How to Work with Your Doctor

DO YOUR HOMEWORK

By Neil Shulman, M.D. and Rowena Sobczyk, M.D.

To get more out of your office visit than just standard medical advice and warnings requires a change in mindset. Too many people worry only about what they are going to wear to the doctor's office, not how they are going to use the doctor to get answers to improve their health. Hippocrates (460-370 B.C.E.), the father of medicine, developed the principles of medical diagnosis and treatment along with a code of ethics for medical care. Most doctors are ethical, but not all possess a friendly bedside manner. You should feel comfortable talking to your doctor. Some doctors will label patients they don't get along with, because of personality clashes, as "difficult." They may treat their "difficult" patients with less regard and try to pass their healthcare onto other providers within the organization. This is known as dumping. If you feel you are being dumped from one provider to another within a group, or if you leave every appointment feeling rushed and uncertain with unanswered questions and concerns, consider changing to a doctor with a different bedside manner or a to different group. Remember, your doctor has to believe that you are sick. If you have a doctor who believes your illness is "in your head," you will not get effective treatment or good advice.

Your Doctor is a Consultant

You need to start thinking of your doctor as your personal healthcare consultant instead of as the person who can make you well. Your body, not the doctor, makes you well and keeps you well. Together with your doctor, you can do things to maintain health and to speed the healing process, but it is up to your body to remain healthy and to recover. Obviously, you know your body better than anyone else. You are the person who must do the preventive maintenance to stay well and who experiences the symptoms of illness when disease strikes. Consequently, it is common sense for you to be in partnership with your doctor in making healthcare decisions.

Think about how you work with other consultants in your daily life. You state the problem, answer any additional questions the consultant might have, and then you discuss the report that the consultant prepares. Throughout the entire process, you are in control. It is up to the consultant to present compelling reasons for you to follow his advice. In other words, start relating to your doctor in the same way you relate to your auto mechanic. Prior to taking your vehicle in for service, you list the performance issues you have with the vehicle and, in addition, any preventive maintenance tasks you want performed.  Unfortunately your body does not come with an owner's manual. The mechanic will discuss the performance issues, look at your vehicle, and then discuss your options and the cost of each. Based on this, you decide whether or not you want the work done. If you are not sure about what the mechanic recommends, you talk to a knowledgeable friend or see another mechanic. Start relating to your doctor in this fashion. Don't be intimidated. The doctor is the consultant and you are paying to hear and understand his medical opinion of your problem.

Just as being friendly with the mechanic helps you get better vehicle service, having an ongoing relationship with your doctor is an advantage. A doctor who understands how you reacted to illness in the past can put your current symptoms into proper perspective. In addition, she can tailor your treatment to your preferences. For example, if you have religious beliefs that preclude certain treatments, your doctor may be able to advise acceptable alternatives.  Within your health plan, your doctor is your advocate. Obviously a doctor who has a long-standing relationship with you is more likely to fill out forms and to petition committees to help you get the care you want. This help can be as simple as obtaining a brand name medication instead of a generic or as complex as getting a surgery approved for coverage. If your doctor says something is not allowed by your health insurance plan, make sure you ask about how an appeal can be filed. The practice of medicine is not always clear cut.  Through an appeal, your case will be reviewed by a different doctor or panel of healthcare providers who may feel an exception to the health plan protocol is warranted in your case. During the appeal process, the medical reasons why an exception should or should not be made in your case are discussed. As with everything else in life, it never hurts to ask.

Know Your Coverage

Needless to say, healthcare delivery is more critical for you than getting your vehicle serviced because it involves life and death. Although you can always buy a new car, you only get one body. In addition, healthcare is complicated by health insurance and health plans. Vehicular service and repairs are either under warranty or they are not. You pay for work not covered by warranty, so you decide what gets done, when, and where. Depending upon what kind of healthcare insurance you have, your choice of healthcare providers may be limited, the insurance payment for a service may be less than the doctor bills, or you may not even be allowed to have a certain service covered. Part of preparing for your doctor visit is figuring out if your problem is covered by your insurance and, if it is, which type of doctor you may consult. Your insurance card is imprinted with telephone numbers and information to help you with this process. If you have never looked at your card, it is wise to read the information on it prior to seeing your doctor so you know the basics of your healthcare coverage. A complete listing of your benefits can be found in the brochure you received from your insurance carrier or on their Web site.  Unfortunately, this information is often confusing. Discuss what you don't understand with your employer's human resource department or contact your insurance carrier's customer service department. Typically, you will need to know the social security number of the health insurance policy holder and the group identification number in order for the customer service representative to answer your questions. The latter can be found on your insurance card.

