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From: B. Harris)
Subject: Re: - A Startling Article
Date: 29 Jan 2000 23:37:31 GMT

In <86r6o0$oj9$> "Wayne" <> writes:

>by Brenda C. Coleman
>Associated Press
>22 Dec 99
> In nine out of 10 decisions made between doctor and patient in
>routine office visits, the doctor did not discuss the issue enough to
>allow the patient to make an informed choice, a study found..

  UPI (Washington, D.C.)  And in yet another study, researchers found
that while most people would prefer to have their very own one-on-one
personal tutor with a decade of higher education answer their every
question about any complicated subject for a long as they were
interested, nobody actually wanted to pay for this.

   Government officials were contacted but had no official comment.
One white house advisor stated, on condition that he not be named, that
the present administrationgovernment wasn't about to pay for private
tutoring, either. "You've got to be kidding. Class sizes even in K12
are up around 30, if you're lucky."  A senior official contacted by
this paper coroborated this policy position, and: "You know, the
government doesn't actually make much money on its own! Actually, we
get almost all of it by taking it away from average folks like
yourself. So you actually pay for most of this government stuff, sooner
or later. Plus my salary. But don't quote that."

From: B. Harris)
Subject: Re: - A Startling Article
Date: 31 Jan 2000 02:39:20 GMT

In <> TheVindicator
<> writes:
>Steve:  Hyperbole - on either side  - will not advance a discussion
>toward a resolve.  It only begs for additional hyperbole.

   There wasn't much hyperbole.  Do you think it should cost you more
for half an hour information consultation with a lawyer, or a medical
doctor?  Or about the same?

   Truth is that we are only philosophical about the costs of
personally consulting a lawyer because we expect we personally won't
ever have to.  Or won't have to much. If it's the other guy paying a
lot of legal bills, we figure he deserved or invited it, somehow.  So
we just shrug and observe that a lawyer's time is expensive; what did
you expect?

   It's a tad harder to lie to oneself about eventual need for a doctor
though.  Even though all the same arguments about why costs of this are
what they ARE, apply.

   As for informed consent, it's basically a matter of paying for the
information, one way or the other. You can pay for it out of your life
by paying tuition, or by sitting on your butt in a library, or mining
it out of the internet.  Or you can pay a professional to do that for
you.  Same as with the law.

From: (Jonathan R. Fox)
Subject: Re: Oncologist salary (bottom line)
Date: Sun, 20 Feb 2000 21:38:26 GMT

On Sun, 20 Feb 2000 11:36:53 -0600, ronald <> wrote:
>people in medical schools are not the only people who work hard.
>furthermore, there are some very intelligent people who *didn't*
>go to medical school; you would be surprised.  i went to mit, and
>i suspect that without meeting you i can say with a fair degree of
>certainty that i've met people who are *much* more intelligent than
>you are; people who didn't go to medical school.  in fact, most
>people at mit don't go to medical school, the biggest school is
>the school of engineering.

I think it goes without saying that there are plenty of absurdly
brilliant people who aren't doctors.  Let me just add to your comments
that there are plenty of nearly complete morons who attend and even
graduate from medical school.

>as it turns out, i have pretty good research skills.  and also, as it
>turns out, i am no "fool", so i was able to become quite knowledgeable
>about my mothers condition.  however, i SHOULD NOT have had to go that
>route because some big egoed physicians didn't want to suffer me, a
>fool, gladly because i didn't know anything about the condition.
>i mean, the reason why people go to physicians is because most of us
>*don't* know about medical conditions.  the last thing that a person
>wants in that situation is some physician who comes with this "i was
>at the top of my class" mentality of intellectual superiority assuming
>that the people who come to see him are mental midgets; or worse, those
>who try to use their knowledge to try to intimidate people who ask
>so out of my experience i have become a strong advocate
>for trying to tell people that they don't have to put up with the
>big egos and intimidation; they have a right understand with is going
>on without being considered a "fool" because they don't know already.
>i mean, i don't care what the field is, be it a physicist or a
>physician, if they can't explain concepts in fundamental, and
>understandable terms, then they don't really understand it themselves
>and are using all of the ego display as a cover.

