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Survive Your Doctor's Care

In today's world of managed care and HMOs, getting quality health care can be very difficult, but not it's not impossible.

In her new book, "How to Survive Your Doctor's Care," Dr. Pamela Gallin of Columbia Presbyterian Medical Center in New York City gives advice that can help keep you and your family make better health care choices.

Gallin stopped by The Saturday Early Show to explain the essentials of navigating the health-care system. She says now, more than ever, patients must assume a more active role in their care.

Even though she's a doctor, Gallin has her own health-care horror story: "I'm a right handed surgery and I needed surgery on that hand. The operation went fine, but the doctor put the cast on too tight. I complained, but he said that everything was fine. My error is that I should have insisted that he or an associate of his see me right away. Instead I waited a few days and had complications and had to have two more surgeries to correct the errors. I should never have felt cowed by him."
So, is it possible for the average person to get good care?

Gallin says yes, absolutely! She offered some tips:

Choose the medical center you want before you choose the doctor
Most people choose their doctor before they choose their hospital or medical center. But, she says, it's a good idea to choose a hospital first, because you will also be indirectly dealing with a team of "invisible" doctors, such as a radiologist or pathologist. And, at a good hospital, you can be assured the "invisible" doctors are of a high caliber. If you have a wide choice when selecting a hospital, pick one that's affiliated with a medical school.


Investigate "affiliate" hospitals
An affiliate hospital is a smaller center that is connected to a larger institution. For example, a big city hospital may have a branch in the suburbs. In some cases, doctors from the larger hospitals will visit the smaller branches and do some of their rounds there. In other cases, the affiliate hospitals are only connected to the bigger hospitals on paper. Gallin recommends that if you decide you want to go with an affiliate hospital, do your homework to see if the doctors there also work at the bigger institution.

Stick with the same medical center
Gallin says it's a good idea to get all or most of your medical care through the same medical center. Doctors at the same institution often interact with each other on a regular basis and many of your records are in the same computer system. If you skip around to different hospitals, it's harder to keep track of your records and your doctors will be dealing with people they don't interact with on a regular basis.

Get a primary-care physician
Many women use their ob-gyn as their primary physician, but Gallin says this is a bad idea. She says you need to have a doctor who has an overview of your entire health history. And if you have a good primary-care physician, that person can always refer you to a specialist. Gallin says that in many cases they'll only refer you to a specialist who has a good track record. They will not recommend you go to someone who other patients have complained about.

Get a second opinion on all biopsies
A biopsy will determine the entire course of your treatment, so it better be right. Gallin says it's very easy to express mail your slides anywhere in the country and get quick results. But, many people are members of HMOs that don't always pay for second opinions on biopsies. Gallin says this is a case where you should bear the brunt of the cost on your own. So, put off buying a new pair of shoes or going out for dinner because there is nothing more important than your health.

Get an advocate
Gallin says when you are sick or in the hospital, you are not thinking clearly because your emotions are often guiding you. Or you might be unconscious, or under medication that keeps you from thinking clearly. So it's important that you designate someone who has your best interests at heart. That person should convey your needs to those around you. In many cases, a family member will do. But, family members can also get caught up in emotions. So, you may want to pick a friend or someone who you know can keep a cool head in a difficult situation.

Don't take no for an answer
Gallin says if you think something is wrong, it probably is. So, listen to that little voice in your head. Even if the doctor says that everything is fine, it may not be. Don't be afraid to speak up and ask the tough questions.

Read an excerpt from "How To Survive Your Doctor's Care":


CHAPTER TWO

The Medical Center:

Your Most Important Choice
THE MOST SIGNIFICANT DECISION you make in setting up your medical care is choosing a hospital or medical center. If that surprises you, you're not alone. Most people consider the hospital secondary to the physician. After all, the physician is the one who tends to you.

The hospital is seen simply as the backdrop, the setting for your physician's care. But a smart medical consumer will zero in on the hospital. One reason is that all hospitals are not created equal. Another is that once you've chosen a hospital, you're well on your way to getting your personal medical care system in place.

The old model of medical care was based on the sole-proprietor small business; a doctor ran a kind of Mom-and-Pop operation. Today, however, doctors function as part of a larger organization. When in search of a treatment or diagnosis, rarely do you consult and receive care from just one doctor.

