Map of life expectancy at birth from Global Education Project.

Tuesday, March 14, 2006

Don't be afraid to ask questions

Until the mid 20th Century, the generally accepted relationship between physicians and patients in the West was on of benevolent (hopefully) paternalism. The expertise and wisdom to choose the appropriate treatment of disease resided entirely with the physician. The patient's role was to trust the physician and to follow "doctor's orders" --a condition analogous to childish dependency.

Patients ordinarily could be said to have consented to treatment, if only because, as a practical matter, they had to physically submit to the surgeon's knife or swallow the doctor's potions. However, there was no expectation that the patient would be specifically informed about the physician's theory of the patient's disease state, the theoretical basis of the proposed remedy, possible adverse effects, or alternative treatments.

This norm came into serious question after 1950, in connection with broad changes in social attitudes about hierarchy and personal autonomy, and the growing technical complexity of medicine, which, along with more effective treatments, brought increasing uncertainty and tradeoffs among risks and benefits. (In the past, most treatments didn't work and were dangerous, so at least we didn't have to worry so much about uncertainty.)

Now we generally accept an ideal that physicians and patients are partners. While physicians possess expertise about diseases and treatments, the patient is the expert on his or her own tolerance for pain and inconvenience, fear of disability or death, and other subjective factors essential to determining the consequences of a treatment choice for the patient's well-being. And, we believe that self-determination has intrinsic value.

But this is one of those cultural norms that everyone articulates, but hardly anyone observes in reality. We might be able to fool an anthropologist from Mars, but we all know better, or should. According to actual research (the same kind that proves there is more fruit filling than crust in a pop tart), psychiatrists do not routinely disclose the side effects of neuroleptic medications to their patients. Most emergency department patients don't know that they have the right to make treatment decisions. Audiotapes of routine office visits reveal that patients are rarely informed of the risks and benefits of proposed procedures. Many cancer patients who had undergone chemotherapy were found not to recall the nature of the procedure or the risks involved. The basic elements of informed decision making, even using the least stringent criteria, are absent from the majority of clinical decisions -- mostly prescribing of drugs -- in a set of tape recorded general medical visits.

Doctors say that they don't like to tell patients about all the possible side effects of drugs because they are afraid the patients won't take the drugs if they are informed. You know it's true. The last time your doctor wrote a prescription, I'll bet you a free pick in the NCAA office pool that she or he just said, "Take these pills." And you probably did it. Okay then.

1 comment:

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