How Doctors DON’T Think: Groopman on the Today Show

My physician-guru, Dr. Jerome Groopman, was on the Today Show this morning to highlight some of the excellent points he made in his book, How Doctors Think. (My editorial opinion — it’s a must-read for anyone who is having trouble getting diagnosed correctly.)

But I’m beginning to swerve from my usual train of thought surrounding how most doctors think. Whereas I’ve always taken it to a next step to help patients help themselves — I’m taking a bit of a detour today.

Groopman’s background information about the way doctors arrive at diagnoses must be understood by patients:

1. Doctors make snap judgments about their patients. For example, a doctor will ascribe any symptom a woman over age 50 has to menopause. Or if a patient is diabetic, the doctor will assume any subsequent health problems are related to diabetes.
2. Doctors always go with their first impressions — and they form them within the first 18 seconds of seeing the patient — which also means they not only don’t listen to anything the patient says after those first 18 seconds, but also means that they try to fit any additional symptoms the patient might recognized into their first impression.
3. Doctors are not taught to think in med school. They are taught to answer quickly — which means — they don’t think outside the box, because that takes too long.

So the bottom line is that smart patients will bring doctors up short on all this by asking “what else can it be?” or questioning their doctors about symptoms that don’t seem to fit into a profile for their diagnoses.

And I absolutely agree with that bottom line — I’ve agreed with it many times before.

However — I’m also beginning to think a bit differently about this conundrum, too. Whereas I am all about the patient taking responsibility, and I think all patients should be actively participating in their diagnosing and treatment decisions — at what point do we just say, “Whoa!! Hold on!! That may be how doctors think — but they are thinking wrong!”

Groopman stated that 15 to 20% of all diagnoses are incorrect, and that half those patients are then harmed by that misdiagnosis.

Think about it this way: that means that, on average, if you have been to the doctor 10 times, then YOU WERE MISDIAGNOSED TWICE!

Patients themselves can’t make up for that deficit. In addition to patients taking responsibility for participation, I think we need to throw some of the onus back on doctors, too. We can’t simply accept that they don’t do their jobs correctly, we must begin making them responsible for getting it right.

So whereas I usually provide a bottom line to patients, today I’m going to do that for doctors:

• Doctors, stop interrupting us.
• Doctors, begin thinking outside stereotypes and profiles.
• Doctors, stop trying to fit our symptoms into your own little boxes and start building the right boxes to fit them into.

(OK — I can’t help myself here…..)

And patients — start making doctors do all of the above!

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Doctors are Blamers or Fixers, too

A week ago, I posted about Blamers and Fixers.

Blamers are those people who have been hurt by our healthcare system in some way, and can’t get beyond the hurt. They are stuck in the anger, frustration and pain. It’s understandable, certainly, especially in cases where some permanent horror has come from it. From the loss of a loved one, to the loss of a body function or limb, it’s understandable, but not particularly helpful, that these folks are stuck in the blaming.

Fixers are about moving on. They, too, have suffered at the hands of the system, many of them in similarly devastating ways, but they have taken their anger, frustration and pain to create something positive for someone else. I listed the people I know who have done such. In some cases, they have lost their children to medical horrors, or they have suffered in some way that would just make your heart break. But they have taken that experience to a platform that creates a better situation for others. It’s cathartic and it’s useful.

I consider myself a Fixer.

Turns out that there are doctors who are Blamers and Fixers, too! I probably shouldn’t have been surprised by that, but I was. Just this week, two articles were shared with me that prove the point.

The first article comes from the Portsmouth Herald — actually published last March — about Dr. Terry Bennett, considered to be a “controversial and opinionated” gentleman titled, Doctor: Greed subverts health care. In the article he takes no prisoners, blasting doctors, facilities and HMOs in particular, then Medicare and Medicaid — in other words — just what you’ve heard me say many times before: American healthcare is not about health or care; it’s about sickness and money.

But the bottom line from the article is this: Dr. Bennett is just a Blamer. Period. He even states that he’s waiting for a “general consumer/voter uprising” to fix the system.

Um. Doctor Bennett…. just what are you doing to help? You are in a good position to be a Fixer. What are you waiting for?

Well — perhaps he is waiting for Dr. Rich Fogoros who has, in fact, analyzed how American healthcare has become so dysfunctional, and has offered his solution. And you know what? It makes a lot of sense!

Just a bit of a disclaimer here — I’ve read Dr. Rich’s book entitled, “Fixing American Healthcare — Wonkonians, Gekkonians, and the Grand Unification Theory of Healthcare“. Dr. Rich and I have corresponded on several occasions. I’ve even provided a testimonial for his book. And you can guess why — because he is a Fixer!

