Bioethics Discussion Blog: Medical Decisions: Role of the Physician's Personal Opinion

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Monday, July 31, 2006

Medical Decisions: Role of the Physician's Personal Opinion

These days, medical paternalism has seemingly faded and has been replaced by the concept of patient autonomy. Current view of medical practice warns against physicians "deciding" for the patient. There has even been emphasis that the decisions should be 100 percent by the patient with no personal suggestions by the physician. I brought this issue up on my currently inactive "Bioethics Discussion Pages". I thought the responses were quite interesting, so I am copying the topic and comments here. The oldest comments are at the bottom of the page. Perhaps my current visitors have some thoughts on the subject or what they have experienced. If so, feel free to write your comments to my blog. ..Maurice.





Every person makes decisions based on their own experience, value system, goals and morals. In medical decision making, a patient draws on these and also, hopefully, an analysis of the burdens and benefits of the anticipated test or treatment. The objective facts should be provided by their doctor. Doctors also will have their own personal opinions as to what medical decisions would be appropriate for themselves but should they express their opinions of what would be appropriate for the patient? If a patient asks the doctor "What would you do if you were me?" How should the doctor answer? Should the doctor ever give a personal opinion without being asked?

Here is the question:

Should doctors tell patients their own personal opinions of what should be done?

---- THE DISCUSSIONS ----

Date: Sat, Apr 22, 2000 5:34 AM From: davidh@midusa.net To: DoktorMo@aol.com

DoktorMo, I am a nurse of 22 years experience. I think that patient families are often "getting a crash course in bioethics" at the bedside of their family members. Thus they are often not in the mind to do a lot of learning and they often don't have time to do the learning because a decision must be made (to do the surgery, to do the trache, to do the g-tube, to place on the vent).

In a perfect world, families would have thoughtful and deep discussions about what they would do in the event of handicap, disability, choices about technology. You know, the kind of discussions that we health professionals OFTEN have with our family members. So families may not have the time to make the decision and due to their "limited" life experiences they have no idea of what can be the long term out come of their decisions that day. Of course, we as health care professionals don't either, but we have pictures of the worst case and best case scenarios in our minds and families generally don't have that.

I was priveleged to hear a health ethicist speak last summer and his feeling was that as health providers we were often "under involved" in helping our clients with decision making. He was not advocating patriarchy--in fact he categorically deplored it. But the opposite of patriarchy is this atmosphere of "consumerism" where the family decides, as if they were fully informed and insightful consumers. We as health care providers must realize that we bring to the table some specific knowledge about the range of possible outcomes and how long terms disability affects families in a financial and dynamic way. Let's face it, people: sometimes what we send people home to live with devastates the entire family.

As a group both doctors, nurses and families get caught into a swirl of, "Because we can provide it, we ought to." Please do not think that I am advocating the opposite. I am not. GIven the widest range of choices, I am pretty convinced that some families will choose to proceed with aggressive, life sustaining care in the face of profound disability. But somehow, families must be exposed to the glimpse of profound affect that this will have on them personally, financially and within their family dynamic and they must understand that they never loose their opportunity to re-choose and become less aggressive in their curative approach while always maintaining an emphasis on CARE.

Good discussion forum.

Janet, RN, KS


Date: Fri, Mar 24, 2000 6:49 AM From: "ocsio"@hotmail.com;ann@marist.edu.ph;;; To: DoktorMo@aol.com

Doctors should always give patients adequate facts and figures. Personal opinions if solicited should be given, but never volunteered. I tell my patients to go home to talk it over with relatives and friends. I encourage my patients to see other medical experts for second or more opinions. Patients should feel that they have exhausted all possible sources of objective as well as subjective matters regarding their cases, prior to coming back to me for definitive but within sound medical/ surgical decision.

