Heart Health

My Agenda

March 23, 2009

My Agenda

When you come to see me as your regular cardiologist I begin our interaction even before I greet you.  I start with your chart, reviewing your previous health history—let’s take the hypothetical patient: previous heart attack, two angioplasties followed by a bypass surgery, high blood pressure, cholesterol, occasional rhythm abnormality—and create a “problem list,” a list of the things I need to pay attention to during my visit with you.  This becomes my agenda.  I ask pointed questions to determine if you’ve had trouble with any of your specific problems:

  1. Coronary artery disease (prior heart attacks, bypass surgery): any chest pain, shortness of breath?
  2. High blood pressure: check out today’s vitals, review home readings, review pertinent medications
  3. High cholesterol: when was your blood last checked, are you on the right medications, are you at your recommended goal?
  4. Arrhythmia: any palpitations, lightheadedness? Review need for blood thinners.

Once my agenda is satisfied I come to the most important part: What are your questions or concerns?  If you are a patient I’ve never met I will likely reverse the order and ask you your concerns first, but I still cover the same territory.

Whether you know it or not you as a patient also have an agenda and it should come as no surprise to you that your agenda often has little or no resemblance to mine:

  1. My legs hurt.
  2. I’m tired all the time and I think it’s due to one of my drugs.
  3. My wife thinks I eat too much salt and I disagree.
  4. I hope you don’t start me on any expensive new medication or order another costly test.

You’ve got a limited amount of time with your doctor (generally 10-30 minutes, depending on specialty) and you can bet that you will not be able to get through all the items on both agendas.  So whose agenda prevails?  Whose should prevail?

I don’t think the answer is obvious.  In most situations I as the doctor will make it through my list—the doctor-patient relationship tends to favor the will of the doctor over the will of the patient.  I check all my boxes and feel satisfied that our encounter was successful.  Some patients are assertive enough that they launch into their list and occupy most of the visit satisfying their concerns, but such a patient is clearly the exception.

Where’s the right balance?  In defense of my agenda, if I don’t make it through my entire list you as a patient might suffer.  If I get through items 1 through 3, but miss the discussion about the need for a blood thinner with your arrhythmia, you might be at risk for a stroke.  If we don’t get through your list you come away dissatisfied at best, and at worst you failed to convey to me a symptom or problem that could potentially become dangerous.

Here’s my proposal.  You should do exactly what I do and come to the appointment armed with a list of items you’d like to discuss.  Tell me up front that you have a number of questions so that I know to leave plenty of time for your issues.  As we go through your list we may find that some of the items are better addressed by your primary care doctor or another specialist.  Some of your complaints may relate to medical conditions for which I (perhaps anyone, for that matter) can’t do anything about and you’ll simply have to live with them.  If the list is long enough or any of the problems complicated enough we may have to schedule another appointment to address them all.

But whatever you do, don’t leave the office until all your most important questions are answered.  This is your body, your health, and although the office belongs to me (figuratively speaking), its only purpose is to serve you.  Our agendas will likely never be the same, but when we say goodbye we need to make sure we are both satisfied.

2 Comments
  1. Arie

    I'm curious if--in this age of WebMD, House, and blogs like this--you as a doctor notice a difference in the way patients interact with you? Do you find that patients come into your appointments with a diagnosis already in mind and tell you the tests they want done to verify it? And if so, do you appreciate a better informed clientele or do all us amateur doctors complicate things?

  2. Dr. Van De Graaff

    Arie I've heard other doctors lament the rise of the internet and the curse of patients who get too much bad information online, but I've got to say that in the years I've been practicing I've seen only a handful of people who come to me with truly misleading information gleaned from the web. This is probably due to several factors. First, most of my patients tend to be older and simply don't look for knowledge on their computer as much as the younger population. Second, there are so many good and reliable web sites out there that most of the stuff they come across is accurate and up to date. Finally, the field of cardiology tends to deal with more concrete problems (heart attacks, rhythm abnormalities) that have fairly straightforward solutions. This is probably not true of specialties that handle ailments that are less likely definitively treated or cured, such as cancer and chronic pain. A patient with pancreatic cancer (generally considered incurable) might be more inclined to look past his doctor's office and to the internet than the patient with high blood pressure (which is relatively easily treated). For these reasons I may not be the best to answer your question completely. From my own perspective I would have to say that I welcome the patient who has already done their homework and comes to my office armed with information drawn from the internet. When I diagnose a problem that is somewhat uncommon I'll recommend to the patient that they check it out online (WebMD is a good choice) so that they can answer some of the questions I invariably forget to address. I hadn't thought about recommending an episode of House, though. Who knows, that might not be a bad idea . . .

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