Reflections on COMET

That's the Communication, Medicine and Ethics conference I just attended. First, I'm very happy to say that we honored Elliott Mishler last night, who is 87 years old and still going strong. In the circles I travel, he's really famous, but I expect most readers have never heard of him. Elliott is best known for discovering what he called the Voice of Medicine and the Voice of the Lifeworld, which is a way of saying that medical encounters, in general, are cross-cultural. People don't have to be from an exotic clime or speak Albanian to find themselves in a strange world when they go to see the doctor, or enter the hospital. And rather than reaching out to cross the chasm, doctors tend to try to force us to operate in their universe, without necessarily giving us much help.

A commenter on the previous post gives a very concrete example -- failure to give basic, helpful anticipatory guidance. How often, when your doctor has written a prescription, have you had a meaningful conversation about the alternatives, the possible side effects, and the benefits vs. alternatives or doing nothing? I will bet your typical experience is "Here, take one of these pills twice a day." The profession nowadays expresses the ideal that patients should make "informed choices" and that decision making between physicians and patients should be "shared."

I'm not sure it's meaningful to talk about "shared" decisions. Either the people agree, in which case it's trivial, or they don't, in which case someone will prevail. Shared decision making ultimately has to mean that the doctor convinces you to do things her way, because otherwise you will do what you want. After all, they aren't legally allowed to strap you down and pump in pills or cut you open without your permission.

However, it is very rare for people to possess the information and understanding they need to engage meaningfully in health care decision making. After all, doctors are experts. That's why they make the big bucks. If we could know everything they do, we wouldn't need them. What we don't yet understand very well is the essential scaffolding that people need to be functionally empowered to make decisions that make sense for them. Without deep and detailed knowledge of the biological science, there are likely to be a few basic ideas and probabilities that are really relevant to your choices. But exactly how an explanatory model of disease and treatment can be judged to be accurate enough to be functionally equivalent to a scientifically complete model, and how explanatory models interact with people's decision rules, is difficult ground.

What I am saying is, there is no excuse for physicians not to give us basic information, that is easy to understand, and that would really matter to us. But it is more challenging for physicians and patients to enter into each others' worlds far enough to truly achieve partnership. It would be rather grandiose to adopt that as a mission for this blog, we'll see if we can't advance the cause a bit anyway.