Jul 16 2008
I sometimes lecture on science-based medicine to my colleagues and one of the most common questions I get is how to deal with a patient who expresses belief in unscientific treatments. The dilemma for the physician is that professionalism requires that we do not confront patients regarding their personal beliefs. We are there to inform and advise, not preach. And yet proper medical care is often hampered by unscientific beliefs on the part of patients.
David wrote previously about a case he reviewed in which a woman with a very treatable early stage of breast cancer opted for “alternative” treatment rather than the standard treatment, which carries a > 93% good outcome. As a result her cancer progressed horribly – but she clung to belief in CAM despite its obvious failure in her case. This story highlighted the fact that giving patients proper medical advice sometime requires confronting their false beliefs.
Unscientific and bizarre medical practices are in vogue and are increasingly infiltrating the medical system through a combination of misguided political correctness, stealth, and apathy. This is exacerbating the dilemma for science-based practitioners who are caught between the imperative to do the right thing in accordance with evidence-based guidelines and the default respect for the patient and the desire to maintain a therapeutic relationship.
In my experience, however, these two goals do not have to be mutually exclusive. An uncompromising but non-judgmental approach works very well.
One of the more challenging aspects of ethical clinical practice is to balance various ethical and practical concerns that are at cross-purposes. For example, the need to give patients informed consent includes the requirement to give them a realistic sense of their medical condition. If a patient has a terminal illness, they need to be told so. Gone are the paternalistic days when a doctor would lie to a patient to protect them.
It is even more important to inform a patient of the consequences of their medical decisions. If a patient refuses a recommended treatment and they are likely to die without the treatment, they need to be told so in no uncertain terms.
At the same time we don’t like to scare patients unnecessarily and cause undue stress. Therefore we won’t tell a patient that we think they may have cancer when it is still uncertain. It’s better to wait for the test results.
But what if a patient declines to take a test that will indicate whether or not they have cancer? Then it may be necessary to inform them that the purpose of the test is to look for things that are potentially serious and treatable. If they still refuse, you may need to break down and inform them that they may have cancer and the test is needed to rule it out.
In other words – part of the art of medicine is knowing how much information to give a patient in order to help them make the right decision. Or, at the very least, if they are about to make a risky decision it becomes necessary to inform them in stark terms why the decision is risky. The desire to protect the patient from unnecessary stress takes a back seat to giving them the information they need to make an informed decision.
Along the same lines, health care providers should not confront the personal beliefs of a patient, but what if those personal beliefs are motivating them to make very bad medical decisions? Then, in my opinion, it depends upon the nature of the beliefs. Religious beliefs should be completely out of bounds. It is not the place of the physician to validate or refute personal religious beliefs.
Non-religious ideological beliefs are the same. The point is that the physician cannot impose their value system onto their patient.
That doesn’t mean that nothing can be done within the confines of professional ethics. If a patient refuses a life-saving intervention because of their religious beliefs it is reasonable to make sure that they fully understand the consequences of their decision. It is also reasonable to suggest that they consult with family members. You may even offer to refer them to a support group or even counseling.
This can be done in a completely non-confrontational and non-judgmental way. You can respect their religious belief and their right to make their own decisions, but just advise them to take advantage of available support structures in making such a huge decision.
I think where most of the confusion comes in is confusing the approach to personal values or ideological beliefs with the proper approach to medical claims. While beliefs and values are out of bounds, any factual claims are fair game – regardless of their motivation.
First it is important to recognize that patients who are in a doctor’s office have already made the decision that the expertise and experience of that physician is worthwhile. By consulting a physician a patient is tacitly giving that physician permission, even the obligation, to provide their unvarnished medical opinion. In fact, holding back on giving an honest medical opinion is a throwback to the old paternalism – it in essence says that the patient is incapable of handling the honest opinions of their doctor and they need to be coddled to some extent. In reality, in my opinion, failure to give an honest opinion is misguided and harmful – and I suspect may be designed to protect the physician from an uncomfortable confrontation more than the patient.
It is far better to be unapologetic in stating that one is a science-based practitioner (this article is written for the science-based practitioner) and that one’s medical advice is based upon the best scientific evidence available. I find that when patients come to my office, that is exactly what they want. They are very happy to get my honest opinion, even if it directly contradicts what they believe. I don’t dance around the issue at all.
Most experienced clinicians already know to avoid dismissive, insulting, or judgmental statements. In confronting unscientific medical beliefs, it is easy to do so. Simply confine your opinions to the scientific evidence. For example, if a patient asks me about acupuncture for migraine headaches I simply tell them that I have reviewed the published literature which does not support the use of acupuncture for migraines. I therefore do not recommend it. I am then happy to discuss the evidence with the patient as much as they desire. But almost always patients appreciate the fact that I have taken the time to actually read the literature and they respect my opinion. They may not follow it – but that is their choice.
Sometimes patients ask me about treatments that I believe to be fraudulent and exploitive – for example I am frequently asked about whether or not it is worth it to fly to China to get stem-cell therapy. In these cases I tell my patients, in a very factual and dry manner, that such clinics are fraudulent. What evidence we have shows that their treatments are not safe and that they do not work. In my opinion the people operating the clinic are committing fraud to steal money away from desperate patients. To do anything less is to fail to properly inform a patient.
I have even confronted the beliefs of patients that vaccines have caused their child’s autism – in some cases hardcore true believers. I validate the patient’s concerns and acknowledge the evidence that is out there. I reassure them that I simply want to give them the best advice I can, that I have read the literature thoroughly and then I give them my scientific opinion. It is often helpful to explain to patients how I approach evidence and my philosophy of science-based medicine. The response is almost universally positive.
Physicians and other clinicians should not be afraid to defend the scientific basis of good medicine and to explain to patients that we are scientific practitioners. In my experience there is still a great deal of basic respect for science in the public. As long as you take a thoughtful, professional, and evidence-based approach to your opinions, patients will respect them, even if they disagree with them.
It is profoundly misguided and harmful to fail to confront pseudoscience or bad science in medicine out of fear of offending a patient. Such fears are overblown and misplaced.
Given the medical environment today, clinicians are obligated to have a working knowledge not only of science-based medicine but of the unscientific practices and claims with which their patients may be faced. We are obligated, as part of good practice, to know the literature and the nature of unscientific claims and to help our patients navigate through them. Otherwise we are throwing them to the wolves.
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