Why Doctors Hate Science [Archive] - Page 3

Skeptic Ginger

21st March 2009, 06:54 PM

I'm still going with self fulfilling prophesies here.

I come from a nursing background. And we've had extensive discussions about the paternalistic medical model vs the more 'autonomous patient' nursing model on this forum before. I find many patients ask that I take more of a paternal medical role in our interaction while others do not. "I don't know, you tell me" is a frequent response when I give a lot of information in the belief the patient can choose the best option when there are more than one.

As a health care consumer, and coming from a long history of having to assert a collegial role in the doctor/nurse relationship (in the old days ;) ), I am sensitive to an overly paternalistic doctor. But they are rare. They most definitely are not common.

The experience I had with the doctor who didn't want to give me credit for knowing my own diagnosis was new. She was not used to her role and was threatened by my confidence. But I'm sure after a couple years, she would have had enough confidence to not be threatened by a patient's competence. I think that was more from her inexperience than her paternalism.

Skeptic Ginger

21st March 2009, 07:02 PM

Everything I'm reading says it is.
Like:

http://www.physiciansnews.com/spotlight/1106.html

http://journals.lww.com/co-criticalcare/Abstract/2008/12000/Medical_decision_making__paternalism_versus.15.asp xFrom your second link:Although it is clear that a shared decision approach is popular and desirable to some, it is not universally favored; some patients prefer to leave final treatment decisions up to the doctor.That's exactly what I said.

The first article is talking about good nursing care.JW: Merely telling someone they have a scientifically validated risk factor, such as a high BMI, or prescribing insulin for validated hyperglycemia will not result in as good an outcome, in terms of diabetic control and weight reduction, as providing the information and insulin in a patient-centered collaborative context, so that the patient can become confident in managing both the blood sugar and weight. You can’t get all the way just by handing out scientifically validated pills, for example, if the patient has other issues and won’t take the pills. Any good nurse knows this.

But in past discussions about this very thing, it seems to me that the majority of the physicians on the board did as well. The consensus, if I recall, was that medicine and nursing overlapped in both directions.

kellyb

21st March 2009, 07:04 PM

I'm still going with self fulfilling prophesies here.

Maybe. I see FPs when I can, and like the patient centered, shared decision making style TAM uses. For my last baby, part of my pregnancy was with an OB who I didn't like (for reasons way beyond paternalism) so I switched to an FP, who provided care a lot more similar to the midwife model of care, it appears. And it was glorious.:D

T.A.M.

21st March 2009, 07:57 PM

I have a patient, a little boy, who has a very rare (about 1 in 500,000 to 1 in 1,000,000 incidence) disorder. When we (myself, his mother, and the specialist I sent him to) finally figured out what he had, I said to the mother,

"This is going to be a journey in learning for both of us. The difference is, he is your only 'patient', where as I have thousands. You will end up teaching me about his condition."

TAM:)

fls

21st March 2009, 08:01 PM

Isn't medical paternalism the opposite of the "patient centered care" model?

No, beneficence is patient centered.

Linda

fls

21st March 2009, 08:24 PM

Yes, even doctors.

Exactly. There's no reason to hold lay-people exempt from those processes we have already documented with respect to decision-making in medicine when studying doctors. Except that it lacks those features which mitigate bias (experience, feedback, accountability, training, awareness of alternatives, etc.)

Linda

fls

21st March 2009, 08:31 PM

So...what did you mean?

Cognitive errors lead to errors in decision-making. Certain circumstances and strategies reduce these errors. Some of these circumstances and strategies are not available to lay-people.

Linda

kellyb

21st March 2009, 08:34 PM

No, beneficence is patient centered.

Linda

Do you agree with this?

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

Many patients
may not be prepared or ready for absolute autonomy,
and may be best served by a model that he calls
“guided paternalism” whose objective is to strive to
enhance and optimise the patient’s autonomy(17).
This approach, while acknowledging that the final
say should ultimately reside with the patient who
has to live with the consequences of the medical
decision, stresses on responsibility of the patient(16),
and the effectiveness of the clinical management.
As a “deliberative model”(8), it sees the physician as
a teacher and a friend who helps the patient in value
clarification and in processing the various potential
interventions. The aim is not only to discuss what
the patient could do, but also what the patient
should do in a particular situation. This will help the
patient to formulate plans and make decisions that
are most authentic and relevant to him. Such a model
that provides for professional guidance is especially
relevant in this Internet age, where patients are flooded
with information, some of which are unprocessed
and lack validation. Conceptually, this is consistent
with what Pellegrino and Thomasma advocate as
“true beneficence”(10); the physician’s efforts to help
make decisions in the patient’s best interests should
include facilitating and enhancing the latter’s capacity
for self-determination, in accordance to the patient’s
own perspectives. Beneficence and autonomy are
therefore not conflicting, but congruent principles

fls

21st March 2009, 08:50 PM

Do you agree with this?

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

That essay hits on the same points that I have been making.

Linda

fls

21st March 2009, 09:31 PM

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

The article mentions something that I made brief reference to earlier. Two codes of ethics are quoted and contrasted - one from 1847 and one from 1990.

“The obedience of a patient to the prescriptions
of his physician should be prompt and implicit. He
should never permit his own crude opinions as to their
fitness, to influence his attention to them. A failure in
one particular may render an otherwise judicious
treatment dangerous, and even fatal(4).”
In contrast, AMA’s opinion in 1990 on “Fundamental
Elements of the Patient-Physician Relationship” now
states a radically different position:
“The patient has the right to make decisions
regarding the health care that is recommended by his
or her physician. Accordingly, patients may accept or
refuse any recommended medical treatment(5).”

It is stated that the positions are radically different and that one represents paternalism and the other autonomy, yet the meaning of both is essentially the same. A physician makes a recommendation and the patient accepts or refuses that recommendation - even a paternalistic physician does not have the benefit of force, and even the autonomous patient has been presented with a set of instructions which requires her/his attention. It seems that the perceived difference between the two is really in how the patient's behaviour would be characterized if they refused. If it is negative, the physician is paternalistic, if it is neutral or positive, the patient is autonomous.

Linda

kellyb

21st March 2009, 09:37 PM

That essay hits on the same points that I have been making.

Linda

Gotcha.

I think “true beneficence” is a good thing. As long as there's a lot of dialogue about the best options and why one treatment is being chosen, it doesn't matter (sometimes...it depends on the situation) if the physician "lets" the patient choose. And the patient does still have autonomy in that situation, if the physician is choosing the treatment based on (in part, when applicable) patient values and their particular circumstances.

Like, if TAM were our doc and I showed up with anxiety, and he'd been our doc for 5 years and knew me really well, he'd probably say "Since I'm guessing you'd prefer to try non-drug methods first, I'm going to refer you to so and so"...which wouldn't "lock me out" of saying "Actually, normally I would prefer that, but right now there's this unusual situation in my life where I need whatever works the fastest, so if a pharmaceutical might be the best bet, I'd like to talk about that option." Or whatever. It's really just a matter of two-way communication.

ETA:
It seems that the perceived difference between the two is really in how the patient's behaviour would be characterized if they refused. If it is negative, the physician is paternalistic, if it is neutral or positive, the patient is autonomous.
Yeah, it is.
Well, and the "crude opinions" part isn't PC now. lol

kellyb

21st March 2009, 09:58 PM

“The obedience of a patient to the prescriptions
of his physician should be prompt and implicit

The word "obedience" is kind of loaded now, too. Maybe it wasn't in 1847.
The evolution of the wording "obedience" to "compliance" to "adherence" does reflect a genuine philosophical shift, I think, with regard to patient autonomy.

And to bring this full circle to the original topic of the thread, while I totally support comparative effectiveness research, I do worry about the potential of third party payers to limit patient autonomy by using p4p measures to manipulate doctors.
I'm a little paranoid about insurance companies becoming the new ultimate medical patriarch, since they have no code of ethics.

BillyJoe

22nd March 2009, 03:28 AM

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.
What has "the doctor explaining why he is making a recommendation" to do with the question of patient autonomy.

If the doctor is also a skilled magician, not very much.
Well, perhaps I'll expose the doctor's magic trick: The more information he gives you, the less able you will be to make a decision.
What I have actually exposed here, of course, is the illusion of patient autonomy.

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.
Nice diversion.
I'm not sure it had anything to do with the manufacturer's recommendations. Presumably brake pads have a certain average life that is affected by many variables including how heavily he applies the brakes and how often he needs to use them (infrequent for country drivers and often for city drivers for instance).
But, if you remember, I said it was his opinion, based on his experience, that the brake pads would last way past the next service and that he would check them again then.

BillyJoe

22nd March 2009, 03:41 AM

"I don't know, you tell me" is a frequent response when I give a lot of information in the belief the patient can choose the best option when there are more than one.

Congratulations, skeptigirl, you have just exposed patient autonomy.

Maybe you should all give your patients as much information as possible.
It will surely kill off all this nonsense about patient autonomy.

BillyJoe

22nd March 2009, 03:49 AM

I have a patient, a little boy, who has a very rare...I said to the mother,

"This is going to be a journey in learning for both of us. The difference is, he is your only 'patient', where as I have thousands. You will end up teaching me about his condition."

Let's hope she treats him more as her son than as a patient.

I have an acquaintance who used to bragg how he showed up his wife's doctors for their lack of knowledge about her condition that he had extensively looked up on the internet.

BillyJoe

22nd March 2009, 04:06 AM

It is stated that the positions are radically different and that one represents paternalism and the other autonomy, yet the meaning of both is essentially the same. A physician makes a recommendation and the patient accepts or refuses that recommendation - even a paternalistic physician does not have the benefit of force, and even the autonomous patient has been presented with a set of instructions which requires her/his attention. It seems that the perceived difference between the two is really in how the patient's behaviour would be characterized if they refused. If it is negative, the physician is paternalistic, if it is neutral or positive, the patient is autonomous.

The doctor's magic trick, "The Illusion of Patient Autonomy", is achieved by keeping a neutral or positive countenance to distract the patient whilst simulataneously slipping the treatment choice unobtrsively into the patient's cranium.

:D

BillyJoe

Professor Yaffle

22nd March 2009, 05:23 AM

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

I just asked a question, Linda, because you seem to be using the word paternalism differently to some other people in the thread and I was trying to clarify what it meant to you. You seem to be using it as a synonym of beneficience, whereas others on the thread (including some medical types) are not. For example Dr Imago said (my italics added):

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.

So if you offer different alternatives, and the patient decides they don't want the alternative that you consider the best and would prefer a different (less good IYO) option, then you will prescribe their preferred option? If so, how on earth is that an "illusion" of the patient having a choice? Please explain it to me, as I am really not understanding you.

Oh and by the way, I presume Ivor was using the word confound with the definitions "To fail to distinguish; mix up".

T.A.M.

22nd March 2009, 06:20 AM

Let's hope she treats him more as her son than as a patient.

I have an acquaintance who used to bragg how he showed up his wife's doctors for their lack of knowledge about her condition that he had extensively looked up on the internet.

Well knowing this mother, she will be both, but of course, always a mother first. I know you get the point of my comment though, so I will not go into it further.

TAM:)

Toke

22nd March 2009, 06:33 AM

BillyJoe

22nd March 2009, 06:51 AM

First of all, I don't think it's a cost saving to have a blood test before antibiotics.
Secondly I don't think a blood test can distinguish reliably between a viral and bacterial infection.
Thridly, whatever happened to clinical acumen.

fls

22nd March 2009, 07:03 AM

I just asked a question, Linda, because you seem to be using the word paternalism differently to some other people in the thread and I was trying to clarify what it meant to you. You seem to be using it as a synonym of beneficience, whereas others on the thread (including some medical types) are not. For example Dr Imago said (my italics added):

My question was meant to apply under both uses of the term. Is a father expected to abandon their responsibility to a child at the first signs of misbehaviour?

So if you offer different alternatives, and the patient decides they don't want the alternative that you consider the best and would prefer a different (less good IYO) option, then you will prescribe their preferred option?

Why wouldn't I?

I think this goes back to what I mentioned earlier about the characterization of the patient's behaviour when they refuse. If that characterization is negative, then the model is paternalism. And we expect some sort of punishment or censure for negative behaviour. That was why I switched to talking about beneficence, since it doesn't seem to carry that same expectation.

If so, how on earth is that an "illusion" of the patient having a choice? Please explain it to me, as I am really not understanding you.

The illusion is that the choice is fully informed or that emphasizing patient autonomy over beneficence serves/protects the best interests of the patient. That is the major shift from pre to post-Nuremberg medical ethics. And I think that emphasizing patient autonomy does provide better protection against maleficence, which was perhaps the main impetus at the time. But if the only conflict is between beneficence and patient autonomy, then autonomy can only mean that the patient is free to act against their own interest. Whether or not this is 'best' is more of a socio-political discussion.

I see the emphasis on beneficence as placing a greater responsibility on the physician to make sure the patient isn't floundering - to ensure that any choices made adequately reflect the patient's interests.

Oh and by the way, I presume Ivor was using the word confound with the definitions "To fail to distinguish; mix up".

So did I, but he says that he wasn't.

Linda

T.A.M.

22nd March 2009, 07:19 AM

Regarding unneccery procedures/drugs.
My country have a sensibel/strict policy on antibiotic. (except in animalfodder)

I once showed up at the doctor with something that could be either flu or an infection of throut/head cavities. A nurse took a small blood sample, and I was told there were no infection, and I could not get a presciption for antibiotics.

