How to Be a Savvy Patient: Making the Most of Your Doctor’s Visits

In this episode of The Savvy Patient, hosts Erin Stein and Dr. Gillian Goddard tackle what it really takes to navigate healthcare as a patient. We dispel the myth of the single "best doctor," emphasizing instead the importance of finding a provider whose style fits your personal health philosophy. We break down how to prepare for your appointments to get the best outcomes and cover how to frame your health goals, collect concrete data on your symptoms, and use reputable medical sources for research rather than falling down the rabbit hole of search engine horrors or extreme Reddit threads. We also address the inescapable reality of navigating health insurance, explaining why understanding your own coverage beforehand is essential. We teach you how to get savvy!

Resources:

Dr. Gillian Goddard mentioned mayoclinic.org/symptoms and mayoclinic.org/drugs-supplements for research. She also mentioned beyondtype1.org/ as a resource for those living with Type 1 diabetes.

We take a moment to remind you that while this is a medical discussion, it is not providing a diagnosis or treatment or any medical advice. The only way to get a diagnosis, treatment or medical advice for your particular condition is through a discussion with your doctor.

Please subscribe savvypatient.substack.com

Visit www.thesavvypatient.com/podcast for episode transcripts.

Watch full podcast episodes @TheSavvyPatient on Youtube.com.

Get your copy of The Hormone Loop by Dr. Gillian Goddard wherever books are sold.

This episode was produced and edited by Erin Stein. Music: “All We Live For (instrumental)” by Wolfclub licensed through Audiio.com. Intro and outro edited, and video created, by Ian Mayer. The Savvy Patient logo by Amanda Spielman.

TRANSCRIPT

Erin Stein: Welcome to the Savvy Patient. Today is all about being a patient.

Gillian Goddard: All about being a patient. I have thoughts on this.

Erin Stein: Well, I have thoughts also, and I think this is going to be fun because we are both patients. You are also a doctor, so you have a very different perspective on it. You should speak to this. I think sometimes it's harder to be a patient when you're a doctor, but maybe not.

Gillian Goddard: In general, doctors are terrible patients. unless you're a patient in your own area of expertise, we tend to know a little bit that we learned along the way, but we're not experts in every area of medicine. It's impossible to be. And medicine changes so much over time that we know just enough to be dangerous in areas that are not our areas of expertise. 

Erin Stein: Yeah, so you're obnoxious is what you're saying. 

Gillian Goddard: Exactly.

Erin Stein: We will talk about that because some non-doctor patients also know a lot about things and come in with some pointed questions. So that's not so different.

Gillian Goddard: No, no, I think that you make a good point.

Erin Stein: I always do. [laughter] We're going to talk about how to be a good patient, what to do before your appointment, at your appointment, after your appointment. And the point is not to scold people, but to help you get the most out of these doctor patient appointments and visits and get what you need. There are ways to help you do that.

Gillian Goddard: There are ways to do that. You've got 10 to 15 minutes to have this important conversation. And so, you have to be efficient.

Erin Stein: Generally, yes. You got to. but before we get into all of that, we should just talk about the doctor and the patient. Choosing your doctor, the relationship with your doctor. 'Cause there's not just one anymore. You don't just have your primary care physician anymore. You should be seeing a lot of different doctors as discussed in our You Turned 40 episode.

Gillian Goddard: Yes. Correct. Correct. And I think that there has historically been this idea that there's like a best doctor. Like this is the best, I don't know… cardiologist. This is the best orthopedist… and certainly doctors have areas of expertise where they may actually have a lot of knowledge, but what doesn't get enough attention when we talk about this is fit.

Erin Stein: Mm-hmm.

Gillian Goddard: Because different people want different things from their relationship with their doctor, especially when you're talking about those doctors that you might have a very long-term relationship with, like your PCP, like your gynecologist. Some doctors are very exhaustive in their testing, in giving you referrals to go to different tests and different specialists. And some people love that. That's really what they want. And some doctors are a little bit more relaxed, and they tend to be a little more minimalist. Not to say that they're not thorough when it’s indicated, but they might be just a little bit more low key when it comes to prescribing tests and giving referrals. Neither of those approaches is wrong, but you have to know which approach works best for you and for your mental well-being.

Erin Stein: Yes. and with the specialist experience, who's the best, I think that sometimes is more applicable when you're talking about surgeons who may have done a certain procedure a bajillion times. And so, you might want to go to that surgeon over one who's only done it a couple of times, but that's not the same as going to your primary care doctor or going to your gynecologist. Those are more general conversations. You want them to know a lot about a lot of different things. It's funny because I think about it the same way as when I was an editor working at a publisher; the fit with an author was very much the same. Like, how do we want to work together? How do we communicate? How do they prefer I give them notes? How many notes do they want or not want? And it's very much a specific relationship, that certain people are better suited to work together or not. And I think your doctor is kind of the same. You know, there are vibes when you meet with your doctor, if you feel good, if you like them, if they seem confident, if they're listening to your questions, they're answering your questions. And like you said, some of us want to investigate every little, tiny thing. And some of us are like, well, I'm happy to wait and see if it's not bothering me that much.

Gillian Goddard: Yeah.

Erin Stein: All of those things are important and they're not necessarily about credentials. I mean, obviously your doctor should have some credentials, I would hope.

Gillian Goddard: Yeah, you want a doctor with a degree, an MD or a DO and probably a board certification.

Erin Stein: Yes, but we tend to see all doctors as authority figures and all doctors must know everything and all doctors must be great and that's not necessarily true. You might see a doctor, and it might not be a good fit for you, and that's okay.

Gillian Goddard: It is okay. In fact, some of my most painful interactions with patients have been when we have not been well suited to one another, when our approach has not been well suited. And that's all right. I have a certain practice style, and that works well for many, many patients. But it's not going to work well for all patients. I'm not offended, by the way.

Erin Stein: Yeah. and if your doctor acts offended, you should definitely get a new one. it's your health, it's your body, and your doctor is supposed to be supporting you and helping you do what you want to do for yourself.

Gillian Goddard: Agreed.

Erin Stein: It is very important and it's not quite personality fit, like, you're not hanging out all day, every day, but you want to feel like they understand what you're looking for, and you understand what they're giving back to you.

Gillian Goddard: 100%.

