There is a Plan B (and Sometimes a C,D,and E…)

Let’s say you are a patient and you see your doctor for a rash. He evaluates you and gives you a cream to try. The rash doesn’t go away. What is your next response?

  1. Go to another doctor because that first one didn’t know what he was doing.
  2. Go to another doctor because the first one did not recommend a follow-up appointment.
  3. Use the cream for longer than the recommended period of time
  4. See a naturopath because you would prefer to try natural therapies.
  5. Call the initial doctor’s office for instructions.

 I hope your answer is #5.

 Unfortunately, I see choices #1 and #2 too frequently in real life. Why do I find this unfortunate? These options can lead to fragmented (expensive) healthcare.

Sometimes, a physician does not explicitly detail out all of the thoughts that go along with diagnosing and treating a patient, especially when rushed. They may come up with a diagnosis and treatment plan in minutes, but there is a lot of cerebral processing that occurs within a single patient visit. There are pros and cons to revealing all of this information. Pro: better understanding by a patient of the issue at hand and that there are other possible diagnoses for a single problem. Con: information overload and more confusion.

In the interest of time or of not overwhelming a patient, a physician may focus on the most likely diagnosis and not mention others or talk about them in detail. And, trust me, there are almost always other possibilities. It is rare to see a patient who has only one potential diagnosis when first evaluated. Even a simple cold can have what we call a list of “differential diagnoses” (a list of other causes for the same symptoms).

The inherent problem with only talking about the most likely diagnosis is that a patient walks away with an impression that there is only one potential diagnosis and one treatment plan. If physicians are not clear about follow-up and the treatment fails, patients may feel that perhaps they were “misdiagnosed” and they may look for another opinion.

Physicians should be better at informing patients at least about the next step by addressing what patients should do if their treatment does not work as planned. I try to do this consistently. A common parting statement I make is, “If this is not working as we discussed, [come back or call our office]. If I don’t hear from you I am going to think this issue has completely resolved.” Of course, for more serious issues that I want to monitor, like depression or uncontrolled hypertension, I plan a follow-up appointment. But for relatively minor issues, I don’t want to waste a patient’s time or block my schedule for other patients who need to be seen when an appointment is not necessary.

Doctors, try not to let the patient leave the exam room without a follow-up plan or at least letting her know she can contact your office if a treatment isn’t working.

Patients, keep in mind that – even if unspoken – your doctor has a plan B, and may even have plans C, D, and E in the back of her mind. If you’re tempted to get another opinion for an issue you just had evaluated once by another physician, consider not “giving up” too easily on that initial doctor. It would be wise to see if the doc has an alternative recommendation. I would be surprised if she didn’t.

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About Linda Pourmassina, MD

Internal Medicine physician.
This entry was posted in Patient education/tips and tagged , , , , . Bookmark the permalink.

One Response to There is a Plan B (and Sometimes a C,D,and E…)

  1. Dangerboy says:

    Very good advice, especially physician-side. It takes me forever to find a doctor that I like, and I stick with them. Invariably they listen to my input, and they discuss further steps. (“If thing 1 doesn’t work, we’ll do thing 2”) And they are not irritated by my questions.
    I have been to several that weren’t communicative, and that always led me to option 1. I want to feel like my doctor and I are on the same team. (Currently have a great one)

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