Bioethics Discussion Blog: July 2004





Friday, July 30, 2004

Growing Ideal Doctors

Virtually all of my postings on this blog so far have dealt with the challenges to physicians in their relationship with their patients. Remember that it is not only the physician who face challenges but also the patient with their physician. The doctor-patient relationship is ideally a two way relationship and one must not only consider what makes an ideal doctor but also what makes an ideal patient to benefit and support this relationship. However, it is the patient who is ill and who is the recipient of the physician's care and therefore it is primarily the physician who bears the responsibility and burden of attempting to make the relationship work to the patient's benefit.

Last year a visitor to my Bioethics Discussion Pages website wrote the following:

Since I have been a student at a large medical center, I have had the opportunity to interact with many different kinds of doctors from a wide range of specialties. In my opinion, there are several qualities that make up the ideal doctor. First and most important of all, I think that doctors need to be excellent listeners. I'm sure it is very overwhelming to them sometimes because they must listen to patients, family members and all members of the health care team. But, if they can truly listen to what everyone has to say, they can provide even better care because they understand all aspects of the patient. Another quality of the ideal doctor is to be an expert at their field of study. If they don't know something, then who is going to know? I'm not saying that they need to know every tiny detail because that would be impossible, but the ideal doctor should be able to admit when they don't know something, and be able to be resourceful enough to find the right answer for their patient. I think in today's world, many patients have some knowledge of health care and actually do research on what conditions they might have. The ideal doctor can realize this and counsel with the patient so they can discuss all available treatment options. I also believe that the ideal doctor has the qualities of empathy and compassion. Just by having those two qualities, I think that patients sense this and feel more bonded and trusting to their physician.

Doctors have a very important and life changing position, and I feel that the ideal doctor would not abuse this power. The ideal doctor is understanding, competent, and conducts himself after thinking about things ethically. Overall, I am glad to have been able to think about this subject, and I hope that everyone will decide for themselves what makes their "ideal doctor!"

I think that most of us would agree with this visitor's description. Beyond technical knowledge and competence, how does the medical profession grow and develop the compassion, empathy, understanding, ethics and even altruism (all of which is part of professionalism) in their physicians? Actually, the development of a person to later become an ideal doctor begins well before entry into medical school. It is seen in how the person deals with others in his/her social interaction, how stressful and frustrating issues of life are dealt with, what are the individual's views and goals and finally what is the motivation to become a physician. Then comes medical school.

Prior to last few decades, professionalism was really not taught the students in medical school. It was felt that they would learn how to behave by watching and interacting with their colleagues and mentors as they began to treat patients. This approach was, in recent years, felt to be inadequate and so there has been some effort to include teaching professionalism in medical school. Unfortunately, explicit teaching of compassion, empathy and ethics and more that makes a physician not just a technician but the ideal doctor described above has not really been continued as the student goes into his/her clerkship, internship and residency years. In fact, what the student learned in the earlier years of medical school tends to be deminished and altered by the stress and pressure of increasing patient responsibility and trying, out of self-interest, to follow the leads of their superiors regardless of what behavior their superiors demonstrate . Unfortunately, their superiors may not represent the behavior of the ideal physician and their tacit teaching may be deconstructive rather than supportive of the student's earlier teaching. Fortunately some students seem to be "immune" to these influences and demonstrate the features of the ideal doctor. Others go on to be simply technicians or doctors who practice a disregard for the emotions or values of their patients and maintain "doctor knows best" attitude.

What is need for the growing of the ideal doctor is not only a good seed but also a nourishing soil, most likely in the form of mentors, during the developing years, who themselves demonstrate the best of professionalism and who are themselves ideal doctors.

To read more on this topic: Coulehan and Williams, "Conflicting Professional Values in Medical Education", Cambridge Quarterly of Healthcare Ethics, v.12, p.7-20, 2003.

Wednesday, July 28, 2004

More on Confidentiality

For an amusing and pertinent cartoon regarding an issue of medical record keeping and hospital confidentiality click the link below.

