16 Comments

I always tell my patients that my job is to give them my opinion and my recommendations based on my training and my experience. Their job is to choose to do what is best for them.

Even in the case above of the woman who declined the Whipple and died 7 months later, she still may have made he right decision for herself. We, as doctors, don't know everything about our patients. We know only what they choose to tell us. Some people have strong reasons for refusing surgery or for choosing to avoid prolonging their lives. In the end, it is their decision to make. Our job is to support whichever decision they have made so long as it was made fully informed and free of coercion.

Dealing with the families understanding why the patient makes the decision they make is an entirely different conversation. . . .

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The reality is that when I am severely unwell, as in severe pain, then I need a Dr who knows my agenda and will make decisions for me based on my agenda... Reality is that in that scenario I'm not going to get my family dr who can do that, but the time poor ED clinician who couldn't give a stuff... Not a life and death decision, but the only time I've taken the worst migraine of my life to ED, the Dr did blood tests on me without my knowledge or consent (I thought all they were doing was inserting an IV prior to treatment)... And totally unnecessary, you can't diagnose a migraine or exclude a sub-arachnoid (not that it had any red flags beyond worst headache of my life) with a blood test... My family dr knows I'm fussy about informed consent and prefer minimal/no investigations, but some random in ED, who in reality is the person I'm going to get when I'm acutely unwell, is of dubious quality and as I found out, sub-par

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Intrigued by the painless jaundice... If I was feeling well and had painless jaundice, I wouldn't be going to the ED... I'd make an appointment with my family doctor... and be a bit more obsessive with handwashing in the meantime... (And I've had a healthy cousin die from fulminant hepatitis) And secondly, I can't work out why an initial hospital admission was necessary for this patient anyway? Apart from the fact that that's how it is done, I can't think of a reason she needs to be inpatient... Surely the tests/procedures could be done outpatient? Asking, I haven't been on hep-bil.

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Because everything will get done in the hospital in a few days rather than weeks as an outpatient and hopefully the patient will not dangerously obstruct in that time.

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Helping the patient/family to make decisions is the art of medicine. My mom had MS, diabetes, and dementia. She then got Wegeners but the only diagnostic they could offer was an invasive biopsy (all imaging and labs supported the Wegeners dx). The best nephrologist told us, we can do the biopsy to confirm, but would she want to treat it? She spent 20 blessed months with us until she passed from her kidney failure. She was the sweetest dying woman you’d ever meet. Thank you for reminding us of what matters.

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Dr. Cifu you keep me coming back to SM.

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Does it EVER occur to ANYONE in the medical community that there has to be a reason(s) for people to present conditions that are not normal? For every distress, disease, or affliction there is a reason it is happening. Yet, no medico gives a rat's butt...they just fire away with tests, more tests, procedures and drugs and more drugs and more drugs and things progressively go down hill because the root causes are never assimilated and addressed. You call this medicine? It's torture for profit.

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I’ve been trying to get to the root cause of some troublesome symptoms for at least a year. Other than extensive testing, I’ve been told that there isn’t always an answer, like “etiology unknown,” with no effort to go beyond that. This, and being misdiagnosed a couple of times, has undermined my trust in physicians.

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I'm curious to know what you mean by 'reason'?

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“All healthcare should be collaborative care.”

That’s the most important sentence I’ve read today, this week, this year. Enough said.

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As a Pulmonologist, the first question I have for a patient with a lung nodule is this: "if this is cancer, would you want surgery/radiation/chemotherapy"? If the answer is "No," then I say, "have a nice day. We are not doing anything further about the nodule."

The patient is the ultimate decision maker, and it is our job as Doctors to guide them with the most accurate information as possible.

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Very interesting.

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It is more than this too. While we might see the calculus being risk reward ,for some the calculus is something altogether different. We need to remain aware of that.

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In many cases, with patients that were able to 'hear' what I was saying and needed an extended explanation, I would tell them something like this:

This is what I think you have - here are the reasons why I think this - and this is the treatment I think you need. If I'm right about this, then you should get better in this amount of time - getting better will likely feel/proceed like this.

If I'm wrong about what you have (and here are some possible alternative conditions you coul have) you likely won't be getting better as I predict, and certainly if you're getting worse then it's likely I didn't get things right. Though if you're not getting better (or you're getting worse), I might still have been right but you're for some reason not responding the way most people would.

In any case, if the treatment I'm recommending doesn't seem to be working, you need to come back (or see your PCP, etc) right away for a re-evaluation.

Remember - every diagnosis is a hypothesis, and every treatment is an experiment hoping to support the validity of that hypothesis.

So - now - what questions do you have ..

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Adam, thanks as always for this insight! Great examples of the daily complexities of medical practice.

The things I've noticed and come to realize:

Physicians are simply giving advice (which is certainly worth something as we've got the training and expertise to give that advice). it is totally up to the patient whether they take it or not. If they don't follow our advice, it is not something to take personally. It does not convey "disrespect" or distrust. A decision has to be made and many variables factor in.

The main thing: whatever decision the patient ultimately makes is the correct one. Conveying that to the patient is always helpful. And remembering that as a physician is comforting.

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Informed consent is such an integral part of the medical process! Thank you for these illustrations!

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