Dr. Groopman Answers Your Questions

Last week, the Evening News talked with Dr. Jerome Groopman about his new book, "How Doctors Think." Hundreds of viewers wrote in with insightful questions, and Dr. Groopman has responded to some below.



Question: Since being fat in America is considered by many the equivalent of ugly, I have often suspected my health care providers stereotype me as a fat woman & blame everything on obesity. How do I find out what their responses to my symptoms would be if I was thin?

Thanks,
JoAnne Dauphinee
Brewer, Maine

Answer: You raise a very important issue. Indeed, there is considerable prejudice against people who are overweight. This extends to stigmatizing an overweight person as undisciplined and unhappy. As with other stereotypes, such assumptions make doctors prone to "attribution errors," meaning that we attribute the symptoms and problems to the stereotype rather than considering that this particular medical issue could be unrelated. Prejudice of any type is harmful, both for inhibiting broad clinical thinking and for conveying a negative attitude towards the patient. In your case, you should feel comfortable saying to a doctor "I know I'm overweight, but I want to be sure that when you think about my symptoms, you think broadly and don't immediately attribute them to a weight issue." A good doctor will acknowledge the wisdom of your statement, and you will get better care







Question: I saw you on CBS News with Katie Couric tonight. Thank you for your insights. I look forward to reading your book.

I am a young adult, in my 20s, and recently graduated. During my recent physical, I was asked by my doctor, "How many sexual partners have you had in the last 6 months?" I asked him to clarify "sexual partner". He said, "vaginal intercourse." I said, "0." He said, "That's great! We have nothing to worry about!"

But...I was disappointed because he did not consider that I was not heterosexual like him and probably 80-90% of his patients. I'm not; I'm gay. But I don't announce it to the world in rainbow colors. My answer for his question -- if he had not assumed that everyone coming into his office is straight (or people who somehow "look" straight are indeed straight and not gay) -- would be vastly different if he had considered that there are gay people in this world.

As he was about to go onto his next question (vaccination status), I apologized and interrupted him, and brought up the courage to tell him I'm gay...even though I could lose my job for this (in 33 states this is legal), even though I have no recourse for it if I were in fact fired for being gay, even though I could be disowned by my family who is very religious (evangelical Christian) which I know a couple friends have been, etc. And so I volunteered information about my sexual history.

My question is: How can doctors be less "assuming" about their patients' sexual orientation and more pro-active about welcoming a dialogue about gay/bi issues with their patients -- because we all want the best care and diagnoses for all patients.

Thank you very much.

Sincerely,
A concerned patient

Answer: Every physician needs to know a patient's social context, in the same way the doctor should know about a patient's family history and occupation. Every dimension of a person's life is relevant to his or her health, and must be factored in when a doctor thinks about symptoms or clinical problems. I usually ask: "What are your current social or romantic relationships?" This open-ended statement is clearly generic, not specific in its language with respect to heterosexual, homosexual, or bisexual partnerships. A doctor should not, as you say, "assume" what their patient's sexual orientation is; rather, the physician should establish a dialogue based on trust, so that the patient can comfortably discuss his or her relationships. It's also reassuring for a patient to know that there are currently very strict laws around confidentiality. There are called HIPPA regulations. Nothing that is told to a physician can be divulged to anyone else without the express permission of the patient. Gay and bisexual individuals, as you say, deserve the best care and diagnoses possible. There is a wonderful old Latin proverb that I teach my medical students: "Nothing that is human is foreign to me." This should be the creed of every doctor.


Question: Hi, as a first year medical student at NYU, I'm learning about how to be sensitive towards patients through our physician, patient, and society course. Is this program-type being implemented at other medical schools? What more do you thinks we as medical students can learn to prevent this type of problem when we, in the future begin to take care of our patients? - Vasthie Pruden

Answer: Medical schools are starting to foster sensitivity and humanism among their students. During internship and residency, it can be very difficult to focus on caring while enduring tremendous time pressure and the daunting challenges of learning how to deliver treatments and learn procedures. Nonetheless, senior physicians should serve as models to trainees, emphasizing that, in the words of Dr. Francis Peabody, the secret of the care of the patient is in caring for the patient. A major gap in today's medical education is the lack of attention to thinking about how we think as doctors. This is relevant, because our emotion, both positive and negative, can strongly color our diagnoses and decision making. I hope that your generation of students will benefit from an evolving curriculum that integrates both cognitive psychology and models of authentic caring, along with the necessary knowledge of physiology, pharmacology, pathology, etc.


Question: I would like to ask Dr. Groopman how does a person know when they are about to engage in a "fencing match" with a doctor, and how can it be defused so that both doctor and patient can work together to get to the bottom of the problem. Thank you so much.

