Thursday, March 03, 2005

Advisor or dictator of care?

This post by Kevin,MD was interesting, but the comments are off the wall.

I don't like the paternalistic attitude of some physicians, but I don't think we are here to provide everything the patient wants. We are not just merchants. I often see the "Walmart" philosophy in the ER. Patients think, "I came here for an X-ray" and get upset if they don't get one. A major part of my job is to figure out what the patient came here for so I can address it, one way or the other. I have found that if I explain the uselessness of a nasal bone xray, the patient will usually make the choice to avoid it.

I truly see myself as an advisor or teacher. I get most of my enjoyment from teaching a patient about her disease process and seeing the light go on with understanding. When a patient with asthma or diabetes is educated, not only are you empowering the patient but you are not going to get those phone calls.

It doesn't matter what I want the patient to do, it matters what the patient decides to do. I'm not going to her house to place the pills in her mouth, I have to educate her to the point where she makes the decision for herself to do it.

In the case cited by Kevin,MD, perhaps the patient should be offered the less medically acceptable alternative. The physician might describe the choices, orchiectomy, biopsy, or do nothing and help the patient understand the risks/benefits of each. If he were my patient, I don't think I would do a biopsy without a concurring second opinion and very careful documentation regarding informed consent and my specific, forceful opinion that the patient's decision was wrong. I don't know that I would refuse to do it, but my documentation would be extensive. I do know that I wouldn't just go along with it simply because that is what the patient wanted.