Specialty Area: Pulmonary

Description of Specialty: A pulmonologist is a physician skilled in the anatomy of physiology of the lungs and the diagnosis and treatment of lung disorders.

General Questions

1. At this stage in the evaluation (completion of history and physical and initial laboratory data), what do you think is most likely wrong with me, if anything?
2. What are other possibilities (differential diagnosis)?
3. Would review of old chest x-rays, CT scans, records be of help?
4. Are there successful treatments for any of these conditions?
5. Do the treatments differ among those problems in the differential diagnosis?
6. If the treatment is no different among the likely possibilities, why not just start treatment?
7. If further diagnostic evaluation is recommended, how is this likely to affect treatment and/or outcome?
8. Among the diagnostic tests recommended, what are their possible benefits and what are their possible consequences?
9. Among the diagnostic tests recommended, what is the likelihood that they will provide an answer that is diagnostically meaningful?
10. Among the diagnostic tests recommended, what is the likelihood that the results will be therapeutically meaningful?
11. How accurate are the recommended diagnostic tests?
12. What is my diagnosis in medical terms?
13. In lay terms, what does this diagnosis mean to me?
14. What can I do that is important in improving health status?
15. What should I not do that is important in preventing worsening of health status?
16. How does the prognosis of my diagnosis differ if treated or if untreated?
17. What are the side effects of the proposed treatment and how likely are they to occur?
18. What are treatment alternatives and how successful are they?
19. For the treatment that you recommend, what can I do to minimize the frequency and severity of side effects? I
20. wish to speak with you about my feeling of end-of-life care. Is this a good time for you? If not, when?

1. Diagnosis: Chronic Obstructive Pulmonary Disease         (chronic bronchitislemphysema)(COPD)

Questions that should be asked:

1. At this point, does this diagnosis account for all my symptoms?
2. In order to maximize symptom reduction and health improvement, how must my behavior change?
3. In order to minimize symptoms and maximize health status, do I require additional diagnostic testing either for the COPD or for other conditions that may explain currently unexplained symptoms?
4. Are pulmonary function tests indicated? How extensive should this testing be? Why?
5. What medications, if any, should I take regularly and what medications, if any, should I take when symptoms worsen?
6. When should I communicate with you in between appointments?
7. If I do not follow your recommendations, what would you expect the course of my health problems to be?
8. Are there more aggressive treatment options (gene therapy, surgery, alternate health care, and antiprotease replacement therapy) that I should evaluate? Why?
9. Is pulmonary rehabilitation an important part of treatment?
10. How does it work?

2. Diagnosis: Carcinoma of the lung

Questions that should be asked:

1. If cancer is suspected, why do we have to confirm the diagnosis?
2. Is treatment different for small cell versus non-small-cell carcinoma of the lung?
3. What is the difference between the terms "operability" and "resectability"?
4. Can pulmonary function tests help determine resectability?
5. Is it possible for surgery to result in a "cure" of my cancer (alive and well without evidence of malignancy in 5 years)?
6. What is the difference between curative and palliative therapy?
7. Is my cancer one that regularly is responsive to chemotherapy?
8. Is my cancer one that regularly is responsive to radiation therapy?
9. Is my lung function adequate to undergo the treatment recommended?
10. Is my overall health adequate to undergo the treatment recommended?
11. If I do not accept the recommended treatment at this time, can it be done later?
12. If surgery is recommended, how often does the recommended surgeon perform this type of surgery?
13. Would it be advantageous to seek evaluation/care/surgery at another facility?

3. Diagnosis: Asthma (allergic, adult onset, exercise-induced, occupational, chemically-induced)

Questions that should be asked:

1. How certain are we of the diagnosis of asthma?
2. I have been told that asthma is a chronic disease that is always present; why are my symptoms intermittent?
3. In your treatment plan, what medications should be taken all the time (even if I have no symptoms) and what medications should I take to help reduce symptoms when I get them?
4. What environmental changes (at home and at work) are appropriate to minimize the severity and frequency of symptoms?
5. How does exercise affect my health problem?
6. How should I exercise?
7. Is there any condition or environment that I must avoid or should avoid?
8. Is my condition inherited?
9. What does that mean to my children?
10. When should I contact you in-between appointments?
11. How important, in your opinion, are peak flow measurements?
12. When are formal pulmonary function studies indicated?
13. Under what circumstances should I go directly to an emergency room?
14. What should I do when I feel that symptoms will be worsening?
15. Does yellow sputum mean infection in my case? Always?

4. Diagnosis: Obstructive Sleep Apnea

Questions that should be asked:

1. Why do you believe I might have obstructive sleep apnea?
2. Is there need to confirm the diagnosis with a sleep study?
3. Do the results of a sleep study have any implications to treatment?
4. Once a treatment plan is established (discontinuation of nocturnal tranquilizers, sedatives, alcohol; CPAP, BIPAP), how should I feel different?
5. Will weight loss help my symptoms?
6. Is it possible for weight loss to eliminate the need for other forms of treatment?
7. Can I drive a vehicle now?
8. If not, when can I resume driving?
9. What are the dangers of not following the recommended treatment regimen?
10. Are there other treatments (surgery, diet, etc.) that may help?
11. When are they indicated?

