By Guest Blogger Chris Gilbert MD PhD
Doctors can be intimidating. But having the courage to confront them can save your life and the life of your loved ones.
Laura was 62 years old when she started having rectal pain and a little rectal bleeding after each bowel movement. At first, she didn’t worry, but after a couple of weeks, she went to see her primary care physician. The waiting room was packed. A nurse took her in to check her blood pressure, heart rate, and temperature, which were all within the normal range then sent her back to the waiting room. After one hour of patiently waiting, she was finally called into an examination room. 15 minutes later, her physician came in the room, got behind his computer and asked her why she was there. As she mentioned the pain and rectal bleeding when having a bowel movement, he checked when her last colonoscopy was, and because the test was the normal five years prior, he suggested the bleeding was probably hemorrhoids and prescribed an anti-hemorrhoidal cream, telling her to come back in three months if she wasn’t better. Altogether, he spent about five minutes with her, didn’t examine her, and wrote his note and his prescription during that time. She respected his opinion, bought the cream, and went home.
Three months later, despite applying the cream every day, her pain got worse and the bleeding too. She made an appointment to see her primary care physician again. As usual, his waiting room was packed. When she finally got to see him, he decided to prescribe a different anti-hemorrhoidal cream telling her to come in another three months if she wasn’t better. Again, he didn’t examine her and stayed behind his computer the whole time.
Three months passed, a total of six months after the onset of her symptoms, her pain wasn’t better. She decided to make an appointment with her doctor again who happened to be on vacation. The back-up doctor had a very different approach. He spent much less time on his computer and actually examined her. He did a rectal examination and felt a hard large mass in her rectum. He ordered a blood test and immediately referred her to a gastro-enterologist for a colonoscopy.
The following week, she was diagnosed with very aggressive rectal cancer and anemia due to chronic bleeding. She was immediately referred to a surgeon for aggressive treatment (surgery, radiation therapy, and chemotherapy). Unfortunately, now, one year later, a lung metastasis has been discovered for which she needs surgery, radiation and chemotherapy again. The question now is: will the right chemotherapy at the right dose be given to her?
What shocks me in this story is that Laura’s primary care physician saw her twice with complains of rectal pain and bleeding but never examined her. Had he examined her the first time, he would have felt the tumor. Her diagnostic and treatment would have happened six months earlier, greatly improving her prognosis. The sooner you address and treat cancer, the better the odds are for a good outcome.
My advice to patients when faced with this kind of scenario is to confront your doctor and request that your doctor examine you.
1. When to confront your doctor
- When your doctor doesn’t examine you.
Physicians today are extremely pressed for time, a situation that has been aggravated by requirements to fill out detailed electronic medical records. As a result, physicians are overwhelmed with stress and rely heavily on laboratory and radiological tests.
Studies confirm that many doctors don’t examine their patients. Sandra Boodman writes in Kaiser Health News describing the case of a 40-year-old woman who had several hospital admissions before a chest X-Ray showed large cancerous tumors in her breasts. Her cancer had spread to the rest of her body, leading to a grim prognosis. Had her physician examined her breasts at the first office visit, or during any of the hospital admissions, the diagnosis would have been made earlier, treatment would have been easier and prognosis better.
In all, 68 percent of medical mistakes are caused by a failure of physicians to physically examine their patients, according to a 2015 survey in the American Journal of Medicine.
And medical mistakes are the third leading cause of death in the U.S.
You should also confront your doctor:
- When you have a lot of side effects from your medication.
Your doctor may think that the same medication dose needs to be given to men and women regardless of their sex, age and metabolism. Yet, the same medication at the same dose can be very well tolerated by most people and give horrible side effects to other people.
Don’t assume your doctor will take the time to carefully consider the right dose for you., or even knows that doses of certain drugs need to be tailored to individual patients.
- When you or a family member is diagnosed with cancer.
Your doctor may still think that for colon cancer, one type of chemotherapy should be used whereas for lung cancer another category of chemo is needed. This represents a longstanding belief that the choice of chemotherapy should be determined by the organ or type of tissue in which the cancer originates. Although this idea is often correct, recent research, as written below, shows otherwise.
2. Why confront your doctor?
- The importance of hands-on examination
A hands-on physical examination with bare hands and a stethoscope can reveal a lot in just a few minutes. Starting by looking at the patient’s skin for abnormal dark irregular spots that could be signs of melanoma, looking inside a throat searching for inflammation, palpating the upper neck searching for lymph nodes, then the lower neck exploring the size of your thyroid gland, using a stethoscope on your chest, listening to your lungs and heart, making sure there is no heart murmur or irregular beats, examining breasts for women and men, looking for tumors, going down to the abdomen, exploring the size of your liver and spleen, the amount of gas or fluid in your abdomen, doing a scrotal and rectal exam for men looking for tumors, doing a rectal and vaginal exam on women, then checking that there is a strong arterial pulse and no lymph node in the inguinal area, pressing on the ankles making sure there is good blood flow and no swelling, looking at the nails to rule out any fungal infection. This invaluable exam takes just a few minutes, and is inexpensive because it uses minimal technology.
This simple exam can diagnose a problem early, such as Laura's rectal cancer.
Also, by systematically examining you, your doctor can notice an abnormal lymph node in your neck, a dangerous melanoma on your skin, etc. even if you came in with an unrelated back pain complaint. This can save your life.
- Every person has a different body: the importance of Precision Medicine
We are now discovering that one size doesn’t fit all. Some people metabolize drugs quickly and others are slow. The fast metabolizers need higher doses of the same medication whereas slow metabolizers need lower doses for the same effect.
