According to Ezekiel and Linda Emanuel there is a struggle between patients and physicians regarding the amount of control that patients have in the decision making process when it comes to their medical care. This struggle arises because of the unbalanced nature of human rights of the patient verses the physicians duty to keep patients from harm even if its from themselves. So in order to give a solution to the problem they have outlined four types of physician-patient interactions that have occurred in clinical settings.
The first of the models is the Paternalistic model. This model only ensures that the patients receive the best interventions solely based on their health and well-being. The physician has no regard for the patients values or desires. The second model is the Informative model, where as the physician gives the patient all the vital information to make their own choice in the type of medical intervention that he or she wants and then the physician follows through with what the patient has chosen. The physician in this case only does what the patient wants(not bothering to ask the patient of his or her values and/or desires) and does not suggest his or her own thoughts as to what the patient should do. Thirdly, you have the Interpretive model where the physician tries to elucidate the patients values and desires of what he or she actually wants and then tries to help the patient select the best possible medical option that correlates to the patients values. In this case the physician seems to care about the values of the patient and tries to offer some advice as to what should be done.
Lastly, you have the Deliberative model where you have the patient and physician both collaborating with one another on the best medical care and the best course of action in order to make the patients values come to life( or give them a more realistic view of the situation) for overall optimum health. In each one of this case the patient can also be an issue in regards to their own health. Patients can range from not being able to voice their desires to being blatantly defiant with what the physician suggests, or waiting on the doctor to tell them what they should do and not questioning what other possible solutions there may be.
In my opinion the deliberative model is the best in terms of physician-patient relationships. I want a physician that is not only going to give me information, but listen to my desires and values and help me try to facilitate my views in a realistic sense.And I want to be able to grasp the knowledge that the physician as given in order to be able to satisfy my level of autonomy. But all to often I hear stories of physicians and patients being the latter. I have a best friend that is diagnosed with Ehlos-Danlos Syndrome and she has had doctor's that have represented each one of the models that have been named. Also, I have seen patients that refuse to act right when it comes to their own health and medical care that they have gotten from the doctor. Then in the same breath ask why do I have to feel like this or why me? And now are running to the doctor and asking what can they do "now " to make the issue that they have go away.(because they have made the problem worse.)
All in all, I believe that a physician would have to embody all of the models because it depends on the type of patient that he or she encounters. And be able to discern the type of patient that you have before you so that they will be able to give diagnosis, prognosis, and possible treatment solution in certain manners with regards to the patient that they are treating. With out this knowledge the patients autonomy could be in trouble.
So what should be the ideal Physician-Patient relationship for you? And where does you level of Autonomy fit in?
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The quotation on page 84 expresses one of my worries about the deliberative model:
ReplyDelete"At the level of clinical practice, medicine should be value-free in the sense that the personal values of the physician sohuld not distort the making of medical decisions."
The deliberative model suggests patients reveal details of their values and, to some extent, his/her life situations to the physician. Though the physician may not be explicit, s/he may disapprove of the patient's lifestyles and values. Such disapproval, or disagreent, of the patient's values may affect medical decisions.
Furthermore, in some cases, the patient may be unwilling to reveal so much about his/her life and value systems to the physician and create a bonding that stretches beyond the kind illustrated by the informative model. Perhaps it is true, as Emanuel&Emanuel asserts, that the society's image of an ideal physician is not limited to the kind illustrated by the informative model; however, one must not neglect the simple fact that the society's ideal physician may not be an individual's ideal physician. Some patients would rather go see House than Wilson.
From a more practical perspective:
Emanuel&Emanuel admits that "and no doubt, in practice, the deliberate physician may occasionally lapse into paternalism" (85). My worry here is that promoting the deliberate model in doctor-patient relationships may result in a slippery slope that eventually leads to disguised paternalism.
The second practical point:
Under the deliberative model, a physician will have to spend more time with each of his/her patients. The medical advantage (the magnitude of which is controversial) gained from closer patient-doctor relationships might not justify the extra time that is spent with each of the patients. The physician may be better off if he treated more patients, instead of engaging in multiple sessions of pseudo-life counseling with patients.
I agree with Jamespointdexter with the belief that a physician would have to embody all of the models because it's necessary for the different types of patients that they encounter.
ReplyDeleteI think that the interpretive model is the best for physician-patient relationship. I did not feel right about one of the objections with the deliberative model, being that this model misconstrues the purpose of the physician-patient interaction. Patients see physicians to receive health care, not to engage in moral deliberation or to revise their values.
