You, the individual, can do more for your health and
well-being than any doctor; any hospital, any drug,
and any exotic medical device.
Joseph Califano

Chapter 2

The Wise Medical Consumer

The quality and the cost of medical care depend more on you than on your doctor.

To become a wise medical consumer, start with three basic principles:

By following these three principles, you will gain more control over the quality and cost of your health care than you have ever had before.

Work in Partnership With Your Doctor/Nurse Practitioner

Good partnerships are based on a common goal, shared effort, and good communication. If you and your doctor can make these things happen, you will both gain from the partnership. You will get better care and your doctor will practice good medicine.

Five Ways to Be a Good Partner

  1. Take good care of yourself.

    Both you and your doctor would prefer that you don't get sick in the first place. And if problems arise, you both want a return to good health as soon as possible.

  2. At the first sign of a health problem, observe and record your symptoms.

    Your record of symptoms will help both you and your doctor make an accurate diagnosis. And, the better job you do recording early symptoms, the better you and your doctor can later manage the problem.

    • Keep written notes on the symptoms. Record when, how long, how painful, etc., for each symptom.

    • Note anything unusual that might be related to the problem.

    • Measure and record vital signs. See page 32.

    • Add regular updates and watch your progress. Are your symptoms getting better or worse?

  3. Practice medical self-care at home.

    As the front-line partner, you can manage a lot of minor health problems on your own. Use this book, your own experience, and help from others to create a self-care plan.

    • Learn what you can about the problem.

    • Keep notes on your self-care plan and what you do.

    • Note whether home treatment seems to help.

    • Set a time to call a health professional if the problem continues. See page 13 for more on calling your doctor or advice nurse.

  4. Prepare for office visits.

    Medical appointments are often scheduled for only 10 to 15 minutes per visit. The better organized you are, the more value you can get from the visit.

    • Prepare an Ask-the-Doctor Checklist like the one on page 2.

    • Update and bring your list of symptoms and your self-care plan [called out under point 2 above]

    • Write down your main concern (chief complaint) and practice describing it. Your doctor will want to hear that first.

    • Write down your hunches or fears about what is wrong. These are often helpful to your doctor.

    • Write down the three questions you want answered the most. (There may not be time to ask a long list of questions.)

    • Bring along a list of the medications you are taking.

  5. Play an active role in the medical visit.

    • State your main concern, describe your symptoms, and share your hunches and fears.

    • Be honest and straightforward. Don't hold anything back because of embarrassment. If you don't intend to fill a prescription, say so. If you are getting alternative treatment such as acupuncture or chiropractic treatments, let your doctor know. To be a good partner, your doctor has to know what is going on.

    • If your doctor prescribes a drug, test, or treatment, get more information. See page 14.

    • Take notes. Write down the diagnosis, the treatment and follow-up plan, and what you can do at home. Then read it back to the doctor to be sure you have it right.

Calling Your Doctor

Is it okay to call your doctor?

Of course it is. Often a phone call to the doctor or advice nurse is all you need to manage the problem at home or determine if a visit is needed. Here's how to get the most from every call:

Prepare for your call.

Leave a clear message.

Follow through.

Finding the Right Doctor

If you don't have a family doctor (primary care physician), now is the time to get one. Everyone needs a regular doctor. A host of specialists working on separate health problems may not see the whole picture. In choosing a doctor there are lots of questions to ask, but these two matter the most:

Training and Experience

For most people, a good choice for a family doctor is a board-certified family practice doctor or internist. These doctors have broad knowledge about medical problems. See page 20 for a brief description of medical specialists. Does this doctor work with nurse practitioners or physician assistants? These primary care providers have special training for managing minor and routine medical problems. For many health problems, these professionals can often see you sooner, spend more time with you, and help you just as well as a doctor.

Partner Potential

During your first visit, tell your doctor that you would like to share in making treatment decisions.

Pay attention to how you feel during the visit.

But I Want a Take-Charge Doctor

Not everyone wants to be a partner with their doctor. Perhaps you don't like to ask your doctor questions.

Perhaps you don't want to share in any decisions. Perhaps you would rather just let your doctor tell you what is best for you. If that's what you prefer, tell your doctor. Most doc- tors have a lot of patients who don't want to be a partner. The doctor just needs to know what you expect.

Is It Time for a Change?

If you are unhappy with how your doctor treats you, it may be time for a change. Before you start looking for a new doctor, tell your current doctor how you would like to be treated. Your doctor would probably be pleased to work with you as a partner - if only you would tell him that's what you want. Otherwise, he may think that you, like many of his patients, want him to do all the work.

