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Talking with your Doctor – If you are hospitalized

This is a continuing series using information from the booklet written by the National Institute on Aging working with the National Institutes of Health called: Talking with Your Doctor. (U.S. Department of Health and Human Services, NIH Publication No. 05-3452 August 2005 (Reprinted April 2010)

This is a continuing series using information from the booklet written by the National Institute on Aging working with the National Institutes of Health called: Talking with Your Doctor. (U.S. Department of Health and Human Services, NIH Publication No. 05-3452 August 2005 (Reprinted April 2010)

The pamphlet does not mention this but I believe one of the more important things you will need to do is notify the person who is your agent on your medical power of attorney, commonly known as an Advanced Health Care Directive (AHCD) or the person who is going to act as your advocate. It does not matter whether or not your visit to the hospital is a routine surgery, you need to make sure your agent knows the details. The will need to know the questions to ask in the event that you are not able to ask. They will need to know the name of your primary physician (PrP) and you need to let your PrP know your advocate may be contacting him/her in the case of emergency. While your PrP may not have any authority at the hospital he/she may have vital information that will help the hospital doctor in assessing and prescribing treatment for you.

The pamphlet suggests that hospitals have routines and you may be able to make requests of service within those routines. For non-emergency visits there is generally a preparation period. During that time you can ask some of your questions. If you ask for the normal times your doctor is likely to visit you can prepare to have some of the more difficult questions ready when he/she visits. During emergency visits your advocate will need to ask the questions for you if you are not alert. At a minimum  and if possible, they should at least be present when the doctor explains what they are going to do and the reasons for their procedures.

Questions for non-emergency visits

• How long can I expect to be in the hospital?
• When will I see my doctor?
• What doctors and health professionals will I see?
• What is the daily routine in this part of the hospital?

Questions for emergency visits

• Will you talk to my primary doctor about my care?
• Do I need to arrange any further care? (it has been my experience that the discharge nurse or social worker will let you know)
• May I get instructions for further care in writing? (I have found that the hospitals I have worked with all provide written instructions when they discharge you. The issues I have seen is that the patient is not usually alert enough or too distracted to ask questions at this time. This is the time for your advocate to ask. If they were not present when the doctor or staff came through then have them call the discharge nurse or social worker to ask the questions)
• Is there someone here who speaks my language and can explain the instructions? (I am assuming here that the person reading this is advocating on behalf of a patient who doe not understand English. Hospitals are required to provide a translator or at least have the instructions written in the language of the patient. This is another good reason to have an advocate)

Second Opinions

This is directly from the pamphlet:

“When surgery is recommended, patients often seek a second opinion. Hearing the views of two different doctors can help you decide what’s best for you. In fact, your insurance plan may require it. Doctors are used to this practice, and most will not be insulted by your request for a second opinion. Your doctor may even be able to suggest other doctors who can review your case.

Always remember to check with your insurance provider in advance to find out whether a second opinion is covered under your policy, if there are restrictions to which doctors you can see, and if you need a referral form from your primary doctor.”

Next time: Practical Things

Did you know?

• Physicians, on average, interrupt patients within the first 23 seconds of their opening comments.[i]

Interruption is a pervasive communication style with doctors.  In a well-known study by Beckman and Frankel patients were allowed to complete their opening statement expressing their agenda in its entirety in only 23% of physician interviews.  The average time to interruption was 18 seconds.  This study’s findings have been replicated by several others.  In a more recent study of primary care residents, patients were allowed to speak for only 12 seconds on average before they were interrupted.  Female patients experience interruption more frequently than males. In contrast, studies have suggested higher rates of patient satisfaction with physician visits during which patients and doctors interrupt at similar frequency and also with visits in which there is more “reflective” silent time during the conversation.  Perhaps the tendency to interrupt extends to all physician derived professional communications, as in my case with the neurosurgeon on the phone.

