Why Doctors Hate Science

[Ivor the Engineer]

1. The entry into medical school is a complex, multi-factoral one. Is it perfect? Not by a long shot. You still have the occasional one go completely off the rales...murderers, pedophiles, they occasionally happen. However, I think that trying to seek out "compassion" in a candidate is something that we strive for when selecting medical school candidates. Whether it be through the type of volunteer work that they do, or the answers to particular questions in the interview, it is looked for.

But its common knowledge that volunteer work, preferably within a medical setting, is highly advantageous when applying to medical school, so anyone with any common sense who is interested in medicine is going to do 6months in a hospice or similar setting to appear to be the correct kind of candidate.

2. Because there are more people then places, there will naturally be a tendency towards the "best" of the bunch, for sure, but that is not a question answered purely with academic prowess. In my class we had english majors, music majors, teachers, engineers. Yes the bulk of the students were science (Biochem, Biology, Nursing) majors, but that is to be expected. As well, the academic average and MCAT scores are only two of many factors, and not neccesarily the most important.

I was thinking more of the situation selecting people with a competitive nature, rather than just high academic scores.

3. I would say that many things motivate people to become physicians. Challenge, Curiosity, Altruism, Money, Respect, and yes, Gratitude. I suspect the need for gratitude is not a major factor by a long shot, although I would be interested in reading a study that proves me wrong on that one.

I'll start searching.:)

4. Your comments, to me, sound tinged with a combination of bitterness and annoyance.

TAM:)

http://radio.weblogs.com/0108814/stories/2002/06/25/doctorsVsGeeks.html

Unfortunately, geeks have done too good a job of simplifying what they do for users, hiding the complexities of the systems they build, and their ultimate value to society. I think the reality is that doctors keep individuals' physical infrastructure functioning and geeks keep society's infrastructure functioning. How many people would lose their lives tomorrow if the telephone system stopped working? if the avionics in all 747s failed? if the GPS guidance system in a cruise missile failed? if the computer systems running the nation's power grid failed? Don't kid yourself. Geeks do a job that is likely far more important to the safety and welfare of a larger number of people than the medical profession does. They just do it in a quiet, unassuming way that doesn't require elevating individual accomplishment. And people do take it for granted. That should be a tribute to the geeks for a job well done.

One day, the medical profession will have eliminated all of the mystery surrounding the human body. When that day comes, doctors as we know them will likely cease to exist. Medicine will just become one more system for the geeks to model and implement. Until then, people are going to continue to elevate those who keep them alive and continue to overlook the others who merely simplify their lives, even if they don't know who's who.

;)

[Ivor the Engineer]

Why should I?

Because it would be interesting to know what knowledge and/or skills you think newer physicians are missing.

[Ivor the Engineer]

Right, 'cuz you simply assumed the outcome - that my response was non-serious and that it was so because I have contempt for you - in the same way that one assumes that changes in practice represents provision of excess services or that the presence of conflict of interest creates biased guidelines. It's of interest and useful (I assume) to uncouple those assumptions, at least occasionally.

Linda

*Sigh* (I'm doing that a lot recently)

You know, I'm aware of a study which does contradict the phenomenon of PID and I was hoping my posts may have motivated someone to post it. What I found interesting about it was that it was performed in Norway. Other research I've looked at was about the ultimatum, dictator and trust games in behavioural economics. One of the studies compared the behaviour of two very similar groups of twins, one from the US and the other from Sweden. The striking difference between the two groups was the Swedish participants were far more likely than their US counterparts to trust their twin with 100% of their stake. Another piece of research demonstrated that students who take economics courses become more self-centered than before they took the courses.

This got me thinking about whether PID may be influenced by culture and learning, and so in countries where capitalism, individual responsibility and self-reliance are considered more important than solidarity and community, PID would be more prevalent.

[fls]

I thought geeks were those side-show performers who pounded nails into their nasal cavities?

Linda

[Professor Yaffle]

As a member of the Elite Physician's Cabal, I am very interested the answer.

Plebeians and peasants should know their place :p

The right answer, or the one she gave?

[roger]

All I know is that the doctors here in Boulder are obviously woefully undertrained in incentivived. :mad:

When I went in for my allergies the doctor suggest I waterboard myself, I mean buy a cheap nasal irrigation thingy at Walgreens, rather than take drugs that he could prescribe.

When I was in the hospital recently the doctor mentioned a bunch of tests he could do, but then advised me not to do them because other symptoms would rear their head in plenty of time if I had anything those tests would find.

When wunky was in the hospital yesterday the doctor spent a lot of time in examination eliminating tests that he could perform, and then advised her that an over the counter medicine would actually be better than anything he could prescribe her.

Who trained these people???? :mad:

[kellyb]

*Sigh* (I'm doing that a lot recently)

You know, I'm aware of a study which does contradict the phenomenon of PID and I was hoping my posts may have motivated someone to post it. What I found interesting about it was that it was performed in Norway. Other research I've looked at was about the ultimatum, dictator and trust games in behavioural economics. One of the studies compared the behaviour of two very similar groups of twins, one from the US and the other from Sweden. The striking difference between the two groups was the Swedish participants were far more likely than their US counterparts to trust their twin with 100% of their stake. Another piece of research demonstrated that students who take economics courses become more self-centered than before they took the courses.

This got me thinking about whether PID may be influenced by culture and learning, and so in countries where capitalism, individual responsibility and self-reliance are considered more important than solidarity and community, PID would be more prevalent.

That actually makes a lot of sense.

[T.A.M.]

First question at my sister's interview for medical school: "So, why on earth would the daughter of a TV repairman (said in a sneering voice)want to become a doctor?"

Yikes. I guess not all medical schools, or entrance interviews, are of the same standards or conduct.

A shame.

TAM:)

[T.A.M.]

But its common knowledge that volunteer work, preferably within a medical setting, is highly advantageous when applying to medical school, so anyone with any common sense who is interested in medicine is going to do 6months in a hospice or similar setting to appear to be the correct kind of candidate.



I was thinking more of the situation selecting people with a competitive nature, rather than just high academic scores.



I'll start searching.:)



http://radio.weblogs.com/0108814/stories/2002/06/25/doctorsVsGeeks.html



;)

1. You have a point, and I agree, there are ways to build what is considered the "Desirable" resume for entrance. That is why it is only one of many factors. Even the interview is to be studied for. A week or two before, you try to keep up on current events, start asking yourself questions about deep, thought provoking issue.

2. Competitive...absolutely. We would always say our medical school class was all chiefs and no indians. It was a challenge to get a group of students to work as a team, as each one wanted to be the leader, and no one the follower. That, however, is one component they LOOK FOR, in applicants, as it is what will HOPEFULLY, allow the future PHYSICIAN to be the team leader in the health care team, which he/she often is.

3. The end of medicine, as a human practice, is far from at a close...if ever. As much as it is science based, and evidence based, you cannot replace the art of medicine, or the instinct that the years of practice and training provide.

TAM:)

[T.A.M.]

All I know is that the doctors here in Boulder are obviously woefully undertrained in incentivived. :mad:

When I went in for my allergies the doctor suggest I waterboard myself, I mean buy a cheap nasal irrigation thingy at Walgreens, rather than take drugs that he could prescribe.

When I was in the hospital recently the doctor mentioned a bunch of tests he could do, but then advised me not to do them because other symptoms would rear their head in plenty of time if I had anything those tests would find.

When wunky was in the hospital yesterday the doctor spent a lot of time in examination eliminating tests that he could perform, and then advised her that an over the counter medicine would actually be better than anything he could prescribe her.

Who trained these people???? :mad:

Canadians.

TAM:D

[Mouthfire]

All I know is that the doctors here in Boulder are obviously woefully undertrained in incentivived. :mad:

When I went in for my allergies the doctor suggest I waterboard myself, I mean buy a cheap nasal irrigation thingy at Walgreens, rather than take drugs that he could prescribe.

When I was in the hospital recently the doctor mentioned a bunch of tests he could do, but then advised me not to do them because other symptoms would rear their head in plenty of time if I had anything those tests would find.

When wunky was in the hospital yesterday the doctor spent a lot of time in examination eliminating tests that he could perform, and then advised her that an over the counter medicine would actually be better than anything he could prescribe her.

Who trained these people???? :mad:

I hope you're being sarcastic..... I would LOVE a doctor like that....

[Ivor the Engineer]

Sources for my previous post:

http://www.ncbi.nlm.nih.gov/pubmed/11373837?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

The focus of the present study is to examine whether supplier-induced demand exists for primary care physician services in Norway. We compare how two groups of physicians, with and without incentives to induce, respond to increased competition. Contract physicians receive their income from fee-for-item payments. They have an incentive to compensate for a lack of patients by inducing demand for services. Salaried physicians receive a salary which is independent of output. Even though increased competition for patients reduces the availability of patients, they have no financial incentive to induce. Neither of the two groups of physicians increased their output as a response to an increase in physician density. This result could be expected for salaried physicians, while it provides evidence against the inducement hypothesis for contract physicians.

http://en.wikipedia.org/wiki/Ultimatum_game

The ultimatum game is an experimental economics game in which two players interact to decide how to divide a sum of money that is given to them. The first player proposes how to divide the sum between themselves, and the second player can either accept or reject this proposal. If the second player rejects, neither player receives anything. If the second player accepts, the money is split according to the proposal. The game is played only once, and anonymously, so that reciprocation is not an issue.

...

Experimental results

In many cultures, people offer "fair" (i.e., 50:50) splits, and offers of less than 20% are often rejected.[2] Research on monozygotic and dizygotic twins has shown that individual variation in reactions to unfair offers is partly genetic.[3]

http://en.wikipedia.org/wiki/Dictator_game

The dictator game is a very simple game in experimental economics, similar to the ultimatum game. Experimental results in the dictator game have often been cited as a conclusive rebuttal of the rationally self-interested individual (homo economicus) model of economic behavior,[1] although this conclusion is controversial.[2]

In the dictator game, the first player, "the proposer", determines an allocation (split) of some endowment (such as a cash prize). The second player, "the responder", simply receives the remainder of the endowment not allocated by the proposer to himself. The responder's role is entirely passive (he has no strategic input into the outcome of the game). As a result, the dictator game is not formally a game at all (as the term is used in game theory). To be a game, every player's outcome must depend on the actions of at least some others. Since the proposer's outcome depends only on his own actions, this situation is one of decision theory and not game theory. Despite this formal point, the dictator game is used in the game theory literature as a degenerate game.

This game has been used to test the homo economicus model of individual behavior: if individuals were only concerned with their own economic well being, proposers (acting as dictators) would allocate the entire good to themselves and give nothing to the responder. Experimental results have indicated that individuals often allocate money to the responders, reducing the amount of money they receive.[3] These results appear robust: for example, Henrich, et al. discovered in a wide cross cultural study that proposers do allocate a non-zero share of the endowment to the responder.[1]

If these experiments appropriately reflect individuals' preferences outside of the laboratory, these results appear to demonstrate that either:

1. Proposers fail to maximize their own expected utility, or
2. Proposer's utility functions include benefits received by others.

Additional experiments have shown that subjects maintain a high degree of consistency across multiple versions of the dictator game in which the cost of giving varies.[4] This suggests that dictator game behavior is, in fact, altruism instead of the failure of optimizing behavior. Other experiments have shown a relationship between political participation and dictator game giving, suggesting that it may be an externally valid indicator of concern for the well-being of others.[5][6]

Results for the trust game:

http://www.pnas.org/content/105/10/3721.figures-only

[luchog]

I think there is a genuine problem, but also a resistance born more of machismo from some older doctors. If they went through that hell in order to get where they are, then so should younger doctors. Like some sort of bizarre initiation rite.

I know that that "it was good enough for me, and it's good enough for them" attitude is far too common; but it's not the only reason for long hours. There's also the "stress test" aspect to it. Medicine can be very stressful at times; particularly if one is working in certain fields. The long hours and grueling work can be a way of weeding out those who are less dedicated, and less able to handle the stresses of, say, an emergency room at peak capacity.

Obviously there needs to be a balance between the stress test, and working someone so hard that fatigue and overload results in otherwise easily avoidable, and potentially fatal, errors.

And, of course, there's the training issue mentioned earlier. 48 hours per week results in a lot less training and experience than 70 or 80 hours a week; which means extending the training period by a year or more; or accepting less experienced doctors into a field where "learning on the job" is not a desirable modus.

[luchog]

I thought geeks were those side-show performers who pounded nails into their nasal cavities?

Linda

No, that's a "Blockhead". "Geek" was the industry term for what was typically billed as a "Wild Man"; and was the one who bit heads off of animals or ate large insects; and later came to include performers of actions which the viewers would find repugnant or horrific, but still entertaining.

[dudalb]

I do find it amusing that UK docs are complaining about a 48hour work week. When I started residency, I regular went through a 100 work week and the surgeons regularly went higher. The 80hour max work week rule came to my hospital half way through my residency and it was such a major change.

48hours a week is not enough for certain specialties and I see signs that a 80hour work week may well not be enough. I think it is barely enough for pediatricians, ER docs and General Internists, but for a Surgeon, even with 5-6years of residency, I'm seeing some of new grads lack certain skills that was once expected from the older generation.

One of my Doctors Joined the Marine Corps before going to College, and he described being an Intern as the Medschool answer to Parris Island.

[T.A.M.]

One of my Doctors Joined the Marine Corps before going to College, and he described being an Intern as the Medschool answer to Parris Island.

an intern is the worst.

All the responsibilities of a full fledged Staffman (for the most part), with little of the experience, and none of the respect from the others (nurses, techs, Janitors...lol) you work with. Hurrendous hours, can't complain or it gets worse...oh those were the days...lol

TAM:)

[Dancing David]

Do you think there's an under supply of physicians?

If so, what do you think are the causes and how may they be mitigated?

(I'm listening:))

Wow, in th US there are a number of issues.

First off dioctors are not seen as making as big an income as lawyers, financial officers and other professions. So there are not as many people who want to be doctors.
Second many qualified individuals choose to go into a specialty, so they are not GPs doing internal medicine. They are seeing a select group of pateints often for a higher salary and better hours.
Third, a lot of people don't want to be on call or have the work hours, or the caseload of a GP.
Fourth, there is not as much pretige in being a doctor in recent times.
Fifth, renumeration from thrid party payors. Mainly the government, Medicare and Medicaid, the burden of paper work is huge, the fees are capitated, and they are often 50% to 25% of what private insurance pays. Consequence, limited access for people on government insurance.
Sixth group practices are easier for doctors, they have less call time and smaller case loads. But they also are the most likely to refuse the government insured patients.
Seventh, the lack of general health insurance. creates a heavy burden on doctors who do see uninsured and underinsured patients.

Those are just some of the reasons why there are not enough doctors or there are not doctors who are willing to see government insured or no insurance patients.

[Ivor the Engineer]

Could someone please explain what an 80 hour week means for a physician in a hospital? How many of those hours are spent resting?

Compare the hours doctors are expected to work with airline pilots:

http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&sid=3efaad1b0a259d4e48f1150a34d1aa77&rgn=div5&view=text&node=14:2.0.1.3.10&idno=14#14:2.0.1.3.10.11.8.32

§ 91.1059 Flight time limitations and rest requirements: One or two pilot crews.

(a) No program manager may assign any flight crewmember, and no flight crewmember may accept an assignment, for flight time as a member of a one- or two-pilot crew if that crewmember's total flight time in all commercial flying will exceed—

(1) 500 hours in any calendar quarter;

(2) 800 hours in any two consecutive calendar quarters;

(3) 1,400 hours in any calendar year.

(b) Except as provided in paragraph (c) of this section, during any 24 consecutive hours the total flight time of the assigned flight, when added to any commercial flying by that flight crewmember, may not exceed—

(1) 8 hours for a flight crew consisting of one pilot; or

(2) 10 hours for a flight crew consisting of two pilots qualified under this subpart for the operation being conducted.

(c) No program manager may assign any flight crewmember, and no flight crewmember may accept an assignment, if that crewmember's flight time or duty period will exceed, or rest time will be less than—

|Normal duty|Extension of flight time
(1) Minimum Rest Immediately Before Duty|10 Hours|10 Hours.
(2) Duty Period Up to|14 Hours|Up to 14 Hours.
(3) Flight Time For 1 Pilot|Up to 8 Hours|Exceeding 8 Hours up to 9 Hours.
(4) Flight Time For 2 Pilots Up to|10 Hours|Exceeding 10 Hours up to 12 Hours.
(5) Minimum After Duty Rest|10 Hours|12 Hours.
(6) Minimum After Duty Rest Period for Multi-Time Zone Flights|14 Hours|18 Hours.

And here's a study indicating how physicians working long hours significantly affects their performance:

http://content.nejm.org/cgi/content/abstract/351/18/1838

Background Although sleep deprivation has been shown to impair neurobehavioral performance, few studies have measured its effects on medical errors.

Methods We conducted a prospective, randomized study comparing the rates of serious medical errors made by interns while they were working according to a traditional schedule with extended (24 hours or more) work shifts every other shift (an "every third night" call schedule) and while they were working according to an intervention schedule that eliminated extended work shifts and reduced the number of hours worked per week. Incidents were identified by means of a multidisciplinary, four-pronged approach that included direct, continuous observation. Two physicians who were unaware of the interns' schedule assignments independently rated each incident.

Results During a total of 2203 patient-days involving 634 admissions, interns made 35.9 percent more serious medical errors during the traditional schedule than during the intervention schedule (136.0 vs. 100.1 per 1000 patient-days, P<0.001), including 56.6 percent more nonintercepted serious errors (P<0.001). The total rate of serious errors on the critical care units was 22.0 percent higher during the traditional schedule than during the intervention schedule (193.2 vs. 158.4 per 1000 patient-days, P<0.001). Interns made 20.8 percent more serious medication errors during the traditional schedule than during the intervention schedule (99.7 vs. 82.5 per 1000 patient-days, P=0.03). Interns also made 5.6 times as many serious diagnostic errors during the traditional schedule as during the intervention schedule (18.6 vs. 3.3 per 1000 patient-days, P<0.001).

Conclusions Interns made substantially more serious medical errors when they worked frequent shifts of 24 hours or more than when they worked shorter shifts. Eliminating extended work shifts and reducing the number of hours interns work per week can reduce serious medical errors in the intensive care unit.

How many extra physicians would be required to bring their working week down to 48 hours?

[T.A.M.]

an 80h work week varies from physician to physician.

Surgeon:

Mon to Fri

Morning Rounds from 6-730AM
Surgery prep from 730-800AM (case review, etc..)
Surgery from 800AM-600PM
Evening Rounds from 600-700PM

13h day, x 5 days = 65h

Saturday - Morning Rounds 800-900AM
Saturday - Afternoon Paper Work 12PM-3PM
Sunday - off

= 4h

A total of 69h.

You add in a MINIMUM of "on call" once a week, and you easily have your other 11 hours

Now that is a busy surgeon, likely without residents or interns as support staff (a rural surgeon for instance).

city GP:

Mon-Fri

8AM-4PM = Clinic
4-5PM = Paperwork

9x5 = 45h

On Call 1 in 4, that is an additional 12h every 4 days, or 24h every 8 days.

so roughly 69-70h per week (though not all of that is straight work, but some bad nights on call it can be).

Rural GP:

Mon to Fri

7-8AM = Hospital Rounds
8AM-4PM = Clinic/Out Patients
4-5PM = Paper Work

10h/day x 5 days = 50h

1 in 3 on call = 24h every 6 days of extra call. On average you are awake and working half of this, so call it 12h work, 12h waiting to work.

Giving an average of 62-74h per week depending on how you look at it.

See how hard it is to quantify. I am sure there are things in the Surgeon (as I am not one) category I may be leaving out.

TAM:)

[Skeptic Ginger]

....

My main dog in this race is my abhorrence with the art of coercing doctors to do what vested-interest laced guidelines demand. I think good doctors should be truly free to follow their clinical judgment. It should not cut into their paycheck if they see that a certain patient needs a treatment approach that deviates from the usual guidelines.I think you misunderstand what guidelines are all about. You wouldn't follow them if they didn't fit the patient's needs. That's silly. You follow guidelines because it keeps your practice up to date with the best/latest research.

[Skeptic Ginger]

That's another good example.

I said: People with knowledge and experience have provided useful and interesting information.

You heard: People should be sub-ordinate to authority figures....And then there is the matter of some patients wanting that paternalistic provider. I often have patients defer decisions back to me when I try to give them the information to make their own informed choice.

