Here is another post from my recent book How to Talk To Your Child’s Doctor. It’s about how to handle a doctor whom I call an avoider.

Most of us are, to some degree, procrastinators. We avoid or postpone doing unpleasant things. In this sense, physicians who are avoiders are no different from anyone else. For a doctor, however, avoiding things often leads to poor, or at least less than frank, communication with parents.

One kind of avoidance behavior is when the doctor avoids answering your questions. These doctors do not behave this way because they are poor listeners; they just find it uncomfortable to answer your questions. Often this doctor takes the oblique approach of not quite answering the question you asked, and instead rephrasing it into a question he would rather answer. He tends to talk around issues, especially those that are part of serious, unpleasant, or intractable medical problems. He also tends to use euphemisms for unpleasant things, commonly retreating into medical jargon because medical language seems more sanitized and neutral.

I have considerable professional experience with avoiders because my own subspecialty of critical care often presents parents and physicians with difficult choices, situations in which there are sometimes no good options, just less bad ones. Many times I have spoken with parents who, after an interview with a physician who is an avoider, must ask me what the doctor really meant to say. And that is the key to the avoiding-type of physician: he probably thinks he is doing what is best by filtering what he says and not speaking directly, but parents invariably want their questions answered as directly as possible. If you find yourself in an interview with a doctor like this, you really have no option except to press him for an explicit answer to the question you actually asked, not the one he chose to answer.

There is another variety of the avoiding physician encountered by parents whose child has ongoing medical problems. This is the doctor who just plain avoids them and their child. These are doctors who only reluctantly return your telephone calls or, if your child is admitted to the hospital, always seem to miss you when they come around to see your child in her room. This seems like odd behavior for a physician, but it is not rare. The reason for it is that the doctor procrastinates or even avoids conversations that he believes, for any number of reasons, will be difficult or uncomfortable either for you or for him. Of course, that is all the more reason to have the discussion. Nothing interferes more with a conversation than one of the parties not showing up to partake in it.

A few months ago I wrote about the issue of knowing if your child is in a good PICU or not. Recently the federal Department of Health and Human Services began the first halting steps toward allowing ordinary citizens to compare easily how different hospitals perform — they put up an easy-to-use website that lets you compare up to three hospitals at a time with a couple of simple mouse clicks. The site is here. The Commonwealth Fund also has begun a project, aptly termed “Why Not the Best,” that you can find here. The notion, of course, is that transparency of this sort will allow smart healthcare consumers (who in simpler times we called patients) to shop around for hospitals with the best outcomes. There are at present, however, several serious problems with the notion.

One problem is that the data don’t really tell you much about outcomes, which is what we really want to know. Rather, the sites mostly concern process. That is, it measures how many patients received a particular treatment recommended by the experts for a particular condition. The assumption is that if the accepted, correct process is followed, things will turn out better for the patient. This is only an assumption, and it carries with it the possibility that hospitals will be vigilant only about process measures. In effect, they may “teach for the test” mainly to make themselves look good. The only outcome statistics are death rates for three conditions (all in adults) — heart attacks, heart failure, and pneumonia. And they don’t give you the actual numbers, just if the hospital was significantly above or below the national average.

Another issue, one Dr. Bob Wachter well discusses on his excellent blog here, is that no one is paying any attention to these statistics anyway. Most people still choose their hospital based upon recommendations of friends and doctors — word of mouth.

In the long run, though, the site is an example of what is coming in the future. One day hospital performance will be out in the open for all to see and evaluate. Although there is virtually nothing available yet about children’s hospitals (and their PICUs), this, too, is probably coming.

Here is another post from my recent book How to Talk To Your Child’s Doctor. It’s about how to handle a doctor who is excessively defensive.

