Thursday, December 13, 2007

The Top 10 Questions Patients Should Ask Their Docs (And That Docs Should Be Asking Themselves)

There's a very good article in that's worth talking about. It lists 10 key questions to ask your doctor. Some are right on and some are problematic.

Click here for my scintillating observations!
Here is a very good article on entitled 10 Questions You Must Ask Your Doctor. The questions proposed are pretty good but I would like to throw my 2 cents in. It is MY blog after all!

First of all, I rather like the tone of the article. It recommends a reasonable, nonadversarial approach for patients to take with their physicians. Always a nice change from the usual How to Tell If Your Doctor is Screwing You Over pieces that I seem to run across.

So here we go:

1) Do I really need this test? Great question but the author is preaching not to the choir, but to the tree stump. It's pretty well documented that as far as the patient is concerned: "Nothing is too good for my long as someone else is footing the bill." My feeling is that it's the patient that is the main driver to more extensive test-ordering. This is really a question the doctor should be asking until such time as patients are required to assume a greater personal responsibility for their routine medical expenses.

2) Where would you send your wife or children? Another great question. In fact, this is a version of a question I try to ask myself and that I try to teach housestaff to ask on their patients' behalf: "What would I do if this patient was my mother-father-child-etc.? Nothing focuses the mind like putting yourself in your patient's place.

3) How many surgeries do you perform each year? I would rephrase this as "How many of this type of operation do you perform each year?" As the article notes, There's an substantial body of literature that supports the notion that practice does indeed make perfect. This is true for both surgeons and for the hospitals in which they operate.

4) Can I schedule my surgery in the morning? I wasn't aware that outcomes for first procedures of the day were better but it seems plausible. The surgeons I know are mostly morning people. I'm ashamed to say that when I was a medical student, I definitely saw surgical cases rushed through because they were the last ones of the day.

5) If I get sick, will you see me in the hospital? Uh oh. And the author was doing so well. The fact of the matter is that hospital medicine has become so specialized that its best practitioners are those that do it the most. In fact, I point out (with some irony) his suggestion of the ideal response to question 3. In fact there's a large body of evidence to support the notion that hospitalists have better outcomes, shorter lengths of stay, and more cost-effective care than non-hospitalists. If a GP isn't admitting large numbers of patients per year, his skills are going to get a bit atrophied.

6) Do you earn bonuses based on performance? This is a tough one. The premise of this question is that, "Many hospitals pay their physicians bonuses based on how quickly they move patients out the door." First of all, there are very few settings where hospitals pay bonuses directly to hospitalists. That said, there are many situations in which hospitalist performance is evaluated at least in part on patients' average length of stay (ALOS). I don't know that many hospitalist groups are so crass as to pay a straight bonus on this basis but it can pretty much be guaranteed that ALOS is definitely looked at in reviewing their salaries. However, other quality measures are definitely examined as well: outcomes, bounce-backs, patient satisfaction, etc.

Should you refuse care from any physician whose income is in some way affected by the ALOS? If so, you may find yourself being cared for by the guy delivering the meal trays.

7) When did you graduate from medical school? The author cites a review suggesting that doctors more than 20 years out of medical school are 48% less likely to be on top of current developments in their fields. Like everything in medicine, the key question is whether your doctor is representative of the population studied. If you have confidence in your doctor, he explains things well in an easy-to-understand manner, and has a personality that clicks with your own; I wouldn't put too much weight on this finding.

Of course as one who will shortly approach that 20 year mark myself, this piece of commentary may appear curiously self-serving.

8) What the hell does that say? The point here is that "neatness counts" when penmanship is the issue. There have been countless cases of serious badness (as my infinitely more hip residents like to say) due to poorly written prescriptions and hospital orders. Reviewing your prescription with your doctor and making sure it's legible is obviously a good idea.

9) Will you remove that wedding ring? Hmm. The idea is that the risk of transmitting an infection to the patient is greater if his care providers are wearing rings. I don't know if this has ever been formally studied.

