Physicians’ Opinion: Damned If You Do, Damned If You Don’t
In a patient interview, the most common question asked after the discussion of options is always ‘what would you do?’ or its multiple variants. This is usually a question one can sidestep with some degree of grace or fall into it headlong without any qualms.
I have had discussions lasting hours, with colleagues on the appropriate answer to this question. There are the ones who say that as consultants, we are just that; the patients need to know what side of the fence we stand? They have come to seek our opinion on what needs to be done. We need to give it to them. Some of them have even waited for days and travelled far miles to do so. Any ambiguity in our response to it is merely a shirking of our duty. We should discuss their options, but also add in our opinions.
The flip side of the argument is that we are there to guide them, not make their choices. We are the gatekeepers to the cross roads of medical decisions and can merely inform them of the potential consequences of each road they take. It depends on the patient to take an informed decision and we need to the providers for that information. (reword) and We need to appear as neutral as possible to avoid any personal biases to interfere with the patients’ care.
There is no right answer to this has been my conclusion after spending many a car journey and hours of precious sleep dedicated to this endeavor. It always boils down to the question whether, the patient can decide within the confines of the medical interview, regarding what is best for him. The proponents of neutrality mention that given the fact that current medical knowledge is evidence based, we can present the evidence to make a case for both sides of a decision and then use the numbers to guide the decision making. The other side simply refutes it by mentioning the fact that for most cases, evidence is relatively weak and therefore, it does boil down to tailored therapy rather than mere application of established guidelines. The patient may not want to choose between available options. In this situation, the personal opinion of the physician could be the tipping point towards decision making in that direction.
We can use guidelines to sway decision making on one way or the other, however the guidelines are just that; GUIDELINES. The opinion of a good clinician may outweigh the benefit of affording uniform decision making to all. To adhere rigidly to them to facilitate decision making is a good exercise to understand the subject initially, however with time understanding the pitfalls and being able to tailor this from the macrocosm of the population to the microcosm of the individual patients, reflects the maturing of the clinician.
Whereas there is no right way about how to advise patients on making decisions, there can be a safer protocol followed to optimize this process. They could be encouraged to mull on decisions for a period of time, which may not involve the confines of the clinic. Actively offering them, the time to reflect on opinions given or information provided, in the comforts of their choosing, may help them make better decisions. In practices which may involve rapid turnover, allowing the patient the chance to go home and call back with their decisions regarding possible course of treatment, especially if it a challenging one to make, may yet serve the patient better. It may allow them ownership of what they have decided, as well as feel better with the outcomes or the collateral damage when it does happen. It may allow them to be on board in a better manner if desirable outcomes are not met and embark yet again on another round of decision making.
At the end of the day, the bond that allows one person to trust the opinion of another, in making decisions that could profoundly impact their lives, is the bond that we seek to preserve. This is fraught with powerful emotions that may leave a lasting impact on both parties concerned. Being able to offer opinion in a manner that one feels is of the best use to the patient is the goal of every consult made and that needs to be the guiding light through this journey.
Deepak Padmanabhan, MD
Clinical Cardiac Electrophysiology Fellow, Mayo Clinic, Rochester, MN
Deepak Padmanabhan is an Electrophysiology fellow at Mayo Clinic , Rochester, MN. His research deals with ventricular arrhythmias, cardiac device therapy and translational medicine. His opinions are solely his own. Follow him on Twitter @manak_18.