Why do physicians interrupt?  In practical terms, throughout the course of a given day a physician may be tasked with listening to twenty to thirty patient derived histories and with solving difficult problems for each of these patients in a matter of ten to fifteen minutes. This is a tough, if not impossible job.  Consequently, once a physician believes that the meat of the story is out there, he or she may respond and interrupt before hearing details that the patient (or colleague) feels are important.  In more abstract terms interruption is a communication strategy that reinforces physician dominance in the hierarchy of the patient-physician relationship.

http://thehealthcareblog.com/blog/2012/06/12/why-doctors-interrupt/

It is interesting to note that there are a plethora of sites dedicated to how do doctors talk to patients. The following link is to the final session of a seminar given at the Mayo clinic. This is a woman talking to doctors about how to talk to patients. I thought you would like to know that if communication in marriage is hard, it is equally as hard in the medical field.

http://mindthegap.smarthealthmessaging.com/2014/03/13/the-power-of-conversations-between-physicians-and-patients/

• Physicians do not ask patients if they have any questions in more than 50 percent of outpatient visits.[ii]

• Physicians typically spend less than one minute of a typical visit discussing new prescriptions.[iii]

• Patients are afraid to ask their doctor questions for fear of appearing to challenge them.[iv]

Next time: If you are hospitalized

[i] Marvel MK, Epstein RM, Flowers K, Beckman HB. (1999 Jan 20). “Soliciting the patient’s agenda: have we improved?” JAMA, 81(3): 283-7.

[ii] Naik AD, Kallen MA, Walder A, Street RL Jr. (2008 March 18). “Improving hypertension control in diabetes mellitus: the effects of collaborative and proactive health communication.” Circulation, 117(11): 1361-8.

[iii] Tarn DM, Paterniti DA, Kravitz RL, Heritage J, Liu H, Kim S, Wenger NS. (August 2008). “How Much Time Does It Take to Prescribe a New Medication? Patient Education Counseling. 72(2): 311-319.

[iv] Frosch DL, June SG, Rendle KA, Tietbohl C, Elwyn G. (June 2012). “Authoritarian Physicians and Patients Fear of Being Labeled “Difficult” Among Key Obstacles to Shared Decision making.” Health Affairs, 31(5): 1030-38.

This is a continuing series using information from the booklet written by the National Institute on Aging working with the National Institutes of Health called: Talking with Your Doctor. (U.S. Department of Health and Human Services, NIH Publication No. 05-3452 August 2005 (Reprinted April 2010)

There may come a time when your needs take you beyond your doctor’s abilities and he or she refers you to a specialist. According to the booklet, you may even request one yourself but you will need to check with your insurance plan for any requirements regarding referrals from your primary doctor. When you finally visit the specialist you should prepare to ask questions in the same way you would with your doctor.

The specialist should have already seen your medical records or test reports. While the booklet doesn’t say this I think a good specialist will ask questions first before discussing the diagnosis. I say this because there may be things the generalist misses or you may not have thought to disclose. I find it is also a safety feature so that they are diagnosing the patient they think they are meeting. Have you noticed that even in a regular appointment that each new nurse will ask the same questions that last one did and then the doctor usually asks them again? At least it seems to work that way in the big organizations. The small offices may not operate that way but when going to the specialist, one whom you have not visited before, they should be asking questions of you before any discussion of diagnosis.

When they start describing their diagnosis they will probably use terms that you are unfamiliar with. Ask them about the terms. Don’t be hesitant to say, “I don’t know much about that. What does that mean?” If you are still wondering, ask for materials or referrals to other sources for research. The booklet recommends that you have the specialist send material to your doctor. That allows him/her to be part of the discussion and keep track of your medical care.
Here are some questions you might ask your specialist:

• What is your diagnosis?
• What treatment do you recommend? How soon do I need to begin the new treatment?
• Will you discuss my care with my primary doctor?

Next: Things You May Experience When Talking with Your Doctor

This is a continuing series using information from the booklet written by the National Institute on Aging working with the National Institutes of Health called: Talking with Your Doctor. (U.S. Department of Health and Human Services, NIH Publication No. 05-3452 August 2005 (Reprinted April 2010)

Do you search for information on the internet? It is a great resource but here are some questions to ask because not all information is reliable. The following questions may be useful to consider when you look at a health-related website.

