Paternalistic Medicine

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To my surprise I've a string of patients lately who've simply said, "You tell me, you're the doctor with the training, what should I do?" These are not the cultural groups we are taught and known to have a preference for this. It then takes extra time to review that my job isn't to tell folks what to do - most of the time - but to line up their options so they can pick for themselves.

The latest thought I've had, is how much contribution has the flip from paternalistic model of decades ago to maitre d' of therapeutic options has had on the emergence of customer/press ganey scores/admin controlled/technician model healthcare? Has the switch from paternalistic medicine been a good one? What have the negatives been? Should we revert back? Was this change part of the early demise of Physician? An observation in other countries that still respect and expect paternalistic medicine there are no mid-levels, there are no admins run amok, etc

As a student I was able to see a single FM practice where the doctor practiced paternalistic medicine with his medicaid heavy practice, and this doctor had no better outcomes. The patients just felt more empowered to tell the doctor off - "hell, no! I'm not quitting smoking and I don't want to lose weight!" These patients loved this doctor despite their often confrontational encounters.

 

[splik]

Franz Inglefinger, who was editor in chief of NEJM in the 1970s said (he was dying of cancer at the time and found physicians who deferred to him utterly unhelpful): "A physician who merely spreads an array of vendibles in front of the patient and then says, "Go ahead and choose, it's your life," is guilty of shirking his duty, if not of malpractice. The physician, to be sure, should list the alternatives and describe their pros and cons but then, instead of asking the patient to make the choice, the physician should recommend a specific course of action. He must take the responsibility, not shift it onto the shoulders of the patient. The patient may then refuse the recommendation, which is perfectly acceptable, but the physician who would not use his training and experience to recommend the specific action to a patient — or in some cases frankly admit "I don't know" — does not warrant the somewhat tarnished but still distinguished title of doctor."

There is a false binary between paternalism and patient-as-customer. The shared decision-making model is the right way for the most part. Some patients may wish for us to take more of a leading role in decision making which is fine if they are not abdicating personal responsibility. I think some physicians demur from making decisions for their patients in the mistaken belief that they will have less liability if the patient is the one making the decision.

In psychotherapy it is a little different in that patients usually don't want us to tell them what to do no matter how much they may insist otherwise. But certainly when it comes to recommending meds etc I think it is our job to tell patients what we recommend. Similarly, it is our job to counsel patients that cannabis is not helping their condition even if they choose to continue smoking.

 

[Liquid8]

I think the trick is working out quickly where our patients fall along the decision making spectrum and adjusting our approach accordingly. In an ideal consult we will outline the pros and cons of various treatment options and allow our patients to make an informed choice, but have to recognise we may have to be more directive and paternalistic if there’s resistance to this. At an initial consultation if they really can’t make a decision, I will usually give them some information sheets, encourage them to discuss it further with family and come back another day. Often they’ll call back in a few weeks having been able to consider things and make a decision under less pressure.

Every so often I get referred patients who have been started on an antidepressant – then I find out that their family doctor gave them a script for it, but they weren’t sure and wanted to wait to be seen by a psychiatrist before commencing it. Unless the drug of choice is very left field or wildly inappropriate I will usually agree which gives the patient confidence to start - in those cases it never crosses my mind to tell the patient that they have to make up their own mind.

Sometimes I do wonder if the pendulum has swung too far in terms of patient autonomy. Have one patient who told me that their last psychiatrist would tell them to, “Look up a few mood stabilisers or antipsychotics and tell me which one you want to try.” Another reported their previous doctor gave then a bunch of scripts to try out - it was obvious that neither felt comfortable with those approaches, and personally I’d probably feel the same way when we take into account that there’s an overwhelming amount of information (and disinformation) available online, and people are paying for the services of an expert.

 

[Ceke2002]

I personally think a more middle ground approach, with a willingness to compromise and adapt to specific patient circumstances (from both sides) is the better way to go.

