Can patients decide for their own care?

When the Covid-19 vaccinations became available, Jackie (a false name, but a true story), who suffers from allergies, was unsure whether or not to get the vaccine. She asked her doctor. His response was, “Do what you think is right. Of course, your own preferences should guide your choice of health. Except, in this case, Jackie had no choice but to do the right thing – if only she knew what it was.

Leaving the decision in her hands could be interpreted as treating her as a “healthcare consumer,” a term that has grown exponentially on Google Scholar, the world’s academic research repository, as a new, more powerful term for “patient.” “. We have come a long way since 1847, when the American Medical Association’s code of ethics stated, in the paternalistic fashion of the day: “A patient’s obedience to his doctor’s orders must be prompt and implied. He should never allow his own rude opinions about their suitability to influence his attention to them. The legal introduction of informed consent into the International Code of Medical Ethics, which the World Medical Association adopted in Helsinki in 1949, required people to be informed of what was to come to them and to have a choice in what to do with it. matter. In 1982, a presidential commission appointed by Ronald Reagan declared that beyond its legal basis, informed consent “is essentially an ethical imperative”.

But now we may have gone a little too far and these patient rights have become burdens on patients; that amid a growing wave of information, the expansion of consumer culture into healthcare, accompanied by an apparent tactical withdrawal of physicians, is leaving patients too unattended.

Hypothetically, in the age of the Internet, any medical question could be resolved with information that was previously the preserve of personal physicians. Many patients now routinely seek this out, but not all; people are more likely to do this when they feel that social norms encourage them, according to research, and when they have enough health knowledge and self-confidence. Researchers at the University College of London have found that patients often bring information online to help them make a case for treatment, but when it comes to making the final decision, they’re always looking to get away from it. hand over to the authority of their doctor.

Evidence shows that doctors are increasingly giving in to their patients’ preferences.

This is undoubtedly a step forward, that’s for sure. When I was a teenager, thrown in a back brace for scoliosis and without any information about options from my doctor, I could only dream of the knowledge available at hand today which might have indicated to me that in my case, the corset might be unnecessary. But internet-based empowerment also has its limits. Take Jackie: Like any good millennial, she had previously researched ‘Covid-19 vaccine allergies’ and read a WebMD article, but had a hard time understanding it, so instead of feeling empowered, Jackie felt abandoned.

Unofficial sources have been filling this void more and more for a generation now. RxList, a drug index with patient education, launched in 1995, WebMD in 1996, and Healthline Media in 1999. Medical information has become more accessible, but not more objective, after the FDA relaxed direct-to-consumer advertising regulations. drugs to consumers in 1997 When Jackie’s doctor didn’t tell her what to do, the US pharmaceutical industry spent $ 4.5 billion on direct-to-consumer advertising in the United States in 2019 to tell patients which drug to choose . This ad sounds clear and authoritative, which is what people need when they are anxious and overloaded with information.

Another potential source of better answers is telemedicine, which the pandemic has helped popularize. In March 2020, the use of telemedicine increased by 150% from the previous year, removing barriers to care that go beyond Covid by freeing patients from the time and difficulty of going to the office of the doctor. It also allows patients to shop more, if they have adequate insurance.

It’s also convenient for doctors: A doctor can cram three to six digital health visits in the time it takes to have one in person, according to a trade medical publication. Doctors are also increasingly participating in asynchronous “visits” or email exchanges in which patients type in a question and receive an answer later. This potentially effective form of access can broaden the doctor-patient conversation, if it does not replace it.

But the result may also be at odds with what WADA is currently asking its members to do in its Code of Medical Ethics: tailor services to each patient, and remember that patients must always be able to trust physicians to prioritize their care. well-being. The speed-dating nature of remote medicine can diminish the personal bond between physicians and patients, causing physicians to shirk their responsibility to be guides and healers and not just customer service representatives. When people yearn for a more constructive dialogue, telemedicine and its dissociation from human contact is often not enough.

In theory, it is okay for all of us to be health care consumers and to have more say in our medical decisions; we are informed and empowered consumers in other areas, from clothing to coffee. But none of these compare to the challenges or complexity of healthcare, where many choices are irrevocable.

Any prescriptive advice that patients receive may become irrelevant when pain and fear arise.

Yet the evidence shows that doctors are increasingly giving in to their patients’ preferences. In a 2017 study of more than 2,000 physicians published in PLOS One, clinicians reported that more than 20% of the care they provide (drugs, tests, and even procedures) was unnecessary. In almost 60% of cases, doctors said they did it because of pressure or patient demand, such as a barista providing an extra espresso.

For the majority of physicians (85%), the main reason for overtreatment is fear of being sued for malpractice. Litigation has not increased recently, but malpractice lawsuits are receiving greater rewards. With half of American doctors showing signs of burnout, who can blame them for giving in to our demands rather than risking conflict?

But we all find it difficult to navigate health choices if our doctors reduce their role as guides. The stressful issues surrounding healthcare don’t naturally produce our best individual decision-making. Instead, they tend to lead us to what Nobel laureate and behavioral economist Daniel Kahneman called our “System One” thinking – more basic, fast and intuitive and based on emotional cues and little information. , unlike more methodical, data-driven thinking. of system two.

Our doctors must guide us through this labyrinth. Beyond providing care, they have a duty to help patients choose based on evidence and medical knowledge. The first step towards this is to build relationships and trust, followed by the provision of clear and valid information, to give patients the opportunity to use both system one and system two thinking. Patients, on the other hand, need to be aware of their own tendency to react intuitively and be sure to seek out the information they can process. A good question to ask yourself is, “Did I get information about System 2 and how can I best understand it?” “

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Of course, any prescriptive advice that patients receive can become irrelevant when pain and fear arise. I experienced this firsthand when my mom broke her hip. Late that night, I contacted two doctors on the brief recommendation of the emergency nurse. One of them showed up, disheveled, and gave my mother a terse explanation of the procedure, while making eye contact with her hiking boots. “What kind of doctor is this?” Mom asked. “I don’t want him.”

She based her decision on her perception of the doctor’s sympathy and authority – System One thinking, according to the work of psychologist Robert Cialdini. During this time, I was influenced by another factor of System One, the principle of scarcity: it was there, and no one else was. Anxious and emotional, none of us thought to inquire about physician success rates – useful for System Two.

We are all prone to these psychological traps in the absence of reliable and authoritative advice. When we have a hard time getting that, do our doctors allow us to make our own decisions or do they step back from their roles? The risk is patient abandonment, disguised as healthcare consumerism.

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