Review Of Systems

A question sent to Doctor D:

"Why do doctors ask for information that has nothing to do with what I'll be seen about?"

Doctor D asks his patients superfluous questions all the time. You come to Doctor D with ankle pain and next thing you know you are answering questions about your breathing, how much alcohol you drink, if you have fevers, and your sex life. Doctor D asks these questions because he is nosy.

Doctors are nosy, but the more pertinent reason we must ask those questions is because we are lazy. Doctors, like most people, have a nasty habit of jumping to conclusions before thinking carefully. To combat mental laziness the MD powers-that-be came up with the "Review of Systems" where doctors ask a whole lot of questions about your body that don't directly relate to what's bothering you. It forces your doctor to think outside the box. Usually it turns out to be the obvious diagnosis, but the Review of Systems helps your doctor recognize when it isn't.

Doctors also do this because we are greedy: insurance won't pay for your exam unless at least some Review of Systems is done. Fortunately this is one of those situations where your insurance company actually does something for your benefit. They know a Review of Systems is cheaper than a CT Scan.

When you come to Doctor D with a swollen ankle without any injury it is probably gout. But questions about your breathing or your genitals force Doctor D to at least consider that non-traumatic ankle swelling can be caused by a blood clot or a gonorrhea infection.

So now you'll know why we ask all those crazy questions.

Overcoming Doctorphobia

An e-mail to Doctor D:

"I am absolutely TERRIFIED of doctors... I have avoided doctors like the plague... how do I get around my fear of doctors?"

Doctorphobia is a common but curable condition. It can start with your first shots as a child. Throw in an uncomfortable exam of a body orifice, add a few run-ins with jerk doctors while you are wearing nothing but a paper gown, and you can end up with a full-blown phobia of anyone in a white coat.

If you had any idea what a bunch of nerdly social misfits we doctors really are you would be more likely to laugh than tremble. Unfortunately doctors, like dogs, can smell fear and often exploit it. When nervous greenhorn medical students first realize that patients are terrified of them they should respond with compassion. But when they realize being feared makes them feel special and powerful the “god complex” begins.

Here are some techniques for taking the fear out of your doctor visits:

• The Honest Approach: You wouldn't believe how many patients have started their visit with Doctor D by saying, “I hate doctors. They scare the shit out of me!” This reminds Doctor D that he should be friendly and calm. Honestly confronting them with this truth should induce your doctor to respect you. If a doctor is mean right after you admit Doctorphobia then you can move on—you don't need that jerk.

• Remember that doctors are scared too: What your mom told you about snakes in the woods is also true of doctors: “They are more frightened of you than you are of them.” Medicine is an anxiety-producing business, and doctors are nervous most of the time. We are responsible for the life and health of our patients, and most of what we do is based on educated-guesses. We live in constant fear of screwing up. It's enough to give anyone an ulcer. We hide our anxiety well, but you can rest assured that the scary doctor is often more nervous than you. Like middle-school boys, the doctors who strut and yell are usually most insecure. Any doctor that intentionally tries to scare you is more worthy of your pity than trepidation.
  

• Remember that you are the boss: Economically speaking, your doctor works for you. You pay them for a service and if they don't work out you take your business elsewhere. No, this doesn't mean you can order a boat-load of narcotics Michael Jackson-style, but it does mean you should feel more empowered in your doctor-patient relationships. You can always fire your doctor.

• Change doctors: Some people love no-nonsense, semi-abusive doctors, but aggressive docs are not good for people with Doctorphobia. Consider moving to a doctor with a different doctoring style. “Buddy” and “Parent” doctors are usually more gentle (although they do have their problems).

• Picture your doctor naked: This is a time-tested method for overcoming anxiety. Doctors are about the only strangers who can legitimately ask you to disrobe, so you should have no qualms about turning the tables on them in your mind. No doctor can be scary in their whitey-tighties. (Warning: This technique may be too distracting if your doctor is as handsome as Doctor D.)

