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Beyond Informed Consent: Shared Decision-Making

Happy New Year to all our readers! Today marks the completion of 5 years of SBM and the beginning of year 6. My contributions, at one a week, have now reached a total of 260. My first post on this blog, 5 years ago, was a review of an important book about science and alternative medicine, Snake Oil ScienceThis year I’d like to start with an important book about communicating medical science to patients, Critical Decisions,  by Peter A. Ubel, M.D.

I was wrong about informed consent. I thought informed consent was a matter of explaining the risks and benefits of treatments to patients so they could decide what they wanted to do.  That was naïve, simplistic, and misguided. Ubel’s book has radically changed my thinking about how doctors should interact with patients.

Paternalism in medicine is dead. Patient autonomy rules. We respect the right of patients to determine their own treatments, even if their choices seem unwise to us. Patients should do what they want. But there’s a problem: patients may not know what they really want. Emotions and unconscious and irrational forces influence their medical decisions. Preferences can change from one moment to the next, and they can shift with subtle changes in how treatments are described and how the issues are framed. Doctors need to develop a better understanding of what is going on in their patients’ minds, of how the way they present treatment options can inadvertently influence patients, and of how they can participate with patients in a process of shared decision-making. It’s possible to provide direction without paternalism.

The biopsy shows prostate cancer. The doctor explains that the risk of death in this particular case is small and the options include watchful waiting instead of surgery. The patient may hear that as “I have cancer and you’re not going to do anything about it?!” Or be so alarmed (“Omigod, I’m going to die”) that he is unable to process any further information. He is told the risks of surgery, but he can’t imagine what it would really be like to live with impotence or incontinence. He may over- or under- estimate his risk of side effects and how they would affect his life. The doctor typically uses medical words that the patient doesn’t understand, and overwhelms him with abstruse details about Gleason scores and atypical cells and non-aggressive appearance on biopsy. The urologist often doesn’t recognize the emotional impact of the diagnosis and doesn’t respond to the patient’s feelings. He asks if the patient has any questions, and when the patient doesn’t ask any, he is reassured that the patient has understood. But the patient may simply be confused, scared to death, and unable to express his concerns.

What Would It Be Like?

Young people dread the limitations of old age but research shows that happiness actually tends to increase with age. People often think they would rather die than be paralyzed, go blind, etc. because they can’t imagine what it would really be like. They think they would be terribly unhappy. But in reality, people who face those challenges soon adapt to them and are just as happy as they were before. People mis-predict their own long-term emotional reactions to everything from losing a leg to winning the lottery. Winning millions makes them ecstatically happy at first, but as time passes, they end up no happier than people who didn’t play the lottery. The initial emotional impact of an injury or illness is strong, but it wanes over time. People underestimate their emotional resilience. Talking to others who have faced the same challenges may help them to judge more accurately what it would be like for them. In one anecdote in the book, a patient categorically rejects surgery involving a colostomy but doesn’t think it through to realize that he would rather live with a colostomy than die. Making a quick judgment based on an initial emotional reaction is unwise

Don’t Make Families Regret Their Decisions

Families may be reluctant to authorize “Do Not Resuscitate” orders when the doctor tells them the patient is dying and resuscitation would be futile. The current practice is to explain the situation to the family and let them (make them) decide. But Ubel says:

Resuscitating a dying patient is not the worst thing we doctors can do. Making a family regret their decision is far worse… in the vast majority of these conversations, my recommendation [for a DNR order] was met not with resistance but relief. They didn’t want their loved one to suffer, and they knew that CPR would only prolong their pain. But they didn’t want to be the ones who made that choice. My recommendation helped them by sharing the decision-making burden.

