In February 2006, John Paling and I had a dialogue on my website Guestbook about whether, when, and how doctors should give advice to their patients, as opposed to simply giving them the facts. John wrote a final comment in March that was too long to add to the Guestbook exchange, so I gave it its own page.
I value your comments. You make your point well with the hypothetical responses to preface a doctor’s discussion of risks. You have made me reevaluate my own take on this issue and, while I still have reservations about doctors assuming the role of influencer (as indeed do you), I would now start from your point of view and only in certain circumstances revert to my doctor-should-be-a-neutral-source-of-data-to-aid-the-patient stance.
I still happen to disagree with your implication that the communicator who simply conveys information doesn’t care about the patient. I think there are circumstances where that is precisely what the doctor should do because that is what the patient needs and wants. However, I might be misquoting you, and this is a small point in light of so much agreement on other aspects of the matter.
This exchange has prompted me to summarize my own position on advising docs. I think we might both agree on the following (much of it you have already said in our earlier exchanges):
- There is a very wide spectrum of patient needs, wishes, and inherent educational and social limitations, as well as a wide spectrum of complexities of medical conditions and uncertainties as to the reliability of tests (whether the patient is fully aware of them or not). In discussing how medical risks should be presented, one size will not fit all.
- The overriding role of the doctor should be to serve the best interests of the patient – defined first as the patient perceives them, but then secondly as the doctor feels to be in the patient’s best interests.
- Often the doctor will be asked for an opinion and should shamelessly give it subject to your caveats: “The communicator’s obligation under those circumstances is twofold: (a) To acknowledge his/her goal=bias=stake. (b) To be scrupulous about not excluding or understating information that might support an opposing conclusion.”
- There are certain circumstances where particular patients (or loved ones acting on behalf of patients) want to try to understand the factual basis of their options. Then my approach of the neutral communicator seems most appropriate. (I now accept that such instances are likely to be in the minority.)
- Given the fact that healthcare agencies, drug companies and the media typically express medical findings as relative risks (a “50% improvement,” etc.), doctors should be prepared to expect that some patients might arrive with exaggerated impressions of the risks (or the benefits). Thus docs should make sure that, if the patient is concerned to look at the risk likelihood data, these data should be presented as absolute numbers. (For example, “the risk increases from two percent to two and a half percent” is much better than “the risk increases by twenty percent.”) Also, docs should show risks using both positive and negative framing of each issue.
- Consequences are easy to describe but often hard for patients to quantify and may be judged differently according to the circumstances and values of different patients.
- It is easy for communicators to minimize the likelihood of a possible outcome where the odds may be “only 1 in 1000.” However, someone will be that 1 in 1000, and the healthcare professional should give thought to how to administer to the patient's needs if he or she happens to be that one. “Whoops, I am so sorry it was you” is of course no consolation in those circumstances. Approaches like consciously building resilience for life’s downturns should be considered an important element of wellness training.
- (I feel I have come to clarity on this next.) All people commit to make a decision when their feelings tell them that a particular course is the way to go. They can make a decision based on feelings alone – or they may want to quantify and compare their chances, in which case they will still make a decision only when they feel they see the balance in the risk/benefit numbers. In all cases, decision-making is at its root an emotional process. Knowing the numbers is only one route to getting to a point where the patient’s emotions lead to the brain making a decision. For this and other reasons, healthcare professionals should actively be striving to maximize the doctor-patient bond of trust and respect. Beyond all else, this is the most helpful framework within which to carry out risk communication.
Copyright © 2006 by John Paling
