You sit there in that silly little gown, trying to act normal. The doctor comes in. You exchange hellos, then launch into why you’re there.
Within 18 seconds, according to a study of more than 1,000 doctor-patient encounters, the doctor interrupts. Suddenly, you blank out on that chest pain two weeks ago and start babbling about your toenail fungus and how many colds you get. You anxiously scan the doctor’s face as he probes your belly.
At the end, clothed and courageous again, you pause, hand on doorknob, and blurt out why you came: You’re too depressed to sleep. You’re drinking too much. And you get these chest pains.
The doctor sighs. Another tortured medical visit.
Even with a doctor who’s a sweetheart at home and a patient who’s a dynamo at work, communication tends to fall apart in the doctor’s office. The power balance is weird. Patients are scared and tongue-tied, not to mention half-naked. Doctors are busy.
The result, all too often, is frustration on both sides, as well as missed diagnoses and malpractice suits, say those who study patient-physician interactions and ways to improve them.
A big part of the problem, of course, is time. The widespread perception, among patients and doctors alike, is that the length of visits is shrinking, particularly with managed care.
“I don’t know of any good, current information about whether they’re shrinking, but patients and doctors seem to think so,” says Dr. Harold Sox, president of the American College of Physicians and chairman of the department of medicine at Dartmouth Medical School. Asked how long a family doctor’s visit lasts these days, he guesses, “Oh, golly. . .around 8 minutes.”
Maybe even seven, if you believe the January-February issue of “Gratefully Yours,” a newsletter from the National Library of Medicine, though this figure is based purely on anecdotes.
What data there are, in fact, seem to point the other way, says Donald B. White, spokesman for the American Association of Health Plans. According to “Socioeconomic Characteristics of Medical Practice, 1997,” a book put out by the American Medical Association, doctors say the average length of their visits has actually increased from 24.3 minutes in 1985 to 26.9 minutes in 1996.
A more precise study – an analysis of national ambulatory care surveys published in March, 1998 – shows that between 1979 and 1994, average doctor visits, at least for kids and teenagers, grew from 11.8 minutes to 14.2 minutes.
Other studies suggest the average visit for a checkup today is 15 minutes, “about half as long as doctors say they need,” says Dr. Christopher Forrest, an assistant professor at the Johns Hopkins School of Public Health.
So the real issue, whether you get 24 minutes for a checkup or four for a raging sore throat, is how to make the most of the time you get. And that means telling the doctor up front – not when you’re leaving – what’s on your mind, preferably your two or three main concerns, not a litany of 20 vague complaints.
It means remembering to mention other professionals (medical specialists as well as alternative types like chiropractors) you see and all medications (including herbs) that you take. It means asking questions when you don’t understand. And perhaps most difficult, it means having the courage to mention things you’re shy about, like troubling bowel habits, sexually transmitted diseases and anxiety or depression.
“Most people are very impressed with technology like cardiograms and blood tests,” says Dr. Marc D. Silverstein, director of the Center for Health Care Research at the Medical University of South Carolina.
But talking is far more important than tests. In studies at the Mayo Clinic, Silverstein found that history-taking – when you tell the doctor what’s been bothering you – identifies 10 times as many problems as urinalysis, and five times as many as a complete blood count.
That fits with what the American Society of Internal Medicine has been saying for years – that 70 percent of all correct diagnoses are made just by talking with patients.
So how can you communicate most effectively?
“Prepare, prepare, prepare,” says Dr. Barbara Korsch, a pediatrician at Children’s Hospital of Los Angeles and member of the National Academy of Sciences who pioneered the study of doctor-patient relationships. Patients often complain that they never get to ask the most important question, she says.
You can make sure you do, but you have to set priorities. “That doesn’t mean you have to burst in and have an emotional explosion, but you can come in with an agenda in mind, or written down,” she says.
Be specific, adds Molly Mettler, senior vice president at Healthwise, Inc., a health information organization in Idaho. If you think you’ll forget, bring notes on when symptoms begin, what time of day they occur, what type of pain you feel.
And ask about alternatives for treatments or tests your doctor suggests, says Maysel Kemp White, associate director at the Bayer Institute for Health Care Communication in West Haven, Conn.
It may also help to “rehearse out loud” what you want to say, says Dr. Sheldon Greenfield, director of the Primary Care Outcomes Research Institute at New England Medical Center in Boston.
With his wife, psychologist Sherrie Kaplan, Greenfield has conducted studies showing that when patients are coached on how to present problems in an assertive but not adversarial way, they get more answers from doctors – and fare better, with improvements in blood sugar, blood pressure and other measures.
And if your doctor cuts you off, either ask to finish your thought or ask if you can come to back to it in a minute.
The bottom line is that most doctors want to listen. In fact, they’re taught an oft-cited dictum: Listen to your patients – they’re giving you the diagnosis.
It’s the doctor’s job to ask for details. But he can’t listen to what you don’t tell him. Previous “Health Sense” columns are available through the Globe Online searchable archives at http://www.boston.com. Use the keyword columnists and then click on Judy Foreman’s name.
Being prepared helps
Here’s how to talk to your doctor effectively:
- Be prepared, with written notes and questions if necessary.
- Prioritize – talk about your 2-3 most important concerns.
- Write down the doctor’s answers to your questions.
- If you need more time, schedule another visit.
- Bring a relative or friend if you need help communicating, or remembering what the doctor says.
- But if you’re concerned about domestic abuse and the abuser wants to accompany you, ask the doctor to see you alone.
- For general checkups – whose usefulness is a matter of debate, at least for younger people – it may be best to see a primary care physician. If you want to see a specialist such as a gynecologist, ask if that doctor is comfortable doing a checkup.
- Tell the doctor about other health professionals you see and any treatments and drugs, including herbs, you use.
- Don’t assume your doctor is negligent if he says you don’t need some standard tests. Many of them are unnecessary, says the US Preventive Services Task Force, a government panel. The important ones are a cholesterol test, a blood pressure check, a colorectal cancer screening test, and, for women, a Pap smear and mammogram. The value of the PSA test for prostate cancer is still a matter of hot debate.
For more information, you might read:
- “Healthwise Handbook, a Self-Care Manual for You,” by Healthwise, Inc., Boise, Idaho. (On the net, www.betterhealth.com)
- “The Intelligent Patient’s Guide to the Doctor-Patient Relationship,” by Dr. Barbara M. Korsch and Caroline Harding, Oxford University Press, New York and Oxford.
- “Talking with Your Doctor, A Guide for Older People,” a booklet by the National Institute on Aging. (1-800-222-2225 or on the net, www.nih.gov/nia.) Supplies are limited.