Wise to avoid doctor-hopping
UNIVERSITI Malaya Associate Professor Dr Muhammad Muhsin was quoted as saying that general practitioners (GPs) had baseline knowledge in detecting general mental illnesses, but might lack confidence and competency in diagnosing them, “It’s truly a real headache” ( The Star, Oct 21).
In the same report, former president of the Malaysia Psychiatric Association Dr Abdul Kadir Abu Bakar was quoted as saying that doctors at primary healthcare level should be able to diagnose mental illness and prescribe medication.
Why is this seldom done then? As a doctor who is not a psychiatrist, I alluded to the reasons in my letter “When pain can be a problem of the mind” ( The Star, Oct 19). Doctors are uneasy about diagnosing mental illness because their training, at both undergraduate and post-graduate levels, is skewed towards looking for signs to fit the symptoms and positive findings on investigations.
I would like to propose a stepwise approach to help non-psychiatrists diagnose mental illness and the public to understand how doctors arrive at a diagnosis.
A person’s illness may be looked at as a crime with many suspects. In medical terms, we call these suspect ailments differential diagnoses. The purpose of investigations is to eliminate (or in medical terms exclude) one suspect after another so that what is left eventually is the real culprit.
Doctors make a diagnosis based on the patient’s history as well as bedside examination, medical investigations and response to treatment. For example, if a patient’s chest pain does not respond to glyceryl trinitrate tablets placed under the tongue, then it is unlikely to be due to angina.
If a patient’s “gastric” pains do not respond to a course of proton pump inhibitors, a potent acid suppressor, then the problem is unlikely to be acid-related.
I would like to appeal to patients to go back to see their doctors even if the medicines they prescribe do not work or they produce side effects because doctors can gain valuable information from patients’ response to treatment.
Once physical ailments like cancers have been excluded, a doctor may have to think out of the box (like epilepsy as a cause of “gastric” pains) or that the patient’s symptoms are psychosomatic in nature, meaning “the mind affecting the body”. The patient could then be given a trial of anxiolytics or anti-depressants.
Hindrances to this stepwise approach include the phenomenon called “doctor-hopping” by impatient patients when medicines do not work or do not work immediately. If patients choose to exercise their right to get a second opinion, then please bring along all previous investigation results and medicines prescribed by the first doctor in order to save time and money. Ethically speaking, this will also avoid misunderstanding between the first and second doctor.
The second hindrance is the reluctance of some doctors to share information and accept investigations done in another hospital. This is particularly problematic in the two-tier healthcare system in Malaysia. Investigation results done in government hospitals are generally not given to patients because they are deemed government property.
I once had a patient who had to undergo a repeat endoscopy at a government hospital (GH) despite presenting the GH doctor with my endoscopy report which was done a few days earlier.
When doctors share patient information with each other, the cobweb of medical diagnosis will be cleared more efficiently, leading to more holistic patient management.