February 2003: The Doctor-Patient Relationship

Doctors annoyed by list of questions?

Question from Fay: When I go to my doctor, I always take a list of questions with me because I don't want to forget anything important. I get the feeling from my doctor that he thinks I am making up some of my symptoms because I have them written down. Am I doing something that offends doctors?

Answers —Jennifer Griggs, M.D., M.P.H.: In general, getting a list of questions at the beginning of a visit is very helpful, because it helps the doctor structure the visit, especially because time is often limited. However, getting a list of questions at the end of a visit can sometimes throw a physician off: As we feel we're wrapping up, it turns out we haven't even started to meet your needs. That can be frustrating! But presenting a list of symptoms, concerns, and questions is really the only way to make sure you get your needs met during a follow-up visit. You could certainly ask your doctor how s/he feels about your list. Explore the subject with him/her.

Marisa Weiss, M.D., president and founder: If the questions you're asking seem to be coming from a variety of sources, rather than just from you, it is possible that your doctor might respond with some hesitancy. S/he may not know where you're coming from. Don't be defensive if these questions are, in fact, coming from different sources, such as other doctors on your health care team, relatives or friends. That's OK. In fact, it may be helpful to the doctor to know where the questions are coming from so that s/he can best answer them.

Alert doctor's office about questions?

Question from Maleisha: Would it help to let the doctor's office know when I'm making my appointment that I have a lot of questions to have covered? So they can book more time?

Answers —Jennifer Griggs, M.D., M.P.H.: It would probably be more realistic for you to prioritize your questions. Remember all those times you waited for your doctor and s/he was running late? S/he was probably answering another patient's questions. S/he doesn't want to answer questions in a superficial a way that won't be helpful. Perhaps you can pick your most important questions and leave some of the others for other visits.

Marisa Weiss, M.D., president and founder: As you prioritize your questions, pick the ones that are most appropriate for that particular doctor. For example, ask your medical oncologist questions about chemotherapy and hormonal therapy. If you have a question about the best way to evaluate lymph nodes, ask your surgeon.. If you want to know how long it will take to recover after breast reconstruction, bring this up with your plastic surgeon.

Once you've put your tailored list together, then it's fine to call the office ahead of time and let them know you have some questions to sort out. You may even want to fax your list of questions to the doctor's office prior to your visit. This can be particularly helpful if one of your questions is about a pending test. That way, the office staff will know to make sure they have all test results back in your chart by the time you come in.

Jennifer Griggs, M.D., M.P.H.: I have patients who e-mail or send me a list of questions about a week before their visit. This gives me enough time to look over the questions and think about them as I prepare for that patient's visit. I've even had my staff do literature searches for patients who have unusual or challenging questions.

Marisa Weiss, M.D., president and founder: If your doctor is having a particularly busy day, you might find that you can't get to all the questions on your list. Just make sure all the critical questions are answered, and then come up with a plan to get the rest of your questions addressed. One thing that is quite helpful is to consolidate all the questions you and your family members or other people who are authorized to get involved in your care may have. This will help you all to avoid asking the doctor the same thing more than once through different people.

Jennifer Griggs, M.D., M.P.H.: I'd like to add that sites like breastcancer.org can answer many of your more general questions. Then, take your additional questions to your appointment after starting your research on breastcancer.org or other reliable web sites.

How to ask uncomfortable questions?

Question from Cid: Doctors seem worried that anything that does not go just as planned will be part of a lawsuit. They get defensive about honest questions. How do we get around that?

Answers —Jennifer Griggs, M.D., M.P.H.: I don't know that it's actually lawsuits that physicians worry about. I think our biggest concern is that we want our patients to trust us. A question that sounds challenging can threaten the relationship of trust that is so important to doctors and to patients.

Marisa Weiss, M.D., president and founder: Whenever someone doubts that you care about them, or questions your commitment to them, it is very uncomfortable. Trust is the foundation of the doctor-patient relationship, and like all relationships, it needs to be cared for, reinforced, and worked on over time. There are ways to ask direct questions, even about uncomfortable topics, and still maintain a good feeling.

