BethannUK
04-05-2006, 11:02 PM
I have read a lot of posts asking about what we should tell our docs, why they come up with what they do, why they differ in opinion, and how to get them to see and understand how and what we are feeling- this is a post about the way doctors are trained to gather information. I hope it helps you connect to what they are looking for and the best way to get them to really hear what you are saying. For ease, I have called Docs "he"- no bias is intended.
-----------
There are three steps to their information gathering:
1) History and background of general person and wellness
2) History of the current problem
3) Physical examination
GPs and medical folks use a type of decision making called hypotheticodeductive reasoning- I'll call it HTDR for short because I am shocked I even managed to spell it the first time! All of HTDR is based on a theorum called Bayes Theorum- common things are common. Its actually a mathematical formulae that goes through a long process to prove that statistically, things that are rare dont happen as much as things that are common, so its better to first look for common things than to look for rare ones. Brilliant, huh?
They find their differential diagnoses ("differential diagnoses" are the working choices of what they think might be wrong) through a process of elimination, where they look first to find or to rule out the most common causes of any given problem. They use the information they gather in each of the three steps above to guide them through that process. Let me give you an example of how they would diagnose something simple:
I make an appointment because my shoulder hurts.
Doc asks me about my general health- takes my blood pressure, asks me about any ongoing or past health problems, might review my medication, etc. (Step 1- general history) Already he has some ideas about what might be wrong. For example, if I have osteoporosis he may be thinking one way, if I am a star athelete it might be something else.
He then asks me about my arm and shoulder- when did it start to hurt, what was I doing, how did it start, how does it feel, what nmakes it better, worse, etc. (Step 2, specific history of current problem) He now has a couple of different ideas about what is wrong- and he needs to test each of his ideas to see which one fits.
He then checks my arm (physical exam-step 3) so he can test each of his ideas about which is wrong. he may need to use tools for his physical exam- xrays, etc.
After this, he will either be sure of what it is, or not sure. He may need to go through the three steps again, or he may need to gather additional information through additional diagnostic testing like XRays, cat scans, blood work, etc, or referral to someone who knows more about a specific kind of probelm than he does. For example, he may think "this looks autoimmune- I dont know enough about autoimmune disease- a rheumy does... find a Rheumy- my diagnosis is- too hard for me to diagnosis- this person needs another doctor!"
Along this process, he is looking for "hallmarks" or "triggers" that would either "prove" it was the common thing, or indicate something less common or less expected. For example, if I told him that I fell and I heard my arm snap, he would know that this means it may be broken. People who say they heard a snap are likely to have a broken bone.
Now I tell you all this because what may seem insignificant to you or I may be very important to the doctor's reasoning in HTDR. He is looking for little cues and clues to lead him in the right direction. Here are the basic foundation rules that he is taught to follow as part of this process:
1) Common things are common: uncommon things are not common, and shouldn't be considered until all the common things have been ruled out. Rare things are not common.
2) The only way to find out what is wrong is to combine a good interview and a good physical exam: neither one alone will tell you what you need.
3) Patients will complicate this process by telling you what they *think* is important, or not telling you what they are either uncomfortable with or that they don't think is important.
4)At some point, with some patients, you will run out of knowledge before they run out of problems. The best you can do is gather the best information possible to point the patient in the right direction for the right help. This is the hardest thing for a doc to do- especially if he is impressed with himself.
So, by putting together a time line, putting as much detail into as possible, even little things that may not seem important, you will help your doctor quickly get all the information he needs about you. This will lead him to asking the right kinds of questions.
There are two kinds of information the doctor will be seeking: Qualitative and quantitiative
Qualitative is based on the thoughts, feelings and experiences of people as they go through their life. I may dislike marmite- you may like it- neither one of us is right, it's just the way we each feel. example: My chest pain burns, stabs and makes me feel like I can't breathe and I cant climb stairs. You might have chest pain that feels differently. Its individiual, but we still may share it with other people with similar problems.
