really causing it? You might as well hand your wallet over to your mechanic and hope he treats it gently. What’s more distressing is that all those tricks we resort to to keep us from feeling like total rubes – getting a second opinion, finding a mechanic who talks you through the problem – may not amount to anything.
Well maybe finding a physician you can trust isn’t all that different. According to a recent study, service problems that require an expert’s objective measurements – clearly diagnosing and fixing a problem in a timely way – are problems indeed. There’s even a name for it: ‘expert service problem’, because the same expert who is diagnosing the flaw is the one who will be paid to fix it. You can research almost any product online to find the best in its field, the lowest price, and the best place to buy it. Heck, you can even keep yourself from getting snow jobbed by buying a car that way. But when it’s time for the car to get fixed – or your house’s plumbing, or your body’s – your total ignorance can keep you from getting a good deal.
Similarly, when you go to a doctor, the expert service problem arises. Like car mechanics and other experts, doctors bill for both diagnosing and treating. But there is no way to make sure they are actually fixing the problem until after the symptoms fail to disappear or get worse – and the damage is done.
Our doctors’ intent is good; they have entered the field of medicine in order to be healers. And their training is outstanding:
Physicians are some of the most hypereducated professionals around, with eight years of higher education, followed by 3 to 10 years of residency and subspecialty training over thousands of hours. They also must pass some of the most exacting and complex licensing exams ever written, including at least four separate tests requiring weeks of dedicated study to achieve board certification. And yet, according to studies…most doctors in practice don’t pass muster in administering optimal care for elementary conditions like infant diarrhea. What is going on?
The problem is the U.S. health care system creates problems on both the diagnostic end and the treatment end of medicine:
- Most U.S. doctors are paid by our insurance system to provide services – actual health outcomes are often not measured, let alone rewarded.
Clinical training in primary care—including pediatrics, internal medicine, and family practice—excessively focuses on the diagnostic hunt rather than the more routine rounds of treatment that follow. It’s tempting to think that most doctors are detectives nailing baffling diagnoses, like Hugh Laurie’s character on House. To be paid at the appropriate level, physicians must exhaustively document all sorts of irrelevant diagnostic data—such as a rectal exam in toddlers seen for a comprehensive asthma evaluation—rather than the rationale for the treatment they prescribe.
- Even the most routine problems lack uniform treatment guidelines.
- And…..doctors are paid very low rates for primary care office visits. This combined with the high administration costs of running a practice in our complex insurance system means that primary care doctors must squeeze in a lot of visits to cover their costs. This means less time per patient and a greater likelihood that something goes missing – honest mistakes get made.
Yet the nature of the job – the rigorous training and high standards required to practice medicine, the seriousness of being responsible for someone’s life and wellbeing, the fear of malpractice – leads to the typical doctor conducting him/herself with confidence and authority – and the average patient is afraid to question that.
According to a 2006 Consumer Reports study, less than half of those surveyed said they asked the doctor about treatments they’d heard about, brought a list of questions and concerns to the doctor, or brought a friend to an office visit to help understand or question the doctor. We just don’t seem to feel comfortable second-guessing our physician.
Physician and writer Jerome Groopman has written a book to help redress this imbalance. In How Doctors Think he recommends patients do the following:
1. Ask what else it might be.
2. Ask what is the worst it could be.
3. Slow down the doctor’s pace and help him think more broadly.
4. Search for the gaps in his/her analysis.
5. Insist on giving him/her a complete case history, because hidden in your details might be clues that were initially missed.
6. Ask if there is anything that doesn’t fit.
7. Ask if it is possible that you have more than one problem.
These questions and steps will not only shake the doctor loose from first impressions (something that Groopman thinks drives too much of most doctors’ diagnoses) but help the patient to feel empowered. This shift in the power balance can only help the patient and doctor both.
If your doctor resists it, then you know you have the wrong doctor. And that’s a diagnosis you can make.
For more on this:
by David Riff
The New York Times Magazine
February 17, 2008