Wednesday, November 09, 2016

The doctor's dilemma: damned if you do, and damned if you don't

I was talking to a leading cardiologist about the recent controversy over treating patients with statins in order to lower their elevated cholesterol level.  He finds himself in a bind, because he doesn't believe in prescribing them routinely. However, if he decides not to "treat" the patient's high cholesterol level, since he doesn't feel the need to "fix" abnormal lab reports, then some patients feel he is being sloppy and casual, because he has overlooked this finding . On the other hand, if he does feel the need for prescribing a statin, other patients believe he is needlessly overtreating them !

Part of the problem is that the public has started thinking of doctors as being greedy and commercial mercenaries who no longer put their patients' interests  first. 

Along with the gratuitous and ubiquitous media-bashing, two other trends have contributed to this trust deficit. One is Dr Google, which means it's become extremely easy for patients to get information from websites. The problem is that a lot of this is wrong, unreliable and outdated, which is why it's hard for patients to translate what they read into actionable wisdom. They often lack the ability to interpret what they read in the right context, because they need to apply this to their personal circumstances, and this requires a lot of medical expertise and clinical experience - something which patients lack . To add to the poor patient's confusion, every doctor they go to has a different opinion. Lots of doctors are extremely good at bad-mouthing other doctors  and dissing their opinion, because they want to play the game of one-upmanship. By disagreeing with the earlier doctor, they want to prove that they are better. Every doctor positions himself as being the true expert , because they want the patient to come to them for treatment , rather than go to someone else.

This is why doctors find themselves in a bind. For example, he had a patient with a life-threatening cardiac arrhythmia, who needed a pacemaker put in. However, the patients' daughter felt he was advising this expensive and invasive procedure only in order to make money. Thus, though he was following textbook recommendations, and was sure that the patient would  benefit from this advanced life-saving technology, the patient was very distrusting.  This is why doctors find themselves between the devil and the deep sea, and it's become very hard to earn the patient's trust.

While patients are understandably worried about the risks, expenses and side-effects of medical interventions, they do need to remember that not doing anything also carries a risk - and sometimes this could be much higher . Choosing not to do anything is also an action - and is sometimes the worse option.

While a good doctor will try to factor in the patient's personal preferences, at some point, it's the doctor who needs to make the decisions, because the buck stops with him .  A senior doctor used a great analogy. He said that when  patients ask me why I have chosen a particular course of action, I remind them that when they buy a ticket to get on an airplane, they have the right to sit in their seat, but they don't have the right to ask the pilot questions about why he turned left, or why he turned right !

I think it is important that patients use Information Therapy to do their homework, so that they can quiz their doctor until they find a doctor they can trust. Once you have found this doctor, then you should respect his professional expertise and allow him the autonomy to do what he feels is right for you. This is the only way to create a win-win situation.

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