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August 15, 2005
Patient Empowerment - Definitely not a Good Thing
The Sunday NY Times has a long article on the travails faced by patients in the US, in this modern world.
The article is a must-read for all patients and doctors. It traces the history of the current state of affairs, relating it to the movement for access to information that the baby-boomers demanded in all aspects of their lives, including medicine. As the unquestioning role of the doctor diminished and the patients started feeling empowered in making their own decisions, as the amount of ligitation increased along with the subsequent rise of defensive medicine, it led to a situation where the doctors stopped taking decisions for the patients, started putting choices in front of the patients and asked them to make the call.
That’s like asking a blind man to decide on the path to take at a crossroad, by asking him to read the signboards.
A few years ago, an article in the BMJ (I couldn’t find the link) expounded on this subject as well, saying that eventually the role of a doctor would be that of a travel agent. As patients became more empowered, they would themselves figure out their problems and their choices of treatment and the doctor would only help as a facilitator.
This is all so much bull-shit.
The majority of people do not know where their liver is, most can’t even pronounce the word “diagnosis” correctly and the majority of information comes from websites that are not peer-reviewed. The only real acceptable sources of information are through peer-reviewed journals, accessed through a portal like Pubmed, where in any case, without subscriptions, access to a lot of information is restricted. Moreover, even peer-reviewed information can be patchy, seemingly contradictory and often focusing on one tiny aspect of a part of the problem, which may not be apparent to the “lay” individual.
The situation is unfortunate. Though people love the concept of feeling empowered, when it comes to deciding between different lines of treatment, they just don’t have the training, the objectivity and the understanding to make a choice. Eventually the choices are often made on emotional reasons, or on the basis of past personal experience, or the advice of gurus and other well-meaning friends and family, all of which are flawed parameters to use. In India, the problem is further compounded by the plethora of alternative modalities available as well, virtually none of which, barring properly practiced ayurveda, have been proved scientifically to work.
One of the reasons the article gives for this situation to have developed, is the demise of the family physician and the bonding relationship between the GP and the patient, due to a variety of reasons, including litigation. I agree entirely. Even if the GP is not entirely up-to-date (and it is almost impossible to keep entirely updated all the time), the presence of that one person who can serve as a guide, who in difficult situations can help make a guided-choice, can make all the difference.
Many young couples and nuclear families are eschewing the GP even in Mumbai. They go directly to consultants, often by asking friends and family. Except probably for problems related to the eyes, when you could directly go to the ophthalmologists, even going directly to a pediatrician can be fraught with problems. Irrespective of the so-called GP-consultant-lab nexuses, etc, there are enough checks and balances in place. No GP can afford to go wrong with his patients, because he will then lose the confidence of his patients and their families, who may never come back to him. No GP today can afford to lose his paying patients and therefore will rarely take the chance of referring his patients to consultants and hospitals who will not be able to deliver the necessary results. GPs have access to a large formal and informal knowledge-base and can speed up the process of getting appointments, arranging tests, helping in defining the further course of treatment, checking out and treating minor complications and reactions, getting hospital admissions and making sure that the hospital also delivers appropriate care. More importantly, they can even accompany the patient during difficult procedures or consultant visits.
Exercising choices in medicine is not the same as with tourist destinations and car purchases. Even if the available information is inadequate, the worst that can happen is that the car may not be upto the mark or the holiday may be a bit inferior to the one expected. A bad choice in medicine may maim or kill.
In short, patients need to have more information, but they must develop the confidence and faith to let their treating doctors make the choices for them. Where a choice probably needs to be exercised, is in choosing the right GP.
Posted by bhavinj at August 15, 2005 07:19 AM
Comments
Even in Bombay, even amongst the "less educated", there is a feeling that doctors have become more mercenary and not totally trustworthy. Patients are now wellaware of the "cut" system and many "implicitly" distrust doctors. They still go to them, because they have no other alternative. Because this trust is lost, patients demand to know more and more of the whys and wherefores and hence this situation. I feel we have gone beyond a point of no return as far as the "confidence crisis" in doctors is concerened and it is only a question of time before we have a US like situation here - something we can ill afford.
Posted by: Ravi Ramakantan at August 15, 2005 10:15 AM
I have gotten into trouble because of DOctors both in India and the US, good doctors but greed got the better of them. I always rely on my family which has 4 doctors and I do get better treatment when the doctors realize that I am well informed. I am not saying that the patients should make all the decisions, but during this information age , I refuse to be taken for a ride because of ignorance.The doctors are already fabulously wealthy why do they still want to make money by putting patients in harm's way?
Posted by: Anon at August 17, 2005 04:45 AM
Its a strange argument that people who are making conscious choices in everything are unable to make a conscious choice when it comes to their most valuable possession. Patients are well aware of the possible downsides of bad choices in this regard and will go through their choices withe adequate care through whatever mechanism if they feel so inclined. If they feel real life experiences from friends and relatives are valuable - the more the better - so be it. Where's the beef?
Its rather galling to see doctors appoint or is it annoint themselves to a higher moral plane where different laws apply. It is - or certainly should be - a contractual relationship. You cure me I pay you. If you screw up I will sue you.
I trust our pediatrician almost implicitly - We know the practice for 10 years and they have earned our trust. But in today's mobile world that is likely to be more the exception than the rule. Where do people live in one place so long that such a trust will develop?
In addition I do not buy this premise of the GP knowing better than you on medical matters all the time - It depends on the GP , the ailment, the amount of reading you the patient may have done on the ailment, just too many things to make it impossible for such an axiom to work.
As far as market forces keeping the GP honest give me a break - it could be the relationship between the doc and the patient over years or simply the value system of the GP that compels him or her to do the best but market forces ? Come on!! Far too many patients and far too few doctors for that!
Posted by: Anon 2 at August 23, 2005 07:32 PM
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