I grew up in a family that instilled in me a very rigid idea of the 'paternalistic' nature of a Doctor. I probably spent more time being continuously lectured on things like maintaining a proper manner & required levels of deference when speaking to a Doctor than I ever did in an actual Doctor's surgery. And thus I grew up with little to no ability to advocate for my own healthcare needs, and an almost zero ability to question or say no to any treatments offered or given, even when I didn't think the treatments were appropriate or helpful. So a rigidly held paternalistic view of medicine was completely unhelpful to me, but then me swinging too far in the opposite direction, and being allowed too much freedom to 'dictate' what I wanted (or thought I wanted/needed), or start ordering off a menu, so to speak, was also incredibly unhelpful, because in my 20s especially I wasn't always capable of making good decisions for myself in certain regards.

It took me a long time, and at least some of my time in long term therapy, to really get to a point where I was able to finally advocate for my health in a way that was healthy, and to have a more balanced, and ultimately more beneficial approach to the Doctor/patient relationship.

Extremes of approach on either side of the equation very seldom ended with the best possible healthcare outcome, in my experience at least.

 

[Merovinge]

Actually had a similar experience having recently had a child. The Ob/Gyn was detailing some options and then just sort of said "You decide". Despite my wife and I both being physicians, neither of us are Ob/Gyn or even adjacent to the field, we both felt like "isn't this the reason you practice Ob/Gyn everyday". Not easy to look up risks/benefits of things in all situations either that need an acute answer.

I'm consciously working to calibrate myself better in the above regard, laying out the options, detailing where the science is at was my go-to from training. Now I feel like even if things are equivocal from the science (often the case in our field), I will then just let people know what I would do after detailing the above. I think most patients/families do prefer this, I certainly know I do as the patient.

 

[Stagg737]

Interesting topic that I've actually thought about a lot. Some thoughts on the below questions. Keep in mind these are just my opinions/observations.

The latest thought I've had, is how much contribution has the flip from paternalistic model of decades ago to maitre d' of therapeutic options has had on the emergence of customer/press ganey scores/admin controlled/technician model healthcare? Has the switch from paternalistic medicine been a good one? What have the negatives been? Should we revert back? Was this change part of the early demise of Physician? An observation in other countries that still respect and expect paternalistic medicine there are no mid-levels, there are no admins run amok, etc

I'd guess the emergence of the "team" approach to medicine where patients and physicians work together played a huge role in the customer/PG/admin controlled model you describe. I think that largely comes from moving to a team approach in a capitalistic society, though there are similar measures in the VA system so maybe it's inevitable.

I think the switch from rigid paternalism is a good one. Educating the patients on their treatment options and including their opinion and goals when making recommendations will result in better outcomes, especially in our field. While this may not have been mutually exclusive in the more paternalistic eras, the patients goals were more likely to be disregarded if not in line with the physician's goals as is still evident with more rigid paternal docs today. I don't think we should revert back, but we also should not let the pendulum swing too far the other way (which it already has in many ways).

Many negatives are obvious. Empowering patients too much can lead to sub-optimal or totally inadequate treatment and pseudoscientific therapies. Not that snake oil is a new phenomena, but I think we've all experienced the significant resistance or ignorance that patients display when talking about things they've done for their conditions. Dispelling myths and educating people on cannabis and Kratom are nearly daily discussions with my patients, and many of them are resistant even in the face of strong data much like the anti-vaxxer movement. I think this has also led to a greater shift in algorithmic medicine and administrators (especially insurance) dictating treatment. Step-wise care isn't always bad, but a depressed patient who's anorexic and sleeping 3-4 hours a night shouldn't need to fail 2 SSRIs and an SNRI before insurance will cover Mirtazapine.

Interesting observation on the mid-level aspect, but Idk if there's a related causation or just a correlation as both rise of mid-levels and decline of paternalistic medicine seem to be more results of a shift to administrative control.

