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Solving Problems with Your Doctor

Patients and doctors have different temperaments, life experiences, and expectations. As in any relationship, disagreements are inevitable. This fact sheet examines several common problems encountered in medical relationships.

Differences of opinion. Active patients disagree with their doctors on occasion, especially if they have to see them frequently due to a chronic or serious illness. Medical relationships are similar to any other interpersonal relationships--with frequent interaction, friction is inevitable. It is usually far better to work through it than to give up.

No shared decision-making. You have a legal and ethical right to fully participate in your medical treatment. If you have spent time researching and studying your illness and treatment options, only to be told by your doctor that he is in charge of the decision-making, conflict is guaranteed, as happened here:

I lost my first oncologist by asking too many questions. From my reading, I thought I should have one type of chemotherapy, she chose another. I thought she probably had a reason, and wanted to know what it was. She told me that she couldn't give me a medical school course. She was very insulted and suggested I would probably be happier with another oncologist.

I was devastated when this happened because I was not being hostile when I asked the questions. It actually worked out better for me because I next had an oncologist who loved to talk and would answer any question. I always knew I would have to wait for her because she took too long with every patient, but it was worth it.

Not being given the full story. Doctors sometimes tell only part of the story. Some of the reasons for such selective presentations are: saves time, prevents questions, sways patient to accept recommendations, and protects patients from upsetting information. Regardless of the reason, a biased explanation is totally unacceptable. Withholding knowledge of all the facts strips patients of the information they need to make informed decisions.

Not being believed. As medicine tilts more and more toward the bells and whistles of complex machinery, the human voice is sometimes ignored. Many patients complain that their doctors and nurses believe the machines, rather than them. This patient recounts a harrowing experience:

I had liver surgery and was in great pain. The nurses were short-staffed, and when I rang the bell for help, it took the nurse one half hour to come. I told her that I was in bad pain, but she checked the morphine machine and said that the right rate of morphine was going through the epidural (needle in the back) and that I was fine. I kept calling all night long and she kept saying I was fine. She finally called the pain team--three doctors. They couldn't find anything wrong either. But I was in agony.

By the next morning, I was in such extreme pain that I could not move and could barely talk. An orderly came in to get me up to exercise and I said I couldn't move. He said, "Oh, come on, you can do it," and pulled me up. I started to scream. Luckily, my mom and dad walked in at that moment, and my father took over. The pain team came back, and when they took off the tape to check the epidural, they found the needle hanging free--it was not even in my back.

Lack of sympathy. Doctors can sometimes treat patients as merely problems to fix, rather than complex human beings with needs other than just medical. Most patients recognize that the doctor's expertise is not in emotional support, but it is also clear that people need to feel cared for and heard in order to heal. This parent's concerns were discounted by the doctor but not the nurse:

When our son was going through his three-year protocol for leukemia, we often consulted his hematologist about various side effects he was experiencing. The doctor (a very experienced and well regarded doctor) often said, "No, that's not related to the treatment. Never heard of that before." At first I thought she was deliberately minimizing in an effort to keep us from getting upset. Then I noticed that the nurse was standing right behind her and was nodding big time about the things we were experiencing. In the hall she would later tell us, "That happens with a lot of kids."

The fact remains, one of the things we really needed more of as we went through this with our son was validation of our feelings. We weren't complaining to the doctor about the drugs. We just needed to know that others experienced what we experienced and yes, it can be a bitch. No more, no less. Few of the medical staff were able to do this. It wouldn't have taken long, but a little would have gone a long way.

Excessive waiting. Doctors are busy people; so are patients. But patients sometimes find themselves waiting two months to get an appointment, then waiting an hour in the waiting room, and perhaps enduring two weeks of worry while waiting for test results. Waiting heightens emotions such as fear or anger, and may result in a frustrating visit.

Billing problems. If you keep good records of your office visits and tests, errors will probably be easy to identify. Hospital errors are more common and sometimes harder to prove. The following patient resolved her problem with a review of her hospital chart and a letter:

My specialist charged $125 for an appointment. The only problem was that he charged for hospital visits that he did not make. For instance, he'd poke his head in the door, notice that I was on the phone, wave, and disappear. Then I'd get a bill for $125.

I called his office and was told that his bills are always correct. So I copied my hospital chart and made a list of the dates in which he had made a notation in it. These visits did not match his bills. I wrote him a letter noting the discrepancies between his visits and his billed visits (he billed me for 10 phantom visits). I attached a copy of the pertinent pages from my chart and sent a copy of the letter to my insurance company. The bill was adjusted.