"Someday we hope to have a nationwide database containing everyone's medical records so that they can become as readily accessible as, well, a hospital Johnny"

The hospital is a place where you might get better from your illness but you are almost surely to lose a bit of your privacy. Two bed or more wards are still around and talking privately in that environment to your doctor, nurse or family can be very difficult. Though some care is taken to keep your chart and its contents confidential, you still will see it, at times,lying about at the nurses station or elsewhere,casually accessible. Federal HIPAA privacy regulations restrict the nurses from telling medical information to family or others who are not identified as the primary recipient of the information but this may be difficult with unaccepting family or others. Family or strangers may inadvertently hear details about the patient while riding in the elevator with talking hospital staff. If you are an employee or physician who becomes a patient in your own hospital, privacy and confidentiality becomes almost impossible to maintain. Finally, those gowns..those gowns that seem to always open in the back..
Hospitals want to be exemplary models of patient privacy and confidentiality in order to pass their certification requirements. You can help. If you see defects in the system, bring it to the attention of staff or administration. ..Maurice.

Tuesday, July 27, 2004

Patient Confidentiality

AMA (Legal Issues) Patient Confidentiality: "Physicians have always had a duty to keep their patients' confidences. In essence, the physician's duty to maintain confidentiality means that a physician may not disclose any medical information revealed by a patient or discovered by a physician in connection with the treatment of a patient. "

American Medical Association article presents their guidelines and a description of the legal aspects of patient confidentiality and management. However, exceptions to confidentiality are noted: "Communicable diseases and gunshot and knife wounds should be reported as required by applicable statutes or ordinances. Thus, the physician's duty of confidentiality at times must give way to a stronger countervailing societal interest." But these acts which break patient confidentiality are not that ethically simple. In fact they become practical dilemmas that physicians face. Should a physician maintain confidentiality when the patient's spouse or sexual partner is at physical risk because of an HIV infection of the patient and the patient refuses to tell or when genetic testing reveals the potential for illness in other members of the family and the patient refuses to tell? With regard to gunshot, knife wounds and other findings which may have legal implications for the patient, should the treating physician extend his/her role from therapy to police work? What do you think about these questions and how would you answer them if you were the physician? Write and tell me. ..Maurice.

Sunday, July 25, 2004

Who is the Patient?

One may wonder, why the question “Who is the Patient?” Surely, the healthcare worker knows the answer when confronted with an ill person. But, in practice and ethically, the answer may not be so simple or well established. Take for example the young child who is too immature to be competent to understand and make decisions for him/herself. It is the parents who give the clinician the history and are responsible to care for the child. They are the ones sufficiently aware of the nature of the illness to suffer the emotional and financial consequences of their experience with their child and the knowledge of the illness and prognosis. Many pediatricians look to the family and child together as the “patient” and must evaluate and make treatment recommendations accordingly. Here, because the child is not competent, the autonomy rests with the parents.

Another example where the family is considered as the extended patient is in end-of-life hospice care. During the period when the patient is dying, it is often the family who has the potential for suffering, perhaps not in the same way as their ill family member, but suffering non-the-less. Those attending to the needs of the ill person must also attend to the needs of the family. A more prolonged scenario where the family and ill person become clinically integrated would be in Alzheimer’s disease. With Alzheimer’s the family may expend much finances, physical work and emotional attachment involved in the many years of responsibility for care. Other psychiatric illnesses may have similar family involvement but also there may be specific familial dysfunction, which directly contributed to the illness. Again, in these scenarios, the healthcare worker ideally should attend to the family in conjunction with management of the ill person.

In dealing with illness within some cultures, such as American Indians, for example, it is the family or the tribal group who takes the full responsibility for understanding and medical decision-making and thus have been looked upon as the “patient”. In all these examples of adult illness, what has happened to the ill person's autonomy?

As a final example here, genetic counselors consider the family as the patient and must determine why family members seek counseling, not just the person affected or potentially affected with the genetic disease.

Some sociologists and ethicists might even consider society to be included as the patient since it is felt that the physician should consider, in terms of the principle of justice, the effect of their management on, for example, the resources available to others.

The challenge to the practice of medicine by redefining and extending the concept of the patient to include the family and beyond is that it is also extending the limits of the medical responsibility of the physician. For example, while a procedure or treatment may not be medically appropriate for the ill person, if administered for the “whole patient” it could be argued that it might provide some emotional benefit and support for the family component.