• Who is responsible for the content? Is it a government agency, national nonprofit organization, or professional association? An individual? A commercial organization?
• If you are reading a particular article, what are the author’s credentials? Is the author affiliated with any major medical institutions?
• Who reviews the material? Is there a medical advisory board that reads the medical content before it is made available to the public?
• Are sources cited for the statistical information? For example, it’s easy enough to say “4 out of 5 doctors agree…” but where did that statistic come from?
• Is the purpose and goal of the sponsoring organization clearly stated?
• Is there a way to contact the sponsor for more information or to verify information presented?
• Is the site supported by public funds or donations? If it includes advertisements, are they separate from content?
• Because health information gets outdated so quickly, does the website post the source and date for the information?
• If you have to register, is it clear how your personal information will be used? Does the site have a clear privacy policy?
• Is the website trying to sell you something? Don’t forget to talk with your doctor about what you’ve learned online.

That last suggestion is very important…don’t forget to talk with your doctor about what you have learned!

Next article: Talking to Your Doctor in Special Situations

This is a continuing series using information from the booklet written by the National Institute on Aging working with the National Institutes of Health called: Talking with Your Doctor. (U.S. Department of Health and Human Services, NIH Publication No. 05-3452 August 2005 (Reprinted April 2010)

In a sidebar on page 20 is this encouragement:

“Exercise is often “just what the doctor ordered!” Exercise can:

• Help you have more energy to do the things you want to do.
• Help maintain and improve your physical strength and fitness.
• Help improve mood and relieve depression.
• Help manage and prevent diseases like heart disease, diabetes, some types of cancer, osteoporosis, and disabilities as people grow older.
• Help improve your balance.

Many doctors now recommend that older people try to make physical activity a part of everyday life. When you are making your list of things to talk about with your doctor, Ask how exercise would benefit you, if there are any activities you should avoid, and whether your doctor can recommend any specific kinds of exercise.”

According to the National Institute on Aging they list all the above items with the incentive that exercise also helps you remain independent or less dependent on others. They go into more detail such as:

Four types of Activities – 1) those the build endurance, 2) build strength, 3) maintain balance and 4) maintain or build flexibility.

You may want to visit their website: http://www.nia.nih.gov/health/publication/exercise-and-physical-activity

Next article: Evaluating Health Information on the Internet.

This is a continuing series using information from the booklet written by the National Institute on Aging working with the National Institutes of Health called: Talking with Your Doctor. (U.S. Department of Health and Human Services, NIH Publication No. 05-3452 August 2005 (Reprinted April 2010)

Once you have established good communication, the kind that involves not only getting information but also giving it, you will need to work with your doctor on a plan of action.

Keeping in mind the two way communication…

Ask about different treatments.

Whether it is medication or surgery you will need to ask questions. Let’s say that your doctor is prescribing medication for diabetes. Ask, “What are the pro and cons of the medication?” “Do I have any other choices besides this or any medication?” The same questions are good for the surgery. Most doctors will probably be discussing this with you anyway but in the event they don’t you need to ask. If you are uncomfortable with the treatment prescribed then practicing good communication, you need to let your doctor know that.

Here is a summary of ideas to help with your discussion:

Ask about different treatments:

• Are there any risks associated with the treatment?
• How soon should treatment start?
• How long will it last?
• Are there other treatments available?
• How much will the treatment cost?
• Will my insurance cover it?

Ask about prevention:

• Is there any way to prevent a condition that runs in my family—before it affects me?
• Are there ways to keep my condition from getting worse?
• How will making a change in my habits help me?
• Are there any risks in making this change?
• Are there support groups or community services that might help me?

