I do not get it. Day in and day out, I ask patients why they take a medicine. Many do not know. “My doctor put me on it,” goes the common response.
Take statin drugs, for example. I often ask a person why they are taking the drug? With rare exception, the person says it is to lower cholesterol.
That’s not the right answer–and herein lies much of the problem with preventative medicine. A statin drug does indeed lower cholesterol but its main purpose is to reduce the risk of heart attack, stroke or death in the future. Cholesterol is just a number. It’s a surrogate that we can measure but it’s surely not the only way statins provide benefit. (There are many drugs that lower cholesterol but do not decrease the risk of heart attacks or death.)
The point here is that almost no patient I have met can quantify the benefit or harm of these common meds. I’ve written before that statin benefit in patients without heart disease is very small and may be countered by its small-but-real adverse effects.
Antibiotics are another example. The human body has an immune system for a reason. We fear infections but we don’t seem to fear antibiotics. Now, most hospitals in the US are struggling with problems related to antibiotic overuse.
A patient gets a seemingly harmless prescription for azithromycin (Z-Pak) for a case of viral bronchitis and weeks later nearly dies of Clostridium Difficile. Did that person know the benefits or harms or alternatives? I doubt it.
You can apply these lessons to almost any therapy used in modern medicine today.
It is in this context that I wrote my latest piece for WebMD. 4 Questions to Ask Your Doctor
16 replies on “Why don’t people ask their doctors more questions?”
Mostly we don’t ask because of guilt. It is our fault, we did something or we didn’t do something that brought us into an office to see the doctor. To many our personal health is a weak point; we reap the rewards of our actions. We seek an easy answer so we don’t have to face the truth that we have failed. A pill seems like an easy answer to our struggles and so we take it with eagerness in hopes that it will fix what ails us. We all know that the more pills we take the closer to the black hole that will consume our life in old age and declining health we go. But just this once, please give the magic bullet pill that will really make things better. We don’t ask because the answers are tough to face.
If you’d like to have real fun , ask the parent why they don’t vaccine their children !
Btw — I saw ‘old’ card simply ask the patient why they thought he was Rx’ing a certain med . Opened up an educational opportunity — and, good memory link !
This is an easy one… Medicine is complex. Most patients believe “The Doctor Knows Best”.
Thanks for writing about an important issue for patients and doctors.
I’m a bit surprised by your first sentence which says “I do not get it,” since you have in previous posts written about some of the reasons that patients don’t understand their treatments.
Here are a few reasons that come to mind.
1. Brief appointments. Patients see a doctor for a very brief appointment, and may not feel that they have enough time to ask questions, since they donâ€™t want to waste valuable time that (in their minds) might be better spent having the doctor poke, prod, test, and talk. Often an appointment is 15 minutes or less in length, and usually the patient sees the doctor for only a fraction of this time.
2. The unequal power relationship between doctor and patient, i.e., patients may be intimidated by doctors. Unequal power relationships happen in a lot of contexts, not only between patient and doctor. But imagine the patientâ€™s experience at an appointment. She starts by talking to a receptionist. Then comes a medical assistant who takes BP and temperature. Then possibly comes an RN, who asks questions about what brings the patient to the office. Then the door is closed, the patient waits for 10 minutes or so, and finally in strides the doctor. One message a patient may get from all of this:
â€œIâ€™ve climbed the ladder from a receptionist to a medical assistant to an RN and now Iâ€™m at the pinnacle, seeing the doctor. The doctor is at the top of the heap, and I need to treat him with respect, and be careful not to irritate him by asking stupid questions.â€
3. Patients are often seeing a doctor because they are worried and frightened by their symptoms. It is well known that our thinking and reasoning skills are not at their best when we are scared, and unfortunately weâ€™re often scared when we are seeing a doctor!
(A related phenomenon: Often a few minutes or a few days after an appointment, we as patients realize that we should have asked the doctor another question, or that weâ€™re uncertain about important aspects of our treatment. In many practices, weâ€™re out of luck. We can make another appointment, which might be weeks or months in the future. If weâ€™re lucky, our doctor (or more likely a nurse) will accept questions through an online system. But (again this speaks to #2 above) it is very unlikely that a patient could talk to the receptionist and have a chance to talk again to the doctor that afternoon.)