Is that a common test, using a small glass pipe of blood to see if there is bacteria infections?

That is ridiculous.

1. The only test I could see he/she performing on your blood that would in any remote way help would be a WBC count. This would only tell he/she that your body was responding to something by producing an immune response (elevated WBC). It is completely non specific, and useless in this context.

2. Any doctor worth their salt will use their clinical judgement to determine the likelihood of you having a bacterial versus viral infection. Sometimes, in settings where the results are quickly and easily available, a throat swab can be done, but this is only an adjunct to clinical assessment.

eg.

If a patient walks into my office with a "sore throat" I tend to use a scoring system (a recognized, published one) to determine the likelihood of the infection being bacterial...it goes something like this:

Risk Factor= Points
-------------------
Fever= 1
Tender Lymph Nodes=1
Exudate on Pharynx= 1
Absence of coryza=1
Age < 14 = 1

You add up the points, and I do the following,

Score < 4, Sent home on OTC meds and counselled.
Score 4-5, Discussion about, and probable prescription of antibiotics.

The only exception, is the exudative pharynx, which I usually give more weight to. If someone scores a 3, but one of them is the exudative pharynx, I may suggest antibiotics.

TAM:)

fls

22nd March 2009, 07:28 AM

fls

22nd March 2009, 07:30 AM

Toke

22nd March 2009, 07:35 AM

Is that a common test, using a small glass pipe of blood to see if there is bacteria infections?
That is ridiculous.

I have wondered about it, it sounds too usefull to be true without being used more.

It was not the nurse who took the decision, I was checked out by the doctor before being sent home. I just got the impression that the test was her main deciding factor.

Still wonder what the test was for.:confused:

T.A.M.

22nd March 2009, 07:50 AM

Maybe a white blood count plus differential or a CRP? I see both have been tested for utility as a clinical decision tool in related conditions, but I didn't see anything for upper respiratory tract infection. T.A.M. or Pax are more likely than me to know about this as it's a primary/urgent care issue.

Linda

I have not seen CRP used in this context in my province, EVER. Now I have been out of the ER for 4 years, so I suppose they might be using it there...but I highly doubt it.

WBC is so non specific, that it is useless in the context of a throat infection. Viral or Bacterial, the WBC might be up, or might not.

TAM:)

Dr. Imago

22nd March 2009, 08:02 AM

fls

22nd March 2009, 08:42 AM

I have not seen CRP used in this context in my province, EVER. Now I have been out of the ER for 4 years, so I suppose they might be using it there...but I highly doubt it.

Some references:

http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=15353050
http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WJT-4V4PMBX-1&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=ed4855d269c0352ae90a309f20ecd345
http://www.bmj.com/cgi/content/full/311/6999/233?view=long&pmid=7627042

WBC is so non specific, that it is useless in the context of a throat infection. Viral or Bacterial, the WBC might be up, or might not.

TAM:)

Yeah, it seems useful to rule-in some specific conditions (like bacteremia in a febrile child or appendicitis), but I wasn't aware of its use in URTI, even for ruling-out bacterial infections.

Linda

Dancing David

22nd March 2009, 08:53 AM

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

Well, I am sure this is true of most medications but it is very true with mental health.

The drug seeking is just tremendous. As a case manager and a crisis clinician, this is just a constant issue. And so when people start saying certain clues and present with a certain history you begin to wonder if it is efficacy of treatment or life style issues that predominate. requests for Ativan and Xanax were always warning signs.

Mental health treatment is very difficult at times and BOTH the doctor and patient have to show patience and resilience with each other. there are those treatment refractory cases that are just hard to treat, especially psychotic depression.

On the other hand getting clients to STOP using alcohol and street drugs was quite a challenge as a case manager.

Toke

22nd March 2009, 09:21 AM

Linda,
Thanks, that makes sense to me.
A blood sample as a help to determine whether a sinus infection is bacterial and would benefit from antibiotics or not.

I just remembered it as a straith yes/no answer to bacterial infection or not.
And wondered why it is not used more.

T.A.M.

22nd March 2009, 11:54 AM

Toke,

It is likely not used more often because it not that specific (the study says that CRP indicated Bacterial infection, but if you look at what CRP is, it goes up with an immune response in general, so I think it misleading to state that it has a high specificity).

That brings me to,

Linda;

The first link is not that much help (as it seems to be looking only at CRP), but the second one I find interesting. It seems the ratio of CRP to neopterin is of significance, and looks very promising.

The big questions

(A) How long does it take to get these results.
(B) What is the cost to the health care system to order these tests, for what amounts to in the vast majority of cases, a viral sinusitis.

Interesting though. I would like to know from pax if he uses it, or any of his colleagues. I would also like to know what % of ERs and what % of GPs are using it. Like I said, here in Atlantic Canada, I do not recall hearing of any of my colleagues using it.

TAM:)

paximperium

22nd March 2009, 12:02 PM

I have not seen CRP used in this context in my province, EVER. Now I have been out of the ER for 4 years, so I suppose they might be using it there...but I highly doubt it.
Nope. Nothing concrete in our ER literature for a CRP for strep throat.
BTW: Isn't the strep pharyngitis scoring system shown to be terribly unreliable? I like my Rapid Strep test.

paximperium

22nd March 2009, 12:04 PM

Yeah, it seems useful to rule-in some specific conditions (like bacteremia in a febrile child or appendicitis), but I wasn't aware of its use in URTI, even for ruling-out bacterial infections.Uh unfortunately no. I believe the sensitivity and specificity for appendicits is only in the mid to high 50s and even in childhood bacteremia isn't all that good either, the blood culture is usually more useful.

fls

22nd March 2009, 12:25 PM

Uh unfortunately no. I believe the sensitivity and specificity for appendicits is only in the mid to high 50s and even in childhood bacteremia isn't all that good either, the blood culture is usually more useful.

Yeah, I shouldn't have said "rule-in". What I meant is that these decision tools help you decide whether to even bother performing more definitive tests.

Linda

fls

22nd March 2009, 12:28 PM

paximperium

22nd March 2009, 12:39 PM

I thought the scoring system helped you decide who to perform a Rapid Strep test on?

Linda
I use it that way, someone with 3 or more points gets a rapid strep.
I was just wondering if TAM uses solo.

T.A.M.

22nd March 2009, 12:57 PM

Nope. Nothing concrete in our ER literature for a CRP for strep throat.
BTW: Isn't the strep pharyngitis scoring system shown to be terribly unreliable? I like my Rapid Strep test.

When I was in the ER I used the rapid swabs a lot. Not the greatest of value for me in the clinic setting, or cost effective. Pay for the swab, then I would have to pay a courier to bring it to the lab, then once the lab processed it I would have to receive a call with the results, then I would either (A) get the patient back in again, or (B) waste my time on the phone calling the patient, and then the Pharmacy with a script (if positive). If you knew the number of sore throats I see in the clinic in the run of the day.

I use the scoring system alone, and I find it relatively reliable.

http://www.pubmedcentral.nih.gov/pagerender.fcgi?artid=1239715&pageindex=3

This system is a little more complex (use more factors to arrive at a score) and they have a 71% sensitivity, 71% specificity.

I guess, in a perfect world, where easy access to the most effective test were inexpensive and at your fingertips, I would do as I did in the ER, which is pretty much as Pax does, swab those you suspect, and treat those that are positive.

However, in the real GP clinical world, where you pay for the swab, and you pay for the courier, and you pay for the time you are on the phone (you do not get paid to be on the phone with pharm or patient), one has to sometimes compromise.

On average, I treat with antibiotics, about 1 in every 10 cases of sore throat. That is about 10%, so I do not think I am doing too bad.

As soon as the provincial govt coughs up the money to order CRPs, and pay for Rapid Swabs and all the costs of processing it from the satellite GP clinics, then I am in...like Flynn.

As I am sure Pax will attest to, he can score them (and/or simply use his clinical judgement), swab the 3-5 scores, send them back into the waiting room, and in 30-60 minutes his answer arrives in front of him. He then treats and sends...not so easy here.

TAM:)

Ivor the Engineer

22nd March 2009, 01:05 PM

Exactly. There's no reason to hold lay-people exempt from those processes we have already documented with respect to decision-making in medicine when studying doctors. Except that it lacks those features which mitigate bias (experience, feedback, accountability, training, awareness of alternatives, etc.)

Linda

Experience: Familiarity breeds contempt. When a mistake is made and a patient dies, physicians can use the "but the patient would have probably died anyway" excuse to avoid having to examine what went wrong. None of their colleagues are going to rock the boat because they don't want other physicians looking too closely for and at their next cock-up.

Feedback: The feedback physicians get is biased by their belief what they do actually makes a significant difference in most cases. If a physician makes a diagnosis, prescribes a treatment and the patient gets better, the diagnosis and treatment are assumed to have been correct. This line of reasoning is subject to the following two facts:

i) Most people get better with no medical treatment for the majority diseases they get. (Ivor waits for someone to take this statement out of context:))

ii) Many treatments have a wide spectrum of action. The diagnosis may be inaccurate, yet the treatment may still have a beneficial effect.

These make it highly likely physicians will be wildly overconfident in both their ability to diagnose disease accurately and in the efficacy of the treatments they prescribe.

Accountability: From the comments of physicians in this thread (exl. TAM and Dr. Imago) it appears that many of them think their patients are too thick and/or ignorant to know the good diagnoses and treatments from the bad, so it seems a bit of a stretch to then claim they also feel accountable to them when physicians can pull the wool over their patients' eyes whenever they want.

Training: This reinforces physicians' belief in the efficacy of medical intervention and the need to project confidence in the face of uncertainty, a.k.a “bedside manner”.

Awareness of alternatives: Given the enormous variety of medical conditions and treatments available, it is unlikely any physician is aware of all of the alternatives which would be worth considering, and so keep much shorter lists of treatments that have worked in the past.

BTW, I defined 'diagnosis' for you. Could you answer my question please?

And if any physicians are feeling brave they can answer the follow-up:

Of the medical errors you have made, what proportion resulted in the death or permanent injury/disability of the patient?

paximperium

22nd March 2009, 01:08 PM

Does anyone bother to read Ivor's strawmen filled rants anymore?
<snip nonsensical strawman>
Of the medical errors you have made, what proportion resulted in the death or permanent injury/disability of the patient?
None. Thanks for playing.

T.A.M.

22nd March 2009, 01:15 PM

Of the medical errors you have made, what proportion resulted in the death or permanent injury/disability of the patient?

zero.

I am 4 years in General Practice (private) and I have had 8 of my patients die. All of them died of illness they were being appropriately treated for, and none of them died of anything I misdiagnosed.

TAM:)

fls

22nd March 2009, 01:38 PM

Experience:
Feedback:
Accountability:
Training:
Awareness of alternatives:

You misunderstood what each of those factors represents. For example, feedback does not refer to observing what happens after a treatment is prescribed.

BTW, I defined 'diagnosis' for you. Could you answer my question please?

You didn't define 'diagnosis' in a way that was useful. I consider many diagnoses for each case and they can't all be right. Does that mean my diagnoses are mainly wrong and my error rate is high?

And if any physicians are feeling brave they can answer the follow-up:

Of the medical errors you have made, what proportion resulted in the death or permanent injury/disability of the patient?

None.

Linda

Ivor the Engineer

22nd March 2009, 01:51 PM

You misunderstood what each of those factors represents. For example, feedback does not refer to observing what happens after a treatment is prescribed.

Please tell me what you think each of the factors represent.

You didn't define 'diagnosis' in a way that was useful. I consider many diagnoses for each case and they can't all be right. Does that mean my diagnoses are mainly wrong and my error rate is high?

<snip>

http://dictionary.reference.com/browse/diagnosis

1. Medicine/Medical.

di⋅ag⋅no⋅sis

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

I used "the decision reached from such an examination" as the definition of diagnosis.

If you are saying at the end of an examination the list of diseases you treat is greater than one then, excluding correctly identified comorbidities, your error rate is at least 50% by definition.

What definition of diagnosis do you prefer?

Mouthfire

22nd March 2009, 02:17 PM

Experience: [SNIPPED OUT REST]

I think it's becoming abundantly clear that Ivor doesn't understand medicine very well... :(

JJM

22nd March 2009, 02:30 PM

I think it's becoming abundantly clear that Ivor doesn't understand medicine very well... :(Oh noes, not that again. He is a true believer in his beliefs. Now he will waste electrons, not that we need to read his response.

Ivor the Engineer

22nd March 2009, 02:54 PM

The AJoM had a whole supplement May last year on medical error. Here's what's suggested for patients:

http://www.amjmed.com/article/PIIS0002934308001563/fulltext

Patients

Patients obviously have the appropriate motivation to help reduce diagnostic errors. They are perfectly positioned to prevent, detect, and mollify many system-based as well as cognitive factors that detract from timely and accurate diagnosis. Properly educated, patients are ideal partners to help reduce the likelihood of error. For patients to act effectively in this capacity, however, requires that physicians orient them appropriately and reformulate, to some extent, certain aspects of the traditional relationship between themselves and their patients. Two new roles for patients to help reduce the chances for diagnostic error are proposed below.

Be Watchdogs for Cognitive Errors

Traditionally, physicians share their initial impressions with a new patient, but only to a limited extent. Sometimes the suspected diagnosis isn't explicitly mentioned, and the patient is simply told what tests to have done or what treatment will be used. Patients could serve an effective role in checking for cognitive errors if they were given more information, including explicit disclosure of their diagnosis, its probability, and instructions on what to expect if this is correct. They should be told what to watch for in the upcoming days, weeks, and months, and when and how to convey any discrepancies to the provider.