Experiments in Decision Psychology

Research has illuminated how irrational people are at making decisions. If they are trying to get a red jelly bean, they prefer to pick from a bowl of 100 jelly beans with 10 red ones than from a bowl of 10 with one red one. The odds are exactly the same, but somehow the larger bowl seems like it ought to offer more chances, even though they understand on a rational level that it doesn’t. In a hypothetical scenario where a virulent flu will kill 10% of the population and a vaccine will prevent infection but carries a 5% risk of death, people prefer inaction with a higher risk of death to taking an action that results in half the risk. On the other hand, if patients are asked to choose between watchful waiting for a cancer than has a 10% chance of eventually killing them and taking chemotherapy that will eliminate the cancer but kill 5% of patients from side effects, almost no one chooses to forgo the treatment that reduces the risk by half. Apparently there is some kind of unconscious bias against vaccines as compared to chemotherapy (?!). In a scenario where watchful waiting led to a 5% chance of death and surgery carried a 10% risk of death, most people preferred the surgery, preferring to take action even when that action was more likely to harm them. They just wanted that cancer out of their body.

When given a statistical prognosis like a 10% chance of survival, patients tend to think it doesn’t really apply to them, to think there is something about their case that ratchets their chance up to 20% or even more. Doctors, too, tend to over-estimate the chances of the patient’s survival in their unconscious desire for optimism.

The way information is framed is influential. Patients prefer an operation when it is presented as having a 90% survival rate to the same operation when presented as having a 10% mortality rate. And the power of a doctor’s recommendation is very strong. In another experiment, patients were told that the risks of a hypothetical vaccine outweighed the benefits. Then they were told that their doctor recommended it, but that their doctor didn’t know any more about the vaccine than they did. They chose the vaccine because the doctor recommended it, unconsciously feeling that the doctor knew more than they did even when they had been assured he didn’t.

Then there is the power of stories. For a surgery with a 75% success rate, telling one anecdote about a success and one about a failure seemed to cancel each other out, but 3 success anecdotes and one failure anecdote reinforced the 75% statistics and made people more willing to get the surgery, even though the anecdotes were about specific individuals and did not change the information about the actual percentage of people who would benefit.

Telling patients there is a 17% risk of side effects or showing them pie charts or graphs tends to confuse them. Pictographs with 100 squares and 17 filled in with a different color to represent side effects are far better at reminding them of the 83% who don’t get side effects.

Decision Aids

These decision psychology experiments provide clues, but it is still necessary to test every approach. A number of decision aids have been developed, such as videos showing what it is like to live with a colostomy; some patients are reassured to see how real people have adapted and how little it has affected their lives, others are repulsed by seeing a colostomy stoma. We need to test whether each component of the decision aid does more harm or good. We want to inform, not influence.

Decision aids give patients the information they need, but they don’t always change behavior. Informed patients must also be prepared to interact successfully with their doctors. Ubel provides helpful tips and guidelines for patient empowerment and better joint decision-making.

What Does Patient Autonomy Really Mean?

Every doctor has been asked “What would you do if you were me?” “What would you do if it were your mother/wife/daughter?” “What do you recommend?” Sometimes patients really want the doctor to decide for them, either because they just don’t feel confident about their knowledge and judgment or because they don’t want to feel responsible if something goes wrong. Doctors are told not to make those decisions, but to give patients the relevant information and leave the decision to them. But here’s a thought: what if the patient autonomously decides he wants the physician to choose for him? Does that count? Can he delegate and still be autonomous? What are the legal implications? Would he have to sign over a power of attorney for health care to the physician? Would that even be legally acceptable? We need to grapple with this and other thorny issues.

Conclusion

Oliver Wendell Holmes said:

Man’s mind, once stretched by a new idea, never regains its original dimensions.

This book stretched my mind, and it feels good to know that I have learned something and have improved my way of thinking. Admitting that one has been wrong should not be a source of shame, but a source of pride because one is now more right. It is one of the great joys of being a critical thinker.