Erin Stein: and ideally, as you said, some of these relationships are long term, so you can develop some sort of familiarity. I don't know, you tell me, when I see my primary care doctor once a year, I don't think she's going to remember everything year to year. As much as she might pretend to recognize me.

Gillian Goddard: So, this is what I would say. We have some advantage in that we have a medical record that has all of your history written out, including sometimes your picture, if we have like your ID. And I will say that I have some patients that I know better than others. And you're right, a lot of what solidifies that relationship and really solidifies that person in my brain is if we've had times when we've seen each other more intensely. So, they've been pregnant and I've taken care of them through a pregnancy which involved more office visits, or they had a particular emergency. If they have unusual jobs that often will stick in my head because it often affects their lifestyle and that's something that we talk a lot about in our visits. Especially if I'm working with someone on diabetes or medical weight loss, we tend to talk about their lifestyle a lot. But if it's someone that I don't see often, I'll take a peek into their chart and refresh my memory before I go in the room so that I'm not totally unfamiliar with them. So, we cheat a little.

Erin Stein: Yeah, I mean I think that's fair. It's not like I'm remembering everything about my doctor's personal life either.

Gillian Goddard: I'm always surprised what people do remember about my personal life when they do.

Erin Stein: I think it's like you said, like you remember a job or remember talking about a kid or you know, I had a dentist who always talked about his summer vacation every time I went in. You do get to know people a little bit over time. Okay, so assuming you have a doctor, assuming you like this doctor enough, or even if you're going for the first time, what do you do before a doctor's appointment?

Gillian Goddard: The first thing I want to say is we're going to talk through all these steps and stages. But if you want more or you are a person who does better with something written down or want to refresh your memory, the entire last chapter of my book, The Hormone Loop, also talks about this topic, probably in a little bit of a different way. And we'll probably touch on things that are a little bit different, but the overall tenets are the same. And so, I would encourage you to pick up a copy. Thank you, Vanna. For those listening, Erin is holding up a copy of the book and displaying it quite nicely like Vanna White from The Wheel of Fortune.

Erin Stein: Yes, very good job promoting your book. Your publisher will be proud. It's actually out in the world and you can get it. But yes, she has some very good stuff in the back of the book and we're going to cover some of it, but also, I'm going to ask more questions and We're going to talk about more here today.

Gillian Goddard: Absolutely. So, before your doctor's visit, you want to do a little bit of homework. And I don't want it to sound arduous or difficult, but I think…

Erin Stein: Mm-hmm. I already stopped listening. No one wants to do homework, Gillian.

Gillian Goddard: I'm sorry, let's call it legwork. 

Erin Stein: Mm, not any better. … A vision board for your doctor's appointment! That's what we need. You need to have a vision board, sort of. You need to know what your goal is.

Gillian Goddard: You've got to know why you're going. And we go to the doctor for all different types of things from, I'm going because I know I'm supposed to go once a year and get my pap smear and get my prescription to go to my mammogram and get my blood pressure checked. Like that's one reason people go to the doctor, right?

Erin Stein: Yes.

Gillian Goddard: Or it might be that you're having specific symptoms that you would like to have diagnosed, like you think you might have a new diagnosis, or you have symptoms and you just want to feel better and you're less focused on understanding why and more focused on how can I make this situation better.

Erin Stein: Well, I'll just interject quickly because I think we often go to the doctor with symptoms and the assumption is we need to know what's causing the symptom in order to treat it. You go to the doctor, and you say, “This is happening to me. Why?” Because you assume the why will tell you how to treat it and that may or may not be true. Which we have said in probably every episode and will continue to say in every episode.

Gillian Goddard: Yes, yes, absolutely. I think that people hear their doctor offer certain solutions and they see it as Band-aid, that it's masking what's really going on. But the reality is the doctor is offering them a treatment for their symptoms. The reason they're offering that treatment is because that treatment would be the same for a number of the most likely diagnoses. And so, getting to the root cause per se is not always necessary in order to feel better.

Erin Stein: Yeah. I think it's a bit of reframing, right? You know, we go for a checkup, we go to get our regular tests and then deal with that. But if we're going to the doctor because something new is happening or something's going on, we're feeling crappy or we're having pain or whatever, we treat it like taking your car to the mechanic. We're like, “here's my body, what's wrong with it, please fix it,” right? And it's not always a thing to fix. It might just be putting more oil in your engine. Or… now I'm torturing this, but you know, it might simply be treating the symptom. There might not be a way to quote unquote “fix” whatever is happening because it's just your body and that's what it's doing. But you can do something to feel better. 

Gillian Goddard: Correct.

Erin Stein: Especially women in midlife, the more we talk about perimenopause and menopause, the main message is, there's no fixing what's happening. Your body is transitioning and we're managing the transition.

Gillian Goddard: Exactly. I think that's a great point. I also think that when we start talking about goals, some people tend to be very limited when they think about their goal. They're having some symptoms and they are like, “when I Google these symptoms, it tells me that I have a thyroid problem. And so, I'm going to go to the doctor and I'm going to ask them to diagnose me with a thyroid problem” Then you roll into the doctor's office and you say, “I'm tired, I'm gaining weight, my periods are weird, and I have brain fog, and I think I have hypothyroidism. Do I have hypothyroidism?” 

Erin Stein: Yes or no?

Gillian Goddard: Yes or no. And the problem with that approach is that, if the answer is yes, okay, well, then we can treat you for that. But if the answer is no, you are no better off than you were before. I would encourage people when they think about their goal for their visit to their doctor to think in the broadest possible terms, to think “I'm having these symptoms and I'd like to, if possible, understand what's causing them and figure out how to effectively manage them.” And when you go in with that broad goal, then your doctor can be on the same page with you and look for all the possible things that might be leading to your current symptoms and help you feel better. Now, a good doctor will do that. A busy doctor who's just trying to answer your question, who may still be a good doctor, a harried and rushed one having a bad day may not do that. And then you're not really getting the answer or the help that you need.

Erin Stein: Now what if you go in, you're like, “I'm having these symptoms. I think it might be thyroid, but I'm not sure I want to figure it out.”

Gillian Goddard: That's certainly a broader framing.

Erin Stein: if you do have a family history of things, mention that, and say “that's why I'm thinking it might be that, but I don't know and I'd like to figure it out.”

Gillian Goddard: Well, that gets into the next step a little bit.