Any readers have other tips for beating Doctorphobia?

Incompetent Doctors: The Series

What is to be done about dangerous, incompetent doctors?

• The Battle Against Incompetence
  

• Why Do Incompetent Doctors Still Flourish?

• The Competency Witch Hunt!
  

Mystery Illnesses and Big Workups: The Series

Useful (but controversial) information on symptoms that have yet to be diagnosed:

• Diagnosing the Undiagnosable

• What Is A Proper Work-Up?

• Dr. D's Guide To Getting Worked-Up

How To Call A Doctor

A question from WarmSocks:

When my family gets sick I assume that we'll get better in a few days. When in doubt, I phone my doctor's office to ask if something is serious enough to be seen. I am always told to bring the kids in that same day. My doctor is very busy, but he work us in when what I'd really like is assurance that it's okay to wait a few more days. Are there guidelines for when to call the doctor or not?

Your body will sometimes do quirky things that don't require a doctor's visit. The tricky part is figuring out what needs a doctor and what doesn't. It's nice to have advice from a medical professional on which symptoms merit an exam. For this you call them on the phone.

Although the telephone was patented in 1876, we doctors still haven't quite figured out how to use the thing in medical care. Talk is cheap, and this can be a very good thing. In fact it's free. Doctors aren't paid one red cent for talking to you on the phone. Unfortunately if Doctor D tells you over the phone it sounds like a viral cold and you get pneumonia lawyers won't take it easy on Doctor D because the advice he gave was free. Extra risks with no pay makes a lot of doctors avoid phone questions like the plague. You call with a question and the receptionist tells you to make an appointment. This sucks because you often pay for care you didn't need.

So if your doc will talk to you on the phone realize this is a really nice service. Doctor's are always nervous about phone advice. You really don't want to be that guy that causes your doc to say "Screw it, no more phone questions! Just make an appointment for everybody who calls."

Tips on Calling Your Doctor:

• If you feel you simply must be examined don't call and ask. If your doctor saying your symptoms don't warrant a visit will upset you, then just go a head and make your appointment. Patients that get an answer they don't want will either show up angry wanting an appointment anyway or stay home angry. Neither is good.

• Have a specific question or concern when you call. Doctors have very short phone attention spans. People sometimes call Doctor D with long stories about how Little Johnny never did have a strong stomach. After several minutes of this Doctor D has to stop this very interesting story to figure out what the heck you are calling about.
  

• Let your doctor know your expectations. There are a lot of things that might result from a call: reassurance, a prescription, a referral, advice, moving up the date of your appointment, or being asked to come in right away. You probably have expectations of what you think should happen. If you simply call, list your symptoms, and listen to your doctor's response, you often feel frustrated afterward because your doc didn't address your real concern. The best doctor in the world can't read minds. You should politely let the doctor know what you are expecting. Even if your doctor doesn't agree they can respond to your concern.

• Don't try to solve all your problems over the phone. Remember the phone calls are free, and doc has to keep seeing patients in person to keep the lights on. If you want to discuss your entire medical history or every odd symptom you've had in the last year consider an appointment. Your doc just doesn't have the time to cover all that on the phone.

• Accept that different patients get different phone care. If Doctor D has known a patient for years he is very familiar with that patient's body and mind. He is much more comfortable treating that person over the phone than somebody he only met once or twice.

• Acknowledge the uncertain nature of the situation. Medical work involves examining the body. We can't do that over the phone. This makes us less certain. Sometimes that uncertainty (coupled with fear of lawyers) leads us to ask you to come for an expensive checkup when our gut tells us it's really nothing serious. Just saying "I know you can't be certain over the phone, doc, but what is your best guess?" could save you hundreds of dollars.