Health insurance basically comes in two forms: traditional, fee-for-service or indemnity plans and managed care plans. As a rule of thumb, you get greater doctor selection with a traditional plan and more covered services with a managed care plan. Managed care plans can be broken down into Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), and Point of Service (POS) plans. With an HMO you are restricted, except in emergencies, to seeing only doctors within the organization. With a PPO, you pay more if you don't see a doctor within the organization. With a POS plan, you get the best outside coverage only if a doctor within the plan has referred you to the doctor outside the organization. For more information about health insurance and health plans a government Web site gives in-depth coverage of all the options and what they mean at http://www.ahcpr.gov/consumer/hlthpln1.htm#choices.

Part of your responsibility when making an appointment is to find out about typical fees associated with the doctor visit. Also find out which hospital and outside laboratories your doctor uses to make sure they are covered by your health insurance. If your doctor is not on your plan or you do not have health insurance, you want to know what sort of charges to expect. In addition, although you may choose to see an out-of-network doctor, you will most likely want to make sure that she can put you in a covered hospital and order laboratory tests and procedures from a covered facility, because these services can be very costly. Don't wait until you are critically ill and in need of hospitalization to discover you have to change doctors to avoid paying a larger percentage of your hospital bill. If your doctor has a Web site, most of this information will be posted on it. Health plans discourage use out-of-network physicians and facilities because of cost. For in-network groups, the plan has negotiated a fee for a healthcare service which is usually less than what the doctor or facility normally charges, so using an excellent in-network doctor is financially to your advantage. The plan is getting a volume discount.  However, under certain circumstances, such as when you are traveling, exceptions are sometimes made to the regular rules.

Have Forms Ready

Obtain and complete your portion of all the forms that you need prior to arriving at your doctor's office. Not having all the information on a form may necessitate an additional visit or a call back to the office. It is best to be prepared. You will be amazed at the amount of information requested that you don't have at your fingertips. This can be anything from the social security number of the health insurance policy holder to the date of your last tetanus shot. In addition, your doctor may not keep the necessary form in his office.  For example, you request a handicapped-parking permit to allow you to take a disabled elderly parent shopping. Your parent's doctor will have to certify that your parent is disabled and qualified to receive a handicapped permit. You may need to go to your parent's state motor vehicle bureau first to obtain the necessary form. Similarly, although most primary care physicians have school immunization forms available, double check with the receptionist when you are making your appointment to make sure they are there.

Certain employers and schools require documentation that an absence was health-related. Sometimes just a note from the doctor is not enough. If you need a certain piece of paper signed by your doctor documenting your absence, make sure you bring it with you to avoid the hassles of obtaining a signature later. This is particularly true when dealing with Worker's Compensation and other insurance claims. Not having the paper with you can lead to delays in your case being processed. First your medical chart has to be pulled from the record room. A note has to be made about your request. This will be attached to the form and then given to the doctor for her signature while she is busy with other patients. You can see how the paperwork could be misplaced or continually put off to a less busy day.

Do Your Homework

Try to gather a little information about your problem so you can utilize your doctor's expertise and be in partnership with him in making healthcare decisions. With the advent of the Internet, finding reliable medical information has become very easy. In the past, only people with access to a medical library could hope to find comprehensive material about their illness.  The Internet has changed all that. There are excellent sources of medical information currently available to anyone willing to perform a search. You do not even have to know medical terms to obtain information. Valuable information about many diseases can be found by searching for a symptom or a common name.  By reading up on your illness prior to seeing your doctor you will be in a better position to evaluate your diagnostic and treatment options. Of course not all Web sites provide worthwhile information, so be sure to discuss what you have found with your doctor. Even better, print the article and share it with your doctor.