5. Diagnosis: Community Acquired Pneumonia

Questions that should be asked:

1. How is the diagnosis of pneumonia established?
2. Do I need a sputum culture?
3. Do I need a chest x-ray now?
4. Do I need a chest x-ray in the future?
5. What are the advantages and disadvantages of the recommended antibiotic?
6. Is it more advantageous to take more than one antibiotic?
7. What is the cost of the prescribed/recommended antibiotic?
8. Is there clinical advantage of a more expensive one?
9. Are side effects less with a more expensive one?
10. Is treatment in the hospital or as an outpatient more effective?
11. When should I start feeling better?
12. When should my x-ray improve?
13. Under what circumstance should I contact you before the next appointment?
14. When can I return to work?
15. When can I return to full, unrestricted activity?

6. Diagnosis: Sarcoidosis

Questions that should be asked:

1. How certain are you of the diagnosis?
2. Is a biopsy necessary now?
3. Should treatment ever be initiated without a diagnosis confirmed by biopsy?
4. What parts of the body may be affected with sarcoidosis?
5. When non-caseating granuloma are seen on biopsy (lymph node/lung), how certain is the diagnosis of sarcoidosis?
6. What are the indications for the treatment of sarcoidosis with corticosteroids (prednisone)?
7. Are pulmonary function studies helpful to evaluate success of treatment?
8. When I develop new symptoms, how do I know it is due to sarcoidosis or to a new problem?
9. How should the activity of the disease or the response to treatment be followed?
10. Is this disease genetic or contagious?
11. How often does it ever go away all by itself without treatment?

7. Diagnosis: Interstitial Pulmonary Fibrosis

Questions that should be asked:

1. What is the basis for making this diagnosis in me?
2. Is a biopsy of the lung required?
3. Should this biopsy be performed through a bronchoscope or through formal surgery?
4. Are there alternatives?
5. Is it important to determine the specific cause?
6. Why?
7. Do the findings on biopsy influence treatment?
8. What is the indication for medical treatment (corticosteroids, immunosuppressants, oxygen)?
9. Are pulmonary function studies helpful in evaluating success of treatment?
10. What is the indication for lung transplantation?
11. Should the biopsy material be reviewed by an expert pulmonary pathologist?
12. Should I be referred to another doctor/expert for a second opinion?

8. Diagnosis: Pulmonary Embolism

Questions that should be asked:

1. Am I at augmented risk for the development of pulmonary embolism?
2. What are the risk factors?
3. What is the basis for the diagnosis in me?
4. How certain is this diagnosis?
5. In order to increase certainty, when, if ever, are additional tests appropriate?
6. What is the cause of pulmonary embolism in me?
7. What are the treatment options?
8. What is the best form of treatment for me?
9. What are alternative treatments?
10. Is it medically appropriate to become pregnant?
11. What, if any, are the risks?
12. If I'm not to become pregnant, please advise regarding type of birth control.

9. Diagnosis: Cystic Fibrosis

Questions that should be asked:

1. What is the basis for making this diagnosis in me?
2. What is the natural history of cystic fibrosis?
3. What can I do to improve that natural history in me?
4. What can I do to reduce frequency of pulmonary infections?
5. What can I do to maintain an excellent nutritional status?
6. Am I fertile? If yes, what problems, if any, should I expect with pregnancy?
7. How can they be minimized?
8. Please explain the implications of the genetics of cystic fibrosis to me.
9. When cystic fibrosis advances to severe and end-stage level, is it possible to do a lung transplant?
10. Can lung transplant be done with either living related donors, or is it limited to unrelated donors?

10. Diagnosis: Suspected Occupational (Environmental) Lung Disease

Questions that should be asked:

1. Doctor, I prepared a detailed list of my work history and associated potential exposures. Would this be of help?
2. May I please describe what I do in my job to you?
3. Doctor, I prepared a detailed list of my hobbies and non-work associated activities and associated potential exposures. Would this be of help?
4. Doctor, would you like to review all chest x-ray reports, chest x-ray films, and medical records?
5. Doctor, would you like me to describe to you the forms of respiratory protection I used (masks, respirators, etc.)?
6. Is it possible to be certain that my health problem is or is not related to the work place?
7. Is it helpful, from a health standpoint, to be completely certain of that relationship?
8. What is the value of pulmonary function testing?
9. What is the value of CT scan?
10. High resolution CT scan?
11. What is the value of a biopsy?
12. If I discontinue environmental/occupational exposure, what will be the effect on my health, what if I don't?
13. What kind of work can I do safely?

Peter G. Tuteur, M.D. Associate Professor of Medicine Washington University School of Medicine St. Louis, MO