Patient autonomy is good, but shared decision-making is better. The goal of truly informed consent with no hint of bias or coercion is a worthy one, but it’s not enough. The doctor and patient should cooperate in a joint decision-making process that incorporates the doctor’s medical knowledge and the patient’s values and preferences. It’s difficult for a doctor to understand those values and preferences when the patient himself may not consciously understand them or be able to articulate them. If the doctor can develop a deep understanding of the patient’s values and preferences, then he can tell him what he thinks he should do without being paternalistic or coercive. It’s complicated, and our efforts to improve the situation must be tested with the scientific method to see if they are as effective as we would like to think. If doctors and patients could all read this thought-provoking book, we would be off to a good start. Highly recommended.

 

 

 

Posted in: Book & movie reviews, Medical Ethics

Leave a Comment (17) ↓

17 thoughts on “Beyond Informed Consent: Shared Decision-Making

  1. elburto says:

    Sounds very interesting.

    The NHS, here in the UK, has something called ‘Expert Patient’ groups. The basic idea is to use people who’ve been successfully managing a condition (asthma, IDDM, NIDDM, IBD etc.) or living with the effects of a procedure (colostomy, hip replacement, CABG, cochlear implant) to meet with newly diagnosed patients, or those being asked to consider a particular procedure or treatment. Where possible the expert patients and the new ones are matched by age and lifestyle, so that the new patient can get a good idea of how they might be affected.

    There are also Patient Advice and Liaison Services (PALS) teams in hospitals. They can assist patients with questions/complaints/fears about aspects of hospital treatment or care.

    Between those services, condition-specific clinics at GP surgeries, named dedicated nurse practitioners who can be contacted with questions, and telephone/internet information services, it’s a lot easier than it used to be to get information about treatments, therapies, and procedures.

    It also gives patients (and their families) the chance to understand their options, as opposed to just knowing what they are.

    Hopefully it relieves some of the pressure on GPs and consultants to use a limited appointment time to deal with all of a given patients’s fears and concerns.

    It’s obviously a lot easier here though, given that one single mega-entity (the NHS) controls every aspect of public healthcare. Distribution of educational material such as books or DVDs, information packs containing posters and leaflets is therefore able to be centralised, and the information within is standardised and consistent. This would probably be a nightmare to arrange in the US!

  2. brownwetdog says:

    Thank-you for five years of thoughtful, understandable, relevant blogs – looking forward to Year Six. Carol

  3. BillyJoe says:

    Patient autonomy is largely a myth, in my opinion. Perhaps shared decision making comes closer to what’s possible. But, in reality, most patients just go along with what the doctor recommends. They have insufficient intelligence to come to a reasonable decision, and/or insufficient time to research it, and/or insufficient background knowledge to make sense of what they read, and/or they’re bogged down by ideology or logical fallacies or a lack of critical thinking abilities. Hopefully doctors will progressively become sufficiently skilled in science based medicine to lead the patient in the desirable direction in their shared decision making.

    I have had to make one big medical decision in my life: to have or not to have a PSA test. When my father was diagnosed with prostate cancer, I almost went along my my father’s Urologist’s recommendation that all his sons be tested. A chance reading of an article sent me off on a three month review of the literature available on the Internet. I decided there was insufficient evience to have the test, but I continue to monitor the literature. Most patients are really not inclined to spend the time required to do such a review or skilled enough to know how to do it properly and make an intelligent decision based on it.

    Obviously, patients do make a contribution to the decision, if only to agree with what the doctor would do. But, in the large majority of cases, it simply is not an equal partnership. A doctor well versed in science based medicine should not be concerned if the patient leaves the decision to him, because that should ensure the highest probability of a good outcome. His decision would obviously include a consideration of the patient’s particular circumstances. There are situations where no option is any better than any other. In these cases, the patient has to make the final decision. But he might as well flip a coin.

  4. JamesC says:

    Fascinating topic! I think you pose some very good and valid questions.

    I’ve been following Dan Ariely’s RSS feed and podcast and earlier this year he talked to Simona Botti who wrote a paper about patient decisions. Her work appears to show that when patients have to choose between bad outcome A and bad outcome B that they regret their decision regardless of the choice while patients who do not have a choice don’t suffer regret for their choice.

