Why Doctors Hate Science

[fls]

"Yeah, the doc gave me these to take, but they're just so hard to swallow. I couldn't face having to take the full course."

Obviously the above situation can be mitigated by the doctor being even more paternalistic and making it absolutely clear how important it is to finish the course.

You will notice that all of your (you and Professor Yaffle) examples of Paternalism Is Bad are about decisions made without all the relevant information. I'm suggesting that we should consider decisions made with the relevant information, and that we should be realistic about how that can be accomplished.

Linda

 

[Skeptic Ginger]

OK, for those of you who don't like the fact the health care provider believes they have more health care knowledge than most of their patients, are you seriously suggesting the patient knows as much as the provider? Why bother going to anyone for health care then? Just provide your own.

 

[Professor Yaffle]

Exactly.

Linda

But of course if the patient and doctor agree on the best course of action, then the decision has *really* been made by the doctor.

It's ok, we know how fragile your egos are.

 

[Rolfe]

Wouldn't it be simpler to just tell the doctor that?

Sometimes patients make it unnecessarily complicated.

Over twenty years ago my mother telephoned me before her scheduled urology checkup. She'd previously been told that one of her kidneys wasn't functioning and might need to be removed. She said to me, "What should I tell the surgeon when he asks how I am?"

I asked he what she meant. She said, well, he said I might have to have that kidney out, and I thought if that was the case it might be better to get it done before I turn seventy. So I thought, if I just say, I'm fine, he might just say OK, come back in a year for another checkup, and time's going on. But if I say I'm not feeling so good, what will happen? I don't know what to say.

I took a deep breath, counted to ten, and suggested she say to the surgeon exactly what she'd just said to me. She asked me what I meant. I told her to tell the surgeon how she felt, truthfully, then say that she was wondering, if the nephrectomy was going to be necessary, might it not be better to do it before she's 70?

She said she hadn't thought of that.



She had the kidney out a couple of months later.

Rolfe.

 

[Ivor the Engineer]

how does an engineer know "what type" of steel is best to build that skyscraper from?

I mean maybe legos would be more what I prefer, or cork. Maybe I don't want my skyscraper built from Steel or Concrete.

TAM

But there is probably a selection of steels with different characteristics, which could be relayed in terms even a doctor could understand and use to make an informed choice.

This is what the geek was talking about; you probably don't have much idea how a cell phone works, but you can make an informed choice about what phone suits your needs.

 

[Professor Yaffle]

You will notice that all of your (you and Professor Yaffle) examples of Paternalism Is Bad are about decisions made without all the relevant information. I'm suggesting that we should consider decisions made with the relevant information, and that we should be realistic about how that can be accomplished.

Linda

Actually my example of the epidural problem was one where the doctor had been given the relevant information but refused to accept it because she thought the epidural had gone ok. I have a couple of other examples like that too. If some doctors cannot take into account something very obvious, its pretty likely that they will run roughshod over patient preferences in less obvious situations too.

 

[fls]

How does the physician know what is "good" for the patient?

I.e. the physician only has an estimate of the patient's utility function, and a biased one at that. Not everyone weights the 5 D's the same as doctors do.

ETA: To give an example: if I ever need even minor surgery on my eyes, I will have to have a general anesthetic, even though a local may be safer.

I'm sorry, I still don't understand why that wouldn't be part of the discussion.

Linda

 

[Skeptic Ginger]

Its seemed to me that Ivor was drawing similar conclusions to the author of the book. Was the author also drawing false conclusions? Did you actually read anything of the link he provided?

Are you claiming you read this book? How do you know what the authors conclusions were?

It's a textbook for improving one's provider-patient communication skills. The authors' goals are to provide information which improves these skills. Where in the book does it give an overall condemnation of the current medical profession?

I could write a similar book sharing my expertise in infectious disease with other providers. That doesn't mean I'd be concluding every provider who found the book useful was incompetent in the field.

An assessment of where improvement might be needed is not a condemnation of the practices of the people one feels would benefit from the book. And not only that, my medical/nursing education included many hours of patient provider communication skills, as would any medical school curriculum.

 

[Ivor the Engineer]

You will notice that all of your (you and Professor Yaffle) examples of Paternalism Is Bad are about decisions made without all the relevant information. I'm suggesting that we should consider decisions made with the relevant information, and that we should be realistic about how that can be accomplished.

Linda

Most of the people I work with don't have the knowledge to perform the job I do (Digital Logic Design and Signal Processing), yet we manage (in a very informal way compared to many places I've worked) to decide what functionality they want me to provide them with.

I don't see a huge difference between what doctors do and what engineers do.

 

[paximperium]

But of course if the patient and doctor agree on the best course of action, then the decision has *really* been made by the doctor.

It's ok, we know how fragile your egos are.

I don't have any have illusions here. Manipulation and redirection seems to work very well for me. I manipulate and redirect conversations so that patient's do what I would prefer them to do. I give them the information they need and I maximize or minimize certain bits so that they believe they are making an informed decision. I use it a whole lot more the more I believe the patients need it.

"Mr Soandso, we really need to do this lumbar puncture. We cannot be sure you don't have meningitis unless we do this procedure. Meningitis can cause death, brain damage and paralysis. I do this procedure all the time so it isn't dangerous. It may hurt a little bit."

"Mr. Soandso, I don't believe you need a lumbar puncture. Although the risk is rather low we cannot be sure you don't have meningitis unless we do this procedure. Meningitis can cause death, brain damage and paralysis.A lumbar puncture does hurt a bit but it is safe."

 

[fls]

Come on Linda - you have a very obvious sarcastic streak.

I am rarely sarcastic. Even less so in real life.