Erin Stein: Well, I jumped ahead as I always do.

Gillian Goddard: You're always so forward thinking, always ahead of the game. So the next step is to collect some data on yourself. And some of that data is going to be concrete information about your symptoms. So, it's one thing to say, “I'm having brain fog.” It's another thing to say that “over the last six months I've had a lot more difficulty focusing. I've had a lot more difficulty with executive function. It's interfering with my work in these ways. I missed a deadline. I was in a meeting, and I couldn't come up with the word I was looking for, and it made it look like I wasn't prepared and it's been going on this long.” I think that having all those details, including your family history, which we have an episode all about family history, and you can go back and listen to that. But having all those details, you know, “I think I might have thyroid issues for all these reasons and my mom and sister have it. And this is similar to their symptoms.” when you get into that concrete specificity around your symptoms, it makes it much more difficult for your doctor to dismiss them. And so, I recommend while you're waiting for your appointment to really get granular with your symptoms. Now, that doesn't mean coming in with like a dissertation, but the more you can put numbers, timelines, what makes it better or worse, is helpful.

Erin Stein: Yeah. it's very helpful if you're having a recurring symptom, like if you're having headaches, if you're having pain, just jot these things down have a calendar, put it in your notes, whatever. Just jot down the dates because when you go back then you can say, yes, this happened to me five times last month or it happened to me the day before my period every time.

Gillian Goddard: Exactly. I'm having three headaches a month, but they're all clustered around ovulation.

Erin Stein: Yeah. it will help you to narrow down some of this, but it'll really help the doctor if you have some idea. Because I know I do it. I go to the doctor and I'm like, well, I'm kind of feeling this. And they're like, well, how often or when? And I'm like, I don't know. I’m just like, it happens. and the other thing I will add to that is if it's pain that you're going to the doctor for, think about how you would describe the pain because again, from personal experience, you go and they're like, well how bad is the pain and what does it feel like? And then you're like, I don't know, it hurts. And that's not helpful.

Gillian Goddard: Yes. Right, but is it stabbing, dull, achy, is it a crampy, tingly? Is it constant or does it ebb and flow?

Erin Stein: Is it tingly? Does it feel like a Charlie horse? Does it feel like somebody punched you? Try to figure out how you would describe it before you go, because that will help you and you won't have to try and think of it in the moment. And the other thing is everyone will ask you to rate the pain on a scale of one to ten. How is the pain? And you have to think about that. I find that very difficult because especially if you have chronic pain.

Gillian Goddard: Exactly. Yes.

Erin Stein: You're always in pain. So well, it's a five because it's just my daily life and this is average, but maybe it's not really a five. Maybe your regular pain is a little bit higher, and you've just gotten used to it. So, pain in particular is something to think about how you would describe it and how you would explain it because it can be more challenging to find the words for that.

Gillian Goddard: Yeah. There is no way you're going to go to a doctor to talk about pain and not be asked all those questions. That's medical interviewing 101. And there's a reason for that. It helps us understand what the causes might be. Different sources of pain have different qualities.

Erin Stein: Yes.

Gillian Goddard: We're taught to do it that way in med school. It's because then we use that information in a specific way.

Erin Stein: This is homework a little bit. It's research on yourself. Consider yourself a scientist, a medical researcher.

Gillian Goddard: I'm sorry. yeah, we're collecting data on ourselves. And I think that the more you just kind of look at it in that way, the easier it will be. Which leads us to another type of research, which is the type that all patients think doctors don't like. If I had a nickel, as they say, for every time someone said, “I know doctors hate when patients do this, but I Googled it or I put it into ChatGPT.” We don't hate it. We like well-informed patients. It's much easier to have a conversation with a patient who has some frame of reference for what you're talking about. I think where doctors get frustrated with patients doing research is when patients use that research to say they've already got the answer and they just need a prescription for, medicine X. When you come in with that level of specificity for what you're looking for, it's really not just frustrating to the doctor. It's actually detrimental potentially to you as a patient because again you've just really limited your doctor's thinking to this yes or no question, yes, you have this, no you don't. So, I just said doctors don't mind when patients do research so then what type of research should you be doing? And I think that there's really two types of research. One is that you have symptoms and you're looking to see if those symptoms cluster with other types of symptoms. Probably an example would be helpful. 

Erin Stein: I think so.

Gillian Goddard: So, you are having brain fog and fatigue, and you want to look and see with other people who have brain fog and fatigue, what other symptoms do they have? Do they also have difficulty sleeping? Are they sleeping more? Do they also have changes in their hair or their skin? Do they also have changes in their weight or something else about their physical body. I think that it can be helpful then to be like, well, do I have that? Do I have that? Because if there are clusters of symptoms that go with different diagnoses, your doctor is going to ask you about those symptoms. So, if you came in and said, “I have fatigue and brain fog,” I will tell you, my first question will be, how are you sleeping? And so, you want to have given that some thought. If you know what clusters of symptoms often go together, it can be helpful to do a little bit of research about that.

Erin Stein: I will again push back slightly, because that's what I'm here for. We're talking about, you know, if you don't know what's going on, you're exploring something new, you don't want to go in and say, I've already diagnosed myself, right? But sometimes you go to the doctor, and you do know what's going on with yourself. I have a stress reaction sometimes and get hives. That has happened to me multiple times. I've already been to the doctor, figured it out. Sometimes I need to just go get a prescription to deal with my hives. And so, I will go in and explain it and say, “This is what happens, this is what's happening now.” And the doctor will be like, “okay, I get it. You know what you're talking about, and that's fine.” So, we're not saying you don't ever know anything about your own condition, and you should never talk about your past experience, and what you know your body responds to or doesn't. It's more that if you're going in new for a new diagnosis and treatment and information, you need to be more open.

Gillian Goddard: Yes. Yeah, exactly. I think that's a great distinction. If you have a very specific history, it's important to point that out and talk about your specific experience. But if we're talking about something new and undiagnosed, you want to try and think through symptoms. Now, the other type of research helps you formulate questions when you do know what's going on. We talked a little bit about this when we talked about your breast cancer diagnosis. So, you received the diagnosis on the phone, and then you had an appointment to talk through the details with the doctor. And in that case, doing a little bit of condition specific research can be helpful to help you formulate your questions as you're thinking through like these are the things that I really want to make sure that the doctor answers while I'm in this particular visit.