Keith Myers
Indianapolis, Indiana

Answer: In my book I interviewed Debra Roter at Johns Hopkins and Judy Hall at Northeastern University, among the foremost experts in physician-patient communication. They studied literally thousands of videotapes of doctors and patients during clinic visits. Remarkably, when questioned after these visits, both patients and doctors accurately reported when there was tension and what you call a "fencing match." The best way for a patient or family member to defuse a contentious situation is to bring it up in a constructive way. A perfectly appropriate statement would be something like: "Doctor, I sense that we're not communicating as well as we might, and this concerns me." Most good physicians will stop in their tracks and reopen the dialogue in a more positive way. If you feel that a physician is dismissive or irritated, consider that a red flag. As I write in the book, when I raised with other physicians the very question you raise, asking them to imagine themselves as a patient dealing with a contentious doctor, every one of them said they would find a better doctor.


Question: If you are concerned that your annual physical is not comprehensive enough, what approach do you recommend that the patient use to raise the issue.

Answer: The annual physical examination is very important, because preventive medicine is the key to sustaining health and well-being. It's always better to detect a problem early and, if possible, nip it in the bud. If you feel that your annual physical examination is not comprehensive, you should feel comfortable saying to the doctor, "I really believe in being proactive about my health and I know that preventive medicine is important. Please be sure that you are as comprehensive as possible in evaluating me." Again, most good doctors welcome such words. A physician who takes shortcuts, may be setting himself up for a mistake, such as missing an early problem that could be easily remedied.


Question: If you have a conflict with medical policy, such as how the cause of death is determined, who do you contact to have policy reviewed or changed?

Answer: Questions about medical policy, such as how the cause of death is determined, can be addressed to the responsible hospital administrator. A good place to start is with the doctor who is called the "Chief Medical Officer." This is physician who is responsible for all clinical procedures and policies within the hospital.


Question: Sometimes during my physical exam my doctor will be talking at the same time he is examining me. When listening to my chest or back and looking into my ears or eyes I wonder if he is concentrating fully on what he is suppose to or if he is distracted while talking. Could he miss something important?

Thanks,
Ray

Answer: A physician talking at the same time that he is examining you can be good or bad. For example, if I feel a large lymph node in the neck of my patient, while I continue to palpate the lymph node, I will ask questions like: "How long has it been there? Is it tender? Do you think it has been growing in size?" Such questions improve my thinking about what may be responsible for the large lymph node. I try not to make small talk when I am examining someone since it does distract me from focusing on the physical examination. I do like to schmooze with my patients, but usually save this for the end of the visits when we have taken care of all the clinical issues. If someone seems very anxious, sometimes I'll chat with him at the beginning of the visit just to put him at ease before we pursue what's worrying him.


Question: What should a patient do when they suffer a previously diagnosed chronic disorder, but even their specialists brush them off as if they just don't want to be bothered? How does a patient relay their fears and concerns effectively?

Thanks for your advice,
Judith Gamble

Answer: No one should be "brushed off." Good doctors listen actively, and as I write in the book, what we hear as physicians often is the key to coming to the correct diagnosis. If you feel that your doctor is not actively listening, you should feel comfortable raising this concern. A statement like, "I'm trying to explain what's bothering me, and I want to be sure that you hear what I am saying. Should I tell you more about my symptom or my history?" This signals to the doctors that you sense that either you did not communicate well or he is not listening well. Again, physician-patient communication is the foundation of accurate diagnosis and the best treatment.


Question: As I approach 87, I sometimes get the feeling my complaints automatically get placed in the "well, you are getting older" category. I feel that is not a diagnosis of my problem. I want a specific answer not some generalization. Thank you.

Answer: This is a very important issue, and one that is close to my heart. I was very close to my grandparents, and my grandmother lived to 100 years old in relatively good health, But when she was 88, had chest pains that were dismissed as "old age" but actually indicated a brewing heart attack. Luckily, she survived. The mother of a good friend had a similar experience: her doctor stereotyped her because of her age and made an attribution error. She was also in her 80s and her memory and balance began to fail. The doctor would automatically chalk these problems up to old age. It turned out that she had Vitamin-B12 deficiency, a problem that can cause impaired thinking and difficulties with neurological functions, including balance. A very sharp neurologist, Dr Linda Lewis, at Columbia University, happened to see this elderly woman in consultation and made the correct diagnosis because she had an open mind and did not stereotype. An older person should say to his or her physician "Yes, I am getting on in years, but I certainly can develop medical problems that aren't simply due to the aging process, so please keep an open mind." A thinking doctor will think about old age and its consequences as well as clinical disorder that are independent of aging.



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