Problems during procedures. Patients often aren't aware of their legal right to stop a procedure or refuse treatment. In most states, unless they are a danger to themselves or others, adults have the right to refuse medical care. If a procedure is not going well, you have the right to tell them to stop, as this patient did:

I was having a full body skeletal survey done, and I wasn't feeling well. The X-ray technician was very tentative, and he was doing things in a different way than I was used to. He also seemed to be taking way too many X rays. Usually, they take them standing up because it is just difficult for me to lie down on a hard table due to multiple back fractures and harrington rods. He insisted that I lie down, so I did. Then I was able to see the name tag hooked to the bottom of his shirt. It identified him as a student and there was no supervisor present. I said, "Get me off this table!" He said, "You're not done yet." I responded, "Yes, I am." I wrote to my orthopedist (who had referred me there for X rays), the hospital administrator, and the head of radiology. My orthopedist was aghast, the head of radiology apologized, and now I get only senior technicians.

Conflict resolution. The previous section contained just a sampling of the myriad problems that result in conflict between patients and physicians. How can you resolve these vexing problems? The following methods will outline ways to identify and fix misunderstandings and disagreements with your medical caregivers. Patients share many stories of how they persevered until the problems were resolved and what they did if the problem simply couldn't be fixed.

Plan the meeting. Your problem will probably get worse, not better, if you explode at the doctor or staff when you are very angry. Usually, it is better to leave if you are very upset, and wait for your emotions to cool before taking action. Planning a strategy may help you resolve the problem. The following are ideas on what to consider during your planning process:

  • Understand the problem. Think about and clarify the nature of the problem.
  • Decide to whom you need to talk. You may need to talk with the billing supervisor for bill problems, the doctor about treatment disagreements, or the nurse for rude behavior.
  • Get expert information. You can skip this if the problem is about your relationship, e.g., wanting the doctor to not interrupt you so often. If, however, the disagreement is of a technical nature, for instance, choosing between two treatment plans, arm yourself with expert opinions.
  • Decide on a strategy for the meeting.
  • Consider obstacles.
  • Have a positive attitude and expect to succeed.
  • Carry out the plan. Set deadlines and goals for yourself, then gather appropriate information and make the appointment.

Make an appointment to talk. Combining your conflict resolution talk with an examination may backfire. First, you may not have enough time to fully discuss the issue. You also will be at a bargaining disadvantage if you are lying on a gurney looking up at the doctor. If the doctor is not expecting the discussion, you may start off on the wrong foot. Too often, patients irritate doctors by bringing up an unexpected subject late in an appointment, throwing the doctor's schedule off and making it less likely that he will hear your problem with compassion. Lastly, it is common courtesy to forewarn the doctor that you have specific issues to discuss, so that he has time to think about and prepare for the discussion as well.

One doctor remarks on the ability of some doctors to hear what patients are saying:

Some doctors have such a strong ego that they can't even hear a patient's constructive complaint. You have to be very comfortable with yourself to be a good doctor and there are a lot of doctors out there who are not. If they feel that they are being challenged, it affects their sense of self. Many of them cannot be objective about the situation and really hear what's being said. Sometimes they become defensive or belligerent.

When you call for your appointment, tell the receptionist that you need to talk to the doctor and it may take a while. This should ensure that you are given more than a ten-minute slot for your discussion. If the doctor knows she has time for a discussion, she might be less likely to interrupt or rush you. Knowing you have a chunk of time may help you relax, as well. This patient handled such a situation well:

I was extremely concerned about some of the side effects of the treatment my young daughter was experiencing. I called the pediatrician's office and told the receptionist that I needed a lengthy appointment to discuss the problems. I wrote down the side effects that I was concerned about (so that I wouldn't forget any in the heat of the moment), looked into some other treatment options, and went to the appointment with my notebook and articles.

When I went in, he took me to his office rather than an examining room, and we both sat down. He looked exhausted and I felt teary. He apologized at not giving me his full attention and explained that he had been rerouted due to snow the night before and ended up driving all night to get back into town (a mountain pass had been closed). We decided to discuss it another time when we both felt better. And we did.

Get an advocate. If you feel intimidated or overwhelmed, it may help to have an advocate at your side during your appointment with the doctor. Even if you feel strong, another person to take notes or listen to explanations can help you keep focused on questions you're asking. If you feel intimidated, an advocate may help equalize the power equation with your doctor. One advocate recounts:

We have an elderly client with breast cancer whose doctor (a female surgeon, I might add) treats her like she is senile. The patient is 80 years old and quite disabled, but mentally sharp as a tack. She is, in fact, a highly educated and sophisticated woman. But the surgeon keeps treating her like a child. She was trying to ask questions and discuss treatment options with the physician, and the physician would have none of it. We have spent a lot of time with the patient pointing out that she did have some treatment options, and getting her to speak with physicians within her plan who could fill in the picture with absolutely necessary data. In the end, one of the patient's friends, who happens to be a psychologist, went with her to one of the appointments. All she did is sit in the corner and listen and take notes. However, the physician treated the patient completely differently when someone else was present taking notes.