Erin Stein: Yeah, even more so after that first visit where she gave me more details about the kind and the treatment options. Then I researched all of those options and looked into different experiences people have had and talked to other people. That kind of research is very important, too. And family history, get your family history.

Gillian Goddard: The last thing I'm going to say about research is a mention of where to go. these days don't...

Erin Stein: Don't just Google it?

Gillian Goddard: Google is the worst. Google will literally tell you [that] you are dying because you have a toothache. Google is the worst place to start. And I would say, based on some recent research that I wrote about in the Savvy Patient Newsletter, ChatGPT and their health thing is actually probably the second worst. In very systematic research study, some researchers found that it does a pretty bad job, especially when something is serious. I would actually encourage you to use medical websites that are authored by medical people. So, a couple examples of that. If you're talking about symptoms, the Mayo Clinic website actually has a whole database of information where you can search by symptom. That first type of research where you're trying to figure out what symptoms go together and what else should I be thinking about, a site like the Mayo Clinic can be super helpful. When you start talking about specifics about a diagnosis that you may have received or different treatment options, governing boards of the different specialties all have patient websites. So, like the American College of Obstetrics and Gynecologists, the Endocrine Society, all those different organizations have patient pages that are set up with articles about different topics for non-medical people. And those can be really helpful when you're talking about specific diseases or diagnoses.

Erin Stein: Mm-hmm.

Gillian Goddard: And medications, too. A lot of times they talk about medications, and Mayo Clinic has a great medication database where you can read about medications. And so, I would say, focus your research on sites that are written by medical people to provide medical information. I think there are a few places where patient forums can be helpful, but I am often quite cautious about them. Places where they can be helpful, places where other people's experience might be useful from living your day-to-day life? Here I'm talking about, it used to be called JDRF, or Juvenile Diabetes Research Foundation. It's now called Beyond Type 1. It is a whole forum for people with type 1 diabetes or people whose children have type 1 diabetes. And there's all kinds of tips and tricks about giving insulin and traveling with insulin, which are unique to that diagnosis. And so, I think those types of patient forums can be helpful. The ones where I get a little bit nervous are these, you know, Reddit threads or whatever on a topic where what tends to happen is that people who have very extreme experiences tend to be motivated to go on to these sites and talk about their experiences. And what I would say about them is just to recognize that they tend not to reflect the full breadth of patient experiences because people who are kind of in the middle—they're fine, they had a perfectly fine experience with whatever treatment—are not motivated to go on Reddit and talk about it. And so that's important too.

Erin Stein: Right, right. You're seeing more of the “it was great and I had no problem” or “my god it almost killed me.” The extremes. That kind of looking at other patients and what other people with the condition are saying is not so helpful before you have an actual diagnosis.

Gillian Goddard: The extremes. Mm-hmm.

Erin Stein: It's more once you have a diagnosis, you know what you're going through, sharing tips and tricks with other people going through the same thing. But until you've identified that thing that you're going through, it's the hypochondria. “Oh my gosh, I have this, I have that,” because this person talked about it. And also, as human beings, we tend to be like, “oh my god, that happened to me. This is what happened to me. This is definitely what's happening to you. You need to do this, that, or the other thing, right?” And that is not helpful. it might be true, but it probably isn't true because everybody is different and everybody's experience is different, even if there is some overlap. So, resist the urge to do that.

Gillian Goddard: Right. Absolutely. Exactly.

Erin Stein: There's a different kind of research that we're going to tell you to do, and this is even less fun because this is about your insurance. Sorry.

Gillian Goddard: Yes. Insurance is complex and changes often without a whole lot of warning. And it can be difficult to get information from a live person. And sometimes the information that you get from that live person is partially or even completely wrong.

Erin Stein: The real truth bomb is that doctors do not know everything about your insurance.

Gillian Goddard: It's not possible for us to.

Erin Stein: There's a tendency to go to the doctor and assume that they or their staff are experts in insurance because you're not. You just have it through your employer, and you get a card in the mail, and you just give them the card and then they should take care of everything, right? But it's not like you study every single insurance policy. And what is covered or not covered, you often will check for people, but you're just checking with the insurance company.

Gillian Goddard: Yes, so we have Cigna, but Cigna offers a gazillion different plans. And so, my husband's employer picked, you know, three of those gazillion plans and we have one of those three plans.

Erin Stein: Right.

Gillian Goddard: Each of those gazillion plans has subtleties. And so, it's not like you can even say, I have Cigna, so that means X, Y, Z, because it depends on the specific Cigna plan that you have. And if you work for a big employer, like a big tech company like Meta or Google, they often have plans designed specifically for them by an insurance carrier.

Erin Stein: Mm-hmm.

Gillian Goddard: I know trends. I know that in general, certain types of employers offer certain types of coverage. And so, their insurance is more likely to offer X, Y, Z. But I couldn't possibly know the details of all of the thousands of plans out there.

Erin Stein: Yep.

Gillian Goddard: The other thing is Medicaid, in particular, is very tricky. First, it's important to recognize Medicaid is administered by the states. So, there are 50 different states administering Medicaid, which is insurance for people who are low income. Each state is different. With a practice in New York City, I often see patients who come from Connecticut, New Jersey, sometimes Massachusetts, sometimes Pennsylvania. That's a lot of different information. But there's also different types of Medicaid within the state. And so some Medicaid in particular will only offer coverage if you are seeing one of their providers. And that includes they will only cover medications that are written, prescriptions that are written by a Medicaid provider, and they'll only pay for tests that are ordered by a Medicaid provider. And so that's just another example of really understanding exactly how your particular policy is set up so that you don't find out that the labs that you had ordered through Quest aren't going to be covered because Quest isn't in network with your particular plan.

Erin Stein: You need to look at your paperwork and if you are getting it through your employer, they give you paperwork and there's charts and stuff. You need to have a basic understanding. You know, if you go see your PCP, go see your gynecologist, what's your copay going to be? Those basic things should be covered, but then you might need to look into is my mammogram going to be covered? If I need a sonogram, is it going to be covered? Things like that and also, really important I think, is to understand if you need a referral or not. Some plans do, some plants don't,

Gillian Goddard: That is mostly based on the type of plan. So PPOs and EPOs, you usually don't need a referral. HMOs and POS, you usually do need a referral. And that's like in a little box at the top right-hand side of your card, usually. It'll say like PPO, EPO.

