Be assertive and take an active role to improve your health care.
a person with chronic inflammatory arthritis, I have seen many
physicians, surgeons and specialists. Here's a few things I do to make
appointments with my doctors run smoothly. Using these strategies, my
doctors have been more open to trying new treatments that I suggest. At
the same time, it's helped to identify other health problems that could
have been overlooked. It's also kept me from falling between cracks in
the health care system and caught small mistakes made by doctors. The
end result is that my health has improved, going to see the doctor is no
longer stressful or alarming, and I find myself eagerly anticipating my
Keep a record of your health events.
a daily log or journal of events related to your health care. You
don't need to write down something every day, just write down the
important events related to your health. Here are some suggestions:
you will find this information invaluable when you see another doctor
for the first time. It's even great for your regular doctor. If you
are like me, my regular doctors have a two-inch thick folder of
paperwork about me. When I want a corticosteroid injection, rather
than looking in the file, my rheumatologist asks me: "How many
injections have you had in that joint?". Do you think he wants to spend
time looking through that huge file? No. But you know the answer,
because you've written it down in your journal.
- blood test results -- make a table on the first page of your journal and fill it in at your next visit..
- dates of corticosteroid injections
- dates and locations of diagnostic procedures (X-Rays, MRI, bone scan)
- dates starting and stopping a medication
- dates medication missed
- stressful events in your life
- unusual symptoms - quantify it:
Instead of "I feel feverish today", write: "Today my temperature
was 101 degrees Fahrenheit". Instead of "I'm very thirsty", write
"I drank 4 L of water today and I'm still thirsty".
- typical symptoms - quantify it: Rate your pain, stiffness, emotions on a 10-point scale, where 1 = "Not noticable" and 10 = "Can't move!". Example: October 16: Back pain=4, Knee swelling=7, Anxiety=2
the journal on a computer is a good idea. You can print a selection
of it any time you need one. How to organize the diary is up to
you, but over time I have split up my journal into these sections:
A list of doctors' full names, specialty, address, telephone
numbers, fax number, email (if you're lucky), receptionists'
names, date of first visit, and even the date of final visit if
you are no longer a patient there. When I see a new doctor, I
bring this along because sometimes they want to contact a previous
doctor. I print out two copies of this list: one for my home phone book and one for my daily planner.
- Blood Tests.
Record your blood test results and the date the blood was drawn.
By recording a copy yourself, you can keep everything together and
correlate changes in your body with changes in your blood. In my
journal, I include the lab's stated limits for normal people and
my doctor's interpretation of the test. I print out a copy of
the table and take it with me to each appointment to remind me to
ask for the latest blood test results.
- Condensed Journal.
Every month, summarize the regular journal in this section. Just
the facts. It's short, point form, one-line summaries. I send
this to a new doctor before the first appointment. To the doctor,
this is a gold mine. It's a complete history already prepared! She
doesn't have to ask as many questions and I don't worry about
forgetting an important event in my medical history. Here is a sample:
- Two weeks after the corticosteroid, my knee has filled up with fluid again.
- High thirst (drinking 4 L of water daily) still continuting
- 1st visit with Dr. Lochnan
- Dr. Lochnan: Blood test results: No calcium in blood
- Radioactive iodine uptake thyroid scan done
- Liver enzyme levels high (AST is 116)
- Methotrexate and folic acid stopped
- Second liver enzyme level test shows AST is down to 65
Dr. Lochnan's diagnosis: I have a hyper functioning
thyroid nodule, NOT Grave's disease. Referral to Dr.
- Regular Journal.
The gory details. Record how you felt, what your doctor said,
exact procedures that you had, including locations and dates.