    Tragic Choices: Autonomy and Emotional Responses to Medical Decisions
    http://www.columbia.edu/~ss957/articles/TragicChoices_BottiOrfaliIyengar.pdf
    abstract:
    We investigate how making highly consequential, highly undesirable decisions affects emotions and preference for autonomy. We examine individuals facing real or hypothetical decisions to discontinue their infants’ life support who either choose personally or have physicians choose for them. Findings from a multidisciplinary approach consisting of a qualitative analysis of in-depth interviews and three laboratory studies reveal that perceived personal causality for making tragic decisions generates more negative feelings than having the same choices externally made. Tragic decisions also undermine coping abilities, weakening the desire for autonomy. Consequently, participants disliked making decisions but also resented relinquishing their option to choose.

    Dan Ariely’s podcast is called “Arming the Donkeys” and can be found on iTunes. It’s an interesting 5-minute per week podcast following behavioural psychology.

  5. nybgrus says:

    @BJ:

    A good outcome is personally defined. In extreme cases death may be the preferred outcome, though we may initially regard it as objectively “bad.” It is for this reason that a partnership is required. The fact that the partnership is unequal and does not inherently nullify autonomy, or else I would not be autonomous or have any hope of good outcomes in most things I do in life since I am not an expert in most things in life. You say that my decisions as a physician would take into account the patients’ circumstances and indeed I would do so to the best of my ability, but considering how difficult it is for a patient to accurately assess his or her own circumstances in many cases it would be ludicrous to think I could do better in all cases.

    The key here is that a person may not be able to accurately assess his or her own desires or predict the future of how they may handle a given outcome. This makes the partnership more complex and, since it is, unequal makes it ethically requisite for the physician to shoulder more of the burden than an otherwise “fair and equal” partnership would otherwise require (hence my own distaste for physicians and med students who complain about having to work extra hard because their patients are stupid louts who can’t adhere to treatment regimens).

    So while a physician is an expert in medicine, the patient is expert in his or her own life, desires, and values. Knowing what I have written above it is thus necessary for me to shoulder more of that responsibility to help the patient utilize his or her own expertise to the maximum capacity, but I can’t fool myself into thinking I am more expert at being the patient than the patient himself is.

  6. nybgrus says:

    I should add that a simplistic view of “good” and “bad” outcomes on the part of physicians is actually a bad thing – the general physician ethos that death is the ultimate bad and should be avoided at all costs being an excellent example.

  7. WilliamLawrenceUtridge says:

    FSM darn it to noodly hell, every time you do a book review my reading list gets longer. It’s already at 200 titles, could you start reviewing movies? Pamphlets? Short videos on youtube?

    At least I’ve already read Snake Oil Science :)

  8. dinseattle says:

    Am I totally in the minority who can see the value of watchful waiting? That what you know can hurt? Certainly what you don’t know can hurt you, but unnecessary surgical biopsy, which might or might not lead to more surgery and treatment for something that would have been very unlikely to kill me would still have the negative side effects of limiting my energy level and mobility for a time. In middle age that’s is a slippery slope for even less activity, weight gain, metabolic syndrome and heart disease. Is the number one killer of women breast cancer or heart disease?

    But how do I find a doctor who shares a more sophisticated understanding of science, risk and benefit? And who truly understands what patient shared decision making really is? I’ve been happy with my PCP, but gradually am realizing she’s not all on the same page as me. When I questioned annual screening mammograms, she retorted that she had a patient DIE from DCIS! So do I try to educate my doctor or do I look for a new one? Finding a new doctor is a huge hassle and one is never guaranteed to find a better one. If I got her a copy of this book, would she take it the right way?

    I did learn from a breast cancer surgeon that the radiologists have stopped using the BI-RADS 3 category, the watchful waiting category. Patients don’t want to wait and radiologists don’t want to be sued. How can we have shared decision making that way? Because if they say I do need a core needle biopsy for that one tiny spot that is suspicious, but because it is so small, they do the procedure twice because they were in the wrong spot the first time, so I end up getting zapped with all that extra radiation from the stereodactic machine and in 10 years develop a cancer, I really can’t go back and sue the radiologist who bumped you from a BI-RADS 3 to a BI-RADS 4 without my knowledge or consent, can I?

