FWD:NY Times-Patient Power Making Sure Your Doctor Really Hears You

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THE CONSUMER; Patient Power: Making Sure Your Doctor Really Hears You
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By DEBORAH FRANKLIN
Published: August 15, 2006
It's one thing to feel like a master of the universe when wearing a buttoned-down power suit. But how can you negotiate anything -- how can you even contemplate ''Getting to Yes,'' as one motivational best seller puts it -- when standing barefoot in a paper gown under the fluorescent lights at a hospital or a medical clinic?

Research shows that although most people claim to want as much information about their medical conditions and treatments as they can get, even the most confident are struck dumb -- or at least awkward, anxious and often ineffective -- when talking to doctors.

The power gap often shuts patients down.

''My doctor's great in most ways,'' said Katherine Rosenberg-Wohl, a Harvard-trained lawyer turned playwright who has stood up to more than her share of glowering judges and corporate stiffs.

''If we need to talk about something important, he waits until after the exam, after I have my clothes on, and has me come into his office,'' she said. ''But even that doesn't help much.

''He's still the guy with the white lab coat behind the giant desk. He's moved on to being David Letterman, and I still feel like the schlub in the paper dress.''

In the last few years, medical schools have started trying to bridge this gap by teaching students clinical communication skills -- Bedside Manner 101.

As part of earning a medical license, for example, third- or fourth-year students are now required to face actors playing the roles of patients with myriad diseases and dispositions.

The students are then tested on how well they interview the patient, conduct the physical exam and convey the findings to the patient and to colleagues. Empathetic skills are considered a big plus.

The training doesn't stop after graduation. In March 2005, the Communication Skills Laboratory at Memorial Sloan-Kettering Cancer Center began offering a series of three-hour interactive workshops intended to give hospital oncology residents practice in ''Breaking Bad News,'' ''Discussing Prognosis'' and ''Responding to Patient Anger,'' among other touchy topics.

Still, with all the emphasis on doctor-patient communication, the patient side has largely been neglected.

Sure, there are plenty of patient ''empowerment'' Web sites and books, like ''You: The Smart Patient: An Insider's Handbook for Getting the Best Treatment,'' published this year. Written by two physicians -- Michael F. Roizen and Mehmet C. Oz -- the book is a well-written guide, packed with pep talks and tips to help patients cut through medical jargon, find a good surgeon or hospital, get a second opinion and navigate health insurance problems.

But like others in its genre, the book tends to skimp on the rules of etiquette and body language that can transform a hostile or misunderstood exchange into a smooth connection. It offers a checklist of 34 questions you should ask your doctor before surgery, but it doesn't provide guidance on how or when to raise those questions -- or even how to get through the list -- without alienating the guy who's about to carve you up.

Under the time pressure that is part of any medical visit, how exactly do you respectfully disagree with your doctor and still get the help you need?

Virginia Teas Gill, a medical sociologist at Illinois State University, said the number of encounters that require a negotiation between the doctor and the patient seemed to be on the rise.

This is not just because of the time and financial squeezes imposed on every visit by health insurance companies but also because new therapies and sensitive scans and tests are permitting diagnosis and treatment for many diseases much earlier than ever before. Lumpectomy or mastectomy? Injectable insulin or a pump? Statins or simply more exercise and less food?

In many cases, Dr. Gill said, when and whether to treat has become as legitimately debatable as what treatment to use.

Some patients show up to a scheduled appointment with a fistful of questions, ''and that's fine, that's very good,'' Dr. Gill said.

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''But,'' she continued, ''to get them answered, write the questions down beforehand, and say at the outset of the office visit: 'I've got some questions. When would be the best time for me to ask them?' ''

That alerts the doctor -- who has to keep an eye on the time -- to what the patient's agenda is, so that the two can prioritize what to cover and decide whether they'll need a follow-up meeting, Dr. Gill said.

Richard Frankel, a medical sociologist at Indiana University who helped develop a training program that Kaiser Permanente is now using to teach its doctors to be better listeners, suggests that medical encounters often go wrong because doctors assume that the first symptom or concern a patient raises is the only one -- or at least that it's the most important.

Instead, Dr. Frankel said, studies show that the most important symptom or worry -- a suspicious mole or lump, for example, or the feeling that life isn't worth living -- is often the third or fourth item on a patient's list, blurted out at the very end of an appointment. This may be because the patient is afraid, the problem is hard to admit or the patient didn't understand how medical exams were typically structured.

Dr. Frankel advises patients to put all the items on the table at the start of a visit. If the doctor interrupts to focus on the first problem, say something like: ''You know that's one concern, but maybe not my most important. Could I give the full list before we go on so we can prioritize?''

Rather than be offended, most doctors are likely to listen more attentively, he said.

''Patients always have the right to question or refuse treatment or tests,'' Dr. Frankel added. ''Anyone worried about offending the doctor might find it easier to begin such a discussion with something like: 'Could you please review the benefits of this treatment for me again so that I can write them down? Good. Now, could we talk about risks, too? O.K, so tell me again why you think the benefits outweigh the risks in my case?' ''

Patients can improve the quality of their care -- and their lives -- by also being straightforward with a doctor, but as specific as possible.

''Instead of asking, 'Is it important that I start the chemotherapy next week?' don't be afraid to tell the doctor: 'My cousin's wedding is next week, and I'd like to go. Would it be O.K. to start the chemo after that?' '' suggested Carma Bylund, a behavioral scientist in the psychiatry department at Sloan-Kettering who helped create the hospital's communication skills program for students.

Bringing a trusted friend or family member to the exam can also help make sure that delicate questions are asked and answered.

Preliminary research suggests that the Internet is already transforming many medical encounters, Dr. Bylund said. Some patients now come armed with sheaves of journal articles and printouts, and demands for specific treatment.

However, she cautioned, just because patients now have access to much of the same information that doctors do doesn't mean they have the expertise or experience to weigh that information.

Doctors don't like confrontation any more than patients do; they may give in to a patient's request if it is made in an assertive manner. In a study under review for publication, Dr. Bylund found that patients who persistently asked for a specific treatment or test, based on Internet research, were more likely to get it than patients who came in with a vague list of symptoms, or who were more deferential to the doctor.

But be careful, she warned. Anyone who treats a doctor as a dispensary instead of a trusted medical guide loses the advantages of the physician's experience.

Negotiating to win, in this case, may get you what you want, but not what you need.