One of the latest trends in health care is “patient choice,” meaning the patient is in charge of their own care. Our job as a physician is to educate patients about the diagnosis, discuss the various treatment options, go over risks and benefits, then allow the patients to choose the best course of action. Of course, this assumes that patients always make the right choices and are solely motivated to get better. But every physician knows this isn’t always true.
I don’t remember a time when I did not educate the patient about diagnosis, discuss the various treatment options and talk about the risks and benefits. No one is denying that this should be our responsibility. What’s changed is how we are supposed to react to the patient’s choice. We’re meant to put the patient at the helm of his or her own health care ship. What happens when it’s heading for a reef and the captain fails to heed our warning?
In the area where our three-man orthopedic group practiced, there were a lot of older patients so we had considerable experience dealing with hip fractures — sometimes one per day. There are, basically, two ways to treat a hip fracture in an otherwise healthy, ambulatory patient. You can put them on bed rest and then allow the fracture to heal on its own which would take about eight to 12 weeks, or you can operate and fix the fracture which allows the patient to get up and move often within one day. Since you are dealing with an older population, there are always risks in operating, but the risks associated with lying in bed for eight weeks are considerably worse. Needless to say, I would highly recommend the surgery. In fact, it is close to malpractice if you don’t. The problem then becomes: should you even offer the bed rest option? I’ve heard of surgeons who only offered the surgical option, but the patient developed complications and the family sued for not being offered the bed rest option.
I chose to offer both to cover all the bases. But on occasion, there were patients who chose the bed rest option. When I started out in practice, I respected the bed rest option but witnessed how detrimental that was. I also ran into conflicts with the hospital regarding length of stay and nursing home care.
So here was my quandary: How do I handle an otherwise healthy, ambulatory patient with a hip fracture who refuses surgery ?
I decided to do what I had always been doing regarding the discussion of risks and benefits. When I discussed the option of bed rest, I made it clear that if they refused surgery they would have to find another physician. As you can imagine, this did not go over well with some patients or their families.
For several years, my strategy worked well until the age of patient satisfaction scores and patient choice came upon us. I recall several incidents where the families filed complaints against me. My response was the same — bed rest is such a detriment to the health of these patients that it would be a violation of the Hippocratic oath to treat them that way.
What changed was the pressure put upon me to do what the patient wanted.
The last time that happened, the hospital threatened to label me “disruptive.” My response was a counter threat to file a report against the hospital that they were putting the patient’s safety at risk. Needless to say, nothing happened.
Whether or not I got a mark against me on some anonymous patient satisfaction site is impossible to say. How that can possibly be helpful is beyond me. Fortunately, I was able to retire before the age of poor patient satisfaction scores threatening my reimbursement. This has to be one of many reasons for the high rate of physician burnout.
We are now in the throes of patients being in charge of their own health care ship. If our function is to simply play the role of the navigator, what are we to do if the “captain” insists on steering that vessel toward a reef and we are under the threat of being thrown overboard if we don’t comply?
I say then, the best option is to not get on that boat at all. No sense in going down with a doomed ship.
Thomas D. Guastavino is an orthopedic surgeon.
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