Archive for the ‘informed consent’ Category

Why don’t patients ask questions of their doctor?

May 31, 2010

My wife came back from a doctor’s appointment the other day, and immediately, I noticed that she looked puzzled and somewhat confused. So, I asked her about her appointment.  She went over her discussion with the doctor as I kept probing with questions about their conversation.  I found myself asking the following question more than any other: “Well, did you ask him about…?” Before too long, doing what I do for a living, I could not help but wonder why patients aren’t more inquisitive. Is there something about the patient-doctor relationship that makes patients not want to ask questions of their physicians?

Surely, the primary responsibility for gathering information about the patient’s medical conditions is and should be with the physicians. After all, their knowledge of medicine is vastly superior to that of the average patient. Still, when a patient has questions, there is often no good reason not to ask them. Consider a physician who orders hormone replacement for a female patient with a history of blood clots or hypercoagulability of which the physician is unaware. Consider another patient who develops a series of complications after a surgical procedure but who decides to tough-it- out and not ask any questions during follow-up appointments with the physician. In both of these examples, the patient risks developing potentially life-threatening conditions, and, if the patient knows or suspects that possibility for whatever reason, it is probably not a good idea to assume that the doctor will be the one to ask the right questions. So, why are patients sometimes reluctant to ask more questions about their medical care or condition?  I don’t presume to know the answer, but I suspect, in part, it has to do with the patient’s expectations.

For example, when I am pain, I don’t really want to have an extensive Q & A session with my doctor. I just want treatment!  It is simply mentally relaxing to just let go and have someone else take care of me. In addition, my knowledge of medicine is superficial at best. I don’t feel comfortable asking questions if I don’t know what I am talking about. My ego would rather have me in pain than allow me to question a doctor at the risk of looking like a fool.

On a subconscious level, I am probably also dealing with preconceived notions about doctors.  As long as I can remember, I have been told that doctors are intelligent and in control. After all, who else is capable of getting into medical school and then have the stamina to survive some seven to ten years of medical training? All of this makes me think that my doctor can only make the right decisions about my medical care. And then there is the medical office or the hospital. The smells, the patients (most with problems far worse than I have), the complicated machines that look like they belong in a sci-fi movie don’t exactly add-up to a familiar, comfortable environment.  I am in pain, uncomfortable, and somewhat intimidated – not exactly an environment conducive of critical thinking.

Well, if this is how other people feel, I think that might explain why patients are sometimes not as inquisitive as they should be.  What do you think?  If you are a patient or a physician, your feedback is much appreciated. Of course, everyone is welcome to comment.

Contributing author: Jon Stefanuca

Editor’s Note: This piece was written by Jon Stefanuca. My own wife has an advanced degree in pathology, did surgical pathology and autopsies. She DOES ask questions! Do you really need a medically-related degree, however, to ask the basic questions so that you have a clue what you’ve just agreed to by way of medical care? I think not. Moral of the story: be your own patient advocate! If you need help, then have a family member or a close friend accompany you if you have any doubt.

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Best Hospital Rankings – A reply to Dr. K – what’s best for YOU?

May 13, 2010

As readers of our blog know, Dr. Kevin’s blog serves as the source for a number of our posts. Recently, Dr. Kevin posted somewhat of a spin-off –Top hospital rankings doesn’t mean the best medical care | KevinMD.com – of a post he had done earlier about “Top Doctors” does not equal (necessarily) “Best Doctors.” Then today, as I was going through my News Feed on Facebook, lo and behold, here it is again.  I agreed wholeheartedly with him then and  now, and I find myself saying “Amen” to his post.  Problem is – what is the answer, Dr. K?

Check out his blog. He identifies the issue, but does he really suggest the answer? My humble opinion: afraid not!

Let’s explore some ‘tips and tricks’ for you to get close to the right answer. I say ‘close’ because there really is not a perfect answer. If you get great care and all goes well, then that was the best hospital for you and your problem. These after-the-fact answers are always 100% accurate when seen through the best medical instrument available – the retrospectroscope. If you are interested in some tips and tricks for picking an institution for future, non-emergent care, read on.  Let’s see if we can provide you some guidelines for your selection process.