With the interpretive model, the physician is not there to revise their values, but to understand what values the patient has and to help them make a selection according to the patient's values. Therefore, the physician is not swaying the patient one way or the other when it comes to values, but helping the patient make the best decision according to that person's values, even if the physician holds opposing values for themselves.
I think that autonomy is best displayed in this model because the physician is taking in consideration what the patient values, and that gives the patient a strong sense of autonomy, meaning being their own person.
Well said, Lebenswelt. I too am worried that a movement towards the deliberative model could lead to a form of paternalism. This worry became especially clear to me in the clinical case section. In the example the authors give, the physician explicitly tells the patient what she should do, and offers many reasons why she should do this, including how greatly she will contribute to women with breast cancer in the future.
ReplyDeleteThe reasons are so convincing that it seems (at least to me) that it would be almost impossible to turn down the doctor’s advice. Isn’t this impinging on the patient’s autonomy? The Doctor’s advice is so one-sided that he leaves no room for the patient to make her own decision. And if this is the author’s best example of a deliberative physician, I don’t like it.
I agree with ilovelucy that the interpretive model is best. The doctor shouldn’t be there to sway our opinion, but rather counsel us to make the best decision for ourselves that fits with our values.
But, as mentioned before, there’s a different model for every situation and every person’s preferences.
Ilovelucy wrote: The medical advantage (the magnitude of which is controversial) gained from closer patient-doctor relationships might not justify the extra time that is spent with each of the patients. The physician may be better off if he treated more patients, instead of engaging in multiple sessions of pseudo-life counseling with patients."
ReplyDeleteThe question I pose is how is it not justified to have doctors spend more time with their patients? How would spending less time and seeing more patients improve the quality of our broken health care system? As Emanuel and Emanuel stated "we must develop a health care financing system that properly reimburses-rather than penalizes-physicians for taking the time to discuss values with their patients." Now, I personally do not go to a doctor's office to dicuss the morality of my values and the validity of my decisions but I would at least expect a common regard for my emotions and feelings associated with my illness at that time and at the very least more than 15 mintues of their time. (I am sure all of us have come across a doctor that does not even regard you as human.)
I have seen through clincial experience that the informative model does not work for those patients who do not fully understand the information that has been presented to them. In this situation, the model fails the patient. The interpertavtive model may work for this patient but as Emanuel and Emanuel point out, it does not take into account second-order desires or changes in one's values as a result of becoming ill. If the deliberative model was used, at least the doctor could help the patient decide what treatment is best for them by gauging their current health-related values and what ultimate outcome they hope for in their diagnosis. I do believe that it is true that each patient relationship model can be neccessary in different situations but ultimately I believe that the problem with our doctor-patient relationships (by the way who decided that the doctor comes first in that term anyway?) in today's medical world lies in the fact that for too long doctors have used the first two models in their practice and have not looked at their patients as human beings but more as case studies.
Like most of these posts, I agree with jamespoindexter that different situations (ie. patients and their doctors) require different techniques for resolution, but I do also agree with Wasabi with regard to the argument that time should not be a limiting factor on how a patient's care is evaluated. If a doctor sees 50 patients in a day but does nothing but skim the real nature of the problem for those 50 as opposed to spending an extra 15 mins or so listening to and assisting one patient to formulate a successful care plan, how can we see the former as a better solution than the later because ultimately, just as fast food might quench our hunger for the moment, fast health probably could be expected to do little more for our overall health benefits.
ReplyDeleteWhen I read how Emanuel & Emanuel described the models prior to the clinical examples, I was sold on the deliberative model because it seemed the most compassionate while allowing a level of autonomy that I could feel comfortable with. Initially with that model, I thought the doctor was helping the patient by re-stating the patient's value system (for the physician's clarity only) and relating that information to how the patient would be cared for. However, the clinical example changed my mind and brought the differences in the models home for me. Now I am leaning heavily toward the interpretative model.
Just as lebenswelt stated, the deliberative model seems the most invasive as the physician tries to "get in the mind" of his/her patient and persuade the patient to how the physician determines his/her value system. Creepy. Maybe this is appropriate for a psychiatrist or psychologist, but minus these specialties, I don't think the deliberative model is appropriate for me.
I believe the interpretative model, when used deliberately allows the patient the most autonomy. It all boils down to communication. I think that any physician who uses this model when treating their patients would by nature of the definition of this model, be doing their patients a disservice if they could not explain the patient's issues at a level the patient could understand, interpreting the wants of the patient and how to achieve these goals - seems a win-win.
I suppose the beauty of healthcare in America is that we have some choice with regard to who we want to care for us, and if the physician we have has values dissimilar to our own, we can go elsewhere. Right?
