Love/Hate, Doctor/Patient/Internet 
(June 27, 2017)

Remember the time that your normally pleasant, even-tempered doctor suddenly snarled at you and kicked you out of his office so violently that you landed in the street, only narrowly avoiding being run over by a passing vehicle? and you never knew why? Well. It was because you, innocent and trusting person that you are, naively brought a printout of something you got off the internet with you to your appointment. Don’t ever, EVER do that again.

Doctors hate the internet. They truly, madly, deeply hate the internet. The only thing they hate more than the internet is a patient who wants to talk about something s/he read on the internet. Why is that?

If you manage to get up the nerve to ask them, they’ll usually give you some version of the first reason below. But there are at least a couple more that they won’t.

1) People who would never dream of, say, trying to fix their own car, for some reason feel competent to diagnose themselves off the Internet. Because they are unable to do this properly, it ends up making extra work for your doctor who already thinks s/he has too much to do.

See, this is what happens. Say for example that you are feeling unusually tired lately. You google “fatigue” and wind up with a sackful of websites and screeching headlines, all of which look much the same to you. After trying valiantly to make sense of it all for a while, you wind up with a glazed look and a long list of conditions that include fatigue as a symptom.

Next you try to pick the right one off the list by sorting through all the lists of accompanying symptoms. You wind up saying to yourself something like “ok, sometimes I feel dizzy too. And yeah, sometimes my fingertips do feel kind of numb. This must be it." You’ve convinced yourself that you have multiple sclerosis and now, as well as sort out what to do with your problem, your doctor has to talk you out of your own personal diagnosis.

It happens that fatigue is a common symptom. Pretty much anything that goes wrong with anyone is going to include some fatigue in there somewhere, so "fatigue" isn't something that you can use to diagnose. But you only know that if you are a professional and do this stuff all the time.

Diagnosing someone’s health problem is kind of like Michelangelo sculpting an elephant; when asked how he did it, he said, “I just start with a block of marble and chisel away everything that doesn’t look like an elephant”.  The key here is starting off knowing what you are doing. If you do, you’ll eventually wind up with a passable elephant. If you don’t, you’ll wind up with a mess of marble dust, a lot of tears and a useless printout.

2) Doctors get paid for performing procedures, not for physical examination and talking to their patients. Of all the things that doctors do that insurance companies pay for, the activity that far and away pays your doctor the least is doing a physical examination and history. This is only one of many stupid things that insurance companies do, but it is one of the most harmful.

It is harmful because the patient history – the part where you get to discuss your symptoms in detail -- is THE most important source of information in diagnosis. Testing is usually just done to confirm the diagnosis made from the history. In fact, the majority of the time, if all you do as a doctor is let your patient talk about their issue, by the time s/he is running out of steam you pretty much know what’s going on.

A typical insurance company will pay your M.D. about $120 if s/he spends a half an hour with you. I promise you that NO ONE is going to be able to run a typical medical office, then, if they spend a lot of time with their patients.

So you have here a very important reason why your doctor interrupted you (on average) about 12 seconds into your recitation of your symptoms in an attempt to cut to the chase. It is also why you often get handed a prescription instead of having a discussion of diet, exercise and lifestyle. Now you can see why when you pulled out a printout suggesting that your flu is actually dengue fever, your doctor kind of lost it a little bit.

3) It’s really not all that hard to make a doctor look stupid, and they don’t like it any better than anyone else does. If you’ve already got a solid diagnosis of, say, rheumatoid arthritis, and you spend a few hours on the internet, you might find a new study or two that suggests a particular herb might show some benefit. Then when you bring that information to your doctor and make him/her feel stupid because even though they know a lot more about RA than you do, they didn’t know THAT.

You should never injure the pride of someone who spent a decade or more learning their business. This applies to doctors, chefs, mobsters, etc. I’m not saying don’t bring it up. I’m saying just do it with the awareness that your doctor may not know quite what to do with it – and if so, that doesn’t mean that s/he isn't a good doctor.

Patient diagnosis and patient care is NOT all the job of the doctor, with the patient following meekly along. It’s the rare patient who gets well without participating in their own care. But there’s just so much a layperson can do on their own. Don’t follow meekly along behind your doctor, but – as Dirty Harry would have said – ya gotta know your limitations.

--dr. diane holmes
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