I believe clear guidance is key to building a strong doctor-patient relationship. What concerns me is when issues like liability or insurance coverage influence care—especially if a doctor knows something isn’t covered and that affects what they recommend. In those moments, I think transparency is almost always the best approach. Even though I only know you as my friend, I trust your humility, and I believe you strive to practice with transparency because that's just who you are.💕
I think this is the right approach. Except in unusual instances, patients hire doctors to be their advisors, not to make decisions for them or, more broadly, to assume control over their lives. This is equally true for other professionals, such as lawyers. And professionals of all types have difficulty resisting the temptation to take over. Because professionals know more than laypersons, the inclination to assume control is natural. But it must be resisted, and it will be if professionals remind themselves of the limits on their authority. Patients' wellbeing is a stake, and many decisions about treatments require judgments about non-medical matters--judgments that patients are in the best position to make.
As a patient I like the approach you describe as parentalism, noting that you explain this approach by saying "Guidance is based on knowledge, beneficence, and familiarity with patient values and expectations."
But I think that insurers and administrators are the elephant in the room. These days I can't tell to what extent the guidance I receive by physicians is based on knowledge, beneficence, and familiarity, versus also based on what an administrator or insurance protocol allows or incentivizes.
I (half?) remember a parody of Invictus (WE Henley) but I coulldn't find the author of the parody in a quick on-line search. It went something like:
I am the master of my soul
I rule it with stern joy,
I yet I think I liked it more
When I was cabin boy.
The problem about swinging pendula is that it's hard to work out exactly where we want them to stop, or in what direction we'd prefer them to be heading for at the time.
I find it ascribed to Keith Preston (of whom I have not heard previously) in several sources. Here is one. Scroll down to the poem entitled "An Awful Responsibility."
You remembered it almost exactly as it is published at this link!
the only shame is you had to start doing invasive cardiac procedures in the first place on an 88yr old; don't folks know they are frail and need considerate care? Surely medicine has lost its way (totally?) .. deceiving itself it can fix everything; death is a failure; how about being heroically thoughtful; aggressively watchful; actively patient, ...
You're conveniently focusing on the ethically easy scenario of patients refusing to comply with physician directives. The more challenging scenario is what happens when a patient asks for a treatment and the physician has to consider whether to provide it. The Tuskegee Study is a classic example of what happens when the thing you're calling parentalism goes awry. Patients asked for the penicillin they knew they needed to treat their syphilis and their physicians told them tut tut little patient - you can't have the candy so run along now. I'm a PhD molecular virologist who develps vaccines for a living - and I've personally been told tut tut little patient - you don't need a Covid boost/Paxlovid/metformin. Parental advice is OK. Unchecked unilateral knee-jerk withholding based on superficial understanding is not OK.
The central lesson is that before physicians assume the role of in loco parentis, they better be damn sure they know the medical literature on the question backward and forward. Otherwise, the respectful course of action is to err on the side of allowing fellow adults to self-experiment.
Now retired, I practiced what you call parentalism from 1977 until I retired 3 years ago. As an obstetrician, joint decision making fell into place with many prenatal visits including dad and kids. While I had my responsibility to finish pregnancy with everyone alive and healthy, the patients and family had the same goals. In 6000 births, there were NO maternal deaths and NO permanent injury...not even any eclampsia (preeclampsia + seizures) although LOTS of preeclampsia. In my first month of private practice I delivered 46 babies. The only way to do that was to share responsibility for a good outcome. So you might say my parentalism was based in pragmatism. We just needed to find something that worked, and indeed we did. Contrary to what happens today the first year was active care and I remained their primary care doc so we avoided suicide, homicide, drug OD, death from hemorrhage, infection, DVT and cardiomyopathy. Thanks Adam
In our addiction clinic we practice Motivational Interviewing with our patients, helping them find their own motivation to take action and change, putting the locus of control on the patient, since they are the ones who have to make decisions in their lives and we — literally — cannot make them for them. It is not, traditionally, about giving advice. Motivational Interviewing is shortened to MI, but my oldest colleague in the clinic, a brilliant psychologist, has many times said, “Dr. O doesn’t practice MI, he practices MO [my initials].” It’s my version of parentalism, I think, putting the locus of control on the patient, but with a bit of persuasion (usually a decision about starting or staying on a life-saving medication, or staying in care). What a great piece, Adam.
