Seeing Eye to Eye with Your Doctor
Becoming a knowledgeable patient can dramatically change your health care trajectory. A lasting result of learning how to navigate the healthcare system is that you will help minimize healthcare expenditures and decrease medical waste. This is good for your wallet and for the strength of our healthcare system. But, again, this is an added benefit, not the primary goal.
While physicians and other healthcare providers devote many years to studying medicine, patients simply don't have a comparable patient school to attend to learn how to navigate the healthcare system. This book helps fill that void by teaching you how to think more like doctors and nurses. You won't be able to hold a high-level conversation with a neurosurgeon simply by reading this book. But you can make healthcare professionals stand up and notice they are dealing with a well-informed patient. With the right tools you can play a significant role in expediting and optimizing your own healthcare. This will push your interactions with medical personnel to a much higher level, a definite win-win situation. Once you develop a stronger sense of what is important to them and what is not, you and your healthcare providers can walk side by side in your journey to optimize your health and the care you receive.
Most patients do not understand how to communicate effectively and efficiently with their healthcare providers. Think about it. The layperson cannot be expected to grasp intricate physiologic and anatomic principles it took their physicians many years to learn. And truth be told, doctors often forget that medical terminology is not second nature to that precious person seated in front of them on the examining room table. Unfortunately, this disparity is often the basis for missed or delayed diagnoses, excessive testing, and inadequate treatment.
The result is that the patient-physician relationship is frequently not as harmonious as it could or should be. A patient does not come into the office and say, “Doctor, I’ve been searching the internet, and I am sure I have an overactive thyroid. After extensive online research, I’ve decided I want to be treated with radioactive iodine. Now, all I need for you to do is order the test to confirm my suspicion.” Whew! If it were really that simple, MD really would stand for Mountain Doctor (as Granny Clampett in the old sitcom The Beverly Hillbillies claimed). And her grandson Jethro Bodine really could be a brain surgeon with a 6th-grade education.
Physicians are trained to listen to the “presenting complaints” of patients. Then they work backward by asking them questions, performing a physical examination, and finally devising a mental list of possible diagnoses (list of differential diagnoses) that could account for their symptoms.
After obtaining this preliminary information, they focus on ordering tests to “rule in or rule out” specific diagnoses that seem most likely. The stronger the suspicion is about a particular illness the fewer tests are needed to confirm that diagnosis. So, if your history is communicated clearly, there is tremendous potential to save significant money and time. But, more important, you will be treated promptly and efficiently with the least amount of risk and discomfort from what could prove to be unnecessary testing.
The thrust of this chapter is to give you an overview of how to communicate with your physicians to accomplish these goals. This is no easy task. Patients tell their stories in a manner natural for them. We all do. At the same time, physicians concentrate on pulling out the pertinent facts and discarding the rest.
Naturally, it is advantageous to understand some of the key points your doctor will want to know about your current illness before you even step into your doctor’s office. Typically, patients mentally pull together their recollection of their sickness while sitting on the examining table, sometimes assisted by a family member. But what if you’re in pain? What if you are wearing a paper robe as you sit on a cold table? Or, what if you simply don’t recall the answers to his questions?
This approach is time-consuming. It is also frustrating for you and, yes, even for your physician. Taking this approach may lead you to forget to mention very important nuances of your illness, especially if you are already nervous or uncomfortable. Meanwhile, your doctor may feel overwhelmed with the 12 sick patients left to be seen in the next 3 hours and try to cut to the chase of your problem. In this common scenario, you may feel rushed, intimidated, or devalued.
Naturally, this would only escalate any baseline anxiety and fear. This is not a win-win situation for anyone. But, if you have thought through your problem beforehand and you’re prepared to tell a brief yet information-packed short story about your illness by the time your doctor steps foot in your room, you will have overcome an enormous hurdle most patients never do. Patients were never taught how to speak the language their doctors speak. How would you know what the doctor is looking for if no one ever explained this to you?
So, let’s talk about what will help your doctor help you quickly and efficiently. There are eight vital elements surrounding your sickness. Doctors call this your History of Present Illness (HPI). In simpler terms, there are eight essential things your doctor may ask about your current illness. These factors are part of national Evaluation and Management (E/M) guidelines. Insurance company reimbursements to doctors are directly linked to E/M guidelines. Doctors cannot routinely charge for the highest possible level of reimbursement. Instead, they must ‘earn it’. Here, earning it means documenting an appropriate level of detail for each medical visit.
