December 1, 2010

I Need to Understand You Better

Back in the day, your doctor told you what the treatment was going to be, sometimes without even telling you the diagnosis, because they didn't think you could handle it. 

Today, doctors are encouraged to go almost entirely the other way by offering 'patient autonomy' -- you know, lay out the jargony pile of facts and let the patient decide what's best for themselves.

The trouble is, it's not working, physician, author and behavioral researcher Peter Ubel MD told the Trent Center for Bioethics lunchtime lecture at the hospital on Dec. 1.

In a series of ongoing studies that are likely to lead to his next book -- his fourth -- Ubel is videotaping and coding doctor-patient interactions as the doctor delivers a diagnosis and then lays out some possible responses.

"I think of it like the Gary Larson cartoon," Ubel said. "The patient hears 'blah blah blah CANCER, blah blah.'"
 
Because of a "failure to understand what's going on at the other end of the stethoscope," doctors simply aren't able to grasp that their patients don't understand the situation in the same way. 

"We've left our patients wallowing in a swamp of irrelevant information," said Ubel, who recently arrived at Duke to take up professorships in Medicine, Public Policy and Business. The business school is where one finds decision science, he explained. And that's where one learns things like the idea that describing the risks before the benefits results in a different choice than if the benefits are described before risks. Or that 3 in 100 sounds a lot less dangerous than the identical 30 in 1,000 occurrence.

Until better protocols are developed to help patients make good choices, the best thing doctors can do in the near term is take an extra moment to understand, Ubel said.

"When the patient asks 'what should I do?' the doctor should say 'I need to understand you better before I answer that.' "