22 May, 15 | by Iain Brassington
Guest post by Muriel R. Gillick
When physician-law-professor, Jay Katz, published The Silent World of Doctor and Patient in 1984, shortly after I completed my medical residency, I felt he was speaking directly to me. He was telling me what kind of physician to be – not the old-school, paternalistic physician who told patients what treatment was best, but rather a physician who participated in shared decision-making. For the next few decades, I aspired to cultivate patient autonomy by engaging my patients in deciding, with my input, how to approach their medical care.
There were substantial obstacles. There were cognitive barriers to shared decision-making, as Twerksy and Kahneman brilliantly revealed: whether you spoke of a 60% success rate or a 40% failure rate seemed to matter, even though they were mathematically equivalent, as did the patient or doctor’s most recent experiences. Then there was the problem of innumeracy, of patients lacking the tools needed to understand probabilities. There was the challenge of limited health literacy, or inadequate knowledge of the vocabulary and concepts of health and disease. And there were cultural biases, because patients of various ethnic backgrounds had a world view radically different from the physician’s biomedical model. But each of those barriers could be surmounted with careful choice of words, better graphs, or cultural sensitivity. I continued to strive to be a physician who practiced shared decision-making.
But more and more often, I found that patients wanted me to make a treatment recommendation. It wasn’t that they didn’t want to be involved in the decision-making, or that they couldn’t understand medical jargon, or that they didn’t know what odds ratios were – although sometimes those were issues. The main issue was that the purpose of the prevailing model of shared decision-making was to figure out, when multiple treatment options existed, which one to choose. It seemed to me that this focus on what was essentially a technical outcome was misplaced. more…