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Medical Paternalism

By Eric Van De Graaff, MD May 23, 2011 Posted in: Heart Health

I went to an appointment the other day with my investment advisor, a nice guy who struggled through an hour trying to explain to me why I should do something smarter with my money than just stuff it under my mattress. I think I'm a pretty bright guy but there are two distinct areas where I lack any degree of competence: handyman chores and finances.  I'm lucky to be able to change a light bulb (as long as it's a screw-in and not one of those complicated fluorescent things) and when it comes to understanding the nuances of the investing world I'm at a complete loss.

That's the reason I really need an expert to navigate my financial future for me.  But as my analyst transitioned beyond small talk to small cap funds, and from the 401K to the 529, my eyes began to glaze over and my mind drifted toward simpler things like the physiology of the nephron and pacemaker timing cycles.  Despite my clear catatonia, my advisor laid out at least a half dozen different investment products and strategies meant to maximize my position in the market and decrease my exposure to risk.

When the time came for me to make a decision that I'm sure would mean the difference between a life of opulence and one of selling pencils on the street corner (Just kidding.  I would never sell pencils on the street corner—I'd make my daughter do it.  She's cute enough to pull it off.) I came to the realization that I didn't have a clue what we were talking about.  At that moment I found myself wanting to say the same thing that my patients say to me: "Just tell me what to do."

Decades ago the culture of medicine was considerably more paternalistic than it is now.  The doctor was omniscient, the patient was steeped in blissful ignorance, and the doctor could direct the patient's care with minimal discussion and negligible input.  The physician simply told the patient what surgery, drug or tonic was needed and the patient quietly acquiesced.

By the time I got to medical school a great transition had taken place.  The era of patient empowerment had arrived, necessitating a new partnership between patient and caregiver.  We were taught to avoid paternalism and to conduct our affairs with maximal transparency.  Explain the risks and benefits, define the alternatives, be open to unconventional therapies, and above all don't simply tell the patient what to do.

Paternalism is still a four-letter word in the medical lexicon (well, maybe an 11-letter four-letter word) and if you search the internet for this term you will quickly find a dozen recently written discourses condemning this attitude.  In keeping with this general trend I also advocate patient education and personal autonomy over blind obedience to medical authority.  I'd prefer to have a patient who refuses my care or asks for a second opinion than one who submits to my proposed plan but secretly harbors unspoken concern.  I will always encourage my patients to research their illness, bringing to me any doubts or uncertainties, and to talk with friends and family—especially those with an unfavorable previous experience in the world of heart treatments—prior to submitting to the procedures I perform.  I want to be able to address all concerns head-on rather than have the patient suffer with doubts about their care.

Still, despite our living in an age where a nearly infinite amount of information is at the literal tips of our fingers I frequently encounter patients who don't want education, options or choices—they just want me to tell them what to do.

So, how do I handle it?  “Doctor, just tell me what to do,” or, even more loaded: "Doctor, if I were your mother, what would you tell me to do?"

When I first entered practice I went out of my way to stay out of this minefield by dissembling and deflecting.  Without consciously planning my evolution in this regard, however, I've found that over my 18 years as a doctor I have slowly transitioned to a position where I now freely offer such advice when the situation warrants it.  I continue to place a paramount emphasis on patient education (even for those patients whose eyes glaze over during my discussion) but when asked I have no compunction with a forthright reply: "You have a lot of options here, but I can tell you what I'd do in your situation . . ."

For me to handle all patient interactions like this would clearly be wrong.  But for many patients, hearing all the different ways to handle a complex problem is a bit like me sitting with my investments analyst discussing derivatives, IRAs and dollar cost averaging.  Most patients are very comfortable navigating the complexities of modern medical care but there remain many who aren’t.  The real trick for someone in my position is to determine which patients hehfall into the group who want to close their eyes and be told when to show up for surgery.  (Interestingly, in my view, the division between the autonomous patients and those who want a more directed approach has nothing to do with intelligence or education.  I've even had other doctors come to me as patients who, despite their knowledge of medicine, just want me to skip the broad list of options and launch into therapy.)

I've previously written on what I consider is the "art of medicine" and I think this topic falls solidly into the realm of art.  As I get to know my patients I'm also assessing them for their degree of comfort with autonomy.  In a perfect world the patient and the doctor would be equal partners in the patient's health care—each providing input, experience, and feedback in order to divine a course of care that both parties feel comfortable with.  In many cases, however, patients are simply overwhelmed by all the choices and like me—glazed eyes and all—just want to be pointed in the right direction.

I’ve come to the point now where I don’t think that’s such a bad thing.

Eric Van De Graaff, MD
Eric Van De Graaff, MD

Eric Van De Graaff, MD is a Heart & Vascular Specialist at CHI Health Clinic.

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