|REVIEW ARTICLES ON CONTROVERSIES IN MEDICINE
|Year : 2021 | Volume
| Issue : 2 | Page : 163-165
Physicians are not the patient's parents!
Sunil K Pandya
Jaslok Hospital and Research Centre, Dr. G. V. Deshmukh Marg, Mumbai, Maharashtra, India
|Date of Submission||25-May-2021|
|Date of Acceptance||01-Jun-2021|
|Date of Web Publication||30-Aug-2021|
Prof. Sunil K Pandya
Shanti Kuteer, 215 Netaji Subhas Road, Mumbai - 400 020, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Pandya SK. Physicians are not the patient's parents!. J Med Evid 2021;2:163-5
| Introduction|| |
The dictionary defines paternalism as 'the policy or practice on the part of people in authority of restricting the freedom and responsibilities of those subordinate to or otherwise dependent on them in their supposed interest'. The word is derived from Latin: paternus-fatherly, from pater-father.
Historically, physicians have assumed ignorance in their patients and their families on medical matters. (Surgeons are physicians who operate upon patients.) This was justified when physicians were the only learned members of society and where others did not have the opportunity to educate themselves. This was certainly true in the days of barber-surgeons, where these lowly members of the medical community were, themselves, looked down upon by literate and learned physicians.
It was also believed that information on likely complications would scare patients and their families out of their wits and result in their disappearance from the clinic. It was, thus, in the patient's interest for the physician to remain silent on unpleasant and unwelcome aspects of tests and therapy.
Physicians evolved a practice whereby the bare minimum of information was passed on to the patient whilst emphasising their own position of authority. The patient was expected to and did obey dictats without query. Where needed, deception was used – usually with the intent of benefiting the patient.
Times have changed and in the 21st century, with the widespread availability of education, newspapers, journals, books and the now, ubiquitous television channels, Internet and the WorldWideWeb, everyone has ample opportunities for obtaining and assessing information on any chosen subject.
As patients and their families become increasingly knowledgeable on medical matters, edicts from physicians often lose their influence.
Whilst accepting that paternalism usually has, as its motive, the welfare of the patient, we need to review paternalistic attitudes of physicians and at the very least, modify them.
| Circumstances in Our Country|| |
Parents consider themselves more knowledgeable and experienced than their offspring in all aspects of life. They assume the roles of guides and disciplinarians.
Physicians err in equating themselves with parents. Patients come in a variety of shapes, sizes and vintages. At times, the patient may be a learned professor, widely travelled and universally respected, far senior to the physician. Even when the patient is a child, the parents of the child may be more than competent to make decisions on behalf of the child. The parents have the added qualification of deep affection for their offspring.
The illiteracy and poverty of a segment of our population are often used as an argument to justify paternalism. The fact is that such individuals are often more intelligent that their well-to-do and college-educated compatriots. The struggle to survive and make ends meet is a strong stimulus for the development of ingenuity. The poor and illiterate often read faces and body language far more efficiently than do the rest of us. Their senses are especially sharp when matters of life and death are involved. It is true that grinding poverty and the arrogance of landlords, zamindars and others in power may render them subservient. This may result in the scenario where the mai-baap and sarkar are invoked for help.
| The Crux of the Patient–doctor Relationship|| |
The patient seeks the help of a physician for relief of symptoms and where possible, cure. When the physician undertakes to attempt to provide this, there is an unwritten contract. Over time, the rules of this contract have been codified into the principles of medical ethics.
Of special relevance here is the principle of autonomy of the patient. Patients have the power and the right to make decisions and moral choices on all matters concerning themselves. Self-determination, then, is paramount. Physicians can explain, advise and recommend, but the final judgment on the performance of any test or any form of treatment will be made by the patient. Whilst the physician may find a particular decision by a patient irrational, his role remains that of an advisor. The example of the patient needing an emergency operation to prevent rupture of an inflamed vermiform appendix is a case in point. When, after explanations have been provided, the patient refuses the offer to operate upon him, it is incumbent on the treating physician to abide by his decision.
