Why Doctors Hate Science

[fls]

The case-mix could be accounted for by working back from the final diagnoses. Age, sex and SES of patients could also be controlled for.

But all that will really tell you is that Linda really, really doesn't like looking after people who are well and deliberately chooses people with complicated, multi-system problems for her practice - information which is already available for the asking.

Linda

 

[Dr. Imago]

THERE SEEM TO BE A PLETHORA OF TANGENTS AND SIDE-DISCUSSIONS GOING ON IN THIS THREAD... TIME FOR A SPLIT? (In the meantime, I'm going to stick to this one...)

While I could be wrong, I'm pretty sure "patient centered care" (particularly a style of communication, and emphasis on shared decision making) is actually a subject of interest in family medicine.

No, you're not wrong. And, I would even go so far as to say that - dare I use the term - "marketing" to people, both lay and medical (including not only doctors and nurses, but ancillary staff... patient care techs, medical assistants, etc.), may encourage this (what I call) redundancy to get the concept across to EVERYONE involved with the patient's treatment plan.

However...

Don't mistake "autonomy" or "patient-centered care" to mean that the patient gets whatever he/she wants. The diagnosis, treatment, and plan is discussed with the patient, options are given, and the patient can either accept that diagnosis and those options, seek a second opinion, tell the doctor to pound sand, etc.

For example, if a patient, in pain, comes to me and says, "Doc, I've got a pain in my leg, and I want you to prescribe Oxycontin with unlimited refills so I can feel better," I can tell you now that it just ain't going to happen.

This is similar in the way the ACOG approach, in what you reference is, and be careful not to mistake options given as paternalism. As an anesthesiologist, I'm heavily involved in perinatal care of the mother. I offer options, and tell the mother what the plan will be based on certain scenarios. Given a "crash" c-section, or the like, she may not have the option to forgo general anesthesia. The reasons for this are primarily her safety as well as the baby's safety (principle of nonmalficience, which - in this case - trumps autonomy).

There are other instances where beneficence and nonmalficience will trump autonomy, like in an incapcitated patient in the trauma bay or someone who is otherwise incapable of making an informed choice.

I see that far differently than being paternilistic, and that's why using a "patient-centered approach" is really just a dolled-up way of explaining in simplistic terms what we do everyday in the hospital.

By the way, I'm so far derailed right now, someone remind me: What was the point of this thread again?

~Dr. Imago

 

[Dr. Imago]

P.S. Sorry for my spelling in that last post. In the words of Charles Barkley, "It was turrible." (Long weekend, first in a while I didn't have to work. And, lots of basketball.)

~Dr. Imago

 

[kellyb]

THERE SEEM TO BE A PLETHORA OF TANGENTS AND SIDE-DISCUSSIONS GOING ON IN THIS THREAD... TIME FOR A SPLIT?

I actually think all of these tangents are part of the debate presented in the OP.

And, I would even go so far as to say that - dare I use the term - "marketing" to people, both lay and medical (including not only doctors and nurses, but ancillary staff... patient care techs, medical assistants, etc.), may encourage this (what I call) redundancy to get the concept across to EVERYONE involved with the patient's treatment plan.

I think what's being marketed, probably, is the "medical home" and EMR plans to save American healthcare.

Does anyone have an opinion on this?

http://junkfoodscience.blogspot.com/2008/02/welcome-home-medical-home-will-soon-be.html

Right wing woo? True? Some mix? Who knows?

 

[Toke]

I think what's being marketed, probably, is the "medical home" and EMR plans to save American healthcare.

In my unqualified oppinion there is an awfull amount of buzzwords and peptalk.
I balk at thinks like "core values" and "mission statement", the second link in the plan (your previus post) was to acupuncture, that does not improve matters.

It seems to be initiated by pharmaceutical companies, and GM.
Do they really want to reduce cost of healthcare?

