10 Signs & Symptoms of a Good Doctor, Part 2

by Melodie on March 24, 2010

© Logan Ingalls

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In Part 1, we looked at five characteristics of a good doctor. Here are five final points for you to consider:

6. A good doctor avoids common errors in thinking.

Research shows that, as a doctor considers a patient’s condition, she comes up with two or three possible diagnoses from the beginning of the meeting. A really talented doctor may hold four or five in her brain. Then within a short period of time she must form a complete picture of the problem and decide what to recommend. This is where errors in thinking can easily occur.

In “How Doctors Think,” Dr. Groopman describes some common errors. For example, the doctor:

  • Is guided by a stereotype, so she fails to think about possibilities that contradict it.
  • Prefers a diagnosis that she hopes for, rather than a less desirable alternative.
  • Confirms what she expects to find by selectively accepting or disregarding other information.
  • Tends to stop searching for a diagnosis once she finds something that she can make a preliminary judgment about.

These are only a few of the cognitive errors a physician may make if not careful. You can help your doctor guard against these by engaging in the dialogue. Ask questions like: “Is this diagnosis the only thing that could be causing my symptoms? What else could it be?” or “What is the worst thing this could be?” or “Is it possible I’m having more than one problem?” If a doctor focuses on a specific cause of pain you’re having, you can ask, “What other body parts are near where I am having this symptom?” Questions like this invite your doctor to open up her thinking to a full range of possibilities, making it more likely she’ll come to the correct conclusion.

I sometimes encourage a doctor to “think out loud” so I can hear the cascade of thoughts that are leading her to a conclusion. Or I will re-state the steps I think she’s used to come to her recommendation.

If you sense that your doctor is making a decision based on a stereotype or personal prejudice, you can dismantle it with a sense of humor. In “How Doctors Think,”Dr. Groopman tells of a middle-aged woman named Ellen Barnett who sought help for a variety of complex symptoms. “I know I am in menopause, and all five doctors told me that that’s the cause of my problems. And two told me that I’m crazy. And, frankly, I am a little crazy,” Ellen told her doctor with a smile.  “Okay, I know menopausal women have hot flashes. But I think this is something else, that what I’m feeling is more than just menopause.” With this statement, Ellen alerted her doctor to look beyond a common stereotype.

7. A good doctor balances action and inaction.

 In cancer medicine, there’s a fine line between watchful waiting and taking action. The difference can mean life and death. A doctor with a confident, “take charge” demeanor often instills trust in a patient at a time when all seems out of control. But a doctor who is overconfident, whose ego is inflated, may make recommendations for treatments that are not in the patient’s best interest.

Patients and doctors alike believe the doctor’s role is to “do something.” I have often heard people newly diagnosed with cancer say in a panic, “I’ve got to get this tumor out! I can’t live knowing it’s inside me.” Even if that tumor is monitored or appropriately treated with other means, a patient may pressure his physician to remove it or treat it with a more aggressive therapy than is warranted. Doctors are not immune to pressure from patients, and may agree to the patient’s request (or refer to a doctor who will comply) even if the action may result in worse complications.

If your doctor recommends a treatment course that you believe is either too passive or too aggressive, seek out his reasons for this recommendation. Do some research yourself. You might ask that a team of physicians from different specialties meet to discuss your case and agree on a recommendation. Or you may want to seek out a second opinion from another doctor.

8. A good doctor makes recommendations not influenced by financial gain.

Unfortunately, in the United States, many factors converge to create a medical system in which doctors are pressured to prescribe certain medications, use specific medical devices, or recommend high-end treatments. Shrinking incomes, especially for primary-care providers, make offers from pharmaceutical and other companies even more attractive.

It’s a rare doctor’s office that doesn’t have calendars, notepads, pens, educational materials and what-not emblazoned with various brand-name medications, and a pharmaceutical sales representative hanging out at the receptionist’s desk. What you may not see is how many trips the doctor has taken to exotic locations for conferences sponsored by medical-supply companies who want him to use their device in his next surgery or procedure.

Insurance companies contribute to the pressure by reimbursing physicians at a higher rate for surgeries or even just poking a needle in a patient, less for a “watchful waiting” or alternative approach.

“The current culture of medicine fosters lucrative networks of referrals and procedures but discourages critical examination of their value,” writes Dr. Groopman. “It is unlikely that in the near future personal financial gain will be extracted from certain clinical decisions,” he believes.