The exception to this principle is legal incompetence on the part of the patient to decide – from immaturity (as in infants and children), severe mental illness or coma. In such events, one of two scenarios will play out.
Where there is a legally competent relative available, the autonomy to decide will rest with him.
Where there be no competent relative, the physician must decide, especially in an emergency, commonly after consulting one or more colleagues or the head of the institution in which the patient is being treated.
In both the instances, clinical features and the rationale for the form of treatment chosen must be described in detail on paper and signed by a legally competent relative or physician, colleagues and/or head of the institute.
| The Attitude of the Physician towards the Patient|| |
If we have learnt the lessons taught by example by the great teachers and masters of yore, ranging from Çharaka, Susruta and Hippocrates through Boerhaave, Sydenham, Pierre-Alexandre Louis, Charles Morehead and Osler down to our own esteemed teachers, we will have imbibed the basic tenet of respect for our patients. This coupled with our fundamental duties of caring for them and making every attempt at restoring health at the least cost will automatically inspire us to form a fellowship with patients and their families. This fellowship can prove invaluable when events take an unwelcome turn and despite all our efforts, the patient's condition deteriorates.
Conscious of the fact that we have years of education that have put us in possession of knowledge and experience on matters pertaining to health and disease, we shall see transmission of relevant facts and suggestions as our natural obligations to those entrusting themselves to our care.
Our expertise does not place us on a pedestal. Whilst remaining equal to our patients – even the humblest of them – we must remain aware of our possession of vital information that may help them and consider it our obligation to deploy it for their benefit.
As with other human interactions, such benefits must remain heedful of the minds and hearts of those we seek to help. Any step that diminishes them by demoralisation or the induction of a sense of subservience to ourselves is unwelcome and must be avoided.
We must also not lose sight of the fact that when we withhold facts and probabilities from the patient – even when this is done with noble motives – we are swerving from the requirement of telling the truth, the whole truth and nothing but the truth.
| How then do we Bridge the Chasm in Expertise that Separates Patient from Physician?|| |
Osler's reed of humility is of crucial help here. Talking as an equal to the patient and family is, in itself, a major step. Thoughtfulness and empathy are excellent guides on how we should conduct dialogue and discussion.
We need to ensure that we are honest and with an open mind, listening to the patient. In addition to employing the auditory apparatus, we need to use the tools employed by Sherlock Holmes – 'the observation of trifles', understanding body language, picking up unspoken messages and the use of open and closed (direct) questions.
Explanation of facts and suggestions in simple language, free of jargon enables your audience to understand vital information.
It is important to realise that factors such as education, self-confidence (or its lack) and the anxiety that accompanied them to your clinic influence their comprehension. Laws et al. found that patient recall of recommendations and specific decisions regarding treatment was relatively poor in people with little formal education. The recall was also influenced by the number of items to be considered. They suggested that physicians assess the patient's ability to remember.
The patient must be encouraged to participate in the discussion. Limit the amount of information to be remembered in a single visit. Where possible, provide written or computer-printed summaries of the discussion and suggestions which can be studied after the patient returns home.
It may be necessary to repeat your statements, at times on subsequent interviews. This is especially so when unwelcome news such as the need for intervention, surgery or an unfavourable prognosis has to be imparted.
Evidence of your concern and empathy will go a long way in providing your patients much-needed reassurance. There is a palpable release of tension, straightening of slumped shoulders and the return of a smile to troubled faces when you reassure them that the findings show nothing ominous and that the symptoms can be effectively treated.
Lake found two additional methods of great help in reducing the patient's anxieties. Asking the patient, 'How does your illness make you feel?' often elicits a release of hidden feelings. So does telling them, 'I know something about what you're going through because I've been through it too'.
It is imperative that we convey the truth to the patient and family at all times. Whilst measures to soften the blow are often necessary, it would be wrong to mask unwelcome facts in such a manner that they cannot be understood or, worse, be misunderstood.
Undoubtedly, time and energy – often in short supply – are needed, but the humane physician will not grudge these in the care of his patient.