If there is no clear diagnosis, this too should be conveyed. Patients prefer a diagnosis that is delivered with confidence and certainty, but an honest disclosure of uncertainty and the probabilistic nature of diagnosis is probably a better approach in the long run. In this framework, patients would be more comfortable asking questions such as “What else could this be?” Exploring other options is a powerful way to counteract our innate tendencies to narrowly restrict the context of a case or jump too quickly on the first diagnosis that seems to fit.

Be Watchdogs for System-related Errors

In a perfect world, all test results would be reliably communicated and reviewed, all care would be well coordinated, and all medical records would be available and accurate. Until then, the patient can play a valuable role in combating errors related to latent flaws in our healthcare systems and practices. Patients can and should function as back-ups in this regard. They should always be given their test results, progress notes, discharge summaries, and lists of their current medications. In the absence of reliable and comprehensive care coordination, there is no better person than the patient to make sure information flows appropriately between providers and sites of care.

fls

22nd March 2009, 03:20 PM

Please tell me what you think each of the factors represent.

Wouldn't that be a waste of time?

http://dictionary.reference.com/browse/diagnosis

I used "the decision reached from such an examination" as the definition of diagnosis.

If you are saying at the end of an examination the list of diseases you treat is greater than one then, excluding correctly identified comorbidities, your error rate is at least 50% by definition.

Right. Which means that the number is really a measure of the average number of diagnoses on my differential.

What definition of diagnosis do you prefer?

The correct diagnosis was included in those diagnoses given serious consideration.

Linda

Toke

22nd March 2009, 03:22 PM

Toke,

It is likely not used more often because it not that specific (the study says that CRP indicated Bacterial infection, but if you look at what CRP is, it goes up with an immune response in general, so I think it misleading to state that it has a high specificity).

I remember this incident because I was so impressed that it was possible to tell bacterial infection in a few minutes.
That it doesn´t work that simple and certain explains why it is not used more often, and why overuse of antibiotics is a problem.

I recall it as a few minutes to get a result.
What expenses is justified to avoid overuse of antibiotics is a jugdement for the national health autorities, hope they get it right.

I have the impression that antibiotics in animal fodder is a bigger problem.
It translates from danish as "growth enchancers"

Ivor the Engineer

22nd March 2009, 03:29 PM

Wouldn't that be a waste of time?

I don't think so, but you are free to disagree.

Right. Which means that the number is really a measure of the average number of diagnoses on my differential.

Do you think this number could be useful?

The correct diagnosis was included in those diagnoses given serious consideration.

Linda

If you treat a patient for more than one disease and she gets better, how do you determine which disease she had?

fls

22nd March 2009, 03:33 PM

Do you think this number could be useful?

Not really.

If you treat a patient for more than one disease and she gets better, how do you determine which disease she had?

Autopsy.

Linda

Toke

22nd March 2009, 03:41 PM

Nominated
:dl:

Skeptic Ginger

22nd March 2009, 03:42 PM

Congratulations, skeptigirl, you have just exposed patient autonomy.

Maybe you should all give your patients as much information as possible.
It will surely kill off all this nonsense about patient autonomy.I'm not sure I understand your reply here. I do give my patients as much information as possible. I'm saying that in reply some indicate they prefer less information.

Ivor the Engineer

22nd March 2009, 03:43 PM

Not really.

I think seeing how the list changes size over time would be interesting.

Autopsy.

Linda

What fraction of your patients who get better do you send for autopsy?

Skeptic Ginger

22nd March 2009, 03:49 PM

Skeptic Ginger

22nd March 2009, 03:53 PM

...

I have the impression that antibiotics in animal fodder is a bigger problem.
It translates from danish as "growth enchancers"That's because the antibiotics are actually given because they result in larger animals. The drugs are not given for preventing specific infections.

fls

22nd March 2009, 03:58 PM

I think seeing how the list changes size over time would be interesting.

It wouldn't. It's almost entirely dependent upon case-mix.

What fraction of your patients who get better do you send for autopsy?

Well, in a physician-centered model, feedback is more important than autonomy, so quite a few. Wiggling interferes with the gross examination, but this tends to be rectified by the time the heart is weighed.

Linda

kellyb

22nd March 2009, 04:06 PM

kellyb:

I think you are struggling a bit to understand concepts that we already utilize, most of us effortlessly and with aplomb after years of practice, everyday... or you (and Ivor) are trying to conflate the notion of the "self-aggrandizing, unwavering" physician onto the entire profession. That's why I suggested that we discuss the issues separately.

To (briefly) answer a couple of your points...

This "patient-centered care" stuff is redundant, in that (again) all care is patient-centered. It is touchy-feely buzzword nonsense. I already described the ethical principles that guide our patient interaction, and they are all patient-centered. Nobody used the words "patient-centered" in either med school, residency or on the wards. They would get laughed at (i.e., just like we would never use the layman term "partial-birth abortion" in our professional endeavors).

While I could be wrong, I'm pretty sure "patient centered care" (particularly a style of communication, and emphasis on shared decision making) is actually a subject of interest in family medicine. You can even see it reflected in the obgyn guidelines the direct the AAFP vs the ACOG, for example.
Stuff like this:

http://www.annfammed.org/cgi/data/3/4/378/DC1/1

From the early 1980s to the mid-1990s, increasing comfort with the relative safety of TOLAC and rising managed care pressures to control costs appeared to shift options for a woman with a single previous low transverse cesarean from “You must have a repeat cesarean,” to “You may have a trial of labor,” to ”You must have a trial of labor.”
In the early 1990s, concerned that choices for women were being inappropriately limited, the AAFP conducted a comprehensive review and meta-analysis of 292 VBAC studies.1,8 The AAFP meta-analysis showed that women who chose TOLAC had a symptomatic rupture rate that was 24 per 10,000 (0.24%) higher than in women who chose ERCD. While overall maternal outcomes were slightly better with TOLAC, infant outcomes were slightly better with ERCD. The outcomes were thought to be sufficiently similar that the AAFP concluded that the preferences of the woman should determine the mode of delivery.

http://www.annfammed.org/cgi/content/full/3/4/378

The clinical practice guideline published as a supplement to the online version of this issue of the Annals of Family Medicine (http://www.annfammed.org/cgi/content/full/3/4/378/DC1) combines elements both unique and ubiquitous. The guideline, "Trial of Labor After Cesarean (TOLAC), Formerly Trial of Labor Versus Elective Repeat Cesarean Section for the Woman With a Previous Cesarean Section," is unique in that it reflects family medicine’s patient-centered approach to care. At the same time, it embodies the AAFP’s dedication to promoting evidence-based medical practice—a hallmark of all clinical practice guidelines the Academy produces.

My perception might be colored by anecdotes based in coincidence, but I think the AAFP's "uniqueness" in this regard is real, and not just them trying to one up the ACOG or something.

"Patient centered care" is also a political buzzword, in the sense that it's used to promote the IOM's grandiose plan to fix the American healthcare crisis through the "medical home" idea.

"Family-centered care" is something completely different, and a model (currently being pushed in the ICUs) that I think has a noble and admirable purpose, but that I don't necessarily always agree with. In many cases, this can cause sensory and informational overload for the family, along with added emotional stress, and can even result in interference with effective care. I've seen it firsthand.

Ethical principles which guide our care include doing no harm, trying to do what's "right" and best for the patient, allowing the patient (when possible) to decide what's best for him/herself, and trying to use all of the resources at our disposal in a manner that is fair and equitable. In other words, nonmalficience, beneficence, autonomy, and justice.

But, bottom line, this is a decidedly human endeavor, people are not machines where the problem can always be simply isolated and fixed, and to expect perfection - including perfect outcomes - every single time is unrealistic. As a clinician, I try to continuously gage the level of "what my patient needs" and give it to them, in whichever form that may manifest itself. And, that is more art than it is science.

~Dr. Imago

Right. And the way the objectives of nonmalficience, beneficence, autonomy, and justice work out best will vary greatly from one healthcare setting to the next.

Ivor the Engineer

22nd March 2009, 04:07 PM

It wouldn't. It's almost entirely dependent upon case-mix.

<snip>

The case-mix could be accounted for by working back from the final diagnoses. Age, sex and SES of patients could also be controlled for.

Toke

22nd March 2009, 04:37 PM

That's because the antibiotics are actually given because they result in larger animals. The drugs are not given for preventing specific infections.

Yes I know.
Sorry if I was unclear, but the problem I see is multiresistant salmonella in chicken and pork meat. (seems like the perfect way to breed them, (the bugs))
Too much antibiotic for humans gives other problems.

kellyb

22nd March 2009, 04:57 PM

On the subject of "patient centered care" as a political buzzword used to promote the "medical home"....

http://www.aafp.org/online/en/home/media/kits/transformed-nationaldemonstrationproject/transformed.html

Washington, D.C. – In a bold step, family medicine today took the lead in the effort to transform the way primary care is delivered in our country.

TransforMED, an $8 million practice redesign initiative of the American Academy of Family Physicians, today announced the launch of a demonstration project that will test a new and enhanced model of patient care in 36 medical practices across the nation.

The 36 family medicine practices, selected from an applicant pool of more than 300, will undergo transformative change as participants in a first-of-its-kind “proof-of-concept” project. The project aims to determine empirically whether this model of care – the TransforMED Model of Care – can deliver on its promise to improve patient care, patient satisfaction, physician satisfaction and practice performance.

Here are a couple of the practices they selected:

http://www.fmgwmed.com/Mission.php

http://www.harborofhealth.com/services/acupuncture.htm

T.A.M.

22nd March 2009, 05:26 PM

I remember this incident because I was so impressed that it was possible to tell bacterial infection in a few minutes.
That it doesn´t work that simple and certain explains why it is not used more often, and why overuse of antibiotics is a problem.

I recall it as a few minutes to get a result.
What expenses is justified to avoid overuse of antibiotics is a jugdement for the national health autorities, hope they get it right.

I have the impression that antibiotics in animal fodder is a bigger problem.
It translates from danish as "growth enchancers"

I suspect, in the end, as you said, the test was perhaps the tipping point, that made he/she favor antibiotics or not.

The expense of a test is, in part, the domain of health authorities, but when those authorities decide not to pay for it, and throw the cost on to the physician, then it becomes murky. The problem is not the test usually, but the logistics. The courier, for instance, to get the specimen to the lab.

To be honest, I do not think CRP for Upper Respiratory Tracy Infections will catch on. Blood tests cost money, and with the frequency that URTIs present to GP clinics, it might quickly bankrupt the provincial Health Care budget.

TAM:)

fls

22nd March 2009, 06:10 PM

The case-mix could be accounted for by working back from the final diagnoses. Age, sex and SES of patients could also be controlled for.

But all that will really tell you is that Linda really, really doesn't like looking after people who are well and deliberately chooses people with complicated, multi-system problems for her practice - information which is already available for the asking.

Linda

Dr. Imago

22nd March 2009, 06:44 PM

THERE SEEM TO BE A PLETHORA OF TANGENTS AND SIDE-DISCUSSIONS GOING ON IN THIS THREAD... TIME FOR A SPLIT? (In the meantime, I'm going to stick to this one...)

While I could be wrong, I'm pretty sure "patient centered care" (particularly a style of communication, and emphasis on shared decision making) is actually a subject of interest in family medicine.

No, you're not wrong. And, I would even go so far as to say that - dare I use the term - "marketing" to people, both lay and medical (including not only doctors and nurses, but ancillary staff... patient care techs, medical assistants, etc.), may encourage this (what I call) redundancy to get the concept across to EVERYONE involved with the patient's treatment plan.

However...

Don't mistake "autonomy" or "patient-centered care" to mean that the patient gets whatever he/she wants. The diagnosis, treatment, and plan is discussed with the patient, options are given, and the patient can either accept that diagnosis and those options, seek a second opinion, tell the doctor to pound sand, etc.

For example, if a patient, in pain, comes to me and says, "Doc, I've got a pain in my leg, and I want you to prescribe Oxycontin with unlimited refills so I can feel better," I can tell you now that it just ain't going to happen.

This is similar in the way the ACOG approach, in what you reference is, and be careful not to mistake options given as paternalism. As an anesthesiologist, I'm heavily involved in perinatal care of the mother. I offer options, and tell the mother what the plan will be based on certain scenarios. Given a "crash" c-section, or the like, she may not have the option to forgo general anesthesia. The reasons for this are primarily her safety as well as the baby's safety (principle of nonmalficience, which - in this case - trumps autonomy).

There are other instances where beneficence and nonmalficience will trump autonomy, like in an incapcitated patient in the trauma bay or someone who is otherwise incapable of making an informed choice.

I see that far differently than being paternilistic, and that's why using a "patient-centered approach" is really just a dolled-up way of explaining in simplistic terms what we do everyday in the hospital.

By the way, I'm so far derailed right now, someone remind me: What was the point of this thread again? ;)

~Dr. Imago

Dr. Imago

22nd March 2009, 07:10 PM

P.S. Sorry for my spelling in that last post. In the words of Charles Barkley, "It was turrible." (Long weekend, first in a while I didn't have to work. And, lots of basketball.)

