Shared decision making with patients

    There's nothing better than sitting down with a patient, going though an entire visit, and  collaborating on a well thought out plan that meets everyone's expectations. Shared decision making is a wonderful and necessary concept in modern patient care. Paternalistic attitudes are fading away in the medical community as the next generations of doctors continue to get educated on how to manage patients who are very knowledgeable and yearn to be active participants in their care.

    But as patients become more involved in the decision making process, differences in opinion become more prominent. Although these differences can be overcome through open discussion and trust, it is a challenge that is occurring with regularity. In this era of short pressured visits, it's hard to have long conversations to help meet the patient in the middle when there is a difference in opinion. Litigation concerns also influences decision making immensely, and when there is a debate about whether "to test," or "not to test," we might be inclined to align our opinions more towards what a patient wants.

     When a patient adamantly wants something done, and I rationally disagree, it can be a disheartening experience. I reflect on how I've spent years studying, training and practicing. I think about how I've spent years, not just memorizing facts, but cultivating clinical acumen that integrates multiple data points to compute probabilities of disease states and figuring out likelihood ratios of different tests or medicines and whether the benefits greatly outweigh potential harms and costs. And I have to do this within seconds to minutes in my head, while factoring in patient preference and medico-legal concerns.  I do this juggling act countless times a day, and when I'm wrong it hurts. It hurts my ego a little bit. But it hurts more because you always want what’s best for the patient.

   I'm sure we all have stories of things we regretted ordering for our patients. I can think of several instances of how I acquiesced to a patient’s request that resulted in poor outcomes. Antibiotics that I didn't want to give, leading to C-Diff colitis, imaging with incidental findings that lead to unnecessary worry, procedures and complications are just a few examples. I can also think of many instances where patients have come to me with positive test results or better outcomes from things I was reluctant to do.

    Whether you are for or against shared decision making, it is here to stay. Patients want to have to more say in their care and that's a wonderful thing. Involved patients will always do better than detached ones. The modern physician will need a balanced temperament to handle the ups and downs of this two way relationship. Fortunately my ego is just big enough that I return to work every day smiling, feeling good about all my  decisions.  But I do keep my ego in check, mainly by taking some Tums tablets. I've realized my heartburn isn't caused by the coffee I drink, but all the pride I'm willing to swallow and the large heaping servings of humble pie medicine serves me with regularity.