A family member or close friend, rather than the patient himself, is usually the first to recognize the alarming persistence of COPD's major early symptomschronic bronchitis's coughing and excessive mucus production, and emphysema's shortness of breath from mild exertion. The patient typically attributes them to a lingering cold or flu, or to the unavoidable consequences of getting older. Even though pulmonary damage has been gradually progressing over many years, the majority of people we meet recount a story in which the incapacitating aspects of their disease appeared to materialize overnight. This sudden discovery brought them to the doctor's office.

Yet the ideal time to begin medical treatment for COPD is: the sooner the better. The earlier intervention begins, the more it can accomplish. So help should be sought as soon as the persistence of symptoms, no matter how mild, is noticed. Do not think you are making a big deal out of nothing. Many serious diseases, including COPD, begin with symptoms so mild that it is usually impossible for a nonmedical person to realize what s underlying them. So it is your responsibility to see your doctor when your body has not been functioning as it should. Your doctor's job is determining if this change is natural or not, temporary or not, and helping you handle it appropriately.

Two medical specialties overlap for treating COPD: the family physician and the pulmonary internist. Most COPD patients begin with one of these. Then as their disease progresses, other specialistssuch as a cardiologistoften join the treatment team.

The Family Physician: The family doctor (also known as a general practitioner or GP, a primary care physician, or an internist) is usually the first doctor most people consult. In rural areas, this is often the only doctor a COPD patient ever sees. Starting at this point has a major advantage (unless you are new in town or have recently changed doctors): your family doctor knows your history and your general state of health. The main disadvantage is that general practitioners must keep up with changes in so many areas of medicine that without a specific interest in pulmonary disease, they may be less aware of treatment advances until these changes eventually filter down throughout the medical community. Despite this, the family physician can adequately manage most cases. The occasional complicated case should usually be referred to the appropriate specialist.

Pulmonary Internist: In areas where a wealth of medical choices exist, people tend to bypass the family doctor and go directly to a specialist. Someone with a respiratory problem would choose a pulmonologist. These physicians first specialize in internal medicine, then spend further years studying pulmonary medicine, and then must pass an examination to become "board certified" in this subspecialty. Because of a focus on pulmonary disease, the pulmonologist is well informed on the latest treatment advances for COPD.

Unless limited medical resources in your area mean that you have no choice, finding the right doctor can be difficult. A good way to begin is seeking recommendations, either from friends or acquaintances (particularly someone with a pulmonary problem), or from another physician. Keep in mind, though, that nonmedical people are likely to recommend doctors whose bedside manner is particularly pleasing. Another doctor will recommend a colleague he went to school with, or whose medical competence has particularly impressed him.

Obtaining a personal recommendation is not the only way. Most large communities have a Lung Association that can recommend physicians or clinics.

Another approach would be to call the appropriate departmental office (Family Practice or Pulmonary Medicine) of the nearest large medical center. This can be particularly helpful if your symptoms become aggravated while traveling and you need nonemergency medical help.

One source to avoid is a magazine's "Best Doctors" type of list. These evaluations are subjective, and are sometimes little more than a popularity rating.

For those of you who have the luxury of choosing among two or more medically competent physicians, it is critical to select one whose personality works well with yours. As with other long-term relationships, the effectiveness of the patient-physician duo depends much on good chemistry, and the trust and communication that this helps promote. A physician whose attitude is "I'm the doctor and you do as I say," for example, will work poorly with patients who find it important to know what is being done, what effects can be expected, and why.

Three complaints arise most frequently when patients who changed physicians are asked why they did so. Their former doctor: (1) did not explain things sufficiently; (2) was unwilling to try lowering medication dosage; or (3) was hesitant to try new approaches and treatment. Yet most felt satisfied with their current doctor. The first complaint, as we indicated, is basically a matter of personality. Most physicians' approach to medication and new treatments depends much on the attitudes they developed during their medical studies.

The two opposite points of view regarding medication use are "minimal-to-none" vs. "aggressive therapy." The aversion to medication that many patients and some physicians hold stems from the desire to avoid possible side effects of drug therapy as much as possible. Most physicians fall somewhere in between these two extreme viewpoints.

As to nontraditional or not-yet-traditional treatments, physicians are trained to be conservative. "Conservative" in this case means not abandoning treatments of proven benefit until something of greater proven benefit comes along. Doctors are rightly skeptical about new treatments that have not yet passed the rigors of modern investigational criteria. Although some of the physicians we have spoken with adhere only to a traditional treatment plan, the great majority will accept a new form of therapy once they are convinced that: (1) it cannot harm the patient, and (2) the patient will still continue traditional treatment along with it.

Although these different philosophies have no effect on a physician's competency in treating the person, they do affect the doctor-patient relationship. Finding a doctor whose attitudes are in step with your own point of view greatly facilitates good communication. It helps to get an idea of a particular physician's personality and philosophy as early on as possible.

Unfortunately, you will probably have to commit yourself to a first appointment in order to gather this important information. Our adviceassuming you can afford to lose the initial feeis not to settle for the first physician you see unless you feel strongly that this is someone you can work well with. And if a relationship that begins well does not continue to meet your needs as a patient, then it is time to look for a doctor who does.

The severely ill patient who needs frequent hospitalization has an additional factor to consider in choosing a doctor. Since hospitals vary in their standards of patient care, the hospital affiliations of the doctors you are considering become important.

Patients belonging to an HMO may be limited to the participating specialists. It is still essential to meet these physicians and make your choice among them. But if even the best of them leaves you dissatisfied, then if it is feasible we suggest that you contact the closest teaching hospital and locate a specialist there who meets your standards. He can function as a consultant and guide your HMO team.