Map of life expectancy at birth from Global Education Project.

Saturday, August 13, 2011

Now we're talkin'

I hope more people will join this discussion -- it's very helpful to me, anyway.

Yes, doctors obviously are sometimes wrong. Some of those patients who nod and take the prescription and then go home and don't fill it are indeed better off. The problem is that if you don't believe that's exceptional, it's hard to explain why you would go to a doctor in the first place.

From the point of view of physicians, when they think about, write about and study these issues, they almost always assume, implicitly or explicitly, that people are better off doing what the doctor wants them to do just about all the time. If they didn't think that, they couldn't honestly earn their boat payments. Patients, on the other hand, are often wary of medical advice because they've read about all the drug company scandals -- the concealed unfavorable trial results and selective publication more broadly, rigged trials, ghost written articles, various forms of bribery of doctors (now much less common and less socially acceptable but still . . .), and just the seemingly ever changing advice (take antioxidants! no don't! take hormone replacement! no don't!). And that's perfectly rational as well.

From the point of view of a sociologist (YT), I have to assume a stance that's above the fray on the fabulousness or lack thereof of current medical practice and just try to understand how doctors and patients interact, who's trying to accomplish what, and how they go about it. What I find is that it often appears more collaborative, more trusting, and more agreeable than it really is, to both parties. They want to please each other face to face and maintain a good relationship, but the price of that is often avoidance and silence. The real issues are missing from the conversation. You don't know what you don't know.


kathy a. said...

i think there are a lot of variables: what's the condition under discussion; how respectful is the interaction; how informative; what is the patient looking to accomplsh; does the doctor understand enough about this patient to guess at possible obstacles; does the patient understand enough about the situation to ask the right questions; what is the quality of followup; etc.

another problem is that a lot of medical advice is along the lines of "we can try this," and there is not a guarantee that A will produce the desired result; but many patients feel out of their depth, and want to hear "we will do A, it will produce B." many aspects of medicine are more complicated. even with something as routine as treating an ear infection, a particular antibiotic will occasionally not work; or the condition might be chronic enough that another treatment has a better chance of success, like tubes. (and a compliance problem in the ear infection example is stopping the antibiotics when it gets better, contributing to the problem of antibiotic-resistant bacteria.)

i wonder if doctors could use better training about offering choices, explaining pros and cons -- and about how important it is to have a broader understanding of a patient's life and circumstances. a patient with financial problems may not be able to afford a particular medication. a patient with turmoil or chaos in their life is going to be distracted. and there could be other medical things going on that are not the presenting problem, but have implications for the patient. (i found out about my HBP at an ob/gyn exam, for example, but only because BP is monitored at every vist.)

i prefer to have longterm medical relationships because there is some context for the problem of the day. i also think a lot of FNP's, because they take more time with patients, and the ones i've known are pretty good about checking in on "what's going on in your life," a topic one rarely hears raised by a medical specialist.

kathy a. said...

here is one doctor's column about the legacy left by one of her instructors, about how to communicate bad news: