It's Your Care. Take Control of It, Recommends One Physician.

[Guest guest]

Who's in Charge?

It's Your Care. Take Control of It, Recommends One Physician.

 

By Marc Siegel

Special to The Washington Post

Tuesday, July 11, 2006; Page HE01

http://www.washingtonpost.com/wp-dyn/content/article/2006/07/10/AR2006071000701.\

html

 

For much of my 15 years of medical practice, I was a card-carrying member of

the group of doctors who resent know-it-all patients -- the Web surfers, the

health column clippers, the types we suspect are out to feed their egos by

proving they know more than their physicians.

 

But most self-informed patients can sense our cynicism, and they don't like

it. A 2003 study published in the International Journal for Quality in Health

Care added to growing evidence that, for patients, physician " empathy is

perceived as going hand-in-hand with competence. "

 

Fortunately, my jaundiced view has given way to an appreciation for patients

who inform themselves. It turns out that patients we acknowledge as stewards

of their care tend to be more satisfied with their treatment. Several studies

also seem to suggest that informed patients tend to have better outcomes.

For the ideal combination, mix an informed patient with an inquiring

physician. Arthur Caplan, chairman of the medical ethics department at the

University of Pennsylvania, likes to cite a quote attributed to the ancient

Greek physician Galen: " The best physician is something of a philosopher. "

Such a physician does more than " pose questions, " says Caplan. He " isn't

afraid to have them asked. The process of questioning can lead to

understanding and patient satisfaction. "

 

My patient Brian Morton, a 50-year-old writer and teacher, became more

cautious about his health after dealing with his infant daughter's illness.

Morton began to read more about health and medicine and to ask more questions

of me.

 

I treated Morton for high blood pressure with a diuretic and a pill, Diovan,

that dilates arteries. But when I began raising his Diovan dose in response to

high readings -- ranging from 160 to 180 systolic pressure over 100 to 110

diastolic pressure (normal is generally considered less than 130 over 85) --

he was uneasy. Concerned about the potential side effects of higher doses,

including fatigue and dizziness, he began to measure the pressure himself and

record the values at home. The readings he got were consistently lower, 120 to

140 over 80 to 90.

 

What the two sets of readings suggested was " white coat syndrome, " a

recognized phenomenon in which blood pressure levels are higher in a doctor's

presence. These results helped me to adjust his medications more effectively.

Though I didn't disregard my own readings, I did begin to figure his in. I

became less likely to raise his dosage automatically in response to an

elevated value obtained in my office.

 

Some doctors would have been made uneasy by Morton's increasing scrutiny -- he

kept track of all his medicines, and once stopped the pharmacist from

dispensing too high a dose by mistake. But I learned that he wasn't unhappy,

just questioning. Once he saw he could remain in control of his health

decisions, our relationship was able to flourish.

 

Doubting Gout

 

Morton is not an isolated case. Patient knowledge often informs treatment --

or should.

 

Of course, not all information is helpful. Direct-to-consumer ads, which now

account for more than 16 percent of drug company marketing dollars, lead my

patients to pressure me to prescribe the newest and most expensive drugs,

thereby overlooking cheaper tried-and-true generic drugs.

 

I have also found that many Internet Web sites, even when they report factual

information, skew toward severe cases and prompt patients to believe their

health is worse than it is. Even the most reputable online sources, such as

Web-MD ( http://www.webmd.com/ ), the Centers for Disease Control and

Prevention ( http://www.cdc.gov/ ) and the National Institutes of Health (

http://www.nih.gov/ ), may lead many patients to worry unnecessarily about

their symptoms.

 

Whatever the source of a patient's information, a physician is most effective

when he or she isn't defensive, but acts as an interpreter of information and

guide of treatment, leaving the ultimate control to the patient.

 

That's not just my opinion.

 

A 1999 Canadian research review of 22 published studies focusing on crucial

aspects of doctor/patient communication, including " clear information provided

to the patient, mutually agreed upon goals, an active role for the patient,

and positive affect, empathy, and support from the doctor, " found that these

features led to patient satisfaction and adherence to treatment plan. And the

studies showed a " generally positive effect of key dimensions of communication

on actual patient health outcomes such as pain, recovery from symptom anxiety,

functional status, and physiologic measurement of blood pressure and blood

glucose. "

 

Many studies have shown a link between poor patient understanding about his or

her health (that is, poor health literacy) and poor outcomes. In 1999, a

committee of the American Medical Association's Council on Scientific Affairs

tied health literacy to improved health outcomes for multiple diseases. A 2002

study in the Journal of the American Medical Association linked the use of

patient self-management education programs with improved outcomes in many

chronic illnesses.

 

On their own, many of my patients have developed self-education skills, some

of which have led to astute self-diagnoses.

