Can We Talk?
How to communicate with your doctor
Catherine L. Shaner MD FAAP, Fibromyalgia AWARE

Small talk, baby talk, girl talk. We fill our lives with conversation. Sometimes, though, we need to go beyond the chatter - we need to communicate. Communication involves the exchange of ideas and requires listening as well as speaking. In healthcare, good communication provides the best outcomes with the least mistakes. As a bonus, it creates happier and less frustrated patients and physicians.

Establishing excellent communication with your doctor is important. Why is it, then, we sometimes leave our doctor's office feeling that a lot was said but nothing was accomplished? Or we feel as if we conversed in two different languages? For example:

Patient-talk: "I fell out, Doc."

Doctor-talk: "You've sustained a syncopal event, Mr. Smith.

They both mean: Mr. Smith fainted.

Were the doctor and patient talking? You bet. Were they communicating? No way! How can you assure smooth communications with your doctor?

Before The Visit

Organize ahead of time
Keep a list on the refrigerator, by your bedside, or in your purse. Jot notes about symptoms or questions as soon as they arise. A day or two before your visit organize your notes. Be as specific as possible. For "my arm hurts", you might describe the problems holding your arms up for hair drying, lifting children, or hanging laundry. Highlight the items that are particularly worrisome.

Identify goals for the visit
What do you hope to accomplish with your doctor? A diagnosis? Referral to a specialist? Report new symptoms?

Prioritize your goals, listing your primary reason for this appointment first. How many problems should you talk about at a visit? Two to five, depending on the time allotted and the complexity of the problems.

Other notes to make
Make as many lists as you need to organize all the information and questions you need to communicate to your doctor:

Current medication list: including prescription, over-the-counter, herbal supplements, vitamins, topical medications, alternative medications and treatments; allergies and previous adverse reactions; prior medications and why they didn't work.

Problem list: a complete but concise summary of your medical history. Rank conditions in order of importance, with the most important first. Give dates, if possible. Example: Fibromyalgia - 1990, migraines - 1992, gall bladder removed - 1986.

Specialist list: summarize latest recommendations. Example: Gynecologist - August 2002 - hormone replacement started.

Recent tests: include dates and locations. Always ask for copies of your test results so you can have them for your own files.
Changes in symptoms since your last visit
Questions for today
Refills needed
Forms to be completed (with an SASE for return or sticky note with your telephone number)
Bring your lists! If you forget, ask the receptionist for paper and start writing while you wait. Keep copies of your problems and medication lists in your purse or car in case of emergency and update them regularly.

At The Doctors Office

Speak up: Being part of a team requires trust and clear, open communications. Be frank, even if it's embarrassing. Hand your doctor your lists, so he knows what you want to discuss today. Remember your goals for this visit. Voice your ideas. It is best to ask questions as soon as they arise.

Clarify: Use words such as "exactly" or "specifically". Ask: How will this help me? What will happen if I don't do this? When you say to increase activity, exactly what kind and how often? Does exercise mean weights or walking? What do you mean by "come back if not better"? When and how much better?

Negotiate: Request a cheaper drug or one with fewer side effects and less risk. Ask for an easier regimen or a less painful procedure. If a suggestion is unrealistic for you, say so - don't leave discouraged because you can't do it all. Doctors can simplify or adjust treatments so you can live with the recommendations. And remember: it's okay to think about your decision or change your mind. Never be pressured or scared into an action. Short of a life-threatening emergency, there is always time to think things through.

What can get in the way?
Knowing the factors that impede effective communication is half the battle. Emotions, communication style, differing expectations, and lack of time all work against us. When emotions are high, logic is low. The shock of a new diagnosis, fear, embarrassment, resentment, intimidation, and forgetfulness (fibrofog) can all jumble our thoughts. With pain and fatigue, you might not be functioning at your highest level. If you find emotions interfering with your visit, honestly state how you feel. Naming the emotion takes some of the punch out of it. Ask for a moment to compose yourself, count to 10 and breathe slowly and deeply. Begin again if you are able or wait for another time. Consider also that a chronic illness frustrates doctors as well as patients. Although your doctor wants to help, he may feel there is little he can do for you.

Poor communication frequently results when we assume too much. Just as "straighten up your room" has both a parent and a teen interpretation, failure to clarify medical directions may result in differing expectations for you and your physician. For example, assuming your test results will be normal unless you are called could be a deadly mistake. Rather than assume, specify. Request a simpler explanation. If you learn best by seeing or reading rather than hearing information, ask your doctor to draw a diagram or give you a brochure. Ask him to slow down or confirm details. Repeat any instructions he gives you and write everything down or tape record it.

Streamlining your visit
No doubt about it, time is a huge factor in poor communications for today's healthcare providers. In an ideal world, a doctor would have enough time to answer all questions clearly. Since this rarely happens, how can you use your time with your doctor wisely? Studies show that you have 23 seconds to speak before the doctor interrupts, so weed out the irrelevant details. For example, state, "I passed out last night. They took me to the emergency room." Stop right there! Don't add, "And it was really cold in the ER and the nurse looked at me like she'd never heard of fibromyalgia and…" Unless you have more symptoms to add, let your doctor ask you questions. Refer to the list of concerns you brought with you to make sure you have all of them covered.

If there is not enough time to cover everything, request handouts and brochures that will provide you with information. Then schedule another visit with more time to fully discuss your concerns.

Before you leave
Ask the doctor for written instructions. Summarize and make sure to clarify anything you aren't familiar with. Don't leave without fully understanding your diagnosis and treatment. If the doctor has left the room, ask a nurse.

Outside The Office

I forgot to ask…
Realistically speaking, questions come to mind outside of the office. If your problem is urgent, call the office right away. Otherwise, check first to see if your question can be answered in a brochure given to you by your doctor. Consult your pharmacist for medication questions. Are you tempted to ask your chat room support group for advice instead? The Internet is a great place for researching information to discuss with your doctor, but relying on online information for medical answers can be dangerous.

Communicating by telephone
The office RN can handle most questions. Call early in the day, but be aware that your call may not be returned until the end of the day. It is helpful to compose a one sentence description of the problem, including symptoms and dates. Have medication bottles handy as well as your pharmacy phone number. Write down your questions and have a paper and pencil handy to record instructions. Inform the office if family members may receive information.

Communicating by e-mail
The majority of families with computer access want to communicate with physicians via email. Physicians generally are less comfortable with that route. Both sides have concerns about confidentiality. Some benefits of email include: ending telephone tag, speed, cutting costs, more detailed medical records, fewer medical errors, and improved compliance. Risks include: privacy and security, as well as physician concerns of staff workload, reimbursement and malpractice liability. More importantly, access to care might be determined by computer literacy. At present, most doctors do not offer email communication, but it pays to ask.

Communicating by Fax
Transmitting messages via Fax provides many of the same advantages as email. Access to a fax machine (or directly from your computer with PC-fax software, allows you to send detailed, accurate communications. Fax is an especially good method when you have multiple requests and is an excellent way to receive your lab results from the office. Bear in mind that confidentiality is an issue when using shared office equipment.

You have the right to remain silent - but don't!
Communication is a two-way street and it starts with you. Speak up! You have the right to understand your diagnosis, your symptoms, tests, procedures and all the risks and options. Your doctor has the responsibility of treating you with respect, listening, addressing embarrassing questions, educating, informing and considering your opinions and concerns. You are responsible for coming to scheduled appointments, taking your medication as prescribed, reporting adverse effects, becoming knowledgeable about your disorders, informing your doctor about your symptoms, progress, questions and concerns. Communication is an especially important skill for fibromyalgia patients. Make every word count!

Pointers For Successful Communications

Pointer 1: Talking about pain
Mention where, how much (use a scale of 1-10), what makes it better or worse, description (tingly, achy, knife-like), medications used and, most importantly, the impact on your daily functioning. Decide on your pain management goals. "I need better pain control" could mean completely pain-free (but possibly sleepy) or it could mean enough pain control to be able to play with your grandchildren, work 20 hours a week, or sleep comfortably. You and your doctor need to be working towards the same goals.

Pointer 2: Talking about tests
Discuss the reason for the test (diagnosis? Change in treatment?), method, accuracy, preparation, pain involved, when to expect results and insurance coverage. Test results are written in medical-ese, language that can be misinterpreted by non-medical people and well-trained medically knowledgeable friends. Ask your doctor to explain the wording in simple terms. Do not settle for a glossing over such as "that's nothing to worry about."

Pointer 3: Talking about medication
Know the medication's purpose, how to take it (with food, time of day, when to stop), adverse effects, interactions with other medications, when it should take effect, and cost. Make sure you can read the prescription: if you can't, the pharmacist might not be able to either. To minimize errors and complications, it's a good idea to have one doctor all of your prescriptions, even specialty medications.

