Redefining The Doctor Patient Relationship
I recently had the chance to read Atul Gawande’s fourth book, ‘Being Mortal’. It’s a fantastic piece that explores the process of aging and dying and how it’s been distorted by modern medicine. It offers profound insight into what many people’s final months and hours really look like and asks us: “Can we do better?”
The answer (as one might guess) is a resounding yes and I truly think it should become mandatory reading for everyone in healthcare.
Today I wanted to explore one of the topics that Gawande brings up the book regarding the ideal model of the doctor/patient relationship. How should doctors and patients interact? What should be the nature of their relationship?
The Paternalistic Model
The most traditional model is that of paternalism. This model casts the physician as the all-knowing medical authority who simply informs the patient of what’s to be done, much like a parent speaking to a young child.
You have high blood pressure? Take these pills. Why? Because I said so. You have a mass in your kidney? We’re cutting it out first thing next week.
This way of thinking isn’t malicious, it simply assumes that the physician knows best and as such must act as the patient’s guardian. Patient compliance and complete trust in their physician is assumed.
Understandably, this is a model that is now considered archaic and only acceptable in extreme emergencies where there’s no time for discussion. This is because it neglects one of the most important components of the doctor-patient relationship: the patient.
The Informative Model
The next evolution of the doctor-patient relationship is the informative model. In this model, the physician almost acts like a waiter or an encyclopedia. The patient is informed of all of his or her options, the relevant risks and benefits, and is then asked to make a decision.
This model arose as an alternative to paternalism. Instead of physicians making decisions on the behalf of their patients, all choices are instead left up to the patient. As a physician, this has a certain attraction because it seemingly absolves the provider of liability. If a patient has a less-than-stellar outcome then it’s on him because he chose that, right?
But this model is also deficient. Many of these interactions are held within the confines of a 30-minute clinic appointment (or less). How can we reasonably expect someone who may not know anything about human physiology to make complex medical decisions in that kind of environment? I may be able to list off the relative risks and benefits of a certain medication or surgery, but how does those relate to the values and goals of my patient?
The Interpretive/Deliberative Model
This leads us to the final model of the doctor-patient relationship – the interpretative or deliberative model. First described in a 1992 paper published in JAMA by medical ethicists Linda and Ezekiel Emanuel, this a purposeful relationship that looks very different than the above two.
In this model, the physician strives to understand the patient along with their goals and values. He then explains their treatment options through this lens. This goes beyond the intellectual model where risks and benefits are read off as if from a menu. Instead, the physician tries to guide the patient towards a treatment choice that best resonates with their underlying goals and values.
Here’s an (albeit simple) example: when discussing low testosterone, men may have similar hormone profiles but very different priorities. If a patient is particularly wary of needles, I might suggest he’d do better with a daily gel. But if cost is an issue, I might recommend weekly testosterone injections. Both effectively treat the underlying disease process, but do so while respecting different priorities. The same is true for other conditions, whether it’s debating surgery versus medication for an enlarged prostate or trying to decide between radiation or surgery for prostate cancer.
What can I do as a patient?
If you’re a healthcare provider, I think the answer is pretty clear – we should all strive to better understand our patients and guide them towards treatment choices that respect their goals and values. But how does one prompt this sort of approach as a patient?
As a patient, I think one of the best things you can do is explain to your doctor what is most important to you. If you fear complications you witnessed a family member go through, tell him. If you want the most effective treatment above all else, tell him that as well. Then ask what treatment will best reflect those goals.
This is an easy way to prompt your physician to guide you towards a treatment plan that’s the best fit for you.
If you’re a healthcare provider, how would you describe your approach when interacting with patients? If you’re a patient, how would you describe your interactions doctors in the past? Let me know in the comments below or reach out on social media using the links at the bottom of the page!