Am I Seeing The Right Doctor?

Am I seeing The Right Doctor?

When is it time to see a specialist?

When patients first experience signs of urinary incontinence they will usually discuss it with their primary care physician. According to Dr. Hari Tunguntla, assistant professor in the Department of Urology at Robert Wood Johnson Medical School, "patients are initially seen by their primary care physician who treats the condition with lifestyle modifications that may include dietary changes, weight loss, and/or pelvic muscle exercises." When a patient is not seeing improvement after three or more months or the symptoms continue, a primary care physician may refer the patient to a urologist, urogynecologist, nurse specialist, physical therapist, or occupational therapist. A patient should also consider seeing a specialist if they become frustrated that their primary care physician is not engaging in multiple remedies as a behavioral strategy, with or without medication depending on the diagnosis, or not listening altogether and giving it priority. A separate office visit to discuss the bladder control problems is suggested. Some individuals who may desire surgery for their problem might go directly to a specialist from the beginning.

Types of Specialists:

  • Urologist - a surgeon who specializes in the urinary conditions of men and women.

  • Gynecologist - a doctor specializing in the reproductive health of women, some have special interest and training in urinary incontinence and pelvic organ prolapse.

  • Urogynecologist - a gynecologist who has advanced training in treating both surgically and non-surgically pelvic floor disorders in women; including pelvic organ prolapse and incontinence.

  • Physical Therapists (CAPP-Pelvic) - a physical therapist who has a certificate of achievement in pelvic physical therapy from the American Physical Therapy Association (APTA) in standardized courses.

  • Occupational Therapists - an occupational therapist who has advanced training in pelvic floor rehabilitation and may also have a certification in biofeedback from the Biofeedback Certification International Alliance (BCIA). The BCIA offers board certification in biofeedback, neurofeedback, and pelvic muscle dysfunction biofeedback.

  • Nurse Specialist - a nurse or nurse practitioner that has received urology certification from the Certification Board for Urologic Nurses and Associates (CBUNA) may be able to perform urodynamics, urinalysis, provide biofeedback, pessary fitting, pelvic floor muscle exercise instruction, and urethral catheterization. Other advanced practice nurse specialists may include those with a certification of study as a continence nurse offered as a standardized track of the Wound, Ostomy, and Continence Nurses Society (WOCN). These nurses are trained in the management of chronic incontinence, both urinary and fecal, including skin care.

Should I get a second opinion? When?

A patient may consider getting a second opinion once a diagnosis and treatment plan has been determined. Dr. Anthony Komaroff, a practicing physician, professor of medicine at Harvard Medical School, and editor-in-chief of Harvard Health Publications, states that, "a second opinion may simply confirm your first diagnosis or treatment recommendation. Sometimes a second opinion can actually improve or refine the advice you get." Getting a second opinion can help improve your confidence that your doctor has determined the best treatment plan. It also gives you more options in selecting which healthcare professional you will choose for treatment.

Where should I get a second opinion from? 

Dr. Komaroff agrees that, "asking your doctor, nurses, family, and friends for recommendations is a good place to start," when looking for a second opinion. Your doctor may have another specialist within the practice or clinic that could review your history and chart. Patient education organizations, like the National Association For Continence (NAFC), often offer a service to help patients find specialists in their area. NAFC can help you find a urologist, urogynecologist, nurse specialist, physical therapist, or occupational therapist in your area. Another good resource for finding physicians, who are considred experts in continence care for women, is to schedule a visit at a NAFC designated "Center of Excellence." NAFC's Centers of Excellence: Continence Care designation means that the care administered in such a location is performed by appropriately trained, experienced, and credentialed experts and such centers have demonstrated satisfaction in outcomes and care by a majority of their peers.

Will my doctor be offended that I want a second opinion?

"Your doctor shouldn't be offened or mad if you get a second opinion. If your doctor is put out that you want a second opinion - one that could improve your health care - perhaps they're not the right doctor for you," says Dr. Komaroff.

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Getting a Second Opinion

Getting A Second Opinion

Should I Get A Second Opinion?

It is always a good idea to see a physician expert who is well trained in the problems you are experiencing. But not all experts are equal. Sometimes you don’t communicate well with the practitioner or sometimes you do not feel comfortable with the recommendation. A second opinion is always an option.

If surgery has been recommended to you, a second (or even a third) opinion is an excellent idea. Very few things in medicine are black or white. There are often many different approaches for the same problem and many shades of gray in evaluating and judging what is best for the individual patient. In the present managed care environment, some doctors cannot take the time to fully discuss your situation with you. They may not have the extra training needed to offer the best option. They may not be trained in newer or less invasive procedures. If doctors do not know how to perform a procedure, they may not be equipped to discuss or recommend it to you.