[BillyJoe]

Originally Posted by kellyb http://forums.randi.org/helloworld2/buttons/viewpost.gif (http://forums.randi.org/showthread.php?p=4523645#post4523645)
My main dog in this race is my abhorrence with the art of coercing doctors to do what vested-interest laced guidelines demand. I think good doctors should be truly free to follow their clinical judgment. It should not cut into their paycheck if they see that a certain patient needs a treatment approach that deviates from the usual guidelines.
I think you misunderstand what guidelines are all about. You wouldn't follow them if they didn't fit the patient's needs. That's silly. You follow guidelines because it keeps your practice up to date with the best/latest research.

I already tried that response.
But it ran smack up against Ivor's favourite ploy, which is to post more links..
The other point is how does the clinical judgement of one doctor trump the guidelines produced by many doctors (before seeing whether or not applies to the particular patient belonging to the one)

BJ

[Ivor the Engineer]

And then there is the matter of some patients wanting that paternalistic provider. I often have patients defer decisions back to me when I try to give them the information to make their own informed choice.

To all the medical practitioners in the thread:

What fraction of your patients would you estimate want a paternalistic provider?

[paximperium]

To all the medical practitioners in the thread:

What fraction of your patients would you estimate want a paternalistic provider?
Don't know. Perhaps you'd like to do a study on that?

I've always founds it amusing to treat patients taking twenty meds, had ten surgeries done to them and they have no clue what medical problems they have or what the surgeries were for.

[BillyJoe]

If my father was and my mother is anything to go by, it is 100%
My son, however, knows everything there is to know about his thyroglossal cyst.

[Ivor the Engineer]

Thanks TAM for the breakdown of doctors' working hours.

I've been reading several opinion pieces, reports and presentations about how the European Working Time Directive (EWTD) is going to affect the training of physicians and continuity of patient care in the NHS. There appears to be three main types of response:

1) It will result in poorly trained, incompetent doctors and no continuity of care for patients. - Mainly in newspapers, though not uncommon among doctors, particularly those still in the early stages of their careers.

2) Work smarter not harder. - Seems to be a minority at the moment, but those hospitals that have started to implement new systems have found it is possible to organise both doctors' training and patient care in 48 hours. It is a BIG change from how things have been done in the past. E.g., doctors have to actually talk with each other and previously wasted training opportunities have to be utilised, as well as removing training which was of little value (i.e. not every consultant should be considered a useful teacher).

3) **** the EU.

In the long run I think it will result in both happier medical professionals and better patient care, though dragging the medical profession into the 21st century is going to be a struggle.

[Ivor the Engineer]

Don't know. Perhaps you'd like to do a study on that?

<snip>

That's why I was asking you.:)

[T.A.M.]

To all the medical practitioners in the thread:

What fraction of your patients would you estimate want a paternalistic provider?

Given I am relatively young (in practice for 8 years), my population base is very young. I find the younger the patient, the LESS likely they want a paternalistic MD, and the more likely they want a PARTNER in their medical care.

I would say about 30% of my practice wants a father figure physician.

TAM:)

[paximperium]

That's why I was asking you.:)
I'm ER doc so the variation is too wide to draw a firm conclusion.
Older, lower educated and poorer patients tend to want you to tell them what to do more than younger, educated and more affluent patients who wants to be more involved.

[Dancing David]

No, that's a "Blockhead". "Geek" was the industry term for what was typically billed as a "Wild Man"; and was the one who bit heads off of animals or ate large insects; and later came to include performers of actions which the viewers would find repugnant or horrific, but still entertaining.

Like Celine Dion or Rush Limbaugh?

[Ivor the Engineer]

<snip>

I would say about 30% of my practice wants a father figure physician.

TAM:)

Which patients do you prefer dealing with: those who want you to decide, or those who use you as a source of reliable information?

[Ivor the Engineer]

I'm ER doc so the variation is too wide to draw a firm conclusion.
Older, lower educated and poorer patients tend to want you to tell them what to do more than younger, educated and more affluent patients who wants to be more involved.

That makes sense. Which do you prefer?

[Professor Yaffle]

I would think most people lie somewhere other than the extemes of this continuum. I like my doctor to give me all the relevant information, but also for them to tell me what they think the best course of action would be.

[fls]

I would think most people lie somewhere other than the extemes of this continuum. I like my doctor to give me all the relevant information, but also for them to tell me what they think the best course of action would be.

I'm sorry, but how is recommending the "best course of action" paternalism?

Linda

[Ivor the Engineer]

I'm sorry, but how is recommending the "best course of action" paternalism?

Linda

I think it depends on the particular treatment and the prognosis. E.g., in the case of chronic or terminal diseases there are often more intangible factors involved in a person's decision as to what the best course of action is.

[Professor Yaffle]

I didn't say that it was.

To clarify: I have had doctors who have just doled out a prescription without telling me anything, and I have had doctors give me information whilst being very reluctant to offer their opinion on the best course of action - leaving me to make the decision entirely on my own. I don't like either of those approaches - but somewhere inbetween.

[fls]

I think it depends on the particular treatment and the prognosis. E.g., in the case of chronic or terminal diseases there are often more intangible factors involved in a person's decision as to what the best course of action is.

Why assume that can't be taken into account?

Linda

[fls]

I didn't say that it was.

To clarify: I have had doctors who have just doled out a prescription without telling me anything, and I have had doctors give me information whilst being very reluctant to offer their opinion on the best course of action - leaving me to make the decision entirely on my own. I don't like either of those approaches - but somewhere inbetween.

Paternalism isn't the act of making a recommendation or decision, but rather not volunteering information?

Linda

[Professor Yaffle]

Well if you are not given the information to be able to assess your choices, and the doctor just makes a decision, that is paternalism - right? Or am I misunderstanding the term?

[Rolfe]

It's funny how altmed proponents like to criticise doctors fro being paternalistic, while displaying the worst aspects of that paternalism themselves. Indeed, a lot of the attraction of altmed seems to be the authoritative, guru-like pronouncements of the therapists. Makes people feel that someone else is in control and handling their problem for them.

Rolfe.

[Professor Yaffle]

Having done a quick google to familiarise myself with the lingo... I dislike both strong paternalism and the independent choice/decision-making model and favour (in general) something closer to a model of qualified independence or "enhanced autonomy".

[Skwinty]

I always thought that libertarians were the proponents of paternalism as libertarians are the antonym of authoritareans.
I spent over an hour with a new GP today, who incidentally looks a lot like Linda, if the picture in Linda's avatar is indeed Linda. My experience with doctors are as follows:
1. I consult with a Doctor because I don't know what is wrong with me.
I do know however, that there is something wrong with me.
2. The Doctor can do nothing if I sit there and say nothing, so I must participate in the process.
3. Once the Doctor has made a diagnosis, it is not normally a long list of possibilities, and the prescribed treatment is not normally a long list of possibilities.
4 The Doctor would normally say this is your condition and this is the prescribed treatment for your condition.

If the Doctor were to say, this is your condition and here is a list of alternate treatments, please choose one, I would not be impressed, although if the Doctor said this is the treatment I am prescribing and it involved something that I was wary of, I would ask for possible alternatives.
To classify Doctors as paternalistic implies that the patient is passive or weak and unable to participate in the diagnosis.

[Professor Yaffle]

I always thought that libertarians were the proponents of paternalism as libertarians are the antonym of authoritareans.
I spent over an hour with a new GP today, who incidentally looks a lot like Linda, if the picture in Linda's avatar is indeed Linda. My experience with doctors are as follows:
1. I consult with a Doctor because I don't know what is wrong with me.
I do know however, that there is something wrong with me.
2. The Doctor can do nothing if I sit there and say nothing, so I must participate in the process.
3. Once the Doctor has made a diagnosis, it is not normally a long list of possibilities, and the prescribed treatment is not normally a long list of possibilities.
4 The Doctor would normally say this is your condition and this is the prescribed treatment for your condition.

If the Doctor were to say, this is your condition and here is a list of alternate treatments, please choose one, I would not be impressed, although if the Doctor said this is the treatment I am prescribing and it involved something that I was wary of, I would ask for possible alternatives.
To classify Doctors as paternalistic implies that the patient is passive or weak and unable to participate in the diagnosis.

Its not just about the diagnosis though. Once diagnosed there are often many different avenues with regards to treatment. These treatments (or decisions not to treat) can have different strengths and weaknesses which will have different priorities for different patients.

For example if I am in the early stages of pregnancy and suffering symptoms of depression (and previous bouts of depression have only been affected by an antidepressant for which the effects in pregnancy are unknown), I don't want the doctor to independently make the decision about how I should be treated, and neither do I want the doctor to simply say "untreated you might get worse, but the anti-depressant could possibly harm the foetus - come back to me when you have made your decision".

[Skwinty]

Its not just about the diagnosis though. Once diagnosed there are often many different avenues with regards to treatment. These treatments (or decisions not to treat) can have different strengths and weaknesses which will have different priorities for different patients.


Sure, if the presciption says you need a heart transplant and you have no medical aid or finances, then ultimately the doctor says you are going to die. What other choice do you have, other than an alternative treatment like homeopathy, crystal healing, faith healing or chiropractic.

[Ivor the Engineer]

Why assume that can't be taken into account?

Linda

The "best course of action" in the patient's opinion may be different to her physician's. Many treatments are not cures and a trade-off between suppression of symptoms and unpleasant side-effects has to be made.

E.g., a terminal cancer patient can extend her life with chemotherapy, but the quality of the extended lifespan may be lower.

In general the only person who can decide what trade-off is best is the patient.

[Professor Yaffle]

Sure, if the presciption says you need a heart transplant and you have no medical aid or finances, then ultimately the doctor says you are going to die. What other choice do you have, other than an alternative treatment like homeopathy, crystal healing, faith healing or chiropractic.

Well of course there are situations where there are effectively no choices. But many situations aren't like that.

[Professor Yaffle]

The "best course of action" in the patient's opinion may be different to her physician's. Many treatments are not cures and a trade-off between suppression of symptoms and unpleasant side-effects has to be made.

E.g., a terminal cancer patient can extend her life with chemotherapy, but the quality of the extended lifespan may be lower.

In general the only person who can decide what trade-off is best is the patient.

http://www.hospicefoundation.org/teleconference/books/lwg2005/sarah.pdf

[Skwinty]

Well of course there are situations where there are effectively no choices. But many situations aren't like that.

My point is, discuss your treatment issues with the Doctor and the Doctor should then offer alternative medication which may or may not be as effective, to suit your requirement. I don't think paternalism enters the equation.

[fls]

Well if you are not given the information to be able to assess your choices, and the doctor just makes a decision, that is paternalism - right? Or am I misunderstanding the term?

It's not the way people are using the term. The way people are using the term is really "do I have the illusion of making an informed decision or not?"

You don't like being given a prescription without explanation, but a recommendation as to the "best course of action" is okay. If the doctor had explained the medications that could be used and then recommended a particular drug, then you probably would have been okay with the prescription. She/he could even have given you a choice between a couple of different drugs. But pretending that in the course of five minutes you have been given enough information to make a truly informed decision is only an illusion.

The reality seems to matter very little. What seems to matter is the illusion of having the desired degree of information and/or autonomy.

Linda

[Professor Yaffle]

My point is, discuss your treatment issues with the Doctor and the Doctor should then offer alternative medication which may or may not be as effective, to suit your requirement. I don't think paternalism enters the equation.

Unless the doctor happens to be very paternalistic ... And I have encountered some like that - they think their priorities for treatment are "correct" and therefore if the patients disagree with them, their priorities are "wrong".

[Ivor the Engineer]

<snip>

She/he could even have given you a choice between a couple of different drugs. But pretending that in the course of five minutes you have been given enough information to make a truly informed decision is only an illusion.

For more complicated conditions doesn't the illusion of an informed decision apply equally to the physician? I.e. a physician has to appear to be informed about what is the best course of action, yet if you asked 3 different physicians what the best course of action was you would likely get three different answers.

The reality seems to matter very little. What seems to matter is the illusion of having the desired degree of information and/or autonomy.

Linda

That depends on how much time is available to research and consider the alternatives.

[T.A.M.]

Which patients do you prefer dealing with: those who want you to decide, or those who use you as a source of reliable information?

It depends on my mood...lol, j/k!

If I am in a hurry sometimes, it is easier to deal with patients who take what you say as gospel, but actually this is not my preferred practice.

I actually like patients that use the internet, but then come to me to discuss their problem, and what their research has said.

TAM:)

[fls]

The "best course of action" in the patient's opinion may be different to her physician's. Many treatments are not cures and a trade-off between suppression of symptoms and unpleasant side-effects has to be made.

E.g., a terminal cancer patient can extend her life with chemotherapy, but the quality of the extended lifespan may be lower.

In general the only person who can decide what trade-off is best is the patient.

But can we really consider that patient adequately informed about what that trade-off will be, what that experience will be like, by spending 5 minutes listing off side-effects? There is a strong public perception of 'chemotherapy' that tends to inform people's decision-making beyond what is warranted. What makes it okay for a doctor to abdicate their responsibility to a patient by not taking into account that their (the doctor's) experience about chemotherapy is far better informed than the patient's? Should we simply ignore what we have learned about the biases that are brought into decision-making by pretending that "informed consent" gives us plausible deniability?

Linda

[fls]

For more complicated conditions doesn't the illusion of an informed decision apply equally to the physician? I.e. a physician has to appear to be informed about what is the best course of action, yet if you asked 3 different physicians what the best course of action was you would likely get three different answers.

So what's the difference between these two scenarios...

"Here are three roughly equivalent courses of action. Pick one."

"Here are three roughly equivalent courses of action. This is the one I've picked."

Linda

[paximperium]

That makes sense. Which do you prefer?
Neither.
Ignorant patients who decide to dump all the decision on you are not easy to deal with and overly educated/involved patients who second guess everything you recommend are just as annoying. I prefer someone who can make an informed decision and yet will actually listen.

[Ivor the Engineer]

But can we really consider that patient adequately informed about what that trade-off will be, what that experience will be like, by spending 5 minutes listing off side-effects?

No.

There is a strong public perception of 'chemotherapy' that tends to inform people's decision-making beyond what is warranted. What makes it okay for a doctor to abdicate their responsibility to a patient by not taking into account that their (the doctor's) experience about chemotherapy is far better informed than the patient's?

Nothing. The doctor should give the patient a realistic estimate of what the treatment(s) on offer will achieve, including no treatment.

Should we simply ignore what we have learned about the biases that are brought into decision-making by pretending that "informed consent" gives us plausible deniability?

Linda

No. A patient should be given reliable information. This is probably best done in the format of a conversation so the doctor can provide relevant information based on the patient's concerns and at an appropriate pace to allow the patient to make an informed decision.

[Ivor the Engineer]

Neither.
Ignorant patients who decide to dump all the decision on you are not easy to deal with and overly educated/involved patients who second guess everything you recommend are just as annoying. I prefer someone who can make an informed decision and yet will actually listen.

So a patient who came along with his home-made holster ECG and pulse oximeter would probably be your worst nightmare?:o

[paximperium]

So a patient who came along with his home-made holster ECG and pulse oximeter would probably be your worst nightmare?:o
Nah. A well educated computer programmer who Googled his kid's fever on the net and adamantly believes it is a meningitis despite your best explanation that it is nothing more than the common bug AND then demanding that you call the chairman of pediatrics is. I prefer the drug seeking, drunks any day.

[Ivor the Engineer]

So what's the difference between these two scenarios...

"Here are three roughly equivalent courses of action. Pick one."

"Here are three roughly equivalent courses of action. This is the one I've picked."

Linda

If the doctor knows everything that is relevant for the patient when making her choice of treatment, then they are both equivalent. If the doctor is filling in for missing information with her own preferences and beliefs, then the first one has the potential to result in superior treatment.

[Mouthfire]

If the doctor knows everything that is relevant for the patient when making her choice of treatment, then they are both equivalent. If the doctor is filling in for missing information with her own preferences and beliefs, then the first one has the potential to result in superior treatment.

Actually, the best scenario (IMO) is that the doctor says:

Here are the three possible treatments for this condition, and the pros and cons of each. You are free to choose any of the treatments, but this is the treatment I would choose, if it were me or my family member (fill in blanks with reasons why).

This approach preserves the patient's autonomy, but still gives the patient the benefit of the physician's experience and training. I believe that this is the approach that most physicians use nowadays.

[fls]

No. A patient should be given reliable information. This is probably best done in the format of a conversation so the doctor can provide relevant information based on the patient's concerns and at an appropriate pace to allow the patient to make an informed decision.

Ah, while 5 minutes is inadequate, a 10 minute listing of the side-effects is an adequate substitute for 10 years of training and experience.

Linda

[Mashuna]

<snip> We took our complaints to the department of health - the work we were performing was far in excess of those who were paid the same amount and there were serious and unsustainable staff shortages due to inequalities in renumeration - but they wouldn't even come to the table and talk to us since, as far as they could tell, the services paid for were commensurate with what was needed. So we simply informed them that if what they were paying for was adequate, we were going to simply stop performing those services they had deemed unnecessary by virtue of making them not worthy of renumeration. This meant that we would no longer free up hospital beds by managing certain patients as outpatients (which required visits in excess of the once per week we could charge for), we no longer transferred patients from surgical wards to medical wards if their care became complicated (as renumeration was based on length on time in hospital regardless of whether the length was due to complications vs. babysitting for rehab or nursing home placement), we no longer accepted patients for admission who had already been seen by a specialist (the attending physician would not receive any renumeration for their complete history/physical/evaluation), etc.
<snip>

[irritating pedant mode] Sorry to nitpick, but it's remuneration. [/ipm]

[Ivor the Engineer]

Ah, while 5 minutes is inadequate, a 10 minute listing of the side-effects is an adequate substitute for 10 years of training and experience.

Linda

No, the problem is how to integrate the two sources of information (i.e. the patient's concerns and preferences and the doctor's knowledge and experience) to come to the optimal decision for the patient.

Unless among the many skills doctors learn during their 10 years of training includes mind reading, I see no way of reliably reaching good decisions without substantial input from the patient.

Please note I'm still only considering long-term chronic and terminal conditions, not those treated with "take this and come back and see me in a week if the rash hasn't cleared up.", or emergency situations where there is no time to debate the pros and cons of various treatment options.

[Professor Yaffle]

Neither.
Ignorant patients who decide to dump all the decision on you are not easy to deal with and overly educated/involved patients who second guess everything you recommend are just as annoying. I prefer someone who can make an informed decision and yet will actually listen.

But according to Linda, they are not making an informed decision, they just *think* they are.

[fls]

If the doctor is filling in for missing information...

Like what?

Linda

[Professor Yaffle]

But can we really consider that patient adequately informed about what that trade-off will be, what that experience will be like, by spending 5 minutes listing off side-effects? There is a strong public perception of 'chemotherapy' that tends to inform people's decision-making beyond what is warranted. What makes it okay for a doctor to abdicate their responsibility to a patient by not taking into account that their (the doctor's) experience about chemotherapy is far better informed than the patient's? Should we simply ignore what we have learned about the biases that are brought into decision-making by pretending that "informed consent" gives us plausible deniability?

Linda

Nobody is saying that the doctor should not give their informed experience as input - they should just not expect that the things they think are important and relevant are necessarily so to that patient. Just as the patient can't gain a doctor's level of experience in five minutes, so a doctor cannot understand a patient's priorities in 5 minutes. that's why there has to be a conversation and an understanding reached.

[fls]

[irritating pedant mode] Sorry to nitpick, but it's remuneration. [/ipm]

Yeah, I have a couple of words that I always say backwards (another e.g. is signal which I say as "single"). I suppose I should use spell-check.

Linda

[fls]

No, the problem is how to integrate the two sources of information (i.e. the patient's concerns and preferences and the doctor's knowledge and experience) to come to the optimal decision for the patient.

Unless among the many skills doctors learn during their 10 years of training includes mind reading, I see no way of reliably reaching good decisions without substantial input from the patient.

I'm talking about taking patients concerns and preferences into account (by discussion, not by mind-reading).

Linda

[fls]

Nobody is saying that the doctor should not give their informed experience as input - they should just not expect that the things they think are important and relevant are necessarily so to that patient.

Who is saying otherwise?

Just as the patient can't gain a doctor's level of experience in five minutes, so a doctor cannot understand a patient's priorities in 5 minutes. that's why there has to be a conversation and an understanding reached.

What sort of priorities are you talking about that are too complicated for another person to understand?

