Why Doctors Hate Science

[Skeptic Ginger]

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]

Everything I'm reading says it is.
Like:

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



http://journals.lww.com/co-critical...l_decision_making__paternalism_versus.15.aspx

From 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]

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.

 

[T.A.M.]

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]

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

No, beneficence is patient centered.

Linda

 

[fls]

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]

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]

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]

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]

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]

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]

“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]

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]

"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]

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]

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.



BillyJoe

 

[Professor Yaffle]

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.]

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]

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?

 

[BillyJoe]

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.