As person-as-patient my foundational principle is that I alone should decide what is the best option for me, making the inevitable tradeoffs myself, having been fully informed about them by my physician in a non-directive way that does not pre-empt/undermine my preferences under the guise of respecting some nebulous professional oath/cod…
As person-as-patient my foundational principle is that I alone should decide what is the best option for me, making the inevitable tradeoffs myself, having been fully informed about them by my physician in a non-directive way that does not pre-empt/undermine my preferences under the guise of respecting some nebulous professional oath/code (or any other reason). I truly enjoy and benefit from Sensible (i.e. Bayesian) Medicine, but I can't recall the word 'preferences' ever being spoken, even when you (Adam, John and earlier Vinay) are discussing the tradeoff between the consequences of screening/diagnostic test error rates. Friendly enquiry: is this word in your (medical) vocabulary, and, if so, why does it not come naturally and routinely into your conversations and writings? Correction welcomed, of course.
"I am the one who determines what makes sense medically. My patients consider how my recommendations fit with their values, philosophy, and lifestyle. " I appreciate your obvious openness to debate/dissent, so I'll push a little. What makes sense to you (do we need 'medically'?) is what is in line with your risk/time/outcome preferences. The fact that in any specific case these preferences may be those of most/many doctors or guideline panels, most/many lay people - and may well be mine - does not affect their ontological status, or the ethical and legal principle that the relevant ones are fully in the patient's 'lane'. Regarding patients as having 'desires', rather than preferences, segues the SDM task away from being one of informing the patient, eliciting their informed preferences over the consequences of their (uncensored) options, and establishing what option that shared process 'recommends'. For avoidance of doubt I believe you are entitled to refuse to implement an option that you have deemed not OK/ not'sensible'/futile, but that will usually be at the expense of the clinical relaionship
You might take a look at my Substack! Started partly because 70 or so papers in PubMed have not achieved much - but to be honest I never expected them to!
ill push back a little. Physicians do not generally buy patient preferences as normative for us. The medical "move" (in contrast to small-l liberal politics) is to posit a divide (frequently) between patient preferences and patient (medical) interests. We see our job as nudging patient preferences toward their medical interests, even if we do not succeed. And we can be very directive where the contrast between the two is stark. That is our job.
Hi Tom. This looks like an own goal to me whatever one's politics. How do you/'we doctors doing our job' determine patient 'medical 'interests' without injecting preferences into the determination. Your preferences, your institution's, your disciplinary guideline panel's... it doesn't really matter. because you are very clear they are not the patient's preferences. In fact you talk as if only patients have preferences, 'medicine' itself is preference-free
I would like to second Jack here. Preferences, institutional and otherwise, abound. Insured patients are preferred over uninsured patients. Private insurance is preferred over Medicaid. Compliant patients are preferred over refuseniks. Simple patients are preferred over complex ones. The latter two preferences are often baked into the compensation structure for doctors by the grace of their employers' metrics. On and on. It's preferences all the way down not turtles.
Would not say that doesn’t happen. Doc preferences always tempt to diminish from what professional standards would ask of us; and we do not always come through. But the professional ask is always there.
In a sense, yes. Medicine is a practice; we learn it during training. yes, it has a web of norms and standards for what are good medical means and ends. These are not "preferences" in any individual sense--they are what constitutes "good medicine" or a good medical outcome as professionally determined. By the end of our training we possess this practice if our training has been successful. And it is what we do--again, if we're doing it right.
As person-as-patient my foundational principle is that I alone should decide what is the best option for me, making the inevitable tradeoffs myself, having been fully informed about them by my physician in a non-directive way that does not pre-empt/undermine my preferences under the guise of respecting some nebulous professional oath/code (or any other reason). I truly enjoy and benefit from Sensible (i.e. Bayesian) Medicine, but I can't recall the word 'preferences' ever being spoken, even when you (Adam, John and earlier Vinay) are discussing the tradeoff between the consequences of screening/diagnostic test error rates. Friendly enquiry: is this word in your (medical) vocabulary, and, if so, why does it not come naturally and routinely into your conversations and writings? Correction welcomed, of course.
https://www.sensible-med.com/p/friday-reflection-34-disagreement
"I am the one who determines what makes sense medically. My patients consider how my recommendations fit with their values, philosophy, and lifestyle. " I appreciate your obvious openness to debate/dissent, so I'll push a little. What makes sense to you (do we need 'medically'?) is what is in line with your risk/time/outcome preferences. The fact that in any specific case these preferences may be those of most/many doctors or guideline panels, most/many lay people - and may well be mine - does not affect their ontological status, or the ethical and legal principle that the relevant ones are fully in the patient's 'lane'. Regarding patients as having 'desires', rather than preferences, segues the SDM task away from being one of informing the patient, eliciting their informed preferences over the consequences of their (uncensored) options, and establishing what option that shared process 'recommends'. For avoidance of doubt I believe you are entitled to refuse to implement an option that you have deemed not OK/ not'sensible'/futile, but that will usually be at the expense of the clinical relaionship
Sounds like the outline for a good essay! See the about page for submission guidelines.
You might take a look at my Substack! Started partly because 70 or so papers in PubMed have not achieved much - but to be honest I never expected them to!
Will do. Sounds like we’re here for the same reason. 😉
ill push back a little. Physicians do not generally buy patient preferences as normative for us. The medical "move" (in contrast to small-l liberal politics) is to posit a divide (frequently) between patient preferences and patient (medical) interests. We see our job as nudging patient preferences toward their medical interests, even if we do not succeed. And we can be very directive where the contrast between the two is stark. That is our job.
Hi Tom. This looks like an own goal to me whatever one's politics. How do you/'we doctors doing our job' determine patient 'medical 'interests' without injecting preferences into the determination. Your preferences, your institution's, your disciplinary guideline panel's... it doesn't really matter. because you are very clear they are not the patient's preferences. In fact you talk as if only patients have preferences, 'medicine' itself is preference-free
I would like to second Jack here. Preferences, institutional and otherwise, abound. Insured patients are preferred over uninsured patients. Private insurance is preferred over Medicaid. Compliant patients are preferred over refuseniks. Simple patients are preferred over complex ones. The latter two preferences are often baked into the compensation structure for doctors by the grace of their employers' metrics. On and on. It's preferences all the way down not turtles.
Would not say that doesn’t happen. Doc preferences always tempt to diminish from what professional standards would ask of us; and we do not always come through. But the professional ask is always there.
In a sense, yes. Medicine is a practice; we learn it during training. yes, it has a web of norms and standards for what are good medical means and ends. These are not "preferences" in any individual sense--they are what constitutes "good medicine" or a good medical outcome as professionally determined. By the end of our training we possess this practice if our training has been successful. And it is what we do--again, if we're doing it right.