~Dr. Imago

kellyb

22nd March 2009, 07:39 PM

THERE SEEM TO BE A PLETHORA OF TANGENTS AND SIDE-DISCUSSIONS GOING ON IN THIS THREAD... TIME FOR A SPLIT?

I actually think all of these tangents are part of the debate presented in the OP.

And, I would even go so far as to say that - dare I use the term - "marketing" to people, both lay and medical (including not only doctors and nurses, but ancillary staff... patient care techs, medical assistants, etc.), may encourage this (what I call) redundancy to get the concept across to EVERYONE involved with the patient's treatment plan.

I think what's being marketed, probably, is the "medical home" and EMR plans to save American healthcare.

Does anyone have an opinion on this?

http://junkfoodscience.blogspot.com/2008/02/welcome-home-medical-home-will-soon-be.html

Right wing woo? True? Some mix? Who knows?

Toke

22nd March 2009, 08:26 PM

I think what's being marketed, probably, is the "medical home" and EMR plans to save American healthcare.

In my unqualified oppinion there is an awfull amount of buzzwords and peptalk.
I balk at thinks like "core values" and "mission statement", the second link in the plan (your previus post) was to acupuncture, that does not improve matters.

It seems to be initiated by pharmaceutical companies, and GM.
Do they really want to reduce cost of healthcare?

BillyJoe

22nd March 2009, 09:12 PM

I'm not sure I understand your reply here. I do give my patients as much information as possible. I'm saying that in reply some indicate they prefer less information.

It was really a redirect to Ivor. I was suggesting that if his doctor gives him as much information as possible, he would finally have to give up and leave it for the doc to decide what the treatment should be, instead of insisting on participating in the decision regarding treatment.

But I think you mean as much information as necessary (tailored to the individual patient).

Skeptic Ginger

22nd March 2009, 11:43 PM

I tend to give too much. It's my chatty style.

BillyJoe

23rd March 2009, 02:42 AM

After the information avalanche I bet they just give up then and say "um...yeah...whatever you think doc"

I think Ivor should attend you for his medical care. Not only would his irrelevant banter not get an airing but, not knowing anymore what he wants and why he should want it, he would likely up arms and surrender "Whatever you say, doc"

Which is really how it ends up the vast majority of the time.
Am I right or am I right?

BJ

Skwinty

23rd March 2009, 02:57 AM

After the information avalanche I bet they just give up then and say "um...yeah...whatever you think doc"Am I right or am I right?
BJ

I would say you are right.
I have just returned from my GP and after me saying I dont think I should have this PSA test due to the current controversy over its efficacy and the follow up there to etc, the Dr says, well and rattles off a whole lot of info and proceeds to say not only will we do the PSA, but also the enhanced supersensitive version as well.
So, what do I say:
Um oh well whatever you say Doc.:)

Ivor the Engineer

23rd March 2009, 03:20 AM

<snip>

There are other instances where beneficence and nonmalficience will trump autonomy, like in an incapcitated patient in the trauma bay or someone who is otherwise incapable of making an informed choice.

<snip>

Nothing "trumps" the autonomy of competent individuals. What seems to be forgotten here that there are two individuals involved, the patient and the doctor.

The doctor has the right to offer whatever treatments she considers appropriate and refuse to preform anything she considers harmful or pointless.

The patient has the right to ask for whatever treatments she wants and refuse any treatments suggested by her physician.

What appears to be the difference of opinion is whether or not patients, in general, have the competence to be able to make an informed choice about accepting or rejecting treatment proposed by a physician.

Ivor the Engineer

23rd March 2009, 03:35 AM

But all that will really tell you is that Linda really, really doesn't like looking after people who are well and deliberately chooses people with complicated, multi-system problems for her practice - information which is already available for the asking.

Linda

I think it would tell me something about the reasoning processes employed by physicians.

What do you think to the suggestion made in the AJoM supplement I linked to for patients being 'watchdogs for cognitive errors during a consultation'? How do these behaviours fit in with the paternalistic model of patient care you are suggesting may be superior to one in which patients take more responsibility for decisions about their healthcare?

Be Watchdogs for Cognitive Errors

Traditionally, physicians share their initial impressions with a new patient, but only to a limited extent. Sometimes the suspected diagnosis isn't explicitly mentioned, and the patient is simply told what tests to have done or what treatment will be used. Patients could serve an effective role in checking for cognitive errors if they were given more information, including explicit disclosure of their diagnosis, its probability, and instructions on what to expect if this is correct. They should be told what to watch for in the upcoming days, weeks, and months, and when and how to convey any discrepancies to the provider.

If there is no clear diagnosis, this too should be conveyed. Patients prefer a diagnosis that is delivered with confidence and certainty, but an honest disclosure of uncertainty and the probabilistic nature of diagnosis is probably a better approach in the long run. In this framework, patients would be more comfortable asking questions such as “What else could this be?” Exploring other options is a powerful way to counteract our innate tendencies to narrowly restrict the context of a case or jump too quickly on the first diagnosis that seems to fit.

Ivor the Engineer

23rd March 2009, 03:43 AM

It was really a redirect to Ivor. I was suggesting that if his doctor gives him as much information as possible, he would finally have to give up and leave it for the doc to decide what the treatment should be, instead of insisting on participating in the decision regarding treatment.

But I think you mean as much information as necessary (tailored to the individual patient).

Ah, but Ivor's doctor is not so arrogant or insecure to think he knows more about a patient's medical condition they they do.

In return Ivor doesn't expect his doctor to be anywhere near 100% accurate.

BillyJoe

23rd March 2009, 04:08 AM

I would say you are right.
I have just returned from my GP and after me saying I dont think I should have this PSA test due to the current controversy [*see below] over its efficacy and the follow up there to etc, the Dr says, well and rattles off a whole lot of info and proceeds to say not only will we do the PSA, but also the enhanced supersensitive version as well.
So, what do I say:
Um oh well whatever you say Doc.:)

:)

Yes, he is the professional and that's why you went to him: for advice.
Pretty silly to ignore it then, hey?
(Real pity that he is wrong though :D)

not only will we do the PSA, but also the enhanced supersensitive version as well
Do you mean the free PSA/total PSA ratio?

This is generally only done when the total PSA is equivocal.
(I know all this stuff - no one can accuse me of not making an informed decision not to have the test ;) )
If your total PSA is equivocal and the free PSA/total PSA ratio is less than 25%, you are in for an ultrasound guided biopsy of the prostate - and still no evidence that any of this is worthwhile!

Don't say I didn't warn you. :D
(Apparently it hurts real bad! :D:D)

regards though,
BillyJoe

* Skwinty is referring to this thread:
http://forums.randi.org/showthread.php?t=137878

BillyJoe

23rd March 2009, 04:11 AM

The patient has the right to ask for whatever treatments he wants...

Right, I'll have $#!+ load of oxycontin thanks.

BillyJoe

23rd March 2009, 04:18 AM

Ah, but Ivor's doctor is not so arrogant or insecure to think he knows more about a patient's medical condition they they do.

Well, like me and my prostate, you are probably a special patient. ;)

In return Ivor doesn't expect his doctor to be anywhere near 100% accurate.

Well, you are one up/down on me. I don't have one yet.

Ivor the Engineer

23rd March 2009, 04:21 AM

Right, I'll have $#!+ load of oxycontin thanks.

BillyJoe's Doctor: "Now Bill, we've been through this before. You can have the drugs after you let me examine your prostate."

T.A.M.

23rd March 2009, 05:02 AM

skwinty:

Did he even mention the DRE? If despite your reservations he is still insistent on the PSA, I guess your options are to go ahead and get it done, and make a stand further up the investigation line, or to chose a new GP, or to simply refuse, and not get the bloodwork done at all. What is he gonna do, spank you?

TAM:)

BillyJoe

23rd March 2009, 05:20 AM

Did he even mention the DRE?
Maybe Skwinty doesn't want to mention it. ;):D

go ahead and get it done, and make a stand further up the investigation lineI think it's going to get harder and harder to make a stand the further up the investigation line he goes.

That's why I've taken a stand right here - before the DRE! :D

BJ

BillyJoe

23rd March 2009, 05:22 AM

Ivor,

You have a cute dog at least.

Skwinty

23rd March 2009, 05:46 AM

As I said in a previous thread, I have had a DRE some years ago. Wasn't the most pleasant of experiences.
anyway, I was at the doc because of the following reasons.
1. I have type 2 diabetes.
2. I contracted influenza, which turned to a bacterial infection as I was taking viral based meds I suppose.
3. this had some unpleasant side effects for me as I had spent 3 days without my diabetes meds, due to unavailability at the pharmacy.
4. I passed out twice in 3 days at work.
5. Glucose levels spiked very high (16) and increased blood pressure, BP normally 120/80 went to 150/100 and experienced intense nausea.

so, off I go to the doc.
couse of action by doctor.

1. Treat the bacterial infection
2. Investigate newer meds for diabetes.
3. Takes blood samples for glucose 3month average, kidney function, liver function, WBC and then the PSA as I have only had 1 PRE before.
4. Results due on wednesday.

I was in no mood to argue with the doctor re the PSA test, so I succumbed. She tells me that the PSA was developed as men don't like the PRE. Can't say I disagree.

Anyway, I feel relatively positive about not being screened as cancer positive as I have a very healthy sex life and have not presented any other related problems.

As for the follow up being painful, I suppose that depends on your personal pain threshold. Mine is quite high as I often tell myself that pleasure and pain are divided by a very thin line.

T.A.M.

23rd March 2009, 09:08 AM

fls

23rd March 2009, 10:46 AM

I think it would tell me something about the reasoning processes employed by physicians.

Like they generate more diagnoses for complicated cases with multiple problems?

What do you think to the suggestion made in the AJoM supplement I linked to for patients being 'watchdogs for cognitive errors during a consultation'?

Sounds reasonable.

How do these behaviours fit in with the paternalistic model of patient care you are suggesting may be superior to one in which patients take more responsibility for decisions about their healthcare?

Why would there be any conflict between beneficence and autonomy in those guidelines?

Oh, I thought of an example. Some possible diagnoses may cause undue and ultimately unnecessary duress. So, one might not mention the possibility of cancer until it has been ruled-in.

Linda

Ivor the Engineer

23rd March 2009, 01:17 PM

Like they generate more diagnoses for complicated cases with multiple problems?

Yes, and I was thinking of the shape (e.g., rate of decay, oscillations) over time.

<snip>

Why would there be any conflict between beneficence and autonomy in those guidelines?

From my understanding of the meaning of 'beneficence' I'm not sure there would be, but you seem to want to use it to describe something I still think would best be described as 'paternalism'.

Oh, I thought of an example. Some possible diagnoses may cause undue and ultimately unnecessary duress. So, one might not mention the possibility of cancer until it has been ruled-in.

Linda

I think that's a bit of a weak reason to keep the patient excluded from the diagnostic process, especially since many patients already believe they (or their children) have the worst disease they can find on the internet which sort-of matches some of the obvious (and possibly imagined) symptoms without any expert to guide them.

Should medical information about illness only be disseminated by physicians at their discretion to avoid members of the lay-public becoming unduly distressed and demanding diagnostic tests which are inappropriate?

fls

23rd March 2009, 01:50 PM

From my understanding of the meaning of 'beneficence' I'm not sure there would be, but you seem to want to use it to describe something I still think would best be described as 'paternalism'.

Nope, I'm describing beneficence.

I think that's a bit of a weak reason to keep the patient excluded from the diagnostic process,

Yeah, I imagine it would only be relevant to someone who takes the feelings of others into consideration.

especially since many patients already believe they (or their children) have the worst disease they can find on the internet which sort-of matches some of the obvious (and possibly imagined) symptoms without any expert to guide them.

Yes, you discover what sorts of things the patient is already worried about. It's usually better to address their specific concerns. It's a delicate procedure, since people don't always want to say their worst fears out loud (somehow it will make it real). But I also take into consideration the value of avoiding needless duress and the problems that come from information overload. Although I admit that I tend to err on the side of too much information.

Should medical information about illness only be disseminated by physicians at their discretion to avoid members of the lay-public becoming unduly distressed and demanding diagnostic tests which are inappropriate?

Of course. That is why the contents of medical journals are not available to the public, medical textbooks and reference materials are protected by secret societies, medical institutions never put up websites with copious quantities of medical information, and you never find physicians taking part in online forums.

Linda

paximperium

23rd March 2009, 01:55 PM

Of course. That is why the contents of medical journals are not available to the public, medical textbooks and reference materials are protected by secret societies, medical institutions never put up websites with copious quantities of medical information, and you never find physicians taking part in online forums.
Hey, I just got back from my secret lab while secretly experimenting on infants. The crying was getting annoying. Our plans are almost complete. Bwahahaha...
Anything new on this thread?

PS: Are you going to the International Medical Cabal meeting(sponsored by Pfiizer) this summer?

T.A.M.

23rd March 2009, 01:59 PM

Hey, I just got back from my secret lab while secretly experimenting on infants. The crying was getting annoying. Our plans are almost complete. Bwahahaha...
Anything new on this thread?

PS: Are you going to the International Medical Cabal meeting(sponsored by Pfiizer) this summer?

I would go but Merck already has me flying down to Ferrari headquarters to pick up my new ride.

TAM;)

BillyJoe

23rd March 2009, 02:03 PM

T.A.M.

23rd March 2009, 02:06 PM

Ivor,

I don't know about you, but, if I have a headache which I suspect may be due to work overload I have been experiening lately, and I haven't immediately jumped to the conclusion that I have brain cancer, I would not appreciate the doc telling this is one of the possibilities, especially as I will now want a CT scan to rule it out and that test, from a medical point of view, may be totally unjustified.