Pointer 4: Talking about alternative/complementary therapies (ACTs)
Present articles from reliable sources, discuss pros and cons, and determine compatibility with your medications. Understandably, doctors are hesitant to advocate ACTs without scientific testing. However, your doctor may agree to a trial if the treatment has not been shown to be harmful. Obtain a prescription or letter of medical necessity, if possible, because insurance companies sometimes covers alternative therapies.

Allentown PA physician Catherine. Shaner not only sees fibromyalgia patients, she is one, herself, and has a daughter who has rheumatoid arthritis and FM. Trained to believe FM isn't a real disease, she now knows how real it is.

Melissa Kaplan adds...

If you regularly carry a date book with you, stick your problems and medications list in there. If you use a PDA, you check into software that will enable you to download your lists from your computer to your PDA and upload your notes back up to the computer.

Bring a printed copy of your problems and questions list so that you can have one and the doctor has one to use during your visit. Some doctors would like this information before your visit so that they can look things up if needed; ask your doctor if he or she would like this type of "preview" and whether they want it on paper (by mail or fax), or by email.

Depending on your level of pain, fatigue and brainfog on any given day, even very simple, explicit instructions can be mind-boggling and impossible to understand. There is a limit to how much time the doctor, nurses or other staff can spend with you go to over and over and over something. If you can't bring someone with you who can be your brain then bring a tape recorder and tape your session with the doctor and anyone else you ask for clarification on the instructions or information you were given.

If you are seeing different doctors, they all need to know about all of the prescription medications the other doctors have prescribed, as well as all of the over-the-counter, vitamins, minerals, herbs, alternative preparations, enzymes, aminos, pre- and probiotics you are taking. Many symptoms that may be ascribed to your illnesses may in fact be adverse interactions between the various drugs, supplements, herbs, etc. that you are ingesting every day.

Make and keep updated a master list of all the medications (prescription and OTC, topical and oral), vitamins, minerals, herbs, herbal teas, and other products you are ingesting. You will want this not only for your records but so that you can easily print it out and take it with you to each new doctor you are seeing. Give updated copies at least once a year to your regular physician, dentist and other healthcare providers.

Keep all your receipts for all of these medications and products, and copies of your notes on their use, especially when you've discussed them with your doctor. The receipts and notes will provide the back up when you claim them as medical deductions on your income tax as well as document the fact that you are "trying" to get better when you are hit with a social security or long-term disability review, an event that may happen once every three years or so until you reach retirement age.

5 Ways to Help Your Doctor Help You
By Elizabeth Cohen
April 4, 2008 CNN

ATLANTA, Georgia (CNN) -- Dr. Adam Dimitrov doesn't play favorites with patients. But he does have a few favorite patients -- ones who make it easy for him to do his job well.

Take one of his patients who had a liver transplant. Dimitrov is her internist, and she arrives at every visit with a folder. Inside is a list of the medications she's taking, copies of letters from her other doctors and results of her latest imaging studies and lab tests.

This way, Dimitrov isn't searching through her chart for papers that might -- or very well might not -- be there.

"She makes sure that nothing falls through the cracks," he said. This way, he can use their time together to take better care of her.

Now, wait a minute. Shouldn't a doctor have everything -- reports from other physicians, lab test results -- right there? Why is it the patient's responsibility to bring them in?

It's true: In an ideal world, a doctor would have your health history, the medications you're taking and lab results right in front of him. But we live in reality, and the reality is that these things are often lost in a mound of paperwork. So here are five things you can do to help your doctor help you.

1. Bring in a list of medications

Don't waste your precious moments with the doctor saying, "Ummm, I think I take a yellow pill in the morning -- or is it pink? And maybe I take it twice a day?" She's a doctor, not a mind reader. Write a list with the name of the drug, the dosage and how often you take it. "It's surprising and unfortunate how much time is wasted when that list isn't together," said Dimitrov, a family doctor in Baltimore, Maryland.

You can get help making a list from the free Web sites of MedSort and the American Academy of Family Physicians.

2. Come armed with your personal health history

You had your appendix out when? Grandma had Huntington's disease -- or was it Hodgkin's disease? You had a stent for your clogged artery back in '93 ... or was it a balloon? Your doctor wants to know, and you shouldn't rely on your memory (this is particularly important if you have a complicated medical past).

My Personal Health Record and the U.S. Surgeon General's Family History Initiative can help you get it all organized.

3. Bring in your recent test results and doctors' notes

If Dr. Smith the orthopedist ordered an MRI of your bum knee, you should assume that Dr. Jones the rheumatologist has not seen it. You should also assume the two docs haven't spoken to each other. So before your appointment with Jones to nail down the source of your knee pain, get a copy of Smith's notes from your latest visit and a copy of those MRI results.

4. Make a list of your concerns

Dr. Dana Frank, an internist at Johns Hopkins, tells his patients to come in with a written-out list of their top three concerns for each visit. He says it makes the appointment more focused and useful for the patient.

This may sound silly -- after all, you made the appointment, and you know why you're there -- but remember that fuzzy thinking is pretty common when you get to the exam room. Frank said, "What I really want is for patients to be prepared like the Boy Scouts."

Also, if you feel like the doctor is rushing you, ask him to slow down. "There is nothing wrong with saying, 'I feel you are rushing me. I am getting nervous; I can't tell you what I need to tell you,' " Frank said.

5. Don't ask your doctor insurance questions

Don't bother, because he's clueless. "We never know the answer to what is or isn't covered by your insurer," said Dr. Jim Braude, an internist in Atlanta. "Questions about insurance just take away time in the exam room that should be about your health." Insurance questions are, of course, important; a member of your doctor's office staff should know the answer.

Improving Patient-Doctor Communication
by Karen Lee Richards
06-02-2008

The reluctance of many patients to confide fully in their physicians is a serious concern, with responsibilities on both sides.

A survey was recently conducted asking the question: “Do you feel safe talking truthfully about your illness or symptoms with your doctor?” If the answer was “no,” respondents were asked, “Why not?”


Fifty-seven percent of those who responded said they did not feel safe – a startling, albeit not entirely surprising, statistic. More than half of those answering the survey said they do not feel safe enough to be honest with their doctors about their illness. On the positive side, 43% are comfortable and feel safe being truthful with their doctors. But when you consider the fact that we are literally entrusting our lives to our doctors, the inability of so many to be honest with them is a serious concern.


Reasons We May Not Feel Safe

Following are the top 10 reasons patients gave for why they do not feel safe communicating truthfully with their doctor (in order of frequency):


Doctor doesn’t listen or care.
Doctor attributes symptoms to depression or other psychological problems.
Doctor doesn’t understand or believe in my illness.
Doctor doesn’t believe me.
Patient fears being labeled a complainer or hypochondriac.
Doctor trivializes my symptoms.
Patient fears being labeled a drug seeker.
Too many symptoms; doctor doesn’t want to deal with them all.
Doctor is judgmental.
Patient fears being “marked” by insurance companies.
Other reasons mentioned are that: patient fears that medications will be taken away, doctor tries to give too many medications, doctor is tired of hearing complaints, patient is in denial about illness, patient fears more tests being done, patient is embarrassed, patient feels there is a lack of confidentiality.


Things That Will Help Make the Most of MD Communications

Although the responsibility for most of these complaints appears to fall into the laps of the doctors, there are things we as patients can do to help improve communication with our doctors.

1. Educate yourself. Long before you walk into the doctor’s office, learn all you can about your illness. A good doctor usually respects and appreciates patients who have enough self-respect to educate themselves. If you are getting your information from the Internet, make sure you stick to reputable sources. Chat rooms and forums are great places to get support, but you can’t believe everything you read on them.

2. Prepare for your appointment. Your doctor has a limited amount of time to give each patient, so anything you can do to organize your information will be appreciated. Make the following lists before every appointment and take them with you.


• Medications – List all medications you are currently taking. This list should include: prescription drugs, over-the-counter medications, supplements, herbal remedies, inhalers, and medicinal creams or gels.
• Symptoms – List all symptoms you experience on a regular basis. Describe the symptom clearly but try to keep it as brief as possible. Note when the symptom began, how frequently it occurs, and how it affects your life. If you list pain as one of your symptoms, describe the type of pain (that is, throbbing, aching, stabbing, sharp), the location of the pain, how long it lasts, and its severity (using the pain scale of 0 to 10 with 0 being no pain and 10 being the worst pain you can imagine). Note: Avoid the temptation to say your pain level is 50 on a scale of 0 to 10. Although your intention is to have the severity of your pain taken seriously, it will have the exact opposite effect. If you exaggerate your pain level, your doctor will assume you’re exaggerating everything else as well.