 

[BillyJoe]

I'm not sure I understand your reply here. I do give my patients as much information as possible. I'm saying that in reply some indicate they prefer less information.

It was really a redirect to Ivor. I was suggesting that if his doctor gives him as much information as possible, he would finally have to give up and leave it for the doc to decide what the treatment should be, instead of insisting on participating in the decision regarding treatment.

But I think you mean as much information as necessary (tailored to the individual patient).

 

[Skeptic Ginger]

I tend to give too much. It's my chatty style.

 

[BillyJoe]

After the information avalanche I bet they just give up then and say "um...yeah...whatever you think doc"

I think Ivor should attend you for his medical care. Not only would his irrelevant banter not get an airing but, not knowing anymore what he wants and why he should want it, he would likely up arms and surrender "Whatever you say, doc"

Which is really how it ends up the vast majority of the time.
Am I right or am I right?

BJ

 

[Skwinty]

After the information avalanche I bet they just give up then and say "um...yeah...whatever you think doc"Am I right or am I right?
BJ

I would say you are right.
I have just returned from my GP and after me saying I dont think I should have this PSA test due to the current controversy over its efficacy and the follow up there to etc, the Dr says, well and rattles off a whole lot of info and proceeds to say not only will we do the PSA, but also the enhanced supersensitive version as well.
So, what do I say:
Um oh well whatever you say Doc.

 

[Ivor the Engineer]

<snip>

There are other instances where beneficence and nonmalficience will trump autonomy, like in an incapcitated patient in the trauma bay or someone who is otherwise incapable of making an informed choice.

<snip>

Nothing "trumps" the autonomy of competent individuals. What seems to be forgotten here that there are two individuals involved, the patient and the doctor.

The doctor has the right to offer whatever treatments she considers appropriate and refuse to preform anything she considers harmful or pointless.

The patient has the right to ask for whatever treatments she wants and refuse any treatments suggested by her physician.

What appears to be the difference of opinion is whether or not patients, in general, have the competence to be able to make an informed choice about accepting or rejecting treatment proposed by a physician.

 

[Ivor the Engineer]

But all that will really tell you is that Linda really, really doesn't like looking after people who are well and deliberately chooses people with complicated, multi-system problems for her practice - information which is already available for the asking.

Linda

I think it would tell me something about the reasoning processes employed by physicians.

What do you think to the suggestion made in the AJoM supplement I linked to for patients being 'watchdogs for cognitive errors during a consultation'? How do these behaviours fit in with the paternalistic model of patient care you are suggesting may be superior to one in which patients take more responsibility for decisions about their healthcare?

Be Watchdogs for Cognitive Errors

Traditionally, physicians share their initial impressions with a new patient, but only to a limited extent. Sometimes the suspected diagnosis isn't explicitly mentioned, and the patient is simply told what tests to have done or what treatment will be used. Patients could serve an effective role in checking for cognitive errors if they were given more information, including explicit disclosure of their diagnosis, its probability, and instructions on what to expect if this is correct. They should be told what to watch for in the upcoming days, weeks, and months, and when and how to convey any discrepancies to the provider.

If there is no clear diagnosis, this too should be conveyed. Patients prefer a diagnosis that is delivered with confidence and certainty, but an honest disclosure of uncertainty and the probabilistic nature of diagnosis is probably a better approach in the long run. In this framework, patients would be more comfortable asking questions such as “What else could this be?” Exploring other options is a powerful way to counteract our innate tendencies to narrowly restrict the context of a case or jump too quickly on the first diagnosis that seems to fit.

 

[Ivor the Engineer]

It was really a redirect to Ivor. I was suggesting that if his doctor gives him as much information as possible, he would finally have to give up and leave it for the doc to decide what the treatment should be, instead of insisting on participating in the decision regarding treatment.

But I think you mean as much information as necessary (tailored to the individual patient).

Ah, but Ivor's doctor is not so arrogant or insecure to think he knows more about a patient's medical condition they they do.