BJ

http://www.medscape.com/viewarticle/496297

TAM:)

BillyJoe

23rd March 2009, 02:08 PM

Are you going to the International Medical Cabal meeting(sponsored by Pfiizer) this summer?
I would go but Merck already has me flying down to Ferrari headquarters to pick up my new ride.

Hmmm...not to derail, but do you actually attend pharmaceutical company sponsored events?

BillyJoe

23rd March 2009, 02:11 PM

http://www.medscape.com/viewarticle/496297

Thanks, that's what I was thinking when I wrote: "and that test, from a medical point of view, may be totally unjustified".
Or do you mean I should have a MRI scan instead?

You found that link pretty damn quick though!

fls

23rd March 2009, 02:13 PM

http://www.medscape.com/viewarticle/496297

TAM:)

Which takes me to a sooper-secret-secure-enter-your-password page...

I hope that was deliberate. :)

Linda

T.A.M.

23rd March 2009, 02:16 PM

That is odd...anyway, google "ct radiation" and it is the 3rd link on the page.

Must have an automatic redirect for people linking the article.

TAM:)

T.A.M.

23rd March 2009, 02:18 PM

Thanks, that's what I was thinking when I wrote: "and that test, from a medical point of view, may be totally unjustified".
Or do you mean I should have a MRI scan instead?

You found that link pretty damn quick though!

yah, it was the 3rd one on google, under CT radiation. I am well aware myself of the large amount of radiation that a single CT can provide, but figured if I posted such without at least a reference, I would be sent to the corner.

TAM;)

T.A.M.

23rd March 2009, 02:20 PM

Hmmm...not to derail, but do you actually attend pharmaceutical company sponsored events?

lol...of course. They are one of many ways of providing me with continued medical education. I do not attend many, as 90% of my CME is through the Canadian College "Self Learning" modules and online CME, but I do go occasionally.

Why do you ask?

TAM:)

BillyJoe

23rd March 2009, 02:30 PM

Well, 10% is not bad I guess. And even the college would tend to bias you towards doing PSA and DRE on everyone ;) males that is (;

Ivor the Engineer

23rd March 2009, 02:42 PM

Nope, I'm describing beneficence.

Then could you point me to a source which more fully explains what you believe the word 'beneficence' mean please?

Yeah, I imagine it would only be relevant to someone who takes the feelings of others into consideration.

Are they the 'feelings of others', or are they feelings you have projected onto them?

Yes, you discover what sorts of things the patient is already worried about. It's usually better to address their specific concerns. It's a delicate procedure, since people don't always want to say their worst fears out loud (somehow it will make it real). But I also take into consideration the value of avoiding needless duress and the problems that come from information overload. Although I admit that I tend to err on the side of too much information.

Has the alternative even been tried? Do medical students fail if they don't follow a particular model of interacting with patients? Are the problems caused because the public expects doctors to treat them in a certain way - if doctors switched to the interactive model would patients get used to it after a while? Would patients then be distressed if a doctor decided to not share information with them about how she was thinking? i.e., is this just resistance to change in spite of likely benefits for patients (and probably doctors too)?

Of course. That is why the contents of medical journals are not available to the public, medical textbooks and reference materials are protected by secret societies, medical institutions never put up websites with copious quantities of medical information, and you never find physicians taking part in online forums.

Linda

Right. So we agree that there is a benefit for the public being more aware of medical conditions and their symptoms.

BTW, it's refreshing to chat to physicians with their hair down.

kellyb

23rd March 2009, 03:09 PM

Must have an automatic redirect for people linking the article.

TAM:)

No, you just have to be registered and logged in, I guess, to see it. It worked fine for me, but I was in medscape last week for something.

Ivor the Engineer

23rd March 2009, 03:27 PM

Ivor,

I don't know about you, but, if I have a headache which I suspect may be due to work overload I have been experiencing lately, and I haven't immediately jumped to the conclusion that I have brain cancer, I would not appreciate the doc telling this is one of the possibilities, especially as I will now want a CT scan to rule it out and that test, from a medical point of view, may be totally unjustified.

BJ

Funny you should mention that. My last visit to the doctor was for persistent headaches I couldn't understand the cause of.

I couldn't get to see my regular doctor and had to see a locum, who just happened to be the doctor from the hospice who looked after my father. Who died of a brain tumor. Though we hadn't met face to face before, I'm sure she recognised my surname.

Yeah, that wasn't too much of an arse-clenching consultation, with me thinking: 'she's thinking I'm some hypochondriac moron who believes Glioblastoma Multiforme is hereditairy', as well as the usual: 'I'm wasting the doctor's time and taking up a slot which someone who is actually sick could be being helped in'. Oh, and I sound even thicker in person than do on the forum*.:)

After explaining the symptoms and why I didn't think it was caused by eye strain or tiredness, she took my blood pressure (pretty pointless for headaches), looked in my ears and then gave the reassuring doctors act, telling me they were tension headaches (I'd already guessed that the night before) and I was probably inducing them myself (i.e. 'the patient is a hypochondriac and thinks he's got a brain tumor') and should take ibuprofen each day until they go off.

I think I have eventually figured out what was causing them. I often sit with my left hand supporting my chin with the elbow on a table. This makes me clench my jaw, which I presume was causing muscle strain on the top of my head. I've stopped sitting like this for so long and the headaches have gone off. On the other hand it could just be a coincidence and it was something else altogether.

*You should see the shock on medical professionals' faces when I ask something intelligent, such as: 'Is that the fovea on my fundus image?' while pointing.

Yuri Nalyssus

23rd March 2009, 03:35 PM

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.
Brilliant, just brilliant. :blush:

Yuri

fls

23rd March 2009, 04:32 PM

Then could you point me to a source which more fully explains what you believe the word 'beneficence' mean please?

http://en.wikipedia.org/wiki/Medical_Ethics#Beneficence

The article that KellyB referenced earlier also covered the same points about the conflict between beneficence and autonomy.

Are they the 'feelings of others', or are they feelings you have projected onto them?

My feelings. I am, of course, completely devoid of insight.

Has the alternative even been tried? Do medical students fail if they don't follow a particular model of interacting with patients? Are the problems caused because the public expects doctors to treat them in a certain way - if doctors switched to the interactive model would patients get used to it after a while? Would patients then be distressed if a doctor decided to not share information with them about how she was thinking? i.e., is this just resistance to change in spite of likely benefits for patients (and probably doctors too)?

This description is simply too far removed from reality to address.

Linda

Yuri Nalyssus

23rd March 2009, 04:34 PM

"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?"
Brilliant etc...

Yuri

paximperium

23rd March 2009, 04:38 PM

Hmmm...not to derail, but do you actually attend pharmaceutical company sponsored events?
Rarely and it isn't easy to avoid either. My ER group's meetings occasionally gets sponsored so I sit through their spiel, have lunch and continue on with the meeting. There's no way to avoid those.

As for one of the large pharma sponsored events in some nice locales, I don't go to those. I do go to paid medical education events in nice places and sometimes there are pharma sponsors but they usually just keep to their booths and have some banners around.

I personally don't like taking stuff from them. I don't even take pens from them. I can buy a pack of 10 good quality pens from Costco. I don't need to beg for freebies and any medical work related spending is tax deductible.

paximperium

23rd March 2009, 04:41 PM

lol...of course. They are one of many ways of providing me with continued medical education. I do not attend many, as 90% of my CME is through the Canadian College "Self Learning" modules and online CME, but I do go occasionally.

Why do you ask?

TAM:)
I get about 50% free from various hospital programs and I pay for about 20% of them. The rest is free on the Internet...gotta love the Internet.

paximperium

23rd March 2009, 04:43 PM

This description is simply too far removed from reality to address.
The leading and loaded questions were a dead give away.

Ivor the Engineer

23rd March 2009, 04:50 PM

The leading and loaded questions were a dead give away.

Nah, Linda always clams up when I ask her tough questions and instead just looks down her nose at me (metaphorically speaking). I've gotten so used to it I wouldn't know what to do if she did something else.

Piscivore

23rd March 2009, 05:00 PM

In most cases, however, patients clients 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 not so rare).

I get exactly the same thing in the auto insurance industry.

T.A.M.

23rd March 2009, 05:18 PM

I get about 50% free from various hospital programs and I pay for about 20% of them. The rest is free on the Internet...gotta love the Internet.

yah when I was working in the ER we needed regularly updated ATLS and ACLS, so you got 25 credits for each, and only need 125 M1 Credits in a 5 year cycle, so it took the burden off.

Working in a rural ER, I was able to get the health care board to pay for mine.

TAM:D

Ivor the Engineer

23rd March 2009, 05:28 PM

http://en.wikipedia.org/wiki/Medical_Ethics#Beneficence

The article that KellyB referenced earlier also covered the same points about the conflict between beneficence and autonomy.

From the wiki page:

In the medical context, this means taking actions that serve the best interests of patients. However, uncertainty surrounds the precise definition of which practices do in fact help patients.

So beneficence in this context is second-guessing what the patient wants.

I'm pretty sure you decided to make me look foolish in another thread for suggesting a similar strategy when no other source of information was available.

My feelings. I am, of course, completely devoid of insight.

I wouldn't say that. You're just doing your bit for the 'JREF medical professionals unified front'.

This description is simply too far removed from reality to address.

Linda

You are of course free to avoid answering any questions you don't want to.

paximperium

23rd March 2009, 05:30 PM

I wouldn't say that. You're just doing your bit for the 'JREF medical professionals unified front'.
Sieg Heil to the JREFMPUF!!!

Ivor the Engineer

23rd March 2009, 05:40 PM

I like to think I'm a healthy option for woo pack hunters who fancy a bit of variety.:)

Aerik

23rd March 2009, 05:40 PM

fls

23rd March 2009, 07:06 PM

From the wiki page:

So beneficence in this context is second-guessing what the patient wants.

Not at all.

I'm pretty sure you decided to make me look foolish in another thread for suggesting a similar strategy when no other source of information was available.

No, that was merely a side effect. It's really the Golden Rule that's foolish.

I wouldn't say that. You're just doing your bit for the 'JREF medical professionals unified front'.

It's JUMP - I think it was choosen to reflect how amenable physicians are to jumping through hoops,*although I missed a few of the meetings near the end.

You are of course free to avoid answering any questions you don't want to.

Pure altruism on my part. You may be familiar with the study where warnings about false claims were remembered as recommendations?

https://pal.utdallas.edu/pubs/publication/download/148

The problem is that "when did you stop beating your wife" questions require extra-sooper-dooper discussion in order to unpack all the assumptions before addressing the statement. All that reinforcement means that you remember the statement "medical students are not taught an interactive model", but after a bit, you no longer remember whether it is true or false. I wouldn't want you to fall for the "if I remember it, it's probably true" trap and blithely use the statement as though it were true. It might be embarrassing if you find yourself in a conversation with people who know that it's false. I wouldn't want that to happen to you.

Linda

*laughing madly at my joke

T.A.M.

23rd March 2009, 08:06 PM

OK, after 11 pages, did anybody else notice that the author of this article erroneously assumes that every hysterectomy removes the cervix? Literally seconds of real research reveals that often there is a part of the cervix left behind, called the supracervical. And you do still need pap smears on that, as it does get HPV, and hence does get cancer.

yes I believe I mentioned that very early in the thread (or was it in another thread). The older the patient, the more likely this is the case, in general.

TAM:)

Edit: yes post #18 in this thread.

TAM:)

Skeptic Ginger

23rd March 2009, 08:31 PM

...

What appears to be the difference of opinion is whether or not patients, in general, have the competence to be able to make an informed choice about accepting or rejecting treatment proposed by a physician.From my perspective, the difference of opinion is in your not recognizing a physician/nurse practitioner usually takes into account the competence of the patient. You have such a narrow black and white view of the patient provider interaction. That's why I say you may be going into a provider's office already convinced of the outcome.

Skeptic Ginger

23rd March 2009, 08:36 PM

Hmmm...not to derail, but do you actually attend pharmaceutical company sponsored events?Yeah, they usually have the best free food to go with the free CME credits one needs to remain licensed.

I too, however, now get most my CE free online. It's just not worth the time it takes for free dinners and lunches when you have an online option.

BillyJoe

24th March 2009, 03:45 AM

Thanks for your responses. It's nice to see a healthy scepticism of the pharmaceutical companies and an awareness of their potential to influence your prescribing behaviour. :)

Ivor the Engineer

24th March 2009, 04:19 AM

Not at all.

How do you determine what is in the best interests of a patient?

No, that was merely a side effect. It's really the Golden Rule that's foolish.

IIRC, I didn’t suggest starting with the Golden Rule, but falling back on it when other sources of information are unavailable. But you saw a chance to assert your superiority and just couldn’t resist.

<snip>

Pure altruism on my part. You may be familiar with the study where warnings about false claims were remembered as recommendations?

https://pal.utdallas.edu/pubs/publication/download/148

The problem is that "when did you stop beating your wife" questions require extra-sooper-dooper discussion in order to unpack all the assumptions before addressing the statement. All that reinforcement means that you remember the statement "medical students are not taught an interactive model", but after a bit, you no longer remember whether it is true or false. I wouldn't want you to fall for the "if I remember it, it's probably true" trap and blithely use the statement as though it were true. It might be embarrassing if you find yourself in a conversation with people who know that it's false. I wouldn't want that to happen to you.