Send paperwork early. If you need to bolster your position with documentation, fax or deliver it several days before the appointment. You may, for instance, be discussing a difference of opinion on your treatment plan. If you have researched the illness, you probably have recent articles or treatment guidelines to share with the doctor. If he has time to read, think about, and verify the information (perhaps even research rebuttal papers), you will more than likely have a fruitful discussion. It isn't fair to try to discuss articles that the doctor has not had a chance to read. It frustrates him and may be a waste of time for both of you.

Watch your body language. A large amount of what you communicate during a discussion is done nonverbally by body position, eye contact, and distance between you and your doctor. Give some thought to how to use body language to your advantage. For instance, don't try to discuss something important if you are lying down and the doctor is standing at your bedside. If you are confined to a hospital bed, crank up the head and ask the doctor to sit down so you are looking eye-to-eye. Similarly, don't try to talk over something important if you are in an examining room sitting on a table in a short gown. Make arrangements to talk with your clothes on, preferably in the doctor's office. Practice your tone of voice before the meeting. You should strive to sound like a colleague, neither adversarial nor submissive.

State the problem. A clear description of the problem in a nonaccusatory voice sets the stage for resolution. Use concrete terms to describe the problem, and try to limit yourself to one problem per meeting--a long laundry list will create more conflict, not resolve any. In the following case, a businessman made his point to the hospital staff in firm, clear, and pleasant terms.

I asked to get my transfusions after 5:30 P.M. so that I could stop losing all of my vacation and sick time. I was spending four hours a day between 9 and 5 at the hospital attached to a bag. Transfusions can remove hours and hours of work time, but it need not be so!

I pointed out that my insurance was paying close to $250,000 for my bone marrow transplant. In my world of industrial sales a $250,000 customer was treated like a king! I asked that they see me as a customer of that hospital and that their office hours for transfusions were not convenient for this big time customer. I needed to get transfusions after work or lose my job and the big insurance. When I put my request in money and customer service terms, they had no valid objections except that it had never been done. I was warm and pleasant at all times, but very insistent that they find a way. They did.

Here is my point. We should help the medical profession learn good customer service skills. They will never know if we don't speak out.

It also helps to be concise. You might write out or outline what you plan to say, and practice in front of a mirror. When talking to the doctor, make your description of the problem short and to the point. The longer you talk, the more likely it is that you will be interrupted. If you are interrupted, say, "I would like to finish my thought. It will only take another minute or two. Then I'll be very interested in hearing your ideas."

You may be more comfortable writing than talking face-to-face. If this is the case, try to use the same positive tone in your letter. One woman encountered numerous difficulties during her husband's long illness. She explains her approach:

I've written several truly nasty letters myself. Then I tear them up and write a more polite, brief note detailing the problem. Since I have a vegematic tongue (it slices, it dices...) the nasty notes should never be seen by anyone but myself. But writing them really helps clear out my system.

I also make it a point to write thank-you letters to doctors and health care people who have gone out of their way for John.

Explain how you feel about the problem. One excellent way to prevent more confrontation is to use "I" messages. If you state the problem in terms of how you are feeling, it is less likely to sound blaming and more likely to be heard. For instance, you could say, "When you told me the diagnosis and then turned and walked out of the room, I felt terrified and abandoned. I would have felt much better if you had expressed concern or had held my hand." This kind of description is easier to hear rather than a blaming one like, "You treated me like a lump of meat rather than a person."

Clarify what you would like to see happen. After you describe the problem, consider offering a potential solution. This lifts you out of the "complainer" category and into a partnership attempting to work out a constructive solution. Complaining frequently ends in circular discussions of accusation and response, rather than working toward a solution. Setting a clear goal will more likely result in you getting what you want.

Listen. After you have stated the problem and what you would like to see happen, stop. It is your turn to listen without interrupting. Make eye contact and lean forward to indicate your interest. Avoid body language that indicates a closed mind, such as crossed arms and legs, turning away, or moving about.

Restate what you heard. After the doctor stops talking, restate briefly what you heard. For example, if you told the doctor that you wanted to change blood pressure medications because of unexpected side effects, and he explained several other drugs that you could try, respond, "I hear you say that x, y, and z drugs are all possible replacements. Which would you recommend and why?" If, however, the doctor gives a long reply that says there are no alternatives to treat your problem, you could say, "Are you saying that in your judgment there are no other methods to treat my problem?" Then listen for the answer.

Negotiate. Once you and the doctor have each clearly stated your positions, talk over the options. You have a right to vigorously negotiate for what you want.

