I took the road less traveled by…

I took the road less traveled by And that has made all the difference. aia.fernandez111 / CC BY-SA 2.0

Picture the scene – it’s the wee small hours, say around 0330, when the energy really ebbs on a night shift – it is still pitch black and the gentle lightening in the east is still at least a couple of hours away. You’ve been on the go since you started your shift at 2030 the night before. The last patient with chest pain has settled nicely with the gaviscon you prescribed, and you are heading back to the team office for a well deserved sit-down.

The vending machine starts calling at you from down the corridor – a bright light – like a guiding star, constant, ever present – a reassuring island in the maelstrom of a night shift. The bright colours seem to warm you as you approach, and the chocolate offers the prospect of an immediate relief from the doldrums of the night shift, a swift rush of dopamine, with just the right amount of caffeine to get the shift back on track. And anyway, calories on call don’t count, right?

A recent editorial in the PMJ sets out the argument for a greater degree of control over the context in which NHS employees make choices about the food that they eat when they are at work – and how this could have wider benefits to society as NHS workers become advocates for improved diet in their communities.

This proposal is a public health intervention on a bold scale. As Malhotra indicates in the article, effective public health measures, particularly related to perceived choices in lifestyle, are often directed not only at educating the individual to empower them to make better choices, but by altering the context in which those choices are made. That is, move from an obesogenic food environment to a salutogenic environment that positively encourages healthy choices.  This proposal is audacious in view of the powerful compaines that have so much to lose should healthy choices start to become the norm.

Prominent libertarians often protest against public health interventions that seem to curb the choices of individuals – indeed this central to libertarian philosophy… so how much choice does the individual above really have when it comes to what they are going to eat to get through the shift and carry on delivering care over the next few hours? And how much has this choice already been made for them? – the canteen is shut, the crash bleep chains the subject to the hospital grounds, and Abel and Cole don’t do late night take out. The choices really are limited.

But is the consumption of a high sugar, high salt diet the only arena where an illusion of choice exists in medicine?

It may have been an unlucky stretch recently, but of late, I have noticed a few other arenas where the medical profession might be pedalling a ‘choice’ but really are presenting more of a Hobson’s choice.  I have met, and heard of patients who, having looked at the options, weighed up their beliefs, and opinions on the value of a course of treatment, and opted for supportive, rather than disease specific care – both early on in the course of a disease, and in the latter, more desperate stages.

As a result, some of these patients have appeared to be cut off from their treating teams, and left to generalists, to deliver appropriate, but not expert care.  And what have these patients done, except exercise their choice – more insistently and bravely than we do daily when faced with some of the more mundane choices of life in the 21st Century Western Society we inhabit? And so, for swimming against the current, and declining to go along with the conventional rounds of treatments, and escalations to ever more invasive therapies, these patients seem to somehow be treated as if they have personally rejected the physicians offering them, and are therefore offered a cold shoulder.

But as a profession we recognise that the evidence is there that outcomes can be better with less treatment, and that the well informed often take a more conservative approach to management at the end of life.

So whilst I agree that we should support efforts to improve the ability of individuals to make sensible healthy choices about their diets – and any change in the food landscape that makes these choices less one-sided would be welcome…  We must also hold these arguments up to our profession and the ways in which we both propose courses of treatment, and how we react to the choices patients make.

We should not be found guilty of skewing these decisions through a sense of altruism that tends towards paternalism, but instead should ensure that patients have the opportunity to make truly informed choices, and after they have made them, make certain that such pastoral and medical support is available to them as would be had they chosen another option.

  • Jonathon Tomlinson

    How patients make decisions (within the context of a consultation) about issues like this is explored well in Atul Gawande’s new book Being Mortal. He contrasts the paternalistic Dr Knows-Best with the consumerist Dr Informative. Gawande confesses that up until recently he was Dr Informative, giving patients as much information as he could and then asking them what they wanted to do? Their usual response was, ‘I don’t know? What would you do?’ He goes on to explain that Dr Interpretive (I prefer ‘interested’ or dialogic) explores their paitents’ understanding, asks them what matters, and helps them achieve their goals. In General Practice training, these communication skills are taken a lot further and in narrative based care, further still. A consultation is dialogic, where the story-teller (patient) and listener (professional) create meaning together. It’s a creative and risky process, for example the professional might impose their own interpretation or collude with one that is pathological (e.g. patient blaming herself for her genetic disease) Allowing patients to make informed choices is what Dr Informative tries to do, but it’s not sufficient, nor, actually what they actually do.
    The decision making context is, as you start off describing in relation to fast-food vending machines, not bounded by the consultation. Donetto studied medical student’s perceptions of power and showed that they viewed it as solely down to the nature of the relationship between Dr and patient. But it’s also to do with social / structural inequalities, poverty/ purchasing power, literacy, especially health-literacy, social relationships etc. Choices are not a consequence of information. There’s a lot more going on. Gawande gives an example of 60% of patients choosing to continue chemotherapy they didn’t want, because their family wanted them to go on.
    Helping patients make the best decisions about their care is really difficult, but these kinds of conversations make me optimistic about the future possibilities