Linda

[Professor Yaffle]

Maybe I am just relying on my own experience a little too much here, but I HAVE experienced doctors who have basically ignored my experiences and priorities and just gone on and prescribed what they wanted to prescribe. Thats the attitude I don't like and what I am thinking of when I think of paternalism.

[Ivor the Engineer]

Like what?

Linda

Perhaps the doctor has no problem swallowing pills herself and would not consider the different shapes, sizes and coatings on the otherwise equivelent options to be of particular relevance unless made aware by her patient that one of the other alternatives would in fact be preferable.

[Ivor the Engineer]

I'm talking about taking patients concerns and preferences into account (by discussion, not by mind-reading).

Linda

Well then I don't really see how you are disagreeing with what I have said. What do you find unreasonable/impractical/insulting in my previous posts?

[Professor Yaffle]

I think the only difference is that Linda thinks that after listening to the patient's concerns, the doctor should take the decision, as opposed to the doctor helping the patient to make the decision.

(I think - I find Linda a little opaque at times)

[Skeptic Ginger]

I think the only difference is that Linda thinks that after listening to the patient's concerns, the doctor should take the decision, as opposed to the doctor helping the patient to make the decision.

(I think - I find Linda a little opaque at times)But sometimes there is only one option and other times there are more than one. You don't tell a patient you will prescribe antibiotics, pain meds or order surgery that isn't called for just because they want them. OTOH, you do give a patient options when they are equivocal or have a different risk/benefit balance that patient preference is the deciding factor in.

Providers have different levels of paternalism, but there is no black and white, either/or provider as kellyb seems to believe. My impression is that some people resent not being able to find a provider to reinforce their woo beliefs. Some of those people also project the problem as being the provider's desire for control, rather than the fact the person with the unsupportable belief could possibly be wrong.

In rare cases, a provider and patient may indeed just have an issue of power. Certainly I run into this on a rare occasion when my knowledge sets a provider off on the wrong foot. I needed a surgical repair once and the provider I saw insisted there was a different etiology of the problem. She did an inadequate work up and insisted I was wrong about the etiology. Since it was something obvious to me, I went to her office partner who correctly diagnosed the problem, did the repair and I was fine. Again. this is a rare situation.

In most cases, however, patients come in with all sorts of incorrect conclusions about what they have. Not all of them are convinced they are wrong. Then you get resentment (again rare). A patient might believe they are suffering because of the unequal power in the relationship. This is what appears to me to bother kellyb. Ivor is also bothered but it appears to me his gripe is over the unequal power her perceives between himself and the NHS to which he perceives the providers sometimes to be part of the system. I could be wrong about both these assessments. I don't claim to know either of these two well enough to say for certain, but that is the impression I get in the multiple discussions we have on the board.

[Ivor the Engineer]

From Kumar and Clark: Clinical Medicine 6th Ed.

Box 1.9 Qualities leading to good relationships

Primary care physicians (who have never been sued):

* orientated patients to the process of the visit, e.g. introductory comments: 'We are going to do this first and then go on to that'
* used facilitative comments
* asked patients their opinion
* used active listening
* used humour and laughter
* conducted slightly longer visits (18 versus 15 minutes).

[Skeptic Ginger]

From Kumar and Clark: Clinical Medicine 6th Ed.And just what % of providers do you think do not ask for patient's opinions or use active listening?


Because that is medical history taking 101.

[Professor Yaffle]

And just what % of providers do you think do not ask for patient's opinions or use active listening?

Most do - but there is a significant percentage who don't seem to (I can provide examples if you like...)

[Skeptic Ginger]

Maybe I am just relying on my own experience a little too much here, but I HAVE experienced doctors who have basically ignored my experiences and priorities and just gone on and prescribed what they wanted to prescribe. Thats the attitude I don't like and what I am thinking of when I think of paternalism.It can happen, but I contend it is very rare. Selective memory would likely mean you remember those instances more than the unremarkable doctor visits.

[Skeptic Ginger]

Most do - but there is a significant percentage who don't seem to (I can provide examples if you like...)No need, I gave an example of my own.

It's Ivor I was asking the question of, however.

[Professor Yaffle]

For centuries, physicians have been allowed to interfere and overrule patient’s preferences with the aim of securing patient benefit or preventing harm. With the radical rise in emphasis on individual control and freedom, medical paternalism no longer receives unquestioned acceptance by society as the dominant mode for decision-making in health care. But neither is a decision-making approach based on absolute patient autonomy a satisfactory one. A more ethical and effective approach is to enhance a patient’s autonomy by advocating a medical beneficence that incorporates patients’ values and perspectives. This can be achieved through a model for shared decision making, acknowledging that though the final choices reside ultimately in patients, only through physician beneficence can the patient be empowered to make meaningful decisions that serve them best. For such a model to function effectively, the restoration of trust in doctor-patient relationship and the adoption of patient-centred communication are both crucial.

http://www.sma.org.sg/smj/4303/4303sf3.pdf

[Professor Yaffle]

When I was in hospital having my first baby, I encountered several doctors. Of those I was able to form an opinion about (I'll exclude the doctor in charge of getting baby out safely as there wasn't much time for a chat), not one of them listened to me or took into account anything I said to them. I think the old style paternal attitude is still very much in evidence. As I say, it is a minority, but its definitely not a vanishingly small one.

[T.A.M.]

History taking is one of the "art" forms of medicine. Yes I know anyone can ask questions, but it is so much more than that.

You have a finite time period to get your information. I agree that open ended questions work, and they garnish a fair bit of info, and they are one of the pieces to the puzzle.

However, when working on a time line, I find Selective questioning of relevant issues much better.

You start off broad, and work your way into the narrow.

Abdominal pain? How long? What part of your abdomen? What makes it worse? What relieves it? Other symptoms such as Nausea/Vomitting, Change to your bowel habits, fever, etc?

Ah, so it has been there for 3-4 weeks, on the right upper side, and greasy food makes it much worse?

Physical Exam reveal distinct RUQ tenderness.

CBC, LFTs, Amylase, and an Abd u/s for starters...will see from there.

an easy example I know, but you get the picture?

Now the above is more of an ER Doc history.

In the clinic, developing a doctor patient relationship, you use more open ended questions, ask them what they think it is, what they were hoping would happen when they came to see you (did they want medicine, reassurance, a sounding board, all of the above), etc...

I find different methods for different settings works best for me.

TAM:)

[Ivor the Engineer]

And just what % of providers do you think do not ask for patient's opinions or use active listening?

<snip>

At least one it seems:

Ivor is also bothered but it appears to me his gripe is over the unequal power her perceives between himself and the NHS to which he perceives the providers sometimes to be part of the system. I could be wrong about both these assessments. I don't claim to know either of these two well enough to say for certain, but that is the impression I get in the multiple discussions we have on the board.

:boggled:

IIRC, the average time between a patient starting to explain why they are seeing their doctor and the doctor interrupting them is 18 seconds, and less than a quarter of patients complete their opening statement.

Here we go:

http://books.google.co.uk/books?id=Q3M2k7DHgVIC&pg=PA46&lpg=PA46&dq=doctor+interrupting+patient+18+seconds&source=bl&ots=ZZH3G4L1m1&sig=uZJS2XBis2gj7E6YS2wRl53wieY&hl=en&ei=OJbCSfmMHNSujAeJoPyGCw&sa=X&oi=book_result&resnum=1&ct=result

[Professor Yaffle]

How about an anaesthetist who, when you report the classic symptoms of post dural puncture headache to a midwife (who recognises them as such) doesn't even bother to come to speak to you, but just sends a message back saying she is absolutely sure that the epidural was fine.

[Ivor the Engineer]

How about an anaesthetist who, when you report the classic symptoms of post dural puncture to a midwife (who recognises them as such) doesn't even bother to come to speak to you, but just sends a message back saying she is absolutely sure that the epidural was fine.

Now, now. Doctor knows best.:)

[Professor Yaffle]

Now, now. Doctor knows best.:)

Ha, ha! You should have seen her grudging grovelling when she had to perform the blood patch to correct the problem. She couldn't even look me in the eye.

[Skeptic Ginger]

At least one it seems:



:boggled:

IIRC, the average time between a patient starting to explain why they are seeing their doctor and the doctor interrupting them is 18 seconds, and less than a quarter of patients complete their opening statement.

Here we go:

http://books.google.co.uk/books?id=Q3M2k7DHgVIC&pg=PA46&lpg=PA46&dq=doctor+interrupting+patient+18+seconds&source=bl&ots=ZZH3G4L1m1&sig=uZJS2XBis2gj7E6YS2wRl53wieY&hl=en&ei=OJbCSfmMHNSujAeJoPyGCw&sa=X&oi=book_result&resnum=1&ct=resultEncouraging a patient to provide relevant information as opposed to irrelevant story telling has zero to do with getting the patient's opinions.

This is a perfect example of your inability to connect the dots. You don't have the skills to get a patient history so you draw false conclusions about a description of one.

[Professor Yaffle]

Encouraging a patient to provide relevant information as opposed to irrelevant story telling has zero to do with getting the patient's opinions.

This is a perfect example of your inability to connect the dots. You don't have the skills to get a patient history so you draw false conclusions about a description of one.

Its seemed to me that Ivor was drawing similar conclusions to the author of the book. Was the author also drawing false conclusions? Did you actually read anything of the link he provided?

[fls]

Maybe I am just relying on my own experience a little too much here, but I HAVE experienced doctors who have basically ignored my experiences and priorities and just gone on and prescribed what they wanted to prescribe. Thats the attitude I don't like and what I am thinking of when I think of paternalism.

I understand that, and of course nobody likes it. Hence the need for the illusion.

Linda

[fls]

Perhaps the doctor has no problem swallowing pills herself and would not consider the different shapes, sizes and coatings on the otherwise equivelent options to be of particular relevance unless made aware by her patient that one of the other alternatives would in fact be preferable.

Wouldn't it be simpler to just tell the doctor that?

Linda

[fls]

Well then I don't really see how you are disagreeing with what I have said. What do you find unreasonable/impractical/insulting in my previous posts?

Huh?

[fls]

I think the only difference is that Linda thinks that after listening to the patient's concerns, the doctor should take the decision, as opposed to the doctor helping the patient to make the decision.

I think decisions should be fully informed and that it's unrealistic to expect patients to be fully informed.

Linda

[Ivor the Engineer]

Wouldn't it be simpler to just tell the doctor that?

Linda

Yes. How would the patient manage to do that if the doctor had already chosen the medication?

"Here are three roughly equivalent courses of action. This is the one I've picked."

[Professor Yaffle]

I understand that, and of course nobody likes it. Hence the need for the illusion.

Linda

There is no need for any illusion IMO. If a patient and doctor can come to an *agreement* as to what is the best course of action, there is no need to quibble about who actually made the decision. I have seen some good doctors too you know.

[Professor Yaffle]

Wouldn't it be simpler to just tell the doctor that?

Linda

Too late, you are usually in the corridor by then.

[Ivor the Engineer]

Too late, you are usually in the corridor by then.

What a coincidence, you've been treated by that doctor too.:)

[fls]

Yes. How would the patient manage to do that if the doctor had already chosen the medication?

"Here are three roughly equivalent courses of action. This is the one I've picked."

That's a good example, then. Maybe the three choices don't include the best choice if the pill type is important, unless you mention it beforehand.

But that's an easy way to make it look like the patient is making an informed decision - letting them pick the prettiest pill. Yeah, we're partners.

Linda

[Professor Yaffle]

More seriously, many GPs will print out a prescription before they even tell you what they are giving you. This then makes it seem like an imposition and a nuisance to say anything that might make them reconsider.

[Ivor the Engineer]

I think decisions should be fully informed and that it's unrealistic to expect patients to be fully informed.

Linda

Why? So long as patients have:

a) been made aware of the different options for treatment

b) and the risks and likely outcomes of each of the treatments

c) had their concerns and preferences taken into account

they are making a fully informed decision, unless their doctor is misleading them, either through ignorance or self-interest.

What other knowledge do patients need to be fully informed?

[fls]

There is no need for any illusion IMO. If a patient and doctor can come to an *agreement* as to what is the best course of action, there is no need to quibble about who actually made the decision.

Exactly.

Linda

[Professor Yaffle]

That's a good example, then. Maybe the three choices don't include the best choice if the pill type is important, unless you mention it beforehand.

But that's an easy way to make it look like the patient is making an informed decision - letting them pick the prettiest pill. Yeah, we're partners.

Linda

Yes Linda, being patronising is an extremely good way to get the patient to shut up and stop bothering you about what you consider to be minor things.

Some doctors have it down to a fine art.

[fls]

More seriously, many GPs will print out a prescription before they even tell you what they are giving you. This then makes it seem like an imposition and a nuisance to say anything that might make them reconsider.

Oh, I know. I've been there as well.

Linda

[Ivor the Engineer]

That's a good example, then. Maybe the three choices don't include the best choice if the pill type is important, unless you mention it beforehand.

But that's an easy way to make it look like the patient is making an informed decision - letting them pick the prettiest pill. Yeah, we're partners.

Linda

"Yeah, the doc gave me these to take, but they're just so hard to swallow. I couldn't face having to take the full course."

Obviously the above situation can be mitigated by the doctor being even more paternalistic and making it absolutely clear how important it is to finish the course.

[T.A.M.]

"Yeah, the doc gave me these to take, but they're just so hard to swallow. I couldn't face having to take the full course."

Obviously the above situation can be mitigated by the doctor being even more paternalistic and making it absolutely clear how important it is to finish the course.

yes, or he could not say that, and allow the patient to stop the course, and then return with their infection still present, garnishing money for another visit, and give them a different type of antibiotic.

Not every suggestion is meant to be paternalistic.

TAM:)

[fls]

Yes Linda, being patronising is an extremely good way to get the patient to shut up and stop bothering you about what you consider to be minor things.

Some doctors have it down to a fine art.

See? I point out that the asymmetry in knowledge and experience is not amenable to 5 (or 10 or 15) minutes of discussion, and it is necessary to berate* me. It's like we've turned beneficence into a dirty little secret that nobody's supposed to reveal.

Linda

*a gross exaggeration ;)

[Ivor the Engineer]

<snip>

it is necessary to berate* me.

<snip>

No, but it is sufficient.:)

[Ivor the Engineer]

<snip>

It's like we've turned beneficence into a dirty little secret that nobody's supposed to reveal.

Linda

How does the physician know what is "good" for the patient?

I.e. the physician only has an estimate of the patient's utility function, and a biased one at that. Not everyone weights the 5 D's the same as doctors do.

ETA: To give an example: if I ever need even minor surgery on my eyes, I will have to have a general anesthetic, even though a local may be safer.

[Professor Yaffle]

See? I point out that the asymmetry in knowledge and experience is not amenable to 5 (or 10 or 15) minutes of discussion, and it is necessary to berate* me. It's like we've turned beneficence into a dirty little secret that nobody's supposed to reveal.

Linda

*a gross exaggeration ;)

Come on Linda - you have a very obvious sarcastic streak. Some doctors can turn that off when they are with patients (I have no idea whether you are one of them), but others seemingly cannot keep their sarcastic/arrogant/condescending/patronising personalities out of the surgery. This in turn makes many patients reluctant to bring up anything that doesn't fit in with what the doctor already has planned.

To me the problem is not about *who* makes the decision, as long as the patient has been listened to and their views taken into account. The main problem, for me, is that many doctors create an atmosphere wherein patients find it very difficult to provide this sort of input. It's not enough for a doctor to say "well they didn't tell me about their problem with x" when they have created a situation in which it is very difficult for the patient to air their concerns. See Ivor's link to the book about communication skills.

[T.A.M.]

how does an engineer know "what type" of steel is best to build that skyscraper from?

I mean maybe legos would be more what I prefer, or cork. Maybe I don't want my skyscraper built from Steel or Concrete.

TAM;)

[Skeptic Ginger]

See? I point out that the asymmetry in knowledge and experience is not amenable to 5 (or 10 or 15) minutes of discussion, and it is necessary to berate* me. It's like we've turned beneficence into a dirty little secret that nobody's supposed to reveal.

Linda

*a gross exaggeration ;)And here I was just going to say, go to med school if you don't like it.

[fls]

"Yeah, the doc gave me these to take, but they're just so hard to swallow. I couldn't face having to take the full course."

Obviously the above situation can be mitigated by the doctor being even more paternalistic and making it absolutely clear how important it is to finish the course.

You will notice that all of your (you and Professor Yaffle) examples of Paternalism Is Bad are about decisions made without all the relevant information. I'm suggesting that we should consider decisions made with the relevant information, and that we should be realistic about how that can be accomplished.

Linda

[Skeptic Ginger]

OK, for those of you who don't like the fact the health care provider believes they have more health care knowledge than most of their patients, are you seriously suggesting the patient knows as much as the provider? Why bother going to anyone for health care then? Just provide your own.

[Professor Yaffle]

Exactly.

Linda

But of course if the patient and doctor agree on the best course of action, then the decision has *really* been made by the doctor.

It's ok, we know how fragile your egos are.

;)

[Rolfe]

Wouldn't it be simpler to just tell the doctor that?


Sometimes patients make it unnecessarily complicated.

Over twenty years ago my mother telephoned me before her scheduled urology checkup. She'd previously been told that one of her kidneys wasn't functioning and might need to be removed. She said to me, "What should I tell the surgeon when he asks how I am?"

I asked he what she meant. She said, well, he said I might have to have that kidney out, and I thought if that was the case it might be better to get it done before I turn seventy. So I thought, if I just say, I'm fine, he might just say OK, come back in a year for another checkup, and time's going on. But if I say I'm not feeling so good, what will happen? I don't know what to say.

I took a deep breath, counted to ten, and suggested she say to the surgeon exactly what she'd just said to me. She asked me what I meant. I told her to tell the surgeon how she felt, truthfully, then say that she was wondering, if the nephrectomy was going to be necessary, might it not be better to do it before she's 70?

She said she hadn't thought of that.

:hb:

She had the kidney out a couple of months later.

Rolfe.

[Ivor the Engineer]

how does an engineer know "what type" of steel is best to build that skyscraper from?

I mean maybe legos would be more what I prefer, or cork. Maybe I don't want my skyscraper built from Steel or Concrete.

TAM;)

But there is probably a selection of steels with different characteristics, which could be relayed in terms even a doctor could understand and use to make an informed choice.

This is what the geek was talking about; you probably don't have much idea how a cell phone works, but you can make an informed choice about what phone suits your needs.

[Professor Yaffle]

You will notice that all of your (you and Professor Yaffle) examples of Paternalism Is Bad are about decisions made without all the relevant information. I'm suggesting that we should consider decisions made with the relevant information, and that we should be realistic about how that can be accomplished.

Linda

Actually my example of the epidural problem was one where the doctor had been given the relevant information but refused to accept it because she thought the epidural had gone ok. I have a couple of other examples like that too. If some doctors cannot take into account something very obvious, its pretty likely that they will run roughshod over patient preferences in less obvious situations too.

[fls]

How does the physician know what is "good" for the patient?

I.e. the physician only has an estimate of the patient's utility function, and a biased one at that. Not everyone weights the 5 D's the same as doctors do.

ETA: To give an example: if I ever need even minor surgery on my eyes, I will have to have a general anesthetic, even though a local may be safer.

I'm sorry, I still don't understand why that wouldn't be part of the discussion.

Linda

[Skeptic Ginger]

Its seemed to me that Ivor was drawing similar conclusions to the author of the book. Was the author also drawing false conclusions? Did you actually read anything of the link he provided?Are you claiming you read this book? How do you know what the authors conclusions were?

It's a textbook for improving one's provider-patient communication skills. The authors' goals are to provide information which improves these skills. Where in the book does it give an overall condemnation of the current medical profession?

I could write a similar book sharing my expertise in infectious disease with other providers. That doesn't mean I'd be concluding every provider who found the book useful was incompetent in the field.

An assessment of where improvement might be needed is not a condemnation of the practices of the people one feels would benefit from the book. And not only that, my medical/nursing education included many hours of patient provider communication skills, as would any medical school curriculum.

[Ivor the Engineer]

You will notice that all of your (you and Professor Yaffle) examples of Paternalism Is Bad are about decisions made without all the relevant information. I'm suggesting that we should consider decisions made with the relevant information, and that we should be realistic about how that can be accomplished.

Linda

Most of the people I work with don't have the knowledge to perform the job I do (Digital Logic Design and Signal Processing), yet we manage (in a very informal way compared to many places I've worked) to decide what functionality they want me to provide them with.