• Questions – Write down all of your questions in order of importance. Don’t depend on your memory. Doctor visits can be stressful and you’re likely to forget something if you haven’t written it down. By asking the most important questions first, you ensure those questions will be answered even if the appointment has to be cut short due to time constraints.


Ideally your lists should be typed so your doctor doesn’t have to spend time trying to interpret your handwriting. Take two copies of each list to your appointment – one for you and one for your doctor to refer to during the appointment and then include in your file.


3. Think about how you speak. When talking to your doctor, be specific; don’t use generalities. For instance, instead of saying, “My legs hurt when I stand,” try saying something like, “Whenever I stand for more than five minutes, I get a sharp pain that goes all the way down the back of my legs.” The second statement will give your doctor a much better idea of what you are experiencing and what might be causing it.


The tone and timbre of your voice is another important aspect of speaking to your doctor. The more calm and rational your voice sounds, the more likely your doctor will take you seriously. Try to avoid the two extremes: the whiney patient and the adversarial patient…

• Don’t whimper or whine. Sometimes people who are chronically ill will develop the habit of speaking in a whimpering, whiney voice without even realizing it. Unfortunately, no one likes to listen to whining. If you have children, you know how irritating it can be when they whine. Instead of causing you to want to do what they are asking, it only makes you want to get away from them. When adults whine, we tend to consider them less credible. If you have any doubts as to whether or not you sound whiney, ask a family member or friend who will be honest with you. Practice explaining your symptoms in a calm, rational voice.
• Take the chip off your shoulder. If you’ve had negative experiences with doctors before, you may find it difficult to walk into a doctor’s office without having an adversarial attitude – and that attitude will reveal itself in your voice. Taking a “You’d better do what I want or else” approach will only cause your doctor to become defensive and label you a troublemaker. Although you have the right to be listened to and treated with respect, you can’t demand respect. The more antagonistic your attitude, the less likely it is that doctor will listen to you or take you seriously. Try to give your doctor the benefit of the doubt and communicate in a calm rational tone.

4. Have realistic expectations. If you have a chronic illness (especially one like ME/CFS or FM), expecting your doctor to give you a prescription or two that will relieve all of your symptoms is unrealistic. It usually takes a great deal of trial and error to figure out a combination of treatments that will help you. It is realistic to expect your doctor to communicate honestly with you and work as a team with you in an atmosphere of mutual respect and cooperation.


5. Think like a consumer. Remember, as a patient, you are also a consumer. You are paying your doctor to provide a service. Would you continue to go to a hairstylist or barber who refuses to cut your hair as you ask? Would you keep returning to an auto mechanic who insists nothing is wrong with your car, even though it doesn’t run? We demand to receive the services we pay for in other areas of our lives, but often accept less than adequate service when it comes to our healthcare.


Evaluating the Result

The responsibility for developing an atmosphere in which you feel it is safe to be truthful with your doctor is shared by both doctor and patient. You can only be accountable for your part of the communication. If you’ve given it your best effort, applying the principles discussed here, and still feel your doctor is not taking your concerns seriously, then it’s probably time to find another doctor.

Karen Lee Richards is the Expert Patient, specializing in Fibromyalgia and Chronic Fatigue Syndrome. Karen co-founded the National Fibromyalgia Association (NFA) with Lynne Matallana in 1997.

10 Signs It’s Time to Find a New Doctor
by Karen Lee Richards

Are you less than satisfied with your doctor but uncertain as to whether you should look for another? Because the doctor-patient relationship is a very personal one, the decision as to whether or not to switch doctors can be a difficult one to make, especially if you have been seeing the same doctor for several years.

So how do you know when the time is right? Here are 10 signs that it may be time to find a new doctor:



1. Your doctor doesn’t listen to you.

Does your doctor routinely interrupt you after one or two sentences? Do you find your doctor attending to other matters while you are trying to explain your symptoms? Does your doctor repeatedly ask you questions you’ve already answered?



2. Your doctor doesn’t believe you’re really sick.

Do you find your doctor frequently attributing your symptoms to age, stress or hormones? If you have a chronic illness like fibromyalgia or chronic fatigue syndrome, does your doctor dismiss it as either non-existent or a “wastebasket diagnosis”? Does your doctor imply that most of your problems are psychosomatic?



3. Your doctor dismisses all alternative treatments as quackery.

Are you hesitant to tell your doctor about supplements you’ve been taking for fear of the lecture you’ll receive? Does your doctor make you feel foolish if you inquire about an alternative treatment like acupuncture or massage therapy?



4. Your doctor refuses to look at ANY information you find on the Internet.

Does your doctor reject anything found on the Internet regardless of the source? Is your doctor unaware of the fact that there is a great deal of quality, respected medical information available on the Internet (for example, most major medical journals, National Library of Medicine), or is anything found on the Internet dismissed without further investigation?



5. Your doctor is unwilling to consider your ideas.

If you ask to have a lab test run or request a new medication, does your doctor usually refuse without explaining why? When you express concern about something, such as a symptom or medication side-effect, does your doctor tell you not to worry about it without addressing your concerns? If you say you think you might have a particular disease or condition, does your doctor say, “No, you don’t have that” without telling you why that’s not a possibility?



6. Your doctor refuses to refer you to a specialist.

If you ask for a referral to a specialist, does your doctor refuse without explaining why? Is your doctor offended if you ask for a second opinion?



7. Your doctor views each appointment as an isolated event.

Does your doctor fail to review your chart at each appointment to refresh his memory, look for symptom patterns, and observe treatment history? Do you get the feeling your doctor has no idea who you are? Does your doctor treat you like a new patient, asking you the same questions you were asked at your last four appointments?



8. Your doctor is rude, arrogant, or inconsiderate.

Is your doctor’s attitude one of “Do what I tell you to and don’t ask questions”? Does your doctor make you feel as if you are wasting his valuable time? Does your doctor talk to you in a condescending or patronizing manner? When you ask a question, does your doctor ever make you feel foolish or stupid? Does your doctor routinely keep you in the waiting room for several hours? Do you usually have to leave multiple messages before getting a response?



9. Your doctor’s staff is frequently rude or unreliable.

Are staff members rude to you in person or on the phone? Have there been times that your messages were not given to the doctor? Do they fail to call in prescription refills in a timely manner?



10. Your doctor refuses to cooperate with other healthcare professionals as part of your healthcare team.

Is your doctor unwilling to take the time to connect and compare notes with other members of your healthcare team (for example, specialists or physical therapists)?



To Switch or Not to Switch
Should you look for a new doctor if even one of these signs is true of your doctor? Not necessarily. It depends on what characteristics are most important to you. For example, if you’re not interested in alternative treatments, you may not care whether your doctor considers them to be quackery. On the other hand, if you doctor doesn’t believe you’re really sick, it’s definitely time to find a new doctor.

There is no such thing as a perfect doctor. Personalities vary and a doctor that you love, may be intolerable to another patient. Ultimately, the decision is yours. Just remember that you deserve the best healthcare you can get. Your doctor provides a service––healthcare. You, as a consumer, are purchasing that service. If you’re not receiving satisfactory service, you need to take your business elsewhere.

Patients Who Bring Health Information From The Internet Get More Time With Doctor
14 Jul 2008

An increasing number of "healthcare overachievers" are bringing health information from the Internet to the doctor's office to discuss during the office visit. In fact, virtually all physicians report at least some of their patients arrive armed with health information from the Internet, according to the latest physician market research study released by pharmaceutical market research company Manhattan Research. These patients are being rewarded for their efforts, as the majority of physicians report that they spend more time with the patient as a result of their bringing information in to the office visit.

"The Internet has empowered consumers to take an increasingly active role in their healthcare management and their relationship with the physician," says Meredith Abreu Ressi, VP of research at Manhattan Research. "The conversation with the physician used to be a one-way, didactic interaction. But as consumers are increasingly bearing the responsibility for their healthcare costs and decisions, this balance of power is shifting. The Internet is a key tool consumers use to educate themselves on treatment options, and some empowered consumers are discussing their findings with their physician."

41 Secrets Your Doctor Would Never Share
Those free medication samples may not be the best -- or safest.
By Cynthia Dermody & Patricia Curtis From Reader's Digest

If You Only Knew ...
Reader's Digest offered two dozen doctors a chance to tell it like it really is, and general practitioners, surgeons, shrinks, pediatricians, and other specialists took the challenge. Some wanted to be anonymous; some didn't care. But all of them revealed funny, frightening, and downright shocking things that can help you be a better, smarter patient.