Knowing something about your illness prior to your visit can help you describe your symptoms more clearly. You will be able to focus your mind on the crucial aspects of your complaints and thus increase your ability to express your concerns and have them understood by your doctor. It may also help you to remember or notice an important clue that would have gone unmentioned. As suggested earlier, you may want to create a list of these concerns and bring them with you to the visit. Having some basic medical knowledge provides you with a foundation to request special testing from your doctor when you sense something is wrong. You may be able to recognize subtle symptoms of a disease before they become full-blown. For example a man with the vague complaints of feeling less strong, less interested in sex, and more tired than usual might be dismissed as "working too hard" unless he asks about getting his testosterone level checked. After discussion, the doctor and the man may agree that this is a reasonable suggestion in light of the symptoms and any physical exam findings. Even if the testosterone level comes back normal or if, together, they decide testing is not yet appropriate, the man will have partnered with his doctor in making a healthcare decision. The laboratory results, if obtained, could also lead the doctor in a different, but necessary, direction.  Incidentally, if you are worried about your testosterone level, take the "Deficiency in Aging Men" questionnaire located on the Web at http://www.tquiz.com. Use the results to start a discussion with your doctor.

In addition to finding out about the symptoms, testing, and treatment for any problem you are experiencing, you can also learn about disease prevention. You should know if you need to be screened for a specific disease test or to be re-immunized. For example, many adults fail to keep basic immunizations current. Find out the last time you had a tetanus shot. If it has been more than ten years since your last shot, you need a booster. Many adults also fail to get basic screening tests performed like mammograms, Pap smears, and blood cholesterol levels. If a close relative died of colon cancer or a heart attack, you should find out when to request screening. Hopefully your doctor will remind you to get these preventive measures, but as an empowered healthcare consumer you need to make sure nothing is overlooked. It is difficult to request a test that you really don't want to undergo even when you know you need it. The inclination is to feel like you have gotten away with something when your doctor fails to order a needed screening service. However, an ounce of prevention is still worth a pound of cure. Take charge of your healthcare and request from your doctor appropriate screening and preventive measures.

Be Able to Question a Treatment Plan

Another part of being prepared is to understand the questions that need to be asked about a treatment plan. You don't want to blindly accept advice.  Just as you would discuss buying new tires versus just rotating or retreading the old ones, you need to discuss your medical treatment options with your doctor.  In the case of any proposed medication, find out if drugs other than the one he is suggesting are available. Ask about the advantages of one drug over another.  You want to know why your doctor feels a certain drug is best for your condition. The recent advertising by pharmaceutical companies on television has increased consumer awareness of newer medications. However, just because a drug is new to the market doesn't mean it is the best choice for your current disease. What should you do if you forget to take a dose? How critical is taking the medication at the same time of day? If you start feeling better, can you stop the medication or is it important to continue the regimen and take it all? Do you need to avoid certain foods or alcohol while taking the medication?  Would certain foods be helpful? For example, when taking antibiotics, eating live cultured yogurt can decrease side effects because the yogurt replenishes the naturally occurring bacteria within the gut that antibiotics kill.  Does the medication require special storage? Some medications need to be stored in the refrigerator or where light can't reach them.

Additionally, you need to discuss what impact the diagnosis and treatment plan will have on your overall health. Not all diseases are treatable, controllable, or curable. In the past, doctors refrained from telling patients they had a terminal illness but the majority of the medical community now recognizes that patients have the right to know. If you have a serious disease, make it clear to your doctor that you want the truth so you can plan your life accordingly.  Recognize that no one can tell you exactly how quickly the disease will progress or when it will prove fatal. Many factors determine these things.  However, if you have a terminal illness your doctor should be able to tell you the average length of survival from the time of diagnosis. You might want to become an organ donor or sign a living will. It is best if your doctor discusses these important topics with you while you are capable of making such a decision.

When surgery is being considered, you need to focus your questions on the best ways to prepare for the surgery and what to expect during the recovery process.  It is a good idea to bring a relative or friend along to take notes for you when surgery is required, because the emotional impact of having to have surgery can make you forget all the advice your doctor is giving you. This is also true when treatment options for any serious illness, such as cancer, are being discussed. Having the notes to read at your leisure will lead to a better understanding of what is planned and can help alleviate some of your unnecessary concerns and anxiety. Always contact your doctor if you have any further questions about a proposed surgery. Your doctor understands that surgery is scary to think about and wants you to feel comfortable.