Erin Stein: Yes. If you're going to see a specialist of some kind, doublecheck and make sure that that is covered, or if you need something special to get it covered. And also, prescriptions is usually a different plan for many people. It's not the same as your medical insurance. Then you have prescription insurance, so checking medications, making sure they're covered, whether you need to get the generic to get it covered or not. It's a lot and it's certainly annoying but it's better to know some of these things ahead of time before you go to the doctor and then they're like, well you owe us five hundred dollars because we're out of network or whatever. And I will say you can address things sometimes. You know, if something comes as not covered, you get a nice little letter in the mail and it's like, we did not cover this. And you can call and you can say, well, I think this should be covered because my doctor ordered this test or because I had cancer and I needed to check this other thing. And a lot of times it's a coding issue or a billing error and you can appeal it and it can take a little time, and you might have to call more than once, but a lot of times you can have things adjusted. So don't just accept the rejection. Try again.

Gillian Goddard: Yep. Yes, and there are usually staff members in your doctor's office, and part of their job is to recode things, or submit prior authorizations. And so, it's helpful to know who that person is and treat them very, very well.

Erin Stein: Be nice to the people in the office because they are going to help you if you're nice to them. If you're not nice to them, they're not going to help you.

Gillian Goddard: I am gobsmacked by the number of people who come into our office and treat the staff not just dismissively, but rudely, then come into my office to sit with me and are all sweetness and light.

Erin Stein: [laughs]

Gillian Goddard: Doctors can actually fire patients and this is not something that most doctors do very often. I've only fired three patients in my entire career, but I will tell you the reason that I fired those three patients was because their behavior toward the office staff, not toward me, toward the office staff, was so completely inappropriate that I didn't feel safe having them come in and interact with the office staff and I felt like it was unfair of me to expect my office staff to put up with that kind of behavior as a part of their job.

Erin Stein: Mm-hmm. I have witnessed other patients having meltdowns in the office. one particular time, someone was very upset because something hadn't been covered by insurance, and this person was yelling and screaming and scaring everyone, including the other patients sitting in the waiting room and yelling at this poor woman behind the desk. And it is very frustrating when the insurance isn't covering what you thought it was going to cover, but it's not the doctor's fault. It's not the office staff's fault. And you need them to help you fix it. So, you can be frustrated and you can be upset but you should say, I need your help. I need to try and get this covered. Can you help me? Can we look at the billing code? Can we resubmit it? Don't take it out on them because it's not their fault.

Gillian Goddard: And they're the people who have the information and the ability to do something like resubmit. You don't have to be best friends with the office staff. Be courteous and thoughtful. 

Erin Stein: Be courteous. And listen, there are some office staff who are rude to you and we understand that

Gillian Goddard: Agree. If you do feel like a member of the staff has done something inappropriate or behaved in a way that is inappropriate toward you, you can 100 % speak to…it's best to try to speak to that person's supervisor. If it's a front desk person who is like the office manager, depending on how the practice is set up, doctors don't always have the ability to provide that type of feedback to office staff especially if you're in a big hospital practice where the staff is hired and fired by the hospital and not by the individual doctor. Yes, give the feedback, 100%. Do your best to give the feedback to the person who can most appropriately address it. But if you don't know who that person is, you can mention it to the doctor. And the doctor will know who the appropriate staff person is to address that feedback.

Erin Stein: Yes. Staff members like us are all humans and have bad days and can be kind of snippy and busy and whatever… 

Gillian Goddard: And so can doctors, by the way.

Erin Stein: …and so can doctors. But if someone makes a racist comment or a gendered comment that is not appropriate and if they're really not helping you and dismissing you, you can complain and you probably should. I think the doctor would probably want to know that was happening, especially in a smaller practice. 

Gillian Goddard: I would want to know that was happening.

Erin Stein: Yeah. okay, so we're still on paperwork. The portal, the eight million questions that everyone asks you to fill out it feels like three different times before you get to the doctor's office. Gillian, defend yourself.

Gillian Goddard: So, the first thing I would say is the most important forms to fill out are yes, the forms with your demographic information and your insurance information. The more you can take your time with the intake form when you're seeing a new doctor for the first time, the better that will be. I literally go through the intake form with the patient sitting in front of me and confirm all the information and ask questions about it if I have questions. And so do take a moment and fill out those forms. Also, don't ever show up to a doctor's office, even if you've been there a million times, without your insurance card. And now a lot of times, like my insurance card's digital, I have it on my phone. And so obviously that's very convenient. I'm not going to wind up at the doctor's office without my phone, most likely. But there's lots of reasons why we might need your card again. They sometimes change from year to year. Anyway, the more you can show up with all of that information already done, the more it's going to keep the office running smoothly, which will mean you will get the full allotment of your time with your doctor, which is ultimately what I think most of us want: the opportunity to use that full conversational time in the best possible way. And one of the ways you can do that is by making sure all those forms are filled out even if they feel redundant. I know that it is frustrating that everyone has different portals and different medical record systems.

Erin Stein: Mm-hmm. Yet another app to add to your phone and have a password for.

Gillian Goddard: Yes. And of course, everyone has different requirements for what kind of password you need. And I get that that's annoying. It would be amazing if we had one central medical record with one portal. It would be phenomenal. I don't think it's happening anytime soon.

Erin Stein: No.

Gillian Goddard: But the portal is your friend. because every communication that you have with your doctor that goes through the portal goes into your medical record. And every communication is HIPAA protected. It's all password protected, which means your personal information is protected, including your health information. It is technically against the law for doctors to text or email using non-secure emails without explicit permission from patients. And that is why doctors are so emphatic about using the portal. The portal's also a wealth of information. You can see the summary of your last visit. You can see your prescriptions. All of your labs typically go into the portal with a few exceptions. And portals can be a little quirky. Like when I review labs, it doesn't send you a message that I reviewed your lab. So, it's okay to say like will my labs come back in the portal and if so, when will you review them so that I can look at them?

Erin Stein: That is one of the drawbacks, is the labs go in there as soon as they're done. Patients will see them before the doctor has even looked at them. So, you got to slow your roll and just tell yourself, “Okay, but the doctor will look at it and then send me a message, everything's fine.” Don't be mad that the doctor hasn't seen it. It's just that literally the second it's done, it goes in the portal because then everyone can see it.