 

New York microbiologist Guenther Stotzky, a longtime patient of mine,

developed a painfully swollen leg a few years ago. Examining him, I could make

no definitive determination, since there wasn't the kind of accentuated warmth

or redness characteristic of infection or a blood clot. I felt he had probably

strained a muscle, but he felt strongly that he had gout. So did his

cardiologist.

 

" What does your cardiologist know about gout, " I grumbled.

 

I had reason to be skeptical. Yes, his leg was tender and swollen, and

slightly warm to the touch, but it lacked the bright-red, extremely painful

joint inflammation that I -- and other physicians -- commonly ascribe to gout.

But Stotzky had read about atypical presentations of gout on the Internet, and

he convinced me that he was right, especially when his uric acid level came

back suspiciously high, characteristic for gout. I treated him with two

anti-inflammatory medicines, and he improved.

 

I suppose I was more open to Stotzky's ideas because of his scientific

background. But I was also starting to learn that my patients often know their

bodies better than I do, and that they, too, can read up on their symptoms,

coming to me with a diagnosis already in mind. I am less likely to be

embarrassed if I don't battle my patients for control, but let them provide

insights into their own health.

 

A Cholesterol Quandary

 

Some patients readily offer suggestions. Others rely more on my input. A third

kind of patient incorporates their suggestions together with my input.

One patient, a nationally known 52-year-old lawyer, who -- she asked that her

name be withheld so that her medical history not become known to clients or

judges -- preferred that all medical decisions be made jointly -- in much the

way, I thought, that she mediated solutions in her law practice. We had

developed a good rapport. She was in good health and rode horses regularly.

Our main discussion at her yearly checkups concerned her elevated cholesterol

level.

 

Her total cholesterol ranged between 230 and 260 (well over the 200 ceiling

recommended by the American Heart Association) and her low-density lipoprotein

(LDL, or " bad " cholesterol) ranged from 140 to 160, considered borderline

high. Many heart experts feel the target numbers should be lower still.

 

But despite her readings, my patient was reluctant to take

cholesterol-lowering medication since she had no heart disease, no family

history of heart disease and no significant risk factors for heart disease.

She didn't smoke, had normal blood pressure and wasn't overweight. She said

she ate mostly vegetables and few dairy products.

 

I was less comfortable with her high numbers. I mentioned statins every time

she came to see me. She continued to resist. Although the medical literature

showed that these cholesterol-lowering drugs dramatically reduce plaque in the

coronaries of those with known disease, she pointed out correctly, there was

still no direct evidence that the treatment worked in patients without

clinical heart disease.

 

Beyond that, she simply didn't want to start a pill -- for good reason. I've

learned from my patients that pills can be a form of dependency. It is also

too easy for many medicine-takers to forgo important lifestyle changes. Though

it was unlikely to happen with this patient, many people find it is too easy

to revert to a lax diet once they are put on a cholesterol-lowering drug. I

call this the " hot fudge sundae with Lipitor on top " phenomenon.

Finally, when her total cholesterol rose to 265, I admitted to her that I was

on a statin drug myself, expecting this would provide the final reassurance

she needed.

 

" I tolerate it fine, " I said. " Some people have muscle aches, but many feel

nothing at all. I would monitor your liver and your muscle enzymes, but

they're normal in most cases. "

 

" Why doesn't that reassure me? " she replied, dryly.

 

Was there another test that could help us decide, she asked. I thought about

it and suggested performing a high-speed CT (computed tomography) scan of the

chest to look for evidence of calcified coronary plaques. This test wasn't

perfect, and I was one of many doctors reluctant to use it because of concern

it was overly sensitive (meaning that a positive result didn't always

correlate with definite disease). But in this case, we both agreed it would

provide a tiebreaker: no to the drug if negative, yes if the test showed

calcium.

 

She is now set to have the test in mid-July; her insurer will cover the $350

fee. We both hope the test will come back negative.

 

But we feel we've made a reasonable choice. We are working together in the

gray area of health care where there is no right or wrong answer. Our joint

decision on how to proceed is far more gratifying to both of us than a

unilateral one, as occurs when a patient stubbornly refuses a treatment that a

doctor is stubbornly insisting on.

 

In the meantime, my patient's cholesterol readings remain high. After reading

a news report about two patients suing Pfizer over pain, weakness and memory

loss they claim was caused by Lipitor, she shot me an e-mail, saying such

complaints are " exactly what concerns me about the drug du jour. " Still, she

is also more concerned about her cholesterol than before. On my end, there is

a growing appreciation of her right to choose as well as her intuitive wisdom

regarding her health.

 

Marc Siegel is an internist and associate professor of medicine at the New

York University School of Medicine. Comments: health.

 

 

" The only thing that interferes with my learning is my education. " -Albert

Einstein