Some doctors can turn that off when they are with patients (I have no idea whether you are one of them), but others seemingly cannot keep their sarcastic/arrogant/condescending/patronising personalities out of the surgery.

Are you saying that this is a necessary component of paternalism, or do you think it is possible to consider them separately? What if we focussed on the beneficence component?

To me the problem is not about *who* makes the decision, as long as the patient has been listened to and their views taken into account. The main problem, for me, is that many doctors create an atmosphere wherein patients find it very difficult to provide this sort of input. It's not enough for a doctor to say "well they didn't tell me about their problem with x" when they have created a situation in which it is very difficult for the patient to air their concerns. See Ivor's link to the book about communication skills.

I agree that it's often important to have a doctor that listens to you. I just think that it's an issue that can be considered separately from paternalism or beneficence.

Linda

 

[Professor Yaffle]

Are you claiming you read this book? How do you know what the authors conclusions were?

It's a textbook for improving one's provider-patient communication skills. The authors' goals are to provide information which improves these skills. Where in the book does it give an overall condemnation of the current medical profession?

I could write a similar book sharing my expertise in infectious disease with other providers. That doesn't mean I'd be concluding every provider who found the book useful was incompetent in the field.

An assessment of where improvement might be needed is not a condemnation of the practices of the people one feels would benefit from the book. And not only that, my medical/nursing education included many hours of patient provider communication skills, as would any medical school curriculum.

I didn't read Ivor's conclusions as an overall condemnation of the current medcal profession (in this instance). I read it as him saying that a lot of medical professionals having poor communication skills which leads to them not getting the necessary information from their patients.

 

[Skeptic Ginger]

Actually my example of the epidural problem was one where the doctor had been given the relevant information but refused to accept it because she thought the epidural had gone ok. I have a couple of other examples like that too. If some doctors cannot take into account something very obvious, its pretty likely that they will run roughshod over patient preferences in less obvious situations too.

We all have stories of being unhappy with the performance of some professional or other worker be it the contractor who remodeled your house or the doctor who you had a bad experience with.

I wouldn't use those anecdotes to judge an entire profession on.

 

[Skeptic Ginger]

I didn't read Ivor's conclusions as an overall condemnation of the current medcal profession (in this instance). I read it as him saying that a lot of medical professionals having poor communication skills which leads to them not getting the necessary information from their patients.

Define "a lot" and tell us how you know that?

Most providers I have had an experience with have good patient provider communication skills. I see this as what I said before, people selectively remember bad experiences and can tend to project those experiences onto a wider field than they actually apply.

 

[fls]

Actually my example of the epidural problem was one where the doctor had been given the relevant information but refused to accept it because she thought the epidural had gone ok. I have a couple of other examples like that too. If some doctors cannot take into account something very obvious, its pretty likely that they will run roughshod over patient preferences in less obvious situations too.

I simply think that Doctors That Don't Listen is different from Paternalism or Beneficence - I wouldn't want to visit the faults of one onto the other.

Linda

 

[Ivor the Engineer]

I don't have any have illusions here. Manipulation and redirection seems to work very well for me. I manipulate and redirect conversations so that patient's do what I would prefer them to do. I give them the information they need and I maximize or minimize certain bits so that they believe they are making an informed decision. I use it a whole lot more the more I believe the patients need it.

"Mr Soandso, we really need to do this lumbar puncture. We cannot be sure you don't have meningitis unless we do this procedure. Meningitis can cause death, brain damage and paralysis. I do this procedure all the time so it isn't dangerous. It may hurt a little bit."

Mr. Soandso thinking to himself: "Wow, this doc's laying it on thick. Clearly he doesn't have a clue what's wrong with me and is just taking a wild stab in the dark."

"Mr. Soandso, I don't believe you need a lumbar puncture. Although the risk is rather low we cannot be sure you don't have meningitis unless we do this procedure. Meningitis can cause death, brain damage and paralysis.A lumbar puncture does hurt a bit but it is safe."

Mr. Soandso thinking to himself: "Wow, this doc's really different to that Linda woman I saw last week. I appreciate not being treated like a child."

 

[Professor Yaffle]

I posted this earlier, as pretty close to my views. Note the role of communication.

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

 

[paximperium]

Mr. Soandso thinking to himself: "Wow, this doc's laying it on thick. Clearly he doesn't have a clue what's wrong with me and is just taking a wild stab in the dark."

Completely true. Your decision. I have no interest in making this "stab in the dark" decision for you. Choose correctly or else...

Mr. Soandso thinking to himself: "Wow, this doc's really different to that Linda woman I saw last week. I appreciate not being treated like a child."

I'm too busy to waste my time to do an LP on someone who I don't think has meningitis. Stop thinking and leave already.

 

[Ivor the Engineer]

I think the confusion is in the different levels of decision making which go on between the patient and a doctor.

Sure, doctors make decisions that their patients would be unable to make, just as engineers make decisions which the users of their products would not be able to make.

But ultimately it is patients who should be directing their treatment, just as the users of engineers' work specify what they want it to do, given the constraints pointed out by the engineer.

Doctors are a human user interface for medical technology.

 

[Skeptic Ginger]

As Linda notes in post #325, there are two different issues here. One is the quality of care. Good quality care includes skilled patient provider communication.

The second issue is who controls the care that is given. If you hire a housekeeper or a gardener, you as the employer can expect the employee you've hired will follow your instructions.

When you hire a professional such as a lawyer or a doctor or nurse practitioner, you are buying their expertise, you are not employing them. As such, some decisions belong to each party.

Under the model you are suggesting, the health care provider would be an employee of the patient. If that were the case, the patient could ask for drugs and surgery that was not indicated. Surely you can see the problem that would create?