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Posts Tagged decision-making

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. (more…)

Posted in: Book & movie reviews, Medical Ethics

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Diagnosis, Therapy and Evidence

When Dr. Novella recently wrote about plausibility in science-based medicine, one of our most assiduous commenters, Daedalus2u, added a very important point. The data are always right, but the explanations may be wrong. The idea of treating ulcers with antibiotics was not incompatible with any of the data about ulcers; it was only incompatible with the idea that ulcers were caused by too much acid. Even scientists tend to think on the level of the explanations rather than on the level of the data that led to those explanations.

A valuable new book elaborates on this concept: Diagnosis, Therapy and Evidence: Conundrums in Modern American Medicine, by medical historian Gerald N. Grob and sociologist Allan V. Horwitz. They point out that 

many claims about the causes of disease, therapeutic practices, and even diagnoses are shaped by beliefs that are unscientific, unproven, or completely wrong. (more…)

Posted in: Book & movie reviews, Science and Medicine

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Diagnostic Dilemmas

Sometimes diagnosis is straightforward. If a woman has missed several periods and has a big belly with a fetal heartbeat, it’s pretty easy to diagnose pregnancy. But most of the time diagnosis is much more difficult. Alzheimer’s can’t be diagnosed for sure until the patient dies and you do an autopsy. If only we had one of those Star Trek gadgets to point at our patients and give us a quick and accurate answer! Alas! We are far from perfect. All too often, we really have no idea what’s causing a patient’s symptoms. We do a complete workup and still don’t know. What then?

We all know people who have symptoms that a series of doctors have failed to diagnose, who continue to doctor-shop, hoping to find that one doctor somewhere who will find something the others have missed. Occasionally they do; but far more often these people spend a great deal of time and money chasing a will-o’-the-wisp. Sometimes as they are searching, the illness gradually runs its course and goes away. When this happens, whatever they tried last gets the undeserved credit for the “cure.” Sometimes the symptoms persist and these searches consume their life, encourage unhealthy self-absorption, and permanently ensconce them in the “sick” role.

One of the attractions of alternative medicine is that it offers far more certainty than scientific medicine. If your scientific doctor can’t see anything on x-rays, your chiropractor can. He’ll tell you he knows exactly what’s wrong: a subluxation that he can fix. Sherry Rogers will tell you all illness is due to toxins accumulating in your cells and you must “detoxify or die.” Hulda Clark will tell you it’s all parasites that she can eliminate with her magic zapper. Robert Young says the cause of all disease is acidosis. They all have confident, precise answers. Wrong ones.

The One Cause of All Disease?

It’s really easy to figure out what’s causing a patient’s symptoms if you believe there is one simple cause for all disease. While I was writing this I got sidetracked and searched the Internet for “the one cause of all disease.” I found a lot of them, including: (more…)

Posted in: Diagnostic tests & procedures, Science and Medicine

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