I don't see a huge difference between what doctors do and what engineers do.

[paximperium]

But of course if the patient and doctor agree on the best course of action, then the decision has *really* been made by the doctor.

It's ok, we know how fragile your egos are.

;)
I don't have any have illusions here. Manipulation and redirection seems to work very well for me. I manipulate and redirect conversations so that patient's do what I would prefer them to do. I give them the information they need and I maximize or minimize certain bits so that they believe they are making an informed decision. I use it a whole lot more the more I believe the patients need it.

"Mr Soandso, we really need to do this lumbar puncture. We cannot be sure you don't have meningitis unless we do this procedure. Meningitis can cause death, brain damage and paralysis. I do this procedure all the time so it isn't dangerous. It may hurt a little bit."

"Mr. Soandso, I don't believe you need a lumbar puncture. Although the risk is rather low we cannot be sure you don't have meningitis unless we do this procedure. Meningitis can cause death, brain damage and paralysis.A lumbar puncture does hurt a bit but it is safe."

[fls]

Come on Linda - you have a very obvious sarcastic streak.

I am rarely sarcastic. Even less so in real life.

Some doctors can turn that off when they are with patients (I have no idea whether you are one of them), but others seemingly cannot keep their sarcastic/arrogant/condescending/patronising personalities out of the surgery.

Are you saying that this is a necessary component of paternalism, or do you think it is possible to consider them separately? What if we focussed on the beneficence component?

To me the problem is not about *who* makes the decision, as long as the patient has been listened to and their views taken into account. The main problem, for me, is that many doctors create an atmosphere wherein patients find it very difficult to provide this sort of input. It's not enough for a doctor to say "well they didn't tell me about their problem with x" when they have created a situation in which it is very difficult for the patient to air their concerns. See Ivor's link to the book about communication skills.

I agree that it's often important to have a doctor that listens to you. I just think that it's an issue that can be considered separately from paternalism or beneficence.

Linda

[Professor Yaffle]

Are you claiming you read this book? How do you know what the authors conclusions were?

It's a textbook for improving one's provider-patient communication skills. The authors' goals are to provide information which improves these skills. Where in the book does it give an overall condemnation of the current medical profession?

I could write a similar book sharing my expertise in infectious disease with other providers. That doesn't mean I'd be concluding every provider who found the book useful was incompetent in the field.

An assessment of where improvement might be needed is not a condemnation of the practices of the people one feels would benefit from the book. And not only that, my medical/nursing education included many hours of patient provider communication skills, as would any medical school curriculum.

I didn't read Ivor's conclusions as an overall condemnation of the current medcal profession (in this instance). I read it as him saying that a lot of medical professionals having poor communication skills which leads to them not getting the necessary information from their patients.

[Skeptic Ginger]

Actually my example of the epidural problem was one where the doctor had been given the relevant information but refused to accept it because she thought the epidural had gone ok. I have a couple of other examples like that too. If some doctors cannot take into account something very obvious, its pretty likely that they will run roughshod over patient preferences in less obvious situations too.We all have stories of being unhappy with the performance of some professional or other worker be it the contractor who remodeled your house or the doctor who you had a bad experience with.

I wouldn't use those anecdotes to judge an entire profession on.

[Skeptic Ginger]

I didn't read Ivor's conclusions as an overall condemnation of the current medcal profession (in this instance). I read it as him saying that a lot of medical professionals having poor communication skills which leads to them not getting the necessary information from their patients.Define "a lot" and tell us how you know that?

Most providers I have had an experience with have good patient provider communication skills. I see this as what I said before, people selectively remember bad experiences and can tend to project those experiences onto a wider field than they actually apply.

[fls]

Actually my example of the epidural problem was one where the doctor had been given the relevant information but refused to accept it because she thought the epidural had gone ok. I have a couple of other examples like that too. If some doctors cannot take into account something very obvious, its pretty likely that they will run roughshod over patient preferences in less obvious situations too.

I simply think that Doctors That Don't Listen is different from Paternalism or Beneficence - I wouldn't want to visit the faults of one onto the other.

Linda

[Ivor the Engineer]

I don't have any have illusions here. Manipulation and redirection seems to work very well for me. I manipulate and redirect conversations so that patient's do what I would prefer them to do. I give them the information they need and I maximize or minimize certain bits so that they believe they are making an informed decision. I use it a whole lot more the more I believe the patients need it.

"Mr Soandso, we really need to do this lumbar puncture. We cannot be sure you don't have meningitis unless we do this procedure. Meningitis can cause death, brain damage and paralysis. I do this procedure all the time so it isn't dangerous. It may hurt a little bit."

Mr. Soandso thinking to himself: "Wow, this doc's laying it on thick. Clearly he doesn't have a clue what's wrong with me and is just taking a wild stab in the dark."

"Mr. Soandso, I don't believe you need a lumbar puncture. Although the risk is rather low we cannot be sure you don't have meningitis unless we do this procedure. Meningitis can cause death, brain damage and paralysis.A lumbar puncture does hurt a bit but it is safe."

Mr. Soandso thinking to himself: "Wow, this doc's really different to that Linda woman I saw last week. I appreciate not being treated like a child."

[Professor Yaffle]

I posted this earlier, as pretty close to my views. Note the role of communication.

http://www.sma.org.sg/smj/4303/4303sf3.pdf

[paximperium]

Mr. Soandso thinking to himself: "Wow, this doc's laying it on thick. Clearly he doesn't have a clue what's wrong with me and is just taking a wild stab in the dark."
Completely true. Your decision. I have no interest in making this "stab in the dark" decision for you. Choose correctly or else...


Mr. Soandso thinking to himself: "Wow, this doc's really different to that Linda woman I saw last week. I appreciate not being treated like a child."
I'm too busy to waste my time to do an LP on someone who I don't think has meningitis. Stop thinking and leave already.:p

[Ivor the Engineer]

I think the confusion is in the different levels of decision making which go on between the patient and a doctor.

Sure, doctors make decisions that their patients would be unable to make, just as engineers make decisions which the users of their products would not be able to make.

But ultimately it is patients who should be directing their treatment, just as the users of engineers' work specify what they want it to do, given the constraints pointed out by the engineer.

Doctors are a human user interface for medical technology.

[Skeptic Ginger]

As Linda notes in post #325, there are two different issues here. One is the quality of care. Good quality care includes skilled patient provider communication.

The second issue is who controls the care that is given. If you hire a housekeeper or a gardener, you as the employer can expect the employee you've hired will follow your instructions.

When you hire a professional such as a lawyer or a doctor or nurse practitioner, you are buying their expertise, you are not employing them. As such, some decisions belong to each party.

Under the model you are suggesting, the health care provider would be an employee of the patient. If that were the case, the patient could ask for drugs and surgery that was not indicated. Surely you can see the problem that would create?

[T.A.M.]

I think the confusion is in the different levels of decision making which go on between the patient and a doctor.

Sure, doctors make decisions that their patients would be unable to make, just as engineers make decisions which the users of their products would not be able to make.

But ultimately it is patients who should be directing their treatment, just as the users of engineers' work specify what they want it to do, given the constraints pointed out by the engineer.

Doctors are a human user interface for medical technology.

Thank you very much. I love it when someone reduces my 11 years of post secondary education down to an "interface for medical technology". Do you insult everyone this way?

Engineers are a human interface for engineering technology...nothing more. Nothing you could do that a computer, a CAD program, and a village idiot with mechanical skills couldn't do, right?????

I think you merely fear having things out of your control. Are you the same way when you step onto a plane? You despise that someone, such as a doctor or a pilot, could have such power as to make decisions FOR someone else. Maybe I am wrong. Please clarify for me the root cause of your distaste for myself and my physician colleagues.

I am not a big fan of the paternalism either, but it exists, and as you have said, and I would agree, a large portion of people actually prefer it that way...get use to it...it ain't gonna change in our lifetimes.

I am a 100% believer in the Doctor-Patient negotiation model. I always tell my patients that ultimately I am their information provider and ADVISOR. I do also, however, tell them that whatever decision they make, they must live with...and I record such in the chart.

TAM:)

[Ivor the Engineer]

<snip>

Under the model you are suggesting, the health care provider would be an employee of the patient. If that were the case, the patient could ask for drugs and surgery that was not indicated. Surely you can see the problem that would create?

Well they could, just as the operations department we (engineers and physicists) design borehole logging tools for could request that we supply them with all sorts of technology they don't understand, or would not be appropriate to achieve the measurement. This does not happen*.

Instead they request tools which can make particular measurements under certain environmental conditions, and it is left to the engineers and physicists how to achieve this specification. If there are ambiguities in what operations want (and there are always ambiguities in what operations want), we discuss the options we consider feasible and let them decide which of them they want us to implement.

This is how I see the doctor's role with a patient after the diagnosis has been made.



*Except when marketing get involved, then it becomes important to be able to match or out-spec. the competition.

[paximperium]

Thank you very much. I love it when someone reduces my 11 years of post secondary education down to an "interface for medical technology". Do you insult everyone this way?

Engineers are a human interface for engineering technology...nothing more. Nothing you could do that a computer, a CAD program, and a village idiot with mechanical skills couldn't do, right?????

I think you merely fear having things out of your control. Are you the same way when you step onto a plane? You despise that someone, such as a doctor or a pilot, could have such power as to make decisions FOR someone else. Maybe I am wrong. Please clarify for me the root cause of your distaste for myself and my physician colleagues.

I am not a big fan of the paternalism either, but it exists, and as you have said, and I would agree, a large portion of people actually prefer it that way...get use to it...it ain't gonna change in our lifetimes.

I am a 100% believer in the Doctor-Patient negotiation model. I always tell my patients that ultimately I am their information provider and ADVISOR. I do also, however, tell them that whatever decision they make, they must live with...and I record such in the chart.

TAM:)
Such petty digs by Ivor are amusing. I've already met my "life saved quota" for the week and my "piss off the drug seeker" quota is almost there.

This medical interface's ego is satiated.

[Ivor the Engineer]

Thank you very much. I love it when someone reduces my 11 years of post secondary education down to an "interface for medical technology". Do you insult everyone this way?

Engineers are a human interface for engineering technology...nothing more. Nothing you could do that a computer, a CAD program, and a village idiot with mechanical skills couldn't do, right?????

I only lowered your status to that of an engineer or physicist. Quite a drop, but (hopefully) still higher than "a village idiot".

I think you merely fear having things out of your control. Are you the same way when you step onto a plane? You despise that someone, such as a doctor or a pilot, could have such power as to make decisions FOR someone else. Maybe I am wrong. Please clarify for me the root cause of your distaste for myself and my physician colleagues.

No distaste for pilots or doctors. I do always count the rows of seats to the exits and plan my route out if the worst happens. I do the same when I'm flying.

I am not a big fan of the paternalism either, but it exists, and as you have said, and I would agree, a large portion of people actually prefer it that way...get use to it...it ain't gonna change in our lifetimes.

I am a 100% believer in the Doctor-Patient negotiation model. I always tell my patients that ultimately I am their information provider and ADVISOR. I do also, however, tell them that whatever decision they make, they must live with...and I record such in the chart.

TAM:)

I've been impressed with and interested in your posts in this thread. I apologise if I have caused you any offense. (Not meant to sound patronising.)

[paximperium]

I only lowered your status to that of an engineer or physicist. Quite a drop, but (hopefully) still higher than "a village idiot". Nope. I doubt you'll find too many engineers or physics who will take kindly to your assessment of their expertise as nothing more than a "technology" or "science" interface.

You've lowered a physician's or just about any professional or expert's status to bus driver so excuse us for finding your attitude not only insulting but exceeding moronic.

[Skeptic Ginger]

[snip]
This is how I see the doctor's role with a patient after the diagnosis has been made.....You seem to be confusing what health care providers do with your misconception they are not doing it.

When I started my practice 18 years ago, I bought a mailing list. I was going to send a brochure of the services I provided out to all the potential clients in the county. Before I had a chance to send them out, my practice got too busy through word of mouth. I still have the brochures and mailing labels. [Hmmm, now that I am thinking about it, I think I may even have some unused rolls of stamps. I should go look for those.]

My point is, some of us have a lot of feedback we are doing a good job. You must have had either terrible luck with poor quality providers, or you have the problem because you think you know more than you actually do. I'm leaning toward the latter explanation.

[Skeptic Ginger]

Such petty digs by Ivor are amusing. I've already met my "life saved quota" for the week and my "piss off the drug seeker" quota is almost there.

This medical interface's ego is satiated.You rival Linda for pith. :D

[Ivor the Engineer]

Nope. I doubt you'll find too many engineers or physics who will take kindly to your assessment of their expertise as nothing more than a "technology" or "science" interface.

You've lowered a physician's or just about any professional or expert's status to bus driver so excuse us for finding your attitude not only insulting but exceeding moronic.

I didn't think I did that at all.

The level of complexity of the interface to technology a scientist, engineer or doctor provides depends very much on the user. But the function of scientists, engineers and doctors is always to allow those with less expertise than themselves use the products of their labour.

ETA: I'm off to bed. See you tomorrow.

[jj]

I think the confusion is in the different levels of decision making which go on between the patient and a doctor.

Sure, doctors make decisions that their patients would be unable to make, just as engineers make decisions which the users of their products would not be able to make.

But ultimately it is patients who should be directing their treatment, just as the users of engineers' work specify what they want it to do, given the constraints pointed out by the engineer.

Doctors are a human user interface for medical technology.


:jaw-dropp
So, you assert that doctors have no knowlege base, they just look things up on the innertubz or something?

Given your take on doctors and engineers (which includes me), how does new knowlege ever get made, created, happen, whatever?

[Ivor the Engineer]

:jaw-dropp
So, you assert that doctors have no knowlege base, they just look things up on the innertubz or something?

No, not at all.

Given your take on doctors and engineers (which includes me), how does new knowlege ever get made, created, happen, whatever?

By clever scientists, doctors and engineers discovering and/or creating it. They then allow other people who are not as clever as they are make use of this knowledge by presenting it in a more user friendly way.

[BillyJoe]

I think there is too much trying to fit patients and doctors into a mould.

Hey, guess what, everyone's different. Patients come in all varieties. What doctor could possibly want all his patients to be fully informed and armed with information from the internet. What doctor could possibly want all his patients to be docile and obediant. Variety is the spice of life. A businessman in a suit sent in by his wife for a prostate exam. A single mother with three rag kids in tow. A spotty teenager looking for a cure. A carpenter who just wants a couple of stitches whacked in. An elderly woman wondering whether [insert quack cure] will help her arthritis. All with different attitudes and expectations. A doctor surely would want to be able to deal with all these types of patients. Patients, in turn must not expect to dictate how a doctor does his job as long as he does it competently and helps him get better or deal with what can't be cured. If a patient has a problem with the doctors attitude and demeanor, he can always find another doctor more to his liking...you know, the doctor the next patient left to come to this one!


And patient autonomy is a joke?

Hey, it's only an exercise in political correctness and, as Linda says, it is pure illusion. I am reminded of a alternative health practitioner who wanted the paternalism of doctors to stop and wanted every patient to decide for themselves whether they would have the new gardasil vaccine. Can you imagine the time it would take to research the pros and cons of the gardasil vaccine? Google it and you will see what I mean. And then to make sense of it all they will need to get themselves knowledgeable about immunology, the conduct of clinical trials, statistical analysis etc. etc. etc. It's just too ridiculous. The solution is not patient autonomy, it's better trained and informed doctors explaining what the problem is and how it should be treated and communicating that to the patient. That's where communication comes in, not sharing the decision with the patient! If there is no clear treatment course then the patient can be afforded some input.
I don't go to my mechanic and be expected to make a choice about whether to change the brake pads. I wouldn't have a friggin clue. Just change them mate if you think they need changing.

BJ

[Dancing David]

More seriously, many GPs will print out a prescription before they even tell you what they are giving you. This then makes it seem like an imposition and a nuisance to say anything that might make them reconsider.

Wow, some doctors are a pain!

Is this recent? Most doctors I have met, discuss the medication prior to writing the script. Mainly to check on the history of side effects and allergies.

Was this recently? (Now I do admit I go to a great giant practice, associated with a teaching program. Sometimes they are a little, um , clinical vs. homey. But I prefer that.)

That would be rude. On the doctors part, but then as a mental health advocate I got very used to asking doctors questions.

[Dancing David]

Come on Linda - you have a very obvious sarcastic streak. Some doctors can turn that off when they are with patients (I have no idea whether you are one of them), but others seemingly cannot keep their sarcastic/arrogant/condescending/patronising personalities out of the surgery. This in turn makes many patients reluctant to bring up anything that doesn't fit in with what the doctor already has planned.

To me the problem is not about *who* makes the decision, as long as the patient has been listened to and their views taken into account. The main problem, for me, is that many doctors create an atmosphere wherein patients find it very difficult to provide this sort of input. It's not enough for a doctor to say "well they didn't tell me about their problem with x" when they have created a situation in which it is very difficult for the patient to air their concerns. See Ivor's link to the book about communication skills.

This strangely enough cuts into a common area of professionalism, not just doctors.

In the Computers Forum, there have been similar discussions on this issue.

There are two (more like five hundred) sides to the issue.

A person who presents an issue(Person Requesting Services), their level of understanding may or may not be related to issue of technology at hand.

A person who is there is 'deal' with the issue (Person Providing Services), their social skills may or may not be similar to those commonly used by the other person.

This play out in a very similar fashion to what happens with doctors
-the social skills often make the situation uncomfortable and create animosity
-the technical jargon and discussion of the issues in jargon causes a deer in the headlights look or a glassy eyed look
-the person PPS is often knowledgeable about the current issues and can eliminate possibilities out of hand, which interacts with the communication skills
-the PPS may be very frustrated by the interesting ideas and concepts the requestors has, often involving policy issues that are way beyond the providers control
-the PPS may have a unique and often idiomatic/quirky way that they tend to do things, that may or may not have any bearing on what is the best for the requestor or the system level issues

-the PRS sometimes asks for something that just can't be done
-the PRS may have many interesting and unrelated ideas about what the problem is, that are not going to be realistic
-the PRS often wants the IT person to make things 'the way they used to be', when this is just not possible
-the PRS often wants special exceptions or permissions to do things that don't make sense or even worse would really mess things up
-the PRS often wants the provider to do things that are outside the scope of their job, especially provide emotional counseling

[Ivor the Engineer]

<snip>

And patient autonomy is a joke?

Hey, it's only an exercise in political correctness and, as Linda says, it is pure illusion.

Well if Linda, high priestess of all of medicine says it, it must be true.:)

Kumar & Clark: Clinical Medicine 6th Ed.

The three duties of clinical care

The rights of patients may be summarized by three corresponding duties of care which apply to all patients for whom doctors have clinical responsibility.

Protect life and health. Clinicians should practise medicine to a high standard, taking care not to cause unnecessary harm or suffering. Patients should only be given treatments which they need. Treatments should not be prescribed, for example, just because patients request them.

Respect autonomy. Humans have autonomy - the ability to reason, plan and make choices about the future. Respect for these attributes goes hand in hand with respect for human dignity. Doctors should respect the autonomy, and thus the dignity, of their patients. This respect for the autonomy of patients leads to two further rights - informed consent and confidentiality. Competent adult patients should be able to choose to accept proposed treatments and to control personal information which they divulge concerning such treatments. Denying patients such choice and control robs them of their human dignity.

Protect life and health and respect autonomy with fairness and justice. In the conduct of public and professional life, it is generally thought that people have the right to expect to be treated equally. Medicine is no exception and doctors have a duty to practise accordingly. The access to, and quality of, clinical care should be based only on the dictates of need rather than arbitrary prejudice or favouritism.

The purpose of the doctor is to present the patient with the options for treatment, along with sufficient information in a form for them to be able to make a informed decision.

I am reminded of a alternative health practitioner who wanted the paternalism of doctors to stop and wanted every patient to decide for themselves whether they would have the new gardasil vaccine. Can you imagine the time it would take to research the pros and cons of the gardasil vaccine? Google it and you will see what I mean. And then to make sense of it all they will need to get themselves knowledgeable about immunology, the conduct of clinical trials, statistical analysis etc. etc. etc. It's just too ridiculous.

The purpose of producing statistics is to convert complicated information into a form which others with less detailed knowledge can use to make useful decisions with.

The solution is not patient autonomy, it's better trained and informed doctors explaining what the problem is and how it should be treated and communicating that to the patient. That's where communication comes in, not sharing the decision with the patient! If there is no clear treatment course then the patient can be afforded some input.