The Advice Nurse

Advice Nurses are registered nurses who have special training to help you manage short-term illnesses, help you decide an appropriate response to symptoms, and to answer questions about your problem or concern. The Advice Nurses are easily reached by phone (the number is in your member directory).

In many cases, a call to the Advice Nurse may save you the inconvenience of a trip to the clinic. In addition to being a resource for health information, the Advice Nurse works with your health care provider to monitor, support, and adjust treatment for illnesses you manage at home.

The Telephone Advice Nurse Service, pioneered by Kaiser Permanente, is available for Adult Medicine, Pediatrics, Obstetrics/ Gynecology, and for many specialty areas.

Take Part in Every Medical Decision

Except in an emergency, you cannot be given a treatment or test without your "informed consent." You must be informed of the risks and agree to the treatment. In a partnership, however, informed consent may not be enough. The real goal is shared decision making, where you actively participate in every medical decision.

Why should you help make decisions with your doctor? Aren't you paying him to know what to do? Well, the choices aren't always black and white. With many health problems, there is more than one option. Consider these examples:

You have moderately high blood pressure (160/95). Your doctor says that although exercise and diet might bring it down, most people don't succeed that way. He recommends that you start on medication to control it. You would rather try exercise and lose weight than take pills for the rest of your life. The best decision depends on your values.

Your three-year-old has a headache and a fever. The doctor says it's probably nothing to worry about. Then you tell her your hunch that it might be meningitis. Some testing may be appropriate.

You have been suffering from carpal tunnel syndrome for several months. Your doctor is now recommending a wrist splint and a steroid injection. You would prefer trying just the splint with aspirin first. If that doesn't work, you will consider other medica- tions. Your doctor agrees that is a good plan.

In each case, the treatment you choose will have an effect on your life. Therefore, the best medicine for you combines your doctor's medical expertise with your personal values.

Eight Ways to Share in Medical Decisions

  1. Let your doctor know what you want.

    Tell your doctor that you want to help make decisions about what to do for your health problems.

  2. Do your own research.

    Sometimes you need to learn things on your own before you can fully understand what your doctor is saying. Call or visit your Kaiser Permanente facility's Health Education Center for help in getting the information you need. See "Health Education Resources" on page 23.

  3. Ask "why?"

    Always ask "why?" before agreeing to any medical test, medication, or treatment. By asking why, you will often discover another option that better meets your needs.

  4. Ask about alternatives.

    Learn enough to understand the options your doctor thinks are feasible.

  5. Consider watchful waiting.

    Ask your doctor if it would be risky or costly to wait a while (day, week, month) before treatment.

  6. State your preferences.

    Tell your doctor if you prefer one option over another based on your personal desires and values.

  7. Compare expectations.

    Tell your doctor what you are expecting from the treatment and ask if that is realistic. If appropriate, discuss side effects, pain, recovery time, long-term limitations, etc.

  8. Accept responsibility.

    When you share decisions with your doctor, both of you must accept the responsibility for the outcomes.

Shared Decisions About Medical Tests

Medical tests are important tools, but they have limits. Some people think that the more tests they have, the better off they'll be. Wise consumers know medical tests have costs and risks as well as benefits. To help your doctor make good choices about tests for you, you need to:

Learn the basics.

Consider the risks and benefits.

Ask about costs.

Let your doctor know:

If a test seems costly, risky, and not likely to change the recommended treatment, ask your doctor if you can avoid it. Try to agree on the best approach. No test can be done without your permission.

Once you agree to a test, ask what you can do to reduce the chance of errors. Ask about food, exercise, alcohol, or medications to avoid before the test. After the test, ask to review the results. Take notes for your home records. If the results are unexpected and the error rate of the test is high, consider redoing the test before basing further treatment on the results.

Medical Ping-Pong

Shared decision making requires two-way communication, like playing a game of ping-pony.

Ping: You describe your symptoms, main concern, and hunches.

Pong: Your doctor makes a diagnosis and describes treatment options.

Ping: You tell your doctor your personal preferences or ask about other options.

Pong: Your doctor restates the options and how they relate to your preferences.

Ping: You accept one of the recommended options or learn more about what you should do.

With good two-way discussion, the chances are better that you will end up with the treatment plan that is best for you.

Shared Decisions About Medications

The first rule of medications is to know why you need each drug before you put it in your mouth, rub it on your skin, or whatever. The same as with medical tests, there are a few things you always need to know about medications.

Learn the basics.

Consider the risks and benefits.

Ask about costs.

Let your doctor know: Your concerns about the drug.

Shared Decisions About Surgery

Every surgery has risks. Only you can decide if the benefits are worth the risks. Are you willing to live with your problem or do you want to have the operation? The choice is yours.

Learn the basics.

Consider the risks and benefits.