4. Doctors (like the rest of us) arenâ€™t very good at communicating risk clearly. Many studies (Kahneman and Tversky, Gigerenzer, etc.) have shown that people arenâ€™t really good at understanding and communicating risk. In my experience many doctors donâ€™t really understand things like relative risk, absolute risk, number needed to treat, and so on. And many have not thought about how to communicate risk and reward to scared, often quantitatively unsophisticated patients.
What might be done about all of this? I donâ€™t think there are easy solutions. But here are some ideas:
**Provide doctors with better training in understanding uncertainty and risk and in communicating uncertainty and risk to patients. (#4 above)
**Structure medical practices in a way that allows longer appointments, and allows patients the chance to get simple questions (which might arise a few minutes or a few days after an appointment) answered reasonably quickly. (#1 and #3 above) This would probably require doctors to accept lower salaries (or work longer hours), but my sense is that there are many doctors, like you, who would make this tradeoff if it resulted in better patient outcomes.
**Find ways to structure the patientâ€™s clinical experience which make it less intimidating. (#2 above) Here there are probably creative improvements that would not cost a lot, but that would require doctors (and others in medical offices) to change the way they work.
I hope this makes some sense 🙂
Not the patients fault. From the first visit we take our child to(well ob/gyn care that is a whole other nightmare) we are “assured” that the Dr. knows best. That those side effects listed on the medication “are rare, and the Dr. himself has never seen anyone react”… that while no one wants to take a medicine the Dr. has seen the necessity time and time again.. or you ask about the side effects from something like vaccines and are reassured “don’t worry about it, it never happens but we are required to hand out that sheet”… Or how about when you know you have a sinus infection but the Dr. reassures you he knows best and not to worry about it. A week later you are in the hospital with pneumonia and the Dr. says ” why didn’t you call me?” or ” no, it has nothing to do with the sinus infection you had”… Worse then that is that when questioned many Drs. shutdown no matter how nicely and respectfully you ask.. You wonder if the hamburgers, or formula or dairy is causing a symptom and you are promptly assured that no way does food play into any chronic illness. Or how about ” it is genetic, nothing you can do about it”.. so why bother changing your diet to see if helps? Somehow if you are too thin it is your fault you don’t feel well and need an anti depressant, or if you are 5 pds overweight that too is causing your MS and you need an anti depressant but no way the 10 medications prescribed are causing side effects of weight loss or weight gain.. Patients are taught again and again not to ask question and to just do what the Dr. says. If the Dr. says you are fine? You are fine no need for a second opinion. If a Dr. says you need medicines a) b) and c) ? it is for your own good because they know what they are doing. The message is ” It is your fault you are sick, if you are in my office it is because you are unable to get better so you know nothing, and I know everything- do as I say or get a new Dr.” And whatever you do, NEVER admit you looked up the side effects or joined a support group- they will double your script for anti depressants. Apparently, unless a local Dr. within their healthcare system says a medicine has a side effect it is impossible that the Drs. and chemists who researched and wrote the warnings are correct(even from the NIH , from their own association websites)
Pediatrics is worst. I would kill to be a fly on the wall and record the insanity that these poor parents are taught. We were told by one Pediatric Nephrologist that my daughters extreme proteinuria was due to constipation(which she had no history of, if anything the reverse) and that she would be fine I needed to quit worrying. Turns out she had Secondary FSGS. That was just 1 of many bad bad appts where we received bad advice and were discouraged from looking for answers.
With a child who has been chronically ill her whole life, believe me, we have seen it all.
Her medical care improved significantly when she no longer was forced to see pediatric specialists. Granted, there are plenty of adult specialists that insist on having meek and non-questioning or self aware patients but we do what we can to avoid them at all costs.
It’s been my observation that whenever a doctor says “Do exactly as I order or get another doctor”, he – it is generally a he – is giving potentially life-saving advice that should be taken as fast as possible.