Next article: Speaking of Exercise

This is a continuing series using information from the booklet written by the National Institute on Aging working with the National Institutes of Health called: Talking With Your Doctor. (U.S. Department of Health and Human Services, NIH Publication No. 05-3452 August 2005 (Reprinted April 2010)

Asking Questions About Your Medications

Doctors will usually prescribe medication for a symptom. This section will help guide you through some of the items you need to think and ask about. This section in the booklet does not discuss the world of alternative medicine and only hints of it a little later. The point though is that no matter where you go the person, whether a doctor or personal care manager, must know the information you have and you must ask them questions. Open and honest communication is a must. So…

The first thing is to understand why the medication is being prescribed. The doctor usually will write down the name of the medication, instructions and anything of note that he/she thinks you need to know about the prescription. Here is a list of suggested questions:

• What are the common side effects? Did you know that sometimes medications affect older people differently than younger people? If the medication doesn’t seem to be working tell your doctor but the booklet recommends that you ask your doctor first before you stop taking it.
• What should I pay attention to?
• When will the medicine begin to work?
• What should I do if I miss a dose?
• Should I take it at meals or between meals?
• Do I need to drink a whole glass of water with it?
• Are there foods, drugs, or activities I should avoid while taking this medicine?
• Will I need a refill? How do I arrange that?

I emphasize and so does the booklet on page 16 that it is important to include your pharmacist in the discussion. They are trained specifically in the art and science of medications. They generally have a greater understanding of the side effects and drug interactions and, if you use the same store each time you order, they have your records there and you can ask them for an interaction or side effect analysis each time a new prescription is issued. The booklet also emphasizes, as I did in the previous article, that if you use another doctor (such as a specialist) make sure that your doctor knows what they prescribed (and check in with your pharmacist as well).

You should have a handy list of all your medications. The list should include:

• The name of the drug
• What it is for
• Color/shape
• Date started
• Doctor prescribing it
• Dosage
• Instructions

Here are some common abbreviations doctors use when prescribing medications (just for fun, I’ve included what I think are the Latin phrases associated with the translation):

p.r.n. (Pro Re Nata) as needed

a.c. (Ante Cibum) – before meals

q.d. (Quaque Die) – every day

p.c. (Post Cibum) – after meals

b.i.d. (Bis in Die) twice a day

h.s. (Hora Somni) – at bedtime

t.i.d. (Ter in Die) – three times a day

p.o. (Per Os) – by mouth

q.i.d. (Quattuor in Die) – four times a day

ea. Each

The booklet includes a chart for keeping track of your medications. I know this is especially handy if you have several prescriptions.

Next: How Can I Be Involved: Making Decisions With Your Doctor

This is a continuing series using information from the booklet written by the National Institute on Aging working with the National Institutes of Health called: Talking With Your Doctor. (U.S. Department of Health and Human Services, NIH Publication No. 05-3452 August 2005 (Reprinted April 2010)

What Can I Ask? Getting Information

A good detective asks questions. Most doctors don’t volunteer a lot of information. They may run a quick exam on you and then ask you to go have your blood drawn or they may want you to have an x-ray taken. It is not out of line to ask for the reason(s), what is his/her concerns. As you may already know, some of these tests are just part of the routine and really don’t raise a concern but if you brought a symptom to your doctor is it best to ask what he/she is looking for or hoping to uncover with the test. Here are some questions the booklet suggests asking:

• Why is the test being done?
• What steps does the test involve?
• How should I get ready?
• Are there any dangers or side effects?
• How will I find out the results?
• How long will it take to get the results?
• What will we know after the test? 

Of course, when the results are ready, make sure the doctor tells you what they are and explains what they mean. By the way, the booklet also recommends that you ask your doctor for the definitions of any terms that are unclear or unfamiliar to you like aneurysm, hypertension, infarct or for any directions that aren’t clear like taking medication with food; is that during or after a meal, or does that matter?

If you are referred to a specialist it is easy to assume that they will send the results to your primary doctor but that is not always the case so ask that the result be sent.

If the test(s) show results that are not favorable then discuss the diagnosis with your doctor. A diagnosis identifies your disease or physical problem. The booklet states that if you understand your medical condition, you can help make better decisions about treatment. If you know what to expect, it may be easier for you to deal with the condition. The following are some questions the booklet lists that you may want to ask:

• Ask the doctor to tell you the name of the condition and why he or she thinks you have it.
• What may have caused this condition?
• Will it be permanent?
• How is this condition treated or managed?
• What will be the long-term effects on my life?
• How can I learn more about my condition?

