Doubting the Doctor: What to do?

Last September, an article in the journal Pediatrics called “Unfilled Prescriptions in Pediatric Primary Care”caught my eye.  I read the article with interest because I was curious to see how often prescriptions were not filled.  Did you know that more than 20% of prescriptions written by pediatric primary care doctors are never filled?  I thought that was a really high number.
It turns out that there are a lot of contributing factors to why prescriptions are not filled.  Examples include cost, convenience, and what the prescription is written for – an acute illness or a preventive medication.  As you may have guessed, cheaper medications that are filled at nearby pharmacies for acute illnesses have a higher rate of getting filled than medications that are expensive, require going to less convenient pharmacies and do not treat an illness (for example vitamins).

One thing they did not mention in their discussion was the quality of communication on the part of the pediatrician.  I’m not really surprised they didn’t look at that factor because it’s really hard to measure quality of communication in a scientific fashion.  It’s subjective.

A few years ago I was speaking with a friend about her daughter, Emma, who was three-years-old.  She had a sore throat and had gone to see the doctor earlier that day.  She told me Emma was diagnosed with strep throat, given antibiotics and her mom hoped she would start to feel better soon.  She then told me something rather reluctantly.  She said there was another prescription that she didn’t fill.  She said, “It just didn’t seem right.”  Emma’s doctor had written a prescription for steroids.  Steroids are not commonly given for children with strep.  They are reserved for extreme cases of tonsillitis where the child is having difficulty breathing. Emma was not having difficulty breathing.  I think the steroids could have caused more harm than good, and Emma’s mom did the right thing in following her instincts.

I relayed this story because I think it is a good example of why a lot of prescriptions are not filled.  Emma’s mom did not have confidence that what the doctor was doing was the right thing for Emma.  I think, having worked in the hospital emergency department and in primary care, that this happens a lot.  And it worries me that this lack of confidence in doctors’ instructions is occurring more and more frequently as the relationship between doctors and patients changes.  I think back to the image of the family doctor or pediatrician who knows a family through birth and death, illness and health and even over generations of care.  That doesn’t happen that often anymore.  Somehow, without that enduring relationship, physicians need to communicate to families, patients, and parents the rationale for what they are doing, and to instill confidence in their patients.

I write about this with parents in mind.  I want you to know, that as a parent and a pediatrician, it is my experience that most of the time, parents are right about what is going on with their children when they are sick.  There are rare exceptions where parents are really frightened that they are off base, but usually, when it comes right down to it, parents tell me what is wrong with their child.  Their instincts are good.  My job as the doctor, is to find out what is worrying you, so that I can help you tease out what it is that YOU think is going on.  I am a better diagnostician, when I can do that.

If you go to your doctor, and you feel like they’re off base, what do you do?  In my practice, some families tell me they think I’m off base.  Some just seem put-off by what I say.  I’m guessing there are some families that pretend that they are comfortable with the assessment I am giving.  I don’t know for sure.  So usually, what I do is ask families how they are feeling.  Are you comfortable with the plan?  Do you feel that this addresses your concerns?  That usually opens the door for further conversation, and elaboration of symptoms or problems that I might otherwise have missed.  These late coming details often clarify the problem, and allow me to adjust the plan of care.

Does your doctor ask you if you feel comfortable with the plan of care?  Do they offer you the opportunity to follow up if you have doubts?  Do they address your questions?  I hope so.  I think most good doctors do.  But I’m not sure.

The thing I would like to ask of all the parents out there is to be sure not to walk out of the office doubting (or disagreeing with) what the doctor has directed you to do to care for your child, without voicing your concerns.  If you think the diagnosis is off base, you may be right.  And sometimes, it really can make a difference.  Don’t be shy.  Be polite, but do stand up for yourself and your children by voicing your concerns.  If your instincts as a parent say something else is going on, don’t hide that.  Someday it could really make a difference for your family.