Doctor Shopping (Finding a Doctor: Part 3)

Okay, so you make an appointment and see your new primary doctor. Sometimes it is the perfect match. If so, excellent! But some relationships that looked great on paper just don't work out in real life and you need to keep moving. This is where things can get tricky. Physicians are very sensitive about "doctor shopping" patients, so you need to learn how to doctor shop with caution.

First, all doctors (including Doctor D) are arrogant narcissists who always think they are the best doc around. They can't understand why any patient would leave their brilliant care for a second-rate hack.

Second, if you are coming from another doctor or several previous doctors, your new doctor may look at you with suspicion. Doctors assume that those who have been promiscuous with their medical care must be unable to have meaningful relationships. The doctor might assume that you are a "difficult patient" (crazy, demanding, rude, etc.) or a "drug seeker" (addicted to prescription medicines). These are the two dirtiest names doctors call their patients. You don't want to get either label.

So you must approach first visits mindful that doctors are a sensitive, suspicious bunch. The best strategy is to let the doc know right up front you aren't committing to a serious doctor-patient relationship just yet. Say that you are playing the field and if you move on they shouldn't get their feelings hurt. If you do so in a polite way, pointing out that sometimes even the best of doctors won't work out, you should be able to leave the doctor' fragile ego intact. (Many of Doctor D's ex-girlfriends successfully implemented a similar "it's not you, it's me" exit strategy.) This way the doctor isn't upset if you leave and feels extra special if you stay.

Also on your first visit it is essential that you never tell your doctor about what jerks your previous doctors were. Your new doctor will likely assume that you did something to deserve the abuse. Never mention the name of a narcotic pain medicine you just can't live without. If you are a bit unstable try to not to show all the crazy on the first visit. Think about it like a first date. Be yourself, but be the nicest version of yourself.

Unfortunately, the primary care doctor who is stressed and overworked may not be the nicest version of him or herself at the first visit. This can be a good opportunity to see what your doctor is really like. Will the relationship work? Only you can answer that.

Even in today's depressing healthcare system there are lots of examples of really good doctor-patient relationships. So don't give up! The right primary doctor for you is out there.

Doctor D would love to hear patients' perspectives, advice, or horror stories on first doctor's visits.

Read the "How to find a Doctor" Series

Picking a Doctor (Finding a Doctor: Part 2)

Now that you have some idea what style of doctoring will work for you, it's time to actually get an appointment.

This is not Doctor D's area of expertise since he is usually on the "getting picked" end of such things, but he has tried to find doctors for enough of his own family to appreciate that this can be a tricky step. Usually you are stuck staring a a long list of unfamiliar names from the phone book or insurance company. The best way to pick a doctor is to consult the experts in your community: retirees and soccer moms.

These people know stunning amounts about every doctor in a 5o-mile radius since they spend several hours a day discussing every doctor visit they or their friends have had in the last few years. So just saunter up to an Oldsmobile or minivan and show them your list. You'll have to sit through long stories about constipation or little Johnny's ear infection but you'll hear a lot about the names on your list.

A couple things to remember about the advice you get:

• The doctoring style that worked for Harold or little Johnny may not work for you. (Like Ms. Smith from last post) Pay more attention to what they say the doctor said/did more than how they liked or disliked the doc.
• Even the best of doctors (even Doctor D) will sometimes have patients that dislike them. A complex doctor-patient relationship sometimes doesn't work even with good doctors and patients. Don't avoid a doc just because one person hates them. (But if everyone hates them don't go, unless you just want another jerk in your life.)
• Be careful when you hear effusive praise being poured on a doctor. Don't take it too seriously. Anyone who thinks their doctor is the best thing since sliced bread probably has a few screws loose. Doctor D's weirdest patients have sometimes been the ones that fell all over themselves saying he was the answer to all life's problems, when he hadn't done anything for them.

So with those things in mind circle one on your list and get an appointment. We'll talk about what to do at that appointment in Part 3.

Read the "How to find a Doctor" Series

Ms. Smith and the Doctors

So in the last post Doctor D told you about 5 different styles of doctoring, but how would these doctors care for a patient with a difficult situation?

