{"id":946,"date":"2014-09-01T19:04:07","date_gmt":"2014-09-02T02:04:07","guid":{"rendered":"http:\/\/blog.stevenreidbordmd.com\/?p=946"},"modified":"2014-09-02T07:46:09","modified_gmt":"2014-09-02T14:46:09","slug":"between-medical-paternalism-and-servility","status":"publish","type":"post","link":"http:\/\/blog.stevenreidbordmd.com\/?p=946","title":{"rendered":"Between medical paternalism and servility"},"content":{"rendered":"

\"ID-10038434\"<\/a>Even today there\u00a0are patients\u00a0who leave\u00a0diagnosis and treatment entirely to their doctors. \u00a0They make no effort to inform themselves\u00a0about their illness or chart their own course; they do whatever their doctors advise. \u00a0Once the norm, this\u00a0passive, willfully naive attitude has withered in the face of\u00a0a multigenerational attitude shift, coupled with\u00a0the wealth of medical information at hand\u00a0today. \u00a0Direct-to-consumer drug ads on television,\u00a0online peer support,\u00a0medical\u00a0websites and blogs of all stripes, “Dr. Google<\/a>,” PubMed<\/a> \u2014 it almost takes dedicated effort to avoid<\/em> learning about one’s medical issue. \u00a0\u00a0The complementary role\u00a0of\u00a0doctors\u00a0as kindly but\u00a0authoritarian\u00a0caretakers feels outdated by decades, and to many nowadays, offensive. \u00a0“Paternalistic” has become the epithet of choice for doctors who fail to recognize, respect, and make room for patient autonomy and\u00a0medical self-determination.<\/p>\n

Most\u00a0doctors practicing today, even those of us decades\u00a0into our\u00a0careers, began medical training at a time when\u00a0patient empowerment had\u00a0already gained ground\u00a0in the U.S. \u00a0Many of us supported it wholeheartedly. \u00a0In college I studied medical ethics and patient autonomy. \u00a0I volunteered at a community clinic called “Our Health Center” that aimed to empower patients. \u00a0My stated\u00a0goal when\u00a0applying to\u00a0medical school was to help patients take responsibility for their own health. \u00a0Even today I tend to over-explain my reasoning to my patients, and to\u00a0err \u2014 and sometimes it is<\/em>\u00a0an error \u2014 on the side of offering\u00a0a smorgasbord\u00a0of options\u00a0along with their risks and benefits.<\/p>\n

However, over the years the goalposts have moved. \u00a0For a growing subset of patients it is no longer enough\u00a0that we doctors talk to them as fellow adults. \u00a0The one-time goal of shared decision-making has, in some circles, given way to a deep skepticism toward\u00a0doctors and our expertise. \u00a0Some regard us as irksome\u00a0gatekeepers<\/a>\u00a0who add little to medical decision making and serve mainly as roadblocks<\/a> to obtaining the medical tests or treatments they already know they need. \u00a0 In\u00a0this\u00a0jaundiced\u00a0<\/span>view, our role is reduced to rubber-stamping: ordering desired tests, signing requested prescriptions, drafting\u00a0work excuses, and so forth. \u00a0For example, I’ve received many calls from would-be patients seeking a prescription stimulant for\u00a0self-diagnosed “adult ADHD.” The callers\u00a0sound dismayed\u00a0when I point out\u00a0that my diagnosis may not\u00a0agree with theirs. \u00a0Similarly, patients seek me out to provide documentation and advocacy on\u00a0behalf of a psychiatric disability\u00a0they swear they have, but I haven’t yet evaluated. \u00a0I\u00a0find myself wishing that such callers\u00a0could face the consequences of their own decisions without involving the\u00a0unwanted,\u00a0apparently superfluous impediment\u00a0of a\u00a0doctor.<\/p>\n

These examples from my practice could be dismissed as drug-seeking or “gaming the system.” \u00a0But skepticism toward physicians and our expertise\u00a0goes much further. \u00a0Patients insist on antibiotics for viral (or non-existent<\/a>) infections. \u00a0Parents refuse to vaccinate their kids. \u00a0Online forums abound with horror stories of patients misdiagnosed and mistreated, who finally escape this nightmare only by taking matters into their own hands. \u00a0“Ask your doctor” drug ads imply\u00a0that doctors will\u00a0fail to consider the advertised treatment if not for\u00a0patient self-advocacy (and the generous assistance of a multimillion dollar marketing\u00a0campaign). \u00a0California has a voter initiative<\/a> this fall that, among other provisions, would mandate random drug testing of physicians for the first time in the U.S.<\/p>\n

