July 3, 2014

Beware of Doctors Practicing Cookbook Medicine

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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