There is rarely only one way to crack a nut.

I don't go to my mechanic and be expected to make a choice about whether to change the brake pads. I wouldn't have a friggin clue. Just change them mate if you think they need changing.

BJ

Or your mechanic could say: "There's X mm left on your pads (mate), which is good for about Y thousand miles. Do you want me to change 'em now?"

[T.A.M.]

The purpose of the doctor is to present the patient with the options for treatment, along with sufficient information in a form for them to be able to make a informed decision.

Where is that head banging on the desk smilie!!!!

No, the role of the physician is to listen to the patient's problem, ask relevant questions in order to make a diagnosis, or a list of probable diagnoses, and then present the recommended treatment(s), from which the patient may chose (if a selection is available) from, or chose no treatment at all.

Why must you minimize (inaccurately) the role I play in patient care so?

TAM:)

[T.A.M.]

I think there is too much trying to fit patients and doctors into a mould.

Hey, guess what, everyone's different. Patients come in all varieties. What doctor could possibly want all his patients to be fully informed and armed with information from the internet. What doctor could possibly want all his patients to be docile and obediant. Variety is the spice of life. A businessman in a suit sent in by his wife for a prostate exam. A single mother with three rag kids in tow. A spotty teenager looking for a cure. A carpenter who just wants a couple of stitches whacked in. An elderly woman wondering whether [insert quack cure] will help her arthritis. All with different attitudes and expectations. A doctor surely would want to be able to deal with all these types of patients. Patients, in turn must not expect to dictate how a doctor does his job as long as he does it competently and helps him get better or deal with what can't be cured. If a patient has a problem with the doctors attitude and demeanor, he can always find another doctor more to his liking...you know, the doctor the next patient left to come to this one!

<snip>

BJ

Well put, very insightful. Thank You.

TAM:)

[T.A.M.]

This strangely enough cuts into a common area of professionalism, not just doctors.

In the Computers Forum, there have been similar discussions on this issue.

There are two (more like five hundred) sides to the issue.

A person who presents an issue(Person Requesting Services), their level of understanding may or may not be related to issue of technology at hand.

A person who is there is 'deal' with the issue (Person Providing Services), their social skills may or may not be similar to those commonly used by the other person.

This play out in a very similar fashion to what happens with doctors
-the social skills often make the situation uncomfortable and create animosity
-the technical jargon and discussion of the issues in jargon causes a deer in the headlights look or a glassy eyed look
-the person PPS is often knowledgeable about the current issues and can eliminate possibilities out of hand, which interacts with the communication skills
-the PPS may be very frustrated by the interesting ideas and concepts the requestors has, often involving policy issues that are way beyond the providers control
-the PPS may have a unique and often idiomatic/quirky way that they tend to do things, that may or may not have any bearing on what is the best for the requestor or the system level issues

-the PRS sometimes asks for something that just can't be done
-the PRS may have many interesting and unrelated ideas about what the problem is, that are not going to be realistic
-the PRS often wants the IT person to make things 'the way they used to be', when this is just not possible
-the PRS often wants special exceptions or permissions to do things that don't make sense or even worse would really mess things up
-the PRS often wants the provider to do things that are outside the scope of their job, especially provide emotional counseling

1. A well rounded, well trained GP will hopefully have acquired sufficient skill to remove the social discomfort. Very few of my patients find it hard to talk to me, and most tell me I am "much better at it" then there previous doc.

2. A well rounded, well trained GP should have the ability (though not always the time) to break down the technical jargon into laymen terms.

3. A well rounded, well trained GP will likely find policy issues brought up by the patient to be frustrating, not due to any power struggle, or sense of insecurity, but likely out of time constraints.

4. the remainder of your post seems relatively accurate.

TAM;)

[fls]

I am a 100% believer in the Doctor-Patient negotiation model. I always tell my patients that ultimately I am their information provider and ADVISOR. I do also, however, tell them that whatever decision they make, they must live with...and I record such in the chart.

TAM:)

Let me put Pax's example to you, then.

Do you present Mr. Soandso with some information and then have him decide whether or not to get a lumbar puncture?

Linda

[T.A.M.]

Let me put Pax's example to you, then.

Do you present Mr. Soandso with some information and then have him decide whether or not to get a lumbar puncture?

Linda

In an earlier post of mine, I did stress that there is an "ER Doc" method, and then a "GP in the office" method. In the former I tend to ask relevant questions. I perhaps should have said, that in that setting, and depending on the nature of the illness, I might be more or less paternalistic.

However, if a patient were to present in my clinic with a headache, neck stiffness, coryza, and a fever, I would probably tell them this.

"You likely have an viral illness, a variation of the cold, but with your symptoms, and based on your physical, there is a possibility of meningitis. I strongly suggest we send you to the hospital for a CT and lumbar puncture, at the accepting doc's discretion, to rule this out."

If the patient is competent, and refuses to go, I will strongly urge he/she to reconsider, and then write in the chart that the patient was informed, competent, with a GCS of 15, and refused to take my advice.

TAM:)

Edit: so you, see this would be the ADVISOR part of the quote from me that you used.;D

[Ivor the Engineer]

Where is that head banging on the desk smilie!!!!

No, the role of the physician is to listen to the patient's problem, ask relevant questions in order to make a diagnosis, or a list of probable diagnoses, and then present the recommended treatment(s), from which the patient may chose (if a selection is available) from, or chose no treatment at all.

Why must you minimize (inaccurately) the role I play in patient care so?

TAM:)

I thought we were focusing on the role of the physician after a diagnosis has been made? If so, how is what I have said inaccurate?

Sometimes I think people are just looking to take offence in anything I say...

[Ivor the Engineer]

The doctor in Pax's example was playing a game, which is:

a) Disrespectful.

b) Risky, since one day the doctor will meet a better/harder player.

[T.A.M.]

I thought we were focusing on the role of the physician after a diagnosis has been made? If so, how is what I have said inaccurate?

Sometimes I think people are just looking to take offence in anything I say...

Ivor:

I do not know you, and I do not debate much with you, so I do not purposely take offense to ANYTHING you say...lol

Your comments do not seem to specify about at what point you consider us to be "user interfaces for medical technology" etc...

There is so much more to what a physician does, that to make grand, generic, and frankly insulting generalizations is not...well, very nice.

TAM:)

[fls]

In an earlier post of mine, I did stress that there is an "ER Doc" method, and then a "GP in the office" method. In the former I tend to ask relevant questions. I perhaps should have said, that in that setting, and depending on the nature of the illness, I might be more or less paternalistic.

However, if a patient were to present in my clinic with a headache, neck stiffness, coryza, and a fever, I would probably tell them this.

"You likely have an viral illness, a variation of the cold, but with your symptoms, and based on your physical, there is a possibility of meningitis. I strongly suggest we send you to the hospital for a CT and lumbar puncture, at the accepting doc's discretion, to rule this out."

If the patient is competent, and refuses to go, I will strongly urge he/she to reconsider, and then write in the chart that the patient was informed, competent, with a GCS of 15, and refused to take my advice.

TAM:)

Edit: so you, see this would be the ADVISOR part of the quote from me that you used.;D

So it seems like you agree that the choice isn't given to the patient - i.e. paternalism is appropriate and in the best interests of the patient. They may make the choice to ignore our advice, but that can happen under either system.

Linda

[fls]

The doctor in Pax's example was playing a game, which is:

a) Disrespectful.

b) Risky, since one day the doctor will meet a better/harder player.

Exactly!

And why does Pax have to play that game? Because he is forced to pretend that the patient is making an informed choice when he realizes that it is in the best interest of the patient for him (Pax) to make that choice.

Linda

[T.A.M.]

umm...here is what I would say.

There is a time when I advise STRONGLY (ie I strongly suggest) a course of action, but the patient is ultimately left with the final decision. There are other cases where more than one option is available, in which case I am much less paternalistic, and completely leave open the course of action to the patient.

TAM:)

[fls]

umm...here is what I would say.

There is a time when I advise STRONGLY (ie I strongly suggest) a course of action, but the patient is ultimately left with the final decision.

But that's irrelevant, isn't it? Unless we arrest them and strap them down, they are always free to act against their interests (the mark of a truly free society). You're not pretending that they are making a choice that is in their best interest, are you?

There are other cases where more than one option is available, in which case I am much less paternalistic, and completely leave open the course of action to the patient.

TAM:)

Could the choice be made by a coin toss?

Linda

[T.A.M.]

But that's irrelevant, isn't it? Unless we arrest them and strap them down, they are always free to act against their interests (the mark of a truly free society). You're not pretending that they are making a choice that is in their best interest, are you?



Could the choice be made by a coin toss?

Linda

1. No, I am not pretending, or suggesting it.

2. Well for instance, patient presents with signs of generalized Anxiety.

Options:
(A) Psychotherapy/Counselling
(B) A + an SSRI
(C) A + a Benzo
(D) No treatment at all

TAM:)

Edit: I think our mis-connecting here, is based on "influence" and whether influence destroys "free choice". A good debate for sure, but I think it is a murky one. For instance, a drug rep will come in and try to influence you with studies indicating their drug is better at something then the competitors, or that they offer something the other versions do not. Now do you admit this influences you, and if it does, does that eliminate your ability to chose fairly what is best for the patient?

[Ivor the Engineer]

Exactly!

And why does Pax have to play that game? Because he is forced to pretend that the patient is making an informed choice when he realizes that it is in the best interest of the patient for him (Pax) to make that choice.

Linda

I think you are confounding diagnosis and treatment.

I agree that diagnosis should be left pretty much in the realm of the physician, since a typical patient will not have the expert knowledge to be able to perform the task. All I would add is that patients can help a physician avoid falling into cognitive traps by asking questions. Once a diagnosis has been made it tends to be resistant to conflicting evidence.

Once a diagnosis has been made and there are multiple courses of action to choose from, the physician should explain each one in an unbiased way and discuss with the patient which one is appropriate, which can be primarily determined by the patient.

[Dr. Imago]

I think you are confounding diagnosis and treatment.

I agree that diagnosis should be left pretty much in the realm of the physician, since a typical patient will not have the expert knowledge to be able to perform the task. All I would add is that patients can help a physician avoid falling into cognitive traps by asking questions. Once a diagnosis has been made it tends to be resistant to conflicting evidence.

Once a diagnosis has been made and there are multiple courses of action to choose from, the physician should explain each one in an unbiased way and discuss with the patient which one is appropriate, which can be primarily determined by the patient.

That's just not true at all. That's the way the public THINKS and BELIEVES it works, but we actually work on a list of differential diagnoses. Sometimes it can actually take quite some time to pinpoint the etiology of a particular illness.

Ivor, I know you're only trying to keep your belief about how the medical system works and the medical profession in generall intact, but you are really reaching and making a lot of suppositions.

~Dr. Imago

[Ivor the Engineer]

<snip>

There is so much more to what a physician does, that to make grand, generic, and frankly insulting generalizations is not...well, very nice.

TAM:)

Well it looks like I'm the odd one out. I was discussing what I thought engineers and doctors provided the users of their services with an engineering colleague, and he was just as taken aback at the thought of being a human user interface for (in his case mechanical) technology.

I still don't get all the fuss, but I'll accept I have a minority and rather unpopular point of view.

[Ivor the Engineer]

That's just not true at all. That's the way the public THINKS and BELIEVES it works, but we actually work on a list of differential diagnoses. Sometimes it can actually take quite some time to pinpoint the etiology of a particular illness.

Ivor, I know you're only trying to keep your belief about how the medical system works and the medical profession in generall intact, but you are really reaching and making a lot of suppositions.

~Dr. Imago

Yes, I know how to perform differential diagnosis. I use the technique frequently in my line of work.

I am also aware that we naturally tend to look for evidence to confirm a hypothesis rather than that which would disprove it.

[T.A.M.]

Well it looks like I'm the odd one out. I was discussing what I thought engineers and doctors provided the users of their services with an engineering colleague, and he was just as taken aback at the thought of being a human user interface for (in his case mechanical) technology.

I still don't get all the fuss, but I'll accept I have a minority and rather unpopular point of view.

I think it is the general"ness" of your statements.

I will admit that there are certain aspects of my profession, that in this day and age of the internet, are becoming redundant. A good Physician adapts.

For instance, if someone wants detailed info on a particular condition, I will often tell them, at that time, to (A) go to the internet and do a search on it, (B) go to reputable sites, and (C) comeback if you have any questions and we can discuss it.

There are so many things, in both medicine, and engineering, that cannot be done by a computer interface, so to speak, that require the educated and experienced touch of a human.

In medicine:

The tenderness to know when to say something, and when not to. The understanding of context. The compassion, the empathy (where possible). The intuition.

For instance, on intuition, I'll tell you about a case I had a few weeks ago.

I had a man that came into me the other day in clinic. His presentation was as follows...

62 year old man, smoker, normal cholesterol, non diabetic, no significant medical history. Presents with left arm pain, worse with use, that awoke him last PM. Patient took Advil x 2 tabs, and settled within 2 hours.

HE comes to my clinic with mild left arm discomfort (at present time), no shortness of breath, no Chest Pain, No nausea/vomiting. When I examined him his vitals were normal, chest clear, CVS exam normal, and when I pushed on his bicep muscle, he told me "That's the pain".

I have sent a dozen of these presentations home as MSK PAIN, and they have done fine...but something struck me with this guy. He just didn't look well. He seemed "off". Something also alarmed me about the pain WAKING him at night.

I sent him to the hospital for an EKG.

EKG showed some mild ST elevations in the lateral leads. I called the ER doc and had him sent to him.

Cardiac Enzymes were up, and the ST elevations were now prominent. He was admitted and thrombolyzed...MI!

TAM:)

[Dr. Imago]

Yes, I know how to perform differential diagnosis. I use the technique frequently in my line of work.

I am also aware that we naturally tend to look for evidence to confirm a hypothesis rather than that which would disprove it.

Don't compare being an engineer with being a physician. They are not the same. Machines have causes that can, sometimes with difficulty, be definitively pinpointed and corrected. They are generally "binary" problems (e.g., some bolt is broken, find the bolt, fix it, and everyting is okay). Humans, OTOH, are "analog" and far more complex without a single, identifiable and treatable cause that will fix everything else downstream. There are magnitudes and shades of dysfunction, some being more important than others. Knowing that, we are often left to run tests to "rule out" diagnoses as much as to rule them in. Certainly, many times we use tests to confirm what we are thinking where it is important to quantify the problem. Yet other times, those tests will tell us something completely unexpected.

In my previous example, I used the echocardiogram to "rule out", among other things, critical aortic stenosis and significant left ventricular problems. Had it been aortic stenosis, as was a possibility, it would've completely changed my course of action. The patient did indeed have a valve problem, but it wasn't critical. Even just knowing that was clinically important. I could've "guessed" that it wasn't going to affect my planned care, based on other clinical findings. But, I wasn't willing to take that risk in this patient. Other clinicians might have. But, it seems that your core argument is based on whether or not there was a financial incentive to do a test, ie. if I'd somehow received some form of remuneration for ordering that test it would necessarily mean that I only did it because of some perceived financial incentive, or if I hadn't received some financial incentive (which I didn't) I wouldn't therefore do the test... and potentially put the patient at additioinal risk.

Data helps us understand. It is not used solely to confirm what we're already thinking, and I take umbrage that we necessarily "look for evidence to confirm a hypothesis" - i.e., that we only choose to do studies simply to reinforce what we already suppose, and subsequently ignore other possibilities. Everything in medicine is weighed in light of the inherent risk-to-benefit ratio of our planned intervention, which is unfortunately complicated by the fact that many patients can't or won't pay for the gold-standard care they expect. Doctors deal with these issues on a daily basis. For what you otherwise seem to be suggesting we already have a name for: fraud and/or malpractice.

You are being overly simplistic in your logic, which is understandable on an individual basis because you don't really understand how medicine works. But, it's not okay to use that simplistic logic to make sweeping generalizations and form firm conclusions about the field of medicine, and try to convince others a depth of understanding about a field of endeavor in which you are not initimately involved nor have real, working knowledge.

~Dr. Imago

[Ivor the Engineer]

Sorry, I just can't resist:

http://www.cbsnews.com/stories/2008/04/30/health/webmd/main4058664.shtml

Overconfident Docs Need Dose Of Reality

(WebMD) Most of the time a medical diagnosis is on point. But misdiagnoses do occur, and an overly confident doctor may be partly to blame, a new review suggests.

The rate of diagnostic error is as high as 15%, Eta S. Berner, EdD, and Mark L. Graber, MD, write in a special edition of The American Journal of Medicine dedicated to understanding and addressing diagnostic errors.

Physician overconfidence and a lack of feedback following a diagnosis are two important contributors to the problem, they note.

"When directly questioned, many clinicians find it inconceivable that their own error rate could be as high as the literature demonstrates," Berner and Graber write. "They acknowledge that diagnostic error exists, but believe the rate is very low, and that any errors are made by others who are less skillful or less careful."

Berner says it is often the cases physicians perceive as routine and unchallenging that end up being misdiagnosed.

"With the hard cases, doctors generally seek out different opinions or turn to (computer-based) decision support tools," she tells WebMD.

A Missed Diagnosis

Retired engineer Paul Mongerson is all too aware of the problem of medical misdiagnosis, and he has spent the last 28 years addressing the issue.

In 1980, Mongerson was incorrectly told by four different doctors that he had pancreatic cancer, a highly deadly cancer that kills most people who have it within five years.

Mongerson made up a matrix charting his symptoms and test results to help him assess the probability that his doctors were right.

"I determined from that matrix that I didn't have cancer," he tells WebMD.

Just two days before he was scheduled for cancer surgery, a fifth doctor agreed and Mongerson canceled the operation.

"I said at the time that if I survived I was going to see what I could do to help other people," he says.

What Mongerson did was form a foundation to fund the development of computer-based programs designed to assist physicians in diagnosing disease.

While such programs are being used in many hospital and educational settings, they are not yet widely used by private practice physicians.

Mongerson says performing more autopsies and having systems in place to crosscheck medical diagnoses would help address the issue of lack of feedback.

WTF do engineers know?:)

[kellyb]

You will notice that all of your (you and Professor Yaffle) examples of Paternalism Is Bad are about decisions made without all the relevant information. I'm suggesting that we should consider decisions made with the relevant information, and that we should be realistic about how that can be accomplished.

Linda

Aren't doctors who are paternalistic less likely to gather that relevant information?
Whereas TAM would discuss treatment options for generalized anxiety, the Bad Paternalistic Doc would take note of the symptoms and prescribe whatever he, in his clinical judgment, just thought was the most effective treatment.

Although it's worth noting that almost any doctor who is too rushed for whatever reason, is probably almost indistinguishable from one with a paternalistic attitude.

[Ivor the Engineer]

Don't compare being an engineer with being a physician. They are not the same. Machines have causes that can, sometimes with difficulty, be definitively pinpointed and corrected. They are generally "binary" problems (e.g., some bolt is broken, find the bolt, fix it, and everyting is okay).

<snip>

Wrong.

Engineering is intimately connected with the natural world and dealing with all the randomness, chaos and complexity of it is what engineers do.

But I understand why you think the way you do about engineers; we have done a lousy job in explaining what it is we actually do.

[Dr. Imago]

Sorry, I just can't resist:

http://www.cbsnews.com/stories/2008/04/30/health/webmd/main4058664.shtml



WTF do engineers know?:)

You quote an anecdote from 1980? ;)

The proof, so to speak, is in the pudding. The guy didn't die. And, I hope you are the first to recognize that the body of medical knowledge as well as high-tech diagnostic tools at our disposal has changed drastically in the past 29 years.

I admit, we have occassionally have a problem with referrals sometimes, though. If Doctor X consults with Doctor Y about Patient Z, Doctor Y's initial approach to the patient will likely not include revisiting the primary diagnosis offered by Doctor X. The vast majority of the time this is not an issue, but occassionally someone will slip through the cracks as a result.

I'm not at all arguing that people shouldn't be involved in their own care. I'm not saying that you shouldn't know what's going on with your body and speak up if something doesn't make sense. However, on occassion, I will encounter patients who are "resistant" to the correct diagnosis and treatment offered because they believe the doctor(s) can't possibly be correct. The reasons for this resistance are often complex, and I think it speaks to a huge mistrust and misconception of out true intentions... which are, with rare exception by the sad and unfortunate practitioner who ineluctably seems to grab headlines, honorable and only looking out for your health and well-being.