For example, if one of my staff members is rude to a patient of mine, I definitely want to hear about it, although bringing it up to me can feel uncomfortable for the patient. In particular, she may be worried that if she says something, that staff member may not provide her with the best care possible, or that the staff member might express anger towards the patient. I try to create a relationship with my patients that will allow them to report things like that to me without feeling defensive, and without me feeling defensive. It's all about being committed to the best care possible.

You could say to your doctor, 'I know you're committed to my care, and so I want you to know that I had an interaction with your staff member that didn't feel good to me. I'm bringing this to your attention because I know you'd want to address it. Thank you for handling this with care and discretion so this staff member doesn't get angry with me.' This is just an example of something that may feel difficult to talk about.

Jennifer Griggs, M.D., M.P.H.: Sometimes the best way to approach a doctor is to preface questions by saying something like, 'I trust your opinion about these matters, and I would really appreciate it if you could answer some questions I thought about after our last appointment.' When patients approach me that way, I know they trust me and that they are coming to me not to challenge me, but to feel fully informed about their condition and its treatment. Just those few words of preface can make the interchange more positive.

Coordinating four doctors?

Question from Maja: I have a dilemma. I am seeing four doctors: A surgeon, a plastic surgeon, an oncologist, and my primary care physician. How do I coordinate between them all?

Answers —Jennifer Griggs, M.D., M.P.H.: The most important thing is to make sure the doctors are talking to each other via emails, faxes, and the old-fashioned telephone. You should expect your doctors to share information about you and your treatment. One way to make sure this happens is to let your doctor know whom you want copies of all your records sent to. This information is usually gathered at your first appointment with a cancer specialist. However, if you later think of another physician—your gynecologist for example—that you want kept 'in the loop,' let your doctor know.

You may be scheduling a large number of doctor visits, especially early in your treatment. If you feel overwhelmed, feel free to move an appointment to a more convenient date. For example, your medical oncologist may want you to come back for a follow-up visit a month after finishing chemotherapy. S/he wants to make sure that you're recovering from treatment. Of course, by now, you may be in the middle of radiation. Feel free to move your medical oncology appointment so it coincides with the conclusion of your radiation.

Marisa Weiss, M.D., president and founder: You have to keep an updated list of who should and who should not get your medical records. If you find that there are a lot of doctors on your team, you may be able to stagger the visits. Make sure you are seen by one of your doctors at least every three months for the first few years.

For example, a month after radiation, see your radiation oncologist, and three months after that, see your surgeon. Three months after that, see your radiation oncologist again. During that time, if you also received chemotherapy, or if you are taking hormonal therapy, your medical oncologist will also want to see you. Talk to your doctors and ask them to help you coordinate a follow-up plan that ensures you're taken care of without spending your whole life in the hospital.

Jennifer Griggs, M.D., M.P.H.: Of course, if you're having problems tolerating your hormonal therapy, and if your doctor is considering a change, you may want to go to the medical oncologist more often. This is just one example of how your visits should be tailored to meet your needs, not the other way around.

Discussing natural therapies with doctor?

Question from Wednesday: I want to try natural therapies in conjunction with my traditional treatments, but my doctor is not very receptive. How can I make him understand that I need to know I am doing everything I can to beat this?

Answers —Jennifer Griggs, M.D., M.P.H.: It's very common to feel the way you do. You want to do everything you can to improve your outcome. Doctors trained in traditional Western medicine often feel that complementary therapies represent sort of a 'black box.' We don't always feel confident about the safety or efficacy of these therapies. That's probably what you're picking up.

In addition to that, physicians don't want their patients to take anything that might interfere with chemotherapy or radiation therapy. For instance, we usually advise women to avoid antioxidants while undergoing chemo and radiation. Cancer treatments work through oxidation, and protecting cancer cells by taking antioxidants might decrease the likelihood of benefiting from treatment.

