Physicians and patients make decisions together .. right?
A sample of today's shared decisions:
Mammogram at 36? (no)
Antibiotics for acute otitis media? (no)
Aricept for Alzheimer Disease? (yes)
Biopsy to confirm diagnosis of condyloma? (yes)
Incision & drainage of sebaceous cyst vs. trial of antibiotics? (yes)
PSA at 54? (no)
Colonoscopy at 56 (yes)
Counseling and/or family meeting for gambling addiction (no)
Antidepressant medication for depression/anxiety (yes - maybe)
Choesterol testing at 30 (yes)
Medication for smoking cessation (yes)
Physical therapy for back pain (yes)
Annual Pap smear at 35 (yes)
Some decisions, of course, are not final. The prescription for antidepressants is written, but not necessarily filled. Is it bad if the patient doesn't fill this prescription? No. I make it clear that it's not. Indeed, despite the paternalisitic nomenclature that we use .. patients are not necessarily noncompliant .. they just decide not to take the medications that we prescribe. Today I made it clear to my patient that the prescription was my method of putting the power into his hands. If he decides to try the medication after reading about it and thinking and perhaps talking with his wife ... that's OK. If he decides NOT to take the medication, that's OK too. I won't be mad. If he has more questions about it ... he should feel free to call me.
I met a couple this afternoon who were looking for a new physician for their 3 year old daughter, and we started talking about shared decisionmaking. I heard myself saying that I see myself as a resource for them. I won't dictate what to do .. I'll just help guide them. Yes . I may know a few things about medicine .. and yes .. I'll have opinions about what may be best for their daughter .. but they may know some things too .. and if we are all open to each others' opinions ... we can make good prevention and treatment decisions together.
So in this context, every decision is shared. There are some issues that I'll feel strongly about. Do I sometimes lobby for a given approach? Certainly I do. Do I mandate a given approach? No. Will I refuse to do something that I don't think is appropriate? Yes. (I often refuse to treat colds with antibiotics ... but I do so in the context of education .. )
Is an intervention really going to be effective if I impose it? Not likely. So we shouldn't bother imposing interventions .. right?
How many physicians does it take to change a lightbulb? (answer) Get it? If patients don't make the decisions with us .. then any decision we make for them is really irrelevant.
yes yes .. there are exceptions. Self-destructive behavior may be one of them .. but even that's a grey issue. Where do we draw the line? Certainly a suicidal patient needs a decision made for them (but only after we fail to make a decision with them). Is eating a Big Mac self destructive? How about unsafe sex? Smoking?
So I'm searching google for links on shared decisionmaking and I find what looks like a question from a final exam in a medical ethics class:
In a survey performed by the Presidential Commission for Study of Ethical Problems in Medicine, doctors were asked to consider 3 issues: (1) the issue of whether a pregnant woman over 35 should have amniocentesis; (2) the issue of which antibiotic to use for strep throat; and (3) the issue of whether to continue aggressive treatment for a cancer patient in whom such treatment had already failed. The doctors regarded (1) as a patient decision, (2) as a physician decision, and (3) as joint. Do you agree? What are the relevant differences among these issues?
What's the answer?
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