Discussion of risk pervades doctor-patient communication
BMJ 2002; 325 doi: https://doi.org/10.1136/bmj.325.7363.548 (Published 07 September 2002) Cite this as: BMJ 2002;325:548
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The discussion of risk with patients usually starts as the discussion
of potential treatments and their benefits. Risk is then traded against
potential benefits. In most patients I get the feeling that this
calculation is emotional not intellectual. Most big decisions in life are
probably made in this way, we then back up our decisions with a bit of
selective research.
An elderly man with considerable intellect first presented with mild heart
failure and severe aortic stenosis. We discussed the potential risk and
benefits of surgery. He decided that he would prefer at his time of life
not to have surgery; he would take his chances (risk) with medical
treatment. A couple of months later he presented again but with severe
cardiac failure. He changed his mind about surgery. He could now see that
the risk of no treatment was severe illness. He had a full assessment and
died unexpectedly in his sleep while awaiting an inpatient visit from his
potential surgeon.
I have a gut feeling that very few patients are able to use calculations
about their own health. The question then is how we as doctors should use
them. Even that is not easy. Do we persuade, present reasoned argument,
act as a neutral advocate, send the calculations blandly in a letter and
stand back?
Different patients want different things. A fair proportion want their
doctor to support the decision that they have already made. Few change
their minds as the result of discussion.
Am I being too negative about calculated risk and patients use of
objective evidence?
Competing interests: No competing interests
I found Andrew Smith's letter regarding doctor-patient communication
of particular interest as it is one of those topics where it is so easy to
put the cart before the horse!
I submit that communications between these two parties will never be
clearly decipherable due to the unequal distribution of power. Generally,
when faced with a doctor patients become intellectually inept due to the
intimidating nature of the doctor's role in our western culture.
Contributing factors are that doctors have a language all of there own and
can tend to enhance this game of superiority by adopting a condescending
way of communicating, bringing in paternalism (excuse the sexism). This,
of course, is a generalised opinion but one I have had the misfortune to
be confirmed in person by two consultants, despite my educated background.
However, until patients realise that there is no 'nanny state' or
'paternalistic' doctor to take national or personal responsibility for
their health that, ultimately, it is a personal responsibility this
situation will not change. We have a responsibility to ourselves to
become more actively informed and involved in our own health and
wellbeing. Simply waiting until a crisis arrives in order to turn
ourselves obligingly over to medicine feeds the imbalance of power and the
opportunity for miscommunication and misinterpretation of medical
situations.
Perhaps doctors should be leading the way through humility by
learning to adopt a more consultative role with their patients. After
all, without proper communication of signs and symptoms misdiagnosis is a
real possibility as are wrong drug or dosage prescribing.
Competing interests: No competing interests
Whilst your table is helpful in conveying the risk of anaesthesia the
log scale and absence of the risks of postoperative complications and
death from any unappreciated development of incomplete resuscitation
during surgery gives your patients a false impression of the relative
safety of anaesthesia(1).
1. Mythen MG, Webb AR. Intra-operative gut mucosal hypoperfusion is
associated with increased post-operative complications and cost. Intensive
Care Med. 1994;20(2):99-104.
Competing interests: No competing interests
The confession process
Andrew Smith's letter about the dynamics of doctor-patient
communication has not mentioned how the role of confession
takes place in such a domination-subordination relationship.
Patients are in the secondary position in almost all therapeutic
encounters with doctors. For example, patients tell doctors their illness
history and family background without any reservation even in the first
consultation.
Patients will also take off their clothes for physical examination
without any doubts about the needs for such procedures.
Doctors are in the dominant position as our society has given them a
powerful discourse as a profession which is responsible for life and death
issues of our patients.
Eventually, doctors have taken-for-granted attitudes that patients have to
tell them frankly and follow their treatment regimen.
Indeed, every doctor-patient diagolue is a confession process. A one-way confession process that patients disclose themselves in front of
doctors but doctors do not disclose any personal information to patients.
Confession of patients itself is a starting point for medicalizing
patients' symptoms.
Competing interests: No competing interests