I agree, especially with the last sentence.  I encounter many patients
of other physicians in an ambulatory setting, and frequently find that
their parents understand very little about their child's conditions.
Granted, the physician may have indeed explained them and they didn't
comprehend or remember, but I frequently find that after I explain the
condition in a succinct, simple manner, I get responses such as, "No
one ever explained it to me like that before," or, "It never really
made sense until now."

I think there are a number of reasons why patients often feel in the
dark about their conditions:

1.  Physicians explain in medical terms.  I don't know why it is so
difficult for some doctors to switch from medical terms to vernacular.
We use medical terms because they are much more precise and easier to
use, but it's not hard to use lay terms when speaking to a family.  I
have heard a doctor say to a parent, "I think she might have a UTI, so
I'm going to get a UA."  The usual response from the parent to such a
statement, regrettably, is not, "What does all that mean?" but rather
a furrowed brow and silence.  When I say instead, "I think she might
have a bladder infection, so I want to check her urine," they say,
"OK."  I think it also helps to think from the patient's perspective,
to see if something that might seem obvious to you might not be to
them.  One time, when I was a medical student, I saw a surgeon tell a
woman that he was going to repair her rectovaginal fistula by putting
"tissue" in there.  She looked perplexed, and the surgeon didn't seem
to notice, so I said, "He means your own body tissues, not Kleenex,"
at which her expression completely changed and she said, "Ohhh!!!!"

2.  Physicians feel they don't have the time to explain things.  This
is wrong, but under pressure, they skip the step.  With practice,
however, it is easy to explain the diagnosis, treatment, adverse
effects of treatment, and expected outcome in very little time.

3.  Yes, I will admit that the ego does have something to do with it,
though only in a subset of physicians.  I think the physicians who
deny that egos are in the way are the ones who don't let theirs do so
and don't realize that others do.  Although my attitude and behavior
on this newsgroup would not make it apparent, I have done a lot of
study on the physician-patient relationship, paternalism, patient
autonomy, and so on, and I remain quite humble in the examining room.
I only made an egotistical statement to a patient once, and it was as
a joke.  A mother brought her child to our ER because he was quite ill
with a viral illness.  She had seen a doc-in-the-box out in
Hee-Haw-Town, Texas, who told her he has a viral illness, then
prescribed Augmentin, an antibiotic which is not useful in viral
infections.  The mom told me, bless her heart, that she even asked the
physician why he'd need an antibiotic, since she understood that
antibiotics are only for bacterial infections.  (Sounded like a very
non-threatening way to ask as well, in my opinion.)  She said he told
her, "Do you have a medical degree?"  She said, "No, I guess not,"
then drove almost 100 miles to our ER for our opinion.  We laughed
about it, and I told her, "Well, *I* have a medical degree, and *I*
say he doesn't need it!"

4.  Tying in with the ego thing is your last statement above.
Physicians who do not fully understand what they are dealing with do
not want to reveal this fact.  I will never understand why the
physician above prescribed Augmentin, but whatever reason it was, he'd
never reveal it for fear that it's groundless.  I think the ability to
explain your reasoning for something in a way that others can
understand absolutely requires you to understand it yourself.  I don't
think anyone sets out to be a bad doctor -- rather, they just DON'T
try their hardest to be a good one.  Doctors who have spent years
making diagnoses by pattern recognition and doling out therapy by
protocol may end up finding they don't understand much about it
anymore, and have developed various defense mechanisms because of
this.  A truly "good" physician who understands the basis of what they
do will be both more effective therapeutically and more able to
communicate to families.

Let me just add that I absolutely love it when parents who do their
own research.  They keep me on my toes and we can discuss their
child's care at a higher level.  For the ones who don't, I try to do
as much explaining as I can, including drawing diagrams and explaining
the meanings of medical terms.  This is, realistically, however,
limited by time, basic knowledge of the parent, and, yes, the parent's
interest.  Some parents really do just want you to write them a
prescription and don't want to bother understanding exactly what's
going on.  But for the ones who do, I'm happy to explain.

Jonathan R. Fox, M.D.

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