Physician Autonomy vs Patient Participation & Information

This image went viral on Facebook earlier this week. It generated over 125,000 shares and over 7000 comments.

There’s been some good commentary on it (I especially like e-Patient Dave’s post), which I won’t recap here.

Instead, I want to share some thoughts as to how these issues might affect our quest for improving the healthcare of older adults.

Here are some specific things that I’ve either observed or had reported to me over the past several years:

1.Many doctors do not, in fact, provide optimal care to older adults. It pains me to say this, as  I know these clinicians are usually working very hard, have good intentions, and are badly hobbled by a dysfunctional practice environment. But it’s true, and I want to call out two variants of the problem.

Sometimes, this is a failure to implement geriatrics care — meaning healthcare suitably modified for older adults — such as not avoiding risky medications or reducing the dose appropriately, or not reasonably evaluating and managing a geriatric syndrome such as memory loss.

There are many reasons a clinician might fail to implement geriatric care. It might be lack of training, or it might difficulty overriding one’s usual clinical reflexes, or it might be that the practice environment makes it very high friction to try to implement the better geriatrics approach. (We could explore this further in another post; presumably there is some research on why clinicians do what they do — and don’t do what they don’t — that can inform us.)

And then in other cases, suboptimal healthcare reflects a common failure to implement best practices or evidence-based medicine for adult medicine in general. This issue isn’t specific to aging adults, but since they seek healthcare often, they are significantly affected by this problem.

We could quibble about just what is best practice, but let’s face it, we know that examples of this are legion. For instance, inappropriate prescription of antibiotics for URI symptoms, inappropriate cancer screening, and so forth. Now, people often decry cookbook medicine and of course it would be dumb to have doctors just implementing set treatment plans for given conditions.

But then again, if there was a cookbook that provided you with a good starting point for a recipe, and then you could adapt from there as needed, and everyone regularly reviewed the cookbook, the health quality nerd in me thinks you’d probably end up with overall better outcomes. (I know this would be hard to implement properly, having been subjected to treatment recommendations in my own work. But I stand by the principle.)

Furthermore, I don’t often see clinicians documenting their thinking in their notes, and also documenting that they discussed the reasons for their approach with patients. So when they deviate from recommended practices, it’s impossible to know whether that was intentional and considered, or not.

In short: the status quo means older adults — and patients in general — often get suboptimal healthcare. So we shouldn’t stick with the status quo.

2.Patients, family caregivers, and geriatric care managers tell me that many doctors react negatively when their advice is not taken right off the bat. This includes:

  • Responding negatively when patients bring in extra information to try to influence the care plan.
  • Saying “Did you go to medical school?” when extra questions are asked. (I’ve heard this from a few care managers, and suspect some docs may feel more comfortable shooting down a care manager than a patient or family member.)
  • Dismissing information found online or through Google searches.

Of course, many physicians are encouraging their patients to do their own research and bring their findings into the visit. But it remains common for patients and families to encounter resistance.

3.I’ve experienced a few instances of clinicians refusing to share their notes with me, despite repeated requests.

Needless to say, the patients had completed a release of information form, and had also asked their clinician to collaborate with me.

In two cases, this happened after I received an initial set of records from the clinician AND had spoken to the clinician in person. So it’s hard for me to avoid the conclusion that the clinician was — at least at some level — trying to decrease my involvement in the patient’s care, despite the patient and family wanting my involvement.

Summarizing these three issues:

Many older patients are getting sub-optimal care. It’s also not uncommon for clinicians to discourage patients and families from consulting resources online. A few clinicians have gone so far as to refuse to release records to me, when patients have asked for me to weigh in on their health concerns.

What we don’t know is if clinicians who deliver more sub-optimal care are also more likely to discourage families from consulting additional sources of information. But regardless: if you’re a concerned patient or family member, and you want to make sure you are getting optimal healthcare, today you may well have to choose between your doctor’s comfort and your ability to leverage additional information sources.

Now, I do try to give practicing clinicians the benefit of the doubt, and I don’t want to make them out to be bad people or bad doctors. I know that most of them care about their work, they care about their patients, and they truly want to be helping patients with their health.

I also know that most of them practice under a lot of time pressure, with increasing administrative burdens and hassles, which makes it hard to be gracious about anything that introduces friction or effort into the patient-clinician encounter.

Explaining options and one’s thinking to the patient takes time and effort. So does trying to integrate some other information, whether the patient found it on Google or received it via seeking a second opinion. (Or received it due to some spiffy new app or digital health service.)

And I definitely appreciate that it is hard to practice when you feel there are too many cooks in the kitchen. And it would stink to feel that someone else is second-guessing you. And of course a clinician who has the luxury to spend an hour poring over health records and another hour talking to the patient might uncover things, and why the heck isn’t that clinician knuckling down and having to work hard and fast in clinic and taking insurance like real doctors do anyway?

So. If I were in those doctors’ shoes, I would struggle with patients and families asking me questions, and I would struggle with having to integrate the advice of some other doctor when I didn’t make a referral in the first place.

But I certainly wouldn’t refuse to release my clinical notes or any laboratory and other results I had. And I hope I’d be gracious and receptive to additional information the patient was able to bring in…if I couldn’t be, then I’d have to think about leaving the practice environment, because it really is soul-destroying to be unable to care for patients as you feel you should be doing.

The Quandary: Clinician Autonomy & Bandwidth vs Healthcare Quality & Patient Participation

I don’t know that I have much more to say other than that this is a serious quandary, and I’m not quite sure how we get out of it.

I feel for PCPs and I understand they work under difficult circumstances. But at the same time, as healthcare improvers, our priority has to focus on what helps our patients and families get better healthcare.

If that conflicts with what is best for — or preferred by — practicing clinicians, we should not wave off their concerns. We need clinicians to be doing their best work, and they can’t do this when they are frustrated or resentful. But we are going to have to find a way to bridge the gap.

I have no doubt that we overall increase the chances that people will benefit from their healthcare, when we provide them with practical information on recommended care, and encourage them to bring this up with their doctors. And I know that digital health technologies will bring us resources on this front.

But in the short-term, there is often push-back from the clinicians, which can be bad for patients in the short-term. And it’s certainly bad for clinician morale, which means they are even less empathetic with patients and also less equipped to participate in changing healthcare for the better.

Will technology help us get out of this quandary, or make it worse?

In the short-term, both will be true. Hopefully in the longer term, technology will allow us to make better use of clinician bandwidth. With that and some culture change in the clinician-patient relationship, we should be able to find our way towards healthcare that does more of what people need from it, and is a better fit for their preferences.

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