Tuesday, March 06, 2007

The Commotidization of Dr. Angell.......
Kevin linked to a Boston Globe article about the unintended consequences of increased patient autonomy.
Once upon a time, the answer was simple -- doctors made the decisions. They gave you the diagnosis (if they chose to) and they told you what to do about it. Your job was merely to follow "doctor's orders."

Fortunately, those days are gone. Starting in the 1970 s, a long-overdue patients rights movement arose, exemplified by the recognition of living wills to enable people to refuse life support and by requirements that patients give their informed consent before undergoing treatment or participating in research. In effect, the relationship between doctors and patients was renegotiated to incorporate patients' wishes into medical decisions. Doctors were expected to offer advice on the basis of their expertise, but patients would decide whether to take it.
Certainly that is better than the bad old days, isn't it?
In just a few decades, we've swung from one extreme to another. The shift is reinforced by various "consumer-directed" health system reforms that place more of the financial burden on individuals. Patients are sovereign purchasers who choose from a menu of options put before them by their doctors. They search the Internet for information and compare notes with friends to help make their choices. For their part, doctors lean over backward to be neutral.
Ah yes, as Uncle Ben Parker put it in Spider Man:
"With great power comes great responsibility"

While the patients enjoy increased autonomy in the medical decision-making process, they (and physicians) have enjoyed less autonomy in other ways, thanks to the rise of the third party payor:
Adding to doctors' hands-off attitude is the fact that managed care made some people suspicious ; they worried that doctors (or the health plans for which they worked) might have a financial interest in recommending a particular course of action. One way for doctors to deal with that concern was to be non-directive. Also, primary-care doctors came under great pressure to see patients quickly, and it takes less time simply to present options than to evaluate them and make decisions jointly. When specialists are involved, primary-care doctors may rely on them to guide decision making, even though there may be several specialists involved and no coordination among them.
So the physicians and patients have both been reduced to commodities, replaceable parts in the big health care machine. It has left a bitter taste in everyone's mouth.

The physician's don't care for it because it reduces their stature in the physician-patient dynamic. Admin types (hospital and insurance company) have greater influence in areas that in the past the physician alone held sway. The economics of medicine have changed as well, with declining reimbursements and increased expenses. With this loss of "power" has not come a diminishment of responsibility. Older and wiser physicians than myself have pointed this out before.

The patients like the fact that they are "empowered" as never before. The Internet has provided patients with a vast amount of information. Some good, some bad, some ugly. They need help to figure it out and with their physicians "bending over backward to stay neutral" that help may be hard to come by. It is often easier for physicians to lay out the options and say "take it or leave it". They want well-rested and well-rounded physicians, but chafe at the fact that their Doctor is not available to them 24/7.

So what are patients and physicians doing about it? For physicians the response is along "generational" lines. The younger crowd, finding themselves treated as tradesmen, begin to act like them. They share call, limit their workhours (or have it done for them) and base career decisions primarily on lifestyle and family concerns. They are more likely to work for a large group practice, or be employed by a hospital. They are less likely to belong to their local medical society, since those meetings take away from "personal time". Medicine is more like a job than a calling. The older physicians continue to muddle along, counting the days until they retire. Some criticize the younger physicians on their behavior, but others understand their reasoning. Who's right and who's wrong? Both and neither.

The patients who are motivated and resourceful enough to make their decisions with the limited help provided can thrive. Unfortunately not all patients have the resources, time or motivation to do so. They oftentimes make the wrong choice. Those that can afford it may seek out a "concierge" environment. Others may be swayed by the information to seek alternative therapies.

The best advice for patients in Dr. Angell's column is this:
As patients, your best bet is to ask your doctors what they would do in your place, and persist until you get a straight answer. If nothing else, that forces doctors to imagine being in your shoes, at least for a moment, and it may cause them to think more deeply about what you should do.


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