In return Ivor doesn't expect his doctor to be anywhere near 100% accurate.

 

[BillyJoe]

I would say you are right.
I have just returned from my GP and after me saying I dont think I should have this PSA test due to the current controversy [*see below] over its efficacy and the follow up there to etc, the Dr says, well and rattles off a whole lot of info and proceeds to say not only will we do the PSA, but also the enhanced supersensitive version as well.
So, what do I say:
Um oh well whatever you say Doc.

Yes, he is the professional and that's why you went to him: for advice.
Pretty silly to ignore it then, hey?
(Real pity that he is wrong though )

not only will we do the PSA, but also the enhanced supersensitive version as well

Do you mean the free PSA/total PSA ratio?

This is generally only done when the total PSA is equivocal.
(I know all this stuff - no one can accuse me of not making an informed decision not to have the test )
If your total PSA is equivocal and the free PSA/total PSA ratio is less than 25%, you are in for an ultrasound guided biopsy of the prostate - and still no evidence that any of this is worthwhile!

Don't say I didn't warn you.
(Apparently it hurts real bad! )

regards though,
BillyJoe


* Skwinty is referring to this thread:
http://www.internationalskeptics.com/forums/showthread.php?t=137878

 

[BillyJoe]

The patient has the right to ask for whatever treatments he wants...

Right, I'll have $#!+ load of oxycontin thanks.

 

[BillyJoe]

Ah, but Ivor's doctor is not so arrogant or insecure to think he knows more about a patient's medical condition they they do.

Well, like me and my prostate, you are probably a special patient.

In return Ivor doesn't expect his doctor to be anywhere near 100% accurate.

Well, you are one up/down on me. I don't have one yet.

 

[Ivor the Engineer]

Right, I'll have $#!+ load of oxycontin thanks.

BillyJoe's Doctor: "Now Bill, we've been through this before. You can have the drugs after you let me examine your prostate."

 

[T.A.M.]

skwinty:

Did he even mention the DRE? If despite your reservations he is still insistent on the PSA, I guess your options are to go ahead and get it done, and make a stand further up the investigation line, or to chose a new GP, or to simply refuse, and not get the bloodwork done at all. What is he gonna do, spank you?

TAM

 

[BillyJoe]

Did he even mention the DRE?

Maybe Skwinty doesn't want to mention it.

go ahead and get it done, and make a stand further up the investigation line

I think it's going to get harder and harder to make a stand the further up the investigation line he goes.

That's why I've taken a stand right here - before the DRE!

BJ

 

[BillyJoe]

Ivor,

You have a cute dog at least.

 

[Skwinty]

As I said in a previous thread, I have had a DRE some years ago. Wasn't the most pleasant of experiences.
anyway, I was at the doc because of the following reasons.
1. I have type 2 diabetes.
2. I contracted influenza, which turned to a bacterial infection as I was taking viral based meds I suppose.
3. this had some unpleasant side effects for me as I had spent 3 days without my diabetes meds, due to unavailability at the pharmacy.
4. I passed out twice in 3 days at work.
5. Glucose levels spiked very high (16) and increased blood pressure, BP normally 120/80 went to 150/100 and experienced intense nausea.

so, off I go to the doc.
couse of action by doctor.

1. Treat the bacterial infection
2. Investigate newer meds for diabetes.
3. Takes blood samples for glucose 3month average, kidney function, liver function, WBC and then the PSA as I have only had 1 PRE before.
4. Results due on wednesday.

I was in no mood to argue with the doctor re the PSA test, so I succumbed. She tells me that the PSA was developed as men don't like the PRE. Can't say I disagree.

Anyway, I feel relatively positive about not being screened as cancer positive as I have a very healthy sex life and have not presented any other related problems.

As for the follow up being painful, I suppose that depends on your personal pain threshold. Mine is quite high as I often tell myself that pleasure and pain are divided by a very thin line.