Marianne A. Ocsio, Obsetrician-Gynecologist


Date: Sat, Jul 26, 1997 2:11PM From: DocReading@sprintmail.com (William H. Reading, MD) To: DoktorMo@aol.com

I offer personal opinions to my patients. I make sure that patients are aware that I am making a personal opinion. I am also sure that patients are aware of both risks and benefits. In most matters of deciding in major situations, people ask, "if you were in my situation, what would you do?" I ask this of others in medical settings as well as in other situations involving a judgement call. I have asked this question of my peers in deciding the best approach to treating a difficult patient. Patients can often be swayed one way or another by this personal information but it does not mean that they should be deprived of having it. In an involuntary medication hearing, I have been asked by a Judge, "Would you recommend this treatment for one of your own family members?" I believe that this information is a powerful attestation in helping to decide a difficult issue.


Date: Mon, Jul 14, 1997 7:57 PM From: Nrse4morph@aol.com To: DoktorMo@aol.com

Yes, if asked they should be allowed to do so with care. They should not be compelled to do so, If they are aware that the patient is seeking to lay resonsibilty onto someone other than themselves it is not appropriate.

Doctors wield a great deal of power even today. They are sometimes the only source of real infromation based in reality that a patient receives in an out of the hospital setting.

In hospital there are numerous sources of information available to the patient, but either the patient may not avail themselves of those resources or those resources may not inform the patient out of fear of an aggressively controlling physician.

Another factor that must be considered when an opinion is given by a physician is that there is at least the potential for a conflict of interest. In fee for service to run up the bill. In managed care to keep costs low.

Doctors must be careful and use many of the same techniques that other healthcare personnel utilize to avoid the pitfalls of even seeming to impose their own value systems onto the patient. Even if the patient seems to want just that at the time they are very likely to be resentful later


Date: Sun, Jul 6, 1997 3:45 AM From: shaolin@henge.com@henge1.henge.com (Robert Wesley) To: DoktorMo@aol.com

The proper answer to this question is, yes and no, or, more precisely, sometimes yes and sometimes no. The real question is, Under what circumstances would it be appropriate?, and the answer to that question involves judgment, a quality which we do not seem to value much anymore, and the specific relationship between the doctor and the patient. Take the question of whether one should undergo chemotherapy for cancer and add whatever details you like about 5-year survival rates, etc., and then ask this question in each of the following circumstances: 1. A doctor and patient who have known each other for 40 years and who are good friends outside of their professional relationship. 2. A doctor in a clinic who is seeing the patient for the first time and who will likely not ever see the patient again. 3. A doctor who knows the patient well enough to know that the patient is easily swayed by anyone else's opinion and particularly by opinions expressed by authorities. 4. A doctor who knows the patient well enough to know that the patient is independent and that the patient will take the doctor's opinion as merely one more piece of information in making his own decision. Etc., etc., etc. In my opinion, these differences are the essence of the matter, and the best doctors are those who possess the judgment to discern the differences.

Robert Wesley


Date: Thu, May 22, 1997 7:31 AM From: 106721.2574@compuserve.com (Dorothy Onunwakolam) To: DoktorMo@aol.com

Q : Should a doctor ever give a patient his personal opion even when requested by patient ?

My A : Yes, if patient is well known to me and trusts my judgement , I will give him my honest opinion but make it clear that he does not have to take it


Date: Thu, May 8, 1997 7:08 AM From: JMG.Keijman@STUDENT.UNIMAAS.NL (JMG Keijman) To: DoktorMo@aol.com

Being a medical student who has recently made the step from theory to practice I have been thinking about this a lot. This is how I think about it (any comments are very much appreciated): There should be a distinction between the patient asking for the doctors opinion or not. If the patient does not ask for the doctors opinion, he should not give it. Some people do not appreciate it. In this case the doctor should limit himself to thoroughly explaining all possibilities and consequences of what can be done. The patient should be given the oppertunity to think about it, discuss it with family and friends and ask for more information or a second opinion. In most cases the choice will be easy, because the consequences are very clear and distinct. If the patient does ask for the doctors personal opinion, it will mostly be in the cases in which the consequences are unclear and undistict. The doctor should give his personal opinion in these cases. However, some things should be remembered: 1. Stress that it would be YOUR decision if you were in their shoes 2. explain WHY you would make that decision 3. Emphasize that there are OTHER OPTIONS that the patient should consider.

