Why Doctors Hate Science

[kellyb]

Medically appropriate but ineffective and ultimately useless.
If I had a choice of using 2 antibiotics, one cheap but less effective and one expensive but marginally better, the medically appropriate treatment would be the second choice unless the patient can't afford it.

Yes. Old joke, "I cured Mr X's stab wound but he died from an infection."
A dead or untreated patient due to the doctor's part is a failure. A doctor who does not maximize the success rate of his/her treatment from pure arrogance is incompetent.

Huh. I see what you mean, but I'm just not sure patient noncompliance can be blamed on the doc in a case where the patient never volunteered that he hates taking pills.
But I do see what you mean.

 

[kellyb]

There is a spectrum of medical choices that is "medically appropriate" and a patient can choose their treatment within this spectrum. It is the doctor's skill and judgment to pare down all the options available for a patient to decide.

Is it an impingement of autonomy? You betcha.
The Doc has eliminated a bunch of treatment options and will not even offer it to you. Now you have an "illusion" that you have some measure of choice but it is a controlled and already limited one.

So is your autonomy/free in this situation real or an illusion?

I think the patient autonomy is still very much real. I don't think patients want to be offered obviously bad options. That would be completely pointless.

 

[T.A.M.]

That's quintessential "patient centered care", isn't it?

yes, yes it is.

TAM

 

[T.A.M.]

I think you should have a word with TAM, it sounds like you could learn at lot from him about how to treat people with respect.

As I have said before, the ER MD diagnostic and treatment algorithms, in terms of patient choice or decision making, can be SIGNIFICANTLY different from the GP clinic ones.

There are many times where the patient does not have either (A) the time (life threatened, clock ticking) or (B) ability (decreased LoC, etc...) to make a decision at all, let alone an informed one.

I have worked both. I worked in a rural ER for 2 years. I have worked as a salaried GP for 1-2 years, and now have been a FFS Physician for 4-5 years.

TAM

 

[kellyb]

yes, yes it is.

TAM

Do you know what Linda's talking about with regard to PCC rendering poorer outcomes?
Also (if you don't mind me asking) are you a family doc?

 

[Dr. Imago]

"Civil Engineer Ivor, I need a bridge across this ravine."
"Okay, here are the 2 ways we can build it."
"So which is better?"
"So here are the pros and cons..etc."
"I don't get it."
"Well...blah blah blah."
"Uh...okay. Which do you recommend?"
"I suggest A."
"Uh...is it cheaper?"
"No it's actually more expensive."
"Why?"
"Well...blah blah blah."
"Uh...<blank stare> Are you sure we should go with A?"
So what are you going to do Ivor, is there autonomy here or informed consent or are you going to be paternalistic and choose for this customer?

Another important difference is that a civil engineering firm, being offered a contract for service, will have months to prepare bids, plan, offer alternatives, etc. After the bid is presented, there will be sufficient time to answer questions, formally respond, etc.

The above type scenario in a doctor's office occurs sometimes 20+ times a day, and often with information that has just been garnered. You have a finite and limited amount of time to get to your "destination" (i.e., agreed treatment decision) with a patient.

Thought I'd point that out. Not enough time to spend with the doc? Again, don't blame us: blame the insurance companies.

~Dr. Imago

 

[Ivor the Engineer]

I think the patient autonomy is still very much real. I don't think patients want to be offered obviously bad options. That would be completely pointless.

It's not completely pointless. It useful to claim that's what someone was suggesting physicians should do - trying to look clever on the internet by making other people look stupid.

 

[Ivor the Engineer]

As I have said before, the ER MD diagnostic and treatment algorithms, in terms of patient choice or decision making, can be SIGNIFICANTLY different from the GP clinic ones.

There are many times where the patient does not have either (A) the time (life threatened, clock ticking) or (B) ability (decreased LoC, etc...) to make a decision at all, let alone an informed one.

I have worked both. I worked in a rural ER for 2 years. I have worked as a salaried GP for 1-2 years, and now have been a FFS Physician for 4-5 years.

TAM

Yes, and I already said that in those situations where the patient does not have the capacity or time to decide, the physician should use her judgement in the interests of the patient.

But rather than let the meaning of the words in my post sink in, some posters would rather just try to big themselves up by pretending I'm suggesting things I am not.

 

[Ivor the Engineer]

<snip>

The above type scenario in a doctor's office occurs sometimes 20+ times a day...

<snip>

Which is fine if the patient wants the doctor to make the decision and has made that clear to her.

 

[paximperium]

I think the patient autonomy is still very much real. I don't think patients want to be offered obviously bad options. That would be completely pointless.

I believe we are mostly in agreement and are now down to semantics. The problem we run into is the threshold for "bad" varies.

What is bad for one patient(Taking pills for 10days) could be good for others (I hate getting a shot). There are obviously bad options and these are easily discarded; the issue is the gray area that doctors have to decide to even offer.

If you have Doctor 1 offer you option A, B and C but are not even offered option D because the evidence for option D is poor as per his conclusion. However Doctor 2 working in the same office offers you option A, B, C and D because he thinks it works based on one study.

Did Doctor A restrict your autonomy by not even offering option D?
What if Doctor A really really really believes option A is the only effective cure and starts to minimize the benefits of option B and C?

 

[paximperium]

<snip> trying to look clever on the internet by making other people look stupid.

Don't blame me for your remarkable ability to do this yourself.

<snip> some posters would rather just try to big themselves up by pretending I'm suggesting things I am not.

Hand waving away exposed garbage by playing the victim. Wow.

 

[fls]

Because what I determine as the best treatment, may not sit with the patient as the avenue they wish to go down.

