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Medicine 101
Contents
Medicine
101 is not a brief introduction to medicine.That would be a bit
too bold an enterprise for any web site.Our goal here is to
give you some insight into how medicine is practiced; we want
to help you understand how doctors think.Better still, we
would like you to understand how good doctors think,
so that you can anticipate their needs and help them do the
best job possible in helping you.
This page
is intended as a companion and preface to the Symptom Guide.The Symptom Guide
contains the basic information that we believe is necessary
for you to be an intelligent medical consumer.Medicine 101, on the
other hand, explains why this information is
necessary and how you should use this information.
If you are
reluctant to read the reams of material below, never fear: here is a summary of
the high points.
1.Many
factors contribute to the quality of care you receive
from your physician. Some of these factors are
physician-dependent, while others are your
responsibility. It is within your power to influence both
sets of factors; the goal of the Medical Consumer's
Advocate is to provide you with the information necessary
to do so.
2.Without
an adequate history, your doctor may not be able to
arrive at the correct diagnosis for your problem. You can
be an enormous help to your doctor by providing him with
a complete history.
3.The
physical examination will vary from patient to patient,
depending on the specific problem and the pertinent
history.The
bottom line, however, is this: if he does not look, he
will not see.Furthermore, your doctor should "have
eyes to see." In other words, he must have the experience to
make sense of what he hears, sees and feels.
4.A
doctor's ability to diagnose your problem is limited by
the breadth of the differential diagnosis that
he has in mind.
5.A
physician uses clinical tests to narrow a differential
diagnosis.There
are good as well as bad motivations for ordering or not
ordering specific tests.A single pithy question on your part may help
you avoid unnecessary tests or obtain essential tests.
6.There
are always treatment options.You and your
doctor need to discuss the risks and benefits of each
option; ultimately, however, the decision is yours.A key component
to this decision-making process is the concept of outcome.If you and your
doctor have different ideas as to what constitutes a
satisfactory outcome, you may not be able to agree on
what is, for you, the best treatment option.
7.Many
(if not most) doctor-patient problems are due to poor
communication, and either or both parties may be at
fault.You
can help alleviate this problem by modelling good
communication skills.
In a
nutshell, here is how it's supposed to work: you go to your
doctor with a problem.He allows you to tell your story (the
"history"), asks a few pertinent questions, and
performs a directed examination.Your doctor knows of a set of possible
explanations for your problem, something called a differential
diagnosis; he uses what he learns from the history and
physical to eliminate items from this set, eventually
narrowing it down to the correct diagnosis.This process may be
very straightforward, requiring only a history and physical
examination, or it may require a more detailed examination or
further tests.
Eventually,
your doctor arrives at the correct diagnosis.He explains the
problem to you, providing you with all of the information
that he feels you need to know.Additionally, he answers all of your
questions in language that you understand.Finally, he explains
to you all of the treatment options, giving you the
information you need to decide amongst the various options.After you make this
decision, he guides you through the treatment process.He continues to
monitor you during and after treatment, always ready to
reevaluate his initial diagnosis if your response to
treatment is unsatisfactory.
Many
potential problems may erode this idyllic doctor-patient
relationship.Some
of these problems are:
Your doctor may not take an adequate history.
Your doctor may not perform an adequate
physical examination.
Your doctor may perform an adequate history
and physical examination, but may not understand
the full implications of what he hears, sees, or
feels.
Your doctor may not have a sufficiently
complete differential diagnosis in mind when he
considers possible explanations for your problem.
Your doctor arrives at the correct diagnosis,
but nevertheless sabotages your care by failing
to provide you with appropriate treatment.He may be
unaware of particular treatment options, or
perhaps he fails to give you information on your
illness which is essential for your recovery.
By having poor communication skills, your
doctor may impair your ability to make what is,
for you, the best treatment decision.
In some instances, follow-up care is
essential for securing a good outcome.Your
doctor may provide you with excellent initial
care, but nevertheless fail you by not providing
adequate follow-up care.
These
points emphasize the responsibility your doctor has to you.Needless to say, you
are quite capable of sabotaging your own care.Here are some great
ways of lousing up your care:
You may provide your doctor with an
inadequate history.