For this I give you the hypothetical patient: Ms. Smith. Overall she is feeling well and getting all her preventive care, but Ms. Smith has one tricky problem--she smokes. It is a universally acknowledged truth that this bodes poorly for her future well-being. Even tobacco companies now admit that smoking kills. But quitting ain't easy. Ms. Smith may need a doctor to help her get there.

Which of the 5 different doctors would work best for her?

• The Drill Sergeant: "No excuses Ms. Smith, quit now! If you don't stop smoking, I'll fire you as my patient!"

• The Parent: "I understand how hard it is for you, but you really must stop. I will keep asking you till you do, because I care."

• The Buddy: "Think about quitting smoking. It would be really good for you, but if you don't want to that's okay. I'll still take care of you."

• The Consultant: "Smoking significantly increases the risk of premature death from heart disease, cancer or emphysema, as well as worsening respiratory problems and inflammatory conditions. Should you be interested in quitting I can tell you about ten different strategies for doing so."

• The Mechanic: This doctor won't actually talk to Ms. Smith about smoking. The mechanic takes as granted that smoking is just what her body does. The mechanic will provide treatments for the damage that smoking does to her heart and lungs. If Ms. Smith isn't interested in quitting, she might appreciate that the mechanic won't bother her about it.
  

Which one would work best for Ms. Smith? Well she's a fictional person, but perhaps the one you thought best for her indicates which sort of doctor you should be looking for.

More on finding a new doctor.

Types of Doctors (Finding A Doctor: Part 1)

Magda asked how to find a new doctor on this post. She likes her current Primary Care doctor but wonders what she will do when he retires. This is a big question so I'll answer it over several posts:

First, you need to figure out what style of doc you need. Every MD has his or her own style of relating to patients. Knowing what sort of doctor you would work with best will help you choose the right one for you.

Of course doctor is special like unique snowflakes etc... but Doctor D has broken it down into five basic doctoring styles he sees often. Some doctors may combine several styles. Doctors often don't really know what their style is (Doctor D isn't sure where he fits on the list) but the doctor's patients can always tell you.

Five Doctoring Styles:

1. The Drill Sergeant: Gives orders and expects absolute obedience. The drill sergeant is very confident and knows more about your body than you do. These doctors won't take any crap from you or anybody else. This meanness can come in handy since drill sergeants go ballistic on anyone who messes with their patients.

   • Pros: Some patients need no nonsense firmness to get results. If you trust doctors and need to be pushed to live healthy this doctor might work for you.
   • Cons: They tend to be abusive. Your opinions and feelings really don't matter to drill sergeants.

2. The Parent: A warm, wise parental figure who watches out for you. Parent doctors want to know how you are doing and want the best for you. Parenting style medicine is more common in older doctors. These doctors kindly guide you to the healthcare decisions that they know are best for you.

   • Pros: Parent doctors are often the nicest physicians.
   • Cons: You will likely be treated like a child. The parent doctor will often make your decisions for you.

3. The Buddy: Treats you as an equal, wants to be your friend. The Buddy doctor lets you make your own decisions and just wants to help. These doctors worry a lot about whether you like them. Buddies may give you a treatment because you want it, even if they don't think it is the best thing for you.

   • Pros: Works hard for you and treats you with respect and kindness.
   • Cons: May not give you difficult facts or ask hard questions. Sometimes passive-aggressive.

4. The Consultant: Treats your relationship as strictly professional. The consultant's role is to give you information and provide you with treatment options. You make all the decisions. The consultant is just there to answer your questions should you have any. Consultant doctors may overwhelm you with options and the pros/cons of each. They tend to be neither angry nor friendly, but always professional.

   • Pros: Informative, always professional. Consultant doctors don't get emotionally involved which means less drama.
     
