Questioning Your Doctor is Ok

I received a good question(s) from a reader:

In your “Changing the culture” posting there is the comment: “Patients seeking medical treatment should not assume a prescribed therapy is beneficial just because a doctor says it is.”… How then does a patient evaluate a proposed treatment in a way that they aren’t thwarting a doctor from performing what may be a needed course of treatment? … Other writing I’ve seen describes doctors being too accommodative to patients reluctance at a treatment. A bad feedback loop if there was one.

Patients should definitely not assume a treatment (or test) is beneficial just because a doctor says it is. Doctors often practice dogma-based medicine. We get into patterns because that is the way we were trained, or that is the way we have done it for years. One study suggests it takes 17 years for doctors to assimilate evidence into practice.

Take the care of AF patients in the hospital. We, in our hospital and hospitals across the country, are trying to increase the cost-efficiency of caring for patients with AF. The problem is huge variation in care: some docs see a patient, treat her with oral meds, and get her home the same day, while other docs see a similar patient, admit her, put her on IV meds, do many expensive tests and keep her admitted for days.

AF is a variable condition, but one reason there is this much variation in practice is that many doctors don’t keep up. They don’t read the evidence. The other reason for overuse, especially in the US, is that doctors are paid more to do more. Hospitals worry about the latter practice because although they make more money with that approach now, reimbursement will soon favor efficient care rather than more care.

In my last post, I discuss another reason you should not assume a treatment is beneficial even if recommended by a doctor: too often, doctors accept treatments based on weak evidence. Minimally-invasive robot-assisted hysterectomy ended up being 10% worse than traditional surgery. For every 10 women treated with the minimally invasive surgery rather than regular open surgery, one was harmed by having recurrence of cancer.

Doctors–including those who wrote the guidelines–accepted minimally invasive surgery for this indication based on biased weak studies. They thought it was better but when tested in a randomized controlled trial, it was not.

I know questioning a doctor may sound complicated, but it is not. I have written multiple posts (here and here) on the big four questions to ask a doctor about a treatment or a test:

1. What are the chances it will help me?
2. What are the chances it will harm me?
3. What are the alternatives?
4. What if I do nothing?

Also good news for patients is the democracy of information from the digital age. Take a look at this excellent column the journalist David Epstein wrote for the Atlantic. The title says it all: When the evidence says no, but doctors say yes. Here is a brief quote:

“While he was waiting in the emergency department, the executive took out his phone and searched “treatment of coronary artery disease.”

The point is not that you can be a doctor with a smartphone, but you can look learn basic facts and read guideline statements. For instance, the Cochrane Collaboration, a group of researchers the world over, cull evidence and publish what are called systematic reviews on medical/surgical treatments. Each one of these reviews include plain-language summaries.

Having information helps you get more out of a visit with your doctor. The doctor’s role is changing. More and more, we are becoming advisors rather than prescribers. Good doctors offer the needed context for the information you have learned. They can help you make the best decision for you.

Finally, on the last part of the question: what if having good information leads to patients not taking a treatment?

This is ok. For instance, It happens all the time with clot-blocking drugs to prevent stroke in patients with AF. When people learn how much (or, for some people, how little) the drug reduces the risk of stroke and increases the rate of bleeding, they decide not to take it. Others hear the same statistics and decide to take it.

I say this all the time during lectures on shared decision making and informed consent: doctors may be the experts in medicine, but patients are the experts in what is important to them.

JMM