Posted by: notdeaddinosaur | September 1, 2009

The Dirty Little Secret About Patients as Partners in Health Care

Patient empowerment, shared decision making, patients as partners in their health care; these are the latest buzzwords in this age of consumerism, where patients have morphed into glorified shoppers. Under this alleged new paradigm, it is our idealized job as doctors to explain everything to the patient (after properly diagnosing them, which of course includes explaining everything about each diagnostic test or procedure, including all the possible diagnoses we are thinking about) so that the patient can then make an “informed decision” about treatment.

The dirty little secret is that medicine doesn’t work like that.

Despite the abundance of information on the internet, the practice of medicine is more than just the application of an abundance of information. Above and beyond the knowledge conveyed during medical school (half of which is wrong, although no one knows which half) and the experience gained during residency training is the years of day-to-day exposure to that medical knowledge and training experience in real live people — the practice of medicine.

This is why no amount of information — whether obtained from me, the internet, or even those really cool collections of pieces of dead trees called “books” — will ever properly equip a patient to make an actual medical decision. The dirty little secret is that in the final analysis, it will always be doctors who ultimately make decisions about medical treatment.

Although I am technically speaking of paternalism, the concept of one person (who supposedly is more knowledgeable or capable) making decisions for another, I am by no means advocating a return to the days of the “Don’t you worry your pretty little head about a thing” doctor-patient relationship. I firmly believe it is my job not just to make the decisions, but to explain to my patients in as much detail as they want and need exactly why I am recommending a particular course of treatment.

I tell my patients that I only offer them choices when it doesn’t matter. If your blood pressure isn’t controlled on 10 mg of lisinopril, we can either increase it to 20 mg, or add a diuretic. Each of those courses of action is equal in expense, number of pills (it comes in a combination product) and has an equal chance of controlling the blood pressure (and if it doesn’t, the next step is the other option; I have a lot of people who end up on linsinopril/HCT 20/12.5.) I think all doctors should do this. When you stop to think about it, it’s the only thing that makes sense. It would be irresponsible to allow a patient to choose a clearly inferior treatment option.

The interesting thing is that most patients really do understand this. Many of them tell me in so many words that they expect me to make the decision (and to explain it to them, of course). If I were to do the whole “Here are your choices, you decide” tap dance demanded by the “shared decision making paradigm,” not only would I be doing these patients a disservice, but I’d annoy the hell out of them.

The key is for physicians to acknowledge that we actually do have this responsibility. Whether the decision is about antibiotics for respiratory infections or the extent of high tech life support, the final call is ours. If we are honest with ourselves, we will recognize the extent to which we guide our patients to reach the same conclusions we have already drawn.

The bottom line — the dirty little secret — is that no, patients cannot truly be partners in their health care. Just because this truth is badly proclaimed by arrogant doctors and ignored by well-meaning but timid ones, it is still true.

Edited in response to comments:

Most of the comments, the ones from patients, missed my point. I am not arguing about the fact that patients ought to be involved in their medical care to whatever extent they wish to be. That is a given. It is also a given that my job is to explain, educate, discuss, negotiate, and do whatever is required to assure patients’ involvement in their care.

My point — the dirty little secret — is that in the final analysis, patients cannot truly be equal “partners.” The anti-paternalism pendulum has shifted too far the other way when timid doctors abdicate their decision-making responsibility in the name of “patient autonomy.”

(And as for the anonymous pharmacist complaining that lisinopril is a crappy drug with formulary issues, what planet do you spend most of your time on? Sure, there are lots of different drugs available, but lisinopril is a perfectly reasonable first choice for many people. It’s also on everyone’s $4.00 generic list (10 and 20 mg, with and without 12.5 mg of HCTZ), so f*** the formularies.)

One last time:

I’m amassing quite the collection of straw men in the comment trail. I am neither saying nor implying that doctors make decisions in isolation from their patients’ preferences and individual situations.

Think of it this way: what do you do when the patient makes the wrong choice? Not just shades of gray, like doubting a physician’s judgment call about prescription recommendations, but black-and-white, no-doubt-about-it, life-threateningly wrong decisions. “Choices” like the one made by Shadowfax’s patient with a curable tumor in her leg who is refusing chemotherapy. “Decisions” by a woman in labor with a transverse fetus refusing a c-section because she doesn’t want to be the “1 in 3 women who are getting their babies cut out of them.”

Are you all really telling me you’d be willing to let patients suffer and even die, all in the name of “shared decision making”?

That’s the “dirty” part of the secret.

(Thanks to DB for backing me up on this one.)


  1. […] Look at it this way: when a given cancer treatment has a good chance of curing you or of significantly impacting your disease, no responsible oncologist is going to present that option as a “choice“. Sure, lots of people get second opinions. Sure, lots of people ask what will happen if they don’t go through with the proposed treatment. But doctors only offer you choices when it doesn’t actually matter. […]

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