Dr. William Feldman, author of Take Control of Your Health
- June 21, 2007 11:35 AM |
- By Your Voice
CBCNews.ca welcomed Dr. William Feldman, author of Take Control of Your Health, to answer your questions on Thursday, June 28.
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- Download the audio of the interview (Runs 27:33)
Dr. Feldman is general editor of The 3 A.M. Handbook: The Most Commonly Asked Questions About Your Child's Health. He was head of the division of general pediatrics at the Hospital for Sick Children in Toronto and is professor emeritus in the department of preventative medicine and biostatics at the University of Toronto.
In his latest book — Take Control of Your Health — Dr. Feldman looks at why Canadians are losing faith in their doctors.
He looks at issues such as:
- What questions should you be asking your doctor?
- Why are Canadians turning to alternative medicine to treat their health problems?
- Is doctor-recommended treatment really the best remedy?
Dr. Feldman explains it's not the patient who has the problem. It's the system.
With more health information available than ever, patients are turning to the internet for answers — but they're often misdiagnosing their symptoms. Dr. Feldman looks at this issue and offers advice on how to evaluate whether any recommended health intervention will do more harm than good. In the end, he says, it's critical for patients to ask the right questions of their doctors.
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Comments (14)
What advice would you have for a person whose family doctor takes no initiative in trying to solve a current health issue (referals, testing, etc.)? Part of the reason being that he seems to have "written me off" due to an unrelated chronic condition. It's extremely difficult to find another GP willing to take new patients.
Dr. William Feldman
There are a number of different issues that crop up from that particular question. One is the amount of time that physicians have given the fact that there's such a shortage, particularly in family physicians. The good news is that the number of physicians coming out of medical schools and going into post-graduate training is increasing quite strikingly. So within the next few years, I think that problem should be somewhat resolved.
But in the meantime, the doctors don't have much time. Because they don't have much time, I think the question should be very focused. When you focus on the questions, you have to know what the evidence is behind the question you're asking. For example, if you go into your family doctor and say you have this chronic condition and you saw this particular item on television which is going to relieve the discomfort or the pain, you have to be pretty sure when you go in that there's good evidence behind this commercial, and I have to tell you, most of the time this is not the case.
In order for you to know what the evidence is, you have to know things like what is a randomized controlled trial. These are the kinds of facts that I'm trying to get to the public. I think that if patients are better informed about what constitutes good evidence than when they go to their physician, they're going to go with very focused questions. The physicians, by the way, are being trained more and more with the whole concept of evidence-based medicine in the last 30 or 40 years, so that most of what physicians are now doing is based on good scientific evidence.
To get the communication improved between the patient and the physician, the patient is going to have to know more about how to focus that question around their particular need.
there are hundreds of thousands of medical misdiagnosis each year. what type of recourse does an average citizen have when one occurs to them ?
Dr. William Feldman
If you were in the U.S., you wouldn't have to ask that question, because the first thing you'd do is go to your lawyer and your lawyer would get a big bundle of money for you, most likely.
I should point out that, yeah, there may be a large number of misdiagnoses or problems associated with hospitals. On the other hand, I'm not sure the public knows how good our hospitals are. These are a small minority of misdiagnoses or mistreatments. The vast majority of patients who go into hospitals are very well looked after, even given the financial and time constraints that people have.
So, the only point I would make, Holly, is that you might want to do what people in the United States do. Get a lawyer.
Why are naturopaths and chiropractors unfairly treated by governments and medical society systems?
Dr. William Feldman
I think Larry makes a very good point. I think one of the reasons for that has to do with the quality of the evidence behind the particular alternative practice that is going on.
I have to talk a little bit about some forms of alternative medicine which have been studied in good randomized, controlled trials - in other words, where half the patients were given the alternative treatment, the other half were given a sham treatment or a placebo treatment - and it turns out that the alternative treatment was no better than the sham treatment. So, why should the government pay for that? The government pays for evidence-based medicine.
And there will be good randomized, controlled trials on alternative methods, and I think once they become incorporated and there's good evidence that these alternative treatments do more good than harm, my hunch is that they will be done more and more by physicians, and therefore they'll be paid for.
I have a child that has food allergies and will require re-testing for these allergies every 2-3 years - this will be an ongoing procedure for the rest of his life as specific food allergies rarely change. Why do I need a referral to the same allergy doctor from my family doctor each time for re-testing?
Dr. William Feldman
That's a good question and I don't have an answer for that, although I know there are some allergy clinics that I'm familiar with that will set up the follow-up appointments themselves. That's one of the things she should do next time she goes to the allergist is say, "Is it possible for me to come next time without going through my family physician?"
I find there is a real divide between the generations, where physicians don't have the time to listen to the "narrative" (i.e. long-winded) response they sometimes receive from patients (I'm thinking of my mother here!). Yet sometimes there is a pearl in the information. How can patients and physicians address this communication divide?
Dr. William Feldman
That's a good question. Now, I can't talk about the particular patient or the particular physician, but the good news is that the medical schools across North America, and I think most of the developed world, have been concentrating for the past few years on communication skills.
In fact, even in accepting medical students for study in their medical schools, the people doing the studies of potential doctors are looking at the communication skills that they bring into medical school with them. While they're in medical school, they're getting specific courses now on communication.
I hope that in the next little while, the ability of the physician to pick up the pearl of wisdom is going to be there, and hopefully, if there are more physicians, the time to listen to the extensive narrative will be there, as well.
How come the communication between city specialists and rural family physcians is so bad? It seems to be limited to letters when sometimes a discussion would be more helpful.
Dr. William Feldman
I think we're sitting at the beginning of a whole new spectrum of communication between referring physician, the family physician, and the specialist in the major centres. What we're going to be seeing more and more is the use of e-mail. We're going to be seeing video conferencing. More and more of this is already happening.
Maybe Canada is a bit behind compared to some other countries in terms of this. But the communication between referring physician and the specialist is definitely going to improve over the next few years. I agree with Paula, though, that this is a problem now.
My father spent a week in the palliative care ward of his local hospital, during which time the rest of the family took turns at his bedside, not only to comfort him, but also in hopes of getting answers from the doctors and specialists who came through at all hours.
How does one get a clear and full picture of a family member's health situation while he or she is hospitalized?
Dr. William Feldman
I have to tell you that I've been terribly impressed with the quality of palliative care in the places that I've visited over the years. I think it's really improved and it's becoming a specialty now so that people at the end of their lives are getting much better care than they got 20 or 30 years ago.
I think the place where this communication between the family and the physician takes place, I think sometimes the physician may be a little reluctant to have this discussion at the bedside. It may be worthwhile for the family to suggest to the head nurse on the ward, could they meet with the palliative care team in the conference room to discuss the very difficult questions that they have in the back of their minds.
Every year I go to my doctor for an annual physical check-up. And every year the doctor comments on my health based on the tests results (cholesterol level, etc.)from the year before. Then she orders again the same tests...whose results I will not learn until the following year...Can I ask the doctor to order routine tests BEFORE the annual check-up so during annual the visit I can have an up-to-date picture of my health?
Dr. William Feldman
Well, I hate to push my book, but I think this particular caller should have a look at what I say in the book because it's entirely possible that many of these tests aren't necessary.
I have a whole chapter on tests and when do you need a test. If you're a high-risk person, sure. You have to have a test. And if you're a high-risk person, maybe you should have it more than once a year. But if you're a low-risk person with no family history, you're in good shape, you're fit, your blood pressure's normal, you may not need most of those tests.
You should dig out the literature that says, for example, how often you should have your lipids tested or whatever. There is literature there and you have to know how to critique that literature to make sure that if you have that test it's going to do you more good than harm.
The problem is that quite often is does some harm because there are some things that my readers will find out about called false positives. You may have a routine test and there is a chance that you're going to get a positive result which is going to make you and your physician very anxious and it may require you to have a whole bunch of other tests before you find out that it was, in fact, a false positive.
I suppose I have two questions:
1. What can a person do to aid their doctor and increase the efficiency of the system?
Dr. William Feldman
The first thing is not to be so turned on, as some people are, to various tests.
For example, one of the things that's doing a marvellous job at saving time and money is something called the Ottawa ankle rules. These rules were developed some years ago and it looks as though if you sprain your ankle and you go to the emergency department for an X-ray of your ankle, chances are pretty good that you won't get an X-ray of your ankle. You won't have to sit around waiting for the X-ray and for someone to read the X-ray, and you won't have to spend the tax-payers' money to take the X-ray.
There have been some excellent studies which show that the Ottawa ankle rules, under certain circumstances - if you can bear weight on it after the injury, if your physician examines you and it doesn't have any particular telltale signs of a fracture - the yield of an X-ray is about zero.
So, here's a good example of how evidence-based medicine is cutting the costs, making the whole system more efficient.
2. What can a person do to help improve the system as a whole?
Dr. William Feldman
By agitation, by dealing with politicians, for example, the wait list business. By voting for politicians who are going to do something about it. For example, in the province of Ontario there are some excellent systems now in place whereby the wait lists have been shortened quite strikingly. The only problem is you may not be able to have the test or the treatment in your community. They might ship you to another area not too far away where you'll have it done much more quickly. So, the wait-list system is getting better but it didn't get better until there was a lot of agitation and the politicians started putting some money into getting these systems in place.
What recourse is there when a doctor makes a patient agree to treating only one medical problem per visit?
Dr. William Feldman
Again, that's the time issue. I'm not sure what recourse the patient has. If Anne is lucky enough to have another family physician that she can go to or another specialist that she can go to, I think that's the move I would make because there's still plenty of physicians out there who are very happy to treat more than one problem at a time.
Why do we keep hearing from government that wait times are being reduced when anectodally we hear horror stories of the trauma and suffering people are going through as they wait for diagnostic testing, operations and cancer therapy.
Dr. William Feldman
I think that's true. There's still a problem. On the other hand, the anecdotal stories may not account for what's called a triage system.
A triage system means that if you have something which needs to be treated really quickly, if you have chest pain right now, you're not going to wait. They're going to triage you in the emergency department and you're going to be treated in the emergency department within a short period of time and you're going to do well.
The problems with wait lists have to do with chronic conditions and I'd love to see that improve. I think it's going to improve over the next few years if the public agitate enough with their member of Parliament and with their provincial members of legislature.
I have a pressing problem....I am a family physician trying my best to steer my patients to assume responsibility for their health. I am daily faced with obese, smoking, substance abusing patients who abdicate any personal stake for improving their health and are sometimes hostile to any suggestions for change. Any suggestions for this very difficult problem?
Dr. William Feldman
Oh, I wish I had them. I sit on a provincial committee called the Ontario Guideline Advisory Committee, so even though I am a pediatrician, I'm aware of some of the latest evidence involving people of all ages, including the geriatric population.
Dr. Wolloch will probably know very well that with someone who's been obese for a long time, or who's been smoking for a long time, or who's taking no interest in keeping fit, the ability to have a major impact on these individuals is not great. Therefore, we should really be talking about prevention, rather than trying to treat some of these patients.
A lot of people what the "magic pill" because they see it on television or they hear about it on the radio or they see it in the newspapers. I have to give the pharmaceutical industry a fair bit of the blame for this.
As you probably know, the pharmaceutical industry is the biggest lobby group in the United States and one of the highest profit-making industries in the world and it's in their best interest to get people to want a particular cure for whatever it is that ails them and to put pressure on the physicians to prescribe it. Many physicians will try not to if they have good evidence that the treatment is no more effective than a much cheaper, older, safer drug. But sometimes they don't have the time and they say, "You want this? Sure I'll write the prescription for you."
Perhaps, we need to look at our medical schools. I've heard that Canadian medical schools tend to accept students mostly based on marks whereas our commonwealth counterparts such as the UK and Australian schools focus much more on the interpersonal skills. Do you feel this would help with patient care, if Canadian medical schools were more open in their selection? Do you feel our schools should concentrate more on the person rather than quantitative values, like marks?
Dr. William Feldman
Yes, I believe they are, and I think the acceptance of medical students now is not just based totally on marks. I used to go around with the accreditation process to different medical schools to make sure they were doing the right thing and I can remember going from coast to coast in this country and virtually every medical is now paying a lot of attention in their selection process to the interpersonal skills that the individual has.
What should we do if the family doctor is not able to diagnoise the cause of a condition or not satisfied with the diagnosis? How do we get a second opinion?
Dr. William Feldman
I think this person should look up the evidence behind their diagnosis or what it is their physician has said. For example, if it's a chronic pain issue and the treatment you're getting for chronic pain is not sufficient, you may want to look up the literature, you may want to look at the internet to see if there's something better than what your physician has prescribed.
But if you're going to take anything off the internet, you better know how to evaluate the quality of the evidence because, I have to tell you, there's an awful lot of junk out there.
One of the main reasons I wrote my book was to educate the public as to how to evaluate the quality of the evidence that's out there on the internet. For example, if this patient decides to try something that if funded on the internet by a drug company, the changes are very good that it's not a particularly good study. There's a financial interest involved and I would avoid that bit of information.
On the other hand, if it comes from a university or a government, a good randomized controlled trial says that this particular treatment is as good as or better than tradition or [less] expensive treatment, and the study is a good one with a large enough sample size and the patients are followed for long enough, as opposed to the Vioxx example, then I think you may want to go into your doctor's office and I say "I brought you some information that I think might help you in helping me."