Elements of Your HPI (history of present illness)
Remembering this list of eight elements can be challenging. Developing a memory aid to help you remember them is worthwhile. Here is an example:
A QUALITY action movie needs a great LOCATION. The TIMING of the star’s first entrance should be based on the ASSOCIATED CONTEXT of what is going on now. The director should MODIFY the DURATION of each scene based on the SEVERITY of the situation.
Hint: Doctors may ask you to rate your pain on a scale of 1-10.
Doctors must be able to prove the amount they charged the insurance company for your visit is in line with these national Evaluation and Management (E/M) guidelines. Otherwise, they risk fines, big ones, should they be audited. They could even be charged with healthcare fraud and face a prison term! So, it’s easy to see why physicians must meticulously document in your medical record.
But it’s not all about the money by any means. These eight designated elements are instrumental in helping a physician understand what the diagnosis is and what it is not. For instance, if you tell your doctor 3 days ago (timing) you developed mild (severity), sharp (quality) pain in the upper left abdomen (location) immediately after lifting heavy weights (context), and the pain gets worse whenever you twist your upper body (modifying factors), you can rest assured, you doctor is not going to order expensive tests looking for evidence of appendicitis. Your appendix is in your lower right abdomen, and nothing you said would make a doctor focus on an inflamed appendix as your diagnosis. Instead, she’ll probably do a quick examination and treat you for a muscle strain. All eight elements may not be needed for every illness, but it is good to consider each one.
Let’s take a deeper dive into how giving details can expedite your (correct) diagnosis. This example is simply meant for illustrative purposes. Later on, you will be given a chart with details of signs and symptoms to look for if you develop abdominal pain. You can even download this list and make copies for every time you experience pain in the abdomen.
Ready? So, let’s say a person has abdominal pain, her doctor will want to know several key features to help pin down the diagnosis. When the abdominal pain is in the upper right abdomen, doctors think about the organs that lie in that area, such as the liver, gallbladder, stomach, or pancreas. Other conditions can cause pain in the upper right abdomen, even skin conditions. Still, when a patient complains of pain in that region, anatomically speaking, doctors must strongly consider conditions like hepatitis, gallstones, gastritis (stomach inflammation), an ulcer, or inflammation of the pancreas. Other diseases, such as appendicitis, are possible but less likely.
Also, suppose fevers and chills accompany the abdominal pain. There, the reason for the pain is more likely to be related to infection than if they do not. And, if over-the-counter antacids help the pain, it is more likely due to an acid-related condition, such as an ulcer or gastritis. This therapy should not significantly affect other causes of pain.
Radiation of pain is also essential to consider. If upper abdominal pain radiates straight through to the back, pancreatitis and an ulcer are high on the list of possibilities. Gallbladder disease is highly likely if it radiates to the right shoulder blade.
Then the character comes in. Hint: This is not meant to conjure up thoughts about the chill-creating scene of your favorite movie when the underdog steps in to save the day. This character has to do with the details of the pain. For instance, is the pain a burning sensation, as sometimes occurs with indigestion? Is it a dull, achy type of pain? Is it crampy?
Your physician may also want to know if this is the first time this specific type of pain has occurred. If not, did you seek medical attention in the past, and if so, were any tests done to evaluate the pain? For example, let’s say you had similar pain in the upper right abdomen intermittently for several months, and your previous physician ordered an abdominal ultrasound. This test showed no gallstones, so your new doctor will focus her attention on other potential causes of your pain.
If you are not sure of the names of the tests done in the past and their results, precious time could be wasted trying to obtain your old records. Or the doctor may simply repeat a slew of expensive tests so she can get answers fast. So, it may come down to your money or your safety. Guess which will take precedence? The result is that it costs more money to obtain the diagnosis, and the diagnosis may be significantly delayed.
It is also important to acknowledge other symptoms associated with the pain, though they may be less troublesome. For example, let's say a person has also been coughing up yellow sputum (mucus/phlegm mixed with saliva). The cause of the upper abdominal pain may be pneumonia in the lower right lung and not a disease in the abdominal cavity itself. But if this person has recently noticed that his stools are black and sticky, he may have internal bleeding due to an ulcer.
