The days when doctor knew best are long gone. Now the most effective way to get the healthcare you want is to be assertive.
Tuesday June 17, 2003
I was 14 years old when my gym teacher laughed at my shoulder blades in front of the class. "Look how they stick out," she said, "just like wings." Humiliated, I was dispatched to the GP. "Your back is bent but it's fine," he said. "It must have got twisted when you were developing as a baby. It has compensated now."
And it would have ended there if my father hadn't read an article in the New York Times. It said a back like mine had scoliosis, which could put pressure on my lungs and breathing as an adult. My mother showed the article to our doctor, we got a second opinion and I had some spinal surgery.
Twenty years ago this was pushy-patient behaviour. Your doctor knew best and you did as you were told. But fears are being raised that now the pendulum may have swung too far the other way. That assertive patients who read up on their conditions on the internet, ask their doctor questions and believe they are consumers of healthcare are overloading the system.
"It worries me that this trend is deepening inequalities in healthcare, as the better-equipped patients corner more and more of their doctors' time," says Hilda Bastian, a leading inter-national supporter of consumer health rights, in this week's British Medical Journal. "Just how much more demanding can we get before we blow it for ourselves - not to mention take more than our fair share?"
But being more assertive can mean taking less of your doctor's time, argues Clara MacKay, director of policy and research at Breast Cancer Care. And it doesn't have to make them feel irritated or threatened.
"GPs have seven minutes a patient and process people at a high rate. If they hear vague concerns, they may feel they don't have the time to explore them fully. If you go in with clear, succinct ideas of what your concerns are and have kept a clear record of what has been happening then it is helpful to both you and your doctor.
"Your doctor shouldn't have to feel challenged. The relationship between doctor and patient is changing but there is a power element still. We are all intimidated by health professionals. Being assertive means that you are clear in your own mind what you want addressed."
If you feel that something is wrong, says MacKay, make sure your doctor takes you seriously: "It may be minor but it can also be serious and it is important that your doctor deals with your concerns." MacKay accepts that she doesn't always find it easy herself to be assertive. "Like many people I can be clear and assertive at work but when I sit in front of my GP I feel apologetic for taking up his time."
Harriet Gaze, a journalist, was diagnosed with multiple sclerosis 13 years ago. She is 45 and has relapses and remissions, requiring frequent visits to her doctor. "Most people are happy to relate to someone who is interested and knowledgeable, and doctors should be no different," she says. But as well as being assertive, Gaze has also had to use her wiles. "When you have MS, physiotherapy can help get your limbs moving after a relapse. Someone told me that there were huge waiting lists for this and what I had to tell my doctor was that I needed physiotherapy for my hip, because doctors think physiotherapy is useful for that. Really my hip wasn't the problem - I had weakness down the right side of my leg and it was difficult to walk but when I said it was my hip my doctor immediately said, 'Oh yes, physiotherapy can help you.' Otherwise I would have waited for ages.
"Doctors do talk about pushy patients sometimes, but the reality is that you don't get the healthcare you're entitled to get without being pushy."
Recognising that patients may be the best judge of their needs, the government has set up the Expert Patient, an initiative for patients with chronic medical conditions. The initiative quotes research from Coventry University that shows that patients who get involved in their healthcare have fewer symptoms, reduced pain and are happier and more satisfied. Its Expert Patients programme offers self-management courses for patients with chronic conditions, teaching them how to manage their health.
"You need to prepare before you see your doctor," says Kerry Hallam, senior trainer for the programme. "Write a list of your main concerns and questions. Take two, one for you and one for your doctor. Think of the language you are going to use before you raise an issue and practise it on someone. Telling your doctor, 'The last time I saw you, you said ...' is more confrontational than saying, 'At my last visit I felt...' "
"You are the person most likely to keep on top of your health problems. As patients we have a vested interest. We're much more aware of our needs than anyone else is. It's OK to ask questions about your diagnosis and test results.
"If you don't understand what your doctor says to you, you can say, 'I am sorry but I don't understand. Can you explain it in a more simple way or draw me a diagram?' "
While some doctors may be irritated by any questions, most accept that patients are increasingly asking them. "It would help if patients confined their visit to one problem," says Dr Alex Vass, a GP in London.
"You can't be pushy about lots of things because there isn't enough time in a consultation. Doctors recognise they'd be pushy themselves to get the best care. But some doctors take criticism better than others. No one likes being challenged. I'd be OK if the patient was pushy as long as they were pleasant and not aggressive."
Dr Vass warns that patients need to be realistic about what being pushy
can achieve. "There are constraints on the service that no one wants, but
there are waiting lists. Doctors don't like to be told what to do, so if
you do want a referral rather than insist on one it can be better to ask
if it would be beneficial to have another opinion. Sometimes patients need
to learn to communicate as well as doctors."
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