I could say something humorous, but
this is serious and patients need to be aware of the problems some
key words cause. These key words will result in many unnecessary
tests and procedures. Cookbook medicine is very prevalent in medical
practice and even in most hospitals. Doctors follow lists and make
checkmarks for each item checked off. Dr. Leana Wen writes an excellent blog on this.
Many doctors have lost the ability to
rationally think through what the patient may be saying and arrive at
a diagnosis. They use checklists to practice defensive medicine and
could care less about the patient. When they have a patient that
they cannot properly diagnose, the checklist becomes even longer and
more tests and procedures are done. Or they will make some
comforting platitude and send the patient home still having the
symptoms.
The disadvantage of having a doctor
practicing cookbook medicine is that a “cookbook” approach where
you get the same recipe of tests and medications as anyone else will
result in expensive, unnecessary care, and even misdiagnoses and
harm. Think about this, you have a pain from tripping over a toy and
landing on another toy in the lower sternum area and you think it may
be a bruised or cracked rib. You point to the area and immediately
you are set up for a blood draw, EKG, and a chest x-ray. You’re
told this is all part of the “chest pain protocol”. But did you
really need all of these tests done?
Heaven forbid you have a gall bladder attack or a pancreatitis
attack, as you will be sent for the same tests. You may be given an
IV drip of nitro glycerin, a drug or agent, that can cause dilatation
of the walls of blood vessels. After the pain has subsided, you will
probably be admitted to the hospital for observation, at your cost.
This is what happened to me when I had a severe gall bladder attack
over a year ago. When I had the second attack, I went to another
hospital and they suspected gall bladder almost immediately when the
blood tests came back as negative for heart problems.
The following Monday morning I was
scheduled for an ultra sound exam of my gall bladder and the doctor
said I was lucky to have not had the gall bladder burst. He
recommended an immediate removal. Since I could not be operated on
at this hospital, I transferred my records to the other hospital and
was scheduled for surgery. I admit I was hesitant after the poor
care I had had the first time, but since it was a different doctor, I
had the operation and it was successful. After the operation, the
surgeon confirmed that I was fortunate and there was good reason to
have it removed.
Here are five tips to make sure you get
the best, and hopefully personalized care for you:
#1. Insist on telling your
story. Studies have shown that 80% of all diagnoses can be made just
based on the story of your illness. Don’t just say that you have
“chest pain”; explain when it started, what you were doing, and
how it felt. Write down key elements if possible. Practice until you
can tell it in 30 seconds or less. Most doctors will try to
interrupt, but ask them to please let you finish. Please leave the
drama out of the story and stick to the facts.
#2. Give open-ended responses to
close-ended questions. If you suspect that the doctor is going
through a checklist of yes/no questions, try to get the doctor to
focus on you by adding personal elements to your answers. Example:
If you’re asked, “when did you start feeling so tired?”, don’t
just say “two weeks ago.” Add that you’re normally very
energetic and exercise every day, but for the last two weeks, you can
barely get out of bed to go to work. These answers help provide
context to who you are.
#3. Ask about your diagnosis
before you consent to tests. If you’re told you need to get blood
drawn, ask why. Sometimes, that’s enough to stop the “cookbook”
from taking over. Every test should be done for a specific reason,
not just because it’s what’s done in this protocol, but because
it helps focus the diagnosis. Also ask about what to do if the tests
are negative. Just because they’re negative doesn't mean there
isn’t anything wrong, so what should be next steps? Above all, be
polite, but firm if necessary.
#4. Inquire about other
treatment options. In very few situations is there only one test
that could work or one protocol that must be followed. If your
doctor says you need to do this one set of tests, ask what your other
options are. Often, watchful waiting is a perfectly acceptable
alternative. Discussing options may help to remind your doctor to
tailor the treatment to you.
#5. Let your doctor know that
you want to be a partner in your decision-making. If you still think
that your doctor is following a recipe rather than individualizing
care, ask the doctor to explain his/her thought process to you. Say
that you respect his/her expertise, and you want to learn what it is
that he/she is thinking. Your doctor may be so busy or so used to
checklists that your request can help him/her to refocus on you and
your individual needs.
Unless this is an emergency, do not be
afraid of leaving without a diagnosis and finding another doctor
especially if the doctor becomes paternalistic or insists that you
follow his/her instructions. I wish I had known about this at the
first gall bladder attack, as the doctor at the second time did not
continue on the heart problem line of thinking after the results of
the blood draw came back negative.
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