Well said. I do see doctors using “shared decision making” as a way out when they aren’t sure or know less. Besides, we are yet to figure out how best to do shared decision making- expecting sick /worried patients to make sense of probabilities and risks? On the other hand, in current “risk-averse” practice environment, I worry most doctors would just “recommend” maximum tests/treatments without benefit, if left to them to be paternalistic.
By the middle of my career “They must share the basis of their recommendations and admit uncertainty where it exists. They must accept the responsibility for patient outcomes. They must also acknowledge that the patient must ultimately choose how to proceed” is what I mastered for those sometimes dreaded family meetings in the ICU conference room.
But it didn’t happen until I learned to listen.
When I look back those encounters are what I remember most fondly.
“Patients need doctors to be collegial partners in their care. However, in many developing countries, this is often not the case—largely due to cultural beliefs rooted in deference to authority, such as ‘he is the doctor’ or ‘the doctor said’. Paternalism is further perpetuated by limited resources, insufficient training, and a lack of diverse healthcare options.”
Honesty and transparency is the bedrock of a solid relationships. Medical or otherwise. Done with kindness and patience and without attachment is a winner. It also leaves the door open for a change of mind/heart.
I believe clear guidance is key to building a strong doctor-patient relationship. What concerns me is when issues like liability or insurance coverage influence care—especially if a doctor knows something isn’t covered and that affects what they recommend. In those moments, I think transparency is almost always the best approach. Even though I only know you as my friend, I trust your humility, and I believe you strive to practice with transparency because that's just who you are.💕
I think this is the right approach. Except in unusual instances, patients hire doctors to be their advisors, not to make decisions for them or, more broadly, to assume control over their lives. This is equally true for other professionals, such as lawyers. And professionals of all types have difficulty resisting the temptation to take over. Because professionals know more than laypersons, the inclination to assume control is natural. But it must be resisted, and it will be if professionals remind themselves of the limits on their authority. Patients' wellbeing is a stake, and many decisions about treatments require judgments about non-medical matters--judgments that patients are in the best position to make.
As a patient I like the approach you describe as parentalism, noting that you explain this approach by saying "Guidance is based on knowledge, beneficence, and familiarity with patient values and expectations."
But I think that insurers and administrators are the elephant in the room. These days I can't tell to what extent the guidance I receive by physicians is based on knowledge, beneficence, and familiarity, versus also based on what an administrator or insurance protocol allows or incentivizes.
I (half?) remember a parody of Invictus (WE Henley) but I coulldn't find the author of the parody in a quick on-line search. It went something like:
I am the master of my soul
I rule it with stern joy,
I yet I think I liked it more
When I was cabin boy.
The problem about swinging pendula is that it's hard to work out exactly where we want them to stop, or in what direction we'd prefer them to be heading for at the time.
I find it ascribed to Keith Preston (of whom I have not heard previously) in several sources. Here is one. Scroll down to the poem entitled "An Awful Responsibility."
You remembered it almost exactly as it is published at this link!
https://littlecalamity.tripod.com/Poetry/Life.html
An Awful Responsibility
Keith Preston
I am the captain of my soul,
I rule it with stern joy,
And yet I think I had more fun
When I was cabin boy.
Thanks so much for tracking this down…
the only shame is you had to start doing invasive cardiac procedures in the first place on an 88yr old; don't folks know they are frail and need considerate care? Surely medicine has lost its way (totally?) .. deceiving itself it can fix everything; death is a failure; how about being heroically thoughtful; aggressively watchful; actively patient, ...
