Patient or Consumer?

Discussion

Paternalism in medicine is dead. In its place, patients, often (well) informed by Dr Google, expect to be in control of their own health care. Patient autonomy and the “customer knows best” have replaced the “doctor knows best”. In part, this change has been driven by the law, with the principle of autonomy being one of the central values of our legal system.

And yet, at times, there is a tension between patient autonomy and the responsibility of doctors to make sound clinical decisions and provide good medical care. When patients see themselves as consumers of health care, and doctors acquiesce to this model, problems can arise, including risks to patients’ health and medico-legal risks for doctors.

A common theme in serious disciplinary cases against doctors is inappropriate prescribing.² These cases often involve doctors who have prescribed drugs of dependence in response to the direct requests of their patients, where peer opinion does not support the use of these medications. Indeed, the medico-legal landscape is littered with doctors who have allowed the pendulum to swing too far towards patient autonomy and lost focus on their professional responsibilities as a medical practitioner.

Code of conduct

Doctors have a professional obligation to make the care of patients their first concern, and to practise medicine safely and effectively. The Code also tells us that providing good patient care includes recognising and respecting patients’ rights to make their own decisions. We are also told that making decisions about health care is the shared responsibility of the doctor and the patient.³

But what does this actually mean in practice? What if a patient’s view of what is in their best interests does not align with yours? In shared decision-making, the intention is that patients and their doctors share both the process of decision-making and the ownership of the decisions made. Ultimately this may involve the doctor offering a range of options, including no intervention, and the patient making a choice based on their values and beliefs. In most cases a mutually acceptable outcome can be negotiated, but sometimes this won't be possible. Patient dissatisfaction in this situation is not necessarily a sign of bad medical practice, or bad doctors.⁴

“Saying no”, nicely

Mastering the art of “saying no” is one of the most important strategies to reduce medico-legal risk. Every doctor will develop their own strategies, which will vary depending on the individual patient and the particular situation. Some suggested strategies include the following:

• Start a discussion, rather than just “saying no” – there may be value in exploring why the patient wants a particular investigation, treatment or medication.
• Be willing to negotiate – explain the reasons why a patient’s request is not in their best interests or the best option for their management, and offer other options.
• Show empathy – try to understand and acknowledge the patient's perspective⁵ 
• Deflect the blame – it may be appropriate to rely on “the system”, e.g. legislation, or saying, “doctors’ professional guidelines prohibit me from prescribing that medication”.
• When necessary, be firm in “saying no” in simple and respectful terms, e.g. I don’t prescribe oxycodone.⁶

Patient autonomy does not mean you have to comply with a patient's request. Indeed, there are risks for your patients, and to you, if you do so.

Dr Sara Bird
Manager, Medico-legal and Advisory Services
MDA National

This article originally appeared in Good Practice July 2016.

References

1. Victoria Coren Mitchell. The Doctor Won’t See You Now. The Guardian, 29 March 2015.
2. Elkin KJ, Spittal MJ, Elkin DJ, Studdert DM. Doctors Disciplined for Professional Misconduct in Australia and New Zealand 2000-2009. Med J Aust 2011;194:452-456.
3. Medical Board of Australia. Good Medical Practice: A Code of Conduct for Doctors in Australia. 2014. Available at: medicalboard.gov.au/Codes-Guidelines-Policies/Code-of-conduct.aspx
4. McCartney M. The Conflict of Choice. BMJ 2015;351:h5312.
5. Chesarow N. Some Ways of Telling Patients ‘No’ Are Nicer Than Others. Medscape 24 March 2016.
6. Carr N. I Just Want Some Valium, Doc. Aust Fam Physician 1988;27(9):817-821.