   • Cons: May overwhelm you with facts and options without much guidance. As long as you are making informed decisions it's no skin off the consultant's back if you live or die.

5. The Mechanic: Sees your body as a machine that needs tune ups and repair. The mechanic doctor doesn't really recognize you as a person at all. Your medical issues are all mechanical problems to be solved. Don't expect a mechanic to talk to you much. They may speak about your body, but usually this is the doctor talking to himself in medical Latin that you probably won't understand.

   • Pros: Usually very intelligent in a scientific way. Who needs human interaction when you can have a robot doctor?
   • Cons: No real relationship. You probably won't understand a lot of what the mechanic doctor is doing for you. You could ask but the answer usually won't be in plain English.

Next Post we'll look how these doctors would work with a particular patient: Ms. Smith

Read the "How to find a Doctor" Series

Why Would Anyone Ration Healthcare?

You want to know why?

Once upon a time Doctor D was in an Emergency Room. A patient came in by ambulance:

What was the patient's emergency? Dry hands from washing dishes! Why did the patient think this was an emergency? They hurt! Why did the patient come by ambulance? The car was broken down!

The total cost of an ride in a fully-equipped ambulance and a room in a fully-staffed emergency room must have been well in the thousands, which means that Doctor D holds the world record for most expensive tube of Vaseline ever given.

Guess whose insurance premiums and taxes go up when this happens? Everyone!

This patient's healthcare needed serious rationing!

Can you help me with my Doctor-Patient Relationship?

Yes! That's actually why I started this blog.

Think of me as the relational therapist for your doctor-patient relationship! Heck, you can use me as your counselor for your relationship with the medical system in general. Doctor-patient relationships can be full of miscommunication, mistrust, unspoken expectations, and emotional baggage from past relationships. This kind of stuff dooms romances all the time, but when it messes up your medical care it might significantly damage your health.

To make things worse a lot of doctor-patient relationships are arranged marriages (by insurance companies) or random couplings (the doctor that is on-call the day you need care). You may prefer to stay single, but sooner or later you'll need one of those jerk doctors and Boom! ...you are in a relationship. As Doctor D's wife can attest, relationships with doctors can be tricky!

While he is an excellent physician, Doctor D cannot be your personal physician over the Internet. Long distance relationships just don't work out for him. But he is offering to be that guy that understands both you and your significant other and gives some sage advice.

Is Doctor D doing this out of the goodness of his heart or because he is a glutton for punishment? He doesn't know either. Perhaps Doctor D should see a therapist about this, but until then send in those questions!

E-mail Doctor D

How Could Diets Cause Obesity?

Diets with "results" make you drop pounds quickly, which is not always a good thing. Human bodies have very strong instincts to prevent death from starvation. Throughout the ages these instincts have saved a lot of lives. Now for the first time in history lots of people are dying due to obesity. Your instincts weren't designed to save you from fat.

So what happens when you go on one of these diets? All those amazing diet plans you hear about cause your body to dip into it's fat reserves. This triggers some very powerful survival reflexes. Your body drops its metabolic rate drastically. Your mind unconsciously scans your environment for high-calorie foods to save you from starvation. Your body starts finding shortcuts to avoid burning calories. All this is great if you really are trying to survive a famine, but not so good for dieters.

Think of these instincts like a hibernating angry bear. Don't waking up that bear!

Most of us cannot realistically stay on these crash diets the rest of our lives, but the starvation defense mechanisms keep running strong long after the diet is over—sometimes for the rest of you life. It is only the very rare patient I've seen keep their new low weight. A vast majority rise far above their pre-diet weight in a few years. They might have liked how they looked for a trip to the beach, but their overall health ends up much worse, which often pushes them to even more drastic diets. What may have started as a mildly overweight person ends up morbidly obese over a couple diets.

Doctor D has seen it over and over again, so consider yourself warned!

Sorry to ruin your hopes of becoming a swimsuit model, but those dieting books and quick weight loss shows will make you miserable in the end.