Likewise, we just don't have the time to spend with everyone like my medical forefathers did. The insurance companies have put an end to that.

~Dr. Imago

[paximperium]

The doctor in Pax's example was playing a game, which is:

a) Disrespectful.

b) Risky, since one day the doctor will meet a better/harder player.
Bingo. Some people don't know what's good for them and some have this silly illusion that there is a choice when it comes to their care. Sometimes this is true when you can actually choose your care. This is if and only when I decide there is choice that is a viable option.

Impossible in many cases, if you have a meningitis/appendicits/pneumothorax/head bleed, you don't really have a choice, either do as I or the specialists say or you can take you life into your own hands leave, delay care and get a second opinion.

I offer people a service, they can either accept it or refuse it. You have a silly belief that I'm employee of the patients. No, they are hiring a service, an expert opinion. They have all the freedom in the world to listen to me or ignore me.

Call it patronizing or even disrespectful but I'm more than willing to manipulate people to protect their lives and health.

[paximperium]

Aren't doctors who are paternalistic less likely to gather that relevant information?
Do not confuse paternalism with arrogance.

Whereas TAM would discuss treatment options for generalized anxiety, the Bad Paternalistic Doc would take note of the symptoms and prescribe whatever he, in his clinical judgment, just thought was the most effective treatment.
That's not paternalistic, that's incompetent.

[paximperium]

For instance, on intuition, I'll tell you about a case I had a few weeks ago.

I had a man that came into me the other day in clinic. His presentation was as follows...

62 year old man, smoker, normal cholesterol, non diabetic, no significant medical history. Presents with left arm pain, worse with use, that awoke him last PM. Patient took Advil x 2 tabs, and settled within 2 hours.

HE comes to my clinic with mild left arm discomfort (at present time), no shortness of breath, no Chest Pain, No nausea/vomiting. When I examined him his vitals were normal, chest clear, CVS exam normal, and when I pushed on his bicep muscle, he told me "That's the pain".

I have sent a dozen of these presentations home as MSK PAIN, and they have done fine...but something struck me with this guy. He just didn't look well. He seemed "off". Something also alarmed me about the pain WAKING him at night.

I sent him to the hospital for an EKG.

EKG showed some mild ST elevations in the lateral leads. I called the ER doc and had him sent to him.

Cardiac Enzymes were up, and the ST elevations were now prominent. He was admitted and thrombolyzed...MI!

TAM:)
Sounds kinda like the 32year old guy who came in for heartburn...the guy looked ill. Didn't have single risk factor, normal vitals. Normal EKG. Normal vitals and was feeling better with good old morphine.

He says, "I feel better, just a bit more pressure. Can I go home?" I check one more EKG and it had converted to a fullblown ST elevation MI. Up to the cardiac cath lab and stented(Oh the horrible stents are anathema to Ivor) within 30minutes.

[T.A.M.]

Sounds kinda like the 32year old guy who came in for heartburn...the guy looked ill. Didn't have single risk factor, normal vitals. Normal EKG. Normal vitals and was feeling better with good old morphine.

He says, "I feel better, just a bit more pressure. Can I go home?" I check one more EKG and it had converted to a fullblown ST elevation MI. Up to the cardiac cath lab and stented(Oh the horrible stents are anathema to Ivor) within 30minutes.

Yah the "heartburn" ones are tough. Even worse are the middle aged women that come in with some "stomach pain", and their Troponin is through the roof.

I miss the ER sometimes.

TAM:)

[kellyb]

Do not confuse paternalism with arrogance.



Arrogance is one of the primary symptoms of paternalistic attitudes.

That's not paternalistic, that's incompetent.

Well, I was assuming the relevant info making the prescription "not incompetent" was in the patient's chart.

[Skeptic Ginger]

I thought we were focusing on the role of the physician after a diagnosis has been made? If so, how is what I have said inaccurate?

Sometimes I think people are just looking to take offence in anything I say...Right Ivor, it couldn't possibly be that some things you say are offensive, now could it?

As for your medical textbook citation in post #394 re patient autonomy, what do you suppose the result is that such discussion is in a medical textbook? Think it is possible this is part of one's medical education?

Combining these two thoughts, perhaps you are a defensive/offensive patient who creates a self fulfilling prophesy by the way you approach your doctors.

[Skeptic Ginger]

I think you are confounding diagnosis and treatment.

I agree that diagnosis should be left pretty much in the realm of the physician, since a typical patient will not have the expert knowledge to be able to perform the task. All I would add is that patients can help a physician avoid falling into cognitive traps by asking questions. Once a diagnosis has been made it tends to be resistant to conflicting evidence.

Once a diagnosis has been made and there are multiple courses of action to choose from, the physician should explain each one in an unbiased way and discuss with the patient which one is appropriate, which can be primarily determined by the patient.I doubt you recognize the absurdity of your argument here. The doctor in your example can diagnose better than the patient but that same doctor isn't qualified to recommend the treatment?

Your first false premise is assuming a provider does not take into consideration a patient's needs when recommending a treatment. Your second false premise is assuming valid treatment options are not discussed with the goal of eliciting the patient's decision when there are optional treatments.

For example, if surgery or drugs offer different risk/benefit patterns, it may be totally patient preference that guides the decision. But that is not the case in the majority of treatment recommendations.

[Skeptic Ginger]

....

I am also aware that we naturally tend to look for evidence to confirm a hypothesis rather than that which would disprove it.That is not how I make a diagnosis. And a diagnostic procedure which is definitive rules a diagnosis in or out. This is not consistent with your frankly naive view one is looking to confirm an hypothesis.


A health care provider usually merges the following considerations depending on the patient's problem.

First priority is to rule out anything critical or life threatening that you cannot afford to miss.

Second priority is to look for the most likely diagnosis on the dif, and work down the list.

And your third priority is to choose the least invasive tests/procedures to confirm your diagnosis.

[BillyJoe]

Well if Linda, high priestess of all of medicine says it, it must be true.:)

Someone earlier in the thread said that they often find Linda's posts opaque. I was going to respond but forgot, so thank-you for providing me with the opportunity now. What I was going to say to this person was:
If you find Linda's posts opaque, that it not a criticism of her.
And if you don't understand that sentence, that is not my fault either.

Anyway...

There are posters on this forum who are nearly always interesting and insightful and there are others, Ivan, who make me wonder why I even bother.

Humans have autonomy - the ability to reason, plan and make choices about the future. Respect for these attributes goes hand in hand with respect for human dignity. Doctors should respect the autonomy, and thus the dignity, of their patients. This respect for the autonomy of patients leads to two further rights - informed consent and confidentiality. Competent adult patients should be able to choose to accept proposed treatments and to control personal information which they divulge concerning such treatments. Denying patients such choice and control robs them of their human dignity.There is nothing here to say that a patient's role in deciding what treatment they will have is anything more than an illusion.

The purpose of the doctor is to present the patient with the options for treatment, along with sufficient information in a form for them to be able to make a informed decision.Only when there nothing or little to choose between the various options.
Note that the patient's decision in these cases amounts to no more than a coin toss. Some choice.
If you present to your doctor with a headache and he makes a diagnosis of meningococcal meningitis, unless you are stupid enough to make it completely impossible for him, he going give you an injection of an antibiotic and send you by ambulance to the nearest hospital, no matter what noises he might make to make it appear to you that you are taking part in the decision making process.

The purpose of producing statistics is to convert complicated information into a form which others with less detailed knowledge can use to make useful decisions with.But, hold on, if you want to see the statistics supporting various treatment options, don't you also want to see how such statistics were arrived at? Whether they say what they seem to say? Does that not mean that you willl need to have knowledge about statistical methods used to evaluate clincal trials and therefore additional knowledge about clinical trials and how to evaluate them. If not, why not just stick with the doctor's recommendation in the first place.
How much information do you need to give you the illusion that you are participating in the decision making process?

Or your mechanic could say: "There's X mm left on your pads (mate), which is good for about Y thousand miles. Do you want me to change 'em now?"I based this example on something that happened only a few weeks ago.
In fact, I was grateful that he did NOT interrrupt my busy work schedule to ask me that STUPID question. Going by mileage done, the break pads were due to be changed, but he didn't change them because, in his opinion based on his experience, they would easily last untill the next service, and he told me this when I picked up the car.
A truly professional approach in my opinion.

BJ

[Skeptic Ginger]

I looked into the engineer's anecdote Ivor brought up.

Here is the link Ivor provided. It is a typical news report making things look as sensational as possible.
Overconfident Docs Need Dose Of Reality (http://www.cbsnews.com/stories/2008/04/30/health/webmd/main4058664.shtml)Misdiagnoses Occur Up To 15% Of The Time, Physician Overconfidence May Be Partly To Blame



The actual report was from The American Journal of Medicine; Volume 121, Issue 5, Supplement (May 2008); Diagnostic Error: Is Overconfidence the Problem? (http://www.amjmed.com/issues/contents?issue_key=S0002-9343(08)X0007-5)

The abstract (http://www.amjmed.com/article/S0002-9343(08)00040-5/abstract)The great majority of medical diagnoses are made using automatic, efficient cognitive processes, and these diagnoses are correct most of the time. This analytic review concerns the exceptions: the times when these cognitive processes fail and the final diagnosis is missed or wrong. We argue that physicians in general underappreciate the likelihood that their diagnoses are wrong and that this tendency to overconfidence is related to both intrinsic and systemically reinforced factors. We present a comprehensive review of the available literature and current thinking related to these issues. The review covers the incidence and impact of diagnostic error, data on physician overconfidence as a contributing cause of errors, strategies to improve the accuracy of diagnostic decision making, and recommendations for future research.

Foreword by Paul Mongerson (http://www.amjmed.com/article/S0002-9343(08)00158-7/fulltext)After being misdiagnosed with pancreatic cancer in 1980, I founded the Computer Assisted Medical Diagnosis and Treatment Foundation to improve the accuracy of medical diagnosis. The foundation has sponsored programs to develop and evaluate computerized programs for medical diagnosis and to encourage physicians to use computers for their order entry. My role was insignificant, but as the result of much work by many people, substantial progress has been made. Physicians today are clearly more accepting of computer assistance and this movement is accelerating.

However, in 2006, I became worried after questioning my personal physicians as to why they did not use computers for diagnosis more often. Most explained that their diagnostic error rate was <1% and that computer use was time consuming. However, I had read that studies of diagnostic problem solving showed an error rate ranging from 5% to 10%. The physicians attributed the higher error rates to “other” less skilled physicians; few felt a need to improve their own diagnostic abilities....

...It is logical that physicians' overconfidence in their ability inadvertently reduces the attention they give to reducing their own diagnostic errors....

...The papers in this supplement confirm the extent of diagnostic errors and suggest improvement will best come by developing systems to provide physicians with better feedback on their own errors.

Hopefully this set of articles will inspire us to improve our own diagnostic accuracy and to develop systems that will provide diagnostic feedback to all physicians.So the error rate is 5-10%, not 15%. (Perhaps there is a reference to 15% in the body of the paper, but I didn't see it.) While no one wants any errors in medical diagnoses, that's still a pretty low error rate when you consider the sheer number of possible diagnoses and patient presentations health care providers are confronted with. The emphasis on the "overconfidence" isn't quite as pronounced when you consider the studies suggest physicians estimate their own error rates as 1% when the average is 5-10%.

And the providers estimate their own error rates are less than other providers. Well, maybe they were, maybe they weren't. Individual estimates vs real error rates were not discussed. To get an average of 5-10%, some docs probably did have error rates of 1%.

It also depends on specialty. I practice in a very narrow specialty. It's easy to know a lot about a little.

I don't see that this research supports the implication here that most doctors are overconfident, arrogant and paternalistic. I remain confident ;) that my assessment is some people in this discussion self fulfill their expectations as patients when they approach their providers with a chip on their shoulders.


Science Daily: Will You Be Misdiagnosed? How Diagnostic Errors Happen (http://www.sciencedaily.com/releases/2008/04/080428092956.htm) summarizes the supplement articles for anyone wanting the short version that is a bit more accurate than the CBS news version.



Mongerson started a foundation supporting the development of medical informatics. This is a marriage of biological sciences with computer programming science. It's a big focus these days especially in the field of genetics. BioInformatics is two fields of study. It doesn't turn computer programmers into doctors anymore than it turns doctors into computer programmers. Anyone can study dual sciences, but engineering is also not the same as medicine anymore than computer programming is. OTOH, we can all gain insights from other sciences.

A patient's perspective of medical informatics; P Mongerson (http://www.jamia.org/cgi/content/abstract/2/2/79)From my viewpoint as a patient, 1. Medical knowledge has expanded to the point that individuals cannot adequately improve quality without the assistance of computer programs. 2. The medical profession must concentrate on why and how computer program projects must be used, not on why they cannot be used. 3. The successful application of computer programs to clinical medicine is dependent mainly on the efforts of individual institutions and people at the local level.

But just as a reminder how complex decision making is in medical diagnostics, it's worth noting the FDA may need to regulate these programs to assure they provide proper assistance to medical decision making.

FDA Examining Computer Diagnosis (http://www.fda.gov/Fdac/features/795_compdiag.html) When Paul A. Mongerson of Marathon, Fla., had severe abdominal pains in 1980, a battery of tests showed he had an elevated blood level of the enzyme lipase, which could indicate cancer of the pancreas. Though the diagnosis was not confirmed by other tests, his doctor recommended surgery.

"I'm an engineer by training, so I made up a matrix, charting my symptoms and test results, the possible diseases that could cause my symptoms, and what other symptoms would be present with those diseases," Mongerson recalls. "My conclusion was that I could not have cancer of the pancreas, and the fifth doctor I consulted, at Mt. Sinai in New York, agreed with me."

Eventually the pain disappeared, and he was found to have a condition known as pseudolipase, which results in abnormally high readings for the enzyme in tests. Mongerson said he thinks he might have bruised his pancreas while working around the house.

"I said at that time, 'what I did is just what a computer would do.' Medicine has gone about as far as it can without computers. There's a limit to how much the mind can retain, even with the degree of specialization that we've seen in medicine," Mongerson said. "The field of knowledge is so big the human mind is incapable of grasping it all--but a computer could help."

So Mongerson formed a foundation that provided financial assistance to physicians working to develop computer diagnosis systems. Today, medical diagnostic software puts entire medical libraries a mouse-click away. The Food and Drug Administration already regulates some diagnostic software, and as the number of programs expands, so does FDA's review.

[paximperium]

Arrogance is one of the primary symptoms of paternalistic attitudes.
Yeah...was that suppose to have refuted my statement?


Well, I was assuming the relevant info making the prescription "not incompetent" was in the patient's chart.
A doc who ignores a patient's social situation and preference is incompetent. It is a definite way of not having your patient follow through with their treatment.

"Mr Soandso, you have strep throat. Here are some antibiotic pills for it that you have to take for one week. Bye." Mr. Soandso hates taking pills. He take 2 days of antibiotics before stopping because he feels better. Later on he comes back with a peritonsilar abscess. This could've been fixed by offering Mr. Soandso a single intramuscular shot of penicillin.

"Mrs. Soandso, you have a mild pneumonia. Here is some antibiotics for it."
She tries to fill the prescription but its costs $800 because her insurance does not cover that brand. She decide she won't fill it due to the price. This could've been solved by giving an alternate and cheaper antibiotic.

Tell me. Was any of the above not medically appropriate?

[paximperium]

"Civil Engineer Ivor, I need a bridge across this ravine."
"Okay, here are the 2 ways we can build it."
"I don't like it. I want it built up side down with laser beams."
"Uh...okay, I could do it this way."
"No, I want it with laser beams and Swiss cheese."
"But the bridge will collapse."
"Why are you so paternalistic? Why don't you respect my autonomy?"

[fls]

1. No, I am not pretending, or suggesting it.

2. Well for instance, patient presents with signs of generalized Anxiety.

Options:
(A) Psychotherapy/Counselling
(B) A + an SSRI
(C) A + a Benzo
(D) No treatment at all

TAM:)

Do you think those options are equivalent in efficacy?
Is a patient in a better position to understand how one chooses between these options than you?

Edit: I think our mis-connecting here, is based on "influence" and whether influence destroys "free choice". A good debate for sure, but I think it is a murky one.

Really? I think it's pretty clear that choices can be influenced.

I guess I'm asking why it is assumed that "free choice" is preferred over "physician choice" to the point where "physician choice" is synonymous with "paternalism" which is synonymous with "arrogance".

For instance, a drug rep will come in and try to influence you with studies indicating their drug is better at something then the competitors, or that they offer something the other versions do not. Now do you admit this influences you, and if it does, does that eliminate your ability to chose fairly what is best for the patient?

You admit that this influences you and you don't take information from drug reps.

Linda

[fls]

I think you are confounding diagnosis and treatment.

Yeah, I always get those two mixed up. It's because "drugs" and "diagnosis" both start with "d". Damn mnemonics.

And now that I think about it, I've never ever asked for informed consent for a diagnostic test.

I agree that diagnosis should be left pretty much in the realm of the physician, since a typical patient will not have the expert knowledge to be able to perform the task. All I would add is that patients can help a physician avoid falling into cognitive traps by asking questions. Once a diagnosis has been made it tends to be resistant to conflicting evidence.

Yeah, show me the results of the spiral CT and I'm still like "give him another dose of Lasix IV".

Once a diagnosis has been made and there are multiple courses of action to choose from, the physician should explain each one in an unbiased way and discuss with the patient which one is appropriate, which can be primarily determined by the patient.

I'm not disputing that it can be determined by the patient. I'm pointing out that it has been assumed that the result will be in the best interests of the patient when there is evidence that suggests otherwise. It seems that the perception of patient autonomy is valued more than maximizing health. I'm not saying that those priorities are wrong, just that we shouldn't pretend otherwise.

Linda

[T.A.M.]

Do you think those options are equivalent in efficacy?
Is a patient in a better position to understand how one chooses between these options than you?



Really? I think it's pretty clear that choices can be influenced.

I guess I'm asking why it is assumed that "free choice" is preferred over "physician choice" to the point where "physician choice" is synonymous with "paternalism" which is synonymous with "arrogance".



You admit that this influences you and you don't take information from drug reps.

Linda

1. I think that all of them can be relatively equal in efficacy, and that there are other factors besides efficacy to consider. For instance, maybe the patient does not want medication. Or maybe the patient does not want to take anything with addiction or abuse potential.

2. I never said that choices are not influenced. Your example, about Physician choice being synonymous with paternalism and arrogance, is (A) extreme, and (B) Not what I said, anywhere in my posting.

3. I admit that Drug Reps bring information and talking points that are MEANT to influence my decision making concerning drug choice. Yes I take the information, but what influences my drug choice (as I have told reps to their faces) is not their talking points, or a single small or medium study funded by their company, but metanalysis of many DBRCTs, as well as unbias expert medical opinion. Is it possible that they are influencing my choice in some small, unnoticed way...perhaps, I am not claiming to be perfect, but their influence is minimal.

TAM:)

[fls]

Sorry, I just can't resist:

http://www.cbsnews.com/stories/2008/04/30/health/webmd/main4058664.shtml

Overconfident Docs Need Dose Of Reality

(WebMD) Most of the time a medical diagnosis is on point. But misdiagnoses do occur, and an overly confident doctor may be partly to blame, a new review suggests.

The rate of diagnostic error is as high as 15%, Eta S. Berner, EdD, and Mark L. Graber, MD, write in a special edition of The American Journal of Medicine dedicated to understanding and addressing diagnostic errors.

Physician overconfidence and a lack of feedback following a diagnosis are two important contributors to the problem, they note.

"When directly questioned, many clinicians find it inconceivable that their own error rate could be as high as the literature demonstrates," Berner and Graber write. "They acknowledge that diagnostic error exists, but believe the rate is very low, and that any errors are made by others who are less skillful or less careful."

Berner says it is often the cases physicians perceive as routine and unchallenging that end up being misdiagnosed.

"With the hard cases, doctors generally seek out different opinions or turn to (computer-based) decision support tools," she tells WebMD.

I think this is the article that they are making reference to:

http://www.amjmed.com/article/S0002-9343(08)00040-5/fulltext#sec1

What is interesting is that the evidence they present contradicts what is written above. There is a good table of the error rates discovered through various methods within various fields. And I wouldn't dispute the error rate of 15%, although there is almost no precision to that number. What I would dispute is their claim of over-confidence. They seem to base this on these statements:

"When giving talks to groups of physicians on diagnostic errors, Dr. Graber (coauthor of this article) frequently asks whether they have made a diagnostic error in the past year. Typically, only 1% admit to having made a diagnostic error. The concept that they, personally, could err at a significant rate is inconceivable to most physicians."

