In Bill’s room were his doctor, a medical scribe, a physician assistant, and a medical student. Not an imposing group, but in that moment each of them knew more about what was happening to Bill than he did. They were strangers who held keys to his fate.
The doctor first instructed the scribe to generate an electronic note. Then, he turned his attention to the PA to schedule the surgery for Bill. Finally, the medical student got a quick lesson in anatomy and how to read an MRI.
All the while, Bill sat uncomfortably on the examination table. He still had no idea what the terminology being passed around meant. He wasn’t sure what was wrong. He was pretty certain something was torn (after all it was quite a fall he took). But he was also starting to feel better after a few weeks of rest. He was still training; when he scheduled the visit he simply wanted to know if he was still able to continue without causing more harm. He hadn’t expected things to go this way.
Most patients who enter our exam rooms have a few simple concerns:
Will my problem become worse?
Is it cancer?
Can I continue to live as I have if I don’t have surgery?
Bill wasn’t any different. He knew something in his shoulder had changed with his fall, but he was getting better and remained quite active. Putting on his shirt in the morning was a bit of a chore, and forget about reaching into the back of the car to pull something into the front seat. But other than that he was fine.
After his appointment, Bill obtained a copy of the MRI of his shoulder. There, he saw the mention of a “tear” in one of the structures. He searched online, but didn’t understand most of what he read. He’d turned his fate over to a team of experts, yet he still wasn’t sure what was wrong, why he needed surgery, or whether or not there were other options on the table.
Bill was pretty sure he had told the doctor that he was a triathlete in training. He thought he must have mentioned that his shoulder was feeling better. He’d turned over all the information, and surgery was the recommendation. So he signed up for the intended surgery.
Unfortunately, due to a series of factors, surgery turned out to be the wrong choice for Bill. Six months later, he was still in pain, still in physical therapy, and was just coming off of the blood thinners to treat the clot in his lung that almost killed him. He hadn’t put on his running shoes, saddled his bike, or approached a swimming pool. He was pretty sure he never would.
It didn’t have to be like this. Most decisions made in a physician’s office today can and should be organized as a shared decision-making process. Patients don’t have the option standing next to us in the ER, watching us manage and react to unexpected discoveries. But they do sit with us in the exam room, alert and starving for information as we evaluate and plot a course of action. In order for expectations to be met, we need to make sure these individuals have the opportunity to understand what’s wrong, and what the research or literature says about treatment alternatives. Our patients have the right to know the risks of the alternatives available, and with that, the responsibility to take a very active role in choosing a treatment.
Most physicians are open to engaging with patients – and most do care about trying to do what’s right. Sometimes, we fall short at soliciting input, just as patients can find themselves tongue-tied.
Therefore, among the myriad checklists we manage, it’s essential that both doctor and patient remember to initiate and engage in this one:
Before the exam:
What are they symptoms?
Are they changing?
Do they affect quality of life?
After the diagnosis:
Explain what it is. Clearly. Talk about it in more than one way. And draw diagrams or show pictures on the computer if possible.
State why the treatment plan was specifically chosen.
Discuss other options.
Talk about what will happen if no action is taken.
Address the issue of further testing — whether it could help, or be overkill.
At the end of the visit, make sure that the notes are shared and that the patient has the opportunity to go home and process the information, speaking with friends and (yes) going online to learn more. Also, that the patient has the opportunity to follow-up with questions.
Information and realistic expectations, not data points, are the true measure of success and satisfaction in medical treatment. Had Bill had access to this, he might have made a very different decision and will regret it for the rest of his life. It is our responsibility as physicians to help our patients obtain the knowledge they need. Let’s encourage questions and thereby raise the bar on all our outcomes.
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