Where do you think that a physician’s or other healthcare worker’s responsibility ends? With the ill person? Or with the family or even society? The philosopher Hans Jonas in 1969 had the answer: "the physician is obligated to the patient and to no one else .... We may speak of a sacred trust; strictly by its terms, the doctor is, as it were, alone with his patient and God." But,again, I ask "Who is the Patient?" ..Maurice.

Friday, July 23, 2004

Speaking the Language

Translation has always been an important function in the preservation of the doctor-patient relationship. But it has always, in the past, been a background function with not much discussion about it. However, recently within the U.S. the Medicare requirements require that the physician provide translation for physician-patient communication if communication is limited by the inability to communicate in a common language. The necessity for translation in informed consent is obvious.

But, translation has many obstacles which keep from being a faultless substitute for clear native communication. A physician who learns and can casually speak a non-native language may find it satisfactory to go shopping or go on a trip but may be missing much of the subtleties in communication necessary to obtain the best clinical conversation with a patient. Using a translator doesn’t guarantee that these subtleties will be related to the patient or to the physician. The physician has no control or ability to monitor that the expressions he has put to the translator or those expressions which are being related in return from the patient are being accurately reproduced. Some translators who might be used in practice might not understand fully what the patient or physician want to say or may incorporate words or even a philosophy which is generated by the translator him/herself. Sometimes, the translator is hindered by his or her own ignorance of the technical aspects of medicine.

As I noted in a previous commentary, there are cautions to consider when using family members as translators. Family members, though eager to perform translating duties, may not perform the function in an unbiased and impartial manner. Their translation may be influenced by their own conflict of interest issues and therefore not fully represent what the physician wants to tell the patient or what the patient is actually responding.
In some cases it becomes obvious to the physician that the family translator is doing more than simply translating but also at the same time counseling the patient.

Translating, though obviously required for full patient autonomy and informed consent is not the best tool to do this. Communication by a non-native physician who has “learned” the language may also be limited. The best means for the patient to receive and transmit medical information from and to the physician is for the patient to select a physician who is a native to the language. This beneficial relationship with regard to verbal communication would also fit a concept, which has been put forth by ethicist Dr. Robert which better understanding of the moral and religious values of the patient by the physician could be accomplished if the patient selected a physician with these values similar to that of the patient. The practicality of attempting to make such a selection in our current system of medicine is questioned. But with the global relocation of physicians and many foreign born physicians practicing in the United States, for example, perhaps finding a doc who speaks the language may not be too difficult. ..Maurice.

Thursday, July 22, 2004

Unspoken Translation

Unspoken Translation
by Maurice Bernstein, M.D.

“I have this”
She talked through a translator with a language I don’t know
“And it burns”
She pulls up her shirt and points to her kidney
“I am worried”
Why? I ask through a translator
“I am unmarried and have a small child”
Are you worried about your kidney? The translator speaks for me
Tears fill her eyes and move down her cheeks and
I don’t need a translator to tell me more

Wednesday, July 21, 2004

"Self-Paternalism" : Is that Autonomy?

I would like now to move from therapeutic privilege, a lingering form of physician paternalism to another form of paternalism ("self-paternalism") called the Ulysses Contract which is used in the context of psychiatric illnesses but has also been considered in the management of narcotic drug seeking addiction. Go to the link below and read the ethical review of the subject. I look forward to your comments about whether you think this kind of doctor-patient agreement represents patient autonomy and is indeed ethical. ..Maurice.

Advance directives in psychiatric care: "Ulysses contracts are considered a form of justified self-paternalism, just like Ulysses acted paternalistically towards himself by instructing his crew to bind him to the mast of his ship before they sailed past the irresistible Sirens, and to ignore his requests for release (Lavin, 1986). Thus he was able to enjoy the beautiful singing of the Sirens without suffering the disastrous results that would normally have appeared (Elster, 1979)."

Tuesday, July 20, 2004

Therapeutic Privilege:What is It? Is it Ethical?

AMA (Virt Mentor) Medicine and Society: "Therapeutic privilege is an exemption from informed consent guidelines and is, most would say, a frank exercise of paternalism. The AMA Code of Medical Ethics says that physicians may withhold information about a patient"
The question arises, however, under what circumstances can this exemption be invoked? Should the decision to use the "therapeutic privilege" be made by the individual physician or is it so important that other physicians or an ethics committee should evaluate and be party to the decision? Read the article by Matthew K. Wynia, MD and then post your comments here.

