Over the past several years, physicians, ethicists, and medical professional societies have placed a greater emphasis on shared medical decision-making between patient and physician. In contrast to older models of care that left physicians as the primary decision-makers in the patient–doctor encounter, this relatively new framework focuses on informing the patient about important inputs in the decision-making process and arriving at care decisions together. In doing so, it emphasizes a patient’s autonomy and incorporates his or her preferences and values into choices about care.
During my time as a medical and graduate student at Harvard, I witnessed this revolutionary approach to care become a far more influential component of the formal and informal medical curriculum. Now, as an intern in the Department of Medicine at Beth Israel Deaconess Medical Center, I am aspiring to incorporate this practice style into my encounters with patients, but am encountering some unexpected personal challenges. These challenges are rooted in my own compulsion to do what I believe is best for my patients, but they also expose how difficult it can be for even newly minted physicians to disavow some of the traditional, paternalistic practices of medicine. One of the first patients I saw as an intern helped me grasp this more clearly.
Arriving in my clinic on a Wednesday morning, Mr. A presented complaining of a rash he had recently developed. After asking him some questions and talking about potential diagnoses for his condition, we proceeded to discuss his general medical history more thoroughly. Like many people, he did not have a regular physician, and he rarely sought medical attention in the outpatient setting. I was therefore eager to learn more about him and perhaps serve as his primary care provider.
As our conversation transitioned from Mr. A’s past medical problems and surgeries to his medications and allergies, we finally arrived at his social history, at which point came my surprise: “How many beers do you drink each day?” I asked, after he mentioned being a beer drinker. “On average, I’ll have 10 beers, sometimes more, sometimes less,” he responded candidly, with just a hint of the trepidation I have often heard in patients’ voices when they think they are disclosing information their physician will not be pleased to hear.
Immediately thinking back to some of my training in medical school, I recalled a physician telling a group of us that consumption of even a few drinks each day is cause for concern, as many patients with this level of consumption are alcohol dependent or even undiagnosed alcoholics. I proceeded to ask Mr. A some of the screening questions for alcohol abuse that I learned during my psychiatry classes. Though his responses did not elevate my concern about undiagnosed alcoholism, I was still concerned about his well-being and started to discuss some of the long-term risks of heavy alcohol use with him. In particular, I emphasized the potential for irreversible damage to his liver.
We then arrived at a decision point: whether or not to check his liver function for signs of alcohol-related inflammation. Instinctively, I wanted to perform the test: with it, we would gain a sense of Mr. A’s baseline liver function and either rule out concerns about an ongoing, pathological process, or identify it early enough to intervene. However, the case for doing no test at all was also strong. Mr. A did not carry any of the physical signs we often see in patients with liver disease, and his review of systems evaluation was negative. Moreover, I was unaware of any studies that suggested that a screening liver function test improved health outcomes in patients like Mr. A. However, my inclination was to err on the side of caution and investigate the problem further.
As a medical student, I knew what I would probably have done at this crossroads: after explaining the indication for the test to my patient, I would have simply ordered it at the end of our appointment. But this time was different. Reminding myself of my commitment to shared decision-making whenever possible, I put aside my instinct to do what I thought was best for the patient, held my breath in anticipation, and nervously asked, “Is that something that you’d like to do?”
“Yeah, that sounds good,” he responded, and I exhaled. Shared decision-making was, I believe, the right approach to navigating the interaction, but I had not anticipated encountering so much personal difficulty in the process. Though the paradigm of shared decision-making is often discussed in the context of medical decisions that are much weightier—such as whether or not to undergo a potentially beneficial but risky surgery—this relatively minor clinical encounter represented a breakthrough in a much larger issue for me: it was the first time I actively thought about decision-making dynamics in a patient–doctor encounter—and struggled deeply over the possibility that my patient might not do what I considered to be in his best interest. And yet, I sensed that acknowledging Mr. A’s autonomy was fundamentally appropriate.
Mark Aronson, professor of medicine and associate chief of the Division of General Medicine and Primary Care at BID, strongly supports the tenets of a shared decision-making philosophy. “I view shared decision-making with patients as the essence of the doctor–patient relationship as well as a vital element of the patient safety movement. Part of the doctor’s job is to guide patients in difficult decisions by making them fully aware of and educated about the risks and benefits of each decision…. Empowering the patient to partner with the doctor in making [these decisions] leads to better and safer care.”
Mr. A taught me one of my first important lessons as a medical intern, and I intend to carry it with me throughout my training and beyond. Though residency has just begun, I am gaining the sense that I will learn much more from my patients than just how to treat their medical conditions.
Joseph Ladapo, HMS ’08, is an intern in internal medicine at Beth Israel Deaconess Medical Center.
The opinions expressed in this column are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.