It may be hard to determine whether your doctor is entangled in this financial-incentive web. But some questions can help. If he prescribes a brand-name medication, you can ask whether there is a generic or less-expensive brand that you can take. And if he recommends a surgery or invasive medical procedure, ask, “Is there another approach that might be just as effective for diagnosing or addressing this issue?”

9. A good doctor is comfortable with uncertainty.

It’s tempting to think that, because medicine is a science, findings can be applied to clinical situations with certainty. Unfortunately, this view doesn’t take into consideration how variable and unique each person and body is.

“Uncertainty creeps into medical practice through every pore,” says David M. Eddy, professor of health policy at Duke University, in “How Doctors Think.”“Whether a physician is defining a disease, making a diagnosis, selecting a procedure, observing outcomes, assessing probabilities, assigning preferences, or putting it all together, he is walking on very slippery terrain.” He believes it is hard for doctors and patients alike to appreciate how complex these tasks are and to understand how easily different conclusions can be reached.

Uncertainty in medicine arises because a doctor does not know all there is to know about a condition and because current medical knowledge is limited. He may also not be able to distinguish when he doesn’t possess the information he needs and when that knowledge is just not available.

To counter uncertainty, physicians may resort to overconfidence or focusing on positive data because these are emotionally more appealing and suggest a positive outcome.

A doctor needs to acknowledge to himself and his patient that uncertainties exist in the practical application of medical knowledge. Instead of weakening trust between provider and patient, Dr. Jerome Groopman says this approach can enhance patient care because “it demonstrates his honesty, his willingness to be more engaged with his patients, his commitment to the reality of the situation.” It makes a physician more willing to change course if an approach is not working.

A good doctor will move forward in determining a diagnosis or course of action while at the same time acknowledging that the outcome may be uncertain. As a patient, you can look for this kind of vulnerability in your doctor and support it.

10. A good doctor doesn’t make a “zebra retreat.”

 A frequent saying in medical circles is, “If you hear hoofbeats behind you, it’s probably a horse, not a zebra.” This means that when a patient presents with symptoms, they’re likely caused by something common rather than by a rare disease. So doctors will generally look for the common cause first. Unfortunately, some stop there.

Many forces in modern medicine discourage a doctor from looking beyond an expected diagnosis. To look for more unusual causes, a doctor may need to perform lab tests that are expensive, hard to perform or very specialized. Insurance companies provide a strong disincentive to pursue tests that may expose a “zebra.” And often, physicians ridicule their peers who look beyond the usual line-up of easy diagnoses.

After a couple of months of increasing fatigue and other symptoms, I went to a specialist, thinking I might have a chronic sinus infection that had resisted standard treatment. He examined the body parts that his specialty addressed, performed a diagnostic procedure and said he could not find anything wrong. I said, “It’s very possible that the hoofbeats behind me are a horse, but I have a pretty complex medical history, and in the past many of the hoofbeats have been from zebras.”  No, he concluded, “You’re just worried and stressed.”  I left his office, knowing I wouldn’t be back. I was not the kind of person to hang out on the sofa all day; I knew there was something wrong. Fortunately, other doctors I sought out didn’t go into “zebra retreat,” and our search led to, not a horse, but an elusive “zebra”—an unusual condition that this specialist hadn’t been willing to consider.

As a patient, two powerful questions can help your doctor look beyond the common: “Is there anything else that could be causing my symptoms?” and “What is the worst this could be?”

You are your own best ally. I hope that you will consider the “signs and symptoms” of a good doctor and make choices that enhance your care and allow you to work collaboratively with your health-care team.

I’m also aware that, after reading this article, a few of you will get a niggling feeling that your doctor is not giving you the high-quality care you deserve.  I am happy to work with you as a coach to determine how best to address this issue and choices you may want to make. I hope that you won’t stay with the status quo, but will address the issue with your doctor or find another one who will work as your partner toward a Whole Life.

What strengths does your doctor have? How can you work with him to improve your care?

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{ 1 comment… read it below or add one }

1 Pat Grosser March 29, 2010 at 12:17 pm

This compilations of what to look for and do to find a doctor who will work best for you is extremely helpful. I especially like that you suggest talking directly and openly with the doctor when you are questioning his/her diagnosis or treatment approach. When you are sick is not the time to silently accept the first recommendation, but to explore in depth. You have presented suggestions that are not only useful for cancer patients, but also for any patient. Thank you.

Pat Grosser, Maine

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