Traditional medication or surgery may not be the only treatments available. You need to explore the other options with your doctor. The interest and knowledge base in alternative and complementary medicine is growing. Studies have been done that look at the benefits of certain supplements, such as glucosamine for arthritis. When taken properly, glucosamine has be shown to decrease pain and increase movement in people with arthritis and joint pain. Also, medical devices exist that can help in treating specific problems. For example, the use of the medical device RESPeRATE can be an effective supplement to prescription medication in controlling hypertension. Instead of adding another drug to get your pressure down, your doctor may be able to control your blood pressure by having you just breath with this device for fifteen minutes three times a week. http://www.resperate.com

Go Over Your Statement

Remember you are using your doctor as your healthcare consultant. You will be presented with a bill for services rendered. You should go over this statement just like you would any other bill. Even with electronic scanners, the grocery checkout clerk still makes mistakes. Imagine the difficulty the doctor's receptionist has trying to read the doctor's writing. Mistakes do happen.  It is up to you to pay attention to what tests and procedures were obtained during your visit so that you can verify your charges. If you feel you are being charged for a service that was not obtained or that the fees are excessive for what you received, discuss the matter with the appropriate office staff member.  Bring any statements you question with you from previous visits. It is easier to get charges verified while your chart is pulled from the files and readily available than at other times.

The medical record of your visits to a doctor's office is considered yours. The doctor may keep the original but you have a right to obtain a copy.  Legally, your doctor can charge you an administrative handling fee and a copying fee.  The maximum fees allowable are regulated by each state. An administrative handling fee of twenty-five dollars plus a copying fee of ten cents per page is fairly standard. On your first visit to a new doctor having a copy of your medical record can be very helpful, especially if you have a complicated medical history. Your new doctor can obtain a copy of your record from a previous doctor or healthcare facility once you have signed the proper release of medical records form, but getting the record can take weeks. If possible, you should obtain a copy of your record and take it with you on the first visit. Ask the new doctor to copy what she needs so that you do not give up your copy.

Consider a New Consultant

Your doctor is your consultant. It is up to the consultant to present compelling reasons for you to follow their advice. Remember you can always get a second opinion. Some insurance companies even suggest you get a second opinion prior to approving certain surgeries. You have only one body, so if you are not sure about the advice that has been given, seek another opinion.  Getting a second opinion has become even easier with the Internet. You may not have to travel to see the specialist. Well-respected medical institutions across the country, such as the Cleveland Clinic and Massachusetts General Hospital, have started offering on-line second opinion services. For a fee you can send your medical record for review and second opinion by an expert in the field. However, if you have received a second opinion from multiple well-respected specialists and no one has been able to help you, it may be time for you to focus on other aspects of your life as well as your health.

To get the most out of a doctor's visit, start rethinking how you view your doctor. Begin to assume control of the visit. To that end, you need to be prepared. Fill out your part of any required forms before the visit to avoid delays. Know what healthcare benefits you are eligible to receive before you go. Know what basic screening and preventive measures you need so they aren't forgotten. Be prepared to question any treatment plan and discuss the impact of your diagnosis on your daily life and long term plans. If you disagree with or question what you have been told, request a second opinion. Review all fees and charges before leaving the office. Through preparation you can relate to any doctor as a personal healthcare consultant and empower yourself to work with your doctor in making the best healthcare decisions for you.

Empowerment Tips

·       Use your doctor as your healthcare consultant.

·       Read your health insurance card and understand your plan.

·       Do your health condition homework.

·       Know what to expect from your illness and treatment.

·       Go over your bill.

·       Consider a second opinion.

From Your Body, Your Health: How to Ask Questions, Find Answers, and Work with Your Doctor. Copyright © 2002 by Neil Shulman and Rowena Sobczyk. Excerpted by arrangement with Prometheus Books. $20. Available in local bookstores or call 800-421-0351 or click here.