Having been involved with issues relating to the care rendered at numerous hospitals in Washington, D.C., Baltimore and far beyond for many years, I have my own personal opinions where I would go to be treated and where I most assuredly would not go.  In fact, I have often joked that I need to get a medical alert bracelet reading – ‘in event you find me unresponsive do NOT take me to Hospital X (fill-in the blank).”

Lawyers doing medical malpractice have a pretty darn good sense of which hospitals give the best care.  Does the general public? As Dr. Kevin points out, reputation and marketing of that reputation is not the end-all-be-all of defining which hospital (also insert ‘doctor’) gives the “best medical care.”

There’s a certain hospital here in Baltimore that is constantly listed as the “Best.” While that institution does have some of the ‘best’ doctors and allied health specialists, it is also well known to provide substandard care at an alarming rate. The local maxim goes – “If I wind-up having a rare disease, that’s the place I want to go for treatment; however, if it’s garden variety, no way – no how!” Why? Just too busy, too arrogant, not patient- friendly, too willing to turn patient care over to resident-staff-only surveillance and so on. Maybe they are just bored by the ordinary health issue – not complex enough. Who knows?

But here’s the catch – just as ‘top hospital’ rankings doesn’t mean (necessarily) best medical care, nor does overblown reputation mean that there aren’t some, if not many, outstanding physicians at these same institutions. Titles, marketing banners and magazine covers simply do not answer the search for the best institution for your care.

Let’s face it, in an emergency situation you are going to the nearest available institution at least until you are stabilized medically. Whether you elect to stay there for ongoing care may well be a different issue. The more common situation you will probably face is when you are going to undergo elective procedures or care.

Since you are reading this blog, you undoubtedly have a computer. Have you done your homework? Going online to learn more about your medical condition is a good place to start. No, I’m not suggesting you check-out what ranking your doctor or his/her hospital has; that information is precisely at the heart of the problem.

Let’s take one example of putting research into the decision-making process. An obese patient determines that he/she would benefit by bariatric (weight loss) surgery. Putting aside those who see this as a quick-fix alternative to Jenny Craig or Weight Watchers, John Doe (J.D.) – our hypothetical patient – might consider researching the various forms of bariatric surgery. Does J.D. know if he should have gastric bypass surgery or gastric banding? If gastric bypass, does his doctor specialize in open procedures or laparoscopic surgery? Does he know the different approaches a doctor can take? What are the risks of malabsorption or the post-operative complications associated with that form of surgery? Had J.D. just typed in “bariatric surgery” in whatever search engine he likes, he would see there is a world of information out there about the types of bariatric surgery, the risks associated with such surgery and so on. Did that handout he received from his doctor really fully educate him on the alternatives to what was recommended to him?

Okay – let’s focus on J.D.’s surgeon. Does he/she have a ‘preference’ for doing open versus laparoscopic procedures? When is the last time, if ever, he/she did one laparoscopically? Consider: did J.D. think that might be the reason why he/she is recommending J.D. undergo an open Roux-en-Y? Is this really in J.D.’s best interest?

Let’s put you in J.D.’s shoes. Would you ask your prospective surgeon what his/her complication rate is? How about  mortality rate? If you think surgeons don’t know their morbidity/mortality rates, think again. What is the most frequent complication your surgeon  encounters following the surgery or treatment you are considering? Are you, for some reason, at greater risk than other patients for encountering this risk?

Hopefully by now you get the drift. This is your body – protect it! Last time I checked, we’re only here one time around. If your doctor makes you feel ‘uncomfortable’ because of his/her reaction to your questions or  the time it takes for  you to understand what you are agreeing to undergo surgically or medically, that might just be a telltale sign to move on.

Best Doctor/Best Hospital? Hopefully, by doing your homework and having a meaningful discussion with your doctor and understanding better the hospital where this will all be taking place, you will determine exactly who is the “best doctor’ and which is ‘the best hospital‘  for YOU! At least this approach will give you a better chance of a good outcome and experience than making your choice based on a title, magazine cover or a banner hanging on the hospital’s facade.

By the way, the same can be said of lawyers. Are we listed as the ‘best’ and ‘super’? We sure are, but you should ask us (or any lawyer you have occasion to meet) the same type of tough questions. Be pro-active. You’ll be better-off for it.