You may neglect to give your doctor the
necessary direction he needs to perform a good
exam.(A
classic example of this is the difficulty one
might have in finding a small lump in the neck.)
You may not understand what your doctor has
told you, and by failing to question him, you may
not be able to follow his advice in the correct
manner.
You may be noncompliant with your doctor's
directions.
You may neglect to come to your follow-up
appointments.
Clearly,
you can do quite a bit to hold up your end of the
doctor-patient relationship.Some specific suggestions are provided below (and
elsewhere on our web site), but much of this is common sense.What you may not
realize is that you can also influence your doctor's ability
to provide you with excellent care.The key thing is for you to have the
necessary information.
Think of
yourself as a consumer trying to find the "best
deal."If
you were shopping for antiques, knowledge (information) makes
the difference between being robbed and making a steal.With respect to
medicine, it is your health that is at stake, and not a few
dollars.
This all
assumes that you have a doctor who is willing to listen to
you and answer your questions, and is not trying to herd you
in and out of the examination room in five minutes or less.If you are unhappy
with your doctor's habits in this regard (and he is unwilling
to change), you should consider finding a new doctor, or seek
advice from others (for example, by using the Medical
Consumer's Advocate Forum.)
The History
{Some introductory material on the importance of the
history and what constitutes a complete history. This will be
followed by the following top ten list.}
Well,
actually this should read "one easy thing you can
do..." but top ten lists are so much more dramatic.The one easy thing is
this: keep a well-organized file on your personal medical
history.What
should go into the file?Given the previous discussion on the importance of
history, the following should strike you as simple common
sense:
1.Record
allergies to medications. Be as specific as possible.When it comes to
allergic reactions, there is a world of difference between
diarrhea, a chest rash, or severe swelling in your throat
that made it difficult for you to breath.If you were told by
your mother that you had an allergic reaction to a particular
drug, press her for details.
2.Keep a
list of current medications, with doses and indications.Doses are important
because the dose of some medications may vary greatly from
one patient to the next.Indications (in other words, the reason you are
receiving this medication) are important because some
medications are used for a variety of problems.For example, some
antidepressants may also be used to treat pain syndromes.Also include a
list of the over-the-counter medications and herbal remedies
that you take on a regular or occasional basis.
3.Keep a
list of the names, addresses and phone numbers of past and
present doctors.This list does not need to be meticulously
thorough.In
general, you should include the names of your current
doctors, of surgeons who have operated on you and of
physicians who have cared for you for many years and/or for
significant medical problems.
4.Keep a
medical problem list.Anything for which you are presently receiving
treatment is fair game, but other things deserve to be on
this list, too.Some
things can come back to haunt us, even many years later; some
examples are: cancer,
radiation exposure, chemotherapy, physical trauma, and the
use of tobacco, alcohol or other addictive drugs.
5.Keep a
list of hospitalizations.At the very least, this list should
consist of the dates of each hospitalization and the reasons
you were hospitalized.At the very best, you should obtain a copy of the
discharge summary from each hospitalization.
6.Get
copies of your operative notes.If possible, let your surgeon know in
advance that you will want a copy of the operative note.Operative notes can
(on rare occasion, of course) be hastily dictated; if your
surgeon knows that you will be reading the note, he/she will
probably take pains to fill in all of the details.
7.Get
copies of radiologist's reports; when indicated, purchase
copies of important radiologic studies.What's important?You need to use your
common sense.If
you have had ten chest X-rays and the latter nine are each
reported as "no change from previous study", all
you really need is one of these films and the most recent
radiologist report.With CTs and MRIs, it is more difficult to give a
formula dictating when you should shell out the money to buy
a copy.In the
very near future, all radiologic studies will exist only as
computer files; we will be entering a "filmless
era" in which your studies can be sent via modem to any
appropriately-equipped doctor or hospital.Until that time, the
necessity of carrying your films with you will continue to
depend heavily on the ease and speed with which your previous
hospital can find and mail old films to your present
physician.
