Some advice for doctors on how to engage patients and understand their treatment preferences:
- Adopt a mindset of scientific detachment, resisting the instinct to ask themselves, “What would I do in this situation?” because the patient may value the risks, benefits, and side-effects of the treatment options differently.
- Form a provisional diagnosis based on available data on what a patient’s preference is likely to be, without assuming that the patient in front of them is the “average” patient.
- Engage patients in shared decision-making by informing them of the options; discussing the risks, benefits, and side-effects of each, including non-treatment options like watchful waiting; and inquiring if they feel ready to make a decision.
Patients also, of course, have a role and need to come prepared with questions about options. Groopman’s book, How Doctors Think has some good suggestions (here) as well as some other articles (here and here).
Doctors often miss patients’ treatment preferences – Health – CBC News.
As one of my hematologists suggested recording key patient-doctor discussions given his sense that note taking, either by the patient or caregiver, was less accurate, I was interested in this piece of the pros and cons of recording. While much of the article is about situations when a family member wants a recording, not the actual patient, where privacy concerns increase, nevertheless captures some of the issues well.
My own sense is that if this helps the patient, and the doctor is comfortable, the advantages likely outweigh the disadvantages. Quote:
A middle path that could avoid these risks while preserving the benefits might be to record only the beginning and end of the visit, leaving out the physical examination and providing patient and doctor with some privacy to discuss matters that should not be shared. In this case, the patient and physician would decide together what is to be recorded. Perhaps the taped record would include only the patient’s discussion of symptoms (to let him or her discover later whether everything was presented to the doctor) and the physician’s summary of instructions, explanations of prescriptions, follow-up appointments and so on.
Pros and cons of letting patients record doctor visits – amednews.com.
Another in a good series of posts on improving doctor visits. In additional to the usual ‘what to bring’ list, this post provides good guidance on asking the right questions:
If you are given a new diagnosis, find out the following:
- How certain are you about this diagnosis?
- What else could this be?
- Are there other tests that can be performed?
- Is there anything in my history that has contributed to this?
- How is this treated?
- Repeat back what you have heard, to make sure both you and the doctor are on the same page.
Know your next steps. Before you leave, be sure to ask:
- What is the follow-up plan?
- Who do I call with questions?
- When should I schedule my next appointment?
I particularly like the ‘replay’ point, as it helps ensure a common understanding, and helps the doctor know whether he or she has explained things clearly.
Improve doctor visits by bringing checklists to check ups.
Some reflections by Holly Witteman on how to help patients and their families deal with medical trade-offs and options. Quote:
What makes health tradeoffs especially tough is that they incorporate uncertainty. It’s one thing to choose between the butter and the butter money. It’s quite another to choose between a 15% chance of butter and a 12% chance of butter money. And yet, many medical decisions are set up precisely this way, because we never know for sure whether a treatment or therapy will work, or which people taking a drug will experience the uncommon, unpleasant side effects.
She suggests three approaches to help improve our dealing with trade-offs:
- Start how people approach trade-offs, not how we wish them to;
- More research on how to help people facing difficult health decisions; and,
- The trade-offs medical practitioners face in health communications.
Let’s help patients with the tradeoffs in medicine.
A reminder of the risks of desensitization through humour, and that as patients we need to understand how doctors and medical teams may react to us. Groopman’s How Doctors Think has some good examples of patients who defused this risk through preventive remarks (‘I know I may sound a bit crazy….’). Quote:
Humor is an important coping mechanism. We all eventually need to find ways to laugh about even the darkest tragedies.
The dark side of dark humor is that it desensitizes us. In hospitals and medical clinics, such desensitization can cause us physicians to lose empathy for our patients. It can cause us to underestimate their suffering. Perhaps even more importantly, when we physicians lose the ability to appreciate our patients’ perspectives, we also become less able to help them make difficult medical choices.
Think about that the next time you ask your doctor for medical advice or come to her for emotional support. Your physician has emotions too, sometimes very strong ones. But just as often, she has found ways to reduce the strength of her feelings, so she can get through her work day with sanity intact.
That means that your job as a patient is to help your doctor understand where you’re coming from. If you hope to get good guidance from your physician, you need to help her see the world through your eyes. She won’t be able to do that if you remain silent, on the other end of that stethoscope.
Help your doctor understand where you’re coming from.
More on doctors from Sunrise Rounds treating family and friends and the risks involved (see earlier post Why doctors shouldn’t treat their family and friends). Again, one of the main risks relates to the affective fallacy, and how that may cloud a doctor’s judgement.
However, people being people, it is somewhat natural for related doctors and patients to consult each other (we have a number of doctor friends that we consult for informal second opinions), but this should be in a supportive role, not as being responsible for medical treatment and care. Examples include helping know which questions to ask, giving a sense of whether side effects are normal, but all within being acutely aware of the limits and the need to defer to the treating physician.
Doctors should not be allowed to take control of the care of loved ones and in reverse should not demand real control, beyond that guaranteed to each patient and family. Treating physicians must be aware of potential guilt that can lead to controlling behavior and remember that improper control can amplify future guilt.
When a doctor or his family is ill they are patient or loved one. This is a special role that no one else can fill and is vital. By helping physician-patients focus on healing and not being responsible for care, we make the chance that they will return to healthy lives that much greater. For our friends and colleagues there can be no finer honor.
The Doctor as Patient – Sunrise Rounds | Sunrise Rounds.
Although the author could have developed further this piece on how to equip medical students and doctors to cope with the emotional pressures of working with patients and their families, it does capture the challenge of providing dispassionate advice with empathy. Quote:
“Turmoil.” The advice that is generally given, by those in medical school, courses on doctoring, senior colleagues, your peers, is to be sympathetic and removed. Complete dissociation from the red-eyed, pale individual pouring her story into your lap, however, is impossible. The encounters change you, sculpt your responses, awaken you from sleep. A night spent telling a roomful of family members that their sister will not survive til morning, explaining to a woman that her husband, healthy and playing football with his sons just 6 months ago, is now bedridden, are not carried out by an emotionless machine. It is the faces, the pressure of cold hands holding mine, and the hoarse “thank you”s that I remember most. The stern eyes of family who can’t help but blame you for the dissolution of their loved one’s flesh. The raspy breathing of a man lying with eyes closed between 4 steel enclosures in a white hospital bed – it is their faces and the stories of their failing bodies that stay with me. The courage of individuals to say “this is enough, please call my family, I need to say goodbye.”
Humility and humanity is required of us to best respect our patients.