As a consumer, you need to think in terms of the larger organization—in terms of the doctors connected to your primary physician—and choose on the basis of the quality and availability of resources, for that one choice will determine every other aspect of your health care. Learn what you can about your hospital options. Before you put your toe in the water, it's best to figure out what kind of pond you're dealing with.

Addressing the hospital question first helps you keep the big picture in mind. Then, once you're hooked into the hospital, you can find an appropriate physician because many physicians will serve at that hospital. When you work with a doctor, you are really working with a team of doctors—a team of generalists, specialists, and subspecialists continually working together through consultation and referral.

The smart strategy is to pick the team and then choose the player. Think of the Yankees in baseball. All the players are good. Some are better than others, of course, but deciding to put a Yankee on the field gives you a certain guarantee of quality. It's much the same way in medicine.

It's not easy to join a hospital's rank. A doctor can't just waltz up and say, "I want to practice medicine here"; he or she has to be chosen. So if you pick a good team—a good hospital—the institution has done a good amount of the sifting through for you.

No doctor works in a vacuum, so you want to know your doctor has good teammates. Even the simplest exam may require lab tests or X-rays, which means that other medical personnel are already part of your care. As a colleague of mine noted, we rarely see a patient without ordering something or interacting at least informally with someone else.

The competence, timeliness, and judgment of these "invisible" doctors can have a great impact on the treatment you get, without your necessarily knowing it. Although you did not select these other medical professionals individually, you have de facto selected them by choosing a particular institution.

Every patient benefits from the connections between physicians that evolve over time. As a doctor in a hospital, I become used to interacting with other affiliated physicians. The importance of such working relationships may not be apparent to the outside.

For example, let's say I call a pulmonary specialist at my medical center and say, "I have a patient I would like you to see." He would snap to attention. Why? Not because he's doing me a favor, but because he knows that I rarely call him. He will remember that the last time I called him on a patient's behalf, it was serious. And of course it's reciprocal. I'll listen when he calls me. Collegial relationships like this are part of an institution's package.

The hospital also serves as a base for an entire referral network. When you need a specialist, you don't want to be flipping idly through the yellow pages. In any hospital, there are established referral patterns that have achieved prior results. Sure, you can choose your own specialists, but there's a lot to be said for going with a specialist whom your primary care physician is used to working with and knows will treat you well.

What you are looking for in a hospital is internal quality control. A hospital will allow only people with a certain level of credentials to get on staff. You want to know that the hospital you go to has a level of quality control that's extremely rigorous and goes across all the specialties.

It's a lot like going to a hotel: If you go to a Four Seasons Hotel, you're assured that all the services are good and that everyone who serves you is professional, so you don't need to worry about each and every detail. You want some sense of quality because, with any hospital, you're not just getting your doctor; you're getting everything and everybody else.

But first you need to know what kind of hospitals are out there.

DIFFERENT TYPES OF HOSPITALS

The Joint Commission of American Hospitals certifies hospitals on three levels: tertiary, secondary, and primary. In general, tertiary refers to the major medical centers, secondary to good community hospitals, and primary to small rural hospitals. What the differences mean to your actual care may not be immediately evident. Let's look at what you get.

TERTIARY MEDICAL CENTERS

These are the names you've heard: Columbia-Presbyterian Medical Center, UCLA, Massachusetts General, Washington University, Baylor Medical Center, Mayo Clinic, Johns Hopkins. These are full-service, major medical centers. To carry the hotel analogy a bit further, these are the luxury hotels of the hospital world; every possible need has been anticipated. During a stay at the Ritz, you can call room service at 3:00 A.M. and order fois gras, a cheeseburger, or whatever strikes your fancy. Services are that extensive: No matter what you want, they have it when you need it. You may not know in advance that you want it, and that's the point. The hospital equivalent of the Ritz has a helipad, a full surgical team (doctors, an anesthesiologist, and specialized nurses) not merely "available" but actually ready to take care of you, and every specialist and subspecialist known to man.

There are not just neurosurgeons, but neurosurgeons who do backs, neurosurgeons who do tumors inside the head, neurosurgeons who work with seizures. There are ENT (ear, nose, and throat) people who specialize in ears, who specialize in noses, who specialize in cancer, and so on. Among the pediatric staff, there's likely to be an entire children's surgical specialty group, with pediatric surgical subspecialists in ophthalmology, orthopedics, neurosurgery, cardiology, ENT, urology, and pathology, plus a squadron of general surgeons.