The article forwarded to me is a review of the book from Smart Money magazine. It describes Dr. Rich’s theory about the “covert rationing” of healthcare in America — the point that only some people get the care they need and describing the destruction of the doctor-patient relationship. He truly tells it like it is, as ugly as it is. It’s eye opening at the very least.

But the important part is this: Dr. Rich also offers his Grand Unification Theory which describes how to fix it. Yes FIX it. In a fair and acceptable way for all players. Just imagine that!

[If you are one who is interested in the big picture of the healthcare system, if you are curious about how all the disparate pieces of healthcare can come together in a positive way, then you'll want to read Dr. Rich's book. A hint: The letter U in his book has nothing to do with Universal and everything to do with Unification.]

Blamers and Fixers…. If a patient is a blamer, OK — it’s understandable. When you have been directly harmed by the system, and absolutely unable to do anything to help make it better, then I can certainly understand why you might be a blamer — at least for awhile. Been there. Done that. And even if you get past the blaming part and just move on, without becoming a fixer — well, I guess I understand that, too.

But I have real trouble digesting doctor-as-blamer and never moving to the fixer position. Just making a lot of noise. Stirring the pot. I don’t see how a doctor has helped one single patient by doing nothing but publicly complaining. Whine whine whine.

It’s like voting. It drives me nuts to hear people complain about this politician or that one, or this issue or that one — when the complainer doesn’t even get off his duff to vote. Whine whine whine.

So Dr. Bennett — please stop whining and step up to the plate. Read Dr. Rich Fogoros’ book. See what you think. Then step up to become a Fixer.

That’s my guantlet. I’m throwing it down.

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By the way: John Stossel is taking on the challenge of suggesting a fix to the system tonite on 20/20 on ABC-TV. I’ll blog about that in the next few days. [I'm looking for some creative ideas, John!]

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Docs: It’s OK to Say You Don’t Know

I’m spending a few days visiting my parents in Florida and brought along Dr. Jerome Groopman’s book, How Doctors Think.

This is my second reading of this incredibly eye opening and wonderfully useful book. I’m a major fan.

This time I’m actually highlighting and post-it noting and starring and turning down page corners. It will probably take me forever to get through it. To give you an impression of how much important material I’m finding, I’m already on my third color of post-it tabs. And I’ve taken seven pages of notes.

On occasion I’m going to bring you some of Dr. Groopman’s gems. So here is the first one:

In the book, Dr. Groopman tells the story of problems with his hand and getting a diagnosis. He had to visit four doctors before he had a diagnosis that made sense to him. When you remember that he is a physician (a hematologist) then having to see so many doctors for a diagnosis that made sense is remarkable.

Without giving away all the reasons why (because that would be like giving you the good stuff from the book!) I will share his reaction at one of the doctors who wanted to surgically explore the structure of Dr. Groopman’s hand. When Dr. G asked what that doctor thought was the problem, the doctor replied that he wasn’t sure.

And Dr. G stated he was oddly reassured that the doctor would admit he didn’t know. Why? Because he had already been to one doctor who made up a name for a diagnosis that didn’t really exist.

Can you imagine that? A doctor making up a name for a diagnosis that didn’t really exist? Further, can you imagine the gall of a doctor who would make up a false diagnosis for another doctor’s condition? Yikes.

But it brings to mind many emails I’ve received from people asking me to help them find information about diagnoses so they can read more about them. There have been a handful of times they have given me a name I couldn’t find either. I’ve asked them to double check spellings or to ask the doctor to write the name for them. Sometimes all we could do was isolate the body system because most of the time those names are a body part paired with some exotic-sounding adjective.

Maybe those doctors were making up diagnosis labels too?

It’s human nature to want a label, and it’s human nature to want to know all the answers. I believe some doctors make up names to satisfy both those needs — they want to give an answer to someone who craves a label. They want to be heroes, and they don’t want their patients to think they don’t know. As patients, we believe that once we have the label, we’ll have the cure.

However, I can’t think for one minute that any of that is helpful? How can it be helpful for a doctor to make up something fictitious? And how does a made-up label improve someone’s health?

And what are the possibilities that in concocting a label, a diagnosis will be missed?

So here are two pieces of advice I’ve developed from How Doctors Think.

For doctors: when you help us, THEN you will be our heroes. Making something up just to have a name doesn’t help you treat us, nor does it help us heal. Please be straight with us. If a diagnosis eludes you, tell us you don’t know, but you’ll work with us to figure it out. That way we can partner to find the right answers.

For patients: if you suspect your doctor isn’t talking bona fide medicine, call him on it! If you are frustrated by the inability to find a diagnosis, don’t grasp at a label just to have a name. Work toward honing in on the correct body system, then the correct body part if you can, then descriptions of what is causing problems with that body part or system. There are so many reasons why you may not be able to get just one name for your medical problems. Don’t complicate the determination by insisting on a label that’s not accurate.