Remember, you'll be going over it again to make the monthly
summary. So be expressive. If you're experiencing pain or other
symptoms on a daily basis, you can keep track of your progress by
using the 10-point scale as mentioned above. Write down everything you
feel is significant. I keep this part private. Often just
writing things down makes me feel better, because I know I don't
need to think about it anymore. If what I'm experiencing later
turns out to be an important symptom, it's down there in black and
white so I don't have to remember it weeks later at the doctor's
Read as much as you can about your illness and treatments.
you're reading this document, you're already on the right track! But
you need a good solid resource at your fingertips. Go to a bookstore
and buy the following:
recommend that you avoid purchasing a pharmacist's book. It lists
every single side effect ever reported for each drug, easily leading
you to attribute any little change in your body to the medication
you're taking. A medical dictionary. I find the paperback book The Bantam Medical Dictionary (Bantam Books, 1990)
to be the best combination of price and readability. There are
other dictionaries with more terms, but the definitions are more
complicated. The cross-referencing in the Bantam Medical
Dictionary is excellent. Later, if you outgrow the basic medical
dictionary and become interested in the Big Picture, I highly recommend
the following textbook: Totora GJ: Principles of Anatomy and Physiology, 9th ed. John Wiley & Sons, New York, 1999. If you're an information junkie like me, move on up to Taber's Cyclopedic Medical Dictionary 18th ed. (F. A. Davis Company, 1997). However, some of you may be overwhelmed by Taber's graphic, full-color photos of human diseases.
- One of the latest guide to prescription drugs. If the one you have is three years old, throw it out and get a new one. More than once I have been misled by an older edition of this type of guide. I currently have three:
Prioritize appointment objectives.
your appointment, type up a list of things that you wish to have
addressed. Remember that your doctor is busy and won't have a lot of
time, often only 10 or 15 minutes. Put the list in point form only, to
keep you from reading directly off the sheet, and to prevent
distracting your doctor. Sort them by what you think the priority should be. Print out two copies, one for yourself and one for your doctor. Keep it short and simple. Here's a sample:
Dr. Feelgood, March 1st 1997. 3pm
Discuss: (most important first)
- Cytotec 250 micrograms twice daily
- Voltaren 50 mg slow release twice daily
- my occasional dizziness
- stomach ache
- obtain last session's blood test result
- what are the symptoms of a yeast infection?
- inquire about the risk of developing an ulcer
- (if time) discuss the recent reports in the media that NSAID use can prevent Alzheimer's.
important to give a copy to your doctor at the start of the
appointment. There might be a symptom that triggers a warning flag but
you thought was unimportant. The priority of the items on the list
may change during your meeting, but as long as you have the list your
doctor will be able to cover the important ones.
When you're in the waiting room, resist the temptation to read your
favorite magazine. Instead, read over your agenda. Picture what you're
going to say, and how you're going to say it. Get the point where you
know exactly what is on your list without looking at it. You want the
discussion to be natural and smooth.
When you are talking with your doctor, remember to avoid being passive AND avoid being aggressive. Instead, be assertive. There is a good discussion with examples on being assertive at Mediconsult's web site.
a pen in with you and write down notes/answers to your questions
next to your agenda items. If you can't write because of arthritis
or other reasons, ask your doctor to write down key words for you.
KEY POINT: AVOID
bringing published material and printouts to the appointment. (The
only exception should be your little agenda sheet). Such information
is distracting for your doctor. They love paper! I end up feeling
ignored. Don't keep it to the end of the appointment and present it
at the last minute, either. If you give it to him at the end of your
appointment, the article may not get read, or it will distract the
doctor from his next patient. It takes time for your doctor to read and
digest new information.
fax / mail / drop-off the information BEFOREHAND with a covering
note saying that you'd "like to discuss this at our next
appointment, on March 23". I have never met a doctor who didn't
appreciate this. However, when you do send them something, make
certain that you READ it over three times yourself. Look up words in
your medical dictionary. Learn to pronounce and spell the hard words. My rheumatologist was very impressed when I knew how to spell sulfasalazine,
because he always got it wrong himself. If the words are very
difficult, at least make your best effort to understand the
introduction and conclusion, the important parts. Later, you can ask
your doctor to clear up any confusion.
are people too, and anything you can do to make their task easier
means they appreciate you more. You will earn their respect.
The street goes two ways. Remember in school when you talked about
your teachers outside? Guess what... they talked about their
students too. The same applies to doctors. I've heard the
receptionists and the doctors talk about their patients -- which ones
they liked and which ones were annoying.
the receptionists with respect too. They often get dumped on and
can be real sticks in the mud at times. They have bad days just like
everyone else. Be very friendly with them. Never get angry at them
for a long waiting period. If it's a big concern, write it down in
your journal, and bring it up with your doctor at the next
appointment -- just don't be aggressive! Be assertive.
