Have You Stopped Beating Your Wife?

Some questions are loaded, and there’s no good way to answer them.  My high school debate coach was the first to introduce me to loaded questions.  We were taught that lawyers are infamous for this technique, but once you know about it, you recognize it other places, too.  Some of the medical questionnaires I’ve had to complete lately seem to have been designed by people who like loaded questions.

For example, have you stopped beating your wife?  sounds like a simple yes-or-no question.  It’s really a trap.  “No” means you haven’t stopped; you’re still beating her.  “Yes” means you have stopped, so you’ve beat her repeatedly in the past and recognized the need to stop.  When feeling pressured, few people think to say, “I have never beat my wife so there’s no need to stop.”

My family physician only asks for “average number of drinks per week.” I’ve never before seen such questions as these new doctors are asking.  Date you quit drinking?  is one of those questions that really have no good answer.  What if you haven’t quit?  What if you don’t know a date?  What if you do know a date?  Does that mean it was a significant event worth remembering?

Now that my pancreas has decided not to function properly, doctors are actually reading some of my paperwork and looking a little closer at how I answer their increasingly detailed questions.  One of my new doctors flipped through all the forms I’d filled out; apparently I interpreted the loaded question wrong, because he asked, “Have you ever been a heavy drinker?”

Should I ask for a definition of heavy?  I have a neighbor who is drunk before 3:00 every afternoon, but he insists he’s not a heavy drinker.  Does anybody ever respond “Yes”?  Is “No” ever believed?  Is there a way to broach this subject without sounding defensive?  If it won’t change anything, then there’s not really any point in asking.  Are there different treatment tracks based on the patient’s past ETOH use?

Maybe (unlikely) I’d forget all about it, except that I went directly from that doctor’s office to another who insisted that I can’t have chronic pancreatitis, because only long-term alcoholics get that.  Despite the fact that there’s plenty of evidence to the contrary, if that’s what practicing doctors believe, I foresee problems ahead.  I can anticipate being grilled about my drinking history for the rest of my life, and it won’t matter what I say.  If anything, telling the truth will make things worse because the doctor will be convinced that I’m untruthful.  That’s not particularly encouraging.

When doctors put “Date you quit drinking?” on their patient history forms, the line on which answers are written needs to be longer than 1/2″.  I want to write, “I was never a drinker, so there was no reason to quit.”

Referrals: It’s the Money

It is incredibly frustrating to need a doctor and have a referral, yet be unable to get an appointment.

It is maddening to know that if I’d consented to inpatient surgery, all of this would have been resolved in September.  September.  It is now November.  Never again will I attempt to keep expenses down and get out of the hospital as soon as possible.  It is not efficient to try to do things on an outpatient basis.

The gastroenterologist to whom I was referred determined that I need a highly specialized procedure that he doesn’t perform.  He sent a referral to the new GI (let’s call him GI#2) and told me that the new place would call me to schedule an appointment.

I’ve written about this before.  The short version is that after a week without hearing anything, I followed up.  Even though they had all my paperwork, they wouldn’t schedule an appointment.  I was told it would be another 1-3 days before that could happen.  It wasn’t.  A second week went by, then I followed up again.  Still no appointment.  I was told to be patient.  GI#1’s scheduler called me to schedule my follow-up with him since I should have seen doc#2 by now.  Finally I called my gastroenterologist’s (#1) office again and asked if they could please refer me to someone who will actually make an appointment to see me.

Another day, no word.  And another.  I started making phone calls.  There are  doctors much closer who do this procedure.

I phoned my family physician’s office and explained the situation.  “Would it be possible to get a referral to someone else?”  Yes.  “Can I make an appointment so that you can be paid for doing the work?”  No.

My family physician’s office asked which doctor I wanted to see.  I picked the one who had said they could try to work me in this week.  Referrals don’t happen instantaneously; I was told that it would take a day, so I waited two before phoning to make an appointment.  They couldn’t find my referral, but did find my name in their computer so made an appointment and said they’d track down the paperwork.  Good people.

Did I have to wait a week?  Two weeks?  Three?  No.  If it worked for my schedule, they could see me the next day.

A few hours later my phone rang.  It was GI#2’s office.  Once they have a referral, it takes them more than three weeks to bother contacting the patient to set up an appointment.  Caring nothing about my calendar and existing commitments, or the fact that my stomach hurts any time I try to eat, they issued a summons to appear in their office two weeks hence.

I politely accepted the appointment (hedge my bets – I’d hate to say no thanks  after all this time and then discover that there really is only one person in the state who does this procedure), but the following day I met GI#3.  They can  do the procedure and I don’t have to drive to BigCity.  They even gave me a choice between a few dates and will contact me once they can arrange anesthesia.

