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Why Doctors Hate Science

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She/he could even have given you a choice between a couple of different drugs. But pretending that in the course of five minutes you have been given enough information to make a truly informed decision is only an illusion.

For more complicated conditions doesn't the illusion of an informed decision apply equally to the physician? I.e. a physician has to appear to be informed about what is the best course of action, yet if you asked 3 different physicians what the best course of action was you would likely get three different answers.

The reality seems to matter very little. What seems to matter is the illusion of having the desired degree of information and/or autonomy.

Linda

That depends on how much time is available to research and consider the alternatives.
 
Which patients do you prefer dealing with: those who want you to decide, or those who use you as a source of reliable information?

It depends on my mood...lol, j/k!

If I am in a hurry sometimes, it is easier to deal with patients who take what you say as gospel, but actually this is not my preferred practice.

I actually like patients that use the internet, but then come to me to discuss their problem, and what their research has said.

TAM:)
 
The "best course of action" in the patient's opinion may be different to her physician's. Many treatments are not cures and a trade-off between suppression of symptoms and unpleasant side-effects has to be made.

E.g., a terminal cancer patient can extend her life with chemotherapy, but the quality of the extended lifespan may be lower.

In general the only person who can decide what trade-off is best is the patient.

But can we really consider that patient adequately informed about what that trade-off will be, what that experience will be like, by spending 5 minutes listing off side-effects? There is a strong public perception of 'chemotherapy' that tends to inform people's decision-making beyond what is warranted. What makes it okay for a doctor to abdicate their responsibility to a patient by not taking into account that their (the doctor's) experience about chemotherapy is far better informed than the patient's? Should we simply ignore what we have learned about the biases that are brought into decision-making by pretending that "informed consent" gives us plausible deniability?

Linda
 
For more complicated conditions doesn't the illusion of an informed decision apply equally to the physician? I.e. a physician has to appear to be informed about what is the best course of action, yet if you asked 3 different physicians what the best course of action was you would likely get three different answers.

So what's the difference between these two scenarios...

"Here are three roughly equivalent courses of action. Pick one."

"Here are three roughly equivalent courses of action. This is the one I've picked."

Linda
 
That makes sense. Which do you prefer?
Neither.
Ignorant patients who decide to dump all the decision on you are not easy to deal with and overly educated/involved patients who second guess everything you recommend are just as annoying. I prefer someone who can make an informed decision and yet will actually listen.
 
But can we really consider that patient adequately informed about what that trade-off will be, what that experience will be like, by spending 5 minutes listing off side-effects?

No.

There is a strong public perception of 'chemotherapy' that tends to inform people's decision-making beyond what is warranted. What makes it okay for a doctor to abdicate their responsibility to a patient by not taking into account that their (the doctor's) experience about chemotherapy is far better informed than the patient's?

Nothing. The doctor should give the patient a realistic estimate of what the treatment(s) on offer will achieve, including no treatment.

Should we simply ignore what we have learned about the biases that are brought into decision-making by pretending that "informed consent" gives us plausible deniability?

Linda

No. A patient should be given reliable information. This is probably best done in the format of a conversation so the doctor can provide relevant information based on the patient's concerns and at an appropriate pace to allow the patient to make an informed decision.
 
Neither.
Ignorant patients who decide to dump all the decision on you are not easy to deal with and overly educated/involved patients who second guess everything you recommend are just as annoying. I prefer someone who can make an informed decision and yet will actually listen.

So a patient who came along with his home-made holster ECG and pulse oximeter would probably be your worst nightmare?:o
 
So a patient who came along with his home-made holster ECG and pulse oximeter would probably be your worst nightmare?:o
Nah. A well educated computer programmer who Googled his kid's fever on the net and adamantly believes it is a meningitis despite your best explanation that it is nothing more than the common bug AND then demanding that you call the chairman of pediatrics is. I prefer the drug seeking, drunks any day.
 
So what's the difference between these two scenarios...

"Here are three roughly equivalent courses of action. Pick one."

"Here are three roughly equivalent courses of action. This is the one I've picked."

Linda

If the doctor knows everything that is relevant for the patient when making her choice of treatment, then they are both equivalent. If the doctor is filling in for missing information with her own preferences and beliefs, then the first one has the potential to result in superior treatment.
 
If the doctor knows everything that is relevant for the patient when making her choice of treatment, then they are both equivalent. If the doctor is filling in for missing information with her own preferences and beliefs, then the first one has the potential to result in superior treatment.

