Saturday, February 25, 2006

Why are patients so passive ?

I saw a patient today who works as an executive in a leading bank. She is smart, clever and well-informed, and is on the fast-track to a high-profile managerial job.
However, the quality of medical care she had received so far left a lot to be desired, and I was quizzing her as to why this was so.
She had had an endometrial curettage done, after having a spontaneous abortion. I felt this was an unnecessary surgical intervention, and was quite surprised that it had been performed. In her case, the curettage had removed part of her normal uterine lining, causing her to form intrauterine adhesions, which were likely to significantly reduce her fertility. When I asked her why the surgery had been performed, her answer was, " Because the doctor told me to do it". This is the stock answer I receive; and I feel this explains the problem. For any operation, it's not just that the doctor does the surgery on the patient - it is also the patient who requests the doctor to do the surgery. The patient is as important in this equation as the doctor - but this is true only if the patient perceives herself to be the decision maker ! If you treat yourself as a passive "victim", you will be treated by your doctor as one too !

6 comments:

  1. But Dr. Malpani, when a patient agrees to something like that, they are doing so because they believe that the physician knows something about medicine - and consequently, the patient's medical needs - that the patient herself does not know.

    That's why patients see doctors, and listen to what they say: physicians have been to medical school, many (most) patients have not.

    I believe that if, everytime a doctor recommended some procedure, a patient were dig her heels in until she could do the research for herself, or get a second opinion, that the practice of medicine would slow to an impossible crawl.

    The bottom line is: most patients have no choice but to trust their physicians - even when the physician recommends something which is invasive.

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  2. Lisa (mcquea01@hotmail.com)7:47 PM

    I have to agree with moof here. I am a physician and when I make a recommendation to my patient, it is my responsibilty. If I get it wrong, it is my fault. I am pleased to see the old days of "doctor knows best" with blind acquiesence to the physician have passed, but the pendulum has swung so far in the direction of patient autonomy that we now risk blaming the patient for decisions that the doctor should ultimately be responsible for.

    The case you describe hits resonates strongly with me. Two months ago, the tables were turned and I was in the patient's shoes, having discovered a missed abortion. I had had absolutely no symptoms; the announcement that there was no fetal heartbeat at 9 weeks was nothing short of devastating. Fifteen minutes later, when my obstetrician recommended D&C I signed the consent form. I trusted her. Obstetrics is not my medical field, and while I had some currency in the recent literature regarding more sensitive methods of cervical cancer screening and hormone replacement therapy, I knew nothing of the recent literature regarding medical vs. surgical treatment of missed abortions. And Dr. Malpani, I couldn't do that literature search at that moment. I couldn't ask my physician detailed questions. I was just devastated and my mind wasn't operating in a logical, rational way. And I'm a physician! Think how much harder it is for a non-medically trained patient!

    I don't know the answer here; I know that this experience has openend my eyes to the fact that a very routine problem in my field can be nothing short of devastating for my patient; that my words in that moment should be carefully chosen as they will burn themselves into the psyche during the height of the crisis; that the physician holds tremendous emotional power in the moment of devastating news. And with that power comes responsibility.

    Thanks for your provacative post and blog.

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  3. As with everything else in life, the trick is to find the right balance. In an emergency situation, I will allow my doctor to make these decisions. But the vast majority of the time, there's enough time to mull over decisions and consider alternative options.
    Yes, it's true that patients trust their doctors to do what's right for them. If you find the right doctor,
    then you don't need to worry - his recommendations will be made keeping your best interests in mind. But what happens if you have a bad doctor ? Only Pollyanna could believe that all doctors are good ! The sad fact is that some doctors are not good - they could be incompetent ; greedy ; uninformed . Blaming the doctor afterwards for a bad outcome really does not help.
    Trust your doctor - but verify what he says ! And in this day and age, doing your research does not take much time.
    If you do your homework, at least you have peace of mind you did your best, no matter what the outcome !

    Lisa, I agree with you being at the "receiving end" helps doctors to become better physicians. However, your doctor could have given you enough time to consider alternative options - he could have at least discussed them with you. There's no need for you to be an expert in this field - that's what your doctor's job is. An empathetic physician realises you are distraught, and will tailor his counselling accordingly.

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  4. What an interesting post and group of responses. Did you read the recent series of posts and responses on Shrinkette's site (http://nhsblogdoc.blogspot.com/2005/12/learning-how-to-deal-with-helpful.html) about a similar issue? (There, the issue is when patients try to inform their physician about whatever, rather than specifically asking questions of a doctor about a recommended treatment or surgery as here.)

    Nonetheless, they have in common issues of patient assertiveness with implied distrust vs unquestioning trust in physicians with implied passivity.

    Either way seems like a minefield for patients and doctors alike.

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  5. Lisa (mcquea01@hotmail.com)7:43 AM

    Dr. M, I hear what you're saying. But understand that it wasn't an issue of time; I was not in the frame of mind to verify my doctor's recommendation (*her* recommendation by the way). She said something about the size of the fetus (18mm) putting me at an increased risk of bleeding if I didn't have a D&C and I tell you, I didn't want to be walking around with my dead fetus inside me for several days while doing a medline search. Know what I mean?

    It is tough because there are a lot of crappy doctors out there. But (and this is a whole separate topic), the onus of weeding out those crappy doctors rests on us, the physicians. We should be much more aggressive about keeping the lazy ones out of med school, keeping the poorly performing med students from graduating, keeping the clinically weak residents from moving forward. It's no the patient's job to verify the physician's competence; it's OURS.

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  6. I wish doctors were effective at policing themselves. The sad fact is that we are not - and in fact many patients believe that doctors are involved in a "conspiracy of silence"; and they refuse to testify against each other, to protect the " brotherhood " even when there has been gross negligence. Until we learn "how to bell the cat", patients are going to be forced to learn to fend for themselves !

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