When a new patient comes to see me for a second opinion, I ask them to bring all the pertinent medical records including all the notes from previous doctors’ appointments and any relevant test results. If an X-ray, ultrasound, or MRI has already been performed I ask the patient to bring the actual films, hard copy or on a CD file, as I prefer to look at the films myself so that I can come to my own conclusions about the diagnosis. I can then take the time to explain the test results to the patient.

For an individual seeking a second opinion, I begin with a consultation and a review of the records, and then I proceed to a complete physical examination. Often the patient and I go back to my office to discuss the findings and answer any questions that the patient might have. Medical care should be collaboration between patient and doctor. Together the patient and I discuss how best to approach the particular diagnosis. I often use illustrations, diagrams and 3-dimensional models to demonstrate what the problem and potential solutions might be. At this point I make a list of one or more possible diagnoses and outline the treatment options available for each problem. To be complete, I often include even those treatments that I advise against, and the reason. Together we collaborate and determine which choices on this list best meet the individual needs of each patient, seeking choices that are both medically sound and personally acceptable to the patient.

Family members or friends should be welcome to participate in the consultation. Friends and family members are helpful to make sure all the concerns are addressed and to help the patient remember what is said as a lot of material is covered. Taking notes or having a companion who can record notes of what is asked and how it is answered is also helpful. It is a good idea to then digest the information at home to make the best decision. Patients are encouraged to call back with any additional questions they may have or for any clarification they might require after the consultation.

What If You Decide Surgery Is Right For You?

If you decide that surgery is right for your situation, you will need to choose the doctor to perform your surgery. There are a number of factors that should influence your decision. The first is to choose a doctor who will perform a procedure that fits your particular situation and problem. In most cases you should have more than one option from which to choose. It is particularly important to discuss the risk factors for adverse, or negative, outcomes based on research, associated with each option.

The next concern is the skill of the surgeon. How many procedures does the doctor perform in a month?  How many procedures like the one you are requesting are routinely performed? How many of these procedures have they performed in patients with problems like yours? How many and what kind of complications has the doctor had? Studies show that with more surgical experience for a particular surgery, the surgeon performs with fewer complications. In other words, surgeons who perform procedures frequently have lower rates of complications than those with less frequent experience. Many surveys show that some gynecologists and urologists perform as few as one or two major incontinence or prolapse operations a month. Choose your surgeon carefully.

It is important to know something about the training of your surgeon. Did they do any extra training in pelvic floor problems, such as a formal fellowship? Do they teach in an academic program? What is the experience of the surgeon’s support team and the facility where such procedures are routinely performed? What is their track record with respect to success versus failure and how is success defined? What is their track record with respect to complications?

It is also important to feel comfortable with your doctor. Do you get an opportunity to ask questions? Are they answered to your satisfaction? Is the doctor available by phone? Will the doctor be available after your surgery for follow-up and questions as well as support?

If you decide to have surgery, another visit should be scheduled with the doctor you have chosen to go over the specific details of the procedure you are planning. Again, it is nice to have someone accompany you. In my practice, once a decision has been made, we have a conversation called the “Informed Consent”. At this time we go over, in writing, what you should expect from surgery. It includes the details of the operation to be performed, the specific risks of the procedure, the alternatives to the surgery, and the possible consequences if no surgery at all were performed.  Basically, this is the time you will hear about all the possible risks and complications that may occur during and after your surgery. This can be difficult and may feel as if it’s the last thing you want to hear, but ultimately it will be quite informative for you. Whatever you sign should be understandable and agreeable to you. Continue to ask questions until you are comfortable.

During the “informed consent” your surgeon is not trying to erode your confidence, but surgeons are legally and morally bound to tell you about things that could happen that might influence your decision to have surgery. Most people’s emotional reaction to this is some fear, which is understandable. Just remember to be sure and hear the optimism in the fact that there are options available to help you.

To summarize, never hesitate to get a second opinion. If this threatens your doctor, you may need a new doctor. Transparency is the key to a good relationship and optimal outcomes. If you are a woman experiencing incontinence and/or prolapse, you have the option to be treated by a fellowship trained Pelvic Reconstructive Surgeon. This subspecialist can be a gynecologist, a urogynecologist, or a urologist. If a subspecialist is not available in your hometown it may be well worth your while to seek one out as close to home as possible somewhere in your region. Otherwise there are general gynecologists and urologists with significant experience in this area, but you must ask questions to confirm adequate surgical experience with pelvic floor surgery. If you are a man with incontinence, urinary obstruction from the prostate, or other bladder dysfunction, a well-trained urologist is the best choice.

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