Thursday, November 14, 2013

Doctors as decision coaches

One of most important roles which doctors play is helping patients to decide what treatment option is right for them . Patients are often confused because there are so many choices , and they don't know enough , to select the best. They hope their doctor will behave as a medical professional and guide them correctly . They treat their doctor as a trusted advisor.

Sadly, the doctor’s advice is often biased . Doctors , by virtue of being doctors , are predisposed to treat. “ Don’t just stand there- do something !”  They are understandably partial to performing medical procedures , because this is what they have been trained to do – and they are paid well to do these ! Thus, if you have chest pain and go to a cardiologist, it’s quite likely he will advise you to do an angiography, because this is what he has been taught is the right thing to do .  However, this is not necessarily the best advice for the patient , and this is one of the reasons there is such a big trust deficit between doctors and patients today . Many patients rightly conclude that doctors tend to overtest and overtreat.

In the best of all possible worlds , the doctor will hold the patient's hand and help him to decide for himself, so that the patient makes the right decision for himself. Good doctors do this all the time. They use the McKinsey system of making a mutually exclusive and completely exhaustive list of all the possible options – both medical and nonmedical , so that patients can work through these, sort out their priorities and choose what works best for them .

However, the problem is that making medical decisions is an emotionally charged issue . Thus, when an infertile patient comes to me, and I start by discussing the alternative of adoption with them, they get upset and agitated. They feel that I am being very negative – or that the fact that I am talking about adoption  means that I feel their chances with IVF are very poor. Actually, this is not true. I am just trying to be as unbiased and neutral as possible , and am consciously making sure that I don't censor the information I provide .

Sometimes this can be difficult to do , because patients so easily misinterpret my intentions. This is where a second opinion can be very useful - especially if this is provided by a retired specialist . He can provide objective, trustworthy, reliable advice with no commercial interest whatsoever , because he is not going to provide the actual treatment himself.

This is also one of the places where web-based Information Therapy can shine . The digital information provided is objective , neutral and evidence-based . Patients can work through their options by themselves , knowing that they are getting advise which is tested and trustworthy .

However, just providing a list of options is not enough. Making a decision always involves a sense of loss, because when you choose one option, you have to forego the other available choices – after all, you cannot have your cake and eat it too !  Doctors need to provide patients with a process for decision making as well, so that that they can make the right decision for themselves .

A simple tool is that developed by Suzy Welch called 10-10-10, which will help you think logically about the consequences of your decision. Ask yourself – If I select this option, how will I feel about it 10 min from now ? 10 months from now ? and 10 years from now. Knowing your priorities will help you with the 10-10-10 process – and this process can also help you discover them. It allows you to see matters in the right perspective , so that you are at peace with yourself.

It’s important that the doctor learns to be neutral and impartial. Most doctors , like all human beings, are full of biases which influence their decision , without their even being aware of their personal prejudices . Many doctors feel that because they are the medical experts, they need to act as founts of wisdom and decide for the patient, because he is not clever enough to do so himself.  After all, don’t they know much more that the patient does ? And shouldn’t they allow the patient to benefit from their wisdom, experience and expertise ? Isn’t this what the patient expects ? And isn’t this what he is paying them to do ?

This can be a very tricky issue, especially when the preferences of the patient differ from those of the doctor. This is why it’s important that the doctor behave like a coach, and allow the patient to decide for himself.  Part of the doctor’s skill is to help the patient tap into their own heart and brain, so they can listen to what their body and gut is telling them.  While it’s the doctor’s responsibility to ensure that the patient does not make a decision which can harm him, he also cannot take over this key role and start making all the decisions for the patient.  Just like a coach helps the athlete to tap into his inner resources, a good doctor gives the patient the courage and support he needs to look into himself and make the right choice.

Following this path will help patients to live with the consequences of whatever decision they make, no matter what the final outcome. This is always uncertain in medicine, but if the doctor helps the patient to  follow the right process , this will make the patient's life ( and the doctor’s as well !) a lot easier .

Some patients want the doctor to make the final decision because they believe that he is the expert, and they trust him to make the right choice. This is fine as well, because the doctor is then honouring the patient's preference that the doctor do the deciding for him.

However, because all patients are different, doctors need to learn to adapt their styles, to suit the patient’s needs. They need to be flexible, and behave like foxes, so they can do what’s right for the patient sitting in front of them, rather than behave as hedgehogs who are rigid in their approach. Doctors need to be versatile, so they can tailor their behavior to meet the patient’s needs.

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