Ask about costs.

Let your doctor know:

Once you understand the costs, risks, and benefits of surgery, the decision is yours.

Become Skilled at Obtaining Health Care

If you have ever thought that the cost of your medical care doesn't matter because your company or health plan pays the bills, think again. You do pay. Most people have to pay co-payments and deductibles. Employers pay for health care coverage by restricting wage increases. Governments pay for health care by increasing taxes or reducing other benefits.

As medical costs go up, there is less money available for housing, education, wage increases, etc. These costs do affect you. If you can help reduce health care costs, you help yourself - and everyone else.

Once you become a partner with your doctor, you can do a lot to reduce your health care costs. The goal is to get just the care you need, nothing more, and certainly, nothing less.

Who Works on What?

Cardiologist (MD): heart

Dermatologist (MD): skin

Endocrinologist (MD): diabetes and hormonal problems

Family Practitioner (MD): primary care

Gastroenterologist (MD): digestive system

Geriatrician (MD): older adults

Gynecologist (MD): female reproductive system

Head and Neck Surgeon (MD): ears, nose, and throat

Internist (MD): primary care for adults

Neurologist (MD): brain and nervous system disorders

Oncologist (MD): cancer

Ophthalmologist (MD): eyes

Optometrist (OD): eyes when disease is not involved

Orthopedist (MD): surgery on bones, joints, muscles

Pediatrician (MD): primary care for children and teens

Podiatrist (DPM): foot care

Psychiatrist (MD): mental and emotional problems

Psychologist (PhD): mental and emotional problems

Pulmonologist (MD): lungs

Rheumatologist (MD): arthritis and rheumatism

Urologist (MD): urinary and male reproductive systems

Nine Ways to Cut Costs (but not quality)

  1. Stay healthy.

    Healthy lifestyles and regular preventive services are the best ways to keep costs down. See Chapter 3. Also see Chapters 17, 18, and 19 of this book for ideas on how to stay healthy your whole life long.

  2. Use self-care when you can.

    Every time you successfully manage a health problem at home, you reduce the cost of health care for you and for others.

  3. Get your professional care from a primary care provider.

    Family physicians, internists, pediatricians, nurse practitioners, and other primary care providers are the best place to start for most health problems. See page 13 for more information.

  4. Reduce your medical test costs.

    Don't agree to expensive medical tests until you understand how they will help you. Unneeded tests are often done because "it is standard practice" or to protect doctors from possible malpractice suits. The only good reason to do a test is because the benefits to you outweigh the risks and the costs. No test can be done without your consent. See page 15 for more information.

  5. Reduce your drug costs.

    Ask your doctor about every prescribed medication. Ask what would happen if you chose not to take a medication. Don't expect to get a prescription for every illness; sometimes self-care or non-drug remedies are all you need. See page 16 for more information.

  6. Use specialists for special problems.

    Specialists are doctors with in-depth training and experience in a particular area of medicine. For example, a cardiologist has years of special training to deal with heart problems. Specialists generally charge more for visits than primary care doctors, and they routinely prescribe more expensive tests and treatments. Of course, they often provide the information you need to decide what to do about a major health problem.

    When your primary doctor refers you to a specialist, a little preparation and good communication can help you get your money's worth. Before you go see a specialist:

    • Know the diagnosis or suspected diagnosis.

    • Learn about your basic treatment options.

    • Know what your family doctor would like the specialist to do (take over the case, confirm the diagnosis, conduct tests, etc.).

    • Make sure that any test results or records on your case have been sent to the specialist.

    • Ask your regular doctor to remain involved in your case. Ask the specialist to send new test results or recommendations to both you and your regular doctor.

  7. Use emergency services wisely.

    In life-threatening situations, modern emergency services are worth their weight in gold. However, they often charge far more for routine services. Emergency rooms charge two to three times more for routine services than a doctor's office. Also, your records are not available, so emergency room doctors have no information on your medical history.

    Hospital emergency rooms are set up to handle trauma and life-threatening cases. They are not set up to care for routine illnesses, and they do not work on a first-come, first-served basis. During busy times, people with minor illnesses may wait for hours.

    Use good judgment in deciding when to use emergency medical services. If you feel you can safely wait to see your regular doctor, do so. Apply home treatment in the meantime. However, if you feel that it is an emergency situation, by all means go to the emergency department.

    Prepare for the emergency room:

    • Call ahead, if possible, to let them know you are coming.

    • If there is time, take this book and your medical records with you:

      • Use page 1, the Healthwise Approach, to help you think through the problem and report symptoms to the doctor.

      • Use page 2, the Ask-the-Doctor- Checklist, to organize questions for the doctor.

      • See page 15 to review the medical test checklist.