Linda

You might want to check the questions I asked, rather than the questions you thought I asked. Here they are again, split up so we can see which questions are of the form “when did you stop beating your wife?”:

Has the alternative [to the physician hiding her reasoning processes from the patient] even been tried?

Assumes you and the other physicians are being honest when reporting how you practice. Otherwise a perfectly straightforward question.

Do medical students fail if they don't follow a particular model of interacting with patients?

No assumptions in this question. Ironic this was the one you misremembered as being loaded.

Are the problems caused because the public expects doctors to treat them in a certain way - if doctors switched to the interactive model would patients get used to it after a while?

This was in reference to your point about not telling a patient cancer is one of the possible causes of their symptoms until it is ruled-in. As with the first question, it assumes that you and the other physicians haven’t been telling me a pack of lies about how you deal with patients.

Would patients then be distressed if a doctor decided to not share information with them about how she was thinking?

Again, this assumes (based on information provided by you and other physicians) that physicians generally don’t expose their reasoning processes to the patient, but behave instead as medical ‘black boxes’.

i.e., is this just resistance to change in spite of likely benefits for patients (and probably doctors too)?

The assumptions in this question are that physicians generally still practice in a ‘black box’ way, and having patients take an active role in both their diagnosis and treatment would result in benefits for both parties.

Here are the same questions presented in an unloaded way:

1. Has there been any studies performed on what type of doctor-patient relationship produce the best outcomes? If so, did any of them have the doctor being open about her reasoning with the patient?

2. Do medical students fail if they don’t follow a particular model of interacting with patients?

3. In general are physicians open about their reasoning processes with their patients? If not, is this because they believe (rightly or wrongly) that their patients expect them to behave in a certain way?

4. If patients are used to physicians behaving in a particular way, would they be distressed if physicians changed how they behaved? Would this distress be permanent, or would patients get used to the different way of behaving and begin to prefer and expect it after a while?

5. Do physicians resist being moved from their zone of comfort as much as everyone else does?

T.A.M.

24th March 2009, 05:07 AM

Here are the same questions presented in an unloaded way:

1. Has there been any studies performed on what type of doctor-patient relationship produce the best outcomes? If so, did any of them have the doctor being open about her reasoning with the patient?

2. Do medical students fail if they don’t follow a particular model of interacting with patients?

3. In general are physicians open about their reasoning processes with their patients? If not, is this because they believe (rightly or wrongly) that their patients expect them to behave in a certain way?

4. If patients are used to physicians behaving in a particular way, would they be distressed if physicians changed how they behaved? Would this distress be permanent, or would patients get used to the different way of behaving and begin to prefer and expect it after a while?

5. Do physicians resist being moved from their zone of comfort as much as everyone else does?

1. I do not recall a particular study off the top of my head, but I do remember someone mentioning that patients considered "listening" and "bedside manner" as two things that influenced their opinion of their MDs.

2. In Canada we have OSCE (Objective Structured Clinical Exam) which tests clinical skills, and at the CFPC (College of Family Physicians of Canada) level, we have the SOO (Simulated Office Orals) which is totally about clinical skill, bedside manner, open ended questioning, etc... If you do not pass them, you do not receive certification.

3. How open or not, I am with a patient about my reasoning depends on the patient, and my sense of whether or not they want to know, etc...

4. Given how long medicine has been practiced the way it has, I suspect it would take a long time for patients to adapt, but who knows.

5. Of course we do not like being moved from our comfort zone. That does not mean that we do not, or cannot.

TAM:)

paximperium

24th March 2009, 05:27 AM

Here are the same questions presented in an unloaded way:
Much better. And now you'll get your answers.

1. Has there been any studies performed on what type of doctor-patient relationship produce the best outcomes? If so, did any of them have the doctor being open about her reasoning with the patient? Not that I'm aware of. Even dress does not significantly change patient's perception. The problem with such a study is the difficulty for controlling such a multitude of differing factors.

2. Do medical students fail if they don’t follow a particular model of interacting with patients? Not really. In the US, we have History and Physical components that med students must meet but it has more to do with assessing skills in actually collecting information as opposed to interactions. They get advise by the preceptor as to the best way to collect info and to interact with patients. We have a more formal USMLE Step 2-CS component which has more to do with assessing basic clinical skills as opposed to interaction skills.

3. In general are physicians open about their reasoning processes with their patients? If not, is this because they believe (rightly or wrongly) that their patients expect them to behave in a certain way? I am and many who I work with are as well. If I don't know what's causing their chest pain, I tell them I have no idea but I've worked up their heart and lungs to make sure the big scary stuff isn't the cause.

Some patients on the other hand don't care and just want to be told what to do.

4. If patients are used to physicians behaving in a particular way, would they be distressed if physicians changed how they behaved? Would this distress be permanent, or would patients get used to the different way of behaving and begin to prefer and expect it after a while? It depends. Some patients expect a very formal and paternalistic doctor and some expect someone who listens more and get them involved with their care. It's too variable to generalize.

5. Do physicians resist being moved from their zone of comfort as much as everyone else does? I actually enjoy it but then I get moved out of my comfort zone all the time. Comes with working in the ER. Me like the adrenaline.

fls

24th March 2009, 06:44 AM

How do you determine what is in the best interests of a patient?

Evidence-based medicine plus consideration of the individual.

IIRC, I didn’t suggest starting with the Golden Rule, but falling back on it when other sources of information are unavailable. But you saw a chance to assert your superiority and just couldn’t resist.

Why would you assume my opinion is superior to yours? I doubt that you actually believe that.

You might want to check the questions I asked, rather than the questions you thought I asked. Here they are again, split up so we can see which questions are of the form “when did you stop beating your wife?”:

Assumes you and the other physicians are being honest when reporting how you practice. Otherwise a perfectly straightforward question.

It assumes that you have accurately characterized what has been said.

No assumptions in this question. Ironic this was the one you misremembered as being loaded.

That was not the question I was referring to as loaded.

This was in reference to your point about not telling a patient cancer is one of the possible causes of their symptoms until it is ruled-in. As with the first question, it assumes that you and the other physicians haven’t been telling me a pack of lies about how you deal with patients.

It assumes that you have accurately characterized what was said. It also contains the question that contained hidden assumptions

Again, this assumes (based on information provided by you and other physicians) that physicians generally don’t expose their reasoning processes to the patient, but behave instead as medical ‘black boxes’.

It assumes that you have accurately characterized what was said.

The assumptions in this question are that physicians generally still practice in a ‘black box’ way, and having patients take an active role in both their diagnosis and treatment would result in benefits for both parties.

Here are the same questions presented in an unloaded way:

1. Has there been any studies performed on what type of doctor-patient relationship produce the best outcomes? If so, did any of them have the doctor being open about her reasoning with the patient?

Yes.

Yes.

2. Do medical students fail if they don’t follow a particular model of interacting with patients?

No, although that depends upon how vaguely you define "particular model".

3. In general are physicians open about their reasoning processes with their patients? If not, is this because they believe (rightly or wrongly) that their patients expect them to behave in a certain way?

I think generally they are and then circumstances influence whether it is possible or appropriate.

I don't think that physicians generally ignore patient expectations.

4. If patients are used to physicians behaving in a particular way, would they be distressed if physicians changed how they behaved? Would this distress be permanent, or would patients get used to the different way of behaving and begin to prefer and expect it after a while?

I don't think so. Satisfaction is somewhat tied to expectation, but it mostly seems to be tied to patient-centered factors - discussing psychosocial concerns instead of biomedical concerns, patients doing the talking, etc.

5. Do physicians resist being moved from their zone of comfort as much as everyone else does?

I suppose. Although, we have more experience with being forced out of our zone of comfort than average, which may lead to less resistance than average due to familiarity.

Linda

Ivor the Engineer

24th March 2009, 09:17 AM

How do you determine what is in the best interests of a patient?

Evidence-based medicine plus consideration of the individual.

How do you go about taking consideration of the individual?

IIRC, I didn’t suggest starting with the Golden Rule, but falling back on it when other sources of information are unavailable. But you saw a chance to assert your superiority and just couldn’t resist.

Why would you assume my opinion is superior to yours? I doubt that you actually believe that.

Because 90% of the posters in any particular thread in which we have a difference of opinion will agree with you and ridicule me. I therefore believe your opinions are considered by most people to be superior to mine.

<snip>

1. Has there been any studies performed on what type of doctor-patient relationship produce the best outcomes? If so, did any of them have the doctor being open about her reasoning with the patient?

Yes.

Yes.

Could you elaborate please?

2. Do medical students fail if they don’t follow a particular model of interacting with patients?

No, although that depends upon how vaguely you define "particular model".

Do you think the roles of physician and patient are learned? If so, when do you think this learning takes place?

3. In general are physicians open about their reasoning processes with their patients? If not, is this because they believe (rightly or wrongly) that their patients expect them to behave in a certain way?

I think generally they are and then circumstances influence whether it is possible or appropriate.

I don't think that physicians generally ignore patient expectations.

I personally have never experienced medical professionals being open about their reasoning, but this may be because they considered me to be not very intelligent and so not possible or appropriate.

I think physicians have expectations which most patients acquiesce to.

4. If patients are used to physicians behaving in a particular way, would they be distressed if physicians changed how they behaved? Would this distress be permanent, or would patients get used to the different way of behaving and begin to prefer and expect it after a while?

I don't think so. Satisfaction is somewhat tied to expectation, but it mostly seems to be tied to patient-centered factors - discussing psychosocial concerns instead of biomedical concerns, patients doing the talking, etc.

Or perhaps patients just stick to questions on topics they think will not offend or threaten the doctor’s status.

5. Do physicians resist being moved from their zone of comfort as much as everyone else does?

I suppose. Although, we have more experience with being forced out of our zone of comfort than average, which may lead to less resistance than average due to familiarity.

Linda

What do you consider to be physicians’ comfort zone?

fls

24th March 2009, 10:26 AM

How do you go about taking consideration of the individual?

You ask them questions and listen to the answers.

Because 90% of the posters in any particular thread in which we have a difference of opinion will agree with you and ridicule me. I therefore believe your opinions are considered by most people to be superior to mine.

Ah, so in order to avoid your scorn, I should make my posts dull and stupid.

Could you elaborate please?

There are hundreds of studies of the effect of the physician-patient relationship on various outcomes (such as health and patient satisfaction), including studies on the amount and type of communication. Clear communication improves both health outcomes and patient satisfaction. The perception of some participation in the decision-making process improves patient satisfaction. Those benefits are lost with the inclusion of excess information not related to the patient's management and treatment, and with the introduction of increasing uncertainty.

Do you think the roles of physician and patient are learned? If so, when do you think this learning takes place?

Yes.

During physician-patient interactions.

What do you consider to be physicians’ comfort zone?

Confidence in the effectiveness of recommended management plans. Experience with various procedures. Familiarity with a practice setting. Patient visits that follow a routine.

Linda

Ivor the Engineer

24th March 2009, 12:09 PM

You ask them questions and listen to the answers.

How do you know which questions to ask? Wouldn't it be easier to give patients permission to chip in with their thoughts while the physician explains her reasoning?

Ah, so in order to avoid your scorn, I should make my posts dull and stupid.

I don't know how you got to that conclusion from my observation. In many cases I don't think the actual opinion expressed really matters, more the status of the person who is expressing it. Since your status on the forum is much higher than mine, any time our opinions differ you will tend to get far more support than I will.

There are hundreds of studies of the effect of the physician-patient relationship on various outcomes (such as health and patient satisfaction), including studies on the amount and type of communication. Clear communication improves both health outcomes and patient satisfaction. The perception of some participation in the decision-making process improves patient satisfaction. Those benefits are lost with the inclusion of excess information not related to the patient's management and treatment, and with the introduction of increasing uncertainty.

Given homoeopaths get good marks on patient satisfaction surveys I don't think it's a particularly important measure. Health outcome on the other hand is. I would be interested to see studies which showed health outcome was significantly impaired by physicians expressing uncertainty in their diagnoses.

Yes.

During physician-patient interactions.

<snip>

I think it happens much earlier than that, probably in childhood when we're taught how to behave towards and around authority figures.

fls

24th March 2009, 12:18 PM

How do you know which questions to ask? Wouldn't it be easier to give patients permission to chip in with their thoughts while the physician explains her reasoning?

By listening.
No.

Given homoeopaths get good marks on patient satisfaction surveys I don't think it's a particularly important measure. Health outcome on the other hand is. I would be interested to see studies which showed health outcome was significantly impaired by physicians expressing uncertainty in their diagnoses.

http://www.ncbi.nlm.nih.gov/pubmed/3109581

Linda

Ivor the Engineer

24th March 2009, 02:26 PM

Before I pass comment on the study Linda provided, perhaps others (especially the medical practitioners on the forum) would like to review it themselves and tell us what they think. Here's the full article:

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1246362

A group of 200 patients who presented in general practice with symptoms but no abnormal physical signs and in whom no definite diagnosis was made were randomly selected for one of four consultations: a consultation conducted in a "positive manner," with and without treatment, and a consultation conducted in a "non-positive manner," called a negative consultation, with and without treatment. Two weeks after consultation there was a significant difference in patient satisfaction between the positive and negative groups but not between the treated and untreated groups. Similarly, 64% of those receiving a positive consultation got better, compared with 39% of those who received a negative consultation (p = 0.001) and 53% of those treated got better compared with 50% of those not treated (p = 0.5).

