The connection between doctor and patient is one of the most trusted relationships in the professional world. Two physicians from Brigham & Women’s Hospital have co-authored a new book that highlights a danger in the doctor’s office. In the examination of the doctor-patient relationship in “When Doctors Don’t Listen”, Dr. Josh Kosowsky and Dr. Leana Wen argue that diagnosis is quickly becoming a lost art with serious consequences. Using real-life stories, the doctors illustrate how active patient participation can prevent mistakes.
The skyrocketing cost of health care is in the news every day: $2.7 trillion spent on health care, .18 of every dollar, with up to a third of medical costs wasted. But the problem goes much deeper than cost. More than 100,000 Americans die from medical error every year, with the majority of error attributed to mistakes in diagnosis. Every day, patients are going undiagnosed or misdiagnosed despite doctors’ increasing reliance on tests, a large number of which are probably unnecessary.
Patients feel increasingly out of control and out of touch with their own health. Well-intended doctors try their best, but they, too, are trapped in a dysfunctional system, which, at least on the surface, appears to reward “cookbook medicine,” which regards all individuals as alike, and punish good judgment.
Dr. Kosowsky and Dr. Wen believe that taking control of your own health care begins with something even more fundamental: The patient advocates for getting the diagnosis right. To do this, the patient needs to speak up and be heard. In order to truely be heard – the doctors advocate that patient need to follow 8 Pillars to a Better Diagnosis. They are as follows:
1. Tell your whole story. Studies have shown that more than 80% of diagnoses can be made based on history alone. Unfortunately, doctors sometimes seem to want to steer you toward a cookbook “chief complaint” or a series of “yes/no” answers. Learn to tell a succinct, effective story. Prepare and rehearse it.
2. Assert yourself in the doctor’s thought process. Find out what your doctor is thinking as you recount your history, and let your doctor know what’s on your mind. If you’re not starting out on the same wavelength, it’s hard to develop that crucial partnership.
3. Participate in your physical exam. If you’re being examined, make sure you know what the doctor is looking for. Don’t be afraid to ask about the implications of any findings.
4. Make a differential diagnosis together. A “differential diagnosis” is just the list of all the possible diagnoses that could explain your symptoms. Make sure you and your doctor come up with a thorough list, with some estimate of the likelihood of each possible diagnosis. Keep asking what else could be going on.
5. Partner in the decision-making process. Devise a strategy with your doctor for narrowing down the list of possible diagnoses. By partnering with your doctor, you can often arrive at a working diagnosis without a lot of tests.
6. Apply tests rationally. If you do need to undergo further testing, you should understand how a particular test will help narrow down your differential and what the risks and alternatives are. Look out for “cookbook medicine,” and make sure your doctor is tailoring an approach that works for you.
7. Use common sense. You shouldn’t leave the doctor without a working diagnosis that makes sense to you. Don’t just assume the doctor must be right. If the picture doesn’t add up, go back to the drawing board.
8. Integrate diagnosis into the healing process. Talk through your diagnosis with your doctor and make sure you understand its predicted course. What treatment options do you have, and what risks and benefits do they carry? If your working diagnosis turns out to be wrong, what warning signs should you be on the lookout for?
In sum, the relationship between patients and doctors is due for a fundamental re-think. Not less talking, but more. And more listening, too ” by patients and doctors. Especially doctors.
Be safe and be smart.