Quantitative is something that can be measured and replicated. It can be charted, added up, counted. Example: This pain lasts for approximately 2 hours, and I would rate it at a score of 9 on a scale of 1-10, and when I have the pain I am unable to climb more than 5 stairs because I get short of breath.
So, If I feel feverish and sweaty I am giving qualitative information; if my temp is 39.5, I am giving quantitative information. The best description includes both.
Quantitative and qualititative can be combined into documents and charts like pain diaries, temperature charts and activity charts. These are useful because they present information in the way doctors like it- in black and white. They prefer quantitative information because its the way they have been taught to look for things and to think.
The docs will (hopefully) process all of this information in an orderly way. For each issue you bring up, they will ask themselves the following:
-How did it start/ when does it happen- what causes it to happen
-What makes it better/what makes it worse
-Does it relate to anything else (a diagnosis) we already know about?
-Does any of it relate to a medication or side effect from a medication or combination of medications?
-Are any of these symptoms or complaints hallmarks or triggers of specific problems?
-What diagnostic information will help me decide it is- or isn't- something in particular?
- Is there anything I can do to make things better while I figure out what is wrong?
Based on this, they will start to make a picture of your problems and get an idea about what is wrong, or what information they need to gather to figure out what is wrong.
Here comes the reason why doctors come up with different diagnoses:
Along the way, doctors gain experience in different areas of medicine. They begin to develop insight- a like 6th sense about certain illnesses or experiences. They have a heightened awareness- likely because they have seen so much in a certain area that they begin to gather information subconsciously that other doctors may not even be aware is important.
Docs like Hughes have a reputation for this type of diagnostic talent- but remember, the first rule of diagnosis is that common things are common- Hughes has seen more lupus patients than anyone- Lupus is common to Hughes, where it is not common to your GP. He isnt seeing anything any different than anyone else- just *recognising it* differently.
Many of you out there have developed this intuitive, instinctive level of awareness about lupus or the other problems we all suffer from... you have seen, heard and experienced so much that you can make decisions or develop awareness more easily and more quickly than someone else. Its not that you have ESP- its that you have experience and a sense of awareness about certain hallmarks and triggers. Thats what makes places like this so important to us all.
The importance of awareness of hallmarks and triggers was clear in my own diagnosis of Adult Onset Stills Disease- (AOSD)- it was diagnosed not because I had the hallmarks, but because my Doctor recognised my symptoms as hallmarks that meant something ... a doctor who saw the symptoms but didn't recognise them as hallmarks- fever, sore throat, pleural effusion, pressure rash- wouldn't know it was Stills because those symptoms- that recipe- doesn't make anything in his mind. (Thats the doc who put me on antibiotics for a chest infection I didn't have- to him, fever, chest pain and flushing measnt chest infection- the common thing he dealth with).
This doesnt mean he is a bad doctor- just one who doesnt have the experience and understanding of a particular area. The only fault was that he should have sought to prove what was wrong- he should have done a CAT scan because I didn't have the common hallmarks of a chest infection- nop cough, no sputum. He thought he was being insightful, but he was wrong. When I argued with the docs for more diagnotics, I used that inconsistency to get them to listen- "He said I have a chest infection- what symptoms of a chest infection do I have?" When they couldn't answer it- well, it didn't prove I didn't have a chest infection- but it also didn't prove i did. They had to keep looking. The last puzzle piece that brought everythingtogether and made sense everywhere- the diagnosis- wasnt there yet.
So, in conclusion- to get the most out of your consultation with any doctor
Try to organise information about ongoing problems like pain, problems eating, etc, into charts, diaries and logs- knowing that these are easier for the doc to process quickly.
For example, If you are having temperatures, write them in a log- put the temp, date, time and how you were feeling, and what you did to make it better/ what you were doing when it happened. You might even make a line chart showing the pattern.
Be specific about complaints: if you arm hurts, go through the Who, What, When, Where, Why, and How. If you have a rash, describe it and how it occured- what were you doing, how big was it, how long did it last, what made it better, what made it worse. Take pictures.
