点击显示 收起
Without doubt, communication is crucial to good health care. When people take an active role in their care, research shows they fare better -- in satisfaction and in how well treatments work. A passive patient is less likely to get well.
Yet patients often don't speak up for themselves, says Dr. Paul Haidet, staff physician at the DeBakey VA Medical Center, in Houston.
Haidet learned this lesson first hand with a new patient complaining of a cough. A 50-year-old Boston dockworker with no serious illness in his past, the patient said the cough had been hanging on for three weeks. Haidet noted the details, performed a physical exam, and diagnosed an upper respiratory tract infection.
"The guy had a cold," Haidet tells WebMD. He recommended cough syrup and was about to leave, but something gave him pause. The patient "just had this weird look on his face," Haidet recalls.
Haidet learned that the man's best friend had recently died of lung cancerlung cancer and when his friend was diagnosed, he had a very similar cough. As a longtime pack-a-day smoker, the patient was afraid his number was finally up.
The Ideal Doctor-Patient Relationship
Chest X-rays eventually showed the patient had no tumors, but Haidet was astonished by the difference between what he thought the visit was about and what the real reason was. He had assumed the man wanted him to treat his cold, but he really wanted to be assured that he didn't have lung cancercancer.
Haidet, who now runs part of a program at Baylor College of Medicine that helps people communicate with their doctors, feels sure that the patient "would have kept going to doctors until somebody unlocked that story and addressed the real issue for that visit."
The ideal doctor-patient relationship, says Haidet, is like a meeting of two "experts." The doctor comes to the meeting with medical expertise. "The patient is entering with contextual knowledge, what these symptoms mean in the broader context of my life, and what kinds of therapies that broader context is going to support," he says.
So, how do you manage an "expert" meeting of the minds with your doctor?
The ABCs: How to Talk to Your Doctor
The Baylor program hosts "How to Talk to Your Doctor" workshops in the Houston area. The workshops are intended for those who need advice the most, such as seniors -- who tend to be passive in the doctor-patient relationship -- people who speak little English, and cancercancer patients.
"We've tried to boil it down to a simple mnemonic: ABC," Haidet says.
A: Ask Questions
Jessie Gruman, PhD, has more experience talking to doctors than most would ever want, having been treated for three different cancers at various times in her life.
Gruman founded the Center for the Advancement of Health, a nonprofit policy institute in Washington, D.C., and serves as its president. Her experience has taught her to ask, "What does that mean?" when something a doctor says goes over her head. "If I didn't say that, they'd just assume that I knew," she tells WebMD.
"The onus is on the patient to indicate when they don't understand something," she says.
Ideally, doctors should always communicate at a level that matches a patient's knowledge, but that's not a realistic expectation. Gruman doesn't fault doctors for occasional and unintentional lapses in communication.
"They're under incredible time pressure and they know a lot," she says. "If you don't understand, they will stop and explain it to you."
Gruman also asks doctors to consider hypotheses she has formed about her health based on her own observations. "It allows my doctors to say either, 'I hadn't really thought of it that way, maybe that's true,' or it allows them to say, 'that bone isn't connected to that bone, so probably not.'"
B: Be Prepared
The average patient has three issues he or she wants to address during a visit with a doctor. Because time with the doctor is limited, it helps to make a list of the most important issues to cover and take it with you.
"If you have something that's really scaring you, it's best to get that on the table early on," Haidet says.
Avoid "doorknob complaints." Those are things you suddenly remember, or pluck up the courage to mention as you're walking out the door: "Oh, and by the way, I'm having chest pain." At that point the doctor can't do anything but tell you to make another appointment, or to go to the emergency room, as the case may be.
C: Communicate Concerns and Desires
Communication means asserting yourself if you have a problem with the care you're getting, or if there's an issue you want your doctor to consider.
Your out-of-pocket costs, for example, may be a concern. Nearly 46 million Americans lack health insurance, and even those who are insured end up paying about one-third of what they spend on health care out-of-pocket. Nevertheless, many are shy about bringing up financial concerns with a doctor.
"There are many barriers that prevent patients from raising concerns," says G. Caleb Alexander, MD, an assistant professor of medicine at the University of Chicago. Some are embarrassed, he says, while others don't bring it up because they think there's nothing doctors can do, or that they don't have enough time to talk about it. What's more, some people fear they will get substandard care if they mention money is an object.
"The fact of the matter is that in almost all cases physicians have good options available to assist patients who are burdened by their out-of-pocket costs," Alexander says.
For example: the doctor may know about financial assistance programs or other resources to help you pay your bill. Or the doctor may be able to help by discounting the fee for the office visit, or by sending you home with free prescription drug samples. You might also find out that a less expensive treatment option could potentially work just as well as a newer and pricier option.
How to Pick Your Health Care Team
An actively involved patient knows what he or she expects from a doctor. Everyone should expect to be taken seriously and treated with respect, Gruman says. Accept nothing less.
Beyond that, people's expectations vary greatly. The kind of relationship you want to have with a doctor may depend not only on your personal preferences, but also the reason why you need medical care.
"If you're just trying out a new primary care doctor, that's a very different kind of relationship-building experience than if you were just referred to an oncologist because you have a very bad case of pancreatic cancerpancreatic cancer," Gruman says.
In the first instance, there's plenty of time to evaluate the relationship. In the other, things have to click immediately.
How many doctors are involved in your care is another worthy consideration. Seeing too many doctors can sometimes cause unnecessary hassle and costs for patients, and can contribute to errors.
"I think patients benefit from having one main doctor," Alexander says.
Your primary doctor should orchestrate your care -- or at least be kept in the loop about care you get from specialists. There are always exceptions, but as a general rule, it's best not to crowd your health care roster with specialists. Not all arthritisarthritis pain needs to be treated by a rheumatologist, for example.
Specialists can play an invaluable role in diagnosing a condition and deciding the best course of treatment, but eventually they may be no longer needed. At some point, a primary-care doctor may be able to take over. "Don't be afraid to terminate a relationship with a specialist if they're no longer really important," Alexander says.
Can You Stand Up to Your MD?
The things that will make you an active advocate for your health care are simple, but not easy for everyone to do. The doctor's role as an authority figure is still deeply ingrained in the culture.
Do you follow doctor's orders, or do you participate in shared medical decision-making? The latter sounds better, but when you are in the room, with the paper on the exam table crinkling under your bare bottom, you may not feel so empowered.
"What we're doing is fundamentally challenging a lot of patients' basic notions of what the doctor's and the patient's roles are," Haidet says. "That's a huge bar for patients to leap over."
Published July 14, 2006.
SOURCES: Paul Haidet, MD, staff physician, Michael E. DeBakey Veterans Affairs Medical Center, assistant professor, Baylor College of Medicine, Houston. Jessie Gruman, PhD, president, Center for the Advancement of Health, Washington, D.C. G. Caleb Alexander, MD, assistant professor, University of Chicago, Pritzker School of Medicine. JAMA, January 1999, August 2003. Archives of Internal Medicine, May 2003. Patient Education and Counseling, January 2004. U.S. Census Bureau. Kaiser Family Foundation.