Sunday, March 30, 2014

What kind of doctor do you want?

Here's this weekend's column in the Kingston Whig-Standard.

It might sound like an odd question: "What kind of doctor do you want?"
But seriously, if you could choose, what qualities would your ideal doctor have? Well, for starters, we would want them to be clinically competent. Seems obvious, you say?
You’d assume that all registered doctors in the country are clinically competent.
But that’s about as likely to be true as saying all engineers and all architects are competent at what they do. There are invariably great variations among doctors. Still, let’s assume your family doctor is a good technician as far as your body is concerned. Would that be it? Probably not.
The doctor-patient relationship has changed in dramatic ways during the last few decades. In the not-so-good old days, doctors would have thought nothing of it when they withheld vital information from you that would have been relevant to your decision-making.
If different courses of clinical care were available, they would have picked the one they thought would have been the most appropriate. The odds are that they would not have consulted you about the pros and cons of the potential courses of action. After all, doctor knows best, or so they thought.
Well, during the late '60s and '70s, patients didn’t take that attitude quite lying down. They also began to disagree with many doctors’ take on abortion, contraceptives and other matters. Whether an abortion was acceptable or not in particular circumstances turned out to be anything but a professional medical judgment. As patients, we asserted our control over our own bodies against doctors who thought they knew best.
Thankfully, that quasi-religious symbol of doctors’ supremacy over our bodies, the white coat many doctors chose to wear at work, fell by the wayside, too.
There was a flip side to this victory, though. Doctors were now required to share with us information that an imaginary reasonable patient would like to know about. And they were supposed to do it in a way that this imaginary reasonable patient would be able to comprehend and make sense of.
Well, in reality, there is no such thing as a reasonable average patient. Take me, for instance. I’m good with any information my family doctor throws at me about anything pertinent to making a considered choice about available treatment options.
But, try the same scenario at the dentist and I’m anything but reasonable. I still recall that dentist who had invested oodles of money into equipment that permitted her to produce a video of her checkup of my teeth. She then proceeded to show me what she found on a giant monitor.
This was all as well-intentioned as it gets, plus, no doubt, it was charged for, too. How could I make a considered choice on what I would want to see done without knowing what was going on in my mouth? Good point, you say? Well, reality check: I was shocked enough to never go back to her. I didn’t want to know, didn’t want to see.
All I wanted was for her to get on with what needed to be done, and do it as pain-free as possible. My partner, on the other hand, would have enjoyed the video and the grizzly detail of what was going to happen.
These days, I shop around until I find a dentist not insisting on debating endlessly the pros and cons of options. For better or worse, these conversations are deeply distressing for me. I don’t consider it a benefit to have to endure such discussions, at least not while shaking in my boots at the thought of the inevitable pain associated with dental surgery. I’m a wimp, I know, but for better or worse, there are plenty of folks like me. The revolution that has taken place on the health-care professional patient relationship wasn’t straightforwardly better for everyone in all circumstances.
A clinician-blogger in the U.S. has asked his Twitter followers what other competencies they expect of their doctors. It’s quite a lot, ranging from empathy to good listening skills to compassion to whatnot else. Some of the skills on the patient wish list are actually important, such as good listening skills.
You better listen carefully to what your patient is telling you, lest you miss an important detail that could change the nature of your diagnosis. I completely understand the need for an empathetic doctor, but I wonder – just between the two of us – whether it might suffice if doctors faked empathy.
Yes, we would ideally want to feel cared about, but think of what it means for a doctor to be truly empathetic to the suffering of every individual patient. It’s seems an unreasonable demand on any human being to cope with.
Interestingly, unlike the people who answered the Twitter invite, my biggest concern is that doctors simply be professional in their interactions with patients. This means that they keep their private lives out of their practices. God doesn’t belong there, neither does their political party affiliation or anything else that’s irrelevant to their service delivery. You would be surprised how many doctors believe it is entirely appropriate to inflict their religious convictions on their patients, regardless of whether their patients share these convictions or not. I don’t need to know, for instance, that your god disapproves of my atheism, my sex life, my drug-taking habits, and whatnot else. Your insistence on displaying such symbols at work makes it more difficult for me to communicate pertinent health information to you.
We even have plenty of data to support this claim. You would think that doctors truly caring about the health outcomes they deliver would take such information into account and adjust their behaviour accordingly. Many do not.
So, my good doctor is able to talk to me in such a way that I am comfortable sharing relevant health information with her. She tries to clarify well in advance of a potentially bad diagnosis how I would like bad news to be communicated.
She also is capable of explaining different treatment options to me in a manner that permits me to come to a conclusion on what course of action I’d like to follow, that is unless she’s a dentist, then I would really rather not. She also knows that different ways of communicating information could manipulate me unacceptably. Mortality instead of survival frames often result in different choices by the same patient, even though the facts remain exactly the same. Not unimportantly, she understands the difference between a clinical judgment and her own moral convictions.
What’s your ideal doctor like?
Udo Schuklenk teaches bioethics at Queen’s University, he tweets @schuklenk.

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