An article in today’s NY Times Well Blog (http://well.blogs.nytimes.com/2012/03/08/what-doctors-and-patients-dont-want-to-talk-about/#more-72573) relates a recent article in the New England Journal of Medicine by Dr. Robert Truog, who teaches medical ethics at Harvard Medical School and practices intensive care medicine at Children’s Hospital Boston. Dr. Truog writes that while the doctor-patient relationship has become less vertical, less patriarchal, it’s still not fully transparent.
That is, certain subjects are seldom discussed, particularly the omnipresent question of care versus cost. This is one facet of a permanently central issue, what we call “informed consent.” Are we fully cognizant of everything that goes into a medical recommendation? Patients assume that care decisions are made on the basis of medical science, yet an influence at least as dominant is economics: in truth, we’re always rationing. We’ve always rationed and always will. No one but maybe Warren Buffet or Carlos Slim will ever get all the care they want—and it probably isn’t even in their best interest to get that anyway.
Fully informed consent is often abbreviated by incomplete conversations between docs and patients. Says Dr. Truog, “I think a relationship has developed where we as physicians don’t tell patients everything and patients don’t really want to know everything…it’s not like you just do an information dump and that’s all; being transparent and open with your patient goes beyond the rote skills of making eye contact, sitting down instead of standing at the bedside and asking certain questions. It comes down to the words we use and the way choices are framed. The way we present or hide our own values is critical and should receive attention.
“For example, we videotaped experienced practitioners for a project on how to counsel women when they learn a fetus has a congenital defect. What came up was that these physicians often made the assumption that more information, like getting an amniocentesis and really figuring out what the abnormalities are, is always better. In fact, one of the quotes from a wonderful physician was: ‘Information is always good.’ But some patients and families really don’t want more information. They feel that if they have the information, they put themselves in the position of playing God. Not having the information spares them from having to make a choice.”
Exactly. Dr. Truog has expressed the crucial deficiency: we docs assume “communication” means conveying information to the patient. We forget it’s a two-way process. In my experience, speaking is maybe a fifth of communication; the bulk of it is listening, which requires time and skill. Instead of avalanching patients with data and then leaving them to make a choice, why not get to know them first—hear their perspectives, values, and needs, and only then offer information?