By the way Wasabi, I don't think there are any hard and true laws with transposing terms like "student - teacher", "parent - child" or even "physician - patient relationship". My guess is the authors arbitrarily wrote it that way because they wanted to appeal to their audience (this article was cited from the Journal of the American Medical Association), or perhaps their view holds that physicians have a greater priority than patients. I don't think you'll go wrong to write it however you want...as for me, I'm going alphabetical!
After reading the descriptions for all four models of doctor-patient relationships, I had decided that the deliberative model was the best approach for doctors. I believe that it is important for doctors to assume the role of a teacher/friend when interacting with patients, rather than acting as a counselor (interpretative model), mechanic (informative model) or just as someone who knows whats best for us (paternalistic model).
ReplyDeleteFrom just the reading alone, I believed that this model gave the patient the greatest autonomy because of the statement (p80):
"The conception of patient autonomy is moral self-development; the patient is empowered not simply to follow unexamined preferences or examined values, but to consider, through dialogue, alternative health-realted values, their worthiness, and their implications for treatment"
This seems to grant the patient the greatest autonomy, but I do agree that there is room for subconscious persuasion which would shift this model towards the realm of the paternalistic model. Even though there is a possibility of a Freudian view of unconscious influences, I believe that this model is best suited for doctor-patient interactions because it is informative, compassionate, and still grants patient autonomy. I felt that the other models lacked at least one of those qualities and thus were not ideal.
I must respectfully disagree with jamespointdexter “that a physician would have to embody all of the models because it depends on the type of patient that he or she encounters. And be able to discern the type of patient that you have before you so that they will be able to give diagnosis, prognosis, and possible treatment solution in certain manners with regards to the patient that they are treating.”
ReplyDeleteI understand that all patients are different, but do we really need doctors to adjust their patient interactions to such a degree?
If physicians were intellectual supermen this would be possible, however in reality it is simply does not seem feasible to me.
Society demands doctors are intelligent, that is a given. They must know the ins and outs of their area of expertise to the best of their ability, and continually build upon that base of knowledge by staying at the forefront of their field. We even reward those doctors who are technically better than their peers. How can we expect them to not only be exceedingly technically proficient in their given field, but also understand the emotional needs of every patient they see?
Our class discussions seem to dwell on the role of the physician, but what about the physician, him/herself? They are fallible human beings. While they are hyper-educated, there is a limit to what we can expect from them and their interaction with patients.
I am not defending every doctor’s actions, nor am I justifying genuinely mean doctors who do not even treat their patients “as humans,” as Wasabi experienced. But, a physician who sees a patient for 15 minutes cannot determine what that patient needs the doctor to be (paternalistic, interpretive, etc).
Once a certain level of “niceness” is met, why do we need doctors to be even more accommodating and adjust their personality on a scale that ranges from that of a technician to a loving mother, solely dependent on the patient’s psychological needs?
If a patient wants a physician who will use a specific doctor-patient relational role, then it is the patient’s responsibility to research what doctor fits that role. We have talked a lot about patient autonomy and patient rights to medical care, but along with making those decisions, is it not also the patient’s responsibility to chose the doctor they believe will fit their needs best?
Autonomous decisions do not begin when the doctor provides his/her opinion, deciding upon a doctor is an autonomous decision made by the patient as well. If a patient is unhappy with their choice, they should switch doctors.
Excluding emergency room situations, a patient does have the time and resources to find their ideal doctor, and they should. A patient is rewarding the model they think is best by bringing that doctor their business. It is sad that is what medical care has become, but that’s the current state of medical care in the United States.
Society should not force only physicians to adapt to their patients. The patient should adapt to the system and see the doctor they feel fits them best.
After class last week, I was teetering betwenn still wanting the informative model for myself as a patient and thinking the deliberative model as at least a good start for doctor-aptient relationships.
ReplyDeleteThis week's article however on informed consent sent me right back to the informed model. I completely agree with the author of "How we die" stated on pg 97 " (I) do not expect him to "understand my values, my expectations for myself...my philosophy of life. That is no waht he is trained for and that is not what he will be good at. Doctors can impart information but it behooves every patient to study his or her own disease and learn engough about it. Patients should no longer expect from so many or our doctors what they cannot give."
I think my struggle comes down to the whole pratical issue I have with the doctor patient relationship models. I know that this discussion is meant to be in an ideal setting but in the medical world that does not exist and we cannot expect doctors to be trained in all scopes of psychology, sociology, multiculturalisn and medicine, and create a meaningful relationship and dialogue with us in fifteen minutes or less. Regardless of the pratical issue, I still find myself drawn to the informative model once again purely because it creates the most autonomy for the patient.