What your patients are reading about you (book excerpt: You: The Smart Patient)

Two physician authors are telling patients how to take charge of their own care. Here's a peek at what patients are told to expect from physicians.

By Mehmet C. Oz, MD, and Michael F. Roizen, MD, amednews correspondent — Posted June 12, 2006

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It's a two-word utterance that used to cause great tension between doctors and patients, long before "I'll sue!" stole its thunder. Mentioning it still causes anxiety, at least among a percentage of patients who can't shake their outdated notions about us doctors having some sort of all-knowing, all-seeing power.

It's "second opinion."

Of course, today we all know (or should know) the modern viewpoint on second opinions, since talk shows, nightly news segments, newspaper and magazine articles, highway billboards, health insurance newsletters, at least a million self-help books and everything else short of fortune cookies and Bazooka Joe comics have been hammering the rule into our heads for at least fifteen years: Never think twice about getting a second opinion.

You might think that this is difficult for us to say, because, well, it boils down to admitting that we can be wrong and we can be wrong a lot. Sometimes 180 degrees wrong. But it's actually second nature for us to push second opinions. Honestly, to forget about your needs for a moment, you're doing your doctor a big favor by getting a second opinion. You're giving him the chance to have his work and his instincts checked by another qualified doctor, which can only result in three possibilities.

First, the consulting doctor could agree with his diagnosis and advice completely, which will make everyone feel more confident in going forward. Second, the consulting doctor could agree on some points but offer different thoughts on others. Third, the next opinion could be completely different. In either of the last two cases, you've given your doctor a free opportunity to learn something without him having to fly to Salt Lake City to sit through a conference. So from a purely selfless standpoint, never feel embarrassed about going for a second opinion. Your health insurance may require it in many circumstances, but even if not, your doctor almost assuredly expects you to do so. And your doctor should thank you for it. In case he or she forgets, we will:


Feel free to copy these pages and give them to your doctor.

Now, let's talk about the purely selfish reasons for getting a second opinion. It could save you a lot of trouble, and it could save you, period. No smart detective would hang his whole investigation on a single witness's story without making sure it checked out. And no Smart Patient would hang her whole life on a single expert's judgment. Research has found that getting a second opinion results in a new diagnosis in as many as 30 percent of all cases. That's a lot of cases.

Why, oh why, then do people still regard second opinions the way they regarded psychiatry twenty-five years ago? They say it in hushed tones, as if they were talking about an upcoming lobotomy (no offense to those with upcoming lobotomies) or an illicit drug transaction. One day we expect to hear a patient spelling it out to another patient in the waiting room ("I'm getting an S-E-C..."), hoping that what keeps her three-year-old guessing will also trick us.

It would be funny, except this stigma affects decisions. Research shows that only 20 percent of people who seek medical care every year get a second opinion. If only one out of five people seek a second opinion, but almost one in three second opinions result in new diagnoses ... The math is making our heads hurt, but the implication is obvious. There are millions of patients who aren't getting second opinions who clearly should -- and doing so would change the treatment course for large numbers of them. Today, getting second opinions is easier than ever due to technologies that allow doctors to consult from afar. Just like Dick Tracy, use all the technology at your disposal to make getting a second opinion easier. Whether it's e-mail, overnight delivery services or a two-way spy receiver.

This reluctance is understandable in some ways. When you have a health crisis, there's a strong inner desire to put complete faith in your doctor, to see her as a shining beacon of leadership and serenity, a port in the storm, someone who will tell you, "This is what we will do, and it's going to be okay." This gives you a strong sense of clarity: Doc says do this, so we'll do this.

Realizing that you need a second opinion is admitting that this notion is all just a comforting fairy tale, and your doctor is not an infallible authority, but just a human being who's doing his or her best and could very well be wrong. She might've been watching a West Wing rerun last week instead of reading the latest medical journal that discussed a new treatment for your condition. Stripping your physician of this reassuring myth of invincibility can make you feel even more adrift and alone when you're in a bad situation.

In this next excerpt, the authors write about how patients find a physician.

One of the most important decisions you will ever make -- and one you'll likely make more than once -- is choosing your doctor. As the owner of a wondrous commodity (your body), you always have supreme rule, but your doctor is the get-it-done person. Consider your doc to be the head coach of your football team, the floor manager of your Hollywood restaurant, the captain of your ocean liner. Choose wisely, and you could rest easy for many years to come, knowing that your sentinel is on the job, on the ball, and taking care of the duties you need done. Pick an incompetent boob who talks a good game, or even a well-respected professional who is hopelessly overbooked and can't find the time to squeeze you in, and your boat may sink.

We've seen it happen. And we've been called in on salvage operations.