There are times, especially when dealing with querulous individuals, where the physician must call upon his reserves of patience. As he uses his skills in the art of medicine, the good physician can be distinguished from the merely mediocre individual.
Questions will arise in the minds of the patient and family members, at times after they have returned home from your clinic or on the eve of the surgery. It would be folly to dismiss them, especially with such statements as: 'Why are you asking me these questions?' 'I know what I am doing'. 'Do not waste my time. Just do what I tell you to do'.
An important component of autonomy granted to the patient is that of consent. Written consent of the patient is mandatory before undertaking any test or treatment that carries the potential of harming the patient despite all possible care by the physician and institute.
In the early 20th century, this was all that was required.
By 1950, patients had started asking for details, especially when surgery was proposed. Progressively, American courts made it mandatory for physicians to inform patients of risks during and after surgery and obtaining specific authorisation for the operation without which the surgeon was liable for legal action. 'A man is the master of his own body and he may expressively prohibit the performance of life-saving surgery or other treatment'.
Simple 'consent' had, thus, given way to 'informed consent'. Over time, especially in countries like ours, it was noted that printed forms were placed before the patient for their thumbprints, the information on the form regarding the need for surgery not being referred to at all. Paternalism, displayed by resident doctors and at times nurses deputed for obtaining consent, rendered any explanation or translation of text unnecessary.
This led to the next step in the evolution of consent – 'truly informed consent' – where the thumbprint or signature was only to be placed after the pros and cons of the operation and the text on the form had been explained to the patient. Observers in public hospitals have found young doctors and nurses flouting this requirement and have demanded that informed consent be obtained only after independent verification that the patient has understood facts and probabilities. In countries such as ours with rampant crippling poverty, it has also been suggested that where major surgery (on the heart or brain, for example) is planned, a second consent be obtained 24 hours after the first to ensure that the patient has been given time to reflect on details of the operation.
| Unusual Circumstances|| |
There are times when the relative benefits from two differing operations are uncertain or debatable.
An example is a patient with coronary artery disease who is provided the options of angioplasty and bypass grafting. Another example is that of highly toxic chemotherapy for a patient with widespread malignant cancer.
Under such circumstances, after explanations have been offered by the therapeutic team, the patient is seen to remain confused, unsure of the option to be selected.
One way of helping the patient is to answer his query: 'Doctor, if you were in my position, what would you choose?' Obviously, the answer must be honest, sincere and take into consideration the circumstances (social, financial, medical…) of this particular patient. It goes without saying that motives such as personal gain from implementation of the decision should have no place in making the recommendation. This is NOT paternalism. It is behaviour in accordance with the Golden Rule.
| Welcome Consequences of the Physician's Ethical Behaviour|| |
I commend the first-person account by provided by Fiellin – a physician dealing with advanced cancer in her mother. '…The gift of her making her own decision…' sustained the entire family after the patient had passed away.
Staying true to the best interests of your patient will reinforce the hope and trust generated by his feeling that his physician sincerely cares for him and will do everything possible to help.
As further evidence of your zeal becomes evident in the course of treatment, the bond between patient and physician is strengthened.
Under such circumstances, even if events do not turn out favourably for the patient on account of the nature of the illness, you may find the patient and family consoling you by saying, 'Doctor, we are grateful to you for doing your best for us. No one could have done anything more'.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Osler W. Teacher and Student. Aequanimitas: With Other Addresses to Medical Students, Nurses and Practitioners of Medicine. 3rd
ed. Philadelphia: The Blakiston Company; 1932.
Reed J. A medical perspective on the adventures of Sherlock Holmes. Med Humanit 2001;27:76-81.
Laws MB, Lee Y, Taubin T, Rogers WH, Wilson IB. Factors associated with patient recall of key information in ambulatory specialty care visits: Results of an innovative methodology. PLoS One 2018;13:e0191940.
Lake D. Improve Doctor-Patient Relationship with this One Question. Medscape; 2021.
Murray PM. The history of informed consent. Iowa Orthopaedic J 1990;10:104-9.
Fiellin LE. Letting her be in charge. JAMA 2018;320:1241-2.