The chronological sequence of the pain is also significant. For instance, if abdominal pain has been present and gradually increasing over several days, it could be due to hepatitis, gastritis, or ulcers, to name a few things. It is less likely to be due to a slow-growing tumor which takes months to significantly enlarge.
Many illnesses cause vomiting, but the timing of the vomiting and its character are also important. If a person occasionally vomits a couple of hours after eating, the doctor may consider different diseases than if he consistently vomits immediately after eating.
The appearance of the vomitus matters as well. For example, suppose Sue has a stomach virus which causes her to wretch and vomit. Frequent vomiting may cause excessive stress on the esophagus which may cause a blood vessel to rupture. This can cause Sue to vomit bright red blood.
This is a different scenario from John with a bleeding ulcer as a cause of vomiting blood. Blood can irritate the lining of his stomach and induce vomiting. The first time he throws up he may vomit bright blood if the bleeding is brisk. Alternatively, he may have a slow leaky bloody vessel and throw up "coffee grounds" or dark, gritty-looking vomitus. This is because blood mixed with the acid in the stomach turns brown and gritty. John may have bloody or coffee ground vomitus from the beginning. In Sue’s case the vomitus consisting of food and clear fluid eventually turned bloody when the situation became more prolonged and complicated, resulting in trauma to a blood vessel.
Delving further into the issue of vomiting, your doctor may want to know if you vomit up everything you eat and drink or if the vomiting is occasional and not associated with eating. If it is associated with eating, how much time passes after eating before you vomit? How many times a day do you vomit? A little vomitus twice a week, provided there is no evidence of blood, usually will not do much harm if you stay hydrated. However, if you have been vomiting several times a day, you may be at risk of becoming dehydrated. You also risk having a potentially severe alteration in the concentration of vital components of the blood, such as a low potassium level. Here, you may need hospitalization and intravenous fluids until you can obtain regular nourishment.
Besides vomiting, other vital issues need to be addressed. Is there diarrhea or constipation? If there is diarrhea, how many stools are you having a day? Are the stools loose, well-formed, or watery? Do you have to get up during the night to go to the bathroom? Can you hold your bowel movements until you reach the commode? Is there blood or mucus in the stools? Is each bowel movement a large or small amount? Suppose you are having many large-volume watery bowel movements a day. There, you may also be at risk for dehydration and changes in the chemical composition of the blood.
How many stools have you had in the past week if you are having constipation? How does that compare to your norm? Constipation could be due to inadequate fiber in the diet, a thyroid disorder, medications that cause constipation, diabetes mellitus, or a host of other diseases. Still, frequently it is due to no identifiable illness.
A simple complaint such as abdominal pain can have a multitude of different causes. For instance, a person may see her doctor because her stomach has been aching for a few weeks. She may not have thought her constipation was significant because she has gotten used to it. However, after talking to the patient and examining her, the doctor may feel it is worthwhile to assess her thyroid gland. Upon doing so, he finds that her thyroid gland is underactive, causing her to be constipated. Constipation turns out to cause her abdominal pain. The solution is to treat her thyroid disorder, which may be the sole cause of constipation and the root of her stomach pain.
Many potential diagnoses could cause abdominal pain, including:
· ulcers
· pancreatitis (pancreas inflammation)
· gastritis (stomach inflammation)
· hepatitis (liver inflammation)
· gallstones/gallbladder inflammation
· appendicitis (appendix inflammation)
· pneumonia
· irritable bowel syndrome
· constipation
· diabetes mellitus
· psychological issues
· gastroenteritis (‘stomach flu’)
· and many more!
It could be time-consuming and expensive to reach a diagnosis for a complaint as basic as abdominal pain. The preceding is only a partial list. However, with a good history and physical examination, physicians usually need few tests to confirm their suspicion of a diagnosis.
That is where you can play a tremendous role in helping your doctor help you. An excellent historical account of the illness from the patient is often the most important factor in making the correct diagnosis, really!
When a medical school professor told the class I didn’t believe him. How could a patient’s words be as vital in helping a doctor make the correct diagnosis as the advanced medical technology I read so much about? But it didn’t take long to make me a believer. Some conditions are best diagnosed with blood tests or imaging, such as X-rays, CAT scans or MRIs. But think back. How often have you gone to see your doctor and left without an order for any tests? Common things are common, and when a doctor has seen or read about a condition repeatedly making that diagnosis can be a piece of cake.
Next, let’s look at another example. This compares two qualities of historical accounts by a patient.
Dr. Chen: “Hello, Mr. Jones. What brings you to the office today?”
Mr. Jones: “Doc, I’ve been having a burning sensation in the middle of my upper abdomen for several months now. I was sitting in front of the television the first time I noticed it, not doing anything unusual. It’s not always there, but when it starts, it’s severe. It lasts several minutes to a few hours at a time and then goes away, but it comes back, maybe a few days or weeks later. Sometimes it even wakes me up in the middle of the night. I can’t pinpoint what brings it on, but when I have the pain, it gets better a few hours after I eat something. The pain does not move anyplace, my appetite has been good, and I have had a little nausea but no vomiting. My bowel habits haven’t changed. I still have one well-formed stool every day. I haven’t tried any medication for the pain since I know food usually helps. I’m not having any other problems, and other than this annoying stomach pain, I feel great. My mother and brother also have similar stomach problems. What do you think is wrong with me?”
This patient has practically given his doctor his diagnosis. His symptoms are most concerning for an ulcer. In less than a minute, he gave a concise, detailed explanation of his presenting complaint. You can do the same using the symptoms forms provided in this book.
He told his doctor:
o What he was doing the first time he noticed the pain (was watching television)
o When he first noticed the pain (several months ago)
o The character of the pain (burning)
o And the severity of the pain (fairly severe as opposed to mild and almost negligible)
o The location of the pain (mid-upper abdomen)
o The radiation of the pain (none)
o How long the pain lasts when it comes (minutes to hours)
o And what things seem to bring on the pain (no identifiable causes)
o What relieves the pain (food)
o How long it takes for relief to occur (a few hours)
o How effectively food relieves the pain (it sometimes returns)
o Other symptoms or lack thereof
o Other symptoms specifically related to his gastrointestinal tract (nausea, no vomiting, regular bowel movements)
o Other symptoms, or lack thereof, related to other systems of his body (“Other than this annoying stomach pain, I feel great.”)
o Others close to him with similar symptoms (two close relatives)
(Don’t worry about the details this early. We will delve into all this and more later.)
This patient has provided such a good history that his doctor would have a good idea of how she plans to treat him by the time he finishes his last sentence.
There would be no need to order an expensive (potentially painful) battery of tests to get to this diagnosis because the doctor was given such an excellent history. By the end of this book, YOU will be that type of patient. Stay tuned.
After a targeted physical examination, she may give him a trial of antiulcer medication and see him back soon to see how well it worked. She may order one or two focused diagnostic tests.
Compare this previous example to:
Dr. Chen: "Hello, Mr. Jones. What can I do for you today?"
Mr. Jones: "My stomach hurts."
Dr. Chen: "How long has it been a problem?"
Mr. Jones: "Doc, I have been having stomach pain for a long time."
There is a pause. The doctor is thinking, ‘A long time means different things to different people. One person means several years, while another means several days.’
Dr. Chen: "Sir, what do you mean by a long time? Do you mean it has been hurting for a matter of days, weeks, months, or years?”
Mr. Jones: "I'm not sure when it first started. I just know it has been going on a long time."
The doctor is thinking, ‘Okay, I need to help him pin down a general time frame for his symptoms.’
Dr. Chen: "Did you first notice this pain before or after January of this year?"
Mr. Jones: (Pause to reflect.) "It must have been before because Uncle Lorenzo and Aunt Joi came to visit for Christmas, and I remember that I ate something over the holiday that made me feel terrible. I almost called in to work sick, but I decided to go on in any way."
The doctor is thinking, ‘Well, I know his abdominal pain must have been going on at least five months since this is May.’
Dr. Chen: "Where does it hurt?"
Mr. Jones: "Most of the time, it hurts under my rib cage on the right side."
Dr. Chen: “Most of the time? Where else does it hurt?"
Mr. Jones: "I don't pay it any attention. It just seems to hurt all over."
Dr. Chen: “Well, take a moment and give it some thought."
Mr. Jones: (Pause.) “Sometimes it moves to the middle."
Dr. Chen: "Does the pain ever go thru to your back?"
Mr. Jones: "Sometimes."
Dr. Chen: "Is your pain constant, or does it come and go?"
Mr. Jones: "Well, it's not always there. It just hurts sometimes."
Dr. Chen: "How often do you have this pain?"
Mr. Jones: "Oh, I guess a few days a month."
Dr. Chen: "Is the pain constant for those days, or does it wax and wane?"
Mr. Jones: "It waxes and wanes, I guess."
Dr. Chen: "How long does it last when it comes?"
Mr. Jones: "It usually lasts a few hours, but sometimes it hurts all day and all night."
Dr. Chen: "Is it worse when it begins or when time wears on?"
Mr. Jones: "I think when it begins."
Dr. Chen: "Is the onset gradual or abrupt?"
Mr. Jones: "I guess it comes on pretty fast."
Dr. Chen: "When you have this pain, does anything make it better or worse?"
Mr. Jones: "Not that I can think of."
Dr. Chen: "Have you tried any over-the-counter medication?"
Mr. Jones: "Not really. Well, I’m not sure."
Dr. Chen: "Does food make the pain better or worse?"
Mr. Jones: "You know, I never paid any attention to how food affects it, if at all. Wait! I take that back. Once I ate a huge beef taco and that made me feel awful. But, uh, on second thought, it just gave me a lot of gas. When I passed the gas, I felt better."
Dr. Chen: "What does the pain feel like? For instance, is the pain sharp, dull, or crampy?"
Mr. Jones: "All I know is that it hurts like, like wow!"
The doctor is thinking, ‘I really need to know the character of this pain. Let me try something else.’
Dr. Chen: “Would you characterize the pain as an ache, a stabbing pain as if someone were sticking a fork in your belly, like a grabbing and letting go sensation, or ..."
Mr. Jones: "It's an aching sensation, probably."
Dr. Chen: "When you have this pain, do you have any other accompanying symptoms, such as nausea and vomiting?"
Mr. Jones: "Sometimes I feel like I want to throw up, but I don't."
Dr. Chen: "Have your bowel movements changed in any manner?"
Mr. Jones: "I get constipated sometimes."
Dr. Chen: "How long do you go without having a bowel movement?”
Mr. Jones: "Most of my life, I have had a bowel movement every day, but every now and then, I miss a day. But last week, my wife made some killer pinto beans, and I ate a ton. You can imagine how that went (chuckle)."
The doctor is thinking, ‘This is not true constipation.’
Dr. Chen: "Have you noticed anything about your bowel habits since you started having this abdominal pain? For instance, has the color or consistency of the stool changed, or have you noticed any blood or mucus in your stool?”
Mr. Jones: "Well, recently, I have had dark stools, but I thought that was due to eating kale."
Dr. Chen: "Are they black and tarry or just darker than usual?"
Mr. Jones: "Doc, I really don't pay that much attention to my bowel movements. That’s kinda disgusting, don’t you think? I can’t even stand changing my son’s diaper. I’m certainly not going to examine my own stools. Makes me sick on my stomach just to think about it. Yuk!"
Dr. Chen: "Has anything else been bothering you?"
Mr. Jones: "Sometimes my right shoulder aches."
Dr. Chen: "Does this coincide with your stomach pain?"
Mr. Jones: "I never noticed."
Dr. Chen: "Which did you notice first, the abdominal pain or the shoulder pain?"
Mr. Jones: "I really couldn't tell you."
Dr. Chen: "Do you have any fevers or chills?"
Mr. Jones: "Sometimes I get a little warm."
Dr. Chen: "Have you taken your temperature recently?"
Mr. Jones: "No."
This conversation could go on and on and on because the list of potential causes of this patient's abdominal pain is extensive. Yet, there are still additional questions to ask before developing the mental list of differential diagnoses. The doctor probably may order more tests than if she had a clear picture of what was happening. It is unrealistic to expect the layperson to understand what is essential and what is not. That will come with time and practice.
Likewise, you cannot be expected to communicate a perfect history to your healthcare providers unless you have been trained in the medical field, but reading this book is a huge step in the right direction. Still, there are basic questions you should run through your mind before you see your doctor. Doing so can dramatically expedite your communication and your diagnosis.
When relaying an explanation about an illness, these things should be considered:
When did you first notice the symptoms? You don’t have to pinpoint the exact time but try to recall how long ago you first noted the problem, such as two days ago, two weeks ago, or two months ago.
Has anyone around you, or related to you, had similar problems? Some conditions are contagious, while others commonly run in families.
Describe the chronological sequence of the symptoms.
example: “At first, I noticed the pain every day, but over the past month it has been coming less and less frequently. Now, I only notice it once or twice a week.”
4. Describe the severity of the symptoms or relate them to their impact on everyday activities.
example: “My symptoms have been mild, and I can work and do my regular activities without difficulty.”
5. If the symptom is pain, does it move anyplace, or does it remain in one place?
Describe the quality of the pain. Physicians commonly use terms like dull, sharp, piercing, achy, throbbing, burning, or tight to describe pain. Describe the symptom.
example: “It feels like someone is punching me in my stomach.”
7. Are the symptoms constant, or do they come and go?
Is the intensity the same or does it wax and wane?
example: “I feel short of breath all the time, but it seems to be worse by the end of the day.”
9. If they are intermittent, how long do the symptoms last each time they are noted, and how long of a reprieve do you have between attacks?
example: “When I have chest pain, it lasts for 15 to 20 minutes at a time and then goes away for a few days before it comes back.”
10. What other symptoms, if any, accompany the problem?
example: “I have noticed when I have chest pain, I often break out in a sweat and feel nauseated.”
11. What things improve or worsen the symptom?
example: “Aspirin improves my headaches.”
12. Do the symptoms improve on their own, or should you take something for relief? How long does it take to notice this improvement if something brings comfort?
example: “I have noticed that the pain goes away on its own within a few minutes of its inception.”
13. Have you ever been evaluated by a physician for this problem in the past? If so,
· What tests were done? (be specific)
· What diagnosis was given?
· What treatment was prescribed?
· Did that treatment help?
· Why did you stop seeing that doctor?
Please note not all questions are pertinent to all patients’ symptoms. During any medical encounter, you will not be asked all the preceding questions about any given complaint. You may be asked additional questions not listed here as well. Still, take the time to think about the questions listed above. Also, common symptoms, such as abdominal pain and back pain, have downloadable, fillable charts to help you chart important details. Over time, you will learn much about what is and is not significant to your physician.
Remember different doctors have different styles. Your doctor may ask you to relate your symptoms, at which time you can give a concise history of your present illness. But she may take charge of the encounter and ask targeted questions. Regardless of the style of your personal physician consider the questions above before going to the doctor’s office. Then you will be prepared to promptly answer questions, which frees up more time in the visit to potentially address other issues. You can help your doctor help you more efficiently if you think through important issues in the doctor’s diagnostic decision-making process. If there are any associated symptoms not listed in the charts provided write them down.
It is essential to realize that time is money. Patient encounters are “coded” for the level of care commensurate with the time spent and the complexity of the diagnosis. Poor historical information, extensive questioning, a more detailed examination, and numerous laboratory tests can be costly for you, even if your diagnosis is basic. However, suppose you could describe your symptoms, and the doctor only needs three additional minutes to do a focused exam. There, you stand to save a lot of money and get a correct diagnosis on the first visit.
Despite being concise in relating details of your illness it is crucial to be thorough. Do not be consumed by the clock on the wall or feel like you are a failure if your doctor needs to spend considerable time with you. The most important thing is your health. It is unrealistic to believe that you will become an expert at being a patient by reading this or any book. Even physicians are not expert patients when they become ill. [We’re known to be pretty bad patients, but that’s another story.] Do your best to help your doctor help you. Your input will be appreciated. Always remember an accurate medical history can be lifesaving in certain situations. You are the first line of defense against your own illnesses and must be well-informed!
· Develop a memory aid to help you remember the eight elements of your history of present illness (HPI).
· Prepare for a visit to the doctor when you first feel ill.
· The doctor’s Assessment and Plan is her impression of the cause of your symptoms and what she plans to do next.
· Take your time and relay your symptoms to your doctor in a concise, methodical manner.