P.S.  A note to Dr. Groopman:  when I write to you to ask you for your autograph, I’ll buy a new copy to send 

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Groopman, CNN: Fire Your Doctor

Fabulous article for patients today!  From one of my empowered patient gurus, Dr. Jerome Groopman, and CNN.

Read it and act if necessary!

http://www.cnn.com/2007/HEALTH/08/16/ep.fire.your.doc/index.html

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Doctors: How to Treat an Angry Patient

It’s not often I aim my blog posts toward doctors and providers, but this follow up post to Hell of the Angry Patient is just that;  a follow up with ideas for doctors who find themselves and their staffs confronted with an angry patient.

Forgive the regurgitation of some of the earlier post, but I want to be sure you understand it…

The point was that patients, or the loved ones of patients, who have suffered at the hand of healthcare through medical errors, failure to diagnose, misdiagnosis, or even through their own perception, may be angry, and they may transfer that anger to any other doctor or provider.  Because of the nature of healthcare, patients have no choice but to return to the very system that caused the problems to begin with.  It’s no wonder they are angry!

The post goes on to give patients some ideas for overcoming their anger and even moving on toward forgiveness.

Many providers just don’t get it.  I had that experience myself.  After my misdiagnosis was confirmed, I knew I still had to figure out just what had caused the lump to grow on my torso.  If it wasn’t cancer, then what was it?  So I made an appointment with my dermatologist.  The earliest one I could get was almost two months later…. so by then not only was I still angry at the misdiagnosis experience, but I was frustrated with waiting so long to get some REAL answers.

The dermatologist, Dr. D, is very highly respected and I had been to see her twice previously.  But she was a perfect example of how NOT to work with an angry patient.

Read the rest of this post at its new location:

http://www.trishatorrey.com/2007/08/03/doctors-how-to-treat-an-angry-patient/

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Health Insurance Companies Play God

The Today Show this morning featured a vignette about what to do if you are denied a treatment or therapy by your health insurance company – the steps you can take to, perhaps, change their mind.

Yeah, right.  Like that might happen.

The story featured a woman who is dying of a rare form of lung cancer.  The point made by the representative of her health insurance company was that they only provide coverage for treatments and therapies approved by the FDA. In the woman’s case, the treatment her doctor recommended wasn’t approved by the FDA.

Never mind that the woman is dying, and that particular treatment might be her last chance for survival.

Never mind that she has been paying into health insurance for her entire career and now when she needs them to handle their part of the patient support agreement, they are backing down.

Never mind that she has two choices:  she can forget the treatment and die, or she can pay for the treatment herself — $50,000 per year — and have no money left for anything else, and perhaps end up in bankruptcy if it actually is a successful treatment for her.

As I’ve written before, there are dozens if not hundreds of off-label uses for drugs that are prescribed every day,  Most are paid for by insurance.  So — sorry — that seems like a weak argument to me.

We have to remember that the reason the health insurance companies exist is not to help us pay for healthcare at all.  No — they exist to make a profit.  Yes, even the non-profits are there to make more money, even if they have ways of hiding the income so they can continue to call themselves non-profit.  If you saw Sicko, then you know that these companies employ people who do nothing but research someone’s past to enable the company to deny a claim.  And you know that any time a claim is paid out, it is called a “loss.”

Don’t forget — it’s not about health or care — it’s about sickness and money.  I’ll stick by previous claims that the perfect scenario for an insurance company is to get you to pay in and pay in and pay in until you actually need them to pay for something.  Then they would just as soon you die quickly from whatever it is you get so they won’t have to keep paying for it. 

However, time for me to stand down from my pulpit and get back to what’s really important — helping you, my patient-readers, help yourselves through the health insurance quagmire….

The ideas proferred this morning were most definitely a step in the right direction.  They come from Michelle Katz who has written a book, 101 Health Insurance Tips, about how to manage health insurance denials.  I hope these can help you:

1. Check to see if there has been a coding error on your records.  Sometimes your denial might come from a simple coding error and its correction may get you the approval you need.
2. Start appealing as soon as possible because you may have a time limit from the first rejection to carry out an appeal.  Make sure you have copies of everything — all records, paperwork to help you appeal.
3. Check in with your HR department.  They may help you get through the process.
4. Talk to your doctor about your denial.  Since s/he will be denied the payment, too, s/he has a reason to help you get it approved.
5. If you don’t have the luxury of time, then get your doctor involved immediately to help.
6. Alert the watchdogs.  Each state has its own insurance commissioner – contact that person.  Also talk to your state’s attorney general.  A last ditch effort might come through an attorney.

Do you have more ideas?  I’d love to hear them.  Please contact me — I’ll add them, along with your name if you’d like — to my blog.