Daniel A. Hussar, PhD, writing in MerckManual.com points out that everyone responds to drugs differently, depending on their age, sex, weight, diet, their stress level, their heart function, the way their liver breaks drugs, the way their kidneys eliminate them, other drugs that can make the first drug more or less active, etc…
So, if you have many harmful side effects from a medication, you might need a different dose of the same medication or a completely different class of medications that your body will tolerate better.
This brings me to my last point:
- Every cancer is different: the importance of Genomics
Just as every person is different, every cancer is different with its own genes. Two lung cancers can look the same but can have completely different genes. One of them will be sensitive to a certain type of chemotherapy whereas another one will be resistant to the same chemo and will be sensitive to a completely different chemo. Therefore, if you or a loved one in your family is diagnosed with cancer, a genomic analysis of the tumor is needed to find the right chemo.
An example is the diagnosis of a certain mutation called BRAF V600E in the genes of cancer cells that allows 60 percent of melanoma cancer of the skin to be sensitive to drugs such as Vemurafenib and Dabrafenib that target this mutation. Just a few years ago, metastatic melanoma was routinely fatal within 6 months, but now, with BRAF inhibitor drugs, cancer often spectacularly disappears for a while in patients with the BRAF V600E mutation. We are now discovering that some colon cancers and brain cancers also have BRAF V600E mutations.
Breast cancers are another example where genomics is saving lives. Doctors now can examine patients' DNA, looking for BRCA1 and BRCA2 genes. Oncologists also use proteomics, looking for proteins like Human Epidermal Receptor, Estrogen Receptors and Progesterone Receptors to guide their treatments. Recently new tests go even further, sequencing all the genes of tumor cells to find their mutations. For example, by sequencing gene mutations of breast cancer cells by a 21 gene assay, we can now determine that 45 percent of cases are at low risk of recurrence and/or metastasis and therefore, don’t need chemotherapy.
I have seen many patients suffer from harmful chemo side effects, only to find out that chemotherapy was not needed. And I've watched countless other patients suffer three months of debilitating chemo side effects, while their cancer progressed despite aggressive chemotherapy. Medical teams sometimes waste months of precious time and weaken patients tremendously by choosing chemo blindly without the benefit of genetic analysis.
So, always request a genetic analysis of the tumor. And be aware that not all genetic tests are equal. Some tests examine a handful of genes, while others analyze many genes in order to increase precision in the selection of treatment. The more thorough tests can be expensive, and may not be covered by insurance, but your life may be at stake, so at least be aware that in-depth, comprehensive genetic tests are available that might improve chances for success.
3. How to confront your doctor?
This can be challenging. Physicians are usually proud of being the best. They are the authority and don’t like to be told what to do. They have years of training and like to let patients know that their opinion should be considered as gold and not be questioned.
Yet, they will decide not to examine you, not to take into account the way you metabolize medications and not to do a genomic analysis of tumor cells.
In order to protect yourself, you have to be in charge of your own destiny. But when and how do you find the strength to question the authority?
Here are five tools you can use:
- Put in your request at the beginning of the office visit.
Keeping in mind that doctors are pressed for time, put your request in at the beginning of the office visit. This way, your doctor can spend part of the 10 minutes allocated to your case addressing your request. If you wait until the end of the office visit, your doctor will already be out of the door thinking about the next patient.
- Use Diplomacy
Some doctors have big egos. Start by complimenting them on their knowledge and wisdom then ask your question in a non-threatening way. For example:
When asking your doctor to examine you, you might say...
“Doctor, I know you’re the best and I have been very happy with your treatments in the past. I have heard that in some cases, important diagnosis can be made with hands-on physical examination. So, this time, could you take the time to examine me?”
When sensing that you might need precision medicine because standard treatments aren't working or have side effects, you can say:
“I respect your knowledge and your decisions but I have heard that one size doesn’t fit all in medicine. Since I have horrible side effects of this medication, do you think I could take a smaller dose or maybe is there a medication of a different class that could give me the same benefit without those horrible side effects?”
When diagnosed with cancer and wanting genomic tests:
“You have been so wonderful to me so far and I want to thank you for that. I have heard about the fact that every cancer is different and that depending on its genes, certain chemotherapies can be more effective that others. Can we do a genomic analysis of my tumor so that we can find precisely which chemo will work on my cancer, which one will be tolerated the best by my body with minimum side effects and which one will not work? If you or your hospital cannot do this, can you refer me to a hospital and a doctor that will do this?”
- Keep in mind that your doctor works for you
If your doctor intimidates you, remind yourself that your doctor works for you. You and your insurance are paying doctors so they need to do the best job they can. This starts by a thorough examination and continues by prescribing the appropriate treatment for your unique body.
- Keep in mind that you can save other people’s lives
Another way to look at this is that by standing up for yourself, not only can you save your own life, you can save other people’s lives. Often, people don’t find the energy to save themselves but they find the energy when it comes to saving other people.
If Laura had asked her doctor to examine her, he would have diagnosed her rectal cancer much earlier. This would have taught him a lesson and the next time another patient of his would have complained of rectal pain and bleeding, I am sure he would have examined him or her at the first office visit. Early diagnosis and treatment could have saved this person’s life. So remember that if you stand up for yourself, you might save other people’s lives.
- Get a second opinion
If your doctor doesn’t want to listen to your request—a lot of them will dismiss your request and will tell you they know better than you—don’t hesitate to get a second or even a third opinion ideally from a major teaching hospital. Those hospitals tend to be at the forefront of medical discoveries.
Remember that your life is precious. You deserve to have the best health and quality life as possible and as medical discoveries allow. In a perfect world, the best person to look out for your body should be your doctor. But we live in the real world where the best person to look after you body is…. you!
Author of "Dr. Chris's ABC's of Health" and "The French Stethoscope"