Gillian Goddard: That's correct. It used to be that doctors had to approve labs, which meant we had to review them, say that they were reviewed before they went into the portal. That actually changed during COVID because it was delaying the release of COVID testing results at a time when COVID tests were important and still took a week or more to come back. Why they couldn't just apply this change to COVID results, I don't know. They didn't, they made this change during COVID. All lab results go straight into your portal the moment they're available. So, your doctor is not—and you don't want your doctor—spending all their time waiting with bated breath for your specific labs to come into the portal.

Erin Stein: That is a fun fact. I did not realize that happened during COVID, but that makes perfect sense. The portal is sometimes frustrating, and I feel like I can't do what I need to do in it, but I also have been able to upload my family history into it so I can just say, “Well, look at it. I already gave you two pages of crap.” And also, when I had my breast cancer surgery, it was actually kind of wild to read the surgery notes afterward. I was like, maybe I don't want to read all these details? But it it was interesting. I do think the benefit is having more access to your records because you used to go into the doctor's office and they're like, “Well, everything looks fine” but you had none of the numbers. Over time, especially as we're going through our midlife transition, it's good to compare results and have access even if you switch doctors or switch practices. So yes, portal annoying but necessary and protects your privacy. Okay.

Gillian Goddard: Yeah. Correct.

Erin Stein: One more piece of paperwork: Healthcare proxy or POA.

Gillian Goddard: Yes, power of attorney or health care proxy, depending on your state. Have one.

Erin Stein: This is something I need to do. I haven't done it. But explain why we should have this.

Gillian Goddard: Yeah, so in most states, the decision-making abilities of a next of kin—so your spouse, your parent, your child, depending on your relationships—the ability of a person who is next of kin to make decisions about your health when you are unable to is much more limited than the ability of a POA or health care proxy. For example, in New York state, a next of kin cannot withdraw care in a terminal situation, and a health care proxy can. This is another one that amazes me: if the patient is over the age of 18, and this happens the day, believe me, I know I have an almost 19-year-old, it happens the day they turn 18, if the patient is over the age of 18, the only person that can access their records without written permission from that patient is the patient. Just because the kid lives at home and is still in high school does not mean that you have the same access that you had the day before when he was 17 and 364 days old. This applies to college age kids. This applies to our parents. This applies to us. I actually finally filled out my health care proxy form when I was pregnant the first time, starting to think about when things might go wrong. But it's a good idea to get it done and it's something that you need to do with your kids right when they turn 18 also.

Erin Stein: This is obviously in case of emergency, but you want to be prepared.

Gillian Goddard: And you cannot call the doctor's office and get records for a family member without the written permission of that family member. So now, for example, to talk to my son's pediatrician about him, I need his written permission to get details about his labs, or he needs to share them with me. Just something else to be aware of.

Erin Stein: Something else to be aware of. When you're filling out all that fun paperwork, they will ask you who you give permission for your records to go to and you can put something there. But that's not the same as someone being able to make decisions should that need to happen. So especially if you're going to have a procedure or something serious is going on, but really you should just have it in general.

Gillian Goddard: Yes. Correct. Correct. Just in general. And make sure you update it. So, if you get divorced, you may not want your former spouse as your health care proxy. You might. But you might not. And so that's another thing to remember is when relationships change, if your health care proxy passes away, these are things that you want to be aware of.

Erin Stein: Yes, if necessary. Right. You might not. You might. Some people get along still, you know. And we'll probably reiterate this when we get to the episode about dealing with your parents, but you want your parents to have one on file. Make them do it. Whether it's you or somebody else, but they need to have one. And I would argue if both your parents are older, it should not be each other necessarily.

Gillian Goddard: Yes. Yes. Yes.

Erin Stein: So, we're going to finally get to going to the appointment. I know, we spent the whole time just talking about getting ready. It should go faster from here.

Gillian Goddard: This episode's going to be like 30 hours long. [laughs] I do think that getting ready is the most important part and so I think it makes sense that we spent most of our time talking about that.

Erin Stein: Your top tip for your appointment? …Show up.

Gillian Goddard: [laughs] Yes!

Erin Stein: Please give us your plea as a doctor to your patients.

Gillian Goddard: Yes, yes, show up. Just because it is raining, just because it is hot, just because it's the Tuesday after our holiday weekend does not mean that you should not show up for your appointment and or reschedule it if necessary. Everybody understands that emergencies come up.

Erin Stein: And that you might actually get sick and not be able to make it.

Gillian Goddard: Correct. If you have the flu, when you're not seeing me for the flu, I don't really want you in my office getting me, my office staff and other patients sick. but make a phone call, reschedule the appointment. Look, people make mistakes but do your best to actually show up at your appointed time. If you're going to be late, like more than five or 10 minutes late, you should call and let us know so that we can make sure that we can accommodate you because if you're going to be 15 minutes late, that's your whole appointment and it may be difficult for the doctor to squeeze you in after that.

Erin Stein: Yes. And I am guilty of getting the time wrong and showing up like an hour past when I was supposed to be there. And they were very nice and they did squeeze me in. Bless them.

Gillian Goddard: Yeah, yeah. most staffs will do their best. I try to set my schedule six months in advance and try not to make changes to my schedule as much as I can so that I can be there for your scheduled appointment. So please, please, come or at least give us a call.

Erin Stein: Yes. Because also if you don't show up, then another patient could have gotten in. And depending on the doctor, they might have a really long waiting list, so show up. Don't cancel unless you really, really have to. Have your prep with you. All this research that we talked about, have it ready to go, have your questions ready, have your goal that you want met. Know what you want to walk out the door with. Either some more tests or some ideas or a treatment plan or a referral to another doctor.

Gillian Goddard: State that goal pretty high up.

Erin Stein: That is an excellent tip. State it at the beginning of the visit.

Gillian Goddard: Yeah, say, “today I want to make sure we talk about XYZ.” A note about if you're there for your annual visit, but you have questions about diagnosis that is not related to screening. So, say you go for your annual gynecologic visit, your pap smear and breast exam, but you want to talk about something that is not those things. Be prepared to schedule another appointment. It is not possible to do a pap smear, a breast exam, give you your referral for your mammogram, and then have a comprehensive conversation about hormone therapy in a 15-minute appointment. So, I would highly recommend not waiting to address symptoms. That annual visit is really intended to do your health maintenance have a separate specific appointment for your symptoms and schedule that as soon as you are noticing symptoms that you feel need to be addressed. Don't wait.

