Appeared in the print version as "What You Don't Say to Your Doctor Can Kill You"
May 1, 2013
At a major hospital’s emergency department, a 60-year-old patient named May recently told a doctor that she had passed out in the gym locker room after feeling queasy and short of breath during a workout. May answered “yes” to all the doctor’s questions. Yes, she had a headache…an upset stomach…shortness of breath—and chest pain.When the doctor heard chest pain, he linked it in his mind with the patient’s fainting (a possible sign of a heart condition) and proceeded to give her the standard evaluation for heart disease. The tests turned up nothing, but overnight the patient developed a 102°F fever and her “upset stomach” became extremely painful.
This time, doctors gave May a full physical exam and blood tests. Results pointed to a gallbladder infection that could have been treated with antibiotics but had become so severe that she now needed an emergency operation. How was the real cause of May’s distress missed?
This is a classic example of what can happen when a doctor doesn’t keep an open mind about a patient’s health problems—and the patient doesn’t do a very good job of describing the ailment. This type of scenario occurs every day in hospitals and doctors’ offices across the US.
WHAT GOES WRONG
When you have a doctor’s appointment (or go to an emergency department), the diagnosis process starts the moment the physician steps into the examination room. That’s why what you say and how you say it are so critical to getting an accurate diagnosis and the best possible medical care.
You have probably heard that the average patient has less than 20 seconds (some studies say just 12 seconds) to describe the ailment before being interrupted by the doctor.
What’s even more interesting is that the average doctor will have already made a diagnosis during those crucial first seconds. But if he/she hasn’t gotten your full medical history, your odds of getting a correct diagnosis dramatically decline.
THE TYRANNY OF THE “CHIEF COMPLAINT”
When doctors do listen during those initial seconds of the visit, they’ve been taught to organize their thinking around a central focus, or “chief complaint.” This is the problem that brought you into the doctor’s office—for example, “chest pain,” “a sore back” or “a cough that has lasted two weeks.”
The chief complaint prompts the doctor to consider a list of possible diagnoses, ask a standard series of questions (for example, “When did it start?”…“What makes it worse?”) and then order tests to investigate further.
Even though this approach is logical and efficient, it also can be problematic. Once the doctor focuses on just one possible scenario, he is less likely to look at the whole picture because other information can seem irrelevant. In fact, the chief complaint can actually be a distraction from the real story—a false start that leads the doctor down the wrong path.
In some cases, the basis for an entire diagnostic workup may be a chief complaint given to the first nurse you talk to (or even the receptionist) and may not reflect your greatest concerns.
The chief complaint is also a form of shorthand that doctors use to communicate with one another. If your condition is undiagnosed and you’re referred to a specialist, he is likely to base his questions and tests on what he was told was your chief complaint—and you may be stuck in an endless cycle of misdiagnosis.
TALK SO YOUR DOCTOR WILL LISTEN
To prevent this scenario, when you see any doctor—whether it’s your primary care physician, an emergency department physician or a specialist—what’s most important is to tell your story in a way that will help him truly understand what’s happening. My advice…
Plan what you’re going to say beforehand. If you have a doctor’s appointment, write down your complete story and practice beforehand how you’ll deliver it with a family member or a friend. While practicing, work out the details that most accurately describe what you are feeling.
Don’t use medical jargon or diagnose yourself. Because you probably haven’t been trained in medical terms, you may use them incorrectly. In your own words, give a clear, chronological and vivid description of what’s going on without a self-diagnosis. For example, instead of saying, “My stomach ulcer pain is an eight out of 10,” you might state, “I woke up with a terrible stomachache. I felt like my belly was on fire.”
Describe how symptoms have impacted your life. You could say, “I have had such a bad headache that I could not get out of my bed for three days.” If a symptom is chronic, describe how it’s changed over time. For example, “My joint pain improved for a month, but it has now come back and is worse than ever.”
Answer your doctor’s yes/no questions with details. Doctors use yes/no questions because it is a quick (though incomplete) way to gather information. What works best for you, the patient, however, is to answer your doctor’s questions your way, giving pertinent details.
Example: If your doctor asks, “Do you have pain in your chest?” you might say, “Not pain, exactly…but I felt a kind of dull discomfort right here, around the time I got up. It lasted about an hour, and now I have a throbbing sensation in the same place from time to time.”
Don’t let go of your real concerns. If you think the doctor is ignoring your concerns, you might say, “I’ve tried to answer your questions about my chest pain, but I also want to know why I’ve been feeling so queasy after most meals for the last two weeks.”
GET THE INFORMATION YOU NEED
If you want to be fully involved in your medical care, you’ll also need to understand the reasoning behind a diagnosis. When making a diagnosis, doctors develop a list of possibilities (known as the “differential diagnosis”). From this list, doctors select one (or more) that seems most likely (called the “working diagnosis”). After you’ve told your story, ask your doctor what could possibly be wrong and what he thinks your problem is.
Important: If the diagnosis—or anything the doctor says—doesn’t make sense to you, ask more questions. For example, you might say, “Does this explain why I’ve been feeling so tired for weeks?” As the doctor performs a physical exam, participate actively by asking questions such as, “Just what is it we’re looking for?”
If the doctor orders tests: Find out why. Specific questions might include: Just what will the test show? Will it change treatment? Are there risks? Are there risks in not doing the test? Are there alternatives? Is waiting an option?
AVOIDING MISCOMMUNICATION
Back to May: As mentioned earlier, this patient had a gallbladder infection that was misdiagnosed. This might have been prevented if May had said, “Would a heart problem cause the many other symptoms I’m having, such as an upset stomach and a headache?”
Important: If your regular doctor is not open to this type of dialogue, it might be time to find a new one—or if you’re in an emergency room, offer to wait until the doctor can spend a little more time with you.
Source: Leana Wen, MD, emergency physician at Brigham and Women’s Hospital and Massachusetts General Hospital and clinical fellow at Harvard Medical School, all in Boston. She is coauthor, with Joshua Kosowsky, MD, of When Doctors Don’t Listen: How to Avoid Misdiagnoses and Unnecessary Tests (Thomas Dunne). www.DrLeanaWen.com
http://www.bottomlinepublications.com/content/article/health-a-healing/the-misdiagnosis-epidemic-how-to-answer-the-doctors-questions