Try to make it easy for the doc to see what you are talking about. If you have a puffy rashy face, dont cover it with makeup. In the ten or fifteen minutes he has to examine you, he doesnt have time to ask you to wash your face. Be prepared by wearing clothes that will easily allow an exam- In know docs who will not examine a patient if they are wearing excessive undergarments (usually older women with girdles, one pieces, etc, ) because it takes too long to get them undressed!
Write down questions, concerns and worries and ask for a copy to be put in your notes. This puts your doc on notice that he will be held accountable for the answers and he might be a bit mroe fastitidious- you have proof you asked. Take notes when the doctor speaks to you- (see next paragraph for an explanation)
Keep your own record of dates, appointments, blood tests (etc) and what you are told by different professionals. Have a diary where you log each encounter- trust me, it may make you look like a difficult patient, but it will help cut down on the run around and conflicting information when you can say "Actually Doctor, when I saw the pain nurse, she said... but you said..." or "He said I had a chest infection BUT ...."
Finally, if you have information that you think is relevant- bring it up to the Doc. "Doc, I found this article on the internet and it makes sense ..." or "I belong to a support group, and one of the girls there said. she ahd the same thing and this is what it was.." ask what the doc thinks about it, and then put it in your diary along with his response. Some Docs will think you are loony. The good docs however will see you as invested in your health and care. Only a bad doc is threatened by a patient who asks valid questions or asks for valid explanations.
If you have two docs and they give very different diagnoses, ask them to go through what the other doctor told you and to explain why they see it one way and the other sees it the other way. There is nothing wrong with asking your doctor to give evidence for his or her decision making- in fact, it is their obligation. You have a right to ask them to prove why they are saying what they are saying- this is called evidence based medicine, and its a professional, moral and legal obligation.
Last but not least- be willing to complain. Use your diaries and ntoes to formulate a complaint if you are not getting the care you need. You have a right to have the best health possible- and that starts with the doc making the right decisions about you and your condition. Complain in writing, and when you complain be sure to outline what it is that you arent happy with, and what you want as a result of your complaint.
-------------
I hope this long winded sermon is helpful for anyone out there- before I took advanced assessment courses I never realised what a complex and labyrnthine process docs went through. If you know how they are gathering information, however, I hope it will make it easier for you to be heard.
-----------
There are three steps to their information gathering:
1) History and background of general person and wellness
2) History of the current problem
3) Physical examination
GPs and medical folks use a type of decision making called hypotheticodeductive reasoning- I'll call it HTDR for short because I am shocked I even managed to spell it the first time! All of HTDR is based on a theorum called Bayes Theorum- common things are common. Its actually a mathematical formulae that goes through a long process to prove that statistically, things that are rare dont happen as much as things that are common, so its better to first look for common things than to look for rare ones. Brilliant, huh?
They find their differential diagnoses ("differential diagnoses" are the working choices of what they think might be wrong) through a process of elimination, where they look first to find or to rule out the most common causes of any given problem. They use the information they gather in each of the three steps above to guide them through that process. Let me give you an example of how they would diagnose something simple:
I make an appointment because my shoulder hurts.
Doc asks me about my general health- takes my blood pressure, asks me about any ongoing or past health problems, might review my medication, etc. (Step 1- general history) Already he has some ideas about what might be wrong. For example, if I have osteoporosis he may be thinking one way, if I am a star athelete it might be something else.
He then asks me about my arm and shoulder- when did it start to hurt, what was I doing, how did it start, how does it feel, what nmakes it better, worse, etc. (Step 2, specific history of current problem) He now has a couple of different ideas about what is wrong- and he needs to test each of his ideas to see which one fits.
He then checks my arm (physical exam-step 3) so he can test each of his ideas about which is wrong. he may need to use tools for his physical exam- xrays, etc.
After this, he will either be sure of what it is, or not sure. He may need to go through the three steps again, or he may need to gather additional information through additional diagnostic testing like XRays, cat scans, blood work, etc, or referral to someone who knows more about a specific kind of probelm than he does. For example, he may think "this looks autoimmune- I dont know enough about autoimmune disease- a rheumy does... find a Rheumy- my diagnosis is- too hard for me to diagnosis- this person needs another doctor!"
