So-Called Choices

Dr. Schwab has once again waxed eloquent, this time on the issue of immediate versus delayed breast reconstruction after mastectomy for breast cancer. One of the things he admits is that he has a bias, in this case a bias against immediate reconstruction, but that he tries not to let it sway him in how he counsels patients. I have no issue with the specifics of breast reconstruction timing, but I'd like to address the issue of physician bias -- and not at all to bash Sid!

I agree that not only do we all have our biases, but I would like to point out that it is the nature of the physician-patient relationship -- as a practical matter -- to use those biases all the time to make choices for our patients.

That is our job.

This is not a bad thing. We make very good choices for our patients almost all the time. Oh, we tell ourselves that we give our patients all the information they need to make their own decisions and that we respect the choices they make. I submit that we are being dishonest with ourselves, and here's why: when patients make choices with which we don't agree, we call them "inappropriate" and do not honor them.

I am not speaking of paternalism, the essence of which is that the patient should blindly agree with whatever we say. Although we are making the decisions, it is still incumbent upon us to explain to our patients -- in sufficient detail, and at a level they can comprehend -- why the course we are recommending is the "choice" they should make.

Many times, as a practical matter, the only way a patient can make a different choice is to consult another physician.

Look at some examples:

• A patient wants antibiotics for an upper respiratory infection.

I can explain until I'm blue in the face that this is not a good idea, that they don't work and won't make him feel better any quicker, the risks of allergy and resistance and everything else. Although this interaction can be described as explaining appropriate therapy for a URI, the reality is that the patient has made a choice I don't agree with: he has chosen to treat his URI with antibiotics. That's why he's come to my office. My options are to stand my ground and explain my position, or give in and write him the prescription ("honor his choice.") The patient's options are either to come around to my way of thinking (if I'm persuasive enough) or he can go see old Doc Jones up the street who gives out Amoxicillin like candy.

• A woman wants her breast cancer treated with diet and Reiki.

Similar to the above, but with much higher stakes. Everyone will be all over this lady about what a poor choice this is. The unfortunate truth is that in some tragic cases, these patients will not be convinced. There will always be someone -- Reiki masters and NDs -- willing to do whatever it is she wants; who "honors her choice."

• A family wants to continue life support for a patient with no hope of recovery.

This is a frequent occurrence in the ICU setting. My guess is that most physicians would gently explain the limitations of futile care, trying to persuade the family to withdraw heroic measures, ie, disagreeing with the choice they've made, and persuading them them that a different choice would be better.

Now how about this one:

• A family wants to withdraw life support but the physician feels the patient still has a significant chance for recovery.

I know this one is tough to imagine, but imagine a self-limited condition in an otherwise healthy patient; say temporary ventilatory support for pneumonia. The family says, "Dad didn't want to be on a breathing machine," and we rush to say, "That doesn't apply here at all! He's not terminal; the ventilator is only temporary." The family comes around quickly -- and appropriately -- but what really happened is that a family was guided away from making what we felt was a poor choice.

This has been addressed elsewhere:

• A woman wants an abortion but her doctor is morally opposed to the procedure.

Different doctors respond differently to this scenario, but clearly the physician's bias is the major determinant of whether or not the patient's choice -- legal, and hers to make according to standard medical practice -- is honored.

Patients make bad decisions ("wrong choices") all the time. They decide they're sick enough to need an ER, but medical personnel disagree with them, so they wait until others who are correct in their assessments of how sick they are can be cared for first. Much of the time, we as physicians can agree that one given patient decision is better than another, or even that some are "wrong." On the other hand, that agreement is far from universal; witness the abortion "choice" above.

In addition, there are plenty of other clinical scenarios where we can agree there is no clear cut "best" choice: surgery or radiation for prostate cancer? Beating heart CABG or cardioplegia? Immediate surgical repair or casting for Achilles tendon rupture? In cases where the evidence is not yet complete (or where a doctor is unaware of, or chooses to ignore the evidence) physicians have their biases, often very strong ones. Certain urologists truly believe in their hands, prostatectomy is better than radiation. Some orthopedists will never operate on an Achilles tendon; others insist it's the only way to go, and so on. This is where "physician bias" comes into play. We usually call it "experience" instead of "bias" because we often feel we have a rational basis for the decision (let the patient process the cancer experience before going through major reconstructive surgery, per Sid) but all we've done is legitimize our bias. I'm not saying there's anything wrong with it, but it is still a bias.

I have a friend who needed a valve replaced in her heart. The research she did was exhaustive: hospitals; doctors; complication rates; techniques. As medically sophisticated as she was, how did she -- or anyone, really -- have the expertise to choose between multiple tertiary care centers and different surgeons each telling her his approach was best? Here's what I told her: If there were one clearly superior procedure, it would be the only one. The more different people there are telling you different things, the less it matters; your chances of doing well are good whatever you choose.

How are patients supposed to figure all this stuff out?

They're not. We're the doctors. We're the ones who are supposed to know about these things. We are the ones who should be making the decisions. There's nothing wrong with this. It's our job. As long as we communicate with our patients, get to know them and their preferences with regard to their health (ie some people prefer a cheaper med even if it has to be taken multiple times a day, and have no trouble with adherence; others feel the convenience of once daily dosing is worth paying more) and take those factors into account when we make our recommendations, we are indeed collaborating.

As Sid pointed out and as others are sure to echo, many of our patients will ask us, "What would you do if it were you/your family member?" The only way to fully avoid expressing a bias is to refuse to answer, and I don't know many doctors who can do that. Virtually everyone will eventually answer that question: they will tell the patient which choice they ought to make. If that isn't the same as making the choice, it's too close for comfort.

None of what I've said absolves the physician of the responsibility to make as certain as humanly possible that patients understand their conditions, what the treatment options are, and why the doctor is making this specific recommendation at this time. But at the end of the visit, when the pedal hits the metal and the rubber meets the road, we are the ones making the choices.

What's my point? That instead of foisting off the final decision on the patient by citing "patient autonomy" as the ultimate good, we need to recognize that in the end the responsibility is ours. Making these decisions thoughtfully, transparently, in consultation with the patient -- and with the awareness that we are making them -- is more intellectually honest than telling ourselves that "the final choice is up to the patient."