Sunday, July 18, 2004

Telling Bad News

Before Giving a Prognosis to a Cancer Patient:

Allow me to think about the ramifications of my words before I give a prognosis to a cancer patient. Because I have seen others fail, do not let me deny this individual the right to fight. Because I have tried unsuccessfully with others, do not let me condemn this person to a sentence of hopelessness and helplessness until he succumbs. Because I am personally unaware of any treatments that could give him any relief, do not allow me to assume that there are none nor deny him the right to search. Help me use the intelligence and compassion that was given to me and help him search out the best possible resources."
From Fighting Cancer: A Step-By-Step Guide to Helping Yourself Fight CancerPhysician-Patient Communication Published by R.A. Bloch Cancer Foundation.

The telling of bad news to your patient or family is one of the severest challenges facing any physician. Learning how to do it "right" is something that cannot be learned in one day but unfortunately requires the rigors of practical experience. One of the factors which make the telling difficult is that often the physicians themselves are caught up in the emotion of the moment. The physician may feel responsible for the outcome which has lead to the telling. The physician may wish to ignore or deny to him/herself regarding the possibility that a bad prognosis will really happen. The physician, him/herself may personally identify with the bad news because of similar issue has occured in their own or their family's life. And there are other reasons. With this emotional baggage, you can understand why it is possible that the telling of the bad news is also badly done.

We teach medical students about this subject from the beginning of their education. We talk about under what conditions telling of bad news should be carried out. There are some NOTs. NOT OVER THE PHONE: The physician cannot see the expression of the patient as the news is related and the patient may not recognize the voice of the physician, there is no opportunity for the physician to physically touch the patient in a compassionate and supportive manner as if the telling was in person and there is more. NOT IN A HOSPITAL OR CLINIC HALLWAY: The communication is usually hurried because of the situation, the patient cannot sit down during the telling, there is lack of privacy and there is more. NO TELLING BY SOMEONE OTHER THAN THE PHYSICIAN: Sometimes nurses have to tell the bad news, often to family, because the physician is not around but this is usually unsatisfactory since the nurses may not be able to explain the patient's or family's questions. Physicians should arrange a quiet, private environment for the patient and physician to sit and talk. And it is important that the physician has allocated time but also mental attention for this communication so that the physician doesn't become hurried or inattentive because of reponsibilities to other patients.

A point physicians must learn is that bad news need not necessarily be communicated to the patient all at once, in one sitting. Often, partial information can be given and with time allowed for the patient to digest that information. How detailed and how fast to proceed with the telling is something a physician must decide by his/her prior knowledge of the patient and by some preliminary questions. Patients should be informed sufficiently to be able to make decisions about their illness and about their personal affairs. However, the information should be given in a manner set by the individual patient. Emotionally supportive words should be given but there should be a realistic basis for those words. Lying to the patient regarding bad news is rarely acceptable or beneficial.

There is so much more one can write and talk about this subject to medical students but as I have noted as they progress within their responsiblities and career their experiences of actually telling bad news to a patient can be their teacher.

If you would like to read two essays which will extend and develop what I have written above, I recommend that you click on them below:
Talking with Patients and
To Tell or Not to Tell

Saturday, July 17, 2004

More on: How Much Do You NOT Want to Know?

In California, a recent addition to the Probate Code has made it easier for a physician to deal with the issue of informed consent when a competent patient refuses to be informed about the illness or to make personal medical decisions. That patient can immediately select a person as a surrogate who can be informed by the physician about the medical details and who can make a medical decision based on what that person knows about the wishes of the patient and what is in the best interest of the patient. The pertinent portion of the Code is:

SECTION 4711-4716

4711. (a) A patient may designate an adult as a surrogate to make
health care decisions by personally informing the supervising health
care provider. The designation of a surrogate shall be promptly
recorded in the patient's health care record.
(b) Unless the patient specifies a shorter period, a surrogate
designation under subdivision (a) is effective only during the course
of treatment or illness or during the stay in the health care
institution when the surrogate designation is made, or for 60 days,
whichever period is shorter.

Previously, a surrogate could be named only in a Durable Power of Attorney for Health Care document at an earlier time when the patient was competent. The surrogate would then take over decision making only if the patient became mentally incompetent to make his/her own decisions.

How Much Would You NOT Want to Know?

