Tuesday, January 31, 2012

Why doctors should let patients decide for themselves

I recently saw a patient who came to me for a second opinion . She was advised IVF treatment and a workup showed that she had an endometrial polyp which was about five millimeters in size . She'd gone to another doctor , who advised her to get the polyp removed before doing the IVF treatment . This is one of those gray zone areas of medicine where it's always very hard to make a definite decision because different doctors have different opinions as to what needs to be done. Most doctors would take the approach that anything inside the uterine cavity needs to be removed before putting an embryo inside the uterus ; and they would automatically and reflexively suggest an operative hysteroscopy to remove the polyp before doing the IVF cycle. This is standard medical advice and is perfectly reasonable. However, there are other doctors who feel this is unnecessarily aggressive , because there is no proof that a small polyp can affect embryo implantation. This is a vexed issue which is very controversial because there aren’t enough studies to be able to come to a definitive conclusion. This is hardly surprising. Most IVF specialists will see only infertile women , so any time they see someone with a polyp , they will assume that the polyp is the cause for the infertility and will advise removal. However, the fact remains that lots of fertile women will also have endometrial polyps , which neither they nor the doctor will ever find out about , because they have enough sense not to go to a doctor to get this diagnosis !

So what is the doctor to do ? and what about the poor patient ? She gets conflicting advice from different experts, one of whom advises surgery and the other one advices you don’t need to do anything at all about it. This is the kind of situation where information therapy is extremely potent . We need to empower the patient with information so the patient can decide for themselves.

What I usually do is explain both options to the patient along with their pros and cons. While this works well with educated, intelligent patients who are capable of making a decision for themselves , there are lots of patients who don't like this approach. For one , they think I’m wishy -washy ; and for another they conclude that I don't know what to do myself , which is why I'm asking them for their advice ! In reality , I’m not asking them what to do - what I'm helping them to do is to come to a decision which they feel will be right for them.

At the end of the day , outcomes are always uncertain. It's not that removing the polyp will guarantee IVF success ; while keeping the polyp will not mean that the IVF cycle will fail. However, there are some patients who are petrified of surgery and will do anything to avoid it. On the other hand , there are patients who are very sure that they want to maximize their chances of success by removing all possible obstacles and hurdles ( no matter how speculative) which may come in the way of their IVF cycle succeeding.

The trouble is a doctor can’t read a patient's mind which is why we need to ask patients to provide their inputs ; and we need to factor these inputs in when we make a decision. I always tell patients the buck stops with me. After all , I am the professional and since I am the doctor , I guarantee that I will never let them make a wrong decision . On the other hand, when there are choices , I encourage them to apply their own mind and to provide their personal inputs , so that we can jointly make a decision which is right for them.

Enhanced by Zemanta

1 comment:

  1. I didn’t even know they weren’t routine & necessary – so thanks for this article. I went into my first appointment assuming I’d have one. When I went in at my first appt at 9 weeks, I hadn’t had an internal exam or pap smear in over 18 mos, so my CNM did one. I suspect that she would not have performed one if I’d been “up to date” on my exams (she works out of an OB’s office). In retrospect, I’m glad she did.

    ReplyDelete

LinkWithin

Related Posts Plugin for WordPress, Blogger...