A few hours after I returned home from meeting GI#3, GI#1’s office phoned and said that the doctor had written a referral for me to see… the local guy?  another local guy?  No.  GI#4 is another doctor in BigCity.

I was starting to wonder if perhaps GI#1 lives in BigCity and commutes, the way he keeps wanting me to go there as if it’s right next door.  Instead, a recent post on KevinMD makes things quite clear:  Why Patients Get Unnecessary Referrals to Consultants.  GI#1 works for one hospital system.  GI#3 works for a competing system.  My rheumatologist has already told me that they’re not allowed to refer outside the system.

WHY is it about whose employer gets the money, instead of being about what’s best for the patient?

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This post was published in November as part of NHBPM’s – 30 health posts in 30 days

The Conveyor Belt of Medicine

Sometimes it feels as if, as a patient, I have very little say in my medical care.  In the rest of my life, I carefully research options before making an informed choice.  Not with doctors.  The world of medicine is like being thrown on a conveyor belt where you roll blindly along from one station to the next.  The workers on the assembly line know what they’re doing, and have a general sense of where the conveyor belt is going, but the patient traveling on the conveyor belt doesn’t get to know.

Enter the hospital, and there are protocols in place guiding everything that’s done.  The patient doesn’t get to interview nurses, CNA’s, and hospitalists to create a team of people to provide their care.  No.  The patient is trapped in a room, at the mercy of the hospital administrator whose policies control the conveyor belt and dictate who the assembly line workers are and which procedures are done.

Get a referral to a surgeon, and it’s like being tossed onto a different conveyor belt:  pre-op “meet the surgeon” appointment, then do the admission paperwork and show up for the various assembly line workers to contribute their little piece of work to the end product, followed by recovery and post-op appointment.  One identical patient after the next rolls off the assembly line, with no allowance made for the uniqueness of individuals.

If you’re referred to a different specialist, it’s like being moved to a different conveyor belt.  All doctors have their own procedures, their own secret way of doing things to which the patient is not privy.  The patient can check for board certification, but aside from that has no way of evaluating the specialist’s credentials or suitability for this specific situation.  Patients are just supposed to sit on the conveyor belt of medical care and do what they’re told.

In all of this, it would be helpful if medical personnel thought a bit more about the patient’s needs.  A little theory from the world of eduction is pertinent.  People have different ways of processing information.  Some people are very focussed on the immediate, and take a “just tell me what I need to know right this minute” approach to life.  Others need to know more and want to see the big picture.

I am one of those big picture people.  If I have to be tossed onto a conveyor belt, a map of the thing would be appreciated.  In fact, I don’t just want a map; I want to know how the whole thing works, and want to be sure that the entire conveyor belt is operating as smoothly as possible.  I don’t like being stuck, waiting for repairs when the conveyor belt breaks down.

In fact, I want to compare a couple different conveyor belts and choose the one that seems to work the most efficiently while providing the best end product.  I want to pick the workers on the assembly line.  By no means do I want to tell the assembly line workers how to do their jobs – I just want the ones who are doing their jobs.

Ideally, instead of being stuck with whatever conveyor belt I happen to be tossed on, and whatever assembly line workers happen to be scheduled, I want off the conveyor belt.  I want individualized care, and I want a say in how it’s delivered.

Edit to add clarification:

I’m not saying that I always want to be in charge of making the decisions about appropriate treatment.  That’s the doctor’s job.  I want things explained to me so that I understand what’s going on and why the recommended treatment is most appropriate.  I don’t want to be stuck forever with whoever happened to be on call.  I want the option of hiring the doctor who is the best fit for my symptoms/diagnosis/personality.

More specifically, I’m not in charge of saying how to get rid of the stones that remain in what’s left of my biliary system.  I wanted to try a non-surgical option. It made things worse.  From what I’m told, the only thing to do is break the stones into small pieces, then remove them.  If that’s what’s needed then I’m okay with that.  I am NOT okay with being told that there’s only one person in the state who can do it, and that I have no choice in the matter.  I am NOT okay with being ignored when I ask GI if there’s anyone else who can do it sooner.  I am NOT okay with the people at Virginia Mason taking their own sweet time; it’s been three weeks since they got my referral and they still won’t make an appointment for me.  I did hear that they will call and tell me when to come in – as if it’s a court appearance to which I’m being summoned instead of an appointment time that we mutually agree upon.  Given how I feel, it would not be at all surprising if I have another bout of pancreatitis before they get around to me.  I’m still working on seeing someone else to get this done sooner.

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This post was published in November as part of NHBPM’s – 30 health posts in 30 days