Jeroen Keijman, dutch medical student


Date: Thu, Apr 10, 1997 4:51 PM From: SANGRIA111@aol.com To: DoktorMo@aol.com

My view on whether doctors should give their personal opinion to a patient leans both ways. If the patient asks for the doctors opinion, the doctor has a right to express his views. however, if the doctor is not asked about his opinion, he or she should not give it just for the simple fact that they were not asked. We look up to and respect doctors views and sometimes even treat them like God, but there are just some decisions that should be handled by the patient and their families and not the physician.

Mark A. Walker, Univ. of Oklahoma College of Nursing


Date: Wed, Feb 19, 1997 6:25 AM From: theguild@teleport.com To: DoktorMo@aol.com

Two years ago I wouldn't have had more than a mild opinion of my own to your question. After brain surgery to remove a large, but benign tumor, which has left me in a very precarious state, I have a definite answer - YES. Medical doctors try so hard to detach themselves from the psychological and emotional aspects of the disease, that they often appear as clinical automatons, bearing diagnoses, treatment and prognoses in logical, digitized, even-breathed tones, leaving the patient's psyche and soul as disconnected from the physician as he can get. A personal opinion reconnects patient and doctor and puts them back into the realm of person to person. In today's medical world, it has become increasingly necessary to be your own informed advocate - much as the prisoner on death row familiarizes himself with all facets of the law to enable a pardon, a patient had better delve into the medical libraries, literature, discussion groups, and research every available source to become knowledgeable in his or her own health care success. Assuming that this imperative learning endeavor takes a modicum of intelligence on the part of the patient, I think he or she can stand to hear a medical professional's personal opinion, as long as it's presented as such, without drawing a conclusion that this is the only option available. In fact, I think it's insulting not to share, and serves only to further perpetuate the distance between the vast educated help that the doctor can offer, and the confused and frightened patient.

Tanya. Jones

Portland, Oregon

www.teleport.com/~theguild


Date: Wed, Oct 9, 1996 11:09 PM EDT From: ronb@ieway.com To: DoktorMo@aol.com

Signe is way off base, but she is Politically Correct!

I guess I would like to say that in our coin-operated medical system, I value a good physician who has an opinion! I'm a dialysis patient for 31 years. I don't know exactly when it started but somewhere along the line more and more physicians are not explaining the hazards of a life on dialysis. Patients and families need to be made exquisitely aware of what they are getting into when they embark on the road of dialysis and possibly transplantation. Personal responsibility needs to be stressed, possible complications need to be discussed so patients and families can go into treatment (or refuse treatment!) with their eyes open and never have to go back to the physician and say, "You never told me it would be like this." Granted, a physician can not cover all the possibilities because the avenues and outcomes are so numerous, but almost any nephrologist (and I think this related to most other physicians) who has been around five years has a wealth of knowledge that he or she should be willing to impart, in terms of advise or anecdotal information, thereby characterizing and illuminating what this course of treatment I as a patient am about to embark upon will be like. That's what I want from my doctor: an educated guess. I don't hold him to unreasonable standards (humans make mistakes), I don't expect perfection, I just want the benefit of his knowledge.

I don't want to beat this to death, but I lament the loss of physicians who will take a stand with their patients and say what they feel in their hearts which has been provided by the benefit of their experience. Society (and medicine) has largely gotten away from that I guess, and in my opinion we are a lot more piss-poor because of it. We come together as human beings trying to help each other out.. No one considers doctors "gods" as they used to in the old days, they are fellow beings with knowledge. Impart that knowledge to your patients doc!!, do it in a caring and loving way and you will be appreciated for it.

In the course of my 31 years on dialysis I have met numerous patients who have told me, "I don't like this .I never knew it would be this way. I wish I had died and never started treatment." Most of the patients have been older, some have been blind diabetic amputees, others have been just like me, in relatively good physical health but not coping mentally. DOCTORS, WE NEED YOU!! COME BACK!! Otherwise we are going to drop you like a hot rock and rely completely on the coin-operated Computer Database Diagnostician of the future.