    But I also know that I am unusual in that I have the time and the resources to do some research and think for myself. That’s not the case for everyone. Plus, there will be times in my life with significant health and emotional issues where I won’t have the capacity to follow complicated reasoning in order to make decisions for myself or someone I love. I cannot guarantee I will always have a level head.

    I will read the book. Thanks for the work you all do here on SBM.

  9. BillyJoe says:

    nybgrus,

    In what percentage of medical consultations is the patient after a shared partnership?

    I would say it would be a small minority of patients in a small minority of circumstances. Looking at it from the point of view of diagnoses and treatements, I would say that, in the vast majority of situations, the diagnoses and treatments are clear cut and, in the vast majority of cases no imput from the patient is actually required, except to agree with the doctors recommendations. And I would say that, in the vast majority of cases, patients would agree and go along with the doctor’s recommendation. Exceptions would be a patient with a warped sense of reality, or someone with particular religious beliefs, or someone with an unusual life philosophy (financial status is not an obstacle in Australia). Okay, so that patient goes against what the doctor recommends, but is that a shared partnership? The doctor shows the patient all the reasons why he should have a particular treatment, and the patient decides he will not have the treatment because of his quirky sense of reality, religious beliefs, or philosophical outlook.

    In the small minority of situations where there is no clear cut treatment plan, but a variety of options which the doctor is hard pressed to decide between, either the doctor can randomly pick one option or the patient can randomly pick one option. I don’t see a partnership here either.

    So what are we really talking about here? In my opinion, the old domineering doctor and the old paternalistic doctor have given way to doctors trained in the art of diplomacy. It is certainly an improvement in attitude, and I’m sure patients will feel better served by such doctors. But I don’t see a shared partnership.

    I don’t have any medical issues, but last year I found time in my busy schedule to see a dentist for the first time in ten years. Actually a front tooth snapped off, so it was an acute dental emergency! But I took that opportunity to have all my dental disease diagnosed and treated. Most of it was straight forward. There were three teeth minus their previous fillings which needed to be re-filled. The forth tooth had to come out. Why? She told me that the x-ray showed there was a (presumably sterile) abscess at the root of the tooth, and i confirmed that it had been painful at one point. So she explained why, but did I have a choice? The tooth was coming out. Period. Then there was a another front tooth which had previously been fractured in an accident. That tooth had been capped, but the cap had now discoloured. She quoted me the price and I agreed to have it re-capped. Was that a shared partnership? As opposed to her saying “you are going to have that capping replaced” or “don’t be silly, it’s just a yellow tooth, and it won’t subtract much from your ugly son of a bitch appearance”. I mean I did appreciate the diplomacy. There was also a space which she offered to fill at some exorbitant price, but for about a thousand dollars cheaper than the going price. I declined because my son needs a car instead. Was that a shared partnership?

    Maybe it all comes down to definitions.

  10. nybgrus says:

    BJ:

    I agree that in many cases it is clear cut and pretty straightforward and little partnership is needed. When your plumber tells you the leak from your toilet needs a particular widget you don’t go ahead and rebuff him.

    I disagree that so much of medicine is quite that straightforward. My days on the wards of internal medicine were rife with examples contrary to your current statements. We spent every day talking about options – ones which we needed to suss out medicall and each with its own benefits and risks. Who am I to decide which risk:benefit is right for my patient? The magnitude of each is usually quite subjective.