There is a movement afoot to share medical records<\/a> with primary-care patients, ostensibly for doctor-patient collaboration, but often justified on the basis of “transparency<\/a>.” \u00a0It is now deemed paternalistic for doctors to keep private notes of our own work, even though this is\u00a0accepted in other professional and consultative fields. \u00a0Institutions\u00a0no longer trust us to do high-quality work without oversight\u00a0by\u00a0non-physicians who\u00a0track quality and patient satisfaction measures. \u00a0Some patients now\u00a0balk<\/a>\u00a0when doctors ask personal questions, e.g., about religious practices or hobbies, that are not obviously related to a manifest disease process. \u00a0Learning about our patients as people, their strengths as well as weaknesses, is apparently\u00a0also\u00a0paternalistic. \u00a0Shouldn’t the patient decide what areas of information to divulge?<\/p>\n

Reducing doctors\u00a0to servile\u00a0technicians\u00a0renders us\u00a0safely powerless. \u00a0Never mind that we can no longer diagnose or treat illness as well, for example by\u00a0drawing\u00a0unanticipated connections between habits and disease. \u00a0For many patients, and apparently for society at large, it\u00a0is more important not to\u00a0feel a power differential.<\/p>\n

This is\u00a0an odd sentiment indeed. \u00a0Anyone offering a skilled\u00a0service, professional or not, wields\u00a0a degree of power\u00a0\u2014\u00a0and at least a little\u00a0paternalism \u2014 over\u00a0clients or customers. The computer professionals and attorneys who come to my office expect\u00a0their own\u00a0clients to defer to their\u00a0expertise. \u00a0My mechanic knows more about cars than I do, my barber about hair, my grocer about what produce is in season. \u00a0Somehow we don’t find it threatening to put our faith in these authorities, especially when they welcome dialog and involve us in the decisions and recommendations that affect us personally.<\/p>\n

People\u00a0sometimes wonder when they may\u00a0question a\u00a0doctor’s diagnosis or advice. \u00a0I say always. \u00a0I’ve spent a career encouraging patients to be curious, to ask questions, to understand their suffering and what may help. \u00a0This is the legacy of patient empowerment: all of us\u00a0taking responsibility for our\u00a0own well-being, and medical professionals respecting the right of patients to make their own well-informed health care decisions.<\/p>\n

However \u2014 and it is a big however \u2014 this is not the same as physicians rubber-stamping everything patients believe or want. \u00a0Shared decision-making lies between<\/em> “doctor’s orders” and “patient’s choice” and follows the ethical standard of acting in the patient’s best interest (illustration courtesy of Practice Matters<\/a>):<\/p>\n

\"Doctors-orders-chart-450\"<\/a><\/p>\n

 <\/p>\n

Nor should\u00a0fear of sounding\u00a0paternalistic silence us when detractors claim\u00a0that everyone’s\u00a0opinion\u00a0is\u00a0equally valid. \u00a0It is falsely modest and politically naive to deny our own expertise. \u00a0When it comes to medical matters, we doctors, while admittedly fallible,\u00a0are nonetheless right far more often than we are wrong, and far more often than even intelligent, well-read non-physicians\u00a0are. \u00a0Like the attorney, computer professional, mechanic, barber, and grocer, we know things most other\u00a0people\u00a0do not. \u00a0There is no shame in that, nor is it a power trip to point it out. \u00a0A paternalism that demeans others is bad; a servility\u00a0that demeans ourselves may be worse.<\/p>\n

Top image courtesy of Ambro\u00a0at FreeDigitalPhotos.net<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"

Even today there are patients who leave diagnosis and treatment entirely to their doctors. They make no effort to inform themselves about their illness or chart their own course; they do whatever their doctors advise. Once the norm, this passive, willfully naive attitude has withered in the face of a multigenerational attitude shift, coupled with […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"categories":[4],"tags":[65,16,54],"class_list":["post-946","post","type-post","status-publish","format-standard","hentry","category-current-events","tag-medical-expertise","tag-pharmaceutical-marketing","tag-responsibility","odd"],"aioseo_notices":[],"_links":{"self":[{"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/posts\/946","targetHints":{"allow":["GET"]}}],"collection":[{"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=946"}],"version-history":[{"count":9,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/posts\/946\/revisions"}],"predecessor-version":[{"id":958,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/posts\/946\/revisions\/958"}],"wp:attachment":[{"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=946"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=946"},{"taxonomy":"post_tag","embeddable":true,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=946"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}