No offense intended.

Ron Bull


Date: Tue, Sep 17, 1996 1:18 AM EDT From: devilbaby@earthlink.net To: DoktorMo@aol.com

By the way, I was so intent on my particular issue that I did not address the larger ones of opinions and patient's "needs" of such. When patient's are struggling with an issue opinions are probably sometimes warranted. But, remember. many patients know the issues and have made their decisions. They may have been on a particular brand of medication that they find works best for them, and need a new physician to prescribe it, not take the position of treating the patient as someone for the physician to force his particular medical bias of "best" medication upon. Medical decisions have been too long identified with "doctor decision making" versus the more needed and appropriate "patient decision" making.

Robyn LCSW


Date: Tue, Sep 17, 1996 12:57 AM EDT From: devilbaby@earthlink.net To: DoktorMo@aol.com

As a person on prozac for a number of years, and successfully so, I have an opinion more case specific than general. I was misdiagnosed by a psychiatrist (even though I sporadically mentioned how depressed I was) and on the wrong medication for three years. Consequently lost ten years to depression vs. seven. As a person who has a chronic condition to manage and as someone who has learned the hard way I do not feel the need to call my doctor for permission to raise or lower my dosage (such as when my mother died). Since I recognize that I am the expert on my depression or medication needs of the moment A doctors recent request to call him vs. raising my dosage irked and frightened me. I know from hard experience that no on else can completely trusted about my depress but me!!!!The implication of his request (and he is not a psychiatrist at that) was that he would be the one to decide whether I was really depressed or not.EXCUSE ME!!!??? I would appreciate it if anyone could comment on this and if my position is a respected one by some in the medical field. (God, I hope so) By, the way the physician who decided he knows better than me know zilch about me--never asking for details of my depression history or self-management knowledge and history.

Robyn


Date: Fri, Jul 19, 1996 8:28 PM EDT From: af485@lafn.org

My opinion is directly opposed to the prior comment! A physician's responsibility lies first of all in informing the patient as completely and thoroughly as he is able to, as far as diagnosis, therapeutic options and prognosis are concerned. However, in my opinion, he has shirked part of his responsibility by NOT providing his personal input. Without this, he becomes nothing more than a sophisticated computer. When a patient asks: "What would you do/prescribe/choose if you had to make this choice for your own parent/child/mate?" a physician should provide an honest answer. Paternalistic? Yes. But a patient visits a physician, instead of studying text books, to get more than information. He wants someone to talk with about agonizing decisions, to bounce his own reactions off another, to look for support or disagreement regarding his wavering indecision. Finally, there is no way that even the best efforts of providing information can transmit all the nuances of knowledge and the insight gained through years of education and years of experience.

Hans G. Engel, M.D.


Date: Wed, May 22, 1996 5:30 PM EDT From: froboz@indirect.com To: DoktorMo@aol.com

I believe physicians best serve their patients' decision making by keeping the process patient-centered, not-physician-centered. This can best be accomplished by actively listening to the patients' issues, reflecting their concerns, drawing out their values, attitudes, motivations, and beliefs, and helping them scope their alternatives (perhaps by giving examples of what others have done in similar situations). In doing this the physician needs to empathize with the difficulties of decision making and the anxieties and fears which accompany it, and to note some of the points the patients may wish to consider. The approach allows the physician to be compassionate, facilitate the patients' decision making process, support their autonomy, but not offer personal opinions or advice. Because of the inherent power-status inequality between physicians and patients, "whatever" a physician says, even if it's only a personal opinion, is likely to be given considerable weight. This situation is ripe for paternalism. When asked what she/he would do, the physician could respond first with an acknowledgment of how tough a decision it is to make and second with an expression of what the physician would consider in making a decision in this situation, touching on areas already highlighted by the patient. Patients may ask personal opinions/advice of physicians for a plethora of reasons: to seek direction, recommendations, clarification of their own thinking, physician's approval et al. Irrespective of patients' motives, physicians should not offer personal opinions when asked, and should keep their mouths shut when not asked. Is this non-directive approach likely to catch on any time soon? Probably not, because it takes more time, is more difficult to do, and isn't as ego-gratifying as offering personal advice.