Erin Stein: Sometimes you can ask a quick question, or do you think this is something I need. I just want to be clear; we're not telling you don't bring things up. Don't avoid things. You may need to come back again. And it also depends on what kind of office it is. Some doctors' offices have labs right there and they can order you a test right then and there, and some can't, and so it's all a little different, but be prepared.

Gillian Goddard: Sure. Exactly. Just don't be surprised if your doctor says, well, we can talk about this today and then push your annual visit, you know, to a future appointment or we can do your annual visit and talk about that at a future appointment. And sometimes they'll give you the choice depending on how their schedule is set up. But don't be surprised if they ask you to come back is what I'm saying.

Erin Stein: Yeah. You can be annoyed, but you can't be surprised. So, to reiterate, all this prep work you did, these questions, your goal—have it written down. Don't assume you will remember it off the top of your head, because once you walk in the door, it all flies out of my brain, I know, because I have a little bit of white coat syndrome. I walk in and I'm like, I'm at the doctor and they're going to stick a needle in my arm, and I don't like that! So have it written down, put in your phone, bring a piece of paper, whatever you need to do, have it in front of you so you don't forget.

Gillian Goddard: Make sure that you actually look at it while you're in the office.

Erin Stein: Good tip.

Gillian Goddard: Don't wait till the end. Don't sit there, have the whole conversation with the doctor and then be like, wait, I have my list of 10 questions. Have it out ready to go. As you're getting toward the end of the visit scan through it and make sure you've gotten all your questions answered. 

Erin Stein: Yeah. a lot of times someone else comes in first to take your blood pressure, temperature, whatever, and what are you here for today? And they're typing, typing, typing in the computer. Tell them. Tell them here's why I'm here, here's my goal. Type it in there. So, when the doctor walks in, they see it right away. That helps too. The other thing is, try and take a shower. Listen, I am guilty of showing up to the doctor gross and disgusting and it's one thing if it's a hundred degrees outside, there's not a lot you can do about it…

Gillian Goddard: Or if you just had surgery or a baby,

Erin Stein: For my annual pap smear, I try to take a shower.

Gillian Goddard: A basic level of cleanliness is helpful. I don't need you all dressed up and made up. I don't care if you have makeup on. I don't care if you're in your workout clothes. None of that bothers me. But yes, please try to be clean and odor free.

Erin Stein: A little basic hygiene. I felt very bad when I went to the dermatologist recently 'cause I didn't wash my hair and I'm like, I really should have because she checks for moles on your scalp and I thought it would be clean enough and then I woke up, and I'm like, this wasn't clean enough.

Gillian Goddard: Yeah, on your scalp.

Erin Stein: Yeah, so think about that. This person is examining your body usually in some form or another and you don't want it to be totally disgusting for them. I think it's common courtesy.

Gillian Goddard: We tolerate a fair amount. I actually think that this matters more to you than it does to me.

Erin Stein: Yeah, see, Gillian's very generous. I don't believe that all doctors are that way. I think they all talk about us and they'll be like, “this person came in and they smelled so bad!” I'm just saying some basic soap and water. Or a wipe. They have very handy wipes now. We talked about the staff. Don't yell at them. Don't be rude. Be nice. Cause they talk to the doctor as you said, they talk to the doctors.

Gillian Goddard: We did. They sure do. They talk to the doctor, so we know.

Erin Stein: We also kind of already talked about your attitude walking into the doctor, but I think it bears repeating that we are often stressed, we're leaving work and we only have an hour, or we are running late, or the subway or traffic, or you're going to the doctor because you're worried about something. So, you're stressed out and that is normal and that is fine, but you have to try not to take it out on the people you are asking to help you.

Gillian Goddard: Try to take a deep breath. Try to take a moment to collect your thoughts.

Erin Stein: And if you're late, just say, “I'm so sorry I'm late. I'm here now.”

Gillian Goddard: That's what I say when I'm late.

Erin Stein: Right. So sorry I'm late. New York City is special. I feel like you can just say there was train problems. Everybody understands that. 

Gillian Goddard: Yes, my office is on the sixth train. No need to say more.

Erin Stein: What if, you go in to a doctor and you say, I saw this study or I saw this trial and I'm curious about these results and your doctor says, I haven't seen that. I don't know. i.e., your doctor is not up to date on the latest research, which could be for a variety of reasons, some fine, some not so fine.

Gillian Goddard: Yes, I mean, the first thing I would say is the amount of research that gets published on a daily, weekly, monthly basis is vast. And it's pretty difficult to keep up with every study that comes out in every journal the moment that it comes out. So a lot of times patients are hearing about these things through media, like the New York Times website or in a podcast or on the news. Studies are not necessarily the studies that are coming across your doctor's desk all the time. You guys might be reading different newspapers or listening to different newscasters. It's important to react with curiosity. I think the way you said it was just, you seen this? What do you think of this? That's a great way to approach it. My response to that question, if I've seen it, is to respond with my thoughts. If I haven't seen it, I do say, I will track that down. And I'll circle back with you. And then I do. 

Erin Stein: That's shocking. [laughs]

Gillian Goddard: And so, I do read a lot of literature for a lot of reasons, both to stay up to date to take care of my patients, but also because I'm writing about a lot of research and literature through the course of this aspect of my job. But there's definitely studies that patients bring to me or ask me about that I have not seen. And I do. I make a note of those. I look them up. And I get back with my response. It might take me a week, especially if it's not an urgent issue. if a doctor seems like they're not curious about new research, like they are skeptical about whole areas of new research without really giving you a good answer, or if they just seem...

Erin Stein: I would say if they seemed like they think they know everything already, it's not great because medicine is constantly changing and medications are changing, research is changing. As we've discussed, we're finally getting some research about women's health coming out. So, I would be displeased if they were dismissive or there's a “nothing new to learn, I already know everything” kind of vibe.

Gillian Goddard: Yep. Yep.

Erin Stein: And that may be another situation where you want to find a new doctor. 

Gillian Goddard: It might be. It might be.