However, it is plain that the results of this informal survey are wrong, since formal studies provide a far different answer, overwhelming biases (selection, recall, response, etc.) will form the results, and it is a different question from the one they claim to be asking. They summarize one study as "family physicians asked to recall memorable errors were able to recall very few", yet if you look at the results, 90% of the physicians recalled a memorable error and no conclusions can be drawn about the overall number of errors recalled, since each physician was only asked to recall one error. Berner and Graber grossly misrepresent the results of that study and the conclusions that can be drawn. The study actually shows that the overwhelming majority of family physicians are able to recall errors.

One of the studies they reference about over-confidence had physicians rating their confidence as 'low' in 2/3 of the cases and as 'high' in 1/3. This doesn't even remotely support their assertion that physicians rarely consider the possibility that their diagnosis is in error. They don't refer to any studies that support their conclusion, and the references they do provide actually contradict their claims.

A Missed Diagnosis

Retired engineer Paul Mongerson is all too aware of the problem of medical misdiagnosis, and he has spent the last 28 years addressing the issue.

In 1980, Mongerson was incorrectly told by four different doctors that he had pancreatic cancer, a highly deadly cancer that kills most people who have it within five years.

If you look at the details of the story (Skeptigirl already linked to a synopsis), you can tell that Mongerson would not have been told that he had pancreatic cancer. One does not make a diagnosis of pancreatic cancer on the basis of an elevated lipase - not even close. In 1980, the ability to rule-out pancreatic cancer would have been limited to exploratory surgery, and that would have been what the doctors were recommending. So it isn't even an example of medical misdiagnosis - merely a recommendation to rule-out an unlikely, but potentially serious condition.

Linda

[fls]

Aren't doctors who are paternalistic less likely to gather that relevant information?

Not necessarily.

Whereas TAM would discuss treatment options for generalized anxiety, the Bad Paternalistic Doc would take note of the symptoms and prescribe whatever he, in his clinical judgment, just thought was the most effective treatment.

But since being rushed and not gathering relevant information doesn't really have anything to do with paternalism, let's say that the paternalistic doc prescribed whatever she/he thought was the most effective treatment, taking relevant information into account. Is there anything wrong with that?

Linda

[fls]

1. I think that all of them can be relatively equal in efficacy, and that there are other factors besides efficacy to consider. For instance, maybe the patient does not want medication. Or maybe the patient does not want to take anything with addiction or abuse potential.

If no treatment is roughly equal in efficacy, why would you even mention other treatment options?

2. I never said that choices are not influenced. Your example, about Physician choice being synonymous with paternalism and arrogance, is (A) extreme, and (B) Not what I said, anywhere in my posting.

Oh no. I wasn't implying that you said that or that that was your implicit opinion. That was meant to be an indication of how paternalism was being presented in this thread - not by you, but by others.

Linda

[fls]

Someone earlier in the thread said that they often find Linda's posts opaque. I was going to respond but forgot, so thank-you for providing me with the opportunity now. What I was going to say to this person was:
If you find Linda's posts opaque, that it not a criticism of her.

That was Professor Yaffle, but I don't think the comment was meant as a criticism as much as it was an explanation for why she was attempting to restate my position.

Criticism is okay anyway.

But thanks for understanding.

Linda

[BillyJoe]

3. I admit that Drug Reps bring information and talking points that are MEANT to influence my decision making concerning drug choice. Yes I take the information, but what influences my drug choice (as I have told reps to their faces) is not their talking points, or a single small or medium study funded by their company, but metanalysis of many DBRCTs, as well as unbias expert medical opinion. Is it possible that they are influencing my choice in some small, unnoticed way...perhaps, I am not claiming to be perfect, but their influence is minimal.

The millions spent by pharmaceutical companies on Drug Reps, and through them, on doctors, would suggest that this is not generally true. I think it is also possible that you are being influenced far more than you realise. If their information is biased, why do you not just refuse to see them and spend your time more productively?

BJ

[fls]

3. I admit that Drug Reps bring information and talking points that are MEANT to influence my decision making concerning drug choice. Yes I take the information, but what influences my drug choice (as I have told reps to their faces) is not their talking points, or a single small or medium study funded by their company, but metanalysis of many DBRCTs, as well as unbias expert medical opinion. Is it possible that they are influencing my choice in some small, unnoticed way...perhaps, I am not claiming to be perfect, but their influence is minimal.

TAM:)

If you are getting something from them that is useful - samples for patients, reference material, food, eye candy - then even just a sense of reciprocity can lead to influence. If you are not getting something useful from them (and technically, the last two examples don't actually benefit the patient ;)), why are they even around?

Linda

[T.A.M.]

If no treatment is roughly equal in efficacy, why would you even mention other treatment options?



Oh no. I wasn't implying that you said that or that that was your implicit opinion. That was meant to be an indication of how paternalism was being presented in this thread - not by you, but by others.

Linda

Because what I determine as the best treatment, may not sit with the patient as the avenue they wish to go down.

I may suggest psychotherapy and an SSRI as the treatment option I think they should avail of, but that does not mean it is the one they wish, and if there are other options that will help them (psychotherapy alone, psychotherapy and a Benzo) then I have to at least provide them with those options as options, do I not? Perhaps we will have to agree to disagree on this one, but it is the way that I practice.

TAM:)

[T.A.M.]

If you are getting something from them that is useful - samples for patients, reference material, food, eye candy - then even just a sense of reciprocity can lead to influence. If you are not getting something useful from them (and technically, the last two examples don't actually benefit the patient ;)), why are they even around?

Linda

As I said, I am human, so of course there is SOME influence, but in my case, I feel it is minimal.

I love the eye candy reference, btw, as it is striking how much they try to make that play a role.

TAM:)

[kellyb]

Yeah...was that suppose to have refuted my statement?
How could it? Your statement was a suggestion.


A doc who ignores a patient's social situation and preference is incompetent. It is a definite way of not having your patient follow through with their treatment.

"Mr Soandso, you have strep throat. Here are some antibiotic pills for it that you have to take for one week. Bye." Mr. Soandso hates taking pills. He take 2 days of antibiotics before stopping because he feels better. Later on he comes back with a peritonsilar abscess. This could've been fixed by offering Mr. Soandso a single intramuscular shot of penicillin.

"Mrs. Soandso, you have a mild pneumonia. Here is some antibiotics for it."
She tries to fill the prescription but its costs $800 because her insurance does not cover that brand. She decide she won't fill it due to the price. This could've been solved by giving an alternate and cheaper antibiotic.

Tell me. Was any of the above not medically appropriate?

"Incompetent" seems like a very harsh judgement, and I have a hard time thinking it's appropriate for physicians who prescribe evidence based treatments within the standard of care.

Those two examples do seem medically appropriate, just not ideal. Do you really think those are examples of incompetence?

[Ivor the Engineer]

Linda, TAM, Dr. Imago, Pax, Skeptigirl, DeeTee and any other medical professionals who wish to answer:

What do you think your error rate is?

[T.A.M.]

Define "error" for starters.

Are you asking me what % of the time I get the diagnosis wrong?

TAM:)

[kellyb]

Not necessarily.



But since being rushed and not gathering relevant information doesn't really have anything to do with paternalism, let's say that the paternalistic doc prescribed whatever she/he thought was the most effective treatment, taking relevant information into account. Is there anything wrong with that?

Linda

Hmm...
I still think paternalistic docs are less likely to gather relevant information. If the doc does gather the relevant information, and communicates the rationale behind the treatment choice to the patient and the patient agrees, then it can't be paternalistic. That's just "patient centered care" coming from a very competent physician.
While I guess it's possible that a doc (in a non-emergent, PCP setting) could gather all the relevant info and not have an open line of communication with the patient about the prescribed treatment, it's difficult to imagine.
A doctor that communicates with their patient isn't paternalistic-seeming from the patient's point of view.

[Ivor the Engineer]

Define "error" for starters.

Are you asking me what % of the time I get the diagnosis wrong?

TAM:)

What % of the patients visits you have in a year do you reach an incorrect diagnosis?

[Ivor the Engineer]

Yeah, I always get those two mixed up. It's because "drugs" and "diagnosis" both start with "d". Damn mnemonics.

<snip>

I didn't say you got them mixed up. I said you were confounding the two.

I'm not disputing that it can be determined by the patient. I'm pointing out that it has been assumed that the result will be in the best interests of the patient when there is evidence that suggests otherwise. It seems that the perception of patient autonomy is valued more than maximizing health. I'm not saying that those priorities are wrong, just that we shouldn't pretend otherwise.

Linda

What evidence?

[T.A.M.]

What % of the patients visits you have in a year do you reach an incorrect diagnosis?

I would say about less than 5% for sure. Most of that comes from, however, a combination of correct diagnosis, and a fair few where I admit to the patient that their diagnosis could be a couple of things.

For instance,

Patient presents with headache, fever, maxilla pain, green nasal discharge, and cough.

So I will tell my patient,

"This is likely a case of viral rhinosinusitis. However, it may develop into a bacterial sinusitis. In that case you may need antibiotics."

Or, for instance,

25y male patient presents with daily epigastric pain worse with foods, and occasionally with nausea, no radiation of the pain no exertional pain. Exam reveals little to nil on that day.

So I tell my patient,

Your pain may be due to Reflux (GERD), but there is a chance it could be pain secondary to Gallstones. We can either try a week or two of a medicine for reflux, to see if it resolves, or we can proceed to Ultrasound, and wait and see...any further attacks, and to the ER for bloodwork and that Ultrasound.

So in the above cases (off the cuff examples), of course I might be incorrect, or I might be correct.

As I have said many times before, medicine is very grey.

for instance, roughly 40% of abdominal pain presenting to an MD will result in no definitive diagnosis.

TAM:)

[Professor Yaffle]

Quick question for Linda: If you had a patient with two different treatment options, with one option slightly superior, in your eyes, but the patient refused to take this option (for seemingly irrational reasons), would you refuse to treat them with the slightly inferior (IYO) option?

[T.A.M.]

Quick question for Linda: If you had a patient with two different treatment options, with one option slightly superior, in your eyes, but the patient refused to take this option (for seemingly irrational reasons), would you refuse to treat them with the slightly inferior (IYO) option?

This goes to the heart of my Generalized Anxiety example.

My preference for the "Optimal" treatment of GAD may be psychotherapy, the initialization of an SSRI, and a temporary dose of a Benzo, to be used for the first few weeks until the SSRI fully kicks in.

However, if the patient says they do not want to take medications at that time, while I might suggest that it is the better option, I sure would say it is fine for them to go with psychotherapy alone, and to come see me if it doesn't work out to their liking.

TAM:)

[JJM]

What % of the patients visits you have in a year do you reach an incorrect diagnosis?You betray your ignorance of the difference considering the variability of biology, as opposed to the certainty of (properly analyzed) structural components. Medicine is more complex than anything you or I (a medicinal chemist do) despite your delusions of grandeur.

[Ivor the Engineer]

"Civil Engineer Ivor, I need a bridge across this ravine."
"Okay, here are the 2 ways we can build it."
"I don't like it. I want it built up side down with laser beams."
"Uh...okay, I could do it this way."
"No, I want it with laser beams and Swiss cheese."
"But the bridge will collapse."
"Why are you so paternalistic? Why don't you respect my autonomy?"

Now either my communications skills suck, or your reading comprehension does. From what I have said the conversation would go as follows:

"Civil Engineer Ivor, I need a bridge across this ravine."
"Okay, here are the 2 ways we can build it."
"Could you explain the pros and cons of the 2 methods?"
"Sure. The first method has pros p11, p12 and p13, and cons c11, c12 and c13. The second method has pros p21, p22, p23, and cons c21, c22, c23."
"Hmm. I'm a bit confused by what you mean by p12 and c23. Could you explain those in more detail?"
<Ivor explains p12 and c23 in detail, translating the jargon into english.>
"Ok, I understand the differences between the two methods much better now, and I'm thinking I prefer method two, though I'm a bit concerned by c23. Is there another way to build the bridge which would remove it?"
<Ivor thinks hard.>
"I'm not sure. Let me have a look on the net."
<Ivor turns screen so customer can see it and goes to a reliable source of information on bridge construction.>
"You're in luck! Looks like there's a new version of widget X for option 2 which removes c23. It adds about 10% more on the price though."
"Ok then, I think I'm willing to pay a bit more to remove c23. When can you start construction?"

...

[Ivor the Engineer]

You betray your ignorance of the difference considering the variability of biology, as opposed to the certainty of (properly analyzed) structural components. Medicine is more complex than anything you or I (a medicinal chemist do) despite your delusions of grandeur.

Well given you know **** all about what I do, how can you say that?

[kellyb]

What evidence?

I'm looking around, and most of the evidence seems to suggest a positive effect of patient centered care.
I have found this, though:
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1466873
Which seems to be saying that the effect might be some weird varient of the placebo effect. Which would explain why people who see naturopaths swear their quack brings them "better health than any allopath ever did."
I'm still looking for evidence that real MD's who deliver patient centered care have worse outcomes than those who don't.

[kellyb]

This goes to the heart of my Generalized Anxiety example.

My preference for the "Optimal" treatment of GAD may be psychotherapy, the initialization of an SSRI, and a temporary dose of a Benzo, to be used for the first few weeks until the SSRI fully kicks in.

However, if the patient says they do not want to take medications at that time, while I might suggest that it is the better option, I sure would say it is fine for them to go with psychotherapy alone, and to come see me if it doesn't work out to their liking.

TAM:)

That's quintessential "patient centered care", isn't it?

[kellyb]

Still looking for evidence that patient centered care might deliver worse outcomes than the alternative method...
Nothing yet, but this is interesting:

http://www.ncbi.nlm.nih.gov/pubmed/16356677

The moral nature of patient-centeredness: is it "just the right thing to do"?

OBJECTIVE: Patient-centeredness is regarded as an important feature of high quality patient care, but little effort has been devoted to grounding patient-centeredness as an explicitly moral concept. We sought to describe the moral commitments that underlie patient-centered care. METHODS: We analyzed the key ideas that are commonly described in the literature on patient-centeredness in the context of three major schools of ethical thought. RESULTS: Consequentialist moral theories focus on the positive outcomes of providing patient-centered care. Deontological theories emphasize how patient-centered care reflects the ethical norms inherent in medicine, such as respect for persons and shared decision-making. Virtue-based theories highlight the importance of developing patient-centered attitudes and traits, which in turn influence physicians' behaviors toward their patients. CONCLUSION: Different ethical theories concentrate on different features of patient-centered care, but all can agree that patient-centeredness is morally valuable. PRACTICE IMPLICATIONS: In order to sustain patient-centeredness as a moral concept, practitioners and students ought to examine these ideas to determine what their own personal reasons are for or against adopting a patient-centered approach.

Not that the paternalism advocates care what we patients think, ;) but I'm going to go out on a limb here and guess that a vast majority of patients would say that yes, it is just the right thing to do on a moral level.

[paximperium]

Now either my communications skills suck, or your reading comprehension does. From what I have said the conversation would go as follows: AND THANKS FOR CREATING A COMPLETELY NEW SCENARIO THAT HAS NOTHING TO DO WITH THE ORIGINAL. Either your reading comprehension sucks or you're dishonestly changing your scenario from an unreasable customer to the most intelligent and well informed customer around so that you don't have to sound so silly. I wonder why?

Here's a modification to change it back to the original:
"Civil Engineer Ivor, I need a bridge across this ravine."
"Okay, here are the 2 ways we can build it."
"Could you explain the pros and cons of the 2 methods?"
"Sure. The first method has pros p11, p12 and p13, and cons c11, c12 and c13. The second method has pros p21, p22, p23, and cons c21, c22, c23."
"Hmm. I'm a bit confused by what you mean by p12 and c23. Could you explain those in more detail?"
<Ivor explains p12 and c23 in detail, translating the jargon into english.>
"Ok, I understand the differences between the two methods much better now, and I'm thinking I prefer method two, though I'm a bit concerned by c23. Is there another way to build the bridge which would remove it?"
<Ivor thinks hard.>
"I'm not sure. Let me have a look on the net."
<Ivor turns screen so customer can see it and goes to a reliable source of information on bridge construction.>
"You're in luck! Looks like there's a new version of widget X for option 2 which removes c23. It adds about 10% more on the price though."
"Ok then, I think I'm willing to pay a bit more to remove c23. When can you start construction?"
"Hmmm...interesting plan but I still want lasers and I want it made with swiss cheese."
"But that's just silly."
"If you don't do as I say, you're disrespecting my autonomy.

"Civil Engineer Ivor, I need a bridge across this ravine."
"Okay, here are the 2 ways we can build it."
"So which is better?"
"So here are the pros and cons..etc."
"I don't get it."
"Well...blah blah blah."
"Uh...okay. Which do you recommend?"
"I suggest A."
"Uh...is it cheaper?"
"No it's actually more expensive."
"Why?"
"Well...blah blah blah."
"Uh...<blank stare> Are you sure we should go with A?"
So what are you going to do Ivor, is there autonomy here or informed consent or are you going to be paternalistic and choose for this customer?

[paximperium]

"Incompetent" seems like a very harsh judgement, and I have a hard time thinking it's appropriate for physicians who prescribe evidence based treatments within the standard of care.
Medically appropriate but ineffective and ultimately useless.
If I had a choice of using 2 antibiotics, one cheap but less effective and one expensive but marginally better, the medically appropriate treatment would be the second choice unless the patient can't afford it.

Those two examples do seem medically appropriate, just not ideal. Do you really think those are examples of incompetence?
Yes. Old joke, "I cured Mr X's stab wound but he died from an infection."
A dead or untreated patient due to the doctor's part is a failure. A doctor who does not maximize the success rate of his/her treatment from pure arrogance is incompetent.

[Ivor the Engineer]

Ah, I see, you believe most patients are unreasonable and/or thick, so the best strategy is just to treat everyone like a stupid child.

While I'm sure that works in ER, I doubt it would be very successful in family practice, or any place where you might have to interact with the patient for months if not years.

I think you should have a word with TAM, it sounds like you could learn at lot from him about how to treat people with respect.

[paximperium]

That's quintessential "patient centered care", isn't it? There is a spectrum of medical choices that is "medically appropriate" and a patient can choose their treatment within this spectrum. It is the doctor's skill and judgment to pare down all the options available for a patient to decide.

Is it an impingement of autonomy? You betcha.
The Doc has eliminated a bunch of treatment options and will not even offer it to you. Now you have an "illusion" that you have some measure of choice but it is a controlled and already limited one.

So is your autonomy/free in this situation real or an illusion?

[paximperium]

Ah, I see, you believe somemost patients are unreasonable and/or thick, so the best strategy is just to treat someeveryone like a stupid child. Ahhh...so much less straw. Ivor, you can have the straw mannequin back, I'm allergic to such nonsense.

Yes I do. Some people are in fact insane, unreasonable and downright stupid and I have little ethical problem with manipulating them and making decisions for their own good.

While I'm sure that works in ER, I doubt it would be very successful in family practice, or any place where you might have to interact with the patient for months if not years. Beats me, I have a bunch of regulars who seem to love me. Maybe it's the narcotics I dole out.


I think you should have a word with TAM, it sounds like you could learn at lot from him about how to treat people with respect.I treat all patients with respect. I'm working and am a professional. After a conversation with my patients, I can usually figure out who I can give reasonable options to(Would like an IV for your pain or would prefer to try out some pain pills?) or some which I will railroad into doing what I want(Your pain is improving but I'm really worried about an appendicitis. I'm going to do a CAT scan right now.-notice, no options offered?).

I'm also going to make decisions for some of my patients if they are unable to do so. I will not give the drug seeker narcotics just because they are withdrawing. I will not feed someone with a belly infection no matter how much they beg me for water. I will also get my Follow-up Care Nurse to call some of the stupid, demented and insane patients to make sure they are getting better and taking their meds like they are suppose to.

I actually care about the health and lives of my patients more than some silly illusion of autonomy. You can call it paternalism if you wish.

Patients deserve respect to a degree. Bigots on a forum the other hand actually need to earn it.

[kellyb]

Medically appropriate but ineffective and ultimately useless.
If I had a choice of using 2 antibiotics, one cheap but less effective and one expensive but marginally better, the medically appropriate treatment would be the second choice unless the patient can't afford it.