We're Impatient

• I am utterly tired of being your mother. Every time I see you, I have to say the obligatory "You need to lose some weight." But you swear you "don't eat anything" or "the weight just doesn't come off," and the subject is dropped. Then you come in here complaining about your knees hurting, your back is killing you, your feet ache, and you can't breathe when you walk up half a flight of stairs. So I'm supposed to hold your hand and talk you into backing away from that box of Twinkies. Boy, do I get tired of repeating the stuff most patients just don't listen to.
--Cardiologist, Brooklyn, New York

• I was told in school to put a patient in a gown when he isn't listening or cooperating. It casts him in a position of subservience.
--Chiropractor, Atlanta

&bull Thank you for bringing in a sample of your (stool, urine, etc.) from home. I'll put it in my personal collection of things that really gross me out.
--Douglas Farrago, MD, editor, Placebo Journal

• One of the things that bug me is people who leave their cell phones on. I'm running on a very tight schedule, and I want to spend as much time with patients as I possibly can. Use that time to get the information and the process you need. Please don't answer the cell.
--James Dillard, MD, pain specialist, New York City

• I wish patients would take more responsibility for their own health and stop relying on me to bail them out of their own problems.
--ER physician, Colorado Springs, Colorado

• So let me get this straight: You want a referral to three specialists, an MRI, the medication you saw on TV, and an extra hour for this visit. Gotcha. Do you want fries with that?
--Douglas Farrago, MD

• I used to have my secretary page me after I had spent five minutes in the room with a difficult or overly chatty patient. Then I'd run out, saying, "Oh, I have an emergency."
--Oncologist, Santa Cruz, California

• Many patients assume that female physicians are nurses or therapists. I can't tell you how often I've introduced myself as Dr. M. and then been called a nurse, therapist, or aide and asked to fetch coffee or perform other similar tasks. I have great respect for our nurses and other ancillary personnel and the work they do, but this doesn't seem to happen to my male colleagues.
--Physical medicine and rehabilitation doctor, Royal Oak, Michigan

• The most unsettling thing for a physician is when the patient doesn't trust you or believe you.
--Obstetrician-gynecologist, New York City

• It really bugs me when people come to the ER for fairly trivial things that could be dealt with at home.
--ER physician, Colorado Springs, Colorado

• Your doctor generally knows more than a website. I have patients with whom I spend enormous amounts of time, explaining things and coming up with a treatment strategy. Then I get e-mails a few days later, saying they were looking at this website that says something completely different and wacky, and they want to do that. To which I want to say (but I don't), "So why don't you get the website to take over your care?"
--James Dillard, MD

• I know that Reader's Digest recommends bringing in a complete list of all your symptoms, but every time you do, it only reinforces my desire to quit this profession.
--Douglas Farrago, MD



Pills, Pills, Pills
• Sometimes it's easier for a doctor to write a prescription for a medicine than to explain why the patient doesn't need it.
--Cardiologist, Bangor, Maine

• Those so-called free medication samples of the newest and most expensive drugs may not be the best or safest.
--Internist, Philadelphia

• Taking psychiatric drugs affects your insurability. If you take Prozac, it may be harder and more expensive for you to get life insurance, health insurance, or long-term-care insurance.
--Daniel Amen, MD, psychiatrist, Newport Beach, California

• Ninety-four percent of doctors take gifts from drug companies, even though research has shown that these gifts bias our clinical decision making.
--Internist, Rochester, Minnesota

Bills, Bills, Bills

• Doctors respond to market forces. If the reimbursement system is fee-for-service, that results in more services. If you build a new CT scan, someone will use it, even though having a procedure you don't need is never a good thing.
--Family physician, Washington, D.C.

• I really do know why you're bringing your husband and three kids, all of whom are also sick, with you today. No, they are not getting free care.
--Douglas Farrago, MD

• Doctors get paid each time they visit their patients in the hospital, so if you're there for seven days rather than five, they can bill for seven visits. The hospital often gets paid only for the diagnosis code, whether you're in there for two days or ten.
--Evan S. Levine, MD

• Twenty years ago, when I started my practice, my ear, nose, and throat procedures financially supported my facial plastic surgery practice. Today, my cosmetic practice is the only thing that allows me to continue to do ear, nose, and throat procedures, which barely cover my overhead.
--Ear, nose, throat, and facial plastic surgeon, Dallas/Fort Worth

Free Advice

• Avoid Friday afternoon surgery. The day after surgery is when most problems happen. If the next day is Saturday, you're flying by yourself without a safety net, because the units are understaffed and ERs are overwhelmed because doctors' offices are closed.
--Heart surgeon, New York City

• In many hospitals, the length of the white coat is related to the length of training. Medical students wear the shortest coats.
--Pediatrician, Baltimore

• Often the biggest names, the department chairmen, are not the best clinicians, because they spend most of their time being administrators. They no longer primarily focus on taking care of patients.
--Heart surgeon, New York City

The Darker Side

• It saddens me that my lifelong enjoyment and enthusiasm for medicine has all but died. I have watched reimbursement shrink, while overhead has more than doubled. I've been forced to take on more patients. I work 12- to 14-hour days and come in on weekends. It's still the most amazing job in the world, but I am exhausted all the time.
--Vance Harris, MD, family physician, Redding, California

• In many ways, doctors are held to an unrealistic standard. We are never, ever allowed to make a mistake. I don't know anybody who can live that way.
--James Dillard, MD

• Not a day goes by when I don't think about the potential for being sued. It makes me give patients a lot of unnecessary tests that are potentially harmful, just so I don't miss an injury or problem that comes back to haunt me in the form of a lawsuit.
--ER physician, Colorado Springs, Colorado

• Doctors often make patients wait while they listen to sales pitches from drug reps.
--Cardiologist, Bangor, Maine

• It's pretty common for doctors to talk about their patients and make judgments, particularly about their appearance.
--Family physician, Washington, D.C.

• Everyone thinks all doctors know one another. But when we refer you to specialists, we often have no idea who those people are. Generally, we only know that they accept your insurance plan.
--Pediatrician, Hartsdale, New York

• In most branches of medicine, we deal more commonly with old people. So we become much more enthusiastic when a young person comes along. We have more in common with and are more attracted to him or her. Doctors have a limited amount of time, so the younger and more attractive you are, the more likely you are to get more of our time.
--Family physician, Washington, D.C.

• Plan for a time when the bulk of your medical care will come from less committed doctors willing to work for much lower wages. Plan for a very impersonal and rushed visit during which the true nature of your problems will probably never be addressed and issues just under the surface will never be uncovered.
--Vance Harris, MD

• At least a third of what doctors decide is fairly arbitrary.
--Heart surgeon, New York City

• Doctors are only interested in whether they are inconvenienced -- most don't care if you have to wait for them.
--Family physician, Washington, D.C.

The Sensitive Side

• When a parent asks me what the cause of her child's fever could be, I just say it's probably a virus. If I told the truth and ran through the long list of all the other possible causes, including cancer, you'd never stop crying. It's just too overwhelming.
--Pediatrician, Hartsdale, New York

• Most of us haven't been to see our own physicians in five years.
--Physical medicine specialist, Royal Oak, Michigan

• When a doctor tells you to lose 15 to 20 pounds, what he really means is you need to lose 50.
--Tamara Merritt, DO, family physician, Brewster, Washington

• If a sick patient comes to me with a really sad story and asks for a discount, I take care of him or her for no charge.
--Surgeon, Dallas/Fort Worth

• Though we don't cry in front of you, we sometimes do cry about your situation at home.
--Pediatrician, Chicago



Shocking Stats
60% of doctors don't follow hand-washing guidelines.
Source: CDC Morbidity and Mortality Weekly Report

96% of doctors agree they should report impaired or incompetent colleagues or those who make serious mistakes, but ...

46% of them admit to having turned a blind eye at least once.
Source: Annals of Internal Medicine

94% of doctors have accepted some kind of freebie from a drug company.
Source: New England Journal of Medicine

44% of doctors admit they're overweight.
Source: Nutrition & Food Science; Minnesota Medicine

58% would give adolescents contraceptives without parental consent.
Source: New England Journal of Medicine

Anatomy of a Doctor's Bill

Just how much of the $100 your doctor charges for taking 30 minutes to investigate your stomach pain goes into his pocket? After paying the bills, he gets less than half. The breakdown, according to Robert Lowes, senior editor at Medical Economics:

$3.50 for malpractice insurance

$3.50 for equipment, repairs, and maintenance

$6 for supplies, including gowns, tongue depressors, and copy paper

$7 for rent and utilities

$11 for office expenses, such as telephones, accounting fees, advertising, medical journals, licenses, and taxes

$28 for secretary, office manager, and medical assistant salaries and benefits

$41 Amount that goes into the doctor's paycheck

Over the course of a year, that adds up to $155,000, the annual salary of the average family physician. That number rose just 3.3% between 2002 and 2006, while expenses increased nearly 25% over the same period.

Doctors Don't Change Their Routine During Longer Consultations
July 29, 2008

Some patients might feel like they spend more time in the waiting room than actually talking with their doctor, but a new review of studies suggests that these consultations would not be much different if patients had more face time with their physicians.
In five studies conducted in the United Kingdom, doctors did not discuss more problems, prescribe more drugs, run more tests, make more referrals or do more examinations when they had a few additional minutes with patients.

"There was some evidence that blood pressure was checked and smoking discussed more often when more time was available," said Andrew Wilson, M.D., of England's University of Leicester, who wrote the review with University of Northumbria researcher Susan Childs.

However, he said, "The most consistent finding was that several aspects of doctors' behavior remained unchanged.

The review appears in the latest issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews like this one draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.

The patients in the five studies did not feel more satisfied with their care when they were able to consult longer with their doctors. However, in each study, consultation times were only slightly longer than usual, and might have not been enough extra time to make a difference in the doctors' routine or the patients' satisfaction, the researchers write.

A 2007 study in the United States found that patients' visit times with primary care doctors could vary from six to 72 minutes for the same condition. University of California-Davis researcher Estella Geraghty, M.D., who led the 2007 study, said that factors from a doctor's personal style to whether the doctor practiced in an HMO could affect visit length.

Lost in a System Where Doctors Don't Want to Listen
By Benjamin H. Natelson, Wahington Post
August 3, 2008

I'd like to tell you about one of my patients. She's the kind of patient that I enjoy seeing but that many doctors go out of their way to avoid. This means that she's also the kind of patient I worry about most -- a patient who in the near future may be stranded without proper care as fewer and fewer doctors, constrained by time and the economics of our health care system, are willing to perform the fundamental task of diagnosing difficult or unclear medical problems.

My patient is a 37-year-old woman, a mother of two teenagers, with a busy career. She was in perfect health until July 2007, when, overnight, she came down with what her doctor said was a case of flu. This "flu," however, wouldn't go away. Her doctor assured her that she'd get better, but three months after her first visit to him, she was back in his office, still feeling ill. The doctor did a thorough medical evaluation, told her that he couldn't find anything wrong and again assured her that she'd eventually recover. A few months later, she was back again. This time, as she described it to me, the doctor sort of shrugged his shoulders and told her that maybe her problem was all in her head.

As you might imagine, the patient was put off by her doctor's dismissal, which set her off on a gyre of doctor-shopping. Over the next six months, she saw eight physicians, as well as a chiropractor and a homeopath, without getting a diagnosis or any real help. Finally, she did an Internet search and found me, a specialist in medically unexplained illness. All her tests were normal, but I listened to her and was ultimately able to make a diagnosis of chronic fatigue syndrome. We then launched into the treatment of her symptom-based illness, a slow process that unfortunately doesn't end in a cure but often leads to improvement.

The fact that this woman couldn't find a doctor to help her until she found me says a lot about where the U.S. health care system is heading. The economics of modern medicine have converted the doctor from Ben Casey to a factory worker on a conveyor belt, and those economic forces are driving more and more physicians toward specialties where they can spend less time with patients and earn more money.

Learning how to make a diagnosis is a critical part of medical education. It requires the doctor to listen to the patient describe the illness and then put it in a personal health framework by asking about other symptoms, previous medical problems (extending to the patient's family) and elements of the patient's life story. Doctors usually schedule an hour for these initial consultations, then 30 minutes for follow-up appointments.

Half an hour of a doctor's time is normally plenty for a straightforward health problem and more than enough for a cold with a runny nose or a cough with no fever. But what happens when your symptoms don't add up to a clear-cut diagnosis? Studies have shown that in more than 50 percent of cases, patient complaints don't have any diagnosable medical cause that can be determined by careful laboratory testing. Pain, fatigue, dizziness and trouble sleeping are among the most common symptoms, and doctors have problems with these because they don't point to any particular diagnosis.

When that happens, the diagnostic algorithm learned in medical school breaks down. The doctor's not sure what's wrong with the patient, and if he has a busy office, he won't have time to think through the patient's complaints to arrive at a coherent diagnosis. Very often, when all the tests are normal and time has run out, the doctor will conclude a visit, as my patient's initial physician did, by saying: "There's nothing really wrong with you. I'm sure you'll feel better in a few days -- or weeks."

Even doctors with time often prefer dealing with straightforward medical problems. I have a friend who's an allergist in private practice. When I asked him whether he'd be willing to work with some of my patients, he quickly said no. Why, he said, would he want to tackle difficult cases like that when he can take someone suffering from severe allergies and make them better in a day?

Doctors are being lured away from primary care by economic factors as well. Eighty percent of medical students have to borrow money for medical school. The expected median debt of this year's graduating class is about $120,000 for state medical schools and $150,000 for private, according to the American Association of Medical Colleges. At the same time, medical students face a candy store of career choices, all with widely varying earning (and debt-reduction) potential.

I, for instance, am a medical school professor with a practice devoted to patients with medically unexplained symptoms such as fatigue and pain. My patients often have complex medical histories and feel they're at the end of their rope. If a patient has Medicare coverage for disability caused by an illness, Medicare will reimburse me $196 for each hour of interaction with that patient. After expenses and other charges, I'll keep $86, a very good hourly salary.

But consider the neuroradiologist, who specializes in interpreting brain MRIs. Just a few years ago, it would take a radiologist a long time to organize and view many sheets of a patient's X-ray films, but today, thanks to computerization, the well-trained neuroradiologist can assess dozens of images of the brain in just a few minutes. He or she can probably read a patient's images and dictate a report in about 15 minutes. At my previous institution, the hourly reimbursement from Medicare was $492, and the doctor's take-home totaled $216, a substantially better salary than mine.

Physicians in a procedure-driven specialty such as neuroradiology -- and there are many others, such as cardiology and anesthesiology -- always earn more than patient-centric doctors. American medical students are aware of this as they make their career choices. And fewer and fewer are choosing patient-oriented medicine: In 1996, American graduates filled 76 percent of residency training slots in family medicine, while in 2002, they filled only 48 percent. We see similar shifts in general internal medicine. The remaining positions are filled by foreign-born and foreign-trained medical school graduates. They pass the same qualifying tests for licensure as American graduates, but cultural diversity and varying communication skills may affect their approach to patients and their ability to hear subtleties in their patients' stories.

Society has come up with a partial solution to the growing gap in primary care providers: "physician extenders." These master's level health-care professionals are trained to deal with commonly occurring, easy-to-diagnose problems: a flu, hay fever, a splinter, even severe chest pain. Usually, however, they haven't had enough training to give them the know-how to sort through a complex medical history to arrive at a diagnosis that isn't immediately evident. When they're stuck, they have to call the physician, and by then, the 30-minute visit is very often over. The patient is left hanging and disappointed -- on his or her own to figure out what to do next. The inevitable result: patients falling between the cracks of classical medicine.

There's one silver lining in this situation: the increasing number of women choosing medicine as a profession. Approximately 50 percent of most medical schools' entering classes today are women. This trend may work to offset a major patient complaint -- that doctors don't spend enough time listening to them. Research studies show that women in general and women physicians in particular are better listeners than men. Since the turn toward more women in medicine is relatively recent, I'm not sure which path the young female doctor will choose, but I can say anecdotally that quite a few of my own female students seem to be choosing primary care -- either family or internal medicine. I hope that in the next few years, their presence may help offset the dearth of U.S.-trained doctors in primary care.

Meanwhile, what are patients with an elusive diagnosis to do? If they're fortunate enough to live near a medical school, they can search the doctor list for generalists. Physicians in academic centers are encouraged to see patients as part of their duties, and they often have more time than their colleagues in the community. More important, patients can help themselves by knowing more about their bodies, how they work and what can go wrong with them.

But finally, patients will have to understand that finding a doctor who has the time to listen, diagnose correctly and then know how to treat them is going to get harder and harder. Reversing the trend away from patient-oriented and toward procedure-oriented medicine will require attention by legislators as well as medical educators. Reducing the debt of newly minted doctors who choose primary care might be one way of doing this. Cutting back on both the number of postgraduate training positions in procedural medicine and the salary paid such trainees, while raising the salaries of those in primary care, could be another.

None of this will happen, though, unless patients make their voices heard. Otherwise, they may just find themselves on their own the next time puzzling symptoms arise.

Benjamin H. Natelson is director of the Pain and Fatigue Study Center at Beth Israel Medical Center in Manhattan and author of "Your Symptoms Are Real: What to Do When Your Doctor Says Nothing Is Wrong."

How to Talk to Your Doctor About Chronic Pain
By Kate Rope
August 13, 2008

Good chronic pain treatment can be hard to find. A chronic pain patient has every right to believe that his or her doctor will listen sympathetically and prescribe the appropriate treatment, but that is not always the reality.

People who experience chronic pain should be specific when describing it to their doctors, experts say.

Truth is, many doctors have not been trained to deal with the complex, changing area of chronic pain treatment. One 2001 survey of primary care physicians' attitudes toward prescribing certain medications found that only 15 percent said they enjoyed working with patients who have chronic pain.

This can lead to frustrating encounters at the primary-care level, especially if your doctor is rushed.

Pressures on doctors

"Doctors don't want patients to suffer; they want people to get better," said Dr. Bill McCarberg, founder of the Chronic Pain Management Program at Kaiser Permanente in San Diego, California. "But they feel stress; they feel time constraints; they have to deal with pre-authorizations; it's not the kind of practice they wanted. They're stressed, and that leads to moving patients along."

"As a doctor in today's medical system, it's difficult to deal with chronic pain conditions," agreed Dr. S. Sam Lim, a rheumatologist at Emory University School of Medicine in Atlanta, Georgia. "Most practices are forced to see a certain number of patients in a limited amount of time. [With chronic pain,] it's not so simple as five minutes, a few questions and handing out a pill. It takes some time. And our system isn't set up for that."

"The patient needs to realize that the doctor may not be able to discern what's going on in the first visit. Often, it takes a few visits," Lim said. Doctors are frustrated by what they can't "fix."

In 25 years of caring for her chronically sick husband, who was injured in an industrial accident, Ann Jacobs, 62, of Laramie, Wyoming, has watched physicians struggle with the trial-and-error progress of his treatment. "Doctors are programmed for success stories," she said.

Because of its complexity, pain treatment has emerged as a separate, multidisciplinary specialty. That's good, but pain patients often need to get to a pain specialist through their primary care physicians.

Emotions can cloud the diagnosis

The emotional effects of chronic pain may make diagnosis more difficult. Maggie Buckley, 46, of Walnut Creek, California, learned this the hard way. She has Ehlers-Danlos syndrome, a rare genetic tissue disorder that leaves her with chronically painful joints.

"If you say, 'it's really depressing and upsetting me; I'm in so much pain,' " Buckley said, "doctors will see it in terms of emotion and treat it as an emotional problem, referring you to psychiatric care or antidepressants."

That is sometimes the appropriate treatment route, because antidepressants can treat chronic pain, and there is a link between pain and depression, but you need to stand your ground and make sure any treatment is addressing your specific problems.

Be gentle about your pain, but be firm

It's important to be clear about your pain and explain the way it impacts your life when you're talking to your doctor. Don't be intimidated. Stand your ground, calmly.

"Patients really need to be persistent about their complaints in a way that is constructive to get across to the physician that this is something real," Lim said. "There are some physicians who are more open to listening than others. It may take a few doctors to find a marriage."

"You have to go very gently to start with," Jacobs advised. "Listen to what the doctor has to say first."

Then, if you're not satisfied, press harder. But remember that the most important thing is to create a relationship with your doctor in which you're a team, both looking for the best way to alleviate your pain. After he or she has assessed your needs, you can consider seeing a pain specialist.

What Does Your Doctor Think of You?
by CARLY WEEKS
September 26, 2008

People are often quick to criticize a doctor's bedside manner. But how many stop to consider what their doctor thinks about having to put up with them?

A new study of Canadian physicians reveals that many often have to deal with troublesome patients who may act aggressively or refuse to believe the doctor's diagnosis, among a range of other problems.

While such snags may seem like minor annoyances, they could have significant implications for patient safety, according to the study conducted by researchers at the University of Manitoba.

"When you have patients that can't communicate, there's going to be a big issue. ... physicians may not be able to provide the right diagnosis," said Raymond Lee, professor of business administration and one of the study's authors.

And when patients won't heed the physician's advice, "it can affect their actual health outcome if they don't follow through with treatment plans."

In the study, presented in June at a conference on health-care systems and patient safety in Strasbourg, France, researchers asked nearly 300 Manitoba doctors about the daily obstacles they face when dealing with patients. They found that many physicians feel they have insufficient time with patients and that they have difficulty establishing a good rapport.

In addition, some doctors said many patients are quick to self-diagnose using the Internet, and are often resistant to the physician's diagnosis and course of treatment.

"In the modern economy we have the Internet and peer pressure, so there are all kinds of influences," said Brenda Lovell, an instructor of community health science at the University of Manitoba and one of the study's authors. "There's a safety implication."

In addition, many physicians reported they face challenges from patients who don't disclose that they use "natural" or alternative therapies.

Pediatricians were most likely to make this complaint. Although it didn't examine why young patients may be more likely to use natural remedies without telling their doctor, the research raises questions about how frequently this may be occurring and how it could affect a young person's care.

One of the problems is that many people don't realize that natural remedies and herbal treatments can interfere with other medications and lead to potentially dangerous interactions, Ms. Lovell said.

"I think it's important that, for patients, they be educated on the fact there are interactions, especially with drugs," she said.

Communication problems were especially pronounced among physicians dealing with patients of the opposite sex.

Female physicians reported greater difficulty establishing rapport and having sufficient time with male patients. But those difficulties declined substantially when female doctors saw female patients, the survey found.

There is a growing awareness of the need to improve communication between doctors and their patients. said Janet McElhaney, geriatrician and professor of medicine at the University of British Columbia.

"I think that we run into problems when ... people are presented with information that is overwhelming and not understanding the jargon that we sometimes use," she said.

Dr. McElhaney is a member of the British Columbia Medical Association, whose Council on Health Promotion recently passed a motion to help educate patients so they can better understand the information doctors give them.

"I would say we need to do better with what's available with the current technology around giving patients information in ways that are digestible," Dr. McElhaney said.

Primary Care Doctors Play Key Role In Fibromyalgia Diagnosis And Management
01 Oct 2008

Primary care physicians are at the forefront of fibromyalgia management, and deservedly so, a pain management expert said at a Meet-the-Experts Program entitled "Case Studies in Fibromyalgia: Connecting the Dots from Diagnosis to Pain Management" held in conjunction with PAINWeek 2008.

"That's just as it should be," moderator Kevin L. Zacharoff, MD, an anesthesiologist and pain management consultant in Setauket, New York, noted. He is also the co-author of "The PAINEDU Manual: A Pocket Guide to Pain Management."

"While fibromyalgia patients may be referred to specialists like rheumatologists, neurologists, pain experts, and psychiatrists, it is primary care doctors who are best suited to manage most fibromyalgia patients," he said.

Among the reasons:

-- Primary care doctors (more often than specialists) have the requisite tools for assessing and treating fibromyalgia patients.

-- Fibromyalgia is not a static condition but is characterized by symptoms that may peak and trough. No physician knows the patient better than the primary care doctor, who is responsible for the patient's overall health care and has an ongoing relationship with the patient. The specialist, in contrast, manages only a "component" of the patient's health care and has only a "finite" relationship with the patient. The primary care doctor is thus the best "point person" for this disorder.

-- There is a shortage of specialists equipped to manage fibromyalgia.

In order to firmly establish the diagnosis of fibromyalgia, a variety of other conditions first need to be ruled out, Dr. Zacharoff noted. These conditions include rheumatologic and musculoskeletal disorders that can be excluded on the basis of objective measures such as imaging studies, laboratory testing, or physical examination. If these tests produce negative results, the primary care physician then relies on findings of the physical examination and patient history to make a diagnosis. These findings commonly include the presence of tender points at specified sites, such as the neck, back and shoulders, widespread pain, insomnia, fatigue, digestive discomfort, loss of appetite, increased sensitivity, and malaise.

"While these symptoms may point to a variety of other problems, what will 'clinch the deal' is the patient's response to trials of various treatments (both pharmacologic and non-pharmacologic) directed at a diagnosis of fibromyalgia," noted Dr. Zacharoff. "It is also important to recognize that a diagnosis of fibromyalgia is not usually possible during a single office visit but rather over the course of several visits," he added.

When should a fibromyalgia patient be referred to a specialist? According to Dr. Zacharoff, the timing of a referral is fairly straightforward. "As with other medical conditions, patients should be referred when the limitations of the primary care physician have been surpassed," he said. "For example, when the primary care doctor no longer feels comfortable treating the patient or when a long-term treatment plan agreed upon by the physician and patient is unsuccessful - these are a 'flip switch' that it's time for a referral to a specialist."

Finally, the noted pain expert called for increased physician education about fibromyalgia directed at medical students and practicing physicians. "Although pain is the most common reason patients schedule an appointment with their physician, pain management gets short shrift in medical school and afterwards in continuing medical education. It's definitely an oxymoron."

Overall, fibromyalgia affects an estimated 2% to 4% of the general U.S. population, which translates into about six million people. The condition is more common in women than in men and tends to increase with age.

Five Ways to Get More from Your Doctor: Researchers’ Tips for Patients

These days, going to the doctor may seem more like speed dating than care giving. Patients get a few minutes with the clinician, and he or she does most of the talking.

How can a person get the information they need and the outcome they desire in a 15-minute office visit? What if the treatment options don’t feel right? Is it too much for a patient to feel they are considered a partner in their own well-being?

Often, people leave their doctor’s office with more questions than answers, according to researchers at the University of North Carolina at Chapel Hill School of Medicine who are looking at how patients can get more of what they need from the health-care system. They have found that patients (or their advocates) who talk to physicians about their beliefs, values, lifestyle and concerns can get better results from their health-care experience.

“Research shows if you ask doctors what they think is important to patients, and then ask patients what’s important to them, there’s not a great match,” said Dr. Michael Pignone, chief of the UNC division of general internal medicine.

But, as smart as doctors are, they aren’t mind readers, Pignone and his colleagues note.

“A common problem is patients thinking that their physician will know how they – the patient – feels about specific decisions” said Dr. Carmen Lewis, assistant professor of medicine and clinical epidemiology. “Doctors don’t – you need to tell them. People feel the doctor is the expert, but the individual is the expert about his or her lifestyle and how he or she values options and outcomes.”

Pignone offered some tips for becoming what he calls a “pleasantly assertive” patient, so that patients’ health-care providers can better help them.

1. Prepare for your visit. “It might seem silly, but it’s really helpful to write down your symptoms, complaint or problem, then summarize it into a couple of sentences,” Pignone said. “Bring your list and your summary with you to the visit. This allows the doctor to quickly review your condition and ask specific questions, instead of spending time focused on general issues. This one step can make visits 25 percent to 50 percent more effective.”

2. Have an agenda. “Before your appointment, decide what you want from the visit,” Pignone recommends. “For instance, if you’re suffering back pain, you might want to know what is causing the pain as well as a treatment plan for getting better. Make sure you share that with your doctor at the very beginning of your visit. It might feel funny at first, but your doctor will appreciate it. Sharing this information will help you all make better decisions about treatment, make the visit more efficient, and improve the chance that your health-care needs will be met effectively.”

3. Know your medical history and medications. “To help you get the treatment you need, doctors need to know what tests you’ve had – and when – as well as what medications you’re taking,” Pignone said. “Without that information, they might mistakenly re-order tests or prescribe medication that has a bad interaction with something you’re already taking. That can have adverse effects for your health and your wallet.”

4. Tell your provider about your values or lifestyle preferences that could affect your treatment. “It doesn’t make sense to agree to a treatment plan you know you won’t follow – it won’t result in your feeling better,” Pignone cautioned. “For example, if a Wednesday night smoking cessation class conflicts with your book club, it’s not going to be an effective intervention for you. On a more serious level, if you don’t want to deal with the uncertainty of a possible recurrence of cancer, you might prefer a mastectomy to a lumpectomy. Similarly, if you can’t afford medication or to take off work for recurring visits, tell your provider even if you’re embarrassed. There are often ways to work around the challenges if your care team knows about them.”

5. Clarify the decision to be made. “Sometimes you’re offered several options, so be sure you understand the alternatives and if you don’t, ask for clarification,” Pignone said. “Your doctor should be able to give you important details about each option either during the visit, or on a follow-up call. In addition to the details, ask them how good the medical information is.”

Pignone and Lewis acknowledged that this approach results in a very different doctor-patient relationship, but evidence shows that proactive patients tend to get more effective and efficient care.

“The sicker you are, the more this matters,” Pignone said. “But it’s harder to do. If you’re not comfortable interacting this way, involve other people who support you in your life to come with you and play this role.”

Overuse of Opioids
12/08/2008
Bill H. McCarberg, MD

Question
Is prescription drug abuse increasing, and if so, what can physicians do to prevent prescription drug abuse by their patients?

Response from Bill H. McCarberg, MD
Assistant Clinical Professor, Department of Family Practice, University of California San Diego School of Medicine; Founder, Chronic Pain Management Program, Kaiser Permanente, San Diego, California

If a patient is taking an opioid and achieving pain reduction and improved function with minimal side effects, continuing the treatment is indicated. If a patient is abusing an opioid with impaired cognition, worsening function, loss of social interactions, and use to obtain euphoria, then continuing the opioid is illegal.

These represent 2 ends of the spectrum of opioid management where the treatment decision is straightforward. Unfortunately, most clinical presentations are not this simple. Patients may overuse the opioids during times of stress or anxiety, use combinations with alcohol and marijuana, and perhaps fail to improve in function. Some would say that opioids are safe. The response to difficult patients should be a trial of higher doses. Others would argue that opioids should not be used at all in problematic situations. Behavioral issues in opioid management can occur in more than 40% of patients, making these decisions commonplace.

The correct decision comes from clinical judgment and observation. With exposure to the patient, building a longitudinal experience, the decision may become more apparent. Answering the following questions may help:

1. Is there risk for addiction? Use screening tools to help predict risk. If the patient scores low on the screening tool, addiction is less likely.

2. Has function improved? People who are addicted and abusing opioids do not improve in function. Those who are addicted can take opioids safely, lessening pain, but when abusing the opioid, function will deteriorate.

3. Do collateral sources confirm the behavior? Always try to get information from family and friends about medication adherence and function. What patients say and what occurs may be different. If the family describes a patient struggling with pain, attempt to staying functional, then continued use is appropriate.

If the observation, the strength of the relationship you have built, and the information suggest overuse related to poor pain control, escalating the dose is prudent. If overuse results in loss of function or occurs to treat comorbid anxiety or insomnia, then a discussion with the patient should occur. Review appropriate medication use and the desired outcome of functional improvement.

Part of this discussion includes the need to withdraw opioids if adherence cannot be maintained. This is also known as an exit strategy and is easier to do before starting the opioid. Tighter controls over the patient, with smaller quantities given and more frequent office visits to review goals are also indicated.

If the patient continues to overuse and is not adhering to mutual goals, the patient must be withdrawn from the opioid. This strategy can occur even in the face of known pathology and significant pain levels. Pain by itself does not mandate opioid management if behavior and functional outcomes are not satisfactory. Discussions about withdrawal are never easy, but we have to have the patient's best interest in mind and not enable dysfunctional behavior.

How Your Doctor Can Help If You Have CFS/ME
By Charles W. Lapp, M.D.
Editor's Note: Dr. Lapp, Director of the Hunter-Hopkins Center in Charlotte, is one of the few CFS specialists in the United States.

If you are not able to access a provider who is expert on CFS/ME, your next best bet is to find a doctor who is empathetic and willing to help. This person may be your existing primary care doctor or someone else you find who either knows about CFS/ME or is willing to learn about it.

There are four ways your doctor can help:

1) Establish a diagnosis
2) Treat major symptoms
3) Treat other conditions that often accompany CFS/ME
4) Provide usual primary care

While your doctor's role is important, you should recognize that there is no known cure for CFS/ME, so there are limits to what your doctor can do. Medical treatment does not treat the disease; it only palliates the symptoms. Medical treatment will not even speed your recovery, but it will make recovery more comfortable. The key to recovery in CFS/ME is acceptance of the illness and adaptation to it by means of lifestyle changes, for which medical treatment is no substitute.

Diagnosing CFS/ME
We at the Hunter-Hopkins clinic have developed materials for physicians to use to diagnose and manage CFS/ME. The Quick Start Guide provides all information needed to establish a diagnosis and rule out other possible causes for your symptoms. It is available at: www.cfstreatment.info/quick_start_guide ... tition.htm. Similar material for diagnosing and managing CFS/ME is available at the website of the Centers for Disease Control (CDC): http://www.cdc.gov/cfs/toolkit.htm.