I pubmed'd "wedding ring" and found papers in the field of dermatology (eczema, allergic reactions to metals), emergency medicine and orthopedics (how to remove stuck rings, ring-associated injuries), and urology (don't even ask).

I also found a rather intriguing article in the journal Nature entitled Earth Science: The Extraterrestrial Wedding Ring. I'll definitely have to check out that one out.

The point is that I don't know if the evidence supports asking your nurse or doctor to remove his wedding ring. The study cited by the author didn't examine infection rates, only bacteria counts which in this setting may or may not have clinical relevance. Personally, I'd feel a little funny asking someone taking care of me to remove their wedding ring, particularly a woman. Who knows what she'd think!

10) What else can I do to treat my condition? It's true that physicians often lag in their familiarity with medical interventions if they don't involve man-made chemicals or sharp instruments. In fact there are studies that demonstrate the benefits of diet, nutrition, and exercise. Unfortunately, the data supporting them may not be as dramatic or as robust as you might hope. However, I've encountered many physicians who market their practices by emphasizing these more natural treatments.

I have no problem with that at all. Just make sure your doctor also knows about man-made chemicals and procedures involving sharp instruments.

All in all, I give this piece an 8.5. And some of that score has to be because the author raises compelling points that all of us, patients and doctors, should be asking ourselves.

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Anonymous Anonymous said...

Very interesting, but I have to wonder what kind of reception a patient would get to some of these questions.

Would some doctors be offended if a patient questioned the reason for a test? It might sound like the doctor's judgment is being undermined.

Ditto with asking about bonuses - some docs might see that as an intrusive question.

I have no clue what my physician's handwriting looks like. Any and all prescriptions are sent electronically to the pharmacy without ever passing through my sweaty little fingers. I'm not sure if this is good or bad.

In theory, patients are encouraged to be assertive and ask questions. In practice, this doesn't always work so well.

December 14, 2007 7:57 AM  
Blogger Jeffrey Parks MD FACS said...

The literature relating surgical excellence to number of procedures performed is pretty weak. There are plenty of good surgeons in the community who will do a fantastic job on your whipple or thyroid surgery. Similarly, you may get a botched job by the big name at the major tertiary referral center. Reputation of the particular surgeon is more important than what hospital he/she is affiliated with. Also ask where they trained. A communtiy general surgeon who trained at a major center is more likely to have had experience with complicated, advanceed procedures.

December 14, 2007 7:58 AM  
Anonymous Anonymous said...

I might add "Have you had additional training in this procedure?"

For example, I think it is valid info for a pt to know if their dermatologist is fellowship trained in Mohs.

December 14, 2007 8:54 AM  
Blogger DDx:dx said...

I want to point out the order of the questions and their relevance to personal responsibility. Of course, the doctors training and experience are pertinent, but the FINAL question comes away from what are YOU(the doctor) going to do for me, to the appropriate one(I believe), what can I(the patient) do for myself?
I think this reflects the American attitude toward health and personal responsibility....And Insurance amplifies the moral hazard...

December 14, 2007 12:05 PM  
Blogger The Happy Hospitalist said...

As far as I know, tying bonus directly to length of stay is illegal and would never be built into a contract.

Others may appropriately correct me.

December 14, 2007 1:35 PM  
Blogger Toni Brayer, MD said...

Good list. Thanks for the post. If a doctor is offended by any of these questions, I would question the doctor. It also gives an opportunity for the doctor to explain..P4P (hard to explain but...), infection rates, etc.

December 15, 2007 2:56 PM  
Blogger MedStudentGod (MSG) said...

As far as the wedding ring question, I've never heard anything suggesting that rings are causing infections. I think a bigger question to ask is, not will you remove your ring, but have you washed your hands or are you going to wear gloves (sterile or non)? If you're washing your hands regularly the ring gets washed as well.

December 17, 2007 4:26 AM  

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