BMJ  2006;332:981 (22 April), doi:10.1136/bmj.332.7547.981

reviews

Personal view

So what's so new about patient choice?

The current political agenda for choice in medical care is being presented as something new. However, choice has always existed. Not everyone who is ill chooses to seek medical care. For example, 50% of women with heavy periods (blood loss of > 80 ml in each period) do not complain, whereas 50% of those who seek treatment have bleeding that objectively is in the normal range.

There has long been a choice about whom to consult. Many people with acute symptoms prefer to visit the hospital's emergency department rather than seeing their family doctor. Many seek second, or even several, opinions. This option—long available to the wealthy—has been encouraged by medical specialisation. For example, many women lose babies because of going intolabour before term. They are desperate to avoid are petition. They often consult widely and may be seen by a haematologist looking for a thrombophilia, an infertility specialist to help them get pregnant again, an obstetrician planning their care, and an expert on fetal medicine organising surveillance by ultrasonography. The recommendations for the next pregnancy can include subcutaneous heparin, progesterone, low dose aspirin, weekly cervical length measurement by ultrasonography, and even cervical suturing.

Doctors must not be drawn into colluding in patients' inappropriate choices

In most cases these treatments have no scientifically convincing evidence base. However, some women will choose all the treatments "just in case." Many doctors prefer to "do something" rather than employ masterly inactivity (which can be interpreted as lack of concern). It is rational to choose not to have a treatment if no evidence base for it exists, but many people find it difficult to override their preference for action. Patients may choose care simply because they like the doctor who recommends it. Studies show that a doctor's attitudes and behaviour have a substantial influence on the choices patients make—a well established example being rates of caesarean section, which vary widely according to the views of the obstetrician.

Other patients will choose not to have managements for which the evidence base is compelling. Some women choose to have a physiological third stage of labour and refuse prophylactic oxytocics, despite being told that they significantly and substantially reduce the risk of postpartum bleeding and the need for blood transfusion. Their right to do this must be respected. However, doctors must not be drawn into colluding in patients' inappropriate choices. It would be inadvisable to administer an epidural anaesthetic if the woman refuses appropriate maternal and fetal monitoring. On the other hand, many obstetricians will agree to a healthy woman's request for a caesarean section, because they understand that many women fear labour and judge the risk small enough for the choice to fall within the autonomy of a well informed adult.

Choice is difficult when there is equipoise. A woman with mild hypertension induced by her pregnancy but no proteinuria at 40 weeks' gestation can be managed by induction of labour or daily monitoring as an outpatient. When I ask medical students which option they would choose, they usually concentrate on irrelevant medical minutiae. I would ask the woman how she feels. Many such women are uncomfortable and tired of being pregnant and choose induction, happy that they will soon be able to see their long awaited baby. Others have set their sights on "natural" labour and choose to wait. Both choices are valid. If the woman has no preference, I assess staffing on the labour ward and the day assessment unit and recommend accordingly. If both are equally staffed, I toss a coin (out of the woman's sight). The students are sometimes shocked by this arbitrariness, but many medical decisions have an inherent random element (which is preferable to a persistent unjustified bias, because at least half the patients get the better treatment).

Recently, a writer in the New York Times complained that some patients find it difficult to cope with the increasing likelihood of being offered choices and pleaded for more medical direction. But as more effective treatments appear, the amount of choice can only increase—and a return to paternalism is not the answer. Some patients prefer not to choose for themselves and ask, "But what would you do, doctor?" In my view doctors should not answer with the choice that would suit them personally. Instead they should collect as much information about a particular patient's lifestyle and preferences as they can and then recommend the action they think most suits that patient—and document them carefully. If the outcome is not ideal the patient may claim that the doctor should have chosen differently.

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Division of Surgery, Oncology, Reproductive Medicine and Anaesthetics, Faculty of Medicine, Imperial College London p.steer{at}imperial.ac.uk

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