Signe A. Dayhoff

2 Comments:

At Monday, July 31, 2006 7:44:00 PM, Anonymous Moof said...

Dr. Bernstein, you can certainly pick the issues! ;o)

I would answer this one with a resounding yes ... and I don't believe it has anything to do with paternalism.

If I see a physician, it's because he has knowledge that I don't have, and which I need. He also has a wealth of medical experience to draw from ... something else which I lack. That knowledge and experience is why I'm seeing the physician to begin with.

Secondly, there needs to be more than a computer/patient sort of interaction ... a physician should become someone a patient can be open and trusting with. That requires a bit of personal interaction.

Even when you do something as simple as shop for a new computer, unless you're very knowledgeable in your own right regarding the product, the expert advice of the technician is welcome. Why expect and accept expert advice for something mundane, and not expect the same when it comes to your health ... or even your life?

Personally, I'm not entirely comfortable with the new trend toward "patient autonomy." If there are several options, and one is a better choice than the other, I want to know that ... I want feel certain that my physician is going to tell me what he thinks the best decision is.

For patients with no medical background, long medical explanations can sound like a foreign language ... and leave the patient making choices about things they only partially understand, and which can have hugely differing outcomes.

I feel that the physician has a responsibility to explain things as carefully as possible, and then offer advice from his own professional (or personal) experience.

 
At Friday, August 04, 2006 10:56:00 AM, Anonymous Diora said...

I think different patients have different preferences as far as the level of autonomy they want. I, for example, prefer to make my own decisions and research evidence for myself.

I realize that "what would you do" can be a pretty tricky question especially in cases when doctors don't do what they recommend. And often what the best choice is is different for different people but there are professional organization guidelines for a doctor to recommend the course of action. For example, taking a recommended preventive drug reduces patient's risk of something bad happening in future from 3% to 2%. For some people this is important and they are willing to suffer some mild side effects or a significantly smaller risk of a serious side effect now. For other people it is not. A doctor may feel obliged to prescribe this drug because it is "standard-of-care" even if he himself wouldn't do it. I don't know what the doctor should answer for "what would you do" in this type of question, but I think it is better not to answer this question at all than to lie.

An accurate information is important but so is the presentation of the information. One things that doctors shouldn't do that is commonplace now is to misrepresent the information to make the benefit appear larger than it is. I mentioned it before, but it is one of my pet peeves and nobody seems to bring it up. The presentation of the information is just as important as the information itself. For example, in the case above doctors would often say "this would reduce your chance of X by 33%". It is accurate, but is it really honest? If doctor believes that a patient wouldn't understand the true magnitude of benefit, how is this type of statement different from an outright lie? Or "the risk of this side effect is rare it is only 2% but it will reduce your risk of X by 33%, would you rather have X or some-side-effect?". "N people die from this desease every year" -- ok how does this relates to my individual chance of this test/treatment benefitting me? I think this type of deliberately misleading patients happens way too often in medicine. This is one reason I like to research everything myself.

Another reason I prefer to make my own decisions is that doctor's field may make him believe more in treatment/test than the studies show -- i.e. they only see the individual cases which appear to show benefit rather than data from studies. Their belief in test/treatment is almost religious and if the data doesn't show the benefit they believe in they tend to discount the data and claim that studies are flawed.

These are some of the reasons why the autonomy is important. For those patients who want it.

For patients with no medical background, long medical explanations can sound like a foreign language ...
In many cases that deal with odds of various outcomes, it is one's math background that is more important than one's medical background. Epidemiologists are usually in charge of examining data and their prevaling background is in statistics. Relative risk, absolute risk, odds ratio, NNT are statistical not medical concepts. Is a patient with a degree in math, physics, computer science, engineering capable of understanding these concepts? I should hope so. At the same time, I met some doctors here on blogs who don't seem to grasp the difference between relative risk and absolute risk.

 

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