Really? Our experiences have been different. We used to feel that way too. We used to trust and did not bother to talk to the pharmacist and then also google and then also read all the inserts that is until a Ped overdosed our daughter and luckily another Dr. caught the mistake before it killed her… Or the Specialist who recommended “pushing” our daughter because it was all in her head, we followed that advice too- turned out our daughter ended up with damaged kidneys from that great advice. Frankly, anytime we have been told their way or the highway, it has hurt us. Generally, if a Dr. says their way only, it means they disregard their patient and do not see it as a partnership to improve health. Never a good thing for any patient. Granted, our daughter has a difficult to diagnosis disorder(actually a few) but it sure feels like I have spent the last 19 years both trying to find a Specialist that can help and also make sure the specialists don’t hurt her.
Oh, sorry for the lack of sarcastic clarity! What I meant was that you should get up and run, walk, crawl or drag yourself out of his office and never go back! Because submitting to whatever he demands will at the best hurt and cost you, and may kill you.
First I need to let you know that I look forward to reading everything you write. I am not a medical professional and I agree with almost everything you have to say.
A little background about myself. I am 64 years old and have had a dual chamber pacemaker since August 2013 for a diagnosis of sick sinus syndrome and chronotopic incompetence. I had a carotid endarterectomy in September 2010 and a heart attack with stent placement in July 2000. I am also a runner, and, for the last three years, a triathlete (sprint only).
I am a co-founder of a nonprofit whose mission is:
H.E.A.R.T.’s mission is committed to the promotion of expanded and
improved knowledge, awareness, and practical understanding of heart
patients and their cardiovascular health; and improvement and
maximization of their athletic potential through encouragement,
experience, emotional support and education.
You have asked why patients donâ€™t ask more questions. You are generalizing based upon how you practice. I would like to present specifics about my experiences in asking questions. I will limit this to the past month.
I have a Biotronik PM with the home monitor. A quarterly download was done on March 23, as is done every 3 months. I waited a few days, called the device clinic, and questioned them about it. They told me everything was perfect, all the parameters were normal, and the only thing out of the ordinary was a short run of VT on March 18th. I requested a copy of the report, as I always do, and they told me they could only send me the first page. They also confirmed that they rarely have patients request this information.
I have had a continual rash concentrated in the area of the PM for about 6 weeks and went to an express clinic a couple weeks ago to have it checked. They prescribed an antibiotic gel and suggested I call my doctor if it wasnâ€™t improved in 2-3 days. I subsequently called and they sent me to the device clinic to have it looked at. Since I hadnâ€™t had an in person device download since June of last year, they scheduled that also.
During the device download the tech asked, â€œSo what exactly were you doing on March 18th at 5:19AM, probably sound asleep?â€ After she confirmed that it was a Wednesday, I told her I was probably doing pushups or planks. I also knew this was the date they had told me I had a short run of VT.
She then had me push my hands together at chest level, which duplicated whatever she was looking for. She was also training someone during the download, and had me continue pushing while she adjusted the sensitivity on the ventricular lead, explaining it (not to me) as it was done. She turned off the auto mode and slowly increased the sensitivity until at 4.5mV the â€œnew noiseâ€ stopped. She told me the VT run was actually â€œnoiseâ€ from muscle contraction. There was no other explanation, and I donâ€™t question because I donâ€™t have any idea what to ask.
Meanwhile, I still have not been checked for the rash that was the original reason for the appointment.
I was sent back to the waiting room and soon called back in to see the nurse practitioner. She had a discussion with the pacer tech about how I had been already scheduled for a yearly download in July and that I needed to come back for that.
This had been a Friday afternoon appointment so of course I went home and googled â€œnew lead wire noiseâ€. I called the device clinic back on Monday to question what I now saw as a possible lead problem. Someone, who didnâ€™t identify himself, told me, â€œwe adjusted the sensitivity and the oversensing is goneâ€.
Later that day I found the pacer report on my EHR. It includes impedance data. The impedance on the ventricular lead showed 487. I had the impedance on the implant date which was 681. I see a drop of over 28% and google â€œimpedance drop on pacer leadâ€. A study from Medtronic appears indicating that an impedance drop of 30% has a 90% probability of being lead failure. This, on top of the â€œnew noiseâ€, tells me I have a problem.
I called the device clinic and asked the nurse practitioner â€œIs the lead failingâ€? Her two word reply was â€œnot necessarilyâ€.
