tyranny of choice - the case for medical arrogance?

[Alameda]

what do you think? a medical misogynist, sorry, quack explains or medsplains why we prefer to believe they know best

Why misogynist?

oh am sure he is nothing of the kind . . . think this should be in health

"I?m taking the decision out of your hands and giving you the treatment" - this is a quote from the doctor in the article.

I do not agree with this at all. I want to decide whether to have a elcs or not, not my consultant to make this decision for me. Also maybe because I consider myself capable of making this decisions or, if it is "too emotive", I am capable to let other decide, should I so chose at the time.

Not sure why you call him a misogynist though, he despises all his patients regardless of gender, religion or sexual orientation.

I think possibly maybe he might have a point about it being their responsibility - perhaps?

I think that he does have a point about how sometimes people want the doctor to tell them what to do. I know that when my DDs have been ill, yes I do want to have things explained, but I do also want to know what the doctors opinion is of what would be the best treatment. Especially with children when it is harder to be objective.

I think its the same in a lot of professions - you are going to them because you want a professional opinion about the best way forward.

It isnt uncommon for patients when given a set of options to say something along the lines of 'whatever you think doctor', and I think that that is fair enough.

do you want a choice of doctors and hospitals though, or do you just want your nearest ones to be good enough?

It's complicated though. Choice is important, but it needs to be informed choice and a lot of people lack the ability or skill to find the right information and to be able to tell sound information from woo.

Doctors are often between a rock and a hard place. If you look at the ELCS thing for example, you will get very different recommendations, depending on where you look for advice on your choices. If you get your information from websites which are biased towards "natural" birth the risks and benefits of vaginal vs cs will be presented very differently to the information you'll get on a more pro cs website. Both will cherrypick their data according to their agenda, and to the untrained it can be very hard to interpret these studies anyway.

I don't want a choice. I want to be treated by a professional in a clean place with enough staff.

I don't care what art is on the walls. I don't care about the quality of the coffee.

I dont really want a choice of hospital doctors or hospitals. I think trying to develop league tables for doctors would be unhelpful, and otherwise, how do you know who is the best? Obviously if someone has developed a dislike to someone and it is reasonable for someone else to take on the case then fine.

Also different people prefer different doctors. I see it in the waiting room at my GP practice. I know exactly how I would rank them, but it is obvious from the waiting room conversations, and hearing people book appointments that they all prefer different styles of GP.
I think choice with GP's is a bit different, because most people do have the chance to become familiar with the GPs and the way they work (though even there it will be hard in some cases to distinguish if someone knows what they are talking about or are just good at projecting that image.

I would prefer to se an emphasis on high standards of care, with a high bar for the minimum acceptable quality of care.

I agree that in many cases "choice" is a red herring. (For instance, primary schools - I say primary in particular because there might be a tenuous case for forms of specialisation for older children, who are very sporty or very musical for instance - I don't want to choose, I want the one at the end of my road to be perfectly good).
In medicine, and obstetrics in particular, it's tricky because the patient has to be emotionally and psychologically in tune with what is going on for it to be properly successful, but the patient also needs and wants to rely on the expertise of the professionals.
I hated the weeks before my dd2 was born because I got stuck in a sort of decision-making-aporia because I couldn't quite take on board that it was my job to decide (no one was making any decisions at my hospital) and that whatever I decided would be contrary to the view of some professional. I didn't unpack my feelings properly to understand that what was so hard about my making the necessary choices was that I felt it would be overweeningly arrogant to take a view contrary to trained practitioners (any trained practitioners) and that if something went wrong this would increase my burden of guilt. As no one was making decisions for me, or really acknowledging that they need to be made, or explicitly asking me to make them, (it was all a mess - Croydon university hospital - supposedly under the consultant - saw him for 90 secs in about 10 appointments - no one else made any sense) I got stuck. (ended up in MLU btw and had brilliant care)

Mental health is another one. Do you want SSRIs? Do you want counselling? I don't know, you are the doctor. When I first went to NY in the late nineties I couldn't understahd why there were consumer ads for prescription drugs all over the place when you can't buy them over the counter. Now I see why, you can just go to your dr and say you feel like the new drug for such-and-such a thing. It's a capitalism-driven model of what medicine is or should be.

I think doctors are not all trustworthy, but I wish they were all good enough that you could just trust them. I would love it to be the case that you could just say, "if that is what you think best, I'm sure it is". GPs are never like that. They just want to write a prescription and get you out the door.

just read part 2 of the 'why markets do not work in healthcare' and, particularly as vezzie says about mental health, the bit about how best practice can so wholly oppose patient choice does make the ratings thing seem very unfair at best. I would give such a glowing review of any consultant psych who prescribed me reboxetine (a generally worthless antidepressant that has wonderful if ultimately a bit dangerous effects on me) if my mood was low but it would be contrary to best practice - which is not to give me (I think I have the wrong sort of bipolar) any antidepressants at all, just horrible things like lithium or antipsychotics. I expect similar things happen with internal medicine? Patients wanting or expecting certain procedures or treatments that are not indicated or might be harmful, and then giving their doctor or hospital a negative review.

If you have to have any dealings with these these people at all you generally want to put it behind you anyway and move forward, I think. I keep getting surveys to complete from when I was in (an NHS) hospital last year, as if it was a Travelodge or something?