In theory, if patient autonomy principle is to be strictly followed then not only should informed consent be made available for the patient but also, if the patient desires, "uninformed consent". The question arises shouldn't as part of true autonomous decision-making by a patient, the patient should be given the respect not to be told matters that the patient rejects being told about? If this feature of true autonomy is to be followed there can arise complex ethical and legal issues for the physician. At this time, the standards and legal aspects of medical practice fail to account for this possibility. The physician considering complying with the patient's request will be treading in uncharted professional waters with the possibilities of malpractice and licensure reprocussions to be considered. If you were the physician, would you, for example, perform elective surgery or administer chemotherapy without telling the patient the diagnosis, reason for the therapy and the risks and benefits associated with the procedure?

Some patients for various reasons wish not to be told. Within some cultures, it is established norms that patients are not to be told "bad news" for various reasons but often because it is felt that the telling will lead to physical and emotional injury to the patient and contribute to the failing of the patient's medical condition. Family members or members of the community declare that they have become ad hoc surrogates to the patient and expect to be told the medical details and to make the medical decisions instead of the patient. If this view is in direct opposition to the norms of medical practice in the country where the patient is being treated, such as in America, what is the physician to do? A dilemma is faced. Should the physician follow the standards of practice in his/her country but perhaps fail to be beneficent towards the patient? Physicians may decide that they will bypass the cultural norms and go directly to the patient and have the patient tell the physician how much and what the patient doesn't want to know. But how does the physician set the question to the patient without premature and unwanted revelation?

Write me comments about what you would do if you, as a physician, faced this issue. ..Maurice.

Friday, July 16, 2004

How Much Would You Want to Know?

Now as a followup from the last posting on physician conflict of interest, I would like my visitors to answer the following questions and if they care, post a comment about them.

If you were a patient would you want to be informed by your doctor-
a. that the reason she had your appointment rescheduled for 3 weeks later was because at the time of the original appointment she was going to the 6th grade graduation of her child.
b. that the reason she had your appointment rescheduled for 3 weeks later was because she herself was going on a vacation trip with her husband.
c. that the reason she had your appointment rescheduled for 3 weeks later was because she herself was having a breast biopsy.
d. that he owned a financial share of the X-ray laboratory to which he was sending you for a mammogram.
e. that he got paid $1000 for every patient he was able to sign up for a research study on a drug that might be useful for your disease.
f. as a pregnant patient at the first visit with the obstetrician what is his religious beliefs and whether he follows religious directives regarding abortions.
g. that the reason your doctor never questioned you about your smoking was because he himself smokes.

Do you think that you are responsible to know and understand the basis for all actions of your physician dealing with you as his/her patient? If not all, by what criteria would you decide what information you want to know? ..Maurice.

Thursday, July 15, 2004

Conflict of Interest and the Doctor

There is consensus within the United States that the ideal relationship between a physician and his/her patient is one of an equal partnerhip. Equal in the sense that there is a common goal to promote relief and cure the illness and each side contributes toward attempting to accomplish that goal. The physician brings his/her medical knowledge and skills. The patient brings the history, views, wishes and the final decision-making capacity. In other countries and cultures, the physician may still assume a greater role. In any event, there must be cooperation on both sides and there must be trust.

The issue of paternalism by the physician is just one issue which can affect the function of this relationship. Another issue facing the physician for which he/she must consider in order to maintain the trust within a fiduciary relationship to the patient is that of conflict of interest. The physician has a responsibility and duty to always decide and act in the best interest of his/her patient. However, there are potential conflicts of interest which can affect this duty. Some conflicts are related to the physician's personal life and some related to external influences. Consider the conflict between the physician and his/her responsibilities to family vs the patient. An example might be a physician delaying treatment of a patient because of need to attend to a family activity. Examples of external influences may include bias or undue influence by pharmaceutical company prescription drug "education" sessions including gifts or in fact, the physician's financial interest in a pharmaceutical company or in development of a procedure. This may lead to conscious or unconscious decisions in, for example, approaches to drug therapy which might not necessarily have been the best for the patient and probably wouldn't have been selected if the influences had been absent.

The physician must be constantly aware of the potential for conflict of interest and attempt to avoid or try to resolve those conflicts which can degrade the patient's necessary need for trust in his/her doctor.

