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