Do you know the best questions to ask about your healthcare?

expectations, concerns, obstacles-medical communication #askthedoctor

I blog about healthcare communication because you need to understand your doctor better and  we doctors need to understand our patients’ expectations, concerns and obstacles.

Physicians should  use clear understandable plain language with patients. Patients should also be clear and specific when they talk to their doctor.

You may think your doctor knows exactly what you mean, but sometimes we are left trying to read between the lines of what you tell us.

Dr. Aletha talking to a mother and her son
Talking to a patient through an interpreter makes communication extra challenging.

You know it’s important to tell us details of your symptoms, medical history, family history, habits, and other medical facts.   But besides medical information about you , we need to know

Your expectations about your care,

Your concerns about your care,

Your obstacles to getting care,

You may wonder, won’t or shouldn’t my doctor ask me theses questions? Sure, we can ask and probably will, but by volunteering it , you start dialogue that gets you and your doctor communicating effectively much faster. Your doctor knows about disease, but you as the patient know the experience of the illness much better. 

Let me illustrate by giving you some examples. These are all statements patients say  to me in my daily practice. The original statements aren’t bad or wrong, but by rephrasing to add some additional detail they  give your doctor valuable information that will help provide you the best care possible.

The underlined words can be substituted for others listed in parentheses.  The exact words aren’t as important as the  message they convey. 

Hello doctor, I’m here because I want my thyroid checked.

(substitute heart, lungs, cholesterol, blood sugar, kidneys, etc.)

Instead try-

Hello doctor, I’m tired a lot, and wondered if it might be a thyroid problem or something else. What testing would help us find out what’s wrong with me?

It’s better not to limit your doctor to checking just one thing, when there are many possible explanations for your symptoms. You expect a thyroid check, but you’re open to other possibilities.

tubes used to collect blood samples in a lab

 

Doctor, I feel terrible and think I have  pneumonia. The last time I felt like this the doctor said it was pneumonia, so it must be that again.

( sub kidney infection, strep throat, sinus infection)

But if you say this

Doctor, I feel so sick. This illness is similar to when I was diagnosed with pneumonia and I’m afraid I have it again. I am concerned it’s pneumonia again so  I’m here to find out what is wrong, as I realize it may be something else.

You’ve told the doctor your concern about pneumonia but you’re not trying to diagnose yourself.

 

 

I have a family history of cancer so I want to have a mammogram.

(sub any other cancer, heart disease, stroke and other tests)

That’s good, but this is better.

Doctor, I’m concerned about breast cancer as it runs in my family. My grandmother was diagnosed at age 45 and now my sister has been, and she is 40. Do I need a mammogram or any other testing now?

Knowing who in your family had a disease and at what ages helps the doctor make an accurate recommendation. It also tells your doctor this may be an emotional issue  (concern)  for you.

Top 10 cancers in the U.S.

 

 

I need an antibiotic (anti-inflammatory, muscle relaxer, steroid, shot )  for this; I know because my previous doctor always gave me one for this.

Please try this instead:

When I had this before my doctor prescribed an antibiotic; I wonder if that would be appropriate this time?

This tells the doctor your expectation, but also that  you are open to different  advice/recommendation. (and avoid getting a medication you don’t need.) 

6 smart facts about antibiotic use

 

 

 

Will my insurance pay for this? How much will this cost me? Is this an expensive drug?

Patients may expect us to know about insurance and cost, but often we don’t. We can work with you on financial issues if we know more about your obstacle. Try asking-

I need to find out if this is covered by my insurance. Can someone in your office look that up, or help me find out?

I’ve had a lot of medical bills this year that have stretched my budget. I will need to find out what my out of pocket cost will be before scheduling this test. Can your office help me with that?

If there is a generic version of this drug that will work just as well, I would like it, to minimize my out of pocket cost. If not, is there another alternative?

 

 

Is this drug safe? (effective, good, best, dangerous, harmful)  

Few things are 100% safe. But what we can discuss with you is –

What are the risks and side effects of this drug? Is the benefit I get from the drug worth the risks? Are there alternatives that would be effective and less risky?

We always should be concerned about drug use, and safety isn’t the only issue. Don’t hesitate to ask questions.

medication capsules

 

 

 

 

 

How long will I be off work? When can I go back to work?

Here’s what your doctor needs to know –

My job requires me to stand and walk for several hours?

(sit and type; talk on the telephone; drive long distances in my car)

And here’s what you need to ask:

How soon should I expect my stamina to return so I can work part time? Full time?

When can I safely work without interfering with my recovery?

What can I do to hasten my recovery so I can return to work sooner?

Both  you and your employer, need to know when it is safe to return to work.  We have to balance health concerns with your financial concerns and what is expected and allowed by your employer and the law. 

If you are clear  with your concerns and obstacles  and flexible in your expectations it will be easier for your doctor to make the right decision.

 

 

These are just a few examples. I’m sure you can think of others.

Whenever you have a need to consult a physician, think ahead of what your

expectations, concerns and obstacles are before you make the visit so you’ll  be

prepared to share .

Here are  more tips on talking with your doctor-

How to talk to your doctor to improve your medical care

How to tell your doctor what’s wrong with you.

I invite you to follow this blog as we explore the HEART of health together.