    By anecdote:

    I had a patient (now last year) who was a very sweet old lady. 78 years of age, with diastolic heart failure and kidney problems (among other things, but those were the primary issues). She was my patient for 3 admits over 28+ days. We simply could not balance the needs of her failing heart with the needs of her failing kidneys. At the end, we decided we had reached the limits of our capacity to help her and she was very near death’s door. We needed to enter a partnership with her and her family to determine how aggresively to continue treating her and what we could actually offer to help her. Dialysis would not help. It would be a very short term fix with no chance of meaningful recovery. The patient and family asked for it and we explained this. It took some time to accept it. We then conferred with the nephrologist and she confirmed our thoughts. Knowing she was dying, she only wanted to go home and be with her dog and die at home, with her family. But if we discharged her she wouldn’t make it a kilometer down the road before dying in the passenger seat of the car. She and the family were irate – first we couldn’t help her, now we were “refusing” to let her go home. We needed to deepen our partnership to come to the best mutually satisfactory decision. Ultimately, I personally placed a dialysis catheter in her jugular vein for palliative dialysis – just enough to tank her up so she could last a few days at home before dying peacefully. But making sure she understood that was the extent of what we could do and that she would be OK with that and still wanted the intervention required a partnership. Only through my extensive rapport (she was my patient longer than anyone else on the team, resident, physician, or pharmacist) and the support of my team did we ultimately reach the conclusions and understandings we did and managed to send her home to fulfil her final wish.

    To varying degrees that sort of partnership is not only commonplace but the norm in medical care. Just because it can be skipped at times with similar outcomes doesn’t negate the necessity of it. And just because many outpatient clinic cases are much more cut and dried doesn’t mean there isn’t a place for a partnership between the patient and physician. That plumber who tells me I need a widget I’ve never heard of and that it will cost me $XX (money is an issue in the US, but even in Oz the money in my widget example would be analagous to the costs in time, discomfort, and inconvenience) better establish a partnership with me to explain why, what, and justify the cost in order for me to feel comfortable with having it done. Otherwise I’d be a stupid consumer and in the cases where the outcome would be the same either way, I would have been lucky to arrive at the right answer for the wrong reasons.

  11. BillyJoe says:

    Okay, to summarise, the doctor supplies all the medical details regarding the diagnosis, prognosis, and treatment, along with his recommendations. The patient fills in the personal details after which the doctor may need to change or modify his recommendations. The patient can then decide either to go with doctor’s recommendations or choose another path. The basis for choosing another path might be religious, philosophical or, indeed, just irrational. The doctor need not go along with the patient’s decision if it involves some action on his part (ie futile surgery).

    I guess that can be seen as a shared partnership. Perhaps it’s just bringing human warmth and understanding back into the medical consult and swapping diplomacy for paternalism.
    Unless I’ve still missed something.

  12. Harriet Hall says:

    @BillyJoe,

    “Unless I’ve still missed something.”

    Yes, you have missed something, just as I had before I read this book. The devil is in the details, in the unconscious biases inadvertently introduced by the doctor by the way he presents the information, in the complicated psychology of decision-making, in the difference between what the doctor says and what the patient hears, etc. etc. The book is a real eye-opener; I hope you will read it.

  13. nybgrus says:

    I agree with Dr. Hall (and I will be reading the book – I am currently about 25% of the way through a book called “Medicine, A Love Story” by Gene Stollerman which I would already highly recommend…. perhaps after I finish it I will write a review that Dr. Hall and the authorship here would be willing to post up:-D).

    The devil is in the details. It does require a partnership, even for more mundane things. And of course for less mundane, as I explicated.

    Furthermore, there may be multiple reasonable courses of action for a patient – only in uncommon cases is the “right” decision objectively clear cut. And having a partnership not only allows the patient to better understand and rationally decide on an optimal course of action for him or herself but it allows the physician to better appreciate the patient’s needs and desires.

    Another anecdote, this one personal:

    At one time I was extremely competitively fit (doing a year of core rotations will quickly disabuse one of the ability to stay extremely fit) and I had torn a ligament in my left shoulder (the glenoid labrum, as it turned out). Physical exam demonstrated it but an MRI showed that I had a somewhat rare tear – rather than being completely torn or torn from one side as is common, it was torn in the middle, thus making a “tent” shape. Nonetheless it caused me pain and prevented me from surfing, lifting weights, and long cycling rides.