Tuesday, July 13, 2004

Social/Political Paternalism vs Patient Autonomy

Although there may be disagreement on how to define the term "paternalism", there seems to be an origin of paternalism, other than that from the physician, which can affect the degree of autonomy which a patient can express. In my view, paternalism is a parental form of direction or order to the patient to the effect "we know what is best, you may not understand it but follow what we say." This kind I think originates from institutions within our social or political environment.

Here are some examples that come to mind. In many states there is prohibition of a pregnant woman from writing an advance directive or expressing a directive to terminate her life support. There are social pressures interfering with legal abortion, insurance companies and HMOs withholding of medically appropriate diagnostic or therapy procedures, arbitrary inequality of pay for women for similar work by men and social stigma which prevent blacks from receiving the same quality of medical care as non-blacks for certain conditions. In addition, there is the pressures from pharmaceutical companies through their direct to consumer advertising of incomplete and misleading information about their products. How about the "media" setting standards for how men and women should behave and appear. The flood of ads for anti-erectile dysfunction drugs may lead normal healthy men to question their own sexual powers and ask their doctor for a prescription. And social pressures by the media on women describing what is considered beautiful or sexy encourage requesting non-restorative cosmetic surgery.

Some may say that this is not paternalism at all but only social norms or attempts at patient education. On the other hand could many of these actions represent some form of coersion which in essence tends to deprive the patient from making medical decisions about their treatment without undue influence? It would be of interest to read what my visitors would say about this subject. ..Maurice.

Sunday, July 11, 2004

Telling the Truth

Here is a link to a very thoughtful essay on the telling of the truth in medical practice
Honesty in Medicine ..Maurice.

Saturday, July 10, 2004

Physician Paternalism: Not Telling the Truth

To give you some insight into what represents physician paternalistic behavior, I can present the following scenario, which is only an example representing that which has been practiced in the past and may still be practiced.

A) The physician has found, on routine x-ray of the chest of his patient, a shadow which to the physician is suspicious for cancer of the lung. When describing the chest film to the patient, the doctor, however, does not mention the abnormality rationalizing that since he had yet to review the film with a radiologist, which might take a day or two, he would keep his suspicions to himself until the finding was confirmed. The physician felt that until the radiologist confirmed his suspicions it would be beneficent for the patient if unnecessary emotional upset could be avoided.

Would you find this rationale acceptable? If not and you were the physician, what would you say to the patient? If you were the patient, how would you feel about the physician if you discovered that the physician did not tell the truth?

B. Scenario A continues. On consultation with the radiologist several days later, the radiologist could not explain the shadow and advised that the patient obtain a CAT scan of the chest for clarification of the finding. The physician, considering that if a repeat chest film does not show the shadow and realizing that the CAT scan study might cost the patient $1000, decides on his own to order a repeat chest film which costs perhaps 20 times less. He feels that he is doing good for the patient by saving the patient the expense. Also he decided that if no shadow appears, a CAT scan would have been unnecessary. If the shadow was still present then a CAT scan could be ordered later. The physician calls the patient and simply tells him that another chest film is necessary, since on reviewing the film again, he felt the film was of poor quality but does not describe the consultation or advice by the radiologist.

Is the physician doing good for the patient by saving the patient money for a procedure which the physician, himself, feels may not be necessary? Should the physician have now informed the patient about the shadow on the first film and his review with the radiologist? How should the physician explain his previous lack of disclosure? Should the physician have revealed to the patient the advice of the radiologist before ordering another chest film? Who should be making the decisions regarding cost vs. effectiveness of diagnostic tools?

Friday, July 09, 2004

Who is the Boss?

The answer to the question "who is the boss?" in the relationship between a physician and the patient was a no-brainer up until 20-40 years ago -- it was the physician. The physician was the party educated in medicine and medical treatment and it was the patient who was the recipient of the results of that education. Nothing more..nothing less. A patient called upon a physician for diagnosis and treatment and it was mainly the physician who made the decisions and then offered them to the patient for final approval. The approval process was not so much based on patient education on the issue but more based on trust. Society looks back on this relationship and now calls it "physician paternalism"-- the physician acting in medical matters as the parent of the patient.