Marisa Weiss, M.D., president and founder: While you're undergoing conventional therapies, it is important to eat well by following a diet that's full of fruit, vegetables and whole grains. Cut back on fried food and foods containing a lot of fat. To reduce stress levels during treatment, you can try meditation, visualization or yoga, all of which can be can be very helpful and serve to complement conventional therapy.

Things that make doctors uncomfortable include the use of concentrated supplements, vitamins, and herbs. Without solid data that proves their value or their safety when used during treatment, your doctor will probably want you to avoid such things.

Jennifer Griggs, M.D., M.P.H.: It's important to note that some of the complementary/alternative therapies have serious side effects. For example, shark cartilage has been shown to cause severe hepatitis. Gingko, a commonly used supplement, can also cause thinning of the blood. The medical and lay media are full of examples of unregulated drugs causing serious toxicity. On the other hand, you should feel comfortable discussing your ideas and concerns with your doctor, acknowledging the many 'unknowns' that we've just started to address here.

Marisa Weiss, M.D., president and founder: You can find out more about complementary treatments in breastcancer.org's Complementary Medicine section.

Staying with doctor because of nurses?

Question from Sami: The only thing that keeps me going back to my current doctor is that I love and trust his nursing staff. They are so kind and considerate. Am I making a mistake staying with him?

Answers —Jennifer Griggs, M.D., M.P.H.: I love that question! It's SO important to consider your entire health care team, and not just your doctor. Everybody, from the person who greets you when you walk in the door, to the nurse, to the technician, to the person who draws your blood, is part of your team. Sometimes doctors who have poor interpersonal skills have the best nurses. The nurses know that they are helping the patients. They wouldn't work with that doctor if they didn't think he knew what he was doing medically, but they know that they're adding something to the care of that patient that is very important. Your nurses are indispensable to your care, and I don't think you are making a mistake by staying with this doctor.

Marisa Weiss, M.D., president and founder: If you're having trouble communicating with your doctor, and you have a great relationship with the nurses, by all means ask your nurses how best to approach the doctor about what's on your mind.

Getting doctor to listen to problems?

Question from Sharni: I am not coping very well with my treatment. When I mention it to my doctor, he glosses over it, and is interested only in my next test results. How can I get him to understand that I need help?

Answers —Jennifer Griggs, M.D., M.P.H.: I would start a visit by not addressing the symptoms you're having as a result of treatment. Try to decide on a day when you feel particularly strong and maybe had your partner or a friend with you, and make your concerns the main point of the visit—the concern being that you do not feel you're being listened to. There is no way your doctor won't pay attention to that.

Marisa Weiss, M.D., president and founder: It's also important to be firm, but gentle, in how you bring this up. You want to say that you really value his expertise, reputation, and ability to care for you. But also that it is important for him to know that you'd like to shift the focus away from test results to another angle that feels like it's addressing your needs more directly. And you could add that you're confident that he can help you do this.

Then step back a bit and allow him to respond. Give him a chance to re-orient his approach. If you are satisfied with his ability to do that, stick with what's working. If you feel that the relationship can't adjust to meet your needs, then maybe it's worth seeking a second opinion, or shifting your care to another doctor who can provide you with what you need.

Obligated to continue with doctor?

Question from Bella: Once I commence treatment with one doctor, am I obliged to continue with him or her?

Answer —Jennifer Griggs, M.D., M.P.H.: No. But make sure that you're not contemplating a change in doctors because you don't like the news the doctor gave you. In other words, changing because a physician had to tell you bad news will just increase the stress in your life. On the other hand, finding the right doctor is a lot like finding a life partner. I always tell my patients, 'We don't marry the first person we date, and we can't expect to always click with the first doctor.' It is critical that you feel you're getting the best care for you. Sometimes switching to another physician can help you cope with the cancer and its treatment more effectively.

Insurance problems with doctor switch?

