Did you ever go to a doctor's office with a request and leave without getting what you expected? Perhaps you read a newspaper article describing a treatment studied by a highly reputable academic medical center. It sounded so good, so safe, so appropriate for you – why would your doctor say "no" or suggest something else? Or, perhaps you saw an advertisement for a medication that treats a problem you have. If you aren't taking anything for it, or if you are and it's not working, why not see your doctor (as advised at the end of the commercial) and get a prescription? The same can happen for a test or even a referral to a specialist.
How can it be that with so much science and study backing recommendations for health care that the message from news or advertisements varies so much from the one your doctor provides? This happens all the time and is a significant source of confusion, frustration, and even damaged relationships between patients and their doctors.
Reasons Your Doctor Says No
Here are some of the reasons why you may leave your doctor's office without the test, the referral or the prescription that you expected:
- Your information is preliminary. The "latest" information you heard may be based on only a few patients, or based on animal studies or "in vitro" experiments (meaning, in the lab — not an actual experiment that involved living, functioning humans or other animals). Such research may be promising, exciting, and truly newsworthy, but nowhere near ready for widespread use, In fact, the treatment may not even be available other than in research centers.
- Your information is "too new." Because information is generated and delivered faster than ever before, it is quite possible that you will see a study reported in the news before your doctor has had a chance to review it. He or she may not be enthusiastic about recommending it to you until there is time to review the information.
- Your information is outdated. There may be even more recent scientific studies to support your doctor's recommendations and, fortunately, your doctor is up-to-date about it; your other sources of information may not be.
- There may be something unique to your situation. Your other illnesses or conditions may make the information you've read or heard less applicable to you, or your condition may be different from the condition mentioned in the ads or new research. For example, a study might be talking about a new treatment for ulcers, but you have heartburn; a great treatment for ulcers may not help your heartburn.
- You may have a condition that requires no treatment. Even though ads may encourage you to take medication for it, you may not need it. For example, you may see ads for medications to treat anxiety; yet, some degree of anxiety is normal and requires no treatment. Similarly, ads for allergy medications may not be necessary for mild allergies to things you can simply avoid.
- Expense matters. Whether it is cost to you, your insurer, or the "system" at large, if two treatments have identical risks and benefits, the less expensive one may be recommended rather than the one you were requesting. Because cheaper generic drugs are not heavily promoted in the media like expensive brand name drugs, you may get the impression that the brand-name medicines are better. That's usually not the case.
- Your doctor's training and experience are worth considering. Most physicians tend to stick with those treatments that have proved safe and effective. After years of experience, your doctor knows what to expect when prescribing these drugs. It's understandable that many doctors are reluctant to give up on these "tried and true" medicines in favor of recently approved drugs that have not been around long enough for rarer or unexpected side effects to come to light. Physicians who were slow to recommend rofecoxib (Vioxx) rather than older medicines (such as ibuprofen) are good examples of this. For many patients, sticking with the older medicine turned out to be a reasonable and, perhaps, an even safer choice.
- Your doctor has samples. Many doctors’ offices stock samples of drugs that are provided free of charge by the sales representatives of drugs manufacturers. The advantage to you is that you can try the medicine out before spending money on a prescription. The disadvantage is that samples are nearly always for expensive, brand-name medicines; trying them for free encourages their use (and that's, of course, why they are there in the first place). Your doctor may be more likely to recommend a medication for which he or she has samples than the medication you are requesting.
- The "formulary" matters. A formulary is the list of medications a hospital pharmacy carries or that an insurance company will cover. It may determine the choice of medications your doctor recommends. Hospitals or insurers may decide to"carry" one medicine rather than another because they have negotiated a better price for it. In general, this is an issue when more than one medicine is deemed equally safe and equally effective and the only real difference is price. If you are admitted to a hospital, your treatment during your stay and the prescriptions you receive when you leave may be determined (at least in part) by the formulary.
- The "big picture" matters. Decisions to order tests or suggest referrals to see a specialist are typically determined by a combination of your symptoms, your examination, the results of previous tests, and the knowledge, experience and concerns of your doctor. It can be a complicated process of integrating the information that makes up the big picture, but if your doctor is confident of the diagnosis and ideal treatment, he or she may feel that there is no reason for additional testing or consultation even when that's what you were expecting.
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Learning To Say No
Although it is not always easy, doctors must learn to say no, and they are taught to do so in medical school and during later training. For example, many people expect and request antibiotics whenever they or their children have a sore throat or a fever, even though colds and most fevers are due to viruses. Viral infections do not respond to antibiotics.
It's understandable why that expectation is there; perhaps symptoms are not due to a cold, perhaps it’s strep throat or another bacterial (rather than a viral) infection and it's best to "nip it in the bud." Or, there may be misunderstanding about the difference between viral infections and bacterial infections and how they are treated. But widespread use of antibiotics for conditions that do not require them will not help people get better any faster, may cause side effects and may eventually lead to increased resistance to those antibiotics when and if they are needed in the future.
Given all the direct-to-consumer marketing, it's easy to believe that every discomfort, ache, pain, or less-than-perfect bodily function should be evaluated, tested and/or treated. Clearly, every person with a headache does not require an MRI, neurological consultation or the latest migraine treatment. Ideally, such decisions should be shared between patients and their doctors.
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There may be good reasons for what your doctor is saying, even when you aren't getting what you expected. If you don't understand why your health care professional is reluctant to prescribe the medication you expected or to recommend the test you thought you needed, ask for an explanation. Understanding the reasoning can be helpful not only as a way to be better informed about your condition, but also to avoid misunderstanding.
Studies show that many people are ready to switch doctors if they don't get what they want or expect, and that would be a shame if you have a good relationship with your doctor. Don't be afraid to ask your doctor to explain his or her recommendations, especially when they do not match your expectations; it may be the only way to really understand what your doctor is saying.
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Robert H. Shmerling, M.D. is associate physician at Beth Israel Deaconess Medical Center and associate professor at Harvard Medical School. He has been a practicing rheumatologist for over 20 years at Beth Israel Deaconess Medical Center. He is an active teacher in the Internal Medicine Residency Program, serving as the Robinson Firm Chief. He is also a teacher in the Rheumatology Fellowship Program.