8.Keep
copies of blood test results and other studies, such as
electrocardiograms.Sometimes, just knowing that an unusual test
result is nothing new can prevent you from undergoing a storm
of further testing.In this regard, an old electrocardiogram can be as
valuable for comparison as an old chest X-ray.Again, use your
common sense; you certainly don't need the results from every
blood test you have ever had.'Nuff said.
9.Record
your family medical history.In particular, list the medical problems
and causes of death (if pertinent) for your close relatives
(parents, siblings and children).
10.Before
seeing your doctor, make notes regarding the history of your
current problem.Pay particular attention to the timing and order
in which your symptoms arose.Note anything that you believe
may have significance.
The Physical
Exam
If your
doctor does not look, then he will not see.The disincentive to
examination is that it is time-consuming and, much of the
time, does not help the doctor to figure out the patient's
problem.
Why look at all?I try to get three
things from the examination:
From the history, I have formed hypotheses
(educated guesses, really) as to the diagnosis.The
examination enables me to test these hypotheses.
One of my jobs as a doctor is to make sure
that the patient does not have some horrible rare
disease (most of the time, it's cancer that we
are worrying about).If I do not look, I may have
no chance of diagnosing such a problem.
Finally, the physical examination may reveal
things to me that I did not suspect from
the history.
What should
you expect from a physical examination?As medical students,
doctors are taught to perform an omnibus
"head-to-toe" examination, a skill that is
discarded soon after graduation.One of the reasons this type of
examination is not performed is that it is unnecessarily
time-consuming.It
is a well-known fact that the "general physical"
for an asymptomatic adult is a waste of time and money; the
yield (i.e., the frequency with which a problem is detected)
is simply too low to make this a cost-effective practice.It follows that
examinations should be reserved for symptomatic patients, and
the exam should be tailored to the symptom.Thus, no two
examinations will be exactly alike.
Here's a
vague proclamation: the exam should be directed at any region
which may be causing or contributing to the problem.
One of the
shortcomings of the overworked, time-pressured physician is
that he may abbreviate the exam to a greater degree than is
prudent.To
illustrate this point, consider a patient that has come to
her doctor with pain in the left ear.The doctor's examination may be limited
to the patient's ear, and she may feel that she had a
perfectly adequate exam ("he did look in my ear, after
all.")Most
people are not aware of the fact that many non-ear
problems can cause ear pain: inflammation in the TMJ (the jaw joint),
a bad tooth, a throat infection, an inflamed thyroid gland,
even a cancer (anywhere from the roof of the throat to the
upper part of the esophagus!)
Thus, if
this woman's doctor looked in her ear, failed to see any
problems, and blithely diagnosed and treated her for an ear
infection, he would be doing her a disservice.How can a doctor make
such an error?Partly,
such an error may be due to time-pressure.The usual thought
process behind this error goes something like this: "Common things
are common; a low-grade ear infection is probably one of the
more common things that could be causing my patient's ear
pain; if I am wrong, these antibiotics won't do her much good
anyway, so she'll come back still in pain, and we can rethink
the situation if that happens."
But there
is an even scarier possible explanation for the error of
performing an incomplete exam.The doctor may have an overly narrow
understanding of the possible causes of ear pain.If the only things
capable of causing ear pain were a foreign object in the ear
canal or an ear infection, then looking in the ear would,
indeed, constitute a complete examination.Such a doctor does
not know that there are many possible diagnoses that could
expain his patient's ear pain; in other words, his
differential diagnosis for ear pain is much too limited.Differential
diagnosis is a central concept in medicine; I frequently tell
medical students that it is the single most important thing
that they can take away from their schooling.Differential
diagnosis is discussed further in the next section.
What are
the limitations of a physical examination?Now we are assuming
that the physician DOES look, and we are asking, what can
prevent an accurate assessment?
There may be nothing to see.
There may be something to see, but it is not
apparent to the naked eye.
There may be something to see, but the physician
cannot make sense of what he sees.
(An
examination, of course, involves the senses of touch and
hearing, even the sense of smell; I have used the word
"see" here as a simplification of what really takes
place during an examination.)