Question from Sabrina: I was told that if I change doctors my insurance might be jeopardized. Can they refuse to pay out if I change doctors?

Answers —Jennifer Griggs, M.D., M.P.H.: That would be a pretty unusual situation. It is definitely worth a phone call to your insurance company to make sure the doctor you want to change to is in the company's plan. You shouldn't be penalized if you pick another provider who's in your own plan.

Marisa Weiss, M.D., president and founder: Don't be intimidated by the fine print in your insurance policy. These rules were created to be bent for each individual. Sometimes it takes a phone call or letter to get what you need from your insurance company regarding seeing additional doctors or getting specific tests.

Jennifer Griggs, M.D., M.P.H.: Your primary-care doctor can help you negotiate the insurance system with a letter or phone call, and you should not be afraid to ask for help with something this important.

Discussing negative prognosis?

Question from Lorena: I am a Stage III breast cancer survivor. My doctors tell me my time is limited. Do you think doctors should talk that way to me when I am feeling great?

Answers —Jennifer Griggs, M.D., M.P.H.: You and your physicians should be able to talk about your disease and your prognosis in a realistic but compassionate way. Whether you have Stage I or Stage IV cancer, if you are feeling good, you should be encouraged to live life fully. If you find that you and your doctor are not able to talk comfortably about the cancer, you should bring this up with him/her.

Sometimes physicians think patients haven't been told what we consider 'the truth.' We sometimes feel it's our responsibility to make sure that patients know the statistics and how to prepare. On the other hand, if you feel you have been fully informed, you should be encouraged to view your disease and your life in a way that most fits your own style and values.

Marisa Weiss, M.D., president and founder: If you are feeling well and you are living your life, then you are choosing life, whatever amount of time you may have. That's true whether you decide to continue treatment, or stop treatment. There are a number of people, for example, who have Stage IV breast cancer (metastatic disease), that have chosen to go off treatment. If they are feeling well, they are choosing to live in a way that gives them the best quality of life.

As you move along, making various decisions, it's important to know that you can always re-evaluate those decisions. That's one of the reasons you see your doctors on a regular basis. A decision you made in the past may change with future visits. But all along the way, it's important to promote the quality of your life, and your doctor should help you embrace the goodness and joy that you can experience, despite the reality of the disease.

Jennifer Griggs, M.D., M.P.H.: I've seen many patients whose doctors told them they had limited time several years ago, and it turns out that the doctor has since died...

Questions to develop open relationship?

Question from Maybe: Are there specific things I should be asking so that my doctor and I can develop an open understanding?

Answer —Jennifer Griggs, M.D., M.P.H.: The most important thing is to let your doctor know that your questions are coming out of a desire to develop an open understanding. As we said earlier, your doctor wants to feel trusted and respected, so prefacing your questions with comments indicating that you have those feelings would be a good place to start. As you and your doctor get to know each other better, you will get a sense of what s/he means by a particular phrase or expression. This can take a while, just as it takes a while for your doctor to figure out what makes you tick.

Sensitivity training for doctors?

Question from Justine: What sort of training do doctors get in how to be sensitive when dealing with people? Do you think more should be done to educate them in how they talk with patients?

Answers —Jennifer Griggs, M.D., M.P.H.: Medical schools and training programs vary. Whenever courses on increasing sensitivity are offered, they are filled with people who are already very sensitive. As a result, speakers often find they are 'preaching to the choir.' What is encouraging, however, is that such training programs actually work.

In our training program, physicians in training spend a great deal of time with various doctors to learn different styles of talking with patients. It's rewarding to see people learning how to speak with their patients in the most sensitive ways. I absolutely do believe that these are learnable and teachable skills, and that greater emphasis should be placed on these subjects.

Physicians are bombarded with so much information—more and more as the pace of medical science quickens. It's important to remember that most of the healing happens in a quiet room with two to three people listening to each other and respecting each other.