Sometimes I do wonder if the pendulum has swung too far in terms of patient autonomy. Have one patient who told me that their last psychiatrist would tell them to, “Look up a few mood stabilisers or antipsychotics and tell me which one you want to try.” Another reported their previous doctor gave then a bunch of scripts to try out - it was obvious that neither felt comfortable with those approaches, and personally I’d probably feel the same way when we take into account that there’s an overwhelming amount of information (and disinformation) available online, and people are paying for the services of an expert.

Imo, this is not practicing medicine/psychiatry. We are meant to be experts in our field which means educating and providing recommendations. What you describe above is basically just acting as a vending machine, which I'd argue is lazy at best and possibly malpractice at worst.

 

[Stagg737]

Actually had a similar experience having recently had a child. The Ob/Gyn was detailing some options and then just sort of said "You decide". Despite my wife and I both being physicians, neither of us are Ob/Gyn or even adjacent to the field, we both felt like "isn't this the reason you practice Ob/Gyn everyday". Not easy to look up risks/benefits of things in all situations either that need an acute answer.

I'm consciously working to calibrate myself better in the above regard, laying out the options, detailing where the science is at was my go-to from training. Now I feel like even if things are equivocal from the science (often the case in our field), I will then just let people know what I would do after detailing the above. I think most patients/families do prefer this, I certainly know I do as the patient.

If outpatient year has done anything it's helped me understand my own approach more comfortably. I typically try and lay out treatment options for patients and then tell them what I'd recommend and in what order. Sometimes they want to go with option B first, and most of the time it's fine. But it does enable me to provide them with a treatment path and assure them that if option A doesn't work we've still got other plans to turn to. Obviously this approach can't always work, but it has helped me win over a few patients who have either felt like meds were just thrown at them (the "I'm not going to be a guinea pig" patients) or those who just feel really nervous about treatment.

 

[clausewitz2]

Imo, this is not practicing medicine/psychiatry. We are meant to be experts in our field which means educating and providing recommendations. What you describe above is basically just acting as a vending machine, which I'd argue is lazy at best and possibly malpractice at worst.

The people who are practicing like this deserve to get replaced by mid-levels. Our value add is negligible.

 

[Ceke2002]

An observation in other countries that still respect and expect paternalistic medicine there are no mid-levels, there are no admins run amok, etc

I live in Australia. Yes medicine here in the 70s & early 80s was still paternalistic, I would argue that's not the case today. Having said that you might still see some aspects of paternalistic medicine being practiced and appreciated (eg people ultimately deferring to the Doctor's skill and judgement, after considering all courses of action offered to them); however, I think that's less to do with having a paternalistic attitude to medicine and more with the fact that many of us don't treat access to the Medical profession as if it's some sort of commodity that is simply responsible for the handing out of goods and services. My first response upon meeting a Doctor today is not going to be to literally curtsey to them, but that doesn't mean I don't trust and expect that they are the ones with the expertise, and that therefore, even working collaboratively, I shall expect them to advise and guide me towards the best decisions for my own medical health.

 

[comp1]

This is why I prefer inpatient psychiatry. If there's questions about paternalism, the court gets involved.

 

[hallowmann]

I've had no problem laying out options and offering what I recommend or frankly saying that two options are equally reasonable. If it seems like they are agonizing over the idea of choice, then I will often offer further nudge one direction or another.

There certainly are situations where one choice is clearly better, and I do believe that as physicians it's our responsibility to offer that to patients. That said, we should also be comfortable with the idea that if there really are 2 relatively equivalent options, saying that or as described above admitting "I don't know" or I can't necessarily predict what will happen I also perfectly valid. Most patients are comfortable with that. We are humans afterall, we are not omniscient, and I do not believe we lose our value or purpose in the physician-patient relationship by admitting such.

This is all inherent to our role. I think I see it blurred the most when taking care of "VIPs" or physicians, because for whatever reason we feel we should be less inclined to push such individuals in one way or the other. This unfortunately results in worse outcomes or more testing a lot of the time.

 

[Ludwig2000]

Show me someone that is fundamentally opposed to paternalism and I'll show you someone with daddy issues