A Smart Patient will pick his or her doctor wisely. Sometimes, picking your doctor wisely means walking out of a doc's office if he or she isn't the best choice for you, or understanding if we give you a referral to a trusted colleague. A Smart Doctor chooses his or her patients wisely, too. Today there are so many advanced subspecialties of medicine, and so many physicians who have developed expertise in particular specialties while still operating as primary care physicians, that matching the right patient with the right doctor is a far more complex -- but rewarding -- mission than it was just a few decades ago.

Marcus Welby (whom we will continue to abuse, with our apologies to the late Robert Young) seemed to handle the limitless gamut of his patients with equal ease, graciousness, and expertise. Today, if he attempted to keep the same philosophy, he wouldn't find enough hours in the week to give half of those patients cutting-edge care. He'd be a likeable, dangerously ineffectual physician to many of his patients -- so affable and likeable that many wouldn't know that he was unqualified to treat them until something bad happened. Until, say, that beauty mark he repeatedly told you not to worry about turned out to be melanoma, because while he might be a great internist, he's not a dermatologist.

You, however, won't run into these problems. Because you're going to choose -- or requalify and, if necessary, replace -- your physician with an insider's eye, using the criteria that will ensure he or she is the absolute best primary care doctor (PCD) for you. You need the facts. So we'll give you the questions to ask while you're channeling Joe Friday (remember, you just want the facts, ma'am).

There's a shortage of physicians in the United States, and medical schools aren't pumping out numbers to match the increase in population (though women now make up the slight majority of graduates, so not all of the news is dismal). Still, we have more than 700,000 doctors, and if you open your insurance plan's in-network directory, you'll see a bevy of white coats in your area. They all have different backgrounds, different approaches to care, different specialties and different levels of skill. How can you pick the right one without visiting at least twenty-nine or becoming frustrated and just randomly plunking your finger down on the page? Further, what if none of them is the best choice, and you'd be better off paying more for a physician who isn't on that list? Paying much more, that is. It can make you want to drink.

Before you reach for the bottle, though, let's tackle it together.

Although the tips we're giving you will work in qualifying any doctor -- from a cardiologist to a podiatrist to an internist; mostly any-ist, in fact -- the doctor we're talking about here is your primary care physician. Or the head football coach that we referred to earlier. If your health insurance is a health maintenance organization (HMO) or other managed-care plan, you know all too well what a primary care physician is. Such plans most often require you to have one on record. This main doctor tends to your everyday health care needs and is often the "gatekeeper" in referring you to other physicians when you need a specialist, such as a dermatologist or a psychiatrist or a special surgeon. As a Smart Patient choosing a smart primary care doc, you're really looking for a physician who's smart with referrals and has connections with the best specialists in your part of the country.

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Author Q&A

Will this book make you unpopular with doctors?

Our general consensus was that the vast majority of physicians won't mind our being so direct and asking patients to play a more active role because, usually, it makes the interaction with a patient a more fruitful one. Maybe it takes more time, which is the negative. But it makes it more fruitful. ... The average doc interrupts their patients within 23 seconds of the conversation starting, but only 2% of patients actually ever finish their opening statement. If we can get patients to deliver their content in a more comprehensive, concise fashion instead of mumbling through it, then it'll help both sides.

How will what patients get from reading the book make it better for physicians?

It will be a more efficient [office] visit. It will not be a faster visit. There will be much more information conveyed, which will improve the quality of the service provided and won't generate the same number of lab tests. Oftentimes, you can limit the number of tests you do just by taking a better history. It also gives the patient what they want, which is a better experience -- the belief that they actually expressed themselves and the doctor got it.

Do physicians say you're making their lives more difficult or time-consuming?

I've had some feedback from people generally about the fact that we're creating unrealistic expectations for patients, that what we're asking them to ask for may not be easily given by doctors. Of course, no doctor ever says it's true about [him or her]. They say that this is true for other doctors. But I understand the thought.

Do you think most physicians cringe when patients come in with Internet printouts?

In the book, we actually tell [a patient] which sites are good and how to screen sites. We make [the patient] a smarter user of the Internet. [They're] going to bring papers to [the] doctor, but they're going to be papers that will often be of some use to the doctor, not zero use to the doctor.

Where we have the biggest problem with docs is the second opinion area. We tell patients in the book that 10% of them will seek a second opinion, yet 30% of the time, a second opinion would have changed their diagnosis or their treatment. That's a very provocative insight for people who know it, because what we're saying is you've got to be an absolute fool not to get a second opinion. And that irritates docs because it undermines their belief that the patient trusts them. Even though it's a little bit irritating to doctors to think that we're encouraging second opinions, if you see the data, you'd be a fool not to get one.

Interview by Damon Adams

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