As physicians, we learn we must inform the patient of their options. Each patient has a different tolerance for risk. Some want aggressive treatment. Some want conservative management. The patient decides what should be done.
I always thought it awkward to merely present a smorgasbord of options and then stare at the patient asking – “So, what do you want to do?” Not infrequently the patient responds, “I’m not sure. You’re the doctor.” The subtext is that the doctor had years of experience with handling such matters. To the patient, this is their first encounter. Surely the doctor could impart his or her wisdom.
“Doc, if you were me, what would YOU do?”
We ask this question of our financial advisors. We ask this question of our lawyers. We do so because we trust their judgment.
Yes, it is true that the doctor is not the patient. And unless the doctor knows the patient well, he will be substituting his judgment for what the patient might REALLY want.
Still, I think it’s a fair question.
And, when I was a patient a few weeks ago, I found myself asking precisely that question.
I was in a bad cycling accident. I had multiple fractures. My proximal ulna was in 4 pieces. It needed surgery. I had a sizeable hematoma in my elbow. And I had road rash from “kissing the pavement.” The medical question was timing of the surgery. Should we wait 10 days to allow the road rash to heal, decreasing the likelihood of infection? Or should I have the surgery within 24 hours to decrease near-term pain and speed up the recovery. The orthopod thought he could make the incision in a “clean area”, a few mm away from the road rash.
I asked “What would you do?”
He replied, “That’s a fair question. I’d get it done sooner. Yes, there’s a risk of infection. But, if you sidestep that risk, you’ll be back to work and activity sooner. There’s no perfect answer.”
He was right, there was no perfect answer. That’s true of most medical choices.
I followed his advice. Had the surgery done the following day. With the benefit of weeks of hindsight, it was the right call. I never experienced any infection.
I appreciated his advice. I was fully prepared to accept the consequences of the decision.
I’m just glad I didn’t have to make the decision alone. Most patients feel the same way.
What do you think?
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I agree with your thoughts to respond to patient’s request for guidance in areas for which they have little (or no) basis on which to make a decision.
While we have all learned to practice “defensive medicine” who better than us to provide advice within our own specialty?
Obviously this requires a conversation about the pros & cons of reasonable expectations and limitations (AND signed consent) but it seems less than human to throw out the options and be unwilling to offer any guidance.
One man’s opinion…….
Until 20 years and 4 days ago, I wouldn’t answer that question when a patient asked me. I specifically dodged it, saying that I didn’t think my opinion there was valid. On Friday September 13th, I had an angioplasty and placement of 4 coronary stents–at age 49 1/2, with no obvious risk factors. There was a discussion beforehand about risks–at least the risks I was concerned about–and they answered the questions to my satisfaction.
Within an hour after the procedure, I noticed that my systiolic pressures were decreasing and my diastolics were rising. I diagnosed my own tamponade, which wasn’t trivial to corect since I had received 10,000 units of heparin at the beginning of the procedure. The bleeding didn’t stop until I got some protamine. By that time, my crit had fallen from the mid-40’s to the low 20’s.
In retrospect, I’d have done exactly nothing different from what I chose to do. I did interventional procedures my whole career and knew the risks. But now that I’d put my money where my mouth was, I felt that I could reasonably and honestly answer patients’ questions about what I’d do, were I in their shoes.
That said, I never volunteered that information–I only provided that piece of data if asked. And if I thought I’d be on the fence, I’d tell the patient that as well.
On a related note, I had jaw advancement surgery 4 years ago for OSA. Before I had it, I discussed in detail the likely fate of V3 with the maxillofacial surgeon. He told me that I had a better than 50% chance of losing one or both and that at my age, the likelihood of regeneration was pretty small. I decided that sleeping without waking every two minutes (yep: almost 30 episodes/hour) was more important than playing the flute. And the left half of my lower lip is pretty insensate to this day. Happily, the recorder requires no big embouchure finesse.
I didn’t ask him what he’d do. When I consulted other docs before the surgery, most were happy to volunteer that they wouldn’t do it, even though I don’t recall asking any of their opinions. I’m glad I did it.