Have you ever wondered how people get in clinical trials? Well, you should check this out.

April 26, 2010

Are you aware of clinical trials that may be in your neighborhood? I just happened to come across this link to clinical trials.  Perhaps you are a lot more savvy than I (which would not surprise me one bit), but you can get ongoing information on these clinical trials by going to a website called Clinical Connection.

For example, there’s one in Baltimore for overweight folks being conducted at Harbor Hospital involving a new investigational medication.

In fact, if you go to this link, you will see that there are over 15 clinical trials for all types of conditions in the Baltimore area alone. If you are willing to travel 50 miles or less, there are even more in which you can enroll.

Do you have moderate or severe pain from osteoarthritis of the hip or knee?  Well Annapolis just might the place for you to visit and try out a new drug.  You have to be  over 18 years of age and according to the website, “study participants may be compensated for time and travel. All study-related care is provided at no cost and health insurance is not required to participate.”  I don’t know what “may be compensated” means – but if you are interested, check it out.

On the national level, the home page of Clinical Connection says there are 105,555 clinical trials underway – and there’s probably at least one in your neighborhood.

Do you suffer from chronic low back pain of greater than 3 months duration? That’s right – there’s a trial for you taking place at 7 locations, including California, Arizona, Florida, Washington and Nevada.

You name the condition – there just may be some free study out there waiting for you to volunteer.

These programs undoubtedly have very extensive packets of information about the study guidelines and the risks and benefits of the drug or therapy under study.  These trials are called clinical trials since the manufacturer has presumablyjumped over the hurdles of early non-clinical research in order to take the next step – how does our product work with real people?

Make sure you understand what you are signing up for before doing so.  Who knows, it may turn out that you get some real benefit from participating – hopefully you will not be a statistic in terms of adverse outcome. Just take time to understand what you are getting yourself into and what rights you are waiving.  If you’re good to go, we wish you well!

“Top doctors may not always be the best physicians” via @KevinMD – A Commentary and Some Tips

April 26, 2010

OK – so I’m a bit late with this one – since it was posted on April 21st – but sometimes even an ‘old’ post is worth a comment or two.

Dr. Charles writes in his post Top doctors may not always be the best physicians

Some of these doctors are excellent, but many are simply “notable.” They may be well-connected, in leadership positions, or presidents of this or that society. Many are excellent self-promoters, branding themselves through the name brand institutions they work for and the billboards that increasingly advertise their faces. Many are simply well-known or popular among their peers.

Well, he’s spot on with that one.  Of topical interest perhaps in the legal arena is that unless the opposing lawyer isasleep, objections in a courtroom to the question – “Doctor, have you ever been listed in (fill-in the name of the local magazine that rates physicians) as a ‘Top Doctor’?” are universally sustained by the judge.  Maybe judges understand better than the public that ‘Top Doctor’ status may not really be relevant to a physicians ‘expertise’ in a given subject area.

Before going any further, let it be said, however, that many times “Top Doctor(s)” are just that – they are some of the best  in their given specialty or subspecialty.  But how does the public know which ones are the entrepreneurial self-promoters and which ones are the real deal?  I might suggest that if you read Dr. Charles’ piece that you not stop until you read the ‘Comments.’  Here’s just a sample:

This from a gentleman named Kevin Falchuk, who provides the disclaimer – “I think you make excellent points, and this is coming from me, the President of a company called Best Doctors. We’re responsible for creating some of these lists.”

With that said, Mr. Falchuk notes:

[T]he issue in medical care isn’t your doctor’s reputation. Instead, it’s the extent to which he or she is able to spend time with you, think about your problems, and render good advice.

Let me add a few other suggestions:  While you are spending time with your doctor, if you are dealing with a life-threatening or potentially life-altering condition and not just the common cold, you may want to find out what his/her experience is in dealing with your condition.  In the right situation ask – is a referral to a specialist advisable? Perhaps a second opinion? If a course of treatment is recommended, are their alternatives?  What are the risks and benefits to each approach?  Does the recommended treatment have any known and likely side-effects?  Is there anything in your medical history that puts you at greater risk for known complications?

