Power to the Patient: Getting the Best Care with Isadore Rosenfeld, MD
By Isadore Rosenfeld
The opinions expressed herein are the guest's alone. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.
Whether you have a case of the sniffles or a life-threatening disease, you have a right to the best healthcare possible. But in today's assembly-line healthcare system, that basic right can seem unattainable. We got empowering tips and advice from Isadore Rosenfeld, MD, when he was our guest on WebMD Live.
Moderator: Welcome to WebMD Live. Today our guest is Isadore Rosenfeld, MD. Thank you for joining us today, Dr. Rosenfeld. In your book, Power to the Patient, you say that patients must know what treatments to insist on when they get sick. Why do we as patients have to know what to tell the doctor to do?
Rosenfeld: Because the traditional doctor-patient relationship is, in most cases, a thing of the past. Today, one does not often chose one's doctor. He or she is assigned. Now doctors for any number of reasons no longer have the time that patients need and deserve when they are sick. They no longer have the time to give you all your options, both diagnostic and treatment. Also, in some cases doctors are no longer the agents themselves. They have insurance companies looking over their shoulders. When a patient comes to the doctor he or she should be prepared to discuss intelligently any questions about the doctor's recommendations. Some important questions may not be addressed by the doctor for many of the reasons that I have stated.
Moderator: How would you advise patients to prepare for the visit?
Rosenfeld: You are asking me a very obvious question. That's the reason I wrote Power To the Patient. I have selected what I consider to be the 40 most common and important ailments that Americans will encounter in their lifetime. In each case, I have gone into detail explaining the meaning of the symptoms; how they came about, how to prevent them, how most efficiently to diagnose them, and how best to treat them. Any patient with one of these disorders reviewing what I have written -- in lay language so that everyone can understand it -- is then in a position to discuss the doctor's recommendations. People are sometimes embarrassed about doing that and are fearful of offending the doctor. No well-meaning physician will object to an honest discussion with an intelligent, informed patient.
Member: I have been told by my HMO doctor that I should have a hip replacement, however, the orthopedist is encouraging me to have an intra-articular cortisone injection first to see how I respond. I am 65 years old and in relatively good health otherwise. Are these injections safe and what would be your advice? Should I listen to the HMO or the doctor? How do I know what to do?
Rosenfeld: It's not the HMO that made the recommendation; it's one of its physicians. You're lucky to have an HMO that is actually recommending a more expensive intervention. The decision is one that probably requires a third opinion. If your symptoms are bearable there is no reason not to try the injection first. You can always have the operation. However, I can tell you from personal experience, because I had my own hip replaced, the operation in good hands will restore normal hip function. Make sure, however, to determine the experience of the doctor who will be performing the hip replacement. Ask how many he has done and his track record.
Member: My HMO requires that a certain low-cost antibiotic always be tried first for ear infections, but it rarely works on my young son. We usually have to go back to the doctor a second time for a stronger antibiotic. What can I do to get the medication that works best in the first place?
Rosenfeld: If you have tried their recommendation and it has not worked, you should ask for an independent opinion. Such independent panels are mandated in 42 states and the District of Columbia.
Member: What questions should I prepare for my doctor when I am exploring a diagnosis, like of Grave's disease?
Rosenfeld: You should ask how he or she plans to make the diagnosis. You should have at your fingertips the various diagnostic tests commonly used to make that diagnosis. The confirmation of Grave's disease is neither difficult nor controversial. You should have no trouble getting the appropriate diagnostic tests.
Member: I am 61, working, and overweight. I go for a yearly physical. What tests/screenings should my doctor give me during each yearly visit?
Rosenfeld: At 61 years of age regardless of whether you are overweight you should have a thorough physical exam, looking for obvious abnormalities and blood pressure determination. In addition, you should have a diagnostic blood test battery, including in your case because you're overweight, thyroid function. There are several other markers in the blood which I recommend including homocysteine level, and if you have a generous HMO, C-reactive protein and alpha lipoprotein A. These diagnostic tests include lipid profiles, that is, cholesterol and all its cousins, kidney and liver function, sugar levels, and a complete blood count. At 61, you obviously should also have an EKG and if you have any heart murmurs or high blood pressure a stress test and possibly an echocardiogram. For men, I would insist on a PSA test to exclude the possibility of prostate cancer. And a digital rectal exam. Everyone over age 50 should also have a colonoscopy every five years, and more often if there is a family history of colon or cancer. The stool should also be examined for blood and the urine for protein.