There is no
remedy for the first problem.For the second problem, a good physician
will know when to "up the ante" by performing a
more rigorous examination.This may be as simple as looking a second time, or
asking another doctor to take a look.Very frequently, there are ways of
improving sensitivity by employing a bit of technology.
Let's say
my patient is hoarse.At the very least, I will try to look at his vocal
cords using a small mirror placing at the back of his throat.In some cases, this
tells me everything I need to know, but often, I will find
that I would like a better look.In that case, I can use either a rigid
or flexible fiberoptic scope to view the larynx.If I am still
suspicious, I can proceed in a number of ways.There is an
examination (known as videostroboscopy) which, with
the aid of a stroboscopic light source, allows me to see the
vocal cords move in an artificial sort of slow motion.I can also take the
patient to the operating room, place him under general
anesthesia, and look directly at his vocal cords using a
hollow metal tube known as a laryngoscope.I can also position
an operating microscope in line with the laryngoscope to give
me a magnified view of the larynx.These examinations give me different
sorts of information, and I may decide to perform several of
them (or all of them).My decision is based partly on my suspicions, and
partly on my patient's desire to have "an answer."This process is
discussed in more detail in How physicians use
tests.
The third
problem is the nasty one.I know that I, personally, can hear only the
grossest of heart murmurs, and I suspect that few
cardiologists can appreciate all of the subtleties of an ear
exam.To quote
Dirty Harry, a man's gotta know his limitations.
I am making
an argument here in favor of the medical specialist.I do not deny that
this is self-serving, since I am a specialist, but
nevertheless I feel strongly that without intelligent eyes,
ears and hands, the best examination is still flawed.
Under many
health care systems, primary care providers are under a great
deal of pressure not to refer their patients to specialists.The pressure may be
indirect (they may fear that if they over-refer, they will
lose their contract with the HMO), or direct (under a
capitation system, the specialist's fees comes out of the
primary care provider's pocket).
{There will be more text than what is given
below. Basic gist: there are good motivations as well as bad
motivations for obtaining tests (or not
obtaining tests). As an intelligent medical consumer, the
reader should (1) know what tests may be helpful for his/her
particular problem, and (2) question his/her doctor as to the
motivations behind obtaining a test or not obtaining a test.}
If my suspicion is low that his
hoarseness is due to a small cancer which I am unable to
detect by the naked eye, and if he is willing to accept this
and adopt a "wait and see" position, then that is
what we will do.If
my suspicion is high, or if the patient is preoccupied with
the problem and wants a higher degree of reassurance, then we
will proceed to the next level of examination.The only problem that
arises in this ideal scenario is the situation where the
patient and I cannot agree on the appropriate plan.
{Very similar to "How physicians use
tests." The basic idea is that an intelligent medical
consumer should be able to know what the treatment options
are and be able to question his/her doctor about these
options. Readers need to know that there often is not a
single correct treatment option; more often than not, there
are truly two or more options whose risks and benefits must
be weighed by the patient. In my opinion, a doctor should
help his patients make a decision by educating his patients
about the options, but should neither make the decision for
his patients nor unfairly bias the conversation towards one
option.}
{I do not intend to give an intro to outcomes
assessment. I want to discuss the possibility that a patient
and his/her doctor may have VERY different ideas regarding
what is a desirable outcome. This is one of the primary
reasons why it is improper for a doctor to make treatment
decisions for his patients. Desired quality of life and level
of tolerance for risk are two factors that vary considerably
from patient to patient. In order to make an intelligent
choice between treatment options, a patient must be given the
basic information on expected outcomes and possible risks;
the patient must then do a bit of soul-searching to arrive at
what is, for him, the correct decision. ...Obviously, this
discussion is overkill if the clinical problem is a stuffy
nose due to allergic rhinitis, but it is really the key point
if the patient has a laryngeal cancer.}
Dealing
with the problem doctor
{Some general advice on dealing with the
problem doctor; articles and discussion forum will be covered
by Fresh Air.}
Copyright (c) 1998
Douglas Hoffman, all rights reserved. Reproduction in whole or part without
permission is prohibited.