Actually, the best scenario (IMO) is that the doctor says:

Here are the three possible treatments for this condition, and the pros and cons of each. You are free to choose any of the treatments, but this is the treatment I would choose, if it were me or my family member (fill in blanks with reasons why).

This approach preserves the patient's autonomy, but still gives the patient the benefit of the physician's experience and training. I believe that this is the approach that most physicians use nowadays.
 
No. A patient should be given reliable information. This is probably best done in the format of a conversation so the doctor can provide relevant information based on the patient's concerns and at an appropriate pace to allow the patient to make an informed decision.

Ah, while 5 minutes is inadequate, a 10 minute listing of the side-effects is an adequate substitute for 10 years of training and experience.

Linda
 
<snip> We took our complaints to the department of health - the work we were performing was far in excess of those who were paid the same amount and there were serious and unsustainable staff shortages due to inequalities in renumeration - but they wouldn't even come to the table and talk to us since, as far as they could tell, the services paid for were commensurate with what was needed. So we simply informed them that if what they were paying for was adequate, we were going to simply stop performing those services they had deemed unnecessary by virtue of making them not worthy of renumeration. This meant that we would no longer free up hospital beds by managing certain patients as outpatients (which required visits in excess of the once per week we could charge for), we no longer transferred patients from surgical wards to medical wards if their care became complicated (as renumeration was based on length on time in hospital regardless of whether the length was due to complications vs. babysitting for rehab or nursing home placement), we no longer accepted patients for admission who had already been seen by a specialist (the attending physician would not receive any renumeration for their complete history/physical/evaluation), etc.
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[irritating pedant mode] Sorry to nitpick, but it's remuneration. [/ipm]
 
Ah, while 5 minutes is inadequate, a 10 minute listing of the side-effects is an adequate substitute for 10 years of training and experience.

Linda

No, the problem is how to integrate the two sources of information (i.e. the patient's concerns and preferences and the doctor's knowledge and experience) to come to the optimal decision for the patient.

Unless among the many skills doctors learn during their 10 years of training includes mind reading, I see no way of reliably reaching good decisions without substantial input from the patient.

Please note I'm still only considering long-term chronic and terminal conditions, not those treated with "take this and come back and see me in a week if the rash hasn't cleared up.", or emergency situations where there is no time to debate the pros and cons of various treatment options.
 
Neither.
Ignorant patients who decide to dump all the decision on you are not easy to deal with and overly educated/involved patients who second guess everything you recommend are just as annoying. I prefer someone who can make an informed decision and yet will actually listen.

But according to Linda, they are not making an informed decision, they just *think* they are.
 
But can we really consider that patient adequately informed about what that trade-off will be, what that experience will be like, by spending 5 minutes listing off side-effects? There is a strong public perception of 'chemotherapy' that tends to inform people's decision-making beyond what is warranted. What makes it okay for a doctor to abdicate their responsibility to a patient by not taking into account that their (the doctor's) experience about chemotherapy is far better informed than the patient's? Should we simply ignore what we have learned about the biases that are brought into decision-making by pretending that "informed consent" gives us plausible deniability?

Linda

Nobody is saying that the doctor should not give their informed experience as input - they should just not expect that the things they think are important and relevant are necessarily so to that patient. Just as the patient can't gain a doctor's level of experience in five minutes, so a doctor cannot understand a patient's priorities in 5 minutes. that's why there has to be a conversation and an understanding reached.
 
[irritating pedant mode] Sorry to nitpick, but it's remuneration. [/ipm]

Yeah, I have a couple of words that I always say backwards (another e.g. is signal which I say as "single"). I suppose I should use spell-check.

Linda
 
No, the problem is how to integrate the two sources of information (i.e. the patient's concerns and preferences and the doctor's knowledge and experience) to come to the optimal decision for the patient.

Unless among the many skills doctors learn during their 10 years of training includes mind reading, I see no way of reliably reaching good decisions without substantial input from the patient.

I'm talking about taking patients concerns and preferences into account (by discussion, not by mind-reading).

Linda
 
Nobody is saying that the doctor should not give their informed experience as input - they should just not expect that the things they think are important and relevant are necessarily so to that patient.

Who is saying otherwise?

Just as the patient can't gain a doctor's level of experience in five minutes, so a doctor cannot understand a patient's priorities in 5 minutes. that's why there has to be a conversation and an understanding reached.

What sort of priorities are you talking about that are too complicated for another person to understand?

Linda
 
Maybe I am just relying on my own experience a little too much here, but I HAVE experienced doctors who have basically ignored my experiences and priorities and just gone on and prescribed what they wanted to prescribe. Thats the attitude I don't like and what I am thinking of when I think of paternalism.
 

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