Agree on a plan. Your negotiations should end in agreeing upon a plan of action. Make sure that you are comfortable with the solution. This parent's agreement satisfied both the parent and the doctor:

We had a problem with the pediatrician's office not calling the specialist's office with the results of my son's blood work. This would result in worry for me and delay in changing his medications. I told the pediatrician's nurse that I knew how busy they were and how I hated having to keep calling them to get the results. I asked if it was possible for them to give the lab authorization to call me with the results. They thought it was a great idea and it worked well. The lab would fax the doctor the results but call me. I would call the specialist and find out if I needed to change his meds. The specialist would fax the med dose change to the pediatrician's office. It was a win/win situation: the doctor's office wasn't interrupted, they got copies of everything in writing, and I was worry-free.

Agree to disagree. Assertive patients sometimes find that, after a thorough discussion, they simply disagree with their doctor. If you've calmly explained your decision, listened to her side, and still have a different opinion, then it's time to agree to disagree. In rare cases, if your doctor feels that your decision is life-threatening or unconscionable for some other reason, she might remove herself from your case. Usually, however, you will just move on. Here' show one patient handled the issue:

Our pediatrician and I rarely disagree, but when it happens it is resolved in a healthy and graceful way. One instance that comes to mind was over occupational therapy. I thought my child would benefit from a particular type of therapy. The doctor didn't. I brought him in bibliographies of articles from the last two decades. He wasn't impressed. We discussed it and ended up just disagreeing. He didn't feel comfortable writing a referral for a therapy he thought was not helpful, so I didn't ask him to. I just told him it was refreshing to hear his point of view and I wished I could change his mind. Then we both laughed. I worked with my insurance company and got the therapy covered, and I still have a great relationship with the doctor.

Whatever you decide, try not to leave the office dissatisfied. If you can't reach agreement, tell your doctor what you are going to do. For instance, you may say, "I'll have to think about what you've said and decide what to do later." Or you could say, "I feel that this is an important issue. Could we make another appointment to talk some more?" You could end the discussion by stating the obvious: "I think we're beating a dead horse. We just disagree. I respect your position, and I hope you do mine. Here's what I've decided to do."

Problems in the hospital. You sometimes don't have time for deliberation when a problem arises in the hospital. Your best bets are to ask a nurse for help, talk to the social worker or chaplain, talk to the hospital's patient advocate, or get a family member to try to resolve the dispute. It's hard to talk tough when you're flat on your back. Here is advice from a nurse:

I'm an ICU nurse in a teaching hospital. If someone is having trouble in the hospital, I advise them to find a talkative and friendly nurse and ask for advice. There is no better source of information. If I think a resident is in over his head, I try to talk him into calling the attending doctor. If he doesn't, I call the doctor myself. Sometimes the residents get mad, but the patients get the experienced help they need.

If the problem has not been resolved by talking with the doctor, nurse, or social worker, find out about the hospital's process for addressing ethical issues. Hospitals are required by the Joint Commission on Accreditation of Healthcare Organizations to have a method of dealing with ethical problems. Many hospitals, and even some health plans, have ethics committees. How you access this committee varies from hospital to hospital. One doctor describes the system at the teaching hospital where she works.

In our hospital, a patient can pick up the phone, call the hospital operator, and ask to speak to whoever is on call for the ethics committee. We also put a brochure in the admissions material that describes the committee and what it does. It serves anybody--patient, doctor, nurse, social worker. It is a neutral entity. Usually, issues come forward from the patient representative, social worker, nurse, or chaplain. Any issues are addressed, such as organ donation, end-of-life issues (turning off ventilators, hydration, feeding), and balancing economic issues with patient care. Another area is resolving ethnic/religious issues of the patients that are not understood or respected by members of the care team. They basically mediate between people with problems.

Mending fences. If you feel that some damage was done to your relationship in the discussions, you might consider mending fences. This doesn't mean capitulation; rather, it means putting the dispute in context. For instance, if you have had a satisfying and long relationship with your doctor, you might want to write a letter to tell him the things you appreciate about his care. Or you may need to simply clear the air.

The following are some suggestions for things that help with problem solving in medical situations, and things that tend to make things worse.

Deal with one problem at a timeBring in a long list of problems
Speak respectfullySpeak critically
Focus on your goalDigress
Offer clear informationChallenge what he knows
Ask questions to clarifyMake assumptions
Anticipate disruptionsAllow intimidation or interruptions

Problems that can't be fixed. Some disputes can't be resolved, and some relationships break beyond repair. If you find yourself enmeshed in one of these situations, finding a new doctor may be your best recourse. More serious problems--impaired physicians, serious medical errors, violations of confidentiality--require outside help.

This fact sheet was adapted from Working with Your Doctor: Getting the Healthcare You Deserve, by Nancy Keene, © 2001 by Patient-Centered Guides. For more information, call (800) 998-9938 or see www.patientcenters.com.

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