Treating Major Symptoms
There is no known cure for CFS/ME, so currently the goal of treatment is to reduce those symptoms that make your life miserable. Top among these are sleep disruption, fatigue, and pain. The treatment recommendations below also apply to fibromyalgia, with the qualification that people with "pure" FM (minimal fatigue and cognitive impairment) usually tolerate higher levels of exertion and can push somewhat harder.

Treating Sleep
Sleep problems of PWCs [People with CFS] include difficulty falling asleep, difficulty staying asleep, restlessness at night, vivid dreams, and - most importantly - non-restorative sleep. Whether you sleep 4 hours or 14 you probably will not awaken feeling refreshed. CFS specialists agree that sleep is THE most important symptom to address. Poor sleep has widespread effects. Treating sleep can improve quality of life and reduce other symptoms.

The first principle for improving sleep is to practice good "sleep hygiene." This includes: (1) using your bed for sleeping only; (2) avoiding stimulant foods and beverages at night; (3) keeping a regular sleep schedule by getting up every morning at the same time; (4) avoiding daytime naps (although short rest periods are fine); (5) not watching TV or using a computer in the bed at night (instead, try reading, soft music, or relaxation tapes); and (6) hiding the clock from view. Another practice that is often very helpful is to have a "wind-down period" before going to bed. Beginning about an hour before you want to retire, change your activity level and environment.

If you have frequent sleep problems, consider a simple over the counter sleep aid such as diphenhydramine (Benadryl TM 25-50mg), Tylenol PMTM, melatonin (3-9 mg 2-3 hours before bedtime), or doxylamine (12.5 to 25mg), which is the sleep-inducing agent in "Nyquil." Sometimes herbal sleep aids (which usually contain valerian, chamomile, passion flower, or similar) can be helpful.

If your sleep problem is resistant to such simple remedies, talk to your doctor about prescription medications such as zaleplon (SonataTM), eszopiclone (LunestaTM), or ramelteon (RozeremTM) to help you fall asleep. If you have trouble staying asleep, however, ask your doctor to add 5-10mg of cyclobenzaprine (Flexeril), 2-8mg of tizanidine (ZanaflexTM), 2-25mg of doxepin elixir, 10-50mg of amitriptyline (Elavil), or 25-50mg of trazadone (Desyrel). The latter is favored because it has the fewest adverse effects and actually increases the depth of deep sleep.

Zolpidem (AmbienTM) and benzodiazepines like RestorilTM, DalmaneTM, ProSomTM, and AtivanTM are not generally recommended because they may be associated with sleepwalking and amnesia or may actually interfere with deep sleep, respectively.

If these measures do not help your sleep problem, ask your doctor for a referral to a good sleep specialist. These experts can recommend more powerful sleep aides, but they can also check for sleep apnea and other serious sleep disturbances. Sleep disorders are present in over 60% of PWCs, but are frequently overlooked by the primary physician.

Treating Fatigue
Fatigue is extremely hard to overcome. Self-help techniques are frequently effective. Perhaps the most important is pacing, which involves honoring the body's limits and balancing activity and rest. Also helpful are relaxation and other stress management strategies, modest exercise to counteract deconditioning and checking medications for the side effect of sedation. (For more self-help ideas for counteracting fatigue, see Dr. Bruce Campbell's article Fighting Fatigue.)

Stress and blue mood also draw down neurotransmitters in the brain that can interfere with sleep, cause irritability, and magnify both pain and fatigue. For this reason, we frequently recommend a trial of a low dose stimulating-type antidepressant -- not so much for anxiety or depression as to replace those necessary brain chemicals! Favorites include 5-20mg of fluoxetine (ProzacTM), 50-150mg of sertraline (ZoloftTM), 30-60mg of duloxetine (CymbaltaTM), or 150-300mg of bupropion (WellbutrinTM). Bupropion has the fewest side effects and is most activating; but duloxetine is very effective when both depression and pain are problems together.

If you are sleepy during the day (that is, you fall asleep reading, watching TV or riding in the car), then a stimulant medication might be in order. Have your doctor consider modafinil (ProvigilTM) at 50-200mg each morning to help you stay more alert and focused. Another possibility would be amphetamine salts (AdderallTM) at 5-20mg each morning or methylphenidate (Ritalin) at 5-20mg each morning, if your doctor is comfortable prescribing these medications. Remember, stimulants are only helpful if you have excessive sleepiness, not just tiredness or fatigue, which is common to all PWCs.

Treating Pain
Short of anesthesia, there is no drug that will totally alleviate the pain of CFS/ME or FM, so the first step in pain management is the recognition that you will probably always have some pain.

The second step is to employ non-pharmacological therapies such as cool packs, hot packs, liniments (such as over-the-counter Deep Heat, Icy Hot, Aspercream, etc.), warm tub or shower soaks, massage, a vibrating massager, perhaps chiropractic treatment or even acupuncture. Your doctor could consider prescribing a TENS unit or a muscle stimulator, both of which are available on the internet for very reasonable fees. (For more self-help ideas for treating pain, see Dr. Bruce Campbell's article Non-Drug Treatments for Pain: Nine Strategies.)

Pharmacologically, see if you can manage pain with over-the-counter products such as acetaminophen (Tylenol TM and others), ibuprofen (AdvilTM, MotrinTM, and others), naproxen (AleveTM and others), magnesium salicylate (Dones PillsTM) or aspirin. Your doctor will need to be sure you don't use too much, and he/she will need to check liver and kidney function regularly if you use these medications.

Non-narcotic medications that can markedly reduce pain should be tried next, if needed. These include duloxetine (Cymbalta TM), which can be especially helpful if pain and depression run together; gabapentin (NeurontinTM); or pregabalin (LyricaTM).

Failing other pain control methods, tramadol (UltramTM, UltracetTM, and others) is the next best choice because it provides codeine-strength pain relief but is well tolerated and is thought to have little or no addiction potential. Doses of up to 100 mg four times daily can be used (although an overdose condition called "serotonin syndrome" can occur if you are taking certain antidepressants or other drugs).

Narcotic medications are generally not recommended for chronic pain unless absolutely necessary. If you need narcotic-level pain relief your doctor will probably refer you to a pain specialist.

Pain in the lower back can be improved with chiropractic treatment or physical therapy in some cases. Localized heat, liniments, and over-the-counter analgesics such as ibuprofen, naproxen, or magnesium salicylate may also help. Lidoderm Patches can be extremely helpful. You can cut the patches to an appropriate size and apply them to the areas of localized pain.

Treating Related Conditions
Most persons with CFS/ME have additional medical conditions that we refer to as "overlap syndromes" or "shadow syndromes." Probably the most common is fibromyalgia. A majority of people diagnosed with CFS/ME also meet the diagnostic criteria for FM. Besides fibromyalgia, the most common overlapping conditions are:

Irritable bowel and irritable bladder
Temporomandibular joint disorder (TMJ)
Migraine headaches
Restless leg syndrome (while awake) or periodic leg movements (during sleep)
Sleep apnea
Vasomotor (autonomic or non-allergic) rhinitis
Digestive problems such as gut motility disorder with trouble swallowing, early satiety, nausea, and/or constipation
Autonomic dysfunction with low blood pressure
Multiple chemical or food sensitivities
Gluten (wheat or grain) intolerance or celiac sprue-like symptoms
Lactose (milk) or fructose (fruit sugar) intolerance
Orthostatic symptoms or fainting
Dry eyes and mouth (sicca complex)
Vulvodynia or vulvar vestibulitis (vulvar / vaginal pain)
Joint hyperlaxity (hyperextensible or "trick" joints, frequently associated with low blood pressure and autonomic symptoms)
Metabolic syndrome (a pre-diabetic condition characterized by elevated blood sugar and triglyceride levels, a protuberant or pear-shaped abdomen, and insulin resistance)
Your doctor probably already knows how to handle these problems, if present. Just ask him or her to address them ... but one at a time!

Four General Treatment Rules
In considering drugs and other treatments, there are four general rules that you doctor must know:

1) PWCs are extremely sensitive to medications (especially sedating ones), so your doctor should start with low doses and increase slowly. Start low and go slow!

2) CFS/ME and FM are very complex conditions and may require multiple medications to address the numerous symptoms. This "rational polypharmacy" is not unusual or unexpected, and should not deter your doctor from helping you.

3) Your doctor may have to replace medications periodically, since it is not unusual for PWCs to develop tolerance to medications.

4) No medication works for everybody, so you and your doctor will probably have to experiment to find what works for you.

In Conclusion
Even though there is so far no cure for CFS/ME, there are many treatments. The most important is acceptance of the illness and adaptation to it. Good medical care can play a role. While it cannot cure CFS/ME, medical care can help alleviate its symptoms and further reduce suffering by treating other medical problems.