Marisa Weiss, M.D., president and founder: You yourself can be a powerful teacher. You can say to your doctor, 'What would help me most is if you could listen to my concerns and let me know what you're thinking.' Or you might say, 'I'm having a tough time these days. Today I would prefer to just spend the time with you alone, without all of your house staff and students. I can't handle an audience. What I need most is your sensitivity and attention to what's on my mind.'

This type of conversation sets things up in a way that's most likely to meet your needs. It's also a positive way to teach your doctor. By saying you need his sensitivity; you're implying that he has sensitivity. You can also do things to make the conversation more intimate. You could pull your chair a little closer, or you could put your hand on his arm and say, 'Thank you, but today I really need to address something else.' There are a lot of little things one can do in a relationship to make the situation more comfortable.

Getting written/recorded information?

Question from Joann: How about dictating and giving patients a written report, letter, memo, or e-mail, to state and explain findings? That way, things don't get forgotten, as they can with verbal information.

Answers —Jennifer Griggs, M.D., M.P.H.: There's a study that found that patients actually prefer an audiotape to a written summary letter. You can ask to have a copy of a letter that a doctor writes to your primary care physician. Most offices can't generate a letter both to a referring doctor and to a patient, so that's probably not a workable option.

On the other hand, you can bring a portable recorder with you and tape your doctor's visit. Some doctors find this a little off-putting. Sometimes we feel such information could be used against us in a court of law. Reassuring your physician that this is the best way for you to listen to and process a great deal of information should put him or her at ease.

Marisa Weiss, M.D., president and founder: Flatter them! Doctors love to be complimented, and they also love to receive tokens of appreciation. They are people. All people love positive reinforcement. In a relationship where you really want to get what you want, positive reinforcement is essential lubrication. If you give your doctor positive reinforcement, you will probably have more of your questions answered, and you will probably get a more responsive interchange.

Jennifer Griggs, M.D., M.P.H.: Chocolates, in particular, can be both a kindness and lunch, as it was for me today. :-)

Marisa Weiss, M.D., president and founder: Especially dark chocolates! :-) All of you who are reading along are experts at creating and nurturing relationships in general. But sometimes, when it comes to the doctor-patient relationship, you lose confidence in your ability to navigate. That's because the relationship is so important, intimidating, and inherently lopsided—the doctor has the expertise, s/he is fully dressed, you're usually not, you're the one with the health concern, they are presumably well, it's their terminology, their turf—not yours, and you're the one who had to wait to see them. This inherent lopsidedness can set things up in a way that feels uncomfortable and throws you off. When in doubt, just trust your instincts and draw on your ability to handle this relationship as you would any other human relationship.

Jennifer Griggs, M.D., M.P.H.: If you question the strength of your relationship with your doctor, it may help to bring along a friend or family member who hasn't been at every appointment. That person can be a sort of gauge for you. They can debrief with you after the visit, and they can either reinforce or provide a contrasting view of your impression of the relationship.

Marisa Weiss, M.D., president and founder: If you are unsatisfied with your relationship and decide to find another doctor, it's best to find the next doctor before you cut off your relationship with the old one. It can be difficult to change doctors because these are intense, important relationships. Put your personal energy into creating the new relationship. And, at a later time, when you have more space and energy, you can let the old doctor know why you chose to move on, if that's important to you.

Doctors made decision without me?

Question from Colleen: Without my knowledge, my breast surgeon called my plastic surgeon and asked him not to add the implant to my remaining breast. I then went to a different breast surgeon for another opinion and received permission to move forward. I'm supposed to go back to the original surgeon that did the mastectomy, but I feel differently about her now.

Answers —Jennifer Griggs, M.D., M.P.H.: If you think this is a workable relationship, it's important that you talk with your first surgeon about what happened. She may have had a good reason for the recommendation she made. On the other hand, it is important that you let her know, gently, that you were thrown by the fact that she didn't discuss this with you. Regardless of whether you choose to stay with the first or second surgeon, this will be an important learning experience for the first surgeon, and it may help you understand WHY what happened actually happened.