Here's the definition of positive and negative consultations and the treatment:

In the positive consultations the patient was given a firm diagnosis and told confidently that he would be better in a few days. If no prescription was to be given he was told that in the doctor's opinion he required none, and if a prescription was to be given that the treatment would certainly make him better. The negative consultation was an artificial consultation, devised so that no firm assurance was given. This was done by the doctor making one statement: 'I cannot be certain what is the matter with you." If no prescription was to be given the following words were added: "And therefore I will give you no treatment." If a prescription was to be given the patient was told: "I am not sure that the treatment I am going to give you will have an effect." The negative consultations were brought to a close by telling the patient that if he or she was no better in a few days to return to the doctor.

"Treatment" was a prescription for tabs thiamine hydrochloride 3 mg, used as a placebo, and "no treatment" was no prescription.

Ivor the Engineer

24th March 2009, 02:35 PM

How do you know which questions to ask? Wouldn't it be easier to give patients permission to chip in with their thoughts while the physician explains her reasoning?

By listening.
No.

<snip>

How are patients supposed to be able to catch errors in the doctor's reasoning if the flow of information during the diagnostic stage is one way?

Have you changed your mind when you thought the recommendations for patients I posted earlier were reasonable?

Here they are again (for reference):

Be Watchdogs for Cognitive Errors

Traditionally, physicians share their initial impressions with a new patient, but only to a limited extent. Sometimes the suspected diagnosis isn't explicitly mentioned, and the patient is simply told what tests to have done or what treatment will be used. Patients could serve an effective role in checking for cognitive errors if they were given more information, including explicit disclosure of their diagnosis, its probability, and instructions on what to expect if this is correct. They should be told what to watch for in the upcoming days, weeks, and months, and when and how to convey any discrepancies to the provider.

If there is no clear diagnosis, this too should be conveyed. Patients prefer a diagnosis that is delivered with confidence and certainty, but an honest disclosure of uncertainty and the probabilistic nature of diagnosis is probably a better approach in the long run. In this framework, patients would be more comfortable asking questions such as “What else could this be?” Exploring other options is a powerful way to counteract our innate tendencies to narrowly restrict the context of a case or jump too quickly on the first diagnosis that seems to fit.

fls

24th March 2009, 02:43 PM

How are patients supposed to be able to catch errors in the doctor's reasoning if the flow of information during the diagnostic stage is one way?

It's not.

Have you changed your mind when you thought the recommendations for patients I posted earlier were reasonable?

No.

Linda

Ivor the Engineer

24th March 2009, 04:56 PM

Linda,

I'm now totally baffled as to what you are suggesting. As you're now responding with single word answers I presume you no longer wish to discuss the subject with me. Am I correct?

If so, thank you for the interesting (if confusing) discussion.

BillyJoe

24th March 2009, 09:21 PM

Ivor,

Linda has tried the long explanation and it didn't work for you.
Now she's trying (or resorting to) the short explanation and it still doesn't work for you.
What would you like her to try next?

And that study is about the placebo effect.
What it tells you is that.....(I will let you finish)

....hey, that's an idea...maybe Linda can lead you to the answers by asking you questions that you must answer by thinking them out for yourself...hmmm...

In many cases I don't think the actual opinion expressed really matters, more the status of the person who is expressing it. Since your status on the forum is much higher than mine, any time our opinions differ you will tend to get far more support than I will.

Hmmm...maybe :D

regards,
BillyJoe

Ivor the Engineer

25th March 2009, 03:35 AM

Is no one else going to comment on the study Linda linked to?

Here's an idea: Imagine (if you can) Ivor linked to it instead.

Also imagine I'd just said I agreed with the following statement: "If there is no clear diagnosis, this too should be conveyed. Patients prefer a diagnosis that is delivered with confidence and certainty, but an honest disclosure of uncertainty and the probabilistic nature of diagnosis is probably a better approach in the long run."

What would you be calling Ivor? How stupid would Ivor be for linking to a paper which adds support to the exact opposite of what I'd just said I thought was a reasonable idea. Wouldn't many of you be pointing it out with glee?

The interesting thing about this thread is what is demonstrates about most of the people posting in it, which is that you seem incapable of thought which deviates from what those with authority think, and insult anyone who displays this undesirable trait.

So perhaps Linda and the other physicians are right; there really is no point trying to include patients in the consultation (other than giving them the perception they have a choice) because, like you, they really are weak-minded fools who need to be protected from themselves.

fls

25th March 2009, 04:29 AM

BillyJoe

25th March 2009, 05:46 AM

Ivor,

I have read the whole article now and was not surprised to see the word placebo at least half a dozen times. As I said before, it is a study of the placebo effect. When faced with a patient who has symptoms but no abnormal signs and in whom a diagnosis cannot be made (there is an underlying assumption that the patient does not have a serious illness), a positive attitude by the doctor leads to a more postive outcome for the patient. I don't think I would expect anything less of a placebo effect. This positive attitude of the doctor in these situations is at odds with the modern trend towards the "shared consult".

However....

"If there is no clear diagnosis, this too should be conveyed. Patients prefer a diagnosis that is delivered with confidence and certainty, but an honest disclosure of uncertainty and the probabilistic nature of diagnosis is probably a better approach in the long run."

...in the long run, it is probably better to be honest with patients becasue that assumption about the patient not having a serious disease could actually tuen out to be wrong!

So, it makes good sense for the doctor to convey some doubt about the diagnosis or that a diagnosis can be arrived at, even though this might cause some discomfort for the patient. (Of course they don't necessarily have to be told that one of the possibilities is terminal cancer! - is there any other kind as far as patients are concerned? - especially if that is unlikely).

BJ

BillyJoe

25th March 2009, 05:51 AM

After 16 pages of long involved explanations, short direct answers, humour, ridicule, friendship, dismissal, you summarize the conversation by claiming that what has been said is pretty much the direct opposite of what has actually been said. What can we do about that? What would you do?

I think you stole that line from an...um...authority! :D

Ivor the Engineer

25th March 2009, 06:33 AM

I dunno Ivor. What do you advise?

After 16 pages of long involved explanations, short direct answers, humour, ridicule, friendship, dismissal, you summarize the conversation by claiming that what has been said is pretty much the direct opposite of what has actually been said. What can we do about that? What would you do?

Linda

Rather than just making an assertion, would you care to provide a consistent set of facts and reasoning to support it?

No, I didn't think so.

Dr. Imago

25th March 2009, 06:36 AM

Rather than just making an assertion, would you care to provide a consistent set of facts and reasoning to support it?

No, I didn't think so.

With all due respect, Ivor, trying to send Linda on a "fools errand" is the lamest of all debate tactics.

~Dr. Imago

paximperium

25th March 2009, 06:56 AM

I treat Ivor as seriously as any rant from EJ Armstrong or DOC.
You have no idea how uninterested I am with having any conversation with Ivor.

fls

25th March 2009, 07:07 AM

Rather than just making an assertion, would you care to provide a consistent set of facts and reasoning to support it?

No, I didn't think so.

I would like to. It is, after all, what I spend the bulk of my time here doing. And I think that is what accounts for others giving consideration to what I have to say.

But how can I possibly believe that such an activity would be useful, when you've already rejected the possibility that I would do so, as if I hardly ever undertake this endeavour? My normal activities of providing information and explaining my reasoning has made no impact whatsoever on your comprehension. And those same activities from others in this thread has had the same (non)effect. So clearly what is needed is something different. And I'm willing to try something different, but it's also clear that I cannot guess what that would be. What would you suggest?

I honestly don't see how going through the thread cutting and pasting statements from T.A.M., Pax, Skeptigirl and Dr. Imago (and any other health professionals I've forgotten) is going to make a difference. Those statements are already available to you. They obviously did not make an impact the first time you read them. And you simply do not trust me as a source of information, so you would have to repeat the task for yourself anyway, if you were sincerely interested in understanding what has been said here.

Linda

fls

25th March 2009, 07:58 AM

I think you stole that line from an...um...authority! :D

Does "fair use" or "derivative work" allow me to get away with stealing and/or failing to attribute the work? ;)

Linda

Ivor the Engineer

25th March 2009, 08:33 AM

I would like to. It is, after all, what I spend the bulk of my time here doing. And I think that is what accounts for others giving consideration to what I have to say.

Perhaps the reason other people give consideration to what you have to say is because you are a medical doctor with a PhD and rarely say anything most people who identify with the label ‘sceptic’ disagree with. I.e. you are a person of high status telling people what they want to hear.

But how can I possibly believe that such an activity would be useful, when you've already rejected the possibility that I would do so, as if I hardly ever undertake this endeavour?

Because I know you well enough to know that if I fail to bow to whatever you believe after a page or two you clam up.

My normal activities of providing information and explaining my reasoning has made no impact whatsoever on your comprehension. And those same activities from others in this thread has had the same (non)effect. So clearly what is needed is something different. And I'm willing to try something different, but it's also clear that I cannot guess what that would be. What would you suggest?

The problem is that your reasoning is frequently inconsistent. When I suggest something in one thread it is wrong (and your followers in the thread come along and give me a kick just to let me know that I'm wrong). You suggest exactly the same thing in another thread and it is right (and your followers in the thread come along and give me a kick because giving Ivor a kick is the thing to do whenever he disagrees with you).

Probably the best thing for me to do is not even bother to challenge people's preconceived ideas, particularly when you happen to share them.

Let me start for this thread: The vast majority of medical professionals respond to ‘good’ incentives and are resistant to ‘bad’ incentives, always put patients’ needs before their own wants and are right 99.99% of the time when they post on the JREF.

I honestly don't see how going through the thread cutting and pasting statements from T.A.M., Pax, Skeptigirl and Dr. Imago (and any other health professionals I've forgotten) is going to make a difference. Those statements are already available to you. They obviously did not make an impact the first time you read them. And you simply do not trust me as a source of information, so you would have to repeat the task for yourself anyway, if you were sincerely interested in understanding what has been said here.

Linda

The only one of those posters I’ve been consistently impressed by in this thread is TAM. DeeTee is also another poster whom I admire. Perhaps you can figure out why?

fls

25th March 2009, 09:17 AM

Perhaps the reason other people give consideration to what you have to say is because you are a medical doctor with a PhD and rarely say anything most people who identify with the label ‘sceptic’ disagree with. I.e. you are a person of high status telling people what they want to hear.

I do not have a PhD.

However, I do not see people with professional degrees being given a free pass here. People argue vociferously with me, with Pax, with Skeptigirl, with Jeff Corey, with DrKitten, with JJM, with you...it seems to be the content that matters more than the status. And your statements show a quite disturbing lack of respect for others here.

Because I know you well enough to know that if I fail to bow to whatever you believe after a page or two you clam up.

What would you have me do? I say something, you read it as saying something quite different from what I meant, I spend page after page trying to explain what I meant....how long should I carry on? I have yet to figure out how to say things in a way that allows you to comprehend what I have to say. Doesn't it make more sense to just give this up?

The problem is that your reasoning is frequently inconsistent. When I suggest something in one thread it is wrong (and your followers in the thread come along and give me a kick just to let me know that I'm wrong). You suggest exactly the same thing in another thread and it is right (and your followers in the thread come along and give me a kick because giving Ivor a kick is the thing to do whenever he disagrees with you).

But you rarely manage to comprehend my reasoning. That others do manage to comprehend it is not a sign that they are "my followers". I can't even think of more than one or two people here who would tend to accept what I say without question. The rest of us agree and disagree with each other at will. And this is quite a nasty thing for you to say about anyone who happens to disagree with you or happens to share my opinion in any particular thread.

Probably the best thing for me to do is not even bother to challenge people's preconceived ideas, particularly when you happen to share them.

Let me start for this thread: The vast majority of medical professionals respond to ‘good’ incentives and are resistant to ‘bad’ incentives, always put patients’ needs before their own wants and are right 99.99% of the time when they post on the JREF.

Again, how can you expect anyone to have a conversation with you when you so woefully misrepresent what anyone else has to say?

The only one of those posters I’ve been consistently impressed by in this thread is TAM. DeeTee is also another poster whom I admire. Perhaps you can figure out why?

I don't know why.

Linda

fls

25th March 2009, 09:47 AM

Belz...

25th March 2009, 10:13 AM

The problem is that your reasoning is frequently inconsistent. When I suggest something in one thread it is wrong (and your followers in the thread come along and give me a kick just to let me know that I'm wrong). You suggest exactly the same thing in another thread and it is right (and your followers in the thread come along and give me a kick because giving Ivor a kick is the thing to do whenever he disagrees with you).

A bit of advice, Ivor. Insulting the person you are talking to is one thing; but if you insult the people who agree with him/her by calling them "followers", or whatnot, is a sure-fire way of getting the same people to think you're incapable of being reasonable.

Professor Yaffle

25th March 2009, 10:15 AM

A bit of advice, Ivor. Insulting the person you are talking to is one thing; but if you insult the people who agree with him/her by calling them "followers", or whatnot, is a sure-fire way of getting the same people to think you're incapable of being reasonable.

Its quicker if Linda just tells them he's incapable of being reasonable... ;)

Ivor the Engineer

25th March 2009, 11:02 AM

Ivor,

I have a proposed solution to the problem that you do not get a fair hearing in any threads I also participate in. Since I previously agreed to your request not to participate in any threads that you started, I will continue to honour that request. Simply start your own thread when you wish to ensure a fair hearing.