 

Dr. Danielle Ofri’s book  What Patients Say, What Doctors Hear,

details the reasons doctors and patients don’t communicate well

and offers ways to improve our interaction.

What Patients Say, What Doctors Hear by Danielle Ofri, MD
written by Danielle Ofri, M.D.

(this is an affiliate link)

How to tell your doctor what’s wrong with you.

It may sound simple, but I find that patients often have difficulty describing how they feel. They may say they hurt, cough, itch or get short of breath, but give few details. Maybe we have become too used to text messaging with its brevity, abbreviations and emoticons. We have forgotten how to use descriptive words.

eliciting the HPI through an interpreter can be challenging
at a clinic in Latin America-eliciting the HPI- history of present illness- through an interpreter can be challenging

When I see a new patient I may ask why they left their previous doctor. One of the most common reasons I hear is, ” My doctor wasn’t listening to me.”

Accurate communication between doctors and patients is vital for effective diagnosis and treatment but can be difficult for many reasons. One is that doctors and patients may approach the medical encounter from different viewpoints and have different goals.

Patients already know what is “wrong” and want to know what can be done to help or fix their problem as quickly as possible. The physician’s focus is on getting an accurate medical history to help narrow down the possible diagnoses so they can proceed to testing and then treatment.

Medical students are taught to take a “history” from a patient, one of the first skills taught in medical school. The history is the most important part of the medical encounter because, as we are taught,

“Listen to the patient and the patient will tell you what is wrong.”

This doesn’t mean the patient should  give the doctor a diagnosis, although that is what often happens.

What we usually say

Physician: “Hello, I’m Dr. Oglesby. Why are you here today?”

Patient:” I have a ________.”

Fill in the blank with any number of diagnoses that patients believe they have- a bladder infection, the flu, bronchitis, a sinus infection, pulled muscle, poison ivy, ankle sprain, etc.

What it does mean is that the history of the patient’s problem– how and when  it started, how it has progressed, what the current status is- gives the doctor the necessary information to develop a “working diagnosis”- in other words, the most likely explanation for the symptoms. Then the doctor can proceed with further evaluation to confirm or refute that diagnosis, and possibly lead to an alternate diagnosis to explore.

This process is called obtaining the HPI- the History of Present Illness. That distinguishes it from the PMH- the Past Medical History. (Medicine loves acronyms.)

We want to hear from patients a description of the symptoms in their own words. Then we ask questions to clarify and expand.

What we should say

Patient comes to me with complaint of headaches. And says-

“Dr. Oglesby, I have terrible headaches all the time. I think I have a brain tumor and want an MRI as soon as possible.” 

But what I need to hear is –

“Dr. Oglesby, I have headaches. The headaches are brought on by stress. Loud noise aggravates the pain. Lying in a dark room improves them. There is a throbbing pain in one of my temples and it shoots to the top and back of my head. The headaches are so severe that I cannot take care of my family. I have a headache once a week, and it lasts for at least 2 hours.”

It may sound simple, but I find that patients often have difficulty describing how they feel. They may say they hurt, cough, itch or get short of breath, but give few details. Maybe we have become too used to text messaging with its brevity, abbreviations and emoticons. We have forgotten how to use descriptive words.

patient encounter in VietNam

There are various mnemonics used to organize the elements of the HPI .(Medicine also loves mnemonics.)This is the one I learned in medical school- PQRST. The letters stand for the the different types of information we try to elicit in the HPI.

P- Precipitants- what happens to make the symptom begin or recur; Provocation– what makes it worse, increase, more frequent, etc: Palliation– what makes it better, less intense, less frequent

Quality- sharp, dull, cramp, piercing, numbing, tight, burning, tingling, throbbing,

Region and Radiation- where on the body does it occur and where does it move to

Severity– how bad is it- mild, severe, disabling, tolerable, unbearable, worst ever; can also rate  1-10,

Timing- when in the past did it start, how often does it occur now; how long do episodes last; length of intervals between occurrences

Now we can apply this to the above example:

“Dr. Oglesby, I have headachesregion

that are brought on by stressprecipitant

Loud noise aggravates the painprovocation

Lying in a dark room improves them-palliation 

There is a throbbing pain in one of my temples and it shoots to the top and back of my head.-quality, region, radiation 

The headaches hurt so much that I cannot take care of my family- severity 

I  have a headache once a week, and it lasts for at least 2 hours.” –timing 

With this description, I would feel confident that the patient has migraine, not a brain tumor. If  the physical examination is normal, she likely will not need an MRI and we can proceed to planning management of her headaches.

How we can work together

We doctors don’t expect our patients to always recite a rehearsed narrative  about “why I came to the doctor today.” But it does help if you come prepared to answer questions as specifically as possible.

You might try thinking about your problem using the PQRST mnemonic. It will help your doctor identify possible causes for your symptoms, and may also help you understand your problem and even suggest ways you can help yourself.

Here is an entertaining story about how some people tell a “country doctor ” what’s wrong.

Cave: The Patient Who Suggests a Diagnosis Before Telling You His Symptoms

“I have finally come to realize that Hedda carries with her more than a lifetime’s worth of grief, which now and then erupts as a sensation she has no words for. ”

I appreciate all of you who follow this blog; there are numerous other blogs to choose from so I am honored you chose to spend some time here. A special welcome to all my new followers from this past month.

                              Dr. Aletha