      • Use your home medical records to discuss your medications, past test results, or treatments. Information about your allergies, medications, and conditions may be critical.

    • As soon as you arrive, tell the emergency room staff why you think it is an emergency.

  8. Save hospitals for when you need them most.

    Over half of all health care costs are for hospitalizations. A stay in a modern hospital costs far more than a vacation at most luxury resorts. (And hospitals are a lot less fun.)

    If you do need in-patient care, get in and out of the hospital as quickly as possible. This will reduce costs and your risk of hospital-induced infections.

    Don't check in just for tests. Hospitalization is no longer needed for most medical tests. Ask if the tests can be done on an out-patient basis. If you agree to control your diet and activities, the doctor will usually support your request.

    Additional days in the hospital can sometimes be avoided by bringing in extra help at home. With help available, many patients can shorten a hospital stay.

    Hospitals are not the only choice for people with a terminal illness. Many people choose to spend their remain- ing time at home with people they know and love. Special arrangements for the needed care can be made through Kaiser Permanente's hospice care programs. Ask your doctor for a referral or call your facility's hospice office to learn more.

    Hospital Consumer Skills

    When you need to be in the hospital, good consumer skills can help improve the quality of care you receive. However, don't overdo consumerism. If you are very sick, ask your spouse or a friend to help watch out for your best interests.

    • Ask "why?" Don't agree to anything unless you have a good reason. Agree only to those procedures that make sense for you.

    • Provide an extra level of quality control. Check medications, tests, injections, and other treatments to see if they are correct. Your dili- gence can improve the quality of care that you receive.

    • If you get an itemized bill, check it, and ask about charges you don't understand.

    • Get personal. Be friendly with the nurses and aides. Friendships increase the attention paid to your needs and speed your recovery.

    • Know your rights. Most hospitals have accepted the "Patient's Bill of Rights" developed by the American Hospital Association. Ask your hospital for a copy.

  9. Get smart about your medical needs.

    Learn as much as you can about your medical problem. Your research may turn up new options.

    If you need help understanding a complicated problem, or want to learn more about your options:

    • Start by asking your doctor for any written information she might have to lend you.

    • Visit your Kaiser Permanente facility's Health Education Center. See page 23.

    • Review the resources on pages 307 to 311.

    • If you find something interesting, make a copy for your doctor and discuss it at your next visit.

Wise Use of Ambulance Services

Call 911 or your local emergency department of Kaiser Permanente to dispatch an ambulance if:

The person has symptoms of a heart attack: severe chest pain, sweating, shortness of breath. See page 216.

There is severe bleeding or blood loss. See page 219.

The person is unconscious or is having significant difficulty breathing.

The person is having a seizure last- ing longer than seven minutes.

You suspect a spinal or neck injury.

Do not call an ambulance if:

The person is conscious, breathing without difficulty, and in stable condition.

It is not an emergency. Ambulance services are expensive and, if not needed, may not be covered by insurance.

Avoid Health Fraud and Quackery

Millions of people are taken in each year by medical fraud and worthless health products.

Bogus "cures" are often advertised for chronic problems. These promotions target people with ar~ritis, cancer, bald- ness, impotence, or other problems who are ready to try anything. Unfortunately, these cures rarely help and often (one out of ten) cause harmful side effects.

Be suspicious of products that:

Be suspicious of any doctor who:

The best way to protect yourself is to ask questions and be observant. If you don't like what you see, find another doctor.

You Have the Right:

Trust Your Common Sense

Medicine is not as magical as we once thought. If someone takes the time to explain a problem or a treatment to us, we can usually make a pretty good decision about what is best for us.

Use your common sense to become a working partner with your doctors. The best medical tests, diagnosticians, and medical specialists are not enough. Good medical care also requires your own common sense. It will help you find the care that is right for you and avoid services (and costs) that you don't need.

If you trust your common sense, you are on your way to becoming a wise medical consumer.

Health Education Resources

There are 28 Kaiser Permanente Health Education Centers where you can watch videos, read med- ical information, get information to take home, and learn about addi- tional resources. Health Education Centers offer many health educa- tion programs, including classes, counseling, and special programs for children, teens, older adults, couples, families, and others. In addition, a professional health edu- cator is available at every Health Education Center.

You are always invited to call or stop by the Health Education Center at your local Kaiser facility to learn more about maintaining or improving your health, or about a medical condition or treatment.

You may also receive counseling and educational materials from your doctor or other Kaiser health care provider as part of your off~ce visits.

As a Kaiser Permanente member, you will also receive an award- winning quarterly magazine called Partners in Health. This magazine will keep you up to date on health issues, new health education pro- grams, and changes that take place at the medical centers.