From the patient point of view, I have spent hours trying to learn about the situation and have had no information voluntarily provided to me. What I know of my own situation I have basically figured out myself. I have personally found that many cardiologists donâ€™t like being questioned.
Cardiologists can’t agree on when it is appropriate to take a statin, particularly for males in their 60s. You can ask and you will be referred to the â€œrisk calculatorâ€. The risk calculator at http://www.cvriskcalculator.com/ says that a 66 year old male with no risk factors, no symptoms, no “diagnosed” heart disease, BP of 110/70, cholesterol of 130 and HDLs of 57, should be on a medium to high intensity statin because the calculator indicates risk of 7.5%. Those are my numbers. Well, not actually. My cholesterol is 127. The calculator wonâ€™t let you input anything lower than 130. So Iâ€™m off the charts on the good side and my risk is still high enough for statins. If my HDLs were 60, I would drop below the risk requiring statins. 7.5% is just a number. Itâ€™s about the same as 7.4%. Then there is a definition of heart disease. Virtually all males my age have some plaque. So what level is considered CHD? 1% blockage? 10%? 50%? Iâ€™ve been told 50% and any plaque by different doctors. Same thing with CAC (Coronary Calcium). I was told 90% or more males at my age have some coronary calcium. Actually, you can Google it and see the numbers. And they are not even sure it is even a bad thing because the calcium stabilizes vulnerable soft plaques. So a non-zero score means you have some plaque. A zero score doesnâ€™t mean you have no plaque, just that there is less likelihood. Or maybe you have a lot of soft plaque, vulnerable to rupture. In my case, my CAC score is 17. Pretty low. So I asked why the statin. 10mg Pravastatin daily for my risk level. I challenged the script so the cardiologist changed my dosage to Monday, Wednesday, and Fridays only. I was going to ask why Friday and not Saturday instead, but I know he would have said then just take it on Saturday. On the same topic involving a different body part, I got a referral for a colonoscopy. I had 2 in the past. The last one, about 5 years ago, they found a few diminutive hyperplastic polyps in the rectum (near the end). I read that those type never turn cancerous and that without any indication such as symptoms, bleeding, or other testing, the risk of a colonoscopy outweighs the benefit. It gets more complicated. I have atrial fibrillation. I take Pradaxa. I didnâ€™t want to go off the Pradaxa and asked the gastroenterologist if I could have the procedure while on Pradaxa and if they found polyps, I would come back. He practically threw me out of the office. BTW, he hardly looked up at me during my visit as he was typing in the computer the whole time. While I know that anticoagulants like Pradaxa reduce stroke over long periods, there is a recent article about a significant increase in strokes during surgery with Coumadin users who go off for an operation. My thinking is that colonoscopies donâ€™t cure anything, so why assume risk… no polyps, but you had a stroke. So I go to another gastroenterologist and he says to come back in 5 years without me even saying anything. He told me that doctors that order colonoscopies for my type/size/location of polyps are milking the system, exposing patients to real risk, and driving up healthcare costs. Few people have my persistent and confident attitude. After all, everyone is different. I wouldnâ€™t expect them to. So maybe it isnâ€™t the patients that need the lesson in communication.
In my experience, there’s been no time to ask questions; every doc I’ve seen walks in, murmurs something, types into their computer/reaches for an rx pad/educational pamphlet, and heads for the door with hardly any conversation.
The few times Inwas actually able to have a conversation with a doc, they were snarky and not very helpful. I think our badly-broken health care system has a lot to do with it. Patients need to embolden themselves to say “I’d really like to discuss this with you” and prepare for some eye-rolling and blow-back, and docs need to understand that patients are no longer satisfied with the standard 10-minute office call for more complex complaints.
The only folks who get good care and interaction for the most part are the wealthy, who are the only ones who can afford cushier “concierge doctors”
The entire system needs an overhaul. Only then will patients and docs be able to truly communicate and to ask questions of one another.
I’ve often wondered why physicians feel the need to ‘tell’ their patients everything. A common sense half page of written instructions (bonus for hand drawn illustrations) would be wonderful for patients and would keep the doctors from repeating the same information over and over again.