Member: Should women insist on a CA-125 test as part of the annual exam? I've heard that a Pap smear isn't enough, that this is the test to look for ovarian cancer, but most insurance wont' pay for it and most doctors don't routinely do it they way they do PSA tests for men.
Rosenfeld: Good question. Years ago most doctors routinely performed CA-125 determinations. Over the years, however, it became clear that this test resulted in many false positives and false negatives. In other words, a perfectly healthy woman might well end up with an elevated CA-125, which would then cause great and unnecessary anxiety and expensive, unnecessary, and potentially dangerous tests. By the same token, a false negative response would result in false reassurance. So these days most doctors use the CA-125 to follow the progress of patients who have had documented ovarian cancer in order to assess the effectiveness of therapy.
Member: Rarely do women over 40 have complete physicals annually. Is there a concise "list" of tests or the like that one can take to their physician to ensure a complete physical?
Rosenfeld: Yes. Women are particularly prone to breast cancer. Men have it too, but to a much lesser extent. So a female's workup would be determined by her family history and by other characteristics. For example, if she has high cholesterol or is a smoker, has had early menopause, then she would be subjected to the same vascular evaluation as a man of 40. In addition, if there is a strong family history of breast cancer in two or more close relatives such as mother or sister, she might ask for a BRCA1/BRCA2 gene determination to see whether she has these genes and is vulnerable to ovarian and breast cancer. In that event, she might well opt for prophylactic mastectomy. It goes without saying that the Pap test is also a must.
Member: My elderly parents won't question anything the doctor tells them. They complain heavily about the treatment they get, but are meek as sheep in front of the doctor. If I try to interject, they say "Don't make the doctor mad!" What am I to do?
Rosenfeld: You have to sit down with your parents and read my book to them. And they will understand that when you interject you do so for a reason based on an intelligent assessment of their problem. No doctor worth his or her salt will take exception to valid questions. Just as no doctor who feels on solid ground with his diagnosis and recommendations will object to a second opinion.
Moderator: How do you know when to insist on a second opinion?
Rosenfeld: Another good question. Some years ago I wrote a book entitled Second Opinion. It was about 350 pages, but I will try to sum it up for you in a couple of sentences. If you are given a diagnosis that, if correct, can change your life, you should get a second opinion. If you are advised to have major surgery and there is any question in your mind about whether or not you need it, you should have a second opinion. If you are being treated and the results are less than optimal, you should have a second opinion. A good example of the latter situation is somebody with high blood pressure in whom the doctor is having difficulty normalizing the pressure without intolerable side effects. Too many people throw up their hands in despair and walk away from treatment because they conclude that the therapy is worse than the disease. You are entitled to a second opinion whenever you are not happy with the method of, or with the response of your ailment to, a given therapy. Remember there is almost always more than one way to skin a cat in medicine.
Member: Now that I have my diagnosis, I want to get more involved with my own treatment, but my doctor seems wary. I don't want to alienate him but I want to feel I have some control in the care of my chronic condition. How can I do both?
Rosenfeld: Tell him exactly how you feel. Doctors, in these days of litigation, welcome patient involvement in the management of their disease. This is your right and his obligation. Doctors and patients are a team. I'm not just saying that because it sounds good; it is the truth. If you have a doctor who will not embrace you as a partner in the management of your illness, you should find yourself another doctor who will.
Member: In your book you say to check for any financial relationships between provider and insurer. What is the procedure to do that, and how do you know the answer is trustworthy?
Rosenfeld: Well, you can ask the insurer for a statement. If it is not forthcoming, approach your local medical society, particularly its grievance committee, with that request. I used to be, or I was for several years, chairman of the grievance committee of the N.Y. County Medical Society, and such queries are not at all unusual. However, I believe that the insurance company is obligated to reveal any such financial arrangements.
Member: Walk us through the top three diseases that Americans face and what they should ask.
Rosenfeld: For example, if you are a teenager, or a parent of a teenager, with acne, you are [expected] to consider the pimples as normal and a right of passage, so to speak. Yet acne is the commonest cause of emotional disturbances among adolescents. I think it is important that if a youngster has these pimples and is concerned about them, and they are not responding to simple over-the-counter medications, which are often effective, they should see a dermatologist. They should insist on seeing a dermatologist.