Along this process, he is looking for "hallmarks" or "triggers" that would either "prove" it was the common thing, or indicate something less common or less expected. For example, if I told him that I fell and I heard my arm snap, he would know that this means it may be broken. People who say they heard a snap are likely to have a broken bone.
Now I tell you all this because what may seem insignificant to you or I may be very important to the doctor's reasoning in HTDR. He is looking for little cues and clues to lead him in the right direction. Here are the basic foundation rules that he is taught to follow as part of this process:
1) Common things are common: uncommon things are not common, and shouldn't be considered until all the common things have been ruled out. Rare things are not common.
2) The only way to find out what is wrong is to combine a good interview and a good physical exam: neither one alone will tell you what you need.
3) Patients will complicate this process by telling you what they *think* is important, or not telling you what they are either uncomfortable with or that they don't think is important.
4)At some point, with some patients, you will run out of knowledge before they run out of problems. The best you can do is gather the best information possible to point the patient in the right direction for the right help. This is the hardest thing for a doc to do- especially if he is impressed with himself.
So, by putting together a time line, putting as much detail into as possible, even little things that may not seem important, you will help your doctor quickly get all the information he needs about you. This will lead him to asking the right kinds of questions.
There are two kinds of information the doctor will be seeking: Qualitative and quantitiative
Qualitative is based on the thoughts, feelings and experiences of people as they go through their life. I may dislike marmite- you may like it- neither one of us is right, it's just the way we each feel. example: My chest pain burns, stabs and makes me feel like I can't breathe and I cant climb stairs. You might have chest pain that feels differently. Its individiual, but we still may share it with other people with similar problems.
Quantitative is something that can be measured and replicated. It can be charted, added up, counted. Example: This pain lasts for approximately 2 hours, and I would rate it at a score of 9 on a scale of 1-10, and when I have the pain I am unable to climb more than 5 stairs because I get short of breath.
So, If I feel feverish and sweaty I am giving qualitative information; if my temp is 39.5, I am giving quantitative information. The best description includes both.
Quantitative and qualititative can be combined into documents and charts like pain diaries, temperature charts and activity charts. These are useful because they present information in the way doctors like it- in black and white. They prefer quantitative information because its the way they have been taught to look for things and to think.
The docs will (hopefully) process all of this information in an orderly way. For each issue you bring up, they will ask themselves the following:
-How did it start/ when does it happen- what causes it to happen
-What makes it better/what makes it worse
-Does it relate to anything else (a diagnosis) we already know about?
-Does any of it relate to a medication or side effect from a medication or combination of medications?
-Are any of these symptoms or complaints hallmarks or triggers of specific problems?
-What diagnostic information will help me decide it is- or isn't- something in particular?
- Is there anything I can do to make things better while I figure out what is wrong?
Based on this, they will start to make a picture of your problems and get an idea about what is wrong, or what information they need to gather to figure out what is wrong.
Here comes the reason why doctors come up with different diagnoses:
Along the way, doctors gain experience in different areas of medicine. They begin to develop insight- a like 6th sense about certain illnesses or experiences. They have a heightened awareness- likely because they have seen so much in a certain area that they begin to gather information subconsciously that other doctors may not even be aware is important.
Docs like Hughes have a reputation for this type of diagnostic talent- but remember, the first rule of diagnosis is that common things are common- Hughes has seen more lupus patients than anyone- Lupus is common to Hughes, where it is not common to your GP. He isnt seeing anything any different than anyone else- just *recognising it* differently.
Many of you out there have developed this intuitive, instinctive level of awareness about lupus or the other problems we all suffer from... you have seen, heard and experienced so much that you can make decisions or develop awareness more easily and more quickly than someone else. Its not that you have ESP- its that you have experience and a sense of awareness about certain hallmarks and triggers. Thats what makes places like this so important to us all.