Why Are Americans So Fat?

Excellent Question! The "Obesity Epidemic" has been getting a lot of press recently. Americans are too big and getting bigger. Being very overweight seriously raises your chances of all sorts of miserable problems including having to see doctors like me more often.

There are lots of theories for why we are fatter than any other time in human history. Doctor D is a bit concerned that no one is talking about a potentially deadly cause of this trend. Here is Doctor D's unscientific theory of why so many of us are so fat:

Dieting makes people fat!

Think about it, how many people on diets loose weight only to gain back every pound plus some? Everyone believes dieting is wonderful because obesity is bad, but what if diets are making the problem worse? There have always been heavy people, but so many people who get heavier indefinitely till it kills them is a recent problem. People keep getting heavier because they keep dieting.

Stop it now, before you get even bigger. And whatever you do, do not watch “Biggest Loser.” That show is a public health threat. I'm serious!

(Tune in next time to learn why dieting causes obesity.)

Why Are Doctors Such Jerks?

Let's start with a question I know that you have been wanting to ask:

Why are so many doctors jerks?

Excellent question! As any nurse will tell you, doctors are notoriously difficult to work with. We doctors have a much higher percentage of jerks among us than the general population. Even Doctor D (on very rare occasions) has been known to be downright ornery towards patients. There is a epidemic of condescending, difficult, foul-tempered doctors, and you the patient are the one who suffers!

Some doctors have been jerks their whole lives. Maybe they weren't hugged enough as babies. These docs just love having a position of power so they can make others feel small. Such natural-born jerks can be found in any profession, and just one of them (especially as a customer service representative) can make anyone's day miserable. Such doctors will never change. It is best to avoid them whenever possible (unless you need surgery).

But the relatively few natural-born jerks in the world just aren't enough to explain the over-abundance of jerk doctors. This only leaves one explanation: many doctors become jerks by becoming doctors.

The number one reason everyone says they want to go to medical school is "to help people." Believe it or not, we were all once innocent wide-eyed young medical students who really cared about you.

Then they fed us through the decade long meat-grinder of training involving sleep deprivation, endless memorization, calling patients by their diseases, and getting yelled at regularly by our jerk-doctor teachers. At first we hated those other jerk-doctors, then we felt sorry for them. We worked till we were dead tired, and then got told heathcare is cutting back so we had to do the same work twice as fast next time. Patients expect us to work miracles after watching too much TV, and don't see any reason for dieting or quitting smoking since our purpose in life is to cure everything. Despite our good intentions people keep destroying themselves with bad habits, and nice people keep dying, and everyone is angry we can't turn them back into twenty-year-olds. Add to that lawyers promising irritated patients that they can hit the jackpot, if they just sue jerk doctors--It is enough to turn even the nicest medical students into misanthropic bastards.

As a patient that just wants to get your check-up none of this is your fault, but you are going to bear the brunt of this. Your best bet is to look at your doctor, and try to imagine him/her as the kindly, altruistic, and terrified student that showed up on that first day of medical school. Somewhere in your doctor lurks that annoying humanitarian impulse that doesn't die easy.

Look your doctor straight in the eye and say, "Doc, I really appreciate you taking care of me." Only say this and nothing else! Under no circumstances then ask for something or launch into a list of every odd symptom you had in the last year. Just say something nice and leave. A jerk-doctor hasn't seen human kindness and generosity in years might just feel a warm spark of caring in his/her cold heart. Doctors have a bad habit of forgetting we work on real people. Suddenly you become a real person and not just a patient. Trust me, doctors actually care about real people. You just have to remind your doctor that real people exist.

Who knows, your doctor might even be nice to the nurses after seeing you?

Any Questions?

Okay I'll Ask Some Questions

No one is asking questions! But that is probably because you don't know this blog exists yet, so your lack of participation is forgiven.

I will start by asking questions I know you're wanting to ask...