I was thinking that the sorts of things that sit with the patient would be included in your recommendation. A simple example would be a generic drug that you have to take four times a day vs. a brand name option that is taken once a day. One patient may find inconvenience more important than expense, while another patient may have it the other way 'round, meaning that each patient would get a different recommendation.

I may suggest psychotherapy and an SSRI as the treatment option I think they should avail of, but that does not mean it is the one they wish, and if there are other options that will help them (psychotherapy alone, psychotherapy and a Benzo) then I have to at least provide them with those options as options, do I not?

How do you think a patient would choose between those three options?

Linda

 

[kellyb]

Did Doctor A restrict your autonomy by not even offering option D?

I would say "no", because I think good physicians won't (and shouldn't) put a lot of weight in single studies.

What if Doctor A really really really believes option A is the only effective cure and starts to minimize the benefits of option B and C?

As long as he's willing to discuss his thinking and give the patient a quick rundown on what's up, and also consider patient preference [to whatever appropriate extent, depending on the situation] when forming his opinion, that's fine.
If he's familiar with the evidence, and the evidence favors one option as being superior, he doesn't have to hide that or anything.

 

[Ivor the Engineer]

Don't blame me for your remarkable ability to do this yourself.

Hand waving away exposed garbage by playing the victim. Wow.

I think it must really annoy you to know that EKGs, defibrillators, pacemakers, ultrasound, MR and CT imaging, biometric analysis software, hip and joint replacements, and practically every other thing which enables you to do your job was designed and/or developed by engineers, who had to understand the complexities and uncertainties of human biology and often many other aspects of nature, and designed systems which could cope with them.


Think of me each time you use or encounter one of these devices.

 

[fls]

Hmm...
I still think paternalistic docs are less likely to gather relevant information.

That's because you have formed a picture of paternalism which includes negative characteristics that aren't necessarily part of the philosophy, but now represent its use as a derogative term. I'm asking people to take a step back and consider the philosophy. If that's not possible, then I have suggested that one could substitute "beneficence", since it doesn't seem to have the same baggage. Remember that under most circumstances, the goals and results of patient autonomy and beneficence will be identical.

Using the CMA medical ethics as a guide, the only point where you can distinguish the two is with the following:

21. Provide your patients with the information they need to make informed decisions about their medical care...

The rest of them are the same, regardless of whether or not the patient is making a choice between numerous options or a doctor is recommending one or a few as the best options.

22. Make every reasonable effort to communicate with your patients in such a way that information exchanged is understood.

23. Recommend only those diagnostic and therapeutic services that you consider to be beneficial to your patient or to others. If a service is recommended for the benefit of others, as for example in matters of public health, inform your patient of this fact and proceed only with explicit
informed consent or where required by law.

24. Respect the right of a competent patient to accept or reject any medical care recommended.

And actually, if you consider the question under consideration to be "I accept or reject the medical care recommended", then the informed consent referred to in #21 also fits with both beneficence and patient autonomy.

If the doc does gather the relevant information, and communicates the rationale behind the treatment choice to the patient and the patient agrees, then it can't be paternalistic. That's just "patient centered care" coming from a very competent physician.

Yet that is a description of the model of care under paternalism.

While I guess it's possible that a doc (in a non-emergent, PCP setting) could gather all the relevant info and not have an open line of communication with the patient about the prescribed treatment, it's difficult to imagine.

Paternalism doesn't preclude communication.

A doctor that communicates with their patient isn't paternalistic-seeming from the patient's point of view.

Exactly! Paternalism is synonymous with arrogance and non-communication, and the examples of why paternalism in medicine is bad are examples of those behaviours.

My interest is not in whether arrogant physicians or those who communicate poorly are preferable (of course they're not). My interest is in the duty of the physician to provide informed consent and which model best represents that ideal.

Linda

 

[fls]

What % of the patients visits you have in a year do you reach an incorrect diagnosis?

Define "diagnosis".

Linda

 

[Ivor the Engineer]

Define "diagnosis".

Linda

http://dictionary.reference.com/browse/diagnosis

di⋅ag⋅no⋅sis

1. Medicine/Medical.
a. the process of determining by examination the nature and circumstances of a diseased condition.
b. the decision reached from such an examination. Abbreviation: Dx

 

[paximperium]

I think it must really annoy you to know that EKGs, defibrillators, pacemakers, ultrasound, MR and CT imaging, biometric analysis software, hip and joint replacements, and practically every other thing which enables you to do your job was designed and/or developed by engineers, who had to understand the complexities and uncertainties of human biology and often many other aspects of nature, and designed systems which could cope with them.

Not one bit. I know the limits of my knowledge and skills. I'm okay with math but mediocre with physics which is why I decided against a career involving too much of it.

One of my college buds has a degree in biology but went on to engineering and is now in biomedical tech and working a new CAT scanners. I only have a rudimentary understanding of these devices. I have little problem in asking for help in areas outside my skillset.

You really need to stop projecting your inadequacies onto others.

Think of me each time you use or encounter one of these devices.

You want me to think of a jealous, dishonesty and petty online poster whenever I use the GE CAT scanner or Toshiba Ultrasound machine? Uh...sure.

 

[Ivor the Engineer]

http://dictionary.reference.com/browse/paternalism

pa⋅ter⋅nal⋅ism

n. A policy or practice of treating or governing people in a fatherly manner, especially by providing for their needs without giving them rights or responsibilities.

 

[kellyb]

That's because you have formed a picture of paternalism which includes negative characteristics that aren't necessarily part of the philosophy, but now represent its use as a derogative term.

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