Erin Stein: It might be. Again, you're consulting the doctor, you may or may not be satisfied with what you get out of your appointment. And if you're not satisfied, go to another doctor, get a second opinion. Or if it was really bad, switch doctors. We tend to think, “well, I went to the doctor, and they were a jerk and they said this and totally dismissed me.” And that does happen, unfortunately. But that doesn't mean you should just go along with it.

Gillian Goddard: Correct. No, no. This raises another important issue, which is what to do if your doctors don't agree with one another.

Erin Stein: I mean, there's one thing about if the doctor doesn't agree with you or you don't agree with the doctor, right?

Gillian Goddard: Correct. But what if you're stuck between two doctors who don't agree? What are you supposed to do then?

Erin Stein: Give us an example of this because I can't say I've had this experience yet.

Gillian Goddard: So, I have a patient who is having really bad perimenopause symptoms, and she had seen her gynecologist and her gynecologist had her just on progesterone. And I was like, well, that doesn't make any sense. Why is she just on progesterone? You should be on estrogen. And she's like, well, my gynecologist said I can't take estrogen. And I was like, well, why can't you take estrogen? I'm not seeing anything in your history that would be a reason why you couldn't. Here she is having symptoms. I think estrogen is the answer. Her gynecologist, for whatever reason, thinks it's not. And my patient is like, well, now what do I do? And the answer is you try to get your two doctors to talk. Because sometimes somebody's missing something. In this particular case, I was missing a piece of information that the gynecologist had from a hysteroscopy that she had done, a visual exam of the inside of this woman's uterus, and that gave her information that I didn't have. The best thing you can do when your doctors disagree is, try to get them to talk. If they won't talk, which I mean, I've never not taken a phone call from a colleague about a common patient. I've never done that. But if they will not talk to one another, you can think about getting a third opinion, like a tiebreaker opinion. But your best bet is to take yourself out of the disagreement and put the two people who disagree together, if at all possible.

Erin Stein: Ultimately you can talk to each doctor separately and ask them to lay out the risks more clearly for you so you can make a decision. Sometimes this is true when you're helping older relatives manage their care. They often have many doctors, and those doctors need to talk to each other, particularly about medications and how they interact.

Gillian Goddard: Yes, that is true. So now you're at the doctor, you have a plan. Maybe you got a prescription or a lab test. It's important to ask some follow-up questions. If you are having lab tests done, you want to know when they expect those lab tests to be back, when they expect to review them, and what their follow-up will be. Will they put a note in the portal? Will they call you? My party line is, is if everything looks fine, they will go in the portal with a note from me. If you have questions, feel free to send a portal message back. If I have something that I am concerned about, I will call you and we will talk about it on the phone. If you're getting a medication, make sure you understand when to expect the medication to be effective. When side effects typically occur, how long does it take for them to get better. Just make sure you know what the next steps are in a pretty concrete fashion. Make sure you know when you should follow up and schedule that appointment, if possible, before you leave the doctor's office.

Erin Stein: Also with the medication, ask what to do if you have severe side effects and if you should go off of it or when to go to the emergency room. You know, ask all those questions what to do and the best way to reach them.

Gillian Goddard: Mm-hmm. Depending on the medication. Yes. Yes. All doctors are required to have after hours coverage, a number where you can reach someone or have someone contacted to reach out to you.

Erin Stein: Yep. And especially if you're taking medication, ask when you should be following up with them. And even if everything goes well on your medication or whatever treatment plan you're having, you should have the follow up.

Gillian Goddard: Yes. We need to document when things are good too that is just as helpful, just as important as seeing you when you're not well.

Erin Stein: Again, a lot of us only go to the doctor when there's a problem, like we take our car in to get fixed, and if it's running fine, we don't take it in. But if there was something you discussed and there's something you're doing and it worked, you still need to go to the follow up and say, “yes, this is working. This is good.”

Gillian Goddard: Right. Exactly. The other thing I would say is if your doctor is calling you with results, please, please, please answer the phone. I know it's hard. Some phones screen out unknown numbers; put your doctor's office number in your contacts. I know sometimes I make phone calls from home, and I use a specific dialer so that it looks like my office number, but not all doctors do that. Some doctors just make their cell phone number private. If you know you're waiting for a phone call from the doctor and you think that there's any chance that this incoming call is the doctor, answer the phone. Because otherwise, you then call back during office hours, the doctor is seeing patients, the doctor then tries to call you again. I have documentation in some charts of, you know, 10 phone calls back and forth playing phone tag. It's an inefficient use of everybody's time. And I will tell you, I typically, about something non-urgent, will try to reach a patient two or three times and then the balls in your court.

Erin Stein: If you miss a phone call and get a voicemail, call back right away if you can. Sometimes I have caught the doctor because it was only a couple of minutes later, but it is challenging.

Gillian Goddard: Also, listen to the voicemail before you call back. Because the doctor may have given you all the information that you need in the voicemail that they left on your phone. 

Erin Stein: Yes. That's true. That's true. But sometimes they're like, blah, blah, blah, call us back. And then you got to call back. What do you do after your appointment? Answer the phone, number one. if you have questions, because sometimes we think of things afterward, ask questions, that's what the portal is for. I will say I do appreciate that it's easier to message doctors through the portals. And I do get responses. But also, I think the biggest thing is if you got a prescription or they told you to try something or you're starting a treatment, pay attention to how that's going.

Gillian Goddard: Yes. You should be doing the exact same data collection about your symptoms and how you're feeling that you were doing leading up to your appointment when you start a new medication or treatment. Because how else are you going to know if it's working if you don't compare the before and after? And so, I think that the data collection afterward is as important as the data collection you did before.

Erin Stein: If you take it and nothing happens, that's important. I've taken medications and I'm a little nauseous for a week and then it goes away, but I pay attention. How long is that lasting? Just track it the same way you were tracking symptoms before. Track any potential reactions or hopefully track a reduction in symptoms, one would hope, if you're taking something to do that. It's more homework, sorry, but you got to pay attention to whether it's working or not. Otherwise, why are we doing all this?

Gillian Goddard. That's correct. We have a lot to say on this topic.

Erin Stein: I think we had more to say than we realized on this topic. But our podcast is The Savvy Patient.

Gillian Goddard: We want you to be savvy.

Erin Stein: How to be savvy, how to get the most out of that doctor's appointment. If you do all of this and you don't get the most, I don't know what to tell you.

Gillian Goddard: [laughs].