Yes. Old joke, "I cured Mr X's stab wound but he died from an infection."
A dead or untreated patient due to the doctor's part is a failure. A doctor who does not maximize the success rate of his/her treatment from pure arrogance is incompetent.

Huh. I see what you mean, but I'm just not sure patient noncompliance can be blamed on the doc in a case where the patient never volunteered that he hates taking pills.
But I do see what you mean.

[kellyb]

There is a spectrum of medical choices that is "medically appropriate" and a patient can choose their treatment within this spectrum. It is the doctor's skill and judgment to pare down all the options available for a patient to decide.

Is it an impingement of autonomy? You betcha.
The Doc has eliminated a bunch of treatment options and will not even offer it to you. Now you have an "illusion" that you have some measure of choice but it is a controlled and already limited one.

So is your autonomy/free in this situation real or an illusion?

I think the patient autonomy is still very much real. I don't think patients want to be offered obviously bad options. That would be completely pointless.

[T.A.M.]

That's quintessential "patient centered care", isn't it?

yes, yes it is.

TAM:)

[T.A.M.]

I think you should have a word with TAM, it sounds like you could learn at lot from him about how to treat people with respect.

As I have said before, the ER MD diagnostic and treatment algorithms, in terms of patient choice or decision making, can be SIGNIFICANTLY different from the GP clinic ones.

There are many times where the patient does not have either (A) the time (life threatened, clock ticking) or (B) ability (decreased LoC, etc...) to make a decision at all, let alone an informed one.

I have worked both. I worked in a rural ER for 2 years. I have worked as a salaried GP for 1-2 years, and now have been a FFS Physician for 4-5 years.

TAM:)

[kellyb]

yes, yes it is.

TAM:)

Do you know what Linda's talking about with regard to PCC rendering poorer outcomes?
Also (if you don't mind me asking) are you a family doc?

[Dr. Imago]

"Civil Engineer Ivor, I need a bridge across this ravine."
"Okay, here are the 2 ways we can build it."
"So which is better?"
"So here are the pros and cons..etc."
"I don't get it."
"Well...blah blah blah."
"Uh...okay. Which do you recommend?"
"I suggest A."
"Uh...is it cheaper?"
"No it's actually more expensive."
"Why?"
"Well...blah blah blah."
"Uh...<blank stare> Are you sure we should go with A?"
So what are you going to do Ivor, is there autonomy here or informed consent or are you going to be paternalistic and choose for this customer?

Another important difference is that a civil engineering firm, being offered a contract for service, will have months to prepare bids, plan, offer alternatives, etc. After the bid is presented, there will be sufficient time to answer questions, formally respond, etc.

The above type scenario in a doctor's office occurs sometimes 20+ times a day, and often with information that has just been garnered. You have a finite and limited amount of time to get to your "destination" (i.e., agreed treatment decision) with a patient.

Thought I'd point that out. Not enough time to spend with the doc? Again, don't blame us: blame the insurance companies.

~Dr. Imago

[Ivor the Engineer]

I think the patient autonomy is still very much real. I don't think patients want to be offered obviously bad options. That would be completely pointless.

It's not completely pointless. It useful to claim that's what someone was suggesting physicians should do - trying to look clever on the internet by making other people look stupid.

[Ivor the Engineer]

As I have said before, the ER MD diagnostic and treatment algorithms, in terms of patient choice or decision making, can be SIGNIFICANTLY different from the GP clinic ones.

There are many times where the patient does not have either (A) the time (life threatened, clock ticking) or (B) ability (decreased LoC, etc...) to make a decision at all, let alone an informed one.

I have worked both. I worked in a rural ER for 2 years. I have worked as a salaried GP for 1-2 years, and now have been a FFS Physician for 4-5 years.

TAM:)

Yes, and I already said that in those situations where the patient does not have the capacity or time to decide, the physician should use her judgement in the interests of the patient.

But rather than let the meaning of the words in my post sink in, some posters would rather just try to big themselves up by pretending I'm suggesting things I am not.

[Ivor the Engineer]

<snip>

The above type scenario in a doctor's office occurs sometimes 20+ times a day...

<snip>

Which is fine if the patient wants the doctor to make the decision and has made that clear to her.

[paximperium]

I think the patient autonomy is still very much real. I don't think patients want to be offered obviously bad options. That would be completely pointless.
I believe we are mostly in agreement and are now down to semantics. The problem we run into is the threshold for "bad" varies.

What is bad for one patient(Taking pills for 10days) could be good for others (I hate getting a shot). There are obviously bad options and these are easily discarded; the issue is the gray area that doctors have to decide to even offer.

If you have Doctor 1 offer you option A, B and C but are not even offered option D because the evidence for option D is poor as per his conclusion. However Doctor 2 working in the same office offers you option A, B, C and D because he thinks it works based on one study.

Did Doctor A restrict your autonomy by not even offering option D?
What if Doctor A really really really believes option A is the only effective cure and starts to minimize the benefits of option B and C?

[paximperium]

<snip> trying to look clever on the internet by making other people look stupid. Don't blame me for your remarkable ability to do this yourself.
<snip> some posters would rather just try to big themselves up by pretending I'm suggesting things I am not.
Hand waving away exposed garbage by playing the victim. Wow.

[fls]

Because what I determine as the best treatment, may not sit with the patient as the avenue they wish to go down.

I was thinking that the sorts of things that sit with the patient would be included in your recommendation. A simple example would be a generic drug that you have to take four times a day vs. a brand name option that is taken once a day. One patient may find inconvenience more important than expense, while another patient may have it the other way 'round, meaning that each patient would get a different recommendation.

I may suggest psychotherapy and an SSRI as the treatment option I think they should avail of, but that does not mean it is the one they wish, and if there are other options that will help them (psychotherapy alone, psychotherapy and a Benzo) then I have to at least provide them with those options as options, do I not?

How do you think a patient would choose between those three options?

Linda

[kellyb]

Did Doctor A restrict your autonomy by not even offering option D?

I would say "no", because I think good physicians won't (and shouldn't) put a lot of weight in single studies.

What if Doctor A really really really believes option A is the only effective cure and starts to minimize the benefits of option B and C?

As long as he's willing to discuss his thinking and give the patient a quick rundown on what's up, and also consider patient preference [to whatever appropriate extent, depending on the situation] when forming his opinion, that's fine.
If he's familiar with the evidence, and the evidence favors one option as being superior, he doesn't have to hide that or anything.

[Ivor the Engineer]

Don't blame me for your remarkable ability to do this yourself.

Hand waving away exposed garbage by playing the victim. Wow.

I think it must really annoy you to know that EKGs, defibrillators, pacemakers, ultrasound, MR and CT imaging, biometric analysis software, hip and joint replacements, and practically every other thing which enables you to do your job was designed and/or developed by engineers, who had to understand the complexities and uncertainties of human biology and often many other aspects of nature, and designed systems which could cope with them.


Think of me each time you use or encounter one of these devices.:)

[fls]

Hmm...
I still think paternalistic docs are less likely to gather relevant information.

That's because you have formed a picture of paternalism which includes negative characteristics that aren't necessarily part of the philosophy, but now represent its use as a derogative term. I'm asking people to take a step back and consider the philosophy. If that's not possible, then I have suggested that one could substitute "beneficence", since it doesn't seem to have the same baggage. Remember that under most circumstances, the goals and results of patient autonomy and beneficence will be identical.

Using the CMA medical ethics (http://policybase.cma.ca/PolicyPDF/PD04-06.pdf)as a guide, the only point where you can distinguish the two is with the following:

21. Provide your patients with the information they need to make informed decisions about their medical care...

The rest of them are the same, regardless of whether or not the patient is making a choice between numerous options or a doctor is recommending one or a few as the best options.

22. Make every reasonable effort to communicate with your patients in such a way that information exchanged is understood.

23. Recommend only those diagnostic and therapeutic services that you consider to be beneficial to your patient or to others. If a service is recommended for the benefit of others, as for example in matters of public health, inform your patient of this fact and proceed only with explicit
informed consent or where required by law.

24. Respect the right of a competent patient to accept or reject any medical care recommended.

And actually, if you consider the question under consideration to be "I accept or reject the medical care recommended", then the informed consent referred to in #21 also fits with both beneficence and patient autonomy.

If the doc does gather the relevant information, and communicates the rationale behind the treatment choice to the patient and the patient agrees, then it can't be paternalistic. That's just "patient centered care" coming from a very competent physician.

Yet that is a description of the model of care under paternalism.

While I guess it's possible that a doc (in a non-emergent, PCP setting) could gather all the relevant info and not have an open line of communication with the patient about the prescribed treatment, it's difficult to imagine.

Paternalism doesn't preclude communication.

A doctor that communicates with their patient isn't paternalistic-seeming from the patient's point of view.

Exactly! Paternalism is synonymous with arrogance and non-communication, and the examples of why paternalism in medicine is bad are examples of those behaviours.

My interest is not in whether arrogant physicians or those who communicate poorly are preferable (of course they're not). My interest is in the duty of the physician to provide informed consent and which model best represents that ideal.

Linda

[fls]

What % of the patients visits you have in a year do you reach an incorrect diagnosis?

Define "diagnosis".

Linda

[Ivor the Engineer]

Define "diagnosis".

Linda

http://dictionary.reference.com/browse/diagnosis

di⋅ag⋅no⋅sis

1. Medicine/Medical.
a. the process of determining by examination the nature and circumstances of a diseased condition.
b. the decision reached from such an examination. Abbreviation: Dx

[paximperium]

I think it must really annoy you to know that EKGs, defibrillators, pacemakers, ultrasound, MR and CT imaging, biometric analysis software, hip and joint replacements, and practically every other thing which enables you to do your job was designed and/or developed by engineers, who had to understand the complexities and uncertainties of human biology and often many other aspects of nature, and designed systems which could cope with them.
Not one bit. I know the limits of my knowledge and skills. I'm okay with math but mediocre with physics which is why I decided against a career involving too much of it.

One of my college buds has a degree in biology but went on to engineering and is now in biomedical tech and working a new CAT scanners. I only have a rudimentary understanding of these devices. I have little problem in asking for help in areas outside my skillset.

You really need to stop projecting your inadequacies onto others.


Think of me each time you use or encounter one of these devices.:) You want me to think of a jealous, dishonesty and petty online poster whenever I use the GE CAT scanner or Toshiba Ultrasound machine? Uh...sure.

[Ivor the Engineer]

http://dictionary.reference.com/browse/paternalism

pa⋅ter⋅nal⋅ism

n. A policy or practice of treating or governing people in a fatherly manner, especially by providing for their needs without giving them rights or responsibilities.

[kellyb]

That's because you have formed a picture of paternalism which includes negative characteristics that aren't necessarily part of the philosophy, but now represent its use as a derogative term.

Isn't medical paternalism the opposite of the "patient centered care" model?

[Ivor the Engineer]

<snip>

But, hold on, if you want to see the statistics supporting various treatment options, don't you also want to see how such statistics were arrived at? Whether they say what they seem to say? Does that not mean that you willl need to have knowledge about statistical methods used to evaluate clincal trials and therefore additional knowledge about clinical trials and how to evaluate them. If not, why not just stick with the doctor's recommendation in the first place.

It may be that the patient ends up sticking with the doctor's recommendation. But if the doctor can't explain why she's making the recommendation she is in terms the patient can understand, that should raise a red flag.

How much information do you need to give you the illusion that you are participating in the decision making process?

If the doctor is also a skilled magician, not very much.

I based this example on something that happened only a few weeks ago.
In fact, I was grateful that he did NOT interrrupt my busy work schedule to ask me that STUPID question. Going by mileage done, the break pads were due to be changed, but he didn't change them because, in his opinion based on his experience, they would easily last untill the next service, and he told me this when I picked up the car.
A truly professional approach in my opinion.

BJ

Let's just hope you don't end up in a situation where someone can use the fact your brakes weren't changed according to the manufacturer's schedule to sue / not pay you.

[Ivor the Engineer]

Isn't medical paternalism the opposite of the "patient centered care" model?

Not if you make up your own definition of the word.:)

[T.A.M.]

Do you know what Linda's talking about with regard to PCC rendering poorer outcomes?
Also (if you don't mind me asking) are you a family doc?

Yes I am a family doc.

I doubt Linda was claiming that patient centered care results in poorer outcomes. Given this is the trend within the Canadian College, I cannot see them continuing to do so if patient outcome is worsened.

TAM:)

[T.A.M.]

I was thinking that the sorts of things that sit with the patient would be included in your recommendation. A simple example would be a generic drug that you have to take four times a day vs. a brand name option that is taken once a day. One patient may find inconvenience more important than expense, while another patient may have it the other way 'round, meaning that each patient would get a different recommendation.



How do you think a patient would choose between those three options?

Linda

How they chose depends on the patient. Of course, I am influencing them with my suggestion, and I think you and I can agree that that is not paternalism. I have had patients that chose the psychotherapy alone option all the time. I suggest the SSRI and Benzo, and we even have a discussion about the meds and their side effects, but some still decide they do not want them...and I am ok with that, as long as I feel they are informed.

TAM:)

[T.A.M.]

I think it must really annoy you to know that EKGs, defibrillators, pacemakers, ultrasound, MR and CT imaging, biometric analysis software, hip and joint replacements, and practically every other thing which enables you to do your job was designed and/or developed by engineers, who had to understand the complexities and uncertainties of human biology and often many other aspects of nature, and designed systems which could cope with them.


Think of me each time you use or encounter one of these devices.:)

I dunno about Pax, but it does not bother me in the slightest. I appreciate the engineering community and what they contribute to the living and nonliving world.

I would like to think that in most cases it is reciprocated.

TAM:D

[Dr. Imago]

This "patient centered care" stuff... I don't know exactly where you guys are getting this. The entire concept of "patient centered care" is redundant, and I think you are confusing terms. All care is "patient centered".

What I learned in med school are the fundamental ethical principles of patient-physician interaction, and the core concepts that go along with that. Those are: nonmaleficence, beneficence, autonomy, and justice. Provided you are practicing those principles, you are practicing ethically. What you are discussing and calling "patient centered care" is the principle of autonomy. We are all aware of it (at least those of us who were in medical school within the past 10 years), and we all aspire to ascribe to this principle. Paternalism, which is strongly discouraged, would be the opposite of autonomy, and only used in rare circumstances where someone is incapacitated and/or otherwise unable to make their own decisions either by themselves or through a competent surrogate.

Now, if you want to continue to have a discussion on those things, start a new thread, as it may prove to be an interesting discussion. :)

~Dr. Imago

[T.A.M.]

I believe they are referring to this (warning, PDF)...

http://policybase.cma.ca/dbtw-wpd/Policypdf/PD08-02.pdf

TAM:)

[kellyb]

Paternalism, which is strongly discouraged, would be the opposite of autonomy, and only used in rare circumstances where someone is incapacitated and/or otherwise unable to make their own decisions either by themselves or through a competent surrogate.



~Dr. Imago

If paternalism is discouraged (is it a bad thing or a good thing?), then what's Linda talking about here?


http://forums.randi.org/showpost.php?p=4538408&postcount=475

ETA:

This "patient centered care" stuff... I don't know exactly where you guys are getting this. The entire concept of "patient centered care" is redundant, and I think you are confusing terms. All care is "patient centered".

http://www.pbs.org/remakingamericanmedicine/care.html

What is Patient- and Family-Centered Care?
Patient- and family-centered care is an innovative approach to the planning, delivery, and evaluation of health care that is grounded in mutually beneficial partnerships among health care patients, families, and providers. Patient- and family-centered care applies to patients of all ages, and it may be practiced in any health care setting.

[fls]

I didn't say you got them mixed up. I said you were confounding the two.

"confound (mistake one thing for another)"

What evidence?

That people are subject to various cognitive biases when making decisions?

Linda

[fls]

Quick question for Linda: If you had a patient with two different treatment options, with one option slightly superior, in your eyes, but the patient refused to take this option (for seemingly irrational reasons), would you refuse to treat them with the slightly inferior (IYO) option?

Pretending that I practice according to a paternalistic model for the sake of this discussion...

Why would it occur to you that paternalism means that you abandon the patient with little provocation? Paternalism actually proposes that our sense of duty should be excessive, rather than minimal.

Linda

[fls]

I'm still looking for evidence that real MD's who deliver patient centered care have worse outcomes than those who don't.

Why?

Or more importantly, where is there a model of practice that isn't patient-centered for comparison?

Linda

[Ivor the Engineer]

"confound (mistake one thing for another)"

Ok, to be clear, I was using the word in the sense of mingling two different things, not being mistaken about what is diagnosis and what treatment is.

I'm willing to let it drop if you are.:)

That people are subject to various cognitive biases when making decisions?

Linda

Yes, even doctors.

Who could possibly keep their thinking on track while consulting with a patient?

[fls]

Do you know what Linda's talking about with regard to PCC rendering poorer outcomes?

You misunderstood something I said. I didn't say that.

Linda

[kellyb]

Why?

Or more importantly, where is there a model of practice that isn't patient-centered for comparison?

Linda

Well, I guess there's a continum of "patient centeredness" among different physicians.
Here's a PCC study that used audio taping to evaluate the patient centered communication.

http://www.jfponline.com/Pages.asp?AID=2601&UID=

For our observational cohort study data were collected at 5 points: (1) the research assistant identified eligible patients in the physician’s office before the visit; (2) the office encounter was audiotaped and scored for patient-centered communication; (3) the research assistant held a postencounter interview with the patient; (4) we assessed, by chart review, the use of medical care during the 2-month follow-up; and (5) we conducted a follow up telephone interview with patients 2-months after the encounter.

Measure of Patient-Centered Communication Score. The patient-centered communication score is based on 3 of the 6 components of the model of patient-centered medicine.17-20 The first component (exploring the disease and the illness experience) received a high score when the physician explored the patients’ symptoms, prompts, feelings, ideas, function, and expectations. The second component (understanding the whole person) received a high score when the physician elicited and explored issues relating to life cycle, personality, or life context, including family. The third component (finding common ground) received a high score when the physician clearly described the problem and the management plan, answered questions about them, and discussed and agreed on them with the patient. Scoring sheets and procedures are described in detail elsewhere.21 Scores could range from 0 (not at all patient centered) to 100 (very patient centered).

[Skeptic Ginger]

What % of the patients visits you have in a year do you reach an incorrect diagnosis?I misdiagnosed only one patient in 18 years. I missed an adult with Fifth's disease who had an atypical rash.

I have found myself wrong on a regulatory matter every couple years during the time lag after a change occurs before I find out about it, some of which have been important changes. And I've found myself teaching something erroneous every couple years. Any negative consequences of my false information or outdated knowledge has been minimal.

The reason for this record is not because I'm so skilled, it is because I practice in such a narrow specialty.

[kellyb]

You misunderstood something I said. I didn't say that.

Linda

Ivor said:


Once a diagnosis has been made and there are multiple courses of action to choose from, the physician should explain each one in an unbiased way and discuss with the patient which one is appropriate, which can be primarily determined by the patient.

Which is the "shared decision making" part of "patient centered care" (as opposed to the paternalistic model).

...And you said:

I'm not disputing that it can be determined by the patient. I'm pointing out that it has been assumed that the result will be in the best interests of the patient when there is evidence that suggests otherwise.

So...what did you mean?

[Skeptic Ginger]

Still looking for evidence that patient centered care might deliver worse outcomes than the alternative method...
Nothing yet, but this is interesting:

http://www.ncbi.nlm.nih.gov/pubmed/16356677





Not that the paternalism advocates care what we patients think, ;) but I'm going to go out on a limb here and guess that a vast majority of patients would say that yes, it is just the right thing to do on a moral level.What makes you think paternalistic and patient centered are necessarily mutually exclusive?

[Skeptic Ginger]

Isn't medical paternalism the opposite of the "patient centered care" model?No.

[Skeptic Ginger]

This "patient centered care" stuff... I don't know exactly where you guys are getting this. The entire concept of "patient centered care" is redundant, and I think you are confusing terms. All care is "patient centered"....Exactly. And if it weren't it wouldn't be good care.

[kellyb]

No.

Everything I'm reading says it is.
Like:

http://www.physiciansnews.com/spotlight/1106.html

The term "patient-centered" care seems to have its origins as a reaction to paternalistic "doctor-centered" health services.

http://journals.lww.com/co-criticalcare/Abstract/2008/12000/Medical_decision_making__paternalism_versus.15.asp x

Medical decision making: paternalism versus patient-centered (autonomous) care