Linda

It is of course up to you which threads you choose to participate in, but I will remind you the actual request I made was for you to not post in threads I started if you planned on deliberately ignoring my posts - behaviour which you had engaged in for several weeks before I made the request to you via PM.

fls

25th March 2009, 11:24 AM

It is of course up to you which threads you choose to participate in, but I will remind you the actual request I made was for you to not post in threads I started if you planned on deliberately ignoring my posts - behaviour which you had engaged in for several weeks before I made the request to you via PM.

I'm sorry. I thought that had been in a thread.

Linda

T.A.M.

25th March 2009, 02:01 PM

just thought I would pop in to see if anything productive has come about in the last couple of pages...

ok...

bye

TAM;)

Ivor the Engineer

25th March 2009, 03:33 PM

I do not have a PhD.

I apologise for inflating your status.:)

However, I do not see people with professional degrees being given a free pass here. People argue vociferously with me, with Pax, with Skeptigirl, with Jeff Corey, with DrKitten, with JJM, with you...it seems to be the content that matters more than the status. And your statements show a quite disturbing lack of respect for others here.

With the exception of Beth, KellyB and myself, how many people argue with you who don't believe in alternative medicine, psi, or a (possibility of a) sky daddy?

What would you have me do? I say something, you read it as saying something quite different from what I meant, I spend page after page trying to explain what I meant....how long should I carry on? I have yet to figure out how to say things in a way that allows you to comprehend what I have to say. Doesn't it make more sense to just give this up?

I think that's just a rationalisation you use when I start finding inconsistencies in your ideas.

But you rarely manage to comprehend my reasoning. That others do manage to comprehend it is not a sign that they are "my followers". I can't even think of more than one or two people here who would tend to accept what I say without question. The rest of us agree and disagree with each other at will. And this is quite a nasty thing for you to say about anyone who happens to disagree with you or happens to share my opinion in any particular thread.

I think the sign of who are your followers in the thread is when posters start hurling insults my way for disagreeing with you.

Your reasoning in this thread has been to remove all significant meaning from the word 'paternalism' to allow you to claim it means the same as 'beneficence'.

You then present the idea of a doctor who listens to patients, answers their questions and asks them questions to reach a diagnosis and recommend a treatment. The doctor uses an approach to discovering what the patient wants I suggested in another thread and you slapped me down for it. Yet in this thread you think it is a good idea. Then you provide a link to an article which states that a confident diagnosis/prognosis has a significant effect on health outcome. When I suggested in another thread a similar idea for how alt. med. works I'm told lying to patients is unethical and it only affects patients' subjective assessment of their health.

Nowhere have you explained how it is possible for such a doctor's reasoning to be checked by the patient, which you said you thought was a reasonable idea.

Nowhere have you explained how the beneficial effects of a diagnosis delivered with false confidence are consistent with the exact opposite statement you said you thought was reasonable a idea.

Again, how can you expect anyone to have a conversation with you when you so woefully misrepresent what anyone else has to say?

I don't think it is a misrepresentation. The evidence I presented has been dismissed, trumped by your and others' anecdotes or "alternative explanations", for which there is no way to argue against.

I don't know why.

Linda

Because they are fair and give straightforward answers to questions.

ETA: Oh, and just in case you think I don't like you, I think you are a nice person and, from what I can gather, an excellent doctor.

Yuri Nalyssus

30th March 2009, 02:32 PM

IYour reasoning in this thread has been to remove all significant meaning from the word 'paternalism' to allow you to claim it means the same as 'beneficence'.
OK, apologies for reviving this, and apologies if I have missed any of the nuances in this lengthy thread but...

Ivor, do you believe that there is absolutely no place for "doctor knows best"? Are there any circumstances when you think that a doctor should insist on a course of treatment if they know the patient is wrong? (assuming of course that the patient is of sound mind).

Yuri

Ivor the Engineer

30th March 2009, 03:58 PM

OK, apologies for reviving this, and apologies if I have missed any of the nuances in this lengthy thread but...

Ivor, do you believe that there is absolutely no place for "doctor knows best"? Are there any circumstances when you think that a doctor should insist on a course of treatment if they know the patient is wrong? (assuming of course that the patient is of sound mind).

Yuri

Given your assumption, the only times I would think it appropriate for a doctor to actively (rather than passively) override the preferences of a patient would be if there was a significant threat to public health, or if a patient was unable to communicate and a proxy was making decisions for the patient's care which would result in harm.

Yuri Nalyssus

30th March 2009, 04:16 PM

Given your assumption, the only times I would think it appropriate for a doctor to actively (rather than passively) override the preferences of a patient would be if there was a significant threat to public health, or if a patient was unable to communicate and a proxy was making decisions for the patient's care which would result in harm.
Why the distinction between active and passive overriding of preferences - is passive more acceptible, does it imply a degree of patient involvement?

Apart from public health, what if there was a threat to individuals close to the patient (say with a mental health issue (tho I suppose that isn't in the 'sound mind' category) or a sexually transmitted disease) or, particularly, what if the doctor felt (or believed they knew for certain) that the patient was at risk of death or serious, permanent disability by not following their advice? Would any of this be a reason for the doc to insist on a patient following the doc's. chosen protocol and lay down the law as it were?

This is all independent of how exactly the doc could insist or ensure that course was followed.

Yuri

Ivor the Engineer

30th March 2009, 04:37 PM

Why the distinction between active and passive overriding of preferences - is passive more acceptible, does it imply a degree of patient involvement?

A doctor has the right to not provide treatment to a patient if they believe it will be harmful or medically pointless.

Apart from public health, what if there was a threat to individuals close to the patient (say with a mental health issue (tho I suppose that isn't in the 'sound mind' category) or a sexually transmitted disease) or, particularly, what if the doctor felt (or believed they knew for certain) that the patient was at risk of death or serious, permanent disability by not following their advice?

If there's a risk to others then there is a risk to public health. How many 'others' need to be at risk is up for debate.

If the risk is only to the individual and he/she is considered of sound mind, then no, doctors have no right to override what they may consider to be a sub-optimal or harmful choice by the patient.

Would any of this be a reason for the doc to insist on a patient following the doc's. chosen protocol and lay down the law as it were?

<snip>

I don't think so. The doctor can appeal to the patient to change his/her mind, or get a court to rule the person of unsound mind.

Probably my last post tonight. Catch you tomorrow.;)

Deetee

31st March 2009, 05:18 AM

A reminder that GMC guidance exists for doctors in the UK, including good medical practice and the duties of a doctor (http://www.gmc-uk.org/guidance/good_medical_practice/duties_of_a_doctor.asp).
These do not cover all eventualities but serve as a template for good ethical practice.

Also possibly of relevance here is the Mental Capacity act, which states;
Five key principles of the Mental Capacity Act

Principle 1: Capacity should always be assumed. A patient’s diagnosis, behaviour, or appearance should not lead you to presume capacity is absent
Principle 2: A person’s ability to make decisions must be optimised before concluding that capacity is absent. All practicable steps must be taken, such as giving sufficient time for assessments; repeating assessments if capacity is fluctuating; and, if relevant, using interpreters, sign language, or pictures
Principle 3: Patients are entitled to make unwise decisions. It is not the decision but the process by which it is reached that determines if capacity is absent
Principle 4: Decisions (and actions) made for people lacking capacity must be in their best interests
Principle 5: Such decisions must also be the least restrictiveoption(s) for their basic rights and freedoms

Further guidance on capacity and how to assess it here (http://img15.imageshack.us/img15/8435/nict515320f1.jpg).

Puppycow

5th April 2009, 04:56 AM

Believing in Treatments That Don’t Work (http://well.blogs.nytimes.com/2009/04/02/the-ideology-of-health-care/)

As Washington debates health care reform, emergency room physician Dr. David H. Newman explores how medical ideology often gets in the way of evidence-based medicine.

By David H. Newman, M.D.

In the early throes of a heart attack, caused by an abruptly clotted artery, the stunned heart often beats quickly and forcefully. For decades doctors have administered “beta-blockers” as a remedy, to reduce consumption of limited oxygen supplies by calming and slowing the straining heart. Giving these drugs in the early stages of a heart attack represents elegant medical ideology.

But it doesn’t work.

Studies show that the early administration of beta-blockers to heart attack victims does not save lives, and occasionally causes dangerous heart failure. While two studies support the use of beta-blockers after heart attack, there are 26 studies that found no survival benefit to administering beta-blockers early on. Moreover, in 2005, the largest, best study of the drugs showed that beta-blockers in the vulnerable, early hours of heart attacks did not save lives, but did cause a definite increase in heart failure.

Remarkably, the medical community has continued to strongly recommend immediate beta-blocker treatment. Why? Because according to the theory of the straining heart, the treatment makes sense. It should work, even though it doesn’t. Ideology trumps evidence.

The practice of medicine contains countless examples of elegant medical theories that belie the best available evidence.

Recent press reports detailing the dangers of cough syrup for children have noted that cough syrup doesn’t work. True: No cough remedies have ever been proven better than a placebo, either for adults or children. Yet their use is common.
Patients with ear infections are more likely to be harmed by antibiotics than helped. While the pills may cause a small decrease in symptoms (for which ear drops work better), the infections typically recede within days regardless of treatment. The same is true for bronchitis, sinusitis, and sore throats. Unnecessary antibiotics are still given to more than one in seven Americans each year for these conditions alone, at a cost of more than $2 billion and tens of thousands of serious adverse medication effects requiring treatment.
Back surgeries to relieve pain are, in the majority of cases, no better than nonsurgical treatment. Yet doctors perform 600,000 of these surgeries each year, at a cost of over $20 billion.
More than a half million Americans per year undergo arthroscopic surgery to correct osteoarthritis of the knee, at a cost of $3 billion. Despite this, studies show the surgery to be no better than sham knee surgery, in which surgeons “pretend” to do surgery while the patient is under light anesthesia. It is also no better than much cheaper, and much less invasive, physical therapy.
Treatment based on ideology is alluring. Surgeries to repair the knee should work. A syrup to reduce cough should help. Calming the straining heart should save lives. But the uncomfortable truth is that many expensive, invasive interventions are of little or no benefit and cause potentially uncomfortable, costly, and dangerous side effects and complications.

The critical question that looms for health care reform is whether patients, doctors and experts are prepared to set aside ideology in the face of data. Can we abide by the evidence when it tells us that antibiotics don’t clear ear infections or help strep throats? Can we stop asking for, and writing, these prescriptions? Can we stop performing, and asking for, knee and back surgeries? Can we handle what the evidence reveals? Are we ready for the truth?

The administration’s plan for reform includes identifying health care measures that work, and those that don’t. To place evidence above ideology, researchers and analysts must be trained in critical analysis, have no conflicts of interest and be a diverse group.

Perhaps most importantly, we as doctors and patients must be open to evidence. Pills and surgery are potent symbols of healing power, but our faith in these symbols has often blinded us to truths. Somewhere along the line, theory trumped reality. Administering a medicine or performing a surgery became more important than its effect.

. . .

fls

5th April 2009, 05:50 AM

Believing in Treatments That Don’t Work (http://well.blogs.nytimes.com/2009/04/02/the-ideology-of-health-care/)

It bothers me that there are quite a few errors in this article and the links provided for his claims often don't actually support the claim. But I think the point of his examples stands, even if not all of his examples are valid. However, I don't think the issue is ideology but simply responsiveness. Evidence trumps ideology and evidence changes practice. It just seems to be subject to a trickle-down effect whereby early adopters of new ideas tend to be those with primary expertise in the area; those who are in the best position to evaluate the validity of the information. These changes then trickle through the rest of the medical practitioners, following the path of least resistance.

The question isn't whether medicine will put aside ideology in the face of facts - it clearly will. The question is whether its responsiveness to facts strikes a reasonable balance. There are also concerns when new ideas are adopted too readily - off-label uses for drugs, unrecognized serious side-effects of new wonder drugs, rejection of prophylactic practices that were providing benefit, etc. And doesn't the need to reverse recommendations that were made on too little data also erode confidence in physicians?

Linda

T.A.M.

5th April 2009, 03:07 PM

In general, for those who are interested, in Canada, a Physician can commit to a hospital against his or her will, any person who is deemed by that physician, to be a danger to:

(A) his/herself
(B) others
(C) his/her property

This committal will only stand for 24 hours without the signature of a second physician. This committal is enforceable by Law Enforcement, when needed.

TAM:)

Ivor the Engineer

5th April 2009, 03:24 PM

Puppycow

5th April 2009, 06:06 PM

It bothers me that there are quite a few errors in this article and the links provided for his claims often don't actually support the claim. But I think the point of his examples stands, even if not all of his examples are valid. However, I don't think the issue is ideology but simply responsiveness. Evidence trumps ideology and evidence changes practice. It just seems to be subject to a trickle-down effect whereby early adopters of new ideas tend to be those with primary expertise in the area; those who are in the best position to evaluate the validity of the information. These changes then trickle through the rest of the medical practitioners, following the path of least resistance.

The question isn't whether medicine will put aside ideology in the face of facts - it clearly will. The question is whether its responsiveness to facts strikes a reasonable balance. There are also concerns when new ideas are adopted too readily - off-label uses for drugs, unrecognized serious side-effects of new wonder drugs, rejection of prophylactic practices that were providing benefit, etc. And doesn't the need to reverse recommendations that were made on too little data also erode confidence in physicians?

Linda

Good points. I'm not in any position myself to evaluate whether medical info was correct.