Marisa Weiss, M.D., president and founder: Sometimes, after your doctor sees you, s/he will get on the phone and bring another doctor up-to-date on your evaluation. During that conversation, new ideas might come up. It's possible that through this conversation another approach or idea about how to handle the reconstruction was brought up. This is a good thing when your doctors connect and come up with the best plan. But it is also important to circle back to you and bring you up-to-date with the way the team is thinking, and the way they want to guide you through the process.

Communicating by email?

Question from IJG: How do doctors feel about e-mail communications with patients?

Answers —Jennifer Griggs, M.D., M.P.H.: Many patients aren't aware that most hospitals and professional medical organizations advise against e-mail as a means of doctor-patient communication. Even if confidentiality is not a concern of yours, doctors are taught to view confidentiality as one of the most important values in medical care. In addition, e-mail does not effectively communicate feelings, tone of voice, or severity or urgency of symptoms.

I have also received e-mails from patients who want to change their appointments—and I don't even have privileges on our computer schedule! On the other hand, e-mails can be a quick way to let a doctor know that you've canceled an appointment because you're going out of town. Such an e-mail could help the doctor know what's going on with you if you miss an appointment.

It's important to remember that a doctor who receives an e-mail doesn't have your chart with him/her, so bypassing the secretary and her nurse may actually compromise the quality of your care, as the doctor may not have all the necessary information at his/her fingertips. I would advise you to ask your doctor how s/he feels about e-mail and in what case e-mail would be the best method of communication.

Marisa Weiss, M.D., president and founder: Also, doctors are required to document all conversations in order to make your chart complete. Doctors may not always have patient charts attached to their computers or place of e-mail activity. So the e-mail exchange may not be readily documented in the chart.

Problem with breast surgeon?

Question from Colleen: What if I have a problem with my breast surgeon, but not with my plastic surgeon?

Answer —Jennifer Griggs, M.D., M.P.H.: If you feel that you need to change breast surgeons, probably the best person to speak with is the plastic surgeon. Let the plastic surgeon know what the issues are and that you feel strongly that you need to make a change. Most plastic surgeons work with several breast surgeons, so s/he should be able to make a good recommendation. Be careful not to put your plastic surgeon in a position of speaking against a colleague. You can frame this as a personality 'fit,' rather than anything more serious.

Disagreement with doctor?

Question from Mile: I'm a marathon runner, and I want to continue training during chemo and radiation. My oncologist says I really have to cut back, but I heard that exercise is good for breast cancer patients. We're really at an impasse.

Answer —Jennifer Griggs, M.D., M.P.H.: This may be something as simple as a communication problem. Your physician doesn't want you to add additional stress, and may believe that you are trying to run a marathon while undergoing chemotherapy. What you may be talking about is more moderate exercise, which is, as you say, very helpful. There is no medical reason that you can't continue exercise, but your oncologist may be trying to help you have realistic, kinder, gentler expectations for yourself. Having a discussion about this to clarify what you mean and what your oncologist means would most likely clear up the issue.

Uncomfortable with procedure?

Question from Maria: My surgeon wants to do a full lymph node dissection. I want the sentinel lymph node procedure. Why should I lose all my lymph nodes if I don't have to? Should I switch surgeons?

Answer —Jennifer Griggs, M.D., M.P.H.: Without knowing the details of your case, it is hard to know whether the sentinel node procedure is appropriate for you. There are some patients for whom we do not recommend the sentinel node procedure. Again, letting your surgeon know that you view this issue as a 'mismatch' may help clear the air. It is important to know that the success of the sentinel node procedure (correct identification of the sentinel node) is related to the surgeon's comfort level and experience with the procedure. Your surgeon may be more confident with a full node dissection.

Finding regular doctor with no insurance?

Question from Diorella: I don't have health insurance, and my breast tumor was found at a local clinic during a free community health screening. I don't have a regular doctor, and I don't know where to turn.