Avoiding the Power Struggle - Convincing a skeptical doctor to try something new.
times, a meeting with your doctor can feel like a battle. Perhaps
you've read about a new treatment on the news that sounds exciting.
Who knows your body better than yourself? You've read the drug
information book, you know what symptoms to expect. You're being an
educated patient. And yet here's the doctor shooting holes in your
arguments and resisting your suggestions of new treatments to look into.
What's gone wrong?
of all, remember what I said about bringing paper into the meeting.
DON'T bring in an article. Fax it a few days ahead of time with a
small note. But there is something else to consider: the medium
itself, and how it is delivered, rather than the message. A printout
from the web (even this web page, I'm sorry to say) has less impact
than a professionally-printed, multi-colored pamphlet. My doctors
are well aware of the misinformation and scams present on the web.
In fact, they instantly turn off when I say the "Internet". So, I've
stopped saying "Internet" or "the web". Now I say, "This information
is from a non-profit organization that specializes in ..."
all that you can to earn the respect of your doctor. To do this,
you need to make your doctor's job easier. You've done that already
by keeping a diary, being educated, using an agenda and being
assertive. One extra skill that takes a lot of practice is clearing a
mental path for your doctor to follow and allowing her to do her
job. An example will help illustrate my point.
I first started taking minocycline, I did not go to my doctor and
say "I'm experiencing a Jarisch-Herxheimer Reaction". Leave the
diagnosing to them - it's their job. Instead, describe the symptoms.
If they don't make the connection, give them a hint, but be subtle.
Pretend you just thought of it. Say "you know, I think I've heard
about this type of thing before, only it was in people who had Lyme
disease. They often get a fever after taking antibiotics too, don't
they?" By leaving the diagnosing to your doctors but helping them
along, you can safely leverage their knowledge and earn their
respect at the same.
see, it's entirely possible that you may be wrong. Once upon a
time, I was convinced that the annoying thirst I was experiencing
was due to methotrexate. After all, the drug book recommended I
drink lots of fluid with this drug. But when I told my doctor about
this, he said the medication I was taking could not cause me to be
thirsty. The next time we met, I again told him that I was thirsty,
and insisted it was the methotrexate. He sidestepped the issue and
quietly snuck in some extra blood tests that I wasn't aware of. As
it turned out, he uncovered a problem in my thyroid gland, something
completely unexpected. I was correct to be assertive because the
symptom turned out to be very important. But I was wrong to be
telling him what my diagnosis should be. If I had brought up the
subject differently, he would have told me what tests he was running
instead of being secretive.
let doctors think of things for themselves. You're coming to the
doctor to ask for their professional advice, not to tell them how to
treat you. If you want to try IV-delivered antibiotic therapy for
inflammatory arthritis, you'll have to guide your doctor so he will
conclude on his own that IV antibiotic therapy will be beneficial.
You can help by earning their respect and providing them with the
information that they ask for. Sometimes it will take two or three
more appointments. Stick with it, be assertive, be patient.
Hopefully you have found these suggestions beneficial. Go to it!
Here's a summary in case you read like I do, skipping right to the end for the good parts:
- Keep a medical diary of all significant health-related events.
Educate yourself: Seek out new treatments. Know everything about
the medications you are taking. Understand terminology using your
- Write down a concise list of items to discuss before each appointment. Bring two copies.
Don't bring any other photocopies, Internet printouts, or
newspaper clippings to the meeting. Instead, fax them a few days
ahead with a polite note saying that you'd like to discuss them
during your appointment. Be careful when using documents without
references and potentially misleading sources like the Internet.
- Be assertive rather than aggressive or passive.
- Be educated about your illness and symptoms, but leave the final diagnosing to your doctor.
Copyright ©1997-2000 David Elfstrom <email@example.com>
granted to print one complete copy under Fair Use copyright law. This
essay may not be housed on another server or republished without my
Awarded "That's Useful" site of the day Saturday March 29 1997.
Author: David Elfstrom <firstname.lastname@example.org> URL: http://elfstrom.com/arthritis/appointments.html
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