I very much enjoyed the responses to my last post. I’d hoped to engender a vigorous discussion, and it worked. Now we need to expand on the conversation.
We’ve had many discussions on this blog over the years about the conflict in medicine between autonomy and paternalism, that is how much value to place on the choices and freedom of the patient vs. the expertise and advice of the doctor. In the past, medicine relied heavily on paternalism, with doctors dispensing “orders” to patients without needing to answer many questions. In fact, it seems as if paternalism was at its peak when doctors had fewer answers. Over the years both medicine and our culture has changed, with much more being known about medicine, and oddly, more patient participation being both needed and desired.
Do I get a colonoscopy for an eighty year-old patient? I can’t really know without my expertise of cancer screening combined with a knowledge of my patient’s values. What came up in my last post though was both questions: what if a doctor is too paternalistic to know my values, and what if my doctor doesn’t have sufficient expertise?
A certain dose of paternalism is necessary in medicine, and a patient shouldn’t go to a doctor expecting to have to answer all their own questions. I trained for so many years so that I can help patients find the knowledge they need to stay healthy, regain health, or leave the world as painlessly as possible. People who “doctor shop” until they find someone willing to do what no other doctor will (e.g. some fancy, unproven heart test or some bioidentical hormone nonsense) probably misunderstand what expertise is. I have a great deal of respect for people who doctor shop looking for someone with knowledge and compassion; doctors who are willing to listen to and answer difficult questions, and dispense difficult answers. But ultimately there is a level of trust that has to precipitate. The doctor has to trust that the patient is doing their best to give them information, and the patient must trust the doctor to have the proper expertise and to dispense good advice.
There is no one way to confirm a primary care doctor’s expertise. It helps to see if they are board-certified in their specialty (primary care usually includes internal medicine, pediatrics,and family medicine). It also helps to have heard good things about them in the community. But ultimately you have to figure out if you trust them, if they give advice backed up by data when you ask for it, if they give choices (even if a choice is “take this pill or risk a heart attack”), and if they are willing to say things you don’t want to hear.
Every primary care doc has a different pattern of using sub-specialists, depending on their comfort dealing with various problems and the resources at their disposal. I’m fortunate to have been well-trained and to have a lot of resources at my disposal. I’m also not involved in many insurance plans that penalize me for referring. My tendency is to do as much as I can on my own for problems that are within my expertise, and to refer when I’m over my head or a problem is obviously not “mine” (e.g.,I’m not a surgeon, and your appendix is not coming out in my office).
But others may feel less comfortable and may wish to refer earlier. Or they may wish to but face incentives from HMOs not to. It’s a mess out there, and adding in patient preference makes it messier, but it’s necessary. A good doctor knows when to refer and knows when to help guide a patient’s choice. If a patient has lost their trust in me to treat their blood pressure—one of my basic jobs—they probably shouldn’t be seeing me at all. If, on the other hand, I’ve run out of ideas about their blood pressure and want to ask for help, I hope they see this as a strength rather than a weakness.
Patients are in a real bind. They don’t know if a doctor is in over their head, and they don’t know what incentives a doctor may be facing—but they can ask, frankly and often (hopefully asked respectfully, for the sake of the relationship). While insurance and geography may limit choice, there is still often some measure of choice, and doctor’s who aren’t willing to answer questions about their own expertise are either a bit too touchy or more worried than they’ve let on.