Much has changed in the past few decades. With the development of consumerism and with the associated greater education of the public into matters medical there has been a pressure to deminish the strength of physician paternalism. In addition, there has arisen the discipline of medical bioethics which has come forth with principles of ethical behavior in medicine and particularly stressing one principle -- patient autonomy-- the patient has the right and duty to make their own educated decisions about their own healthcare. Together, consumerism and bioethics have led to a change in the doctor-patient relationship from paternalism to patient autonomy. The question arises as to whether this has been a change to improve medical care in the latter 20th and now 21st century or whether the change is detrimental. Patient autonomy has been associated with guidelines and laws to make the physician responsible for assuring that the patient is as best informed about what decisions are available for the condition and informed about the details of benefit and risk with each of the decisions. The physician may suggest a course but finally it becomes the patient to make an informed decision for the patient's own healthcare for which the physician may follow. Patient autonomy suggests that patients may, through education from sources beyond the physician, request courses which the physician wouldn't offer or might be even against standard medical practice. This patient behavior would either produce an unproductive tension between the parties or if the physician "gave in" might lead to unnecessary expense or unnecessary patient harm.

Before I go any further in this discussion of "who is the boss?", I would ask my blog visitors who are old enough to have experienced medical care during the "paternalistic" era as well as now in the "patient autonomy" period to make a comparison of how one felt about this change. Do you recognize any differences in your relationship to your doctors or in decision-making? In which era did you feel the most comfortable or satisfied? I realize that much has changed also between then and now including different doctors, HMOs, procedures and treatment which might affect your answer but let me know what you think. What relationship between doctor and patient do you think should be the most appropriate for the best in medical care?..Maurice.

Broyard on the Ideal Doctor

Continuing with the topic of what makes an ideal doctor, one should include the writings of Anatole Broyard, the longtime book critic for the N.Y. Times, who wrote about his view of the ideal doctor in his own book "Intoxicated by My Illness"( New York: Fawcett Columbine, 1992.) Broyard was dying of prostate cancer at the time.
Now that I know I have cancer of my prostate, the lymph nodes, and part of my skeleton, what do I want in a doctor? I would say that I want one who is a close reader of illness and a good critic of medicine Also, I would like a doctor who is not only a talented physician, but a bit of a metaphysician, too. Someone who can treat body and soul. There's a physical self who's ill, and there's a metaphysical self who's ill. When you die, your philosophy dies along with you. So I want a metaphysical man to keep me company. To get to my body, my doctor has to get to my character. He has to go through my soul. He doesn't only have to go through my anus. That's the back door to my personality. (p. 40) ...
I see no reason or need for my doctor to love me - nor would I expect him to suffer with me. I wouldn't demand a lot of my doctor's time: I just wish he would brood on my situation for perhaps five minutes, that he would give me his whole mind just once, be bonded with me for a brief space, survey my soul as well as my flesh, to get at my illness, for each man is ill in his own way. (p. 44)
Unfortunately, there are not many physicians who meet Broyard's criteria. Can you think of reasons why not? ..Maurice.

Thursday, July 08, 2004

A Doctor's Visit

An excellent example of a therapeutic doctor-patient relationship but in this case not an office visit but a housecall is found in the Anton Checkhov story
A Doctor's Visit.

"The Professor received a telegram from the Lyalikovs' factory; he was asked to come as quickly as possible. The daughter of some Madame Lyalikov, apparently the owner of the factory, was ill, and that was all that one could make out of the long, incoherent telegram. And the Professor did not go himself, but sent instead his assistant, Korolyov. ..."

The Visit to the Doctor

The first issue on this blog I would like my visitors to think about and comment is one about the office visit with a doctor. How have you experienced the visit? If this was the first visit, was it as you expected? What was it about the visit that impressed you.. good or badly. How long did the doctor take to get your history? What was the physical exam like? After the exam, did the doctor discuss with you about the findings, conclusion and plan? Were you satisfied that you understood what your doctor was trying to tell you?

These questions deal with the process of the office visit. But how about the appearance and general behavior of your doctor.. were you made comfortable by how your doctor listened and how your doctor talked to you? If not, what would have made you more comfortable?

For privacy reasons, don't identify your doctor's name here but.. have you ever expressed your opinion about the visit with your doctor or staff?

I teach medical students how to take a history and perform a physical examination on patients and how to relate to the patient. I think I know the factors that make up an ideal physician and an ideal visit but I would most appreciate learning your own opinions. ..Maurice.