"marking place while I think of something to say about parents of sick children being treated like dirt despite them often being experts on their own child and that condition."

It's a difficult one again - as often patients and parents of patient often have done a lot of reading into their conditions and therefore might know more/have more up-to-date knowledge than say, their GP.

On the other hand, they often don't have the training and skills to assess what they read. Take for example the parents of children with cancer who fall prey to the Burzynski clinic. There was an episode in that series about Great Ormond Street recently where parents were shown who had "done all the research" and tried raising vast amounts of money for a sham "treatment" which not only did nothing to help the child but actually actively made her worse.

The oncologist tried his best to explain why going to Burzynski is a bad idea, but it could be taken by those who think they're experts through what they read on the internet as being patronising.

you have a point yak, particularly with rare chronic illnesses where the parents will definitely know more than their GPs - your lived experience alone, signs of relapse or whatever, quite apart from research etc

that is awful and is just incompetence or maybe because the injectable alternative to phenytoin is more expensive?

"choice" is not red herring. everyone should be able to choose to trust their assigned practitioner or to go for the second opinion, they should be able to chose to go for a treatment that is contrary to what the treating doctor recommends (note the word 'recommends' and not 'imposes')

the reason is because almost any medical intervention is about the balance of benefits and side-effects amongst others and only the individual or their representative can decide what is in their best interests. put on the scale the costs that more and more doctors will be forced to consider and i will be firmly in favour of taking more decisions about my medical treatment myself.

this not to say that expert recommendation will be ignored, this is to say that their word will not be decisive as far as i am (or my dependents) are concerned.

and it is nothing to do with "emotions", "emotional"... etc.

'choice' can only exist where there are enough practitioners, eg surgeons, it's slightly illusory - some level of autonomy and the ability to participate in the decision making process is important but these decisions will never ultimately rest with patients, it rests with the treating physician as the final arbiter. They cannot be expected to bend to our will if it is not best practice, in our best interests or is simply unethical though?

am just not 100% convinced that it is fair to expect individuals to know what is in their best interests when they have not received medical education or training to a sophisticated level?

the author presented a case where the patient was qualified to an exceptionally high level but was very unhappy with the expectation that he should make the decisions, which is interesting

market based mechanisms cannot really work as individuals don't face the true cost of their treatment or receive the true benefit. I don't need to see a specialist for a sore throat or take antibiotics for it but if I don't have to pay for it then I might choose to do so. This makes medical care more expensive for everybody.
There are some things: childbirth, pallitative care, where the best treatment involves giving the patient control but this is not I think what this blog is against

is a bit worrying that we are encouraged to see health as a sort of consumer based service here in UK, and confusing choice with control - you can want control over a situation without having to make all the choices, in fact the converse might be true. having to make all the choices could mean a loss of control

hello - pleasantly surprised to see my article discussed here. Of course I am not against patients being involved in the decision-making process. Not all healthcare decisions are made during stressful and emotionally-wraught times, for example in chronic illness, and as mentioned already where an adult or child has a rare disease the patient or her parent may know more about the illness than the doctor who would not have learned as much about it during their training. However the vignettes in my article describe situations where patients were in the unenviable position of making difficult choices, choices they not only did not want, but found too hard to make. I think it is an intolerable cruelty to expect patients to make high pressure decisions and have to bear the consequences of making the wrong decision.

With regards to childbirth, well I am in psychiatry, but during my medical school training I did obstetrics so have some limited experience. In this highly litigious field, I was shocked at how many obstetricians told expectant mothers 'the choice is yours, I'm not telling you what to do'. These were usually high risk births (e.g. breech) where the various options were not things women usually think about and I do not think it is fair to expect women to shoulder excessive burden of responsibility. That is different to shared decision-making, promoting autonomy, allowing patients to have control. It is about doctors abdicating their own responsibility, usually for the erroneous reason they believe if the patient makes the decision they are not legally responsible for the bad outcome. People make bad decisions all the time, the 'choices' in medical care are often between the right decision and several wrong ones and it does a disservice to everyone to claim doctors should just do what their patients want in a marketized system that promotes liberty above life, freedom over protection.

oh hello

I like your neologism - is it a contraction of fraught and wrought?

sorry will read rest of post

bemybebe - is the thing about "emotion" directed at me? Emotions are very important to physical wellbeing and treatment, as you know there is the famous placebo effect for instance. With obstetrics, as childbirth is something the mother has to be actively involved in, her feelings about the decisions which have been made are very important, particularly as pain management is a crucial part of successful vaginal births and emotional state and pain are very closely linked. Considering emotion is not silly, as you seem to be implying.

I do agree with your other points though about "the reason is because almost any medical intervention is about the balance of benefits and side-effects amongst others and only the individual or their representative can decide what is in their best interests" - that is absolutely true, especially where drugs with side effects are involved for instance.

However, what I meant by "choice is a red herring" is that (as with education), talking about choice and pretending that this is the ultimate desideratum is potentially a very effective distraction from the reality, which is that most people want quality more than they want choice. I would rather have my broken leg fixed up really well with all the proper physio afterwards, etc, than have a choice about whether I can go to the hospital 10 miles north of me or 7 miles south.