I divide this kind of communication blocker into two varieties: physician personality and physician mode of practice. The physician with a defensive personality is one who interprets questions from parents as questioning of her medical judgment. Unlike the supremely egotistical doctor, who is often sufficiently secure in her image of herself that she is magnanimous toward parents who ask questions, the overly defensive physician has the opposite sort of personality; she may be inwardly or outwardly unsure herself and often responds to parental questions in self-justifying ways that can border on the argumentative. Parents easily sense this attitude. For example, I have heard exchanges in which the parent feels a need to begin a question to the doctor with something like “I’m not questioning your medical judgment, but what about . . .”

Physicians with naturally defensive personalities probably had those tendencies reinforced in their medical training, since students and residents are often closely questioned, even roughly attacked, by superiors who believe this sort of hazing is a vital part of teaching young doctors. These kinds of teachers are becoming rarer, but there are still enough of them out there that students who fall into their clutches emerge from the experience with whatever defensive tendencies they already had greatly enhanced. Rather than welcoming parents’ questions as an important tool for two-way communication, they are more likely to feel threatened when a parent asks them probing or even quite innocent questions.

A bigger potential problem for parents with sick children is not the physician with a defensive personality but the physician who practices defensively. Medical testing, excessively and inappropriately used, can cause major problems and even place a child at significant risk. Physicians who practice defensively usually order too many tests, thinking that by doing so they are both helping the child and covering their own backsides. In fact, poorly justified, “shotgun” lab testing does neither of these things. Much has been written about how physicians defensively order too many tests because they worry about being sued for malpractice if they miss something. This may be true to some extent. However, my own observation is that physicians who practice this way would probably do so even if the threat of malpractice litigation did not exist, since defensive medical practice is to a great extent a function of the physician’s personality.

Doctors who are excessively defensive in their use of medical tests also tend to use subspecialty consultations in the same way. Very sick children with complicated problems often need the knowledge and skills of experts. But as a subspecialist myself, I know that some doctors call in the subspecialists largely to spread the responsibility more than anything else, a behavior we call “loading the boat.” If you find an overly defensive doctor evaluating your child, you may find that you need to take an active role in questioning the appropriateness of consulting subspecialists. And remember—subspecialists often want even more tests and procedures, potentially adding still more unneeded complexity to your child’s situation.

Medical research is a conversation between the new and the old. What I mean by that is the findings of new studies need to be compared to previous ones, because most times the reason for doing the research in the first place is to answer questions or test theories raised by previous research. Understanding the historical context of a particular research finding is vital. If you don’t know how a particular new finding compares to older ones you won’t understand the importance of the research. Unfortunately, journalists are less and less inclined to give readers that context when they write about the newest and shiniest medical research. The result is public confusion, and it leads to misleading headlines.

Journalists also like conflict, so they tend to write their stories from the angle that a particular medical finding contradicts a previous one, even when it really doesn’t. Journalists also want to write about unusual, unexpected things. As the saying goes, dog bites man isn’t news — man bites dog is hot stuff.

The result of the Babel of medical journalism is that many people just ignore it all, assuming (not unreasonably) that another study may come out the next year contradicting whatever exciting finding this year brings. Fat is bad! No, fat is not so bad! Coffee is bad! Except when it isn’t! And so on.

There is an excellent editorial in a recent issue of the New England Journal of Medicine by Susan Dentzer, a respected health journalist and editor of Health Affairs, about the pitfalls of all of this and how it might be improved. She describes the problem this way: “Journalists sometimes feel the need to play carnival barkers, hyping a story to draw attention to it. This leads them to frame a story as new or different — depicting study results as counterintuitive or a break from the past — if they want it to be featured prominently or even accepted by an editor at all.”

Her solution is pretty simple — journalists need to supply readers with the context, the shades of grey, that are part of interpreting the results of any research study. I don’t really expect that to happen much. The demands of the 24/7 news cycle are too overwhelming. Readers, though, can read more critically, which is one reason I’ve been posting in this blog about how to interpret the validity of research data.

Gary Schwitzer, a professor at the University of Minnesota School of Journalism, keeps an excellent blog about these issues. I check it frequently (he has useful things to say about the Dentzer piece). You can also find a link to it on the right on my blogroll list.