The importance of awareness of hallmarks and triggers was clear in my own diagnosis of Adult Onset Stills Disease- (AOSD)- it was diagnosed not because I had the hallmarks, but because my Doctor recognised my symptoms as hallmarks that meant something ... a doctor who saw the symptoms but didn't recognise them as hallmarks- fever, sore throat, pleural effusion, pressure rash- wouldn't know it was Stills because those symptoms- that recipe- doesn't make anything in his mind. (Thats the doc who put me on antibiotics for a chest infection I didn't have- to him, fever, chest pain and flushing measnt chest infection- the common thing he dealth with).
This doesnt mean he is a bad doctor- just one who doesnt have the experience and understanding of a particular area. The only fault was that he should have sought to prove what was wrong- he should have done a CAT scan because I didn't have the common hallmarks of a chest infection- nop cough, no sputum. He thought he was being insightful, but he was wrong. When I argued with the docs for more diagnotics, I used that inconsistency to get them to listen- "He said I have a chest infection- what symptoms of a chest infection do I have?" When they couldn't answer it- well, it didn't prove I didn't have a chest infection- but it also didn't prove i did. They had to keep looking. The last puzzle piece that brought everythingtogether and made sense everywhere- the diagnosis- wasnt there yet.
So, in conclusion- to get the most out of your consultation with any doctor
Try to organise information about ongoing problems like pain, problems eating, etc, into charts, diaries and logs- knowing that these are easier for the doc to process quickly.
For example, If you are having temperatures, write them in a log- put the temp, date, time and how you were feeling, and what you did to make it better/ what you were doing when it happened. You might even make a line chart showing the pattern.
Be specific about complaints: if you arm hurts, go through the Who, What, When, Where, Why, and How. If you have a rash, describe it and how it occured- what were you doing, how big was it, how long did it last, what made it better, what made it worse. Take pictures.
Try to make it easy for the doc to see what you are talking about. If you have a puffy rashy face, dont cover it with makeup. In the ten or fifteen minutes he has to examine you, he doesnt have time to ask you to wash your face. Be prepared by wearing clothes that will easily allow an exam- In know docs who will not examine a patient if they are wearing excessive undergarments (usually older women with girdles, one pieces, etc, ) because it takes too long to get them undressed!
Write down questions, concerns and worries and ask for a copy to be put in your notes. This puts your doc on notice that he will be held accountable for the answers and he might be a bit mroe fastitidious- you have proof you asked. Take notes when the doctor speaks to you- (see next paragraph for an explanation)
Keep your own record of dates, appointments, blood tests (etc) and what you are told by different professionals. Have a diary where you log each encounter- trust me, it may make you look like a difficult patient, but it will help cut down on the run around and conflicting information when you can say "Actually Doctor, when I saw the pain nurse, she said... but you said..." or "He said I had a chest infection BUT ...."
Finally, if you have information that you think is relevant- bring it up to the Doc. "Doc, I found this article on the internet and it makes sense ..." or "I belong to a support group, and one of the girls there said. she ahd the same thing and this is what it was.." ask what the doc thinks about it, and then put it in your diary along with his response. Some Docs will think you are loony. The good docs however will see you as invested in your health and care. Only a bad doc is threatened by a patient who asks valid questions or asks for valid explanations.
If you have two docs and they give very different diagnoses, ask them to go through what the other doctor told you and to explain why they see it one way and the other sees it the other way. There is nothing wrong with asking your doctor to give evidence for his or her decision making- in fact, it is their obligation. You have a right to ask them to prove why they are saying what they are saying- this is called evidence based medicine, and its a professional, moral and legal obligation.
Last but not least- be willing to complain. Use your diaries and ntoes to formulate a complaint if you are not getting the care you need. You have a right to have the best health possible- and that starts with the doc making the right decisions about you and your condition. Complain in writing, and when you complain be sure to outline what it is that you arent happy with, and what you want as a result of your complaint.
-------------
I hope this long winded sermon is helpful for anyone out there- before I took advanced assessment courses I never realised what a complex and labyrnthine process docs went through. If you know how they are gathering information, however, I hope it will make it easier for you to be heard.