    Since it was a minor tear and in the middle, physical therapy was a viable option for recovery. I would have to eschew all upper body physical work save my progressive physical therapy and after a year, I was told, would have somewhere around a 70-80% chance of a complete recovery.

    Surgery was the other option, but as we all know there are risks with surgery which I won’t waste everyone’s time here expounding on. Additionally there was no guarantee that the surgery would fix the problem and I would still have to do physical therapy, inevitably lose muscle mass (which I still haven’t fully regained exactly 3 years later), and I would have at least 5-6 months before being able to do upper body exercise and I was told at least 6-8 before I could surf again. But there was a higher chance of succes in a shorter time frame. Oh, and I am allergic to narcotics, so I could not take narcotic analgesia making pain control more diffficult.

    So what would be the non-partnership course of action BJ? As a physician, I would know that non-invasive techniques are always preferred and that, at a simplistic minimum, PT for a year has zero chance of death, but even routine outpatient arthroscopic surgery still has a non-zero chance of death or severe morbidity. By your outlook the answer is extremely straighforward – any chance of death for a similar outcome is absolutely not worth the risk. Right?

    Want to guess what I opted for?

    To me, a 20% chance of still needing surgery after a year of losing out on my favorite activities was not worth it. I wanted the surgery and I knew I would be aggresive about my rehab and that I could handle the pain with narcotics (well, I was mistaken about the last part and I have a new sympathy for my post-surgical patients as a result – I have never in my life, before or since, felt such unending pain). My surgeon didn’t want to do it – in fact, he only mentioned the surgery in passing and did not recommend it at first. But because I happened to work in the same ER where he took trauma call at the time we had an established rapport and I was able to convince him that surgery was in fact the better option for me.

    There is obviously more detail, but I hope you can grok what I am trying to get at. And this would be one of those “routine outpatient office visit” type encounters, not even an end-of-life palliative dialysis sort of issue.

    The thing is that if the physician doesn’t even consider that these sorts of things are important, (s)he will inevitably imbue the consultation with his/her values and priorities and completely skew the perspective of the patient thus (potentially) negating the patient’s autonomy without even realizing it. Diplomacy in advising is certainly part of it. And absolutely there are cases when a physician should hold his/her ground (No, I will not prescribe you antibiotics for your flu). But a partnership allows the physician to not only relay information better to the patient, but allows the physician to better understand the values, wants, and needs of his/her patient to make the best possible outcome for the patient. It deepens the ability of the physician to be both a competent science based practitioner and a “healer” (I hate that that term has been co-opted by the sCAMsters along with “holistic”) and still retain high patient satisfaction (which as we know is independently associated with worse patient outcomes when that is the sole goal and metric being chased).

    Of course, I am but a lowly (newly minted) 4th year medical student with very limited experience (which is why I resort to anecdotes like these) so I may be way off base here, but hopefully I am not talking out of my a$$ too much here.

  14. nybgrus says:

    Oh, I forgot to mention – an important confounder is that I would be having the surgery around 1 month before leaving for the land of Oz to start medical school and would only be able to have 2 or 3 PT session before leaving. This is something the orthopod was extremely reticent about, knowing that good PT follow up was absolutely essential for a good outcome. He initially refused to even do the surgery, citing his legitimate concerns for a frozen shoulder due to lack of PT, until I was able to convince him that I really would follow through on my own, in a foreign land, and whilst just beginning medical school. You really do need a partnership for that, and the physician needs to be willing to enter into that partnership as well as the patient.

    As it turned out, I was extremely aggresive in my PT and was surfing again less than 5 months after my surgery. When I saw the orthopedist about 11 months later (another story) he was literally shocked at my outcome and progress, especially surfing less than 5 months after the surgery (for my birthday that year). He half-jokingly asked if he could write about me as an anecdote for his practice since my results were not typical.

  15. BillyJoe says:

    Perhaps I do need to read the book.

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