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Why Doctors Hate Science

BillyJoe said:
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But, hold on, if you want to see the statistics supporting various treatment options, don't you also want to see how such statistics were arrived at? Whether they say what they seem to say? Does that not mean that you willl need to have knowledge about statistical methods used to evaluate clincal trials and therefore additional knowledge about clinical trials and how to evaluate them. If not, why not just stick with the doctor's recommendation in the first place.
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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.

How much information do you need to give you the illusion that you are participating in the decision making process?
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If the doctor is also a skilled magician, not very much.

I based this example on something that happened only a few weeks ago.
In fact, I was grateful that he did NOT interrrupt my busy work schedule to ask me that STUPID question. Going by mileage done, the break pads were due to be changed, but he didn't change them because, in his opinion based on his experience, they would easily last untill the next service, and he told me this when I picked up the car.
A truly professional approach in my opinion.

BJ
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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.
 
kellyb said:
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?
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Yes I am a family doc.

I doubt Linda was claiming that patient centered care results in poorer outcomes. Given this is the trend within the Canadian College, I cannot see them continuing to do so if patient outcome is worsened.

TAM:)
 
fls said:
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.



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

Linda
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How they chose depends on the patient. Of course, I am influencing them with my suggestion, and I think you and I can agree that that is not paternalism. I have had patients that chose the psychotherapy alone option all the time. I suggest the SSRI and Benzo, and we even have a discussion about the meds and their side effects, but some still decide they do not want them...and I am ok with that, as long as I feel they are informed.

TAM:)
 
Ivor the Engineer said:
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.:)
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I dunno about Pax, but it does not bother me in the slightest. I appreciate the engineering community and what they contribute to the living and nonliving world.

I would like to think that in most cases it is reciprocated.

TAM:D
 
This "patient centered care" stuff... I don't know exactly where you guys are getting this. The entire concept of "patient centered care" is redundant, and I think you are confusing terms. All care is "patient centered".

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.

Now, if you want to continue to have a discussion on those things, start a new thread, as it may prove to be an interesting discussion. :)

~Dr. Imago
 
Dr. Imago said:
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.



~Dr. Imago
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If paternalism is discouraged (is it a bad thing or a good thing?), then what's Linda talking about here?


http://www.internationalskeptics.com/forums/showpost.php?p=4538408&postcount=475

ETA:

This "patient centered care" stuff... I don't know exactly where you guys are getting this. The entire concept of "patient centered care" is redundant, and I think you are confusing terms. All care is "patient centered".
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http://www.pbs.org/remakingamericanmedicine/care.html

What is Patient- and Family-Centered Care?
Patient- and family-centered care is an innovative approach to the planning, delivery, and evaluation of health care that is grounded in mutually beneficial partnerships among health care patients, families, and providers. Patient- and family-centered care applies to patients of all ages, and it may be practiced in any health care setting.
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Professor Yaffle said:
Quick question for Linda: If you had a patient with two different treatment options, with one option slightly superior, in your eyes, but the patient refused to take this option (for seemingly irrational reasons), would you refuse to treat them with the slightly inferior (IYO) option?
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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
 
kellyb said:
I'm still looking for evidence that real MD's who deliver patient centered care have worse outcomes than those who don't.
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Why?

Or more importantly, where is there a model of practice that isn't patient-centered for comparison?

Linda
 
fls said:
"confound (mistake one thing for another)"
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Ok, to be clear, I was using the word in the sense of mingling two different things, not being mistaken about what is diagnosis and what treatment is.

I'm willing to let it drop if you are.:)

That people are subject to various cognitive biases when making decisions?

Linda
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Yes, even doctors.

Who could possibly keep their thinking on track while consulting with a patient?
 
fls said:
Why?

Or more importantly, where is there a model of practice that isn't patient-centered for comparison?

Linda
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Well, I guess there's a continum of "patient centeredness" among different physicians.
Here's a PCC study that used audio taping to evaluate the patient centered communication.

http://www.jfponline.com/Pages.asp?AID=2601&UID=

For our observational cohort study data were collected at 5 points: (1) the research assistant identified eligible patients in the physician’s office before the visit; (2) the office encounter was audiotaped and scored for patient-centered communication; (3) the research assistant held a postencounter interview with the patient; (4) we assessed, by chart review, the use of medical care during the 2-month follow-up; and (5) we conducted a follow up telephone interview with patients 2-months after the encounter.
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Measure of Patient-Centered Communication Score. The patient-centered communication score is based on 3 of the 6 components of the model of patient-centered medicine.17-20 The first component (exploring the disease and the illness experience) received a high score when the physician explored the patients’ symptoms, prompts, feelings, ideas, function, and expectations. The second component (understanding the whole person) received a high score when the physician elicited and explored issues relating to life cycle, personality, or life context, including family. The third component (finding common ground) received a high score when the physician clearly described the problem and the management plan, answered questions about them, and discussed and agreed on them with the patient. Scoring sheets and procedures are described in detail elsewhere.21 Scores could range from 0 (not at all patient centered) to 100 (very patient centered).
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Ivor the Engineer said:
What % of the patients visits you have in a year do you reach an incorrect diagnosis?
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I misdiagnosed only one patient in 18 years. I missed an adult with Fifth's disease who had an atypical rash.

I have found myself wrong on a regulatory matter every couple years during the time lag after a change occurs before I find out about it, some of which have been important changes. And I've found myself teaching something erroneous every couple years. Any negative consequences of my false information or outdated knowledge has been minimal.

The reason for this record is not because I'm so skilled, it is because I practice in such a narrow specialty.
 
fls said:
You misunderstood something I said. I didn't say that.

Linda
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Ivor said:


Once a diagnosis has been made and there are multiple courses of action to choose from, the physician should explain each one in an unbiased way and discuss with the patient which one is appropriate, which can be primarily determined by the patient.
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Which is the "shared decision making" part of "patient centered care" (as opposed to the paternalistic model).

...And you said:

I'm not disputing that it can be determined by the patient. I'm pointing out that it has been assumed that the result will be in the best interests of the patient when there is evidence that suggests otherwise.
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So...what did you mean?
 
kellyb said:
Still looking for evidence that patient centered care might deliver worse outcomes than the alternative method...
Nothing yet, but this is interesting:

http://www.ncbi.nlm.nih.gov/pubmed/16356677





Not that the paternalism advocates care what we patients think, ;) but I'm going to go out on a limb here and guess that a vast majority of patients would say that yes, it is just the right thing to do on a moral level.
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What makes you think paternalistic and patient centered are necessarily mutually exclusive?
 
Dr. Imago said:
This "patient centered care" stuff... I don't know exactly where you guys are getting this. The entire concept of "patient centered care" is redundant, and I think you are confusing terms. All care is "patient centered"....
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Exactly. And if it weren't it wouldn't be good care.
 
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