Sometimes you need all this, sometimes you don't. But what you're getting at a major medical center is predictability in circumstances that may be unpredictable. Whatever you come in with, they've seen it before. That's important. If, for example, you are anticipating a complicated delivery, the hospital would have an obstetrician, a pediatric neonatologist, and an anesthesiologist or two waiting in the wings to address any problems. And that's only the personnel you know about.

A hospital is all about the people who staff it. It's not just about a pretty place or equipment. Looks may be deceiving. Many less-than-the-Four-Seasons hospitals are well tended and beautiful. Likewise, a fine major medical center may have dingy offices or hallways. But when you get down to the issue of what's being done for you, don't reject an old physical plant. Because it's not the machines that are important, but the people who run them.

Here is the story of someone who allowed himself to be swayed by the niceties of a lesser place, to his detriment:

John, a family friend and the former CEO of a large financial company, had a complicated neck problem. He was from New York but now lived on the west coast of Florida. He saw a local physician, whose immediate response was, "Go up north and see a neurosurgeon."

In New York, he gathered opinions from several good physicians, and it looked as if the surgery was all set. Then he got a call from his nephew in Florida, a physician administrator for a small community hospital (note: beware of well-meaning relatives) who said, "I've got a great hospital down here," meaning Florida's east coast. "I will take good care of you in my hospital. Come here." When I heard about this, I told John, "No, the place is too small. The surgery should be done in a place where they regularly do this kind of thing. If it were my neck, I'd go north."

I could see no advantage to having the surgery in eastern Florida. Since it was an hour's flight away, his wife would still have to camp out. And while the orthopedist may have been every bit as wonderful as they said, an operation like this should be done by an experienced neurosurgeon.

The smaller hospital would have only a general anesthesiologist rather than a neuro-anesthesiologist. And the surgery was especially complicated because the incision would need to be made in the front. I was nervous about this.
The day of the surgery, I got a call from my mother: "The anesthesia went fine, but the surgeon put his finger through John's esophagus (swallowing tube)." "[Expletive deleted]," I said. The plan now was to wait two weeks and attempt the surgery again.

"What? Go back there?" I said to John when I talked to him later.

"They were so nice," he said. "The surgeon was so apologetic about what happened."

Of course he was apologetic—he was no doubt mortified, if not terrified of a malpractice suit, and, as a diligent physician, quite concerned. Meanwhile, I asked an orthopedist colleague if this kind of thing happened often. He said, "I know it's a rare complication."

I pressed him: "Actually, I never saw it in training or heard of it happening anywhere during that time."

When John went home to recover, his local doctor urged him to rethink his plan, saying, "Will you please go to a larger medical center? Look what almost happened to you!"

John finally agreed to go to New York and had a pre-operative meeting with the anesthesiologist, who asked detailed questions about his medical history, including a previous heart attack. "They never asked me these questions before," he said. "I've never seen anyone so thorough in my life!" Well, this was a neuro-anesthesiologist. At this point, however, the surgery was twice as hard because it was a redo. Nevertheless, because of the surgeon's competency and experience with the exact procedure, the operation was a success. But now John is angry because his neck hurts. Of course his neck hurts—he had two surgeries!

This wasn't a disaster, this was a near-disaster. And a warning.
What you want from a hospital is staff with expertise and judgment. You want people who have seen what you have as well as variations of what you have so they see the patterns and understand how it all fits together
diagnostically. You want to be prepared for every contingency. In a top-notch hospital, at any given time you have operating rooms on full alert like the F-16 pilots who were flying over my house for a couple of months after September 11, making me feel very nice and secure.

In fact, they lulled me to sleep. They were flying over the Hudson between Manhattan and a nuclear plant not far away, and they were protecting us from any mishaps or attacks. It was really nice to hear those guys. I never said hello to them. I never even waved. The same is true at the hospital. You don't have to acknowledge everyone who's there to protect you, but it's nice to know they're there.

From the book, "How To Survive Your Doctor's Care," by Dr. Pamela Gallin; Copyright (c) 2003. Reprinted by arrangement with LifeLine Press. All rights reserved.

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