You're conveniently focusing on the ethically easy scenario of patients refusing to comply with physician directives. The more challenging scenario is what happens when a patient asks for a treatment and the physician has to consider whether to provide it. The Tuskegee Study is a classic example of what happens when the thing you're calling parentalism goes awry. Patients asked for the penicillin they knew they needed to treat their syphilis and their physicians told them tut tut little patient - you can't have the candy so run along now. I'm a PhD molecular virologist who develps vaccines for a living - and I've personally been told tut tut little patient - you don't need a Covid boost/Paxlovid/metformin. Parental advice is OK. Unchecked unilateral knee-jerk withholding based on superficial understanding is not OK.
The central lesson is that before physicians assume the role of in loco parentis, they better be damn sure they know the medical literature on the question backward and forward. Otherwise, the respectful course of action is to err on the side of allowing fellow adults to self-experiment.
A Love Letter From a Virus to MAGA
https://open.substack.com/pub/patricemersault/p/a-love-letter-from-a-deadly-virus?r=4d7sow&utm_medium=ios
Now retired, I practiced what you call parentalism from 1977 until I retired 3 years ago. As an obstetrician, joint decision making fell into place with many prenatal visits including dad and kids. While I had my responsibility to finish pregnancy with everyone alive and healthy, the patients and family had the same goals. In 6000 births, there were NO maternal deaths and NO permanent injury...not even any eclampsia (preeclampsia + seizures) although LOTS of preeclampsia. In my first month of private practice I delivered 46 babies. The only way to do that was to share responsibility for a good outcome. So you might say my parentalism was based in pragmatism. We just needed to find something that worked, and indeed we did. Contrary to what happens today the first year was active care and I remained their primary care doc so we avoided suicide, homicide, drug OD, death from hemorrhage, infection, DVT and cardiomyopathy. Thanks Adam
In our addiction clinic we practice Motivational Interviewing with our patients, helping them find their own motivation to take action and change, putting the locus of control on the patient, since they are the ones who have to make decisions in their lives and we — literally — cannot make them for them. It is not, traditionally, about giving advice. Motivational Interviewing is shortened to MI, but my oldest colleague in the clinic, a brilliant psychologist, has many times said, “Dr. O doesn’t practice MI, he practices MO [my initials].” It’s my version of parentalism, I think, putting the locus of control on the patient, but with a bit of persuasion (usually a decision about starting or staying on a life-saving medication, or staying in care). What a great piece, Adam.
Well said. I do see doctors using “shared decision making” as a way out when they aren’t sure or know less. Besides, we are yet to figure out how best to do shared decision making- expecting sick /worried patients to make sense of probabilities and risks? On the other hand, in current “risk-averse” practice environment, I worry most doctors would just “recommend” maximum tests/treatments without benefit, if left to them to be paternalistic.
Why wasn't bypass considered early? There's a big difference in biologic age (although admittedly, 88 is significant).
you are a wit!
I hate to be a persnickety pedant, but I think you meant timidity rather than temerity in the last paragraph.
By the middle of my career “They must share the basis of their recommendations and admit uncertainty where it exists. They must accept the responsibility for patient outcomes. They must also acknowledge that the patient must ultimately choose how to proceed” is what I mastered for those sometimes dreaded family meetings in the ICU conference room.
But it didn’t happen until I learned to listen.
When I look back those encounters are what I remember most fondly.
“Patients need doctors to be collegial partners in their care. However, in many developing countries, this is often not the case—largely due to cultural beliefs rooted in deference to authority, such as ‘he is the doctor’ or ‘the doctor said’. Paternalism is further perpetuated by limited resources, insufficient training, and a lack of diverse healthcare options.”
Honesty and transparency is the bedrock of a solid relationships. Medical or otherwise. Done with kindness and patience and without attachment is a winner. It also leaves the door open for a change of mind/heart.
i think i will just stay home to die with my fam in my home w/out all the traumatic hospital interventions, despite your good intentions