I’ll never forget the pediatrician who told me ‘the symptoms your son has usually mean X, but I don’ think that’s what he has. I think he has Y instead (he was right, btw). He handed me a bad photocopy of a 2-page review article on X vs Y, we shook hands, he encouraged me to let him know if it didn’t get better, and the visit was over.
I took 10 minutes to read the article and learned more about X and Y than I ever would have in a 5 minute conversation. I easily learned enough to distinguish between X and Y as time went on and symptoms diverged. He didn’t have to guess how much information I wanted or could process at the time (trying to focus while comforting a sick 4 year old) and I didn’t have to try and remember the details later while explaining to my wife. It worked well for everyone!
Triple Bonus points for a short youtube video giving their standard reasoning for the treatment or medication in a particular situation!
The model of telling each person everything they need to know in person can be much improved with very little effort.
I now do all my own plumbing, electrical, and carpentry work rather than risk incompetence in the professionals. For things beyond me, such as auto repair and health care, I must go to the professionals. But which ones? As with plumbers, the only way to tell the good ones is through trial and error. We are all of us humans – all different. Some are better at their chosen craft than others. Plumbers, doctors – we can’t all be above average.
My GP (That was his designation when starting out.) is good. Over the years he has accommodated my questions. On two occasions, when I filled him in on recent research, he asked if he could keep the print-outs and thanked me. And he’s certainly helped educate me in this two way relationship. Sadly for me, he’ll retire soon.
Specialists seem to be preset to act the paternalist. However, I’ve discovered that bringing a brief printed list of carefully considered and pointed questions will pique their interest as well as their respect for you.
Years ago when it became clear to me that all doctors could not know all the recent research in all fields all the time, I availed myself of the library at the local teaching hospital on behalf of a family member in need. Or for myself. I still go back when I need the whole article that I’ve found on the web. So, my questions are, indeed, pointed. The squeaky wheel gets the oil.
I don’t see how concerned patients can abdicate in the way they’re described here. As I’ve suggested elsewhere, it’s a matter of Survival Of The Fittest. Patients who do not cultivate a deep involvement in matters critical to their own health and well-being
Not to be impertinent but, why do you ask a patient why they are on a statin? Statins treat high cholesterol. That’s pretty much it. “Why are you on a beta blocker or an ARB?” I can understand. But a statin? I get asked by a physician staring at my bare chest, “Which side was the mastectomy on?” Really, you can’t tell? It’s the side with the scars an no nipple. That the person performing the echocardiagram asks me 10 times during the procedure why I’m having it done, only pisses me off. The answer didn’t change in the 5 minutes since he asked the last time. I know why I take a statin and why I think I shouldn’t. But if I question it too eagerly, or just don’t take it I’m non-compliant and earn my doctor’s ire and harassment from my insurance company. I can tell you why I take every pill that I take, and whether or not I think it’s pointless. I can tell you precisely why I ignore your warnings against salt. I can even show you the blood work and the 24 hour urine tests that would explain. And you would tell me that my nephrologist and I must be wrong. So, mostly I think it’s pointless to ask questions we already know the answer too. All it does is eat away the 10 minutes a year that I spend in the room with my EP.
Dear Dr. Mandrola
I am cardiologist and a regular reader of your blog and Medscape articles. I work primarily in Coronary Angioplasty and I completely agree with you that nowadays medicine in many cases is more focused on treating disease manifestation than in solving its causes. Regarding the side effects of drugs which we used massively in our daily practice, I would point out the possible relationship between betablockers treatment on healthy patients and paroxysmal atrial fibrillation development. Perhaps you have time to read the letter to the editor which we published this month in International Journal of Cardiologist.
A big hug and praise your work on this blog
Dr. Antonio Ramirez
This is not about patient compliance, its about patient information. For example, although I’m considered to be in great shape for my age, my cholesterol remains high and after of year of increased exercise there was no change so the decision was made by my doctor and I to go onto a statin. He never said the words, “To reduce the chance of heart attack…” His primary goal was to reduce my cholesterol. Patients are not physicians and do not make assumptions when it comes to care.
Spelling it out to us clearly makes a difference. Take your time. In addition, studies show that pharmacogenetic testing helps to improve patient compliance. It allows us to know the medication that will be more or least effective.
A little more effort from our doctors never hurts.