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Of Groopman, Misdiagnosis and Dr. Phil

Dr. Jerome Groopman holds a chair at Harvard Medical School, writes for the New Yorker Magazine, and has just published a book, How Doctors Think.  I haven’t read it yet, but I’ve read at least a dozen reviews.  What I most appreciate is that Dr. Groopman — a doctor held in high esteem by his peers, and uber-believeable by patients — may have created enough of an uproar that the medical profession may finally have to reckon with its malignancy — misdiagnosis.

Based on his own experience, where six different doctors gave Dr. Groopman four different diagnoses for a problem with his hand, Dr. Groopman acknowledges that doctors often do not listen to their patients, do NOT have “total knowledge”, are influenced by all kinds of factors that have nothing to do with the actual patient in front of them, make choices based on whether they like or don’t like a patient, and that they MISDIAGNOSE between 15 and 20 percent of the time.

Scary stuff.  In a way — comforting.  At least a relief of sorts.  And perhaps a fresh start.

First — scary because that means 15 – 20% of patients are being treated incorrectly.  Most will suffer.  Some will die.  Loss will be felt by patients, their families, and their pocketbooks.

Comforting — because it means that I’m not alone in my misdiagnosis odyssey.  Groopman saw six doctors for four diagnoses.  My story involved 13 doctors (including all the pathologists that reviewed my biopsy) and I got four different answers (or non-answers) too.  And I’m not even convinced I ever did get the RIGHT answer. 

A relief — because we can’t change what we don’t acknowledge (thank you Dr. Phil) — and this is acknowledgement by a highly regarded professional of a dirty little secret that has traditionally gone ignored.  Groopman cites a study that shows doctors don’t listen.  In fact, on average, they interrupt a patient within 18 seconds of asking “why are you here today?” Those doctors who still believe they have “total knowledge” (Groopman’s description) — in my experience, the majority of them — are going to find themselves confronting this reality — at last — or else.

And that’s where the fresh start comes in.  Hopefully, in some ways, this will give those doctors the “permission” they need to see reality — and begin partnering with their patients instead of preaching to them.  (And we all know what publicly happens to those preachers who pretend they are something they are not!)

Sharp patients will take Dr. Groopman’s best advice.  Continually ask questions, and be a partner with your doctor.  Ask questions like “What else can it be?”  and  “What other ways can it be treated?”  and if you feel like you and your doctor aren’t communicating well?  Then get another doctor. 

We’ve all known it.  Many just don’t want to believe it.  Doctors are HUMAN, just like the rest of us.  Or, as Grampa used to tell me, they all pull their pants on the same way the rest of us do.

Don’t let your health suffer because you’d rather believe doctors have “total knowledge.”  We know FAR more about our own bodies than our doctors do.  We just don’t have the right words to describe the problems, nor the education to determine what needs to be done to fix us.  Getting the right answers requires BOTH our doctor’s expertise AND our own.

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Want to read more about Dr. Groopman’s book?  Link here for the NPR interview.  Link here for the TIME Magazine review.  Or read Dr. Groopman’s own synopsis at the New Yorker.

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Wall of Silence = Profit

During my post misdiagnosis anger phase, I read everything I could get my hands on about medical errors, their causes, and their consequences.  I’m not sure why, except perhaps I wanted reassurance that I had not been the only one ever to have suffered in such a way.  It was partially cathartic, and partially responsible for inciting me to begin helping other patients empower themselves. (We shall overcome!)

The very first book I read was called Wall of Silence ~ The Untold Story of the Medical Mistakes that Kill and Injure Millions of Americans by Rosemary Gibson and Janardan Singh.  Certainly it reinforced the idea that I was not alone.  Then it made me even angrier!  Finally, it strengthened my resolve to help others.

Fast forward two+ years to this week — when I received an email from Ilene Corina at PULSE asking if I would be willing to talk to Rosemary Gibson about her next book!

That conversation took place yesterday — and what a conversation it was.  Rosemary is now working on a book about the many ways treatments are recommended because they are profitable, and not because they will help a patient.  Her interest in my story is that I accused my original oncologist of insisting I undergo chemo because it was the only way he could make money from me — certainly a case in Rosemary’s point.

Rosemary shared other stories with me briefly — and they are just as compelling for her argument, and her book.  She’s looking for others, too — so if you know of anyone with a similar story, contact me, and I’d be happy to pass on your info to Rosemary.  Networking is incredibly valuable!  And of course, that’s how Rosemary and I hooked up to begin with.

If you’re interested in learning more about the conspiracy of silence within healthcare and the harm it can cause you, I urge you to buy Wall of Silence – here’s a link. 

It will help you understand better why patient empowerment is so necessary, and why advocating for yourself or your loved ones can save lives.

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