Dr. Horton, this is a bit off-topic, but I’m delighted that you can still play the recorder. I am equally hopeful that you have made a full return to good health.
If we lived in the same community, or close I would love to accompany you on keyboard with some Bach recorder/flute sonatas. Medical justice can “verify” that I do in fact have the musical skills to do this, although I don’t want to put him on the spot as a music critic.
They are wonderful, beautiful works.
Michael M.Rosenblatt,DPM
I have performed many of these jaw advancement surgeries for OSA. The advantages for living longer with reduced risk of cardiovascular disease is much better than the irritation of the paresthesia. It does fade in time not to be as prominent. There is no visual evidence of the altered sensation. Most people are very happy with the clinical results of the surgery.
Interesting blog this week. I face this dilemma every day in my practice as a breast cancer surgeon. “Doctor, if this was your wife, what would you do?”, they ask!! Should I have a lumpectomy, a mastectomy or a bilateral mastectomy? What about reconstruction, yes, no and if yes what kind. Chemotherapy, radiation. What do I do?
Well, my wife and I have discussed this scenario many times and in some cases, if appropriate, I will offer up her opinion to those women and their families that ask. Other times I may suggest a different approach, and so forth.
The point is that there is no set answer for any one patient, couple or family. We do not live In an off the rack or one size fits all world.
Try to look at it this way…. We are all truly blessed to have the opportunity to make a good living doing this most amazing job. Treat it as what is it…. AN ART. Handle each case as it comes. No, it is not easy. No one said it would be. Regardless of your specialty, add some compassion to the ART and science. You would be amazed at the results and how much easier these conversations become!
I’m usually asked instead “if this were your parent, what would you do?” I disclose typically that I find it difficult to answer the question faithfully, as I feel that predicting my own response to a similar situation will be imperfect. There are so many variables! Each of us generates his own gut feeling that can be the product of timing, age, health, mood, trust and more. Having this forum here to emphasize the importance of these informed consent procedures is key. These are potentially life-altering scenarios for our patients, and for us as well, and if heaven forbid an outcome is less than optimal, the peace of mind for patient and doctor may rest upon the sense that regardless, “the right decision was made.”
Jeff, refua shlema to you.
Joe, I refused wisdom teeth extractions as a teen (or since) because I had too many friends with consequent nerve injury, and I worried about the effect on my embouchure for the clarinet.
As an oncologist, I am frequently asked, “what would you recommend if I were your mother?” My first response is “well, perhaps you should first ask whether I like my mother.” This always gets a laugh, but also reinforces the fact that everyone’s choice situation is different. And outcomes are often different. The patient needs to own her decision in her personal context and not simply adopt someone else’s choice. My next response is to again review the options and likely outcomes, to offer time to think about the decision, and schedule a follow up discussion time. Fortunately, decision making in my office is rarely urgent.
Also, I occasionally review the outcomes in decision tree format. That is, whether select treatment or not, whether cure or complication with percentages, and how most people would feel with each choice. This helps when a relatively safe but involved treatment contributes to cure. The patient looks more at the long term result than the short term inconvenience. A visual table helps a lot, usually draw out large on the exam table paper and given to the patient. Clean paper, that is.
I mainly perform cosmetic surgery, and cosmetic rehab of the massive weight loss patient. Therefore, the procedures that I perform for the most part, are not necessary (occasionally I have a complication).
For cosmetic procedures, I respond by going over the pros and cons and encourage them to decide based on their values. I will give answers to subjective answers (e.g., which implant is softer, etc.).
For complications and or procedures that need to be done, I take a stronger position. I will explain what is needed to resolve the problem. I will do my duty to explain alternatives and encourage them to do what I feel is the best way to resolve the issue. If there is a reasonable alternative that is a better fit for the particular patient’s situation, I will agree, if it is reasonable.
I guess, in short, wherever possible, I work with the patient as a guide, but when needed, I am more paternalistic, but only when needed.
Sek