A colleague on patient centered decision making

One of my colleagues has commented beautfully on a rant from last Thurday. I am quoting his long commentary to highlight his important contribution.

I loved this article. I strongly value a “patient centered” philosophy of health care. I thought it helpful to read a summary of how physicians and patients estimate and comprehend risk differently.

As a physician, I find it most helpful to think of “patient centered care” as a situation where I try to align my professional actions (toward health, the only area where I am credentialed professionally) with the patient’s values and life context. Discovering which specific patient values and which elements of their context have the most bearing on a particular decision tends to require a lot of open-ended questions. This may be where the “art” of medicine lies.

I confess, however, that there remains considerable challenge in responding to situations where physician and patient have clearly established with each other that they comprehend and value things in very different ways. We may achieve mutual understanding, but ultimately see things very differently. A problem may turn less on ignorance of each others’ values, and more on raw disagreement as to what actions or decisions really are in the service of health.

For example, a patient with a modest but troublingly chronic pain problem, a significant anxiety problem, and a recent history of active substance abuse (perhaps quiescent for a month or a week, perhaps not) may request a prescription for opiate pain medicine (a narcotic) on a long-term continuing basis. As physician, I have been in this situation countless times.

From the patient’s viewpoint at the moment of their encounter with me, the patient-centric valued outcome could be a prescription that many physicians may not wish to write. In some jurisdictions, incidentally, that prescription (depending on the care context in which it is written) could leave its writer susceptible to legal prosecution!

For some physicians, I suspect the instinct not to honor this request may not be particularly well thought out. If I try to put words on some otherwise-inchoate negative reactions I have felt, for instance, I might say “I don’t want to be scammed,” or “I could be feeding an addiction,” or “I don’t like being used.”

All of these notions might hold some grain of valuable truth, maybe. If I hold out such thoughts as justification for any decision I make on behalf of the patient, however, then I could be charged with some sloppy deliberation on the question of what it means to care for patients.

As a justification for how one responds to a patient, fear of “being used” could prove difficult to reconcile with a notion of patient-centered care, ie a notion that care should be aligned with the values held by the patient, and where the clinician’s value ultimately lies in service to the patient. We should strive to be “of use” to patients in the context of their lives, should we not? Most clinicians, I submit, would like to say that they are “of service” but would hate to go home feeling “used.”

My hunch is that the difference between those two states has a lot more to do with how clinicians value the feeling of control and power in relation to patients, and perhaps less to do with deliberations over the patient’s health.

I would like to suggest that the example articulates a larger dilemma that we face in assuring that care is patient-centered. Separate from whether or not one personally stresses over “feeling used,” the hypothetical example may amount to a situation where a clinician is torn between 2 conflicting judgments regarding health. One understanding: a professionally formed judgment of what might seem an undesirable health state (perhaps an addicted state?). The other: the patient’s valid understanding of what health state he or she desires (free from pain, and perhaps free from worry?).

I find it hard not to conclude that there are instances where a professionally-formed and valued notion of “health” could wind up in conflict with an individual patient’s notion of what would be, from his or her perspective, “health.” I submit that a conscientious clinician should feel a measure of anxiety when their understanding of health, for a particular patient, falls into conflict with the understanding of health held by that patient.

Clear and detailed exploration of the patient’s life and understandings should minimize the number of situations where such conflicts appear. Where they do happen, however, a clinician should be able to provide a rational account of what specific values seemed to be in conflict, how they chose a course of action, and what measures they took to continue to care for the patient.

Beautifully stated and well worth reading carefully.