Next: Asking Questions – Medications

This is a continuing series using information from the booklet written by the National Institute on Aging working with the National Institutes of Health called: Talking With Your Doctor. (U.S. Department of Health and Human Services, NIH Publication No. 05-3452 August 2005 (Reprinted April 2010)

What Can I Say – Giving Information

This section gives ideas on what to talk about. I have found that few people are eager to share what is going on with their bodies for fear that something may be devastatingly wrong inside but many times early discovery of a disease will save the person or at least help prepare for the inevitable.

It is important that you tell your doctor about your symptom(s). The booklet describes a symptom as “evidence of a disease or disorder in the body. Examples of symptoms include pain, fever, a lump or bump, unexplained weight loss or gain, or having a hard time sleeping.” While a doctor may perform exams and/or tests, it is your input that helps direct the doctor where to look.

Before you start telling him/her your symptoms it is best to clarify what they are. The easy part is identifying them but when do that happen. Are they constant? If not, when do you experience them (frequency and duration)? When did they start? What are you doing or what have you done recently that may aggravate or ease the symptoms? Do they affect your daily activities? Which ones? How?

The booklet makes the following recommendation:

Take the time to make some notes about your symptoms before you call or visit the doctor. Worrying about your symptoms is not a sign of weakness. Being honest about what you are experiencing doesn’t mean that you are complaining. The doctor needs to know how you feel.

It also states that it is very important to give information about your medications (especially if you are being seen by more than one doctor – example, did you go to the hospital recently and did that attending physician prescribe medication? If he/she did, your doctor would not know about it!) The booklet goes on to state:

It is possible for medicines to interact causing unpleasant and sometimes dangerous side effects. Your doctor needs to know about ALL of the medicines you take, including over-the-counter (nonprescription) drugs and herbal remedies or supplements, so bring everything with you to your visit—don’t forget about eye drops, vitamins, and laxatives. Tell the doctor how often you take each. Describe any drug allergies or reactions you have had. Say which medications work best for you. Be sure your doctor has the phone number of the pharmacy you use.

As you talk with your doctor you must be honest and let him/her determine what may or may not be important. Have your interests changed? For example, you used to be quite active but now you are tired all the time and so you no longer exercise. You may think that being tired is no big deal but your doctor can run a test that may determine if there is a chemical imbalance that is causing this. Did you know that changes like a loss of a loved one (including pets) is a big stress factor and it affects how you function? It has been shown that if there are several of these life changes in a short period of time that it can be debilitating. Your doctor should know things like if you have moved and why you moved. Did somebody move in with you or are you now living with somebody? Did you sell a home, have family move away (or nearby), drivers getting crazier and you are having more near misses?

Look at this time with your doctor as being a detective partner. Instead of solving a crime you are solving the cause of your discomfort.

Next time: What Can I Ask?

In the following weeks I’ll be referring almost exclusively to a booklet written by the National Institute on Aging working with the National Institutes of Health called: Talking With Your Doctor. (U.S. Department of Health and Human Services, NIH Publication No. 05-3452 August 2005 (Reprinted April 2010)

Getting Ready for the Appointment

The hope with this section is that the better prepared you are the better results you will get. A list is important as we tend to forget what it was that we wanted to discuss or compare or…well, you get the idea. Here are some examples the booklet suggests:

[D]o you have a new symptom you want to ask the doctor about? Do you want to get a flu shot? Are you concerned about how a treatment is affecting your daily life?

I thought about other items:

Did you check for interactions between medications? How do I stop smoking? Lose weight? I’m having bladder issues, what do I do?

Of course, you have to remember to bring the list with you! Oh, and take your glasses and hearing aid with you. This is NOT a time for vanity!

The booklet continues:

Consider bringing a family member or friend —

Sometimes it is helpful to bring a family member or close friend with you. Let your family member or friend know in advance what you want from your visit. Your companion can remind you what you planned to discuss with the doctor if you forget, she or he can take notes for you, and can help you remember what the doctor said. If you need an interpreter you can and should bring one.

Next week: What Can I Say – Giving Information