Answers —Jennifer Griggs, M.D., M.P.H.: Most hospitals have social workers and funds to help patients in your situation. You may find help through the local clinic that provided the screening. The doctors there may be able to get you access to a regular provider and to cancer specialists.

Marisa Weiss, M.D., president and founder: Many screening programs take responsibility for connecting people to resources if their programs result in the detection of a cancer. Get on the phone and ask them to give you the names and phone numbers of people who are most likely to help you get the attention you need, quickly. Don't do this alone. Work with the social worker and other key people in the early detection program you participated in.

There are also some resources listed in our Staying on Track with Treatment section that can be helpful with financial issues.

Doctor knowledgeable about new research?

Question from What's For Dinner: My oncologist is a great guy, and I like him a lot. But I was recently diagnosed with a recurrence, and I'm wondering if I should go to a different doctor this time. My doctor is about 60 years old, and I'm not sure he's really up on the latest research.

Answers —Jennifer Griggs, M.D., M.P.H.: Changing doctors at this point may be an unnecessary stress. An older physician will have many years of experience and wisdom that will be very valuable to you as you move forward. Rest assured that most of us keep up on the literature through modern technologies, as well as journals. If, however, you find that your comfort level does not return to where it was before, a second opinion might be helpful. And it does not necessarily mean you need to permanently change your physician. Websites such as ours can help you keep up with the research yourself.

Marisa Weiss, M.D., president and founder: Print out a Research News or content page that you think might be helpful in your situation, and bring it into this doctor to facilitate a discussion.

Doctor isn't responsive?

Question from Folderol: My doctor never returns my calls. She's a great doctor, and I feel like she's giving me good treatment, but I really want someone who's more responsive. What should I do?

Answer —Jennifer Griggs, M.D., M.P.H.: If you get calls back from the office, from a nurse or nurse practitioner, you should feel confident that your medical questions are being answered appropriately. If the office does not return your calls, it may be something as simple as an outdated phone mail system. Letting your doctor know of the system's failure will help other patients, as well as you.

If you have told people in the office that you want to speak specifically with your doctor, and she is not returning your calls, this is an issue you should bring up with her in person when you can feel calm. We always want to feel as if we're our doctor's only patients. When we have an unresponsive doctor, it can make us feel so vulnerable. Letting her know these feelings will very likely improve your communication with her.

Lying to doctor about smoking?

Question from Fitz: I'm a two-time breast cancer survivor, and I'm ashamed to admit that I haven't been able to stop smoking, even though my oncologist keeps telling me to. So I've been lying to him about this. I just can't take him being angry with me on top of everything else. What should I do?

Answers —Jennifer Griggs, M.D., M.P.H.: Sometimes doctors get on a pony and don't get off! Your doctor probably feels that he is doing his job by continuing to urge you to quit, since doctors are often told they don't tell patients often enough to stop smoking. From a medical standpoint, women on tamoxifen who smoke are at an increased risk of blood clots. If this is not an issue in your case, stopping smoking is more of a lung cancer prevention and general health concern. I don't think your doctor will view you differently if you 'confess.' And your doctor may be able to help you hook into places that can help you quit if and when you're so inclined. This is clearly something that is weighing on you, and it's probably worth getting off your chest.

Marisa Weiss, M.D., president and founder: There's only so much you can do at one particular time. Dealing with a breast cancer diagnosis and all the treatment decisions, and following through and getting those treatments is more than a full-time job.

Jennifer Griggs, M.D., M.P.H.: Amen!

Marisa Weiss, M.D., president and founder: If there are a lot of other things you also feel you need to do, write them on a list. Look at that list every once in a while and tell yourself that you will get to those items as soon as you feel more ready and able. If smoking cessation is one of the things on the list, put it toward the top. But also put at the top of the list things that give you pleasure and fulfillment. Helping you live your life and enjoy your life is the bottom line; it's integral to the mission of www.breastcancer.org.