While it is never a good idea for a lay person to diagnose himself/herself, if you are recommended a course of treatment or a surgical procedure, perhaps you might consider educating yourself on what’s out there as far as information about the risks, benefits and alternatives of a procedure or treatment plan.  If you do and you have questions, contact your physician and ask about your concerns. However, sage advice on this approach might be – “If you trust Google more than your doctor then maybe it’s time to switch doctors.” Jadelr and Cristina CordovaChasing Windmills, 08-21-06

I suspect that somewhere during the course of the informed consent discussion with your physician, you or a family member will get a pretty good sense of whether the physician with whom you are speaking is the person for you and truly is one of the Best Doctors for your condition and treatment.

There’s a lot of talk about the medical profession learning how to improve on patient satisfaction. Why should you care if others think your doctor is tops or the best in some magazine?  While this may be a way to initially chose from the dozens of specialists in any given area, it should not be the end of the search.  Choice of physicians – as with any group – yes, even lawyers – is there for you.  Once you are in that physician’s office, only you can decide if he/she is the best doctor for you and you alone.  Also – keep in mind that not all the best doctors (or lawyers, or candlestick makers) are listed in such publications.  Whether your doctor is or is not is perhaps of no moment.  I have always believed in a system that is based on common sense – be an educated patient, ask questions, listen to the answers and follow your brain and your heart. While it does not guarantee a great outcome, you will have at least done what you can do to make sure that – your doctor is the best doctor for you!

Computer May Be Better Than Your Doctor in Providing Information for Obtaining Your Informed Consent

April 13, 2010

When most people think about medical malpractice, they think about a doctor making a mistake during surgery, or failing to order a necessary test, or making the wrong diagnosis. In other words, a mistake in the actual rendering of medical care. However, a doctor can also be negligent in his or her communications with a patient even before the doctor undertakes the treatment at issue.

Under the law, a doctor is required to explain to the patient the risks, benefits and alternatives of treatment so that the patient can make an informed decision about whether to proceed with treatment. This is called “informed consent” and is a critical step in the process of getting competent medical care.  

While some doctors and hospitals have generic consent forms that you sign before surgery, the actual informed consent process is typically handled by the doctor, usually in the doctor’s office. At this time, the doctor is required to explain the treatment, what it entails, the risks involved (i.e., death, infection, etc.), and whether there are any less  invasive alternatives or other available options for care. If the doctor fails to thoroughly explain these issues, then he or she can be held liable if the patient did not understand the full ramifications of the procedure and suffered injury as a result.

One of the difficulties of informed consent is that it is usually done verbally, and we all know the difficulty of trying to remember all the details when someone is explaining something to us, whether it’s directions to a local store, or how to program a new cell phone. It can be especially difficult in the context of a doctor’s office when the patient is already under stress and is being bombarded with complicated medical terminology. It is not surprising that many patients have little or no recall of the actual risks of treatment that doctors routinely say they explain to their patients.

One method that is currently being explored to improve this process is the use of computer programs to help educate patients. In a new study, researchers at the University of Melbourne and Austin Hospital in Australia tested a computer program in forty patients scheduled to undergo surgery to remove the prostate gland.

The computer program included slides with animations detailing the procedure, its potential complications and the post-surgery recovery. Each slide contained questions for the patient to answer, and he could move on to the next slide only after he gave the correct responses.

Patients were randomly assigned to one of two groups. One group received standard informed consent verbally from their doctor. The second group got to use the computer. The study found that the patients in the computer group scored much higher on test questions about the procedure – 78% correct answers versus 57% in the standard group. Why the difference?

Having patients answer questions helps turn the process into an “education and knowledge tool,” according to Dr. Nathan Lawrentschuk, one of the researchers on the study, which appears in the urology journal BJU International.  It may also allow doctors and nurses to “hone in on areas not understood, rather than assuming our patients understand what we say,” Lawrentschuk told Reuters Health in an email.

We look forward to further advances in this technology so that patients can make informed decisions about their medical treatment. Let us know if you have ever given ‘informed consent’ after being advised of the risks and alternatives by a computer.  We would appreciate you sharing with us how, if at all, that process improved your understanding of the surgery you were about to undergo.