Diabetics are vulnerable to vascular disease. Every diabetic should have access to a vascular [blood vessel] consultant and a renal [kidney] consultant. Doctors are notoriously inept in matters nutritional. Diabetes control not only involves the use of insulin, weight control, oral hypoglycemics, but also sound dietary advice. Every diabetic should insist on a consultation with a qualified nutritionist to spell out dietary instructions that they need to follow.
As far as Alzheimer's disease is concerned, we tend too quickly to attribute memory loss and behavioral changes to Alzheimer's in older people. Yet very often these behavioral changes are due to depression, to other neurological [brain and nerve] disorders, to multiple small strokes, and sometimes even to a brain tumor. Remember that at the moment there is no single test to diagnose Alzheimer's. It is a diagnosis of exclusion, and before you buy the diagnosis of Alzheimer's, make sure that the patient's nutritional status has been evaluated because vitamin deficiency can cause behavioral changes. Have a thorough neurological and psychological evaluation as well. I repeat: Alzheimer's is a diagnosis of exclusion [a conclusion that is reached only by eliminating all other possible explanations for the symptoms].
Member: Your article in Parade Magazine says to check a surgeon's track record. How do I get that? What if the hospital refuses to give it to me?
Rosenfeld: I would be very suspicious of a hospital that refuses to tell you the surgeon's track record. In such cases, I would ask the doctor who referred you to the surgeon to find out, and if you cannot get the answer, get another surgeon. I would never be operated on by anyone whose past performance is not available for me to review.
Member: My mom gets her care for free through the Veterans Administration. She is grateful for the free care (she is a vet) but has little or no control over who treats here or how. Most of the time she likes the health care providers she sees, but sometimes is unhappy. She feels trapped because she can't afford to go elsewhere. What can she do? She's not usually shy about anything, but as a retired nurse, she still has the old fashioned notion that a doctor is God. Between her attitude and her economic situation, she sometimes just waits until the rotation of the doctors changes at the VA to see if she can get a better doctor. Any advice?
Rosenfeld: Well this is a special case and I am not sure I can answer that. I have no experience with VA hospitals. Those of my patients who have had occasion to be treated at the VA are usually satisfied. If your mother has no other option, she will simply have to grin and bear it, secure in the knowledge that the doctors at the VA have no ax to grind.
Member: Is it okay for me to insist on tests I think I need but my doc says no?
Rosenfeld: It is okay if there is a rational basis for your request. If you are a woman and insist on a PSA test that is not appropriate. However, if you've read Power to the Patient or some other reliable text, and determined that there is a reason for you to have a specific test based on your vulnerability to a given disorder or symptoms that suggest it, you should by all means insist on it but document the reasons for your insistence.
Member: We are almost out of time. Before we wrap up for today, do you have any final comments for us, Dr. Rosenfeld?
Rosenfeld: I am a practicing physician. I write these books and my column in Parade and my television program in my spare time and on weekends. So what I wrote in Power to the Patient represents not some theoretical opinion, but is the result of years of experience dealing with patients and their hopes, their fears, and their frustrations. I know how reticent they are to question a doctor and to raise even the slightest doubt as to the appropriateness of his or her recommendation, but this is a new kind of medical world in which we live. Doctors are often no longer free agents. Many are employed by or beholden to third party payers or managed care companies. They know that their performance as physicians will be assessed not only in terms of lives saved, but also money saved. I believe that it is extremely important for every patient in some small way to be his or her own doctor. To be able to recognize your body's signals to know when they are urgent and what they may mean. Every patient must know all of his or her treatment options when sickness strikes. Most doctors don't have the time to go through all of them with you. Some may be better than others for you. If you arm yourself with the knowledge of what is available to you and discuss it with your doctor I promise you that you will find him or her very receptive. And you can only benefit from the result of such an interaction. This is the kind of information you will find in Power to the Patient.
Moderator: Unfortunately, we are out of time. Thanks for joining us, members, and thanks to Dr. Isadore Rosenfeld for being our guest. For more information, read his book, Power to the Patient: The Treatments to Insist on When You're Sick. For more information on the latest treatments available for a variety of conditions, be sure to visit WebMD. Read the latest health news, chat on our message boards, and continue to join us for WebMD Live. Be well and goodbye!
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