Insights into navigating American healthcare — time management for patients
In the previous note I discussed the systematic way of thinking used by good clinicians. The process is time consuming and time as a resource is perpetually decreasing. I work in a county, for example, that has approximately 1 psychiatrist for every 50,000 psychiatric patients. Healthcare delivery is personal, requiring an individualized visit and treatment plan. I can see a lot of people every day, but I am still made out of emotional meat — I fatigue and I bruise. Each patient deserves follow up care. I treat chronic illness, so maintenance of therapy is required. These appointments require the use of time.
The note
Let us imagine, for sake of example, that you are a patient scheduled to see a GI specialist for rectal bleeding. Let us assume that the GI specialist is someone who is both knowledgeable and caring — fortunately, this is almost always a true assumption of gastroenterologists. The primary physician has already recognized the need for the specialist because the GI specialist has access to a special life saving investigation: the colonoscopy.
You, being the patient, want to get good care but are naturally a bit anxious. You have some questions and honest fears. How will you make the best use of time during the appointment?
First, write down your understanding of things so far. That might include answers to questions the primary physician asked that help quantify the symptoms: onset, frequency, location, duration, etc. It should also include what tests have been done and what the primary care believes the problem to be (per your understanding).
Next, write down some assumptions and other observations. This might include strange or unusual body feelings, beliefs about the cause of the illness, and fears for what it all might mean.
Last, write down questions you have in the following order:
The absolute most important question
The second most important question
The “if time allows” question
The “patient after me canceled and the doc likes talking to me” question
Bring two copies of this note with you to the appointment. You are going to put one into the doctor’s hand and you are going to hold on to the other.
The visit
You need to be there when the clinic says to be there. Unfortunately, some clinics are very poorly organized and you might wait an unfair amount of time. You are a “captive market,” and have little leverage to change the system, so try to be a lucky person who has access to a well organized front office. Being wealthy helps, but it is not a perfect solution. Be prepared to wait, unexpected stuff happens all the time in healthcare.
In the meantime, use all the charisma you can muster with staff. Smile nicely, bring cookies, and pretend that your anus is not bleeding. I am being serious.
Once it is time to meet the doctor, humanize yourself right away. If you and the doctor have something in common, identify it. Maybe you lived in the same state he or she went to medical school. Maybe you are the same age. He or she looks even younger and more brilliant than doctor primary care described. Flattery works. But only use it for a minute or two because now is the time you are prepared for.
“Doctor, I am nervous for this visit because I want it to go well, and I wrote some things down, would you take a moment to look it over?”
Hand the doctor the note. Now get ready to listen. You can take notes if you like, but make sure you keep normal social eye contact with the doctor as much as possible. Answer clarifying questions the doctor asks. Please ask clarifying questions in return.
N.B.: this is not the right specialist nor the moment to discuss the failures of the American healthcare system, the traffic on the way in, past specialists who misdiagnosed you, the headaches you had since you were 14, or any of the other qualia you forgot to write down on the paper. Stay focused on the main thing, bright red blood on the toilet paper when you wipe.
If at this point you are unsure of what the doctor has said then you should ask this question: “doctor, what do you think my diagnosis and prognosis are?”
Follow up question: “what test results might change your mind about my current diagnosis and prognosis?”
Dealing with uncertainty
Hopefully you have engaged in rapport building and received good and effective communication from the clinician. No matter what, you are always entitled to a second opinion. If your instincts tell you the recommended investigations and interventions are irrelevant and/or ineffective to your problem, then seek a second opinion. In brief, if you seek a second opinion then announce to the second physician that you are seeking a second opinion. Multiple opinions are healthy, but also time consuming and costly. Focus on the objective of obtaining a second opinion, and not an opinion that aligns with your own personal opinion.
There is no substitute for a board certified physician practicing in his or her specialty of residency training. An opinion from an herbalist, acupuncturist, chiropractor, naturopath, neighbor, family member, fortune teller, best friend who is a doctor but did not examine you, google search, Reddit forum, etc. is meaningless next to the opinion from the board certified doctor who legally entered a doctor-patient relationship with you. Those other people will COMFORT you, but they will not accurately diagnose or treat your problem because they did not or could not follow the steps required for diagnosis and treatment.
Uncertainty leads to worry and worry is a form of anxiety. All anxiety feels bad and the human mind will reflexively seek to relieve bad feelings. This reflex leads to irrational thoughts and behaviors. Use the minds of trusted loved ones to seek relief while following through on the professional advice of the doctor who completed the examination. Men, that means you have to tell your family that you are experiencing fear. It is okay, you are made out of emotional meat and you were never bullet proof to begin with.
The worry associated with uncertainty can be mitigated by an understanding of probability — that is why you asked about prognosis and tests that might influence the doctor’s professional opinion. Most humans irrationally prefer a bad certainty over an uncertain good or bad possibility. Think about it and catch yourself doing this sometime.
Follow ups
Treat your appointments with respect. Keep your appointments. If you are a single mother then drag the kit and caboodle to the appointment with you if you have to. It costs time and money, but the life saving colonoscopy does not care that your toddler coughed on a stranger in the lobby. Everything good in life flows through access to good health.
Differently abled
If you have a thought disorder, speech disorder, cognitive disorder, physical disability, social phobia, or are otherwise unable to travel and communicate with the doctor, then you must activate your special power: someone who loves you.
Bring someone who loves you to the appointment. This is the ultimate humanization. If the someone who loves you is an adult daughter then you get a bonus power up of the most caring person you can have in your life.
Do not squander the power of an adult daughter who wants to help you navigate the healthcare system. I recommend kissing the ground she walks on and rejoicing at how lucky you are to have a problem so that you can be so loved.
I have oodles of patients who were terribly abused physically, psychologically, and emotionally by mom and/or dad. Even so, most daughters will put all life on hold to be abused some more in order to be there for a parent. It is a social conditioning that is seldom discussed.
Patient responsibility
Nobody advocates for you better than you. Take ownership of the process and bond together with some doctors and family members in the process. Learn the names of your drugs and memorize the doses. Understand the risk factors for your own disease(s) and take the proposed interventions seriously. You are going to be asked to change some of your habits. Practice in your mind lowering your own resistance to change.
Wishing/praying not to have the illness is ineffective. Alternative treatments in the wellness industry are ineffective. Medical science is the guiding light toward better